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4 July 2026

20 Pages

Narrative Psychotherapy for People with Psychosis: A Narrative Review of Current Research and Psychotherapeutic Approaches

,
and
1
Department of Psychiatry, Richard L. Roudebush VA Medical Center, Indianapolis, IN 46202, USA
2
Department of Psychology, Indiana State University, Terre Haute, IN 47809, USA
3
Erikson Institute for Education, Research, and Advocacy, Austen Riggs Center, Stockbridge, MA 01262, USA
*
Author to whom correspondence should be addressed.
Psychol. Int.2026, 8(3), 42;https://doi.org/10.3390/psycholint8030042
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Abstract

Narrative psychotherapy focuses on jointly discussing life stories with patients to promote shifts in sense of self and narrative identity. Narrative approaches have roots in constructivism which requires various elements or cognitive processes necessary for meaning making, such as the discussion of thoughts and feelings, how thoughts and feeling change over time, and how the patient’s construction of meaning contributes to their sense of self and place in the world. Narrative psychotherapy may have unique elements that promote recovery for people with psychosis. For instance, narrative approaches may help to integrate narratives that are fragmented or focused on illness identity, though the research is limited. The current study is a narrative review that aims to (1) discuss current theoretical and research findings related to narratives and narrative identity in people with psychosis; (2) identify and describe psychotherapy approaches that focus on narratives. We summarize recent findings that highlight positive outcomes for people experiencing psychosis, and how people move towards more integrated and complex narratives. We found a range of therapeutic approaches that focus on narratives including metacognitive therapy (i.e., metacognitive reflection and insight therapy), trauma-based psychotherapy (i.e., trauma-focused cognitive-behavioral therapy for psychosis and narrative enhancement therapy), treatment focused on self-stigma or illness identity (i.e., narrative enhancement and cognitive therapy and self-concept and engagement and life), and art and creative therapies. We discuss interpretation of findings and their implication for mechanisms of change.

