Metacognition, attachment and psychotherapy in first-episode psychosis: a case study

Aim of the study: Psychotherapy in first-episode psychosis is essential for the recovery of affected users. Those with primary psychotic disorders experience impaired abilities to form complex ideas about themselves and others, called metacognitive deficits. They also present important attachment disturbances.Methods: This paper aims to review the concepts of metacognition and attachment in psychosis, present an in-terpersonal metacognitive model incorporating elements of attachment theory and analyze a clinical case to show the integration of different strategies in the initial phase of therapy. The Metacognitive Assessment Scale-Abbreviated (MAS-A) was used to assess changes in the user's metacognitive ability.Results: The therapist adopted the role of secure base and safe-haven to develop an adequate therapeutic relationship, operating through metacommunication and self-participation. Normalization interventions were applied and the user's agenda was consistently prioritized. The user developed greater metacognitive abili-ties in the MAS-A along with better functioning, maintained few symptoms and was able to move into a new phase of therapy. Discussion: The review and clinical case presented highlight the importance of an interpersonal metacog-nitive model that considers the users' attachment pattern and a solid therapeutic relationship. Hierarchical metacognitive interventions are presented that allowed the user to address more complex psychological con-flicts in therapy.Conclusions: Psychotherapeutic models that integrate the concepts of metacognition and attachment theory are promising to improve self-reflective abilities in users with a first-episode psychosis. The clinical case pre-sented would be a contribution to design future studies about these processes.