Translating an integrative metacognitive model of psychotherapy for serious mental illness into a group format: A pilot investigation on feasibility

Abstract

Metacognitive Reflection and Insight Therapy (MERIT) is a one-on-one intervention that targets insight with the aim to help people with serious mental illness develop more integrated ideas about themselves and others in order to respond to their psychological and social challenges more adaptively. There is a growing body of evidence on MERIT’s effectiveness. Considering the clinical demand for more cost-effective group psychotherapies, we modified the original individual MERIT format to a group-based intervention (MERITg) for application in inpatient and outpatient psychiatric settings. Thirty-one participants (inpatient = 10; outpatient = 21) with serious mental illness were surveyed on their experience of MERITg, which was offered adjunctively to their routine clinical care. Program evaluation measures were used to assess feasibility and acceptance of the group. Across locations, more than half of all participants attended more than one group. Participants reported attending the group initially because they thought writing would be helpful, and further reported that they liked the group because they enjoyed writing and the discussion, and that they found it interesting to hear the perspectives and writings of others. Findings further support the need for future research on the efficacy and effectiveness of the group and its relationship to changes in metacognitive capacity and recovery.

Introduction

Metacognition is a key process that supports the formation of integrated ideas of oneself and others (Lysaker et al., 2020c). It refers to a spectrum of activities that enable persons to notice specific thoughts and feelings and form a larger sense of their own and others’ purposes, relationships and future possibilities (Lysaker et al., 2021). Intact metacognitive functions allow individuals to make meaning of and respond to emergent challenges and sustain a sense of connection with their broader community while maintaining a coherent sense of personal identity (Lysaker et al., 2020b). By contrast, individuals with impaired metacognitive capacity have a relatively more fragmented and less coherent sense of themselves and others. Metacognitive deficits have been broadly observed in adults diagnosed with serious mental illness, including schizophrenia, and linked to a range of concurrent and prospective outcomes in the areas of impaired insight, reasoning biases, low self-compassion, low empathy, increased symptoms of psychosis (i.e., hallucinations, negative symptoms), and poorer psychosocial functioning (Arnon-Ribenfeld et al., 2017; Lysaker et al., 2020c).

Metacognitive Reflection and Insight Therapy (MERIT; (Lysaker & Klion, 2017) is an integrative, person-centered, recovery-oriented psychotherapy initially developed to meet the needs of people diagnosed with serious mental illness, such as schizophrenia. Its explicit aim is to enhance clients’ abilities to form an integrated sense of themselves, others, and their place in their larger communities. While promoting awareness of oneself and others, MERIT works with clients to form more adaptive accounts of their psychiatric and social challenges and decide how they want to actively manage them on their own paths to recovery (Lysaker et al., 2020a; Lysaker et al., 2020b).

MERIT supports the enhancement of metacognition by engaging with individuals in metacognitive acts that match their maximal capacity in the moment to think about their experience, and their sense of themselves and others. With the underlying goal of helping individuals make better sense of the world, MERIT supports the development of a sense of agency, a coherent sense of self, and importantly, client-driven recovery through the management of psychological challenges with the promotion of metacognitive capacity. Individual MERIT sessions are typically 45–60 minutes with treatment duration often spanning months to years (Lysaker & Klion, 2017). MERIT contains eight elements, with each element present in every session. The elements are thought to synergistically promote clients’ abilities to form increasingly integrated senses of themselves and others. These elements include 1) a joint focus on the client’s agenda, 2) the client’s experience of the therapist, 3) elicitation of narrative episodes, 4) the social and psychological challenges that a client feels they are facing, 5) reflections on interpersonal process, 6) reflections on perceptions of change, 7) facilitation of both reflection about the self and others, and 8) how to use metacognitive knowledge to respond to psychological and social challenges (Lysaker & Klion, 2017).