1. Introduction

Narrative psychotherapy focuses on processing, evaluating, and re-authoring life stories (Howard, 1991; Ó. F. Gonçalves & Machado, 1999). This style of psychotherapy has been used with general populations and those suffering from mental health challenges, including mood disorders (Hawke et al., 2023). Narrative approaches may offer unique benefits to support recovery for people with psychosis, for example, to surface and stabilize life stories that may be overly illness or problem-focused (Prasko et al., 2010). In more recent years, there has been growing interest in integrating narrative approaches with psychotherapy for people with psychosis (e.g., L. A. Faith & Wiesepape, 2026; Wiesepape et al., 2023, 2026).
Narrative psychotherapy has roots in constructivism, which proposes that people construct their own reality, or mental images, based on experiences (Howard, 1991). In addition, sense of self and identity is formed through experiences, personal narratives, and interpretation of those narratives (i.e., narrative identity). Narratives are told by authors who “write” their stories and include descriptions, interpretations, and characters. A person’s narrative identity allows them to construct the past and envision an imagined future that provides their life with an ongoing sense of purpose and unity (McAdams & McLean, 2013). Crucially, these stories are both evolving and constantly retold based on how the person understands their life and must also be intelligible to people in their community. For instance, if a person’s identity is grounded in a story about being the Messiah based on their perceived supernatural ability to perform miracles and nobody in their community validates their narrative, then the person’s story lacks intelligibility, and they will likely be alienated from others. Within this construction of reality and identity, cognitive processes are necessary for meaning making (Ó. F. Gonçalves & Machado, 1999). In narrative psychotherapy, when the patient begins to unpack their evolving life story, joint meaning between the therapist and patient is formed, and changing thoughts and feelings contribute to a new construction of meaning which may help them understand their sense of self and place in the world. Narrative psychotherapy approaches aim to change one’s life story towards expansion into new areas, for example, ones that are less problem-focused (M. M. Gonçalves et al., 2009).
For people with psychosis, one’s narrative identity may be focused on one aspect of identity (e.g., illness) or fragmented without an integrated understanding of oneself. Bleuler introduced the idea of fragmentation as core to schizophrenia, arguing that a group of disorders was characterized by a primary splitting of the psyche and core mental functions such as thought, emotion, and behavior (Bleuler & White, 1912; Bleuler, 1911/1950). Such fragmentation results in narratives that are lack integration and disrupt a person’s capacity to understand their sense of self and therefore impact goal-directed activity (Bleuler & White, 1912). A related theoretical and treatment model, the integrated model of metacognition, posits that fragmentation is a central problem for people with psychosis (Hamm et al., 2017). Treatment utilizing this metacognitive model therefore aims to address fragmentation by working to integrate experiences (i.e., narratives) to form a more integrative and complex view of oneself (Lysaker & Klion, 2017; Lysaker et al., 2020b; Wiesepape et al., 2026). Although metacognition may not be an explicit focus of many forms of narrative psychotherapy, it is likely that metacognitive processes are a vital part of psychological processes underlying these therapeutic approaches (Lysaker et al., 2020a). As narrative psychotherapy is less focused on discrete experiences of illness and more focused on the whole person and the experiences that make up who they are, it is an ideal approach to combat fragmentation. Narrative approaches can specifically address fragmentation by helping people describe, construct, and integrate their life story and form a more coherent sense of self.
