Metacognition, identity, and durable recovery in adolescent early psychosis: A five-year mixed-methods follow-up

Early intervention in psychosis has improved symptomatic outcomes, yet little is known about how early metacognitive change relates to long-term identity reconstruction and durable recovery. This study examined five-year quantitative and narrative outcomes of adolescents with first-episode psychosis (FEP) or at-risk mental states (ARMS) treated with Recovery-Focused Metacognitive Interpersonal Therapy (MIT-FEP).

Twenty-three adolescents participated in the original naturalistic cohort study; 21 completed treatment and 19 were reassessed five years later. Quantitative measures included subjective recovery, symptom severity, metacognitive functioning, psychosocial performance, service use, and hospitalizations. A qualitative thematic analysis of follow-up narrative interviews explored identity integration, agency, and autobiographical meaning-making.

Improvements in metacognition, symptoms, and recovery were sustained or enhanced at five years. Seventy-nine percent met remission criteria, 63% achieved functional recovery, and 58% met integrated recovery criteria, defined as the concurrent presence of symptomatic remission, functional recovery, and subjective recovery. Thematic analysis identified four core processes: (1) reconstruction of agency, (2) integration of the psychotic episode into a coherent life narrative, (3) transition from illness-centred to developmental identity, and (4) future orientation and meaning-making. Narrative coherence and future orientation were more evident among participants achieving integrated recovery.

Findings suggest that early metacognitive intervention was associated with durable recovery trajectories extending beyond symptom reduction to include identity reconstruction and reduced service dependency. Metacognition may represent a developmental process associated with the maintenance of recovery and sustained psychosocial integration following early psychosis.