MERIT providers must also actively evaluate metacognitive capacity in real-time to guide the interventions within a session by conceptualizing and assessing four domains of metacognition (Lysaker et al., 2020a; Lysaker & Hasson-Ohayon, 2018; Lysaker & Klion, 2017). The first of these, self-reflectivity, refers to one’s ability to recognize one’s own thoughts and emotions, how these influence one another, and how they change over time. The second, awareness of the mind of the other, refers to an individual’s capacity to recognize that others have their own thoughts and emotions that interact with one another. The third domain of mastery pertains to one’s ability to use metacognitive knowledge about oneself to cope with mental illness and psychological distress. Finally, the fourth domain of decentration refers to one’s understanding that events occur independently of oneself and result from complex emotional, cognitive, social, and environmental factors. Applying these concepts, a therapist may stimulate self-reflection and awareness of emotions, for example, by associating physical experiences in one’s body to scaffold awareness of an emotional experience. Further, the therapist may insert their own experiences with self-disclosure to promote self-reflectivity (i.e., “When I feel tightness in my chest, it is usually because I am feeling anxious about something. I wonder if that may have been the case for you?”).

A growing body of research has supported the efficacy of MERIT to enhance metacognition in those with serious mental illness. Studies have suggested MERIT may benefit those with first episode psychosis (Hillis et al., 2015; Leonhardt et al., 2016; Leonhardt et al., 2018), significant deficits in metacognitive capacity (Buck & George, 2016), psychosocial dysfunction (Dubreucq et al., 2016), disorganized symptoms (de Jong et al., 2016a; Hamm & Firmin, 2016), disorganized symptoms and trauma (Hillis et al., 2018), negative symptoms (George & Buck, 2018; Van Donkersgoed et al., 2016), illness identity (Arnon-Ribenfeld et al., 2018), and co-occurring substance use (James et al., 2018). Two qualitative studies have also suggested that MERIT enhances coherence of self-experience from the point of view of the client (de Jong et al., 2020; Lysaker et al., 2015). Additionally, four open label trials (Bargenquast & Schweitzer, 2014; de Jong et al., 2016b; Lavi-Rotenberg et al., 2020; Minor K, 2021) and two modestly sized randomized control trials (de Jong et al., 2019; Vohs et al., 2018) have demonstrated moderate effect sizes, indicative of MERIT’s acceptability and clinically significant effects.

Even though MERIT has been shown to be an efficacious individual intervention for those with serious mental illness, as described above, there is a growing demand to translate individual interventions to more cost-effective approaches (McCrone et al., 2008), as well as calls for the use of group psychosocial interventions for serious mental illness (Burlingame et al., 2020) to enable a greater number of individuals to have access to treatment. We posit that MERIT delivered in a group format (MERITg) may provide therapeutic interactions above and beyond those obtained from individual MERIT treatment. For example, group psychotherapy would offer opportunities for real-time feedback from peers, as well as real-time interactions with others that can be moderated and processed with the assistance of the group facilitator (DeLucia-Waack et al., 2013). These aspects of group interventions may uniquely enhance the goals of MERIT-oriented interventions (i.e., stimulation of the mind of others and decentration).

To address the above, we developed a group-based MERIT intervention (MERITg) that, similar to traditional MERIT, targets the enhancement of metacognitive capacity through the inclusion of a written narrative that is accompanied by a MERIT-oriented process discussion. In this article, we provide initial proof of concept data about the feasibility and acceptability of the intervention across both inpatient and outpatient settings. We hypothesized that the MERIT psychotherapy group could be successfully implemented across settings, and that the intervention would be feasible and acceptable.

Materials and Methods

Subjects

Thirty-one unique Veterans participated in the group-based MERIT psychotherapy group, across acute inpatient psychiatric (n = 10) and outpatient day program (n = 21) settings at the VA Connecticut Healthcare System. Participation was not limited based on diagnosis, and instead open to all Veterans receiving care on the psychiatric inpatient unit or attending an outpatient day program for Veterans with serious mental illness. All participants were fluent in conversational English. On the inpatient unit, participants had severe mental illness diagnoses including psychosis (n = 4), bipolar disorder (n=4) and major depressive disorder (n = 2) with comorbid conditions including post-traumatic stress disorder (PTSD; n = 5), generalized anxiety (n = 1) and substance use disorders (n = 1). In the outpatient setting, participants had severe mental illness diagnoses, including psychosis (n = 1, n = 2 with psychotic features), bipolar disorder (n = 5), major depressive disorder (n = 7), PTSD (n = 6) and generalized anxiety disorder (n = 1) with comorbid conditions including PTSD (n = 7), substance use disorders (n = 7) and generalized anxiety (n = 1). One participant participated in both settings. See Table 1 for sample demographics by setting. Due to the small sample sizes of participants in both settings and overlapping diagnoses of severe mental illness, all participants were combined into one group for analysis.