Although narrative psychotherapy is effective and promising for people with psychosis, only recently has it been utilized more widely with this population (L. A. Faith et al., 2024; Wiesepape et al., 2023, 2026). Importantly, it has also been shown that narratives can be transformed by treatment in people with schizophrenia. For example, one study suggests that explicit changes in narratives may occur following narrative-oriented therapy in schizophrenia (Lysaker et al., 2005). These may include changes in characters (e.g., the people discussed) and self-positions as expressed via dialogue (Lysaker et al., 2003). For example, a person might focus on their position as a patient or a “sick person”, but through dialogue with the therapist and uncovering narratives about job roles, the person may identify a new position as a worker. Recent research has also found that narrative therapy resulted in an improved sense of recovery and positive changes in identity in an individual diagnosed with paranoid schizophrenia (Fernandez et al., 2023). Narrative psychotherapy may be especially beneficial in assisting individuals who lack narrative cohesion and responsivity to develop more integrative and responsive narratives. However, narrative psychotherapy for people with psychosis is not routinely offered nor is it widely recognized as an effective treatment for this population. The current study aims to utilize a narrative review to identify and discuss recent literature that focuses on research relevant to psychotherapies that target life narratives to promote positive change for people with psychosis. We specifically aim to (1) discuss current theoretical and research findings related to narratives and narrative identity in people with psychosis; (2) identify and describe psychotherapy approaches that focus on narratives along with mechanisms of change.

2. Materials and Methods

The current study is a narrative review that aims to integrate the most current findings related to psychotherapy for people with psychosis that emphasizes life stories. We chose a narrative review because this area is under-researched, and a narrative review may be tailored to provide a broad overview with critical examination of its current status. We used guidelines from the recently published literature for appropriate justification and methodology of narrative reviews (Ferrari, 2015; B. N. Green et al., 2006; Sukhera, 2022a, 2022b). The goal of this literature search was to provide a synthesis of the most relevant recent literature, rather than an exhaustive search, to contribute to treatment and theory relevant to the study aims.
A literature search was completed by LF, CW, and JR through searches of PubMed, Google Scholar, and PsychINFO in May and June 2026. Inclusion criteria for selected studies were (1) publication within the last 6 years (2020–2026); (2) relevance to narrative psychotherapy, narrative identity, or therapeutic activities that explicitly emphasized life stories; (3) focus on individuals with psychosis as the primary population. Exclusion criteria were (1) publication in a language other than English; (2) lack of relevance to the overarching goal of understanding narrative approaches for psychosis. Narratives were defined as life events that were spoken, written, or expressed in other non-verbal or creative ways (e.g., visual art or poetry). Both empirical studies and theoretical papers (including reviews) with relevance to narrative therapy were included to provide a broad understanding of narrative approaches in psychosis. Authors focused on individual psychotherapy studies but included other interventions with relevance to the overarching goal, for example, group psychotherapy or other interventions (e.g., art therapy) with an explicit focus on life stories or narrative identity. The search began with pre-determined search terms; however, it was flexible and iterative with the addition of search terms as new narrative therapies were discovered through the initial search (Sukhera, 2022a). All authors completed independent searches, identified articles based on the defined inclusion criteria, and utilized clinical expertise to select articles that were judged to be most relevant to narrative psychotherapy for people with psychosis. All authors reached consensus on selected articles. Table 1 includes search terms and the number of articles that were identified and included. Reference lists of relevant articles were reviewed to identify any additional articles.
Table 1. PubMed literature search.
After relevant articles were selected, the authors organized and integrated these findings. Given that narrative reviews are intended to provide a selective overview and synthesis of the most relevant literature, we recognize that our perspectives and experiences informed problem identification, interpretation, and analysis (Sukhera, 2022a). Specifically, all authors had expertise in metacognitively oriented, narrative psychotherapy for psychosis. Each of the authors has diverse experiences in various settings including Veterans Affairs medical centers, academic settings, residential treatment centers, and inpatient and outpatient hospitals.

