Metacognition, Mindfulness, and Severe Mental Illness
How self-awareness influences mental health treatment and social engagement.
In short: The more neuropsychological research has revealed about metacognition, the more we can understand how to engage with those who lack insight, have trouble remaining present (mindfulness), and live with reality-altering, severe mental illness (SMI).
One of the top three functions of a counselor in session is to increase client insight. Broadening this concept to all mental health professionals, the ability to help clients understand more of who they are and what they are thinking is the beginning of goal attainment. This is one of the harder tasks to achieve as a mental health professional. The research focused on metacognition in neuropsychology has begun to reveal the ways the structure and processes of the brain produce the nuance of the mind. Within this nuance is where metacognition lives and has the power to change our understanding of our reality.
Metacognition in the Structural Brain
Let’s start from the beginning. Metacognition is essentially self-awareness. Self-awareness, or insight, is what practitioners of mindfulness are trying to achieve. For clients who live with reality-altering mental illness (schizophrenia, bipolar disorder, chronic anxiety, and the like), being able to more fully understand their thoughts and how their brain interprets reality differently is a huge step forward in regaining independence and solace.
Metacognition: (noun) awareness and understanding of one's own thought processes.
Knowing Thyself by Stephen M. Fleming has been my recent read and has prompted my journey into metacognition research and literature for the last month. Before reading this novel, I read a few other books on this topic–all of which I recommend at the end of this article–to deepen my understanding of metacognition as it intersects with mental illness, decision-making, communication, and mindfulness. Before all of this, I was mildly obsessed with increasing client awareness during treatment and as edification for life in general, but after reading, it has become a pillar of practice for me.
In his book, Fleming discusses, in-depth and with clarity, the way the mind contrives to make sense of our world. It begins with sensory intake, then moves toward the creation of assumptions about our reality as we are experiencing it, and then ends with subsequent adjustments made in response to successful or erroneous engagement with every single thing we undertake. This is a much simplified version of things, of course.
Metacognition and Psychotic Symptoms
The most interesting and helpful discovery discussed in most of these books is the concept of the brain as a predictive machine. Simply, the brain intakes information via our senses and interactions with the external world and creates assumptions and predictions about what can reasonably be expected during normative situations. One experiment that is mentioned in both Fleming’s and Ananthaswamy’s books is the rubber hand test. In this test, it was found that when a person simply viewed a rubber hand being stroked, their brain integrated that false hand into the senses to create a sensation in the mind. The significance of this finding is that when the brain decouples a person’s ownership over their physical body or mental voices, intense feelings of infiltration and possession by a foreign subject can occur–think of auditory hallucinations in psychotic disorders (although there are other things that can cause auditory hallucinations).
You can see how understanding what neuropsychology is discovering should change the way we approach clients with severe mental illness and integrate mindfulness practices into our eclectic treatment theories for these disorders. The hope is that the more we understand about the way the mind is poorly integrating sensory information and attributing ownership, the better our treatment modalities and psychotropic medications will treat these disintegrations. In fact, there are already modalities developed to address poor metacognition such as Metacognitive Therapy.
Mindfulness as a Function of Metacognition
Mindfulness hinges on the client’s ability to practice the very slippery act of self-monitoring. That is to say, mindfulness draws the individual’s attention to themselves. I will speak for most when I say that this, at the beginning at least, is difficult to attain and truly understand. Whether someone is working hard to repress internal thoughts that are troubling or they generally lack insight, teaching mindfulness is typically a strong first step in increasing insight.
How can we increase insight with mindfulness practices in light of this new metacognition research? Trying to take a more formal approach in the application of mindfulness treatments may be a good place to start. Starting with an assessment of a client’s current level of self-monitoring with this test. Utilizing mindfulness within the framework of a metacognitive treatment modality. And, encouraging wellness activities that enhance therapy, like journaling or meditation.
Mindfulness, bodywork, and awareness-encouraging techniques are very often used to treat clients who have experienced trauma. What has been found is that trauma (early and ongoing) changes the morphology of the pre-frontal cortex (PFC) and insula regions in the brain in different ways which can directly affect our ability to process our own thoughts. This is why damage to the PFC can lead to impulsivity and other traits where self-reflection is required to perform well. Here is the research I found interesting about this change, however, please note that the demographics of the sample and the size of the sample are skewed and small so I will keep an eye out for larger replications of this study.
Point of Interest: What role does priming play on metacognition in light of common priming techniques, such as marketing? How does this subsequently affect cultural beliefs, linguistics, etc?
After reading about metacognition, confirmation bias, and the multitude of ways that the brain works in the background helping us fill gaps in our personal narrative, I began to wonder to what degree marketing and other types of commonly used priming can influence entire cultures through individual’s belief systems. One very obvious example of this influence is in feminine body image distortions. The incidence of eating disorders, body dysmorphia, and purchasing beauty products or procedures are incredibly high for feminine individuals. It has long been discussed that the photoshopping of female images in marketing materials has contributed to the illusion of achieving bodily ‘perfection’ by looking similar to these manipulated images.
“These delicate, reciprocal, and immersive metacognitive interactions allow groups of individuals to subtly modulate each other’s impression of the world” -Know Thyself, p. 159
My point is if we are encouraged or primed to be confident or doubtful about something (our bodies, hair, intelligence, etc), then it seems that could affect how we participate socially, spend our money, and increase our confidence (cope with our metacognitive doubts about ourselves). And my ultimate point of interest is how does that change our language surrounding that trait we are doubtful about and how does that change in language further prime us to doubt ourselves, believe falsehoods, or engage in anxious behaviors?
That, as ever, will require further research. If you are interested, I will likely start here.
Suggested reading on the topic: Books, research articles, my blog posts
A discussion about the way our sense of self-awareness intersects with severe mental illness. (Book)
A neurologically-aware process of pursuing mindfulness. (Book)
Case studies and exploration of unconscious cognition. (Book)
How to approach metacognition in mindful conversation. (Book)
A primer on Shane Frederick’s Cognitive Reflection Test (CRT) (Article)
A piece on the impact of PFC and insula activity on physiology. (Article)
A discussion of the effect of trauma-focused psychotherapy on the structure of the brain. (Article)
All sources are linked or mentioned directly in the article. This article is heavily influenced by the books and articles linked above and combined with my knowledge on the various topics. A friendly reminder: I've done my research, but you should, too! Check my sources against your own, and always exercise sound judgment.