Table 1.

Details of MERIT Psychotherapy Groups (MERITg)

	All Participants	Inpatient	Outpatient
Total number of groups offered	19	6	13
Average number of participants/group (range)	4 (1–9)	3 (1–5)	4 (1–9)
Total number of participants	75	19	56
Total number of unique participants (M:F)a	31 (20:10)	10 (6:4)	21 (14:6)
Age in years ± SD (range)a	49.7 ± 14.5 (29–72)	51.4 ± 16.9 (30–72)	48.9 ± 13.5 (29–72)
Race (B/W/A/NHOPI/AIAN)a, b	5/20/2/1/1	1/8/0/0/1	4/12/2/1/1
Ethnicity (HL/NHL/U/D) a	3/25/1/1	1/9/0/0	2/16/1/1
# of groups attended:
1	15	5	10
2	4	4	0
3	4	0	4
4	3	0	3
5	3	0	3
6	1	1	0
7	1	0	1

Note. # = number; F = female; M = male; SD = standard deviation; B = Black; W = White; A = Asian; NHOPI = Native Hawaiian or Other Pacific Islander; AIAN = American Indian or Alaska Native; HL = Hispanic or Latino; NHL = Not Hispanic or Latino; U = Unknown to Veteran; D = Declined to answer

^a1 outpatient participant missing demographic information

^b1 participant who was female and AIAN participated in both the inpatient and outpatient groups Why Participants Attended Group

Procedures

Clients attended the MERIT psychotherapy group, which we called “Creative Writing,” on a voluntary basis, as the group was offered in the milieu as adjunctive treatment to each client’s individual preexisting treatment plans. The group was offered for 6 and 13 weeks on an inpatient unit and in an outpatient day program, respectively, based on clinical staffing availability. At the completion of each 45-minute group session, participants were asked to complete a brief questionnaire about their experience in the group. Institutional Review Board approval was obtained for chart-review and analysis of the qualitative evaluation data collected as part of the clinically delivered MERIT psychotherapy group.

Measurement-Based Care Assessments

Participants completed a brief qualitative questionnaire about their experience in the group at the end of each group session for the purposes of program evaluation. The questionnaire was designed by the study team and asked participants to indicate why they attended group and what they liked and disliked about the group. Potential responses were provided with instructions to “check all that apply,” as well as the option of “other” with a space to write in a personalized response. Specific questions and all potential responses (including “other”) are available in Tables 2–4.

Table 2.

Why Participants Attended Group

Question: “Why did you attend group today? What made you want to come? (Check all that apply)”
	After First Group Session						After Last Group Session Completed a
	All Participants (N=29b)		Outpatient (n=21)		Inpatient (n=8c)		All Participants (N= 29b)		Outpatient (n=20)		Inpatient (n=9d)
	#	%	#	%	#	%	#	%	#	%	#	%
	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed
I thought writing would be helpful	19	65.5	15	71.4	4	50	21	72.4	16	80.0	5	55.6
I was curious	16	55.2	14	66.7	2	25	12	41.4	10	50.0	3	33. 3
I thought I might learn something	13	44.8	10	47.6	3	37.5	19	65.5	14	70.0	5	55.6
I like talking about things with other people	13	44.8	10	47.6	3	37.5	19	65.5	16	80.0	3	33.3
It sounded fun	10	34.5	7	33.3	3	37.5	10	34.5	7	35.0	3	33.3
Other	8	27.6	7	33.3	1	12.5	6	20.7	5	25.0	1	11.1
I wanted to distract myself from something	5	17.2	3	14.3	2	25	7	24.1	4	20.0	3	33.3
I like the person leading the group	5	17.2	4	19.1	1	12.5	12	41.4	10	50.0	2	22.2
I had nothing better to do	2	6.9	1	4.8	1	12.5	3	10.3	1	5.0	2	22.2
I did not feel comfortable saying no	1	3.5	1	4.8	0	0	3	10.3	2	10.0	1	11.1

Note. Items rank ordered from most to least popular responses across all participants after group 1; # = number; % = percentage

^aAfter last group session completed represents the survey data from the highest number of completed group sessions per subject (including 1 group if participants only completed 1 group session)

^bThirty-one participants completed the group but only 29 completed the questionnaire

^cTen participants completed the group but only 8 completed the questionnaire

^dTen participants completed the group but only 9 completed the questionnaire.