3. Results

3.1. Narratives and Narrative Identity

We identified n = 10 articles within the timeframe that highlighted recent theoretical, review, or empirical findings focused on narratives and narrative identity for people with psychosis. As mentioned above, people with psychosis tend to express life narratives that are fragmented or “stuck” on a certain aspect of identity rather than holistic and integrated. During the review period, there have been an increasing number of theoretical, review, and empirical papers published that are focused on life stories and narrative identity with this population. For example, recent reviews highlight literature that posits life narratives for people with psychosis have consistently been found to lack structure, display fewer themes related to communion and agency, and struggle to respond to experience (Lysaker et al., 2022; Wiesepape et al., 2023). Others have proposed that the narrative identity of individuals with schizophrenia and related disorders may be distinguished by disjointed structures, a focus on suffering, and a detached style of narration which arises developmentally as the experience of psychosis progresses (e.g., early psychosis to more chronic presentations) (Cowan et al., 2021). In addition, because experiences of psychosis tend to develop during a period of identity formation (late adolescence/early adulthood), narrative identity is often impacted. In this way, people may struggle to develop life stories outside of their illness identity. People may be focused on a “sick role” or alternatively may not recognize any challenges or deficits. Narratives may appear to be “stuck” and unable to change or evolve, even in the face of new experiences that contradict previously held beliefs. Older research has proposed that life stories from individuals with schizophrenia may be (1) relatively barren or lack narrative identity, (2) cacophonous or told by an unstable narrator, or (3) monological or rigid and potentially delusional (Lysaker & Lysaker, 2006). Each of these storytelling styles have implications for narrative identity and subsequent psychotherapy. Broadly, alterations in narrative identity and life stories may make it difficult to seek and engage in treatment, establish or maintain relationships with others, or pursue personal recovery.
Although limited in number, empirical studies have added findings to understand narratives for people with psychosis. Lundin et al. (2023) found that people with schizophrenia, compared with a control group, produced life stories that were lower in deep cohesion, and had alterations in first-person language (i.e., more first-person singular and fewer first-person plural pronouns); their social problem-solving abilities also did not correlate with linguistic variables. Another quantitative study found that people with psychosis, compared to a control group, had less complex narratives (Mazurek & Wajda, 2025). Taken together, these results suggest that narratives were more fragmented, less complex, less agentic, and reflected lower social connectedness.
Qualitative studies further seek to explore how narrative identities are impacted by interviewing people with psychosis themselves. Some studies focused on how psychosis can interrupt one’s life and how people navigated life after psychosis. One study evaluated pathways to recovery in published first-person accounts, or recovery narratives, by people with psychosis (B. Green & García-Mieres, 2022). A major theme was the reconstruction of identity and meaning making. First-person accounts mentioned rebuilding an understanding of the world and trust in others, self-acceptance, and making meaning of psychosis. Rebuilding identity also involved the exploration of roles, for example, practicing embroidery or engaging in other activities to promote wellness. Empowerment and agency were described as ways to manage illness and take control of one’s life. Overall, many of the accounts described rebuilding of one’s life and identity to gain agency and move forward. Another study similarly discussed the meaning making of psychosis and how psychosis impacted identity (O’Keeffe et al., 2026). Participants discussed the loss of and return to a sense of self after psychosis, which the authors described as “survival,” or the effort to keep their sense of self alive. Participants also discussed the chaos or unpredictability of psychosis in which they needed to restore stability to move forward in time and regain agency. Others created meaning from psychosis that afforded them access to a new part of themselves. Lastly, the process of “narrative re-storying” was described as attempting to make sense of psychosis, or at times deciding that there were parts of their life they would never be able to understand. Other studies focused more specifically on illness narratives or experiences in the mental health system that affect meaning making and recovery. Participants discussed psychiatric settings as interfering with their sense of self, for example, causing them to overidentify with their illness, stigma that interferes with recovery, or models that are overly focused on stabilization/symptoms (Lawrence et al., 2021; Van Sambeek et al., 2023). It is possible that it is particularly damaging when patients’ symptoms are treated (e.g., with medication) without the opportunity to make meaning of these symptoms or how they affect the person’s account of their life. For example, one study found that people with psychosis thought their negative symptoms resulted from difficulty verbalizing psychosis, or an inability to verbalize narrative accounts (Moernaut et al., 2022).

3.2. Narrative Psychotherapy

In addition to studies focused on specific narratives and narrative identity, we reviewed empirical studies related to narrative psychotherapy. Studies that included narrative-based psychotherapy consisted of a range of treatment approaches, including specific therapies and more general therapeutic styles. Based on the number of articles, we organized our results into the following categories: metacognitive reflection and insight therapy, trauma-based psychotherapy, treatment focused on self-stigma or illness identity, and art and creative therapies. Below, we explore each treatment approach, including recent literature focused on acceptability, efficacy, and outcome. A total of n = 23 studies met inclusion criteria for coverage in this section and are summarized in Table 2. Additional references, including select articles published outside the review timeframe, were included where appropriate to provide historical, theoretical, and treatment-related context.
Table 2. Narrative psychotherapy approaches for people with psychosis.

3.2.1. Metacognitive Reflection and Insight Therapy (MERIT)

The majority of papers reviewed within the timeframe focused on Metacognitive Reflection and Insight Therapy (MERIT). MERIT is an established, evidence-supported treatment that was developed in the early to mid-2000s, with supporting evidence from randomized controlled trials (de Jong et al., 2020; Vohs et al., 2018). MERIT is an integrative psychotherapy that includes eight elements present in each session that focus on the promotion of intersubjectivity, patient agency, and self-reflection through discussing the patient’s life stories (Lysaker & Klion, 2017). MERIT is often offered alongside prescribed antipsychotic medication in published studies (e.g., de Jong et al., 2020; Hasson-Ohayon et al., 2024; Igra et al., 2022; Nikzad et al., 2025) but has been used clinically with patients who are unmedicated and research suggests MERIT may have unique elements that support people who choose not to take medication (e.g., Buck & Lysaker, 2021). MERIT focuses on eliciting narratives from the patient’s life and uses metacognitive interventions to increase patients’ capacity to integrate information towards an improved understanding of themselves and others. Given this explicit focus on narrative integration, MERIT was included here.
Within the timeframe of our search, there has been one MERIT randomized controlled trial (Hasson-Ohayon et al., 2024) that demonstrated improvements in metacognition and symptoms in individuals with schizophrenia spectrum disorders. Other recent studies evaluated mechanisms of change. For example, Nikzad et al. (2025) analyzed linguistic markers of change in life narratives told by patients and found more active and central first-person plural pronoun usage (e.g., we), temporal shift from past-focus towards present- and future-focus, and increased perceptual (e.g., look, heard, feeling) and cognitive process (e.g., cause, know, ought) words after a course of MERIT. The authors discussed how these results may reflect increases in patient agency as expressed in narrative accounts of one’s life and challenges and collaboration in psychotherapy. Igra et al. (2022) found that greater emotional experience, expression, and regulation as expressed through life stories were associated with better post-session subjective well-being, with emotional experience specifically associated with improvement in metacognitive mastery, or the ability effectively manage psychological problems. Related to narrative evolution, the authors discussed the possibility that experiencing emotions in a nonjudgmental intersubjective space may allow patients to improve reflection and discover new meanings.
Three qualitative studies evaluated participants’ experiences of MERIT (de Jong et al., 2020; Kukla et al., 2022; Tsuck-Ram et al., 2024). Participants discussed changes in self-experience, including improved self-awareness and self-expression, self-compassion, and understanding of thinking. Additionally, participants discussed ways they improved their ability to manage difficulties, including self-efficacy and changing their view of problems. Mechanisms of change were discussed in two studies (de Jong et al., 2020; Tsuck-Ram et al., 2024), including therapeutic alliance and therapist interventions such as collaboration, self-disclosure, and having a safe space as well as the patient’s role including engagement inside and outside sessions. One MERIT study specifically evaluated how MERIT therapists’ perspectives of therapy differ from clinicians offering standard psychiatric services that did not focus on narratives (L. Faith et al., 2023). Overall, MERIT therapists were more collaborative, connected, and active, more comfortable with uncertainty, and emphasized patient autonomy. The authors discussed how therapist comfort with uncertainty “seemed to open up a space therapists and patients could enter together to untangle uncharted territory and walk together in uncovering meaning” (L. A. Faith et al., 2023, p. 2191). Similarly, the authors discussed the therapist’s role as collaborative and “thinking together” about the person’s life to uncover ways towards growth. These findings emphasize the active and symbiotic roles of therapist and patient found in patient interview studies.
MERIT has been found feasible and acceptable in several adaptations that remain focused on narratives, including a group format (Schnakenberg Martin et al., 2024), an inpatient setting (Cohen-Chazani et al., 2021), and virtual delivery (L. A. Faith et al., 2023). Group-based MERIT (MERITg) utilizes a writing prompt to elicit narratives of a particular memory (Schnakenberg Martin et al., 2024) and has been found to improve self-reported recovery-oriented beliefs in an outpatient setting (Musket et al., 2024). MERIT adapted for an inpatient setting was found to be feasible (Cohen-Chazani et al., 2021) and results showed improved metacognition and symptoms (Cohen-Chazani et al., 2024). MERIT adapted for the inpatient setting may pay special attention to narratives related to their inpatient stay, for example, related to the crisis that led up to hospitalization, how the setting itself impacts agency, or utilizing the entire ward as a therapeutic space to elicit narratives. Another adaptation, where MERIT was delivered virtually, was discussed with two case examples (L. A. Faith et al., 2023). The authors discussed how the virtual environment positively affected emerging narratives, for example, by using visual cues of the patient or therapist video background or with telephone sessions as less threatening and possibly increasing the number of life stories via a safer environment. Another study utilized an Electronically Activated Recorder (EAR) to audio record real-world social interactions to be used as concrete examples to elicit narratives during MERIT sessions (Minor et al., 2022). Participants using the EAR compared with standard MERIT showed reductions in disorganized symptoms and the belief that their thoughts are uncontrollable. Overall, recent MERIT studies have continued to show efficacy for positive outcomes for people with psychosis, with new adaptations and considerations for personalizing focus of narratives for each patient.