Table 4.

What Participants Disliked About the Group

Question: “What didyou dislike about this group? (Check all that apply)”
	After First Group Session						After Last Group Session Completed a
	All Participants (N= 29b)		Outpatient (n = 21)		Inpatient (n=8c)		All Participants (N=29b)		Outpatient (n = 20)		Inpatient (n=9d)
	#	%	#	%	#	%	#	%	#	%	#	%
	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed
Nothing	20	69.0	13	61.9	7	87.5	18	62.1	13	65.0	5	55.6
It’s too short	7	24.1	6	28.6	1	12.5	7	24.1	7	35.0	0	0.0
I did not get enough time to write	4	13.8	4	19.1	0	0.0	3	10.3	3	15.0	0	0.0
Other	2	6.9	2	9.5	0	0.0	2	6.9	1	5.0	1	11.1
The content did not interest me	1	3.5	0	0.0	1	12.5	1	3.5	0	0.0	1	11.1
I did not get to talk enough	1	3.5	1	4.8	0	0.0	0	0.0	0	0.0	0	0.0
It’s too long	0	0.0	0	0.0	0	0.0	1	3.5	0	0.0	1	11.1

Note. Items rank ordered from most to least popular responses across all participants after group 1; # = number; % = percentage

^aAfter last group session completed represents the survey data from the highest number of completed group sessions per subject (including 1 group if participants only completed 1 group session)

^bThirty-one participants completed the group but only 29 completed the questionnaire

^cTen participants completed the group but only 8 completed the questionnaire

^dTen participants completed the group but only 9 completed the questionnaire.

Group-Based MERIT Intervention

Each group session was approximately 45-minutes long, with 15 minutes devoted to writing and 30 minutes spent in discussion. Unlike individual MERIT, MERITg used a writing prompt that was broad enough for inclusion across participants, but specific enough that participants would focus on a particular memory. These writing prompts were used to simultaneously elicit a narrative account from each group participant. If the prompt did not apply to a specific participant, alternative, related prompts were offered. For example, one of the topics used was, “In as much detail as possible, describe your first job”. If a participant had never worked, an appropriate alternative and related prompt that could have been offered would be, “In as much detail as possible, describe your first-time volunteering.” After writing, discussion about the writing process and content of the writing was initiated. Participants were given the opportunity to read/share their writing or memory with the group. To be MERIT-congruent, facilitators actively accessed metacognitive capacity of participants while implementing the eight tenets of MERIT, as described above. For instance, facilitators elicited details relevant to the narrative, and offered reflections of the mind of the therapist when relevant and appropriate, and at a metacognitive level appropriate for the participant. Additional MERIT-congruent elements included reflections about observed interpersonal processes, when participants described their thoughts or perceptions changing over time, and when participants provided examples of how they used their metacognitive capacity and unique understanding of themselves to respond to psychological and social challenges in the past. Together, MERITg supports the ability of participants to get feedback from and give feedback to other participants which also supports the enhancement of metacognition (e.g., understanding the mind of the other and decentration). Also congruent with MERIT, although writing prompts changed group session to group session, prompts could also be revisited, as revisiting a topic often helps participants expand upon a previously discussed narrative (Lysaker & Klion, 2017).

Statistical Analysis

Groups were first evaluated for total number of unique participants, average number of participants per group session, and number of participants with repeat attendance. Qualitative data was assessed from the questionnaire data. Responses were reviewed after initial group participation as well as after the last group session attended to consider any changes in motivation for attendance over time. For instance, we considered that Veterans may be curious about the group initially, and then may attend because they thought writing would be helpful.

Results

Group Characteristics (Table 1)

A total of 31 unique participants (inpatient, n = 10; outpatient, n = 21) participated in the group over the course of 6 group sessions in the inpatient setting and 13 group sessions in the outpatient setting. Group size was on average 3 for inpatient groups (range: 1–5) and 4 for outpatient groups (range: 1–9). The average number of group sessions attended per participant were 2.4 ± 1.8 (range: 1–7) overall, and specifically, 2 ± 1.5 (range: 1–6) on the inpatient unit and 2.7 ± 1.9 (range: 1–7) in the outpatient setting. On the inpatient unit, half (50%) of the participants returned for more than one group session, and slightly more than half (52.4%) returned for more than one group session in outpatient care. For additional details of group attendance, including a breakdown by number of groups attended, see Table 1.