3.2.2. Trauma-Based Therapy

In addition to literature focused on MERIT, we reviewed more limited research on narrative-oriented trauma therapy. People with psychosis have high rates of trauma and/or PTSD diagnoses (Inyang et al., 2022; Lommen & Restifo, 2009; Spence et al., 2006) but historically have been amongst the most commonly excluded from trauma treatment (Ronconi et al., 2014). Thus, treatment research investigating trauma-focused treatment for people with psychosis has been extremely limited. However, a recent review highlights that emerging research has grown and results are promising (Jankowski et al., 2025). There are a range of trauma-focused treatments that are in early stages of being used with people with psychosis. For the purpose of this review, we selected studies from interventions that focused most on narratives.
Trauma-focused cognitive-behavioral therapy for people with psychosis (TF-CBTp) is a newer approach with recent promising findings. Hardy et al. (2022) examined TF-CBTp with people with psychosis who reported being affected by a traumatic event using a mixed methods approach. The authors did not report whether or not participants were prescribed psychiatric medication. The therapy integrated elements from trauma-focused CBT and CBT for psychosis. Treatment was delivered flexibly, and collaboration, trust, and control were emphasized. In this approach, life stories are used in “memory work” and involved CBT techniques (e.g., cognitive restructuring and emotion regulation strategies) as well as analyzing the meaning of memories (e.g., the interaction of memories on symptoms, emotions, or avoidance). The therapy also focused on addressing problems by using strategies, insight, and other techniques learned during therapy. Overall, results showed that participants improved their PTSD symptoms. Participants discussed therapy being challenging yet helpful and emphasized the therapeutic relationship. Similarly to emotion-based findings in MERIT, participants described the ability to express themselves and explore emotions over the course of therapy. For example, processing and making sense of traumatic experiences was a way to reclaim their narrative. Relatedly, participants discussed feeling hopeful and being able to move forward in their life and their identity beyond trauma, indicating that changes in narrative identity may have occurred. A more recent randomized controlled trial investigated TF-CBTp with a large sample of people with psychosis (Peters et al., 2026). The majority of participants were taking prescribed antipsychotic medications. Authors reported improvement in PTSD symptoms and several secondary outcome measures, including positive symptoms, depression, anxiety, stress, suicidal ideation, and psychological recovery. The authors emphasized that TF-CBTp is highly acceptable and effective for people with psychosis and concluded that this population should no longer be excluded from trauma treatments.
In addition, Narrative Exposure Therapy (NET) is an established, evidence-based and trauma-focused intervention based on cognitive-behavioral therapy and testimony therapy that has been used most often with people with PTSD (Hensel-Dittmann et al., 2011; Neuner et al., 2004) and, more recently, with mixed samples of people with PTSD and serious mental illness (Mayer et al., 2023; Mauritz et al., 2021). NET has recently been expanded for use with people with psychosis. NET is a trauma-focused intervention in which individuals construct a chronological narrative of their life experiences, including both traumatic and positive events, with the support of a therapist. Through repeatedly revisiting and organizing traumatic memories within the broader context of one’s life story, NET aims to promote coherent autobiographical meaning making and reduce trauma-related distress. A recent study assessed the feasibility of using NET with people with early psychosis who reported a history of multiple traumas utilizing qualitative interviews (Sparrow & Fornells-Ambrojo, 2024). The authors did not report whether or not participants were prescribed psychiatric medication. Results suggested that NET helped individuals with psychosis to organize memories, create new meaning, and reconnect with emotions. A larger randomized controlled feasibility study for people with early psychosis will be forthcoming (Fornells-Ambrojo et al., 2026). Although the initial results of narrative-oriented, trauma-focused therapy for use with individuals with psychosis are promising, research is limited and would benefit from expansion.

3.2.3. Treatment Focused on Self-Stigma and Illness Identity

Other types of psychotherapies that emphasize life stories reviewed during our search focused on expanding self-concept beyond illness identity. Illness identity refers to how individuals understand and integrate experiences of mental illness into their broader sense of self and life story. Narrative-oriented approaches emphasize that recovery involves developing a coherent and personally meaningful account of illness while navigating the effects of self-stigma, identity, agency, and hope. Narrative Enhancement and Cognitive Therapy (NECT; Roe et al., 2014) is a group-based psychosocial intervention designed to help individuals with psychosis reduce self-stigma through psychoeducation, cognitive restructuring, and narrative enhancement. It has a growing evidence base with pilot randomized trials completed with people with schizophrenia, schizoaffective, bipolar disorders, and major depression (Hansson et al., 2017; Yanos et al., 2012). Within NECT, narrative enhancement occurs through both written and verbal descriptions of life stories. Prompts are provided which encourage individuals to think about their lives, including challenges they may have faced and overcome, experiences of strength and coping, and hopes for the future. Although NECT has been developed for over 10 years, it continues to expand. One study adapted NECT for late-onset psychosis (age 40 and over) in a small sample of five participants (Ching et al., 2020). The authors did not report whether or not participants were prescribed antipsychotic medications. The authors discussed the therapeutic benefit of reminiscing in older populations, for example, by resolving conflicts, changing personality, and meaning making, and how NECT has overlap with reminiscent therapy. The authors discussed adaptations to NECT narratives for late-onset psychosis, including topics that may be more relevant for older population, for example, employment, social activity, or retirement, depending on the group members. Results suggested promising acceptability, yet it was inconclusive with the small sample. A larger randomized controlled trial tested the effectiveness of NECT with people with chronic schizophrenia inpatient in Taiwan (Huang et al., 2023). The majority of participants were taking antipsychotic medications. The authors discussed how stigma may affect people differently who are residing in psychiatric programs or are living in Asian countries, which may affect life narratives that are shared during the intervention. The authors found that the intervention was acceptable and participants in the NECT group had reductions in self-stigma. More recently, Yanos et al. (2026) adapted NECT for youth receiving first-episode psychosis treatment and provided results from three cases. Authors did not report if participants were taking medication. They found the adapted treatment to be feasible, acceptable, and beneficial. Participants reported changes in the way they viewed themselves and “life as a whole” and benefits to hearing other’s experiences.
Another intervention related to expanding one’s self-concept was recently developed and piloted, Self-Concept and Engagement in Life (SELF; Konsztowicz et al., 2021). This study included people with schizophrenia and schizoaffective disorder who were mostly outpatient, with one inpatient. Some (but not all) were prescribed antipsychotic or mood stabilizer medication, and some were engaged in concomitant psychotherapy. SELF is a brief intervention that targets illness engulfment, or is used when one’s self-concept is defined entirely by illness, with four modules: (1) recovery and discussion about engulfment; (2) identity development and exploration of self-awareness; (3) personal narrative and the impact of mental health on identity; and (4) fostering a healthy self-concept and self-esteem. The intervention utilizes CBT, positive psychology, and narrative therapy. Sessions may involve completing a mood rating, identifying a strength that has helped through a psychological problem, generating a list of words to describe oneself, or bringing in a photo of a meaningful life memory. Results from a pilot study showed that participants reduced engulfment and self-stigma and improved recovery style and self-esteem. Participants reported the intervention helped them remember parts of themselves outside of their mental illness and improve their self-awareness, for example, how negative self-talk affects self-esteem. Both of these approaches seem to have important impacts on expanding narrative identity beyond illness identity, including changes in recovery outcomes, self-concept, and how one understands the broader community or world.