Questionnaire Data: After Participation in First MERIT Group Session (Tables 2–4)

Following the first MERIT group session (total responses = 29), the most popular responses across participants to the question “Why did you attend group today? What made you want to come? (Check all that apply)” included, “I thought writing would be helpful” (65.5%), “I was curious” (55.17%), and “I thought I might learn something” (44.8%). The least popular response was, “I did not feel comfortable saying no,” which was endorsed by 1 participant (3.5%).

Across all participants, the most frequently endorsed responses to the question, “What did you like about this group? Check all that apply” were: “I enjoyed writing,” “Good discussion,” and “It was interesting to hear others’ perspectives/writing,” endorsed at 82.8%, 65.5%, and 65.5%, respectively. The least frequently endorsed response was “Other,” which was endorsed by 1 participant (3.5%, i.e., “I need to keep trying to do better in my writing”).

When asked, “What do you dislike about this group? (Check all that apply)” after the first group session, the most frequently endorsed response was “Nothing” (69.0%), followed by “It’s too short” (24.1%), and “I did not get enough time to write” (13.8%). “It’s too long” was not endorsed by any participants.

Questionnaire Data: After Participation in Last Group Session (Tables 2–4)

After completion of the last group session (total responses = 29), the most frequently endorsed responses to the question, “Why did you attend group today? What made you want to come? (Check all that apply)” included, “I thought writing would be helpful” (72.4%), “I thought I might learn something” (65.5%), and “I like talking about things with other people” (65.5%). The least popular responses were “I had nothing better to do” (10.3%) and “I did not feel comfortable saying no” (10.3%).

The most common responses about what participants liked about the group included, “I enjoyed writing” (86.2%), “Good discussion” (72.4%), and “It was interesting to hear other’s perspectives/writing” (69.0%). The least popular response for why individuals attended group was “Other” (17.2%, i.e., “It keeps me in check, and I let my feelings and emotion out when I write.”).

When asked what participants disliked about the group, the most popular responses included “Nothing” (62.1%), “It’s too short” (24.1%), and “I did not get enough time to write” (10.3%). Nobody endorsed “I did not get to talk enough”.

Discussion

To address the need for more cost-effective group interventions for serious mental illness and to capitalize on the benefits of group-based psychotherapies, we developed a group-based MERIT intervention that, like the traditional individual format of MERIT, targets the enhancement of metacognitive capacity. The group used a singular writing prompt to elicit a narrative episode from each group member simultaneously, followed by a MERIT-oriented process for the discussion of the elicited narrative episodes. In this study, we used program evaluation data to investigate the feasibility and acceptability of this new MERITg intervention.

Consistent with our hypothesis, the group was successfully implemented across an inpatient and outpatient setting and was feasible and acceptable to participants. Across settings, more than 50% of subjects returned for multiple groups, with report that they attended because they thought that writing would be helpful. Generally, participants also reported that the writing and group discussion aspects were the most enjoyable parts of the intervention.

Consistent with previous literature on the relationship between metacognitive capacity and recovery (Lysaker et al., 2020a), MERIT is a treatment approach that posits that addressing deficits in metacognition will help those with severe mental illness make sense of their challenges and further help them decide how they want to manage and respond to those challenges. To make therapeutic gain and elicit a narrative episode from each group member simultaneously, MERITg uniquely utilized a written activity. Other interventions utilizing written narratives, such as Written Exposure Therapy (WET), have also been observed to be effective treatments for PTSD (Sloan et al., 2012), PTSD in Veterans with comorbid opioid use disorder (Meshberg-Cohen et al., 2021), as well as for reducing distress and improving resiliency in trauma nurses (Mealer et al., 2014).

Overall, more than half of all participants returned for additional MERITg group sessions. Given the positive feedback on the questionnaire from the inpatient group, it appears that the group was well-received in this setting, and that the less frequent group attendance (50%), compared to the outpatient setting (52.4%), was unlikely to be related to dislike or lack of interest in group participation. Notably, Veterans may not have been on the psychiatric inpatient unit long enough for the opportunity to attend multiple group sessions due to the traditionally short durations of inpatient care.