3.2.4. Art and Creative Therapy

In addition to therapeutic approaches discussed above, art and other creative therapies may have relevance to narrative identity and allow alternative ways of understanding self in the context of one’s life. We included studies in this category that explicitly discussed how interventions were related to life stories or narrative identity, as these were particularly relevant to the study aims. Iswari and Hasanat (2023) examined a narrative art therapy that included activities related to self-exploration, examining life experiences, and re-authoring stories. The study included two participants who had a history of schizophrenia and schizoaffective disorders. The authors referenced psychiatric medication within case descriptions but details on the type of medication were not provided. The intervention resulted in increased hope and improved understanding of oneself, self-management, and self-efficacy. Participants specifically reported improved relationships, increased participation in the community, and improved understanding of psychological problems, which may indicate increased themes of communion and agency. The authors discussed the mechanism of re-appraising narratives to highlight strengths as a way to improve hope. Study results also support the idea that art can be helpful in creating a complex and integrated life story, even among participants focused on negative views of oneself (Prasko et al., 2010). Mitchell and Meehan (2022) qualitatively explored art therapy with people with schizophrenia during an inpatient psychiatric hospitalization. The authors did not report whether or not participants were taking psychiatric medication. The groups were studio-based art groups facilitated by an artist/lecturer and clinical psychologist/lecturer. The authors described their approach as focused on the person as an artist rather than a patient, and that the experience of art-making is intrinsically healing by itself. As such, the approach included very little verbal therapy during art-making, as described by the authors, but did emphasize the narrative component of re-storying the self in their analysis. The interviews consisted of a few open-ended questions encouraging participants to describe their art-making experience. The authors completed qualitative analysis through the lens of the dialogical self, including how the artists view themselves, their sense of agency, and identity, for example, through narratives and their place in the world. Participants described “pre-reflective” ways of experiencing oneself and being in the world, for example, using art as an immersive activity that can reduce distress via movements and sensory experiences. An implicit sense of time was related to each person’s spontaneous movements and gestures were conducted with different pace and tempo, which created a unique rhythm for each individual. An explicit sense of time was related to participants’ life stories which were interwoven into their artwork. The authors discussed how art can facilitate a coherent life narrative and sense of self and may uniquely help individuals visualize stories across their life by seeing their artwork, which was related to different timepoints in their life, side-by-side. The authors also discussed artwork as a tool for therapeutic scaffold, for example, discussing flexible responses to different life challenges or considering alternative self-positions. Lastly, the authors discussed spatiality as it relates to the experience of unreality or fragmentation in the world. Participants discussed art as a way of feeling “at home” in a place that was not typically homely and incorporating images from home or home-like spaces to expand spatial boundaries, thereby changing the narrative via changing the environment. The authors discussed how this transcendent experience of a familiar place has potential for a sense of transformation that can contribute to a more integrated and complex sense of self. Lastly, participants discussed art as a work-like space that brought meaning and connection with others.
Other creative therapeutic activities may promote exploration of self and narrative identity. Pearson et al. (2024) interviewed participants with self-reported psychosis who engaged in poetry therapeutically or informally in their life. The authors did not report formal diagnoses or current treatment (e.g., psychiatric medication). The authors aimed to further understand the therapeutic potential of poetry for meaning making and recovery. Therefore, this study was selected for its relevance to the study aims, with poetry as a means for self-expression and eliciting narratives. Participants discussed how poetry enabled them to self-reflect and express themselves in new, creative ways. The authors discussed the idea of “Carnivalesque communication,” or speech outside social norms or that defies traditional linguistic rules, challenging coherence. Poetry was a way for participants to play with ideas, reconcile fantasy and reality, and re-narrate their stories that facilitated the process of meaning making. Participants also described ways in which poetry fit into their recovery, for example, as an artifact of times of crisis or growth, or as a way to reclaim their identity as a poet. Overall, these studies suggest that art therapy can facilitate a more complex and integrated sense of self through creative activities promoting narrative identity, interaction with others, immersive activities, and self-efficacy.

4. Discussion

The current study evaluated the literature from 2020 to 2026 related to narrative-based psychotherapy for people with psychosis and related diagnoses. We summarized several studies related to the study aims, including quantitative and qualitative papers focusing on narratives and narrative identity, as well as therapeutic approaches that emphasized narratives. Approaches included individual and group psychotherapy (e.g., MERIT) and other therapeutic approaches that emphasized life stories (e.g., art therapy). Treatments included metacognitive therapy, trauma-based psychotherapy, treatment focused on self-stigma or illness identity, and art and creative therapies.
For our first aim, we summarized findings from theoretical, quantitative, and qualitative studies that were relevant to narrative psychotherapy. Findings were in line with the fragmentation model of psychosis which posits that fragmentation is a core difficulty for people with psychosis (Hamm et al., 2017). In addition to life stories lacking coherence or structure, narratives can be stuck or focused on illness. Qualitative studies provided insight on how life stories are impacted by the experience of psychosis, but also how patients make their way out of psychosis. As described by patients, this seemed to involve a personal process of the making-meaning of their psychotic experiences, either by integrating this experience into their identity, making sense of the events that led up to it, or accepting that no