This first of its kind, proof-of-concept study demonstrates the feasibility and acceptability of our newly proposed MERIT group psychotherapy. This study had some important limitations that should be acknowledged and considered for future research. Firstly, while a strength of the study is that it included participants across both inpatient and outpatient psychiatric treatment settings, questionnaire data were collected from a small sample of participants for program evaluation, making interpretations limited (e.g., some participants completed one group, thus looking at change over time in rationale for MERITg attendance was limited). Larger systematic investigations with a control group are needed to address these limitations. Additionally, this initial feasibility study did not include a measure of metacognition or symptom severity (i.e., PANAS, PANSS, PHQ-9) which would be beneficial for clarifying possible mechanisms of change, the relationship between MERITg and symptom severity, as well as change in symptoms over time. Future research is also needed to determine how participants may be impacted by each unique writing prompt. Finally, it would be imperative that future research determine the ideal number of group sessions needed for meaningful clinical improvement, other potential durations of time in the group spent writing, the ideal number of participants in a group session, and role of peer support and recovery in the group. Collectively, these proposed next steps for future research highlight the necessity of pre-post studies evaluating changes in metacognition and larger randomized controlled trials to investigate the efficacy and effectiveness of MERIT as a group psychotherapy. Given that MERITg is feasible to deliver and acceptable to Veterans, research is needed to evaluate whether the use of written narratives in combination with MERIT-techniques increases self-reflection and mental health recovery.

While MERIT was initially designed to be implemented in a 1:1 dyad between a client and provider, with replication, study findings suggest that MERIT group psychotherapy is both feasible and acceptable for those with serious mental illness. Importantly, being able to offer MERIT as a group intervention allows for more cost-effective and time-limited care.

Table 3.

What Participants Liked About the Group

Question: “What did you like about this group? (Check all that apply)”
	After First Group Session						After Last Group Session Completed a
	All Participants (N=29b)		Outpatient (n = 21)		Inpatient (n=8c)		All Participants (N=29b)		Outpatient (n = 20)		Inpatient (n=9d)
	#	%	#	%	#	%	#	%	#	%	#	%
	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed	endorsed
I enjoyed writing	24	82.8	18	85.7	6	75.0	25	86.2	18	90.0	7	77.8
Good discussion	19	65.5	13	61.9	6	75.0	21	72.4	15	75.0	6	66.7
It was interesting to hear other’s perspectives/writing	19	65.5	16	76.2	3	37.5	20	69.0	16	80.0	4	44.4
Writing was helpful to organize my thoughts	16	55.2	12	57.1	4	50.0	18	62.1	13	65. 0	5	55.6
I like having someone to talk to	15	51.7	10	47.6	5	62.5	16	55.2	10	50. 0	6	66.7
I like the focus on specific topics	10	34.5	8	38.1	2	25.0	10	34.5	8	40. 0	2	22.2
I liked sharing my writing with others	9	31.0	7	33.3	2	25.0	10	34.5	8	40. 0	2	22.2
I like groups in general	8	27.6	7	33.3	1	12.5	9	31.0	8	40. 0	1	11.1
I like thinking about past memories	5	17.2	4	19.0	1	12.5	8	27.6	7	35.0	1	11.1
Other	1	3.5	1	4.8	0	0.0	5	17.2	4	20.0	1	11.1

Note. Items rank ordered from most to least popular responses across all participants after group 1; # = number; % = percentage

^aAfter last group session completed represents the survey data from the highest number of completed group sessions per subject (including 1 group if participants only completed 1 group session)

^bThirty-one participants completed the group but only 29 completed the questionnaire

^cTen participants completed the group but only 8 completed the questionnaire

^dTen participants completed the group but only 9 completed the questionnaire.

Impact Statement.

This first of its kind study sought to evaluate a new group-based format of Metacognitive Reflection and Insight Therapy (MERITg), a psychotherapy for people with serious mental illness. Overall, study findings suggest that the group was successfully implemented and that group participants found the group acceptable and enjoyable. Importantly, study findings also suggest that focusing on improving insight in a group psychotherapy format may have promise for helping those with serious mental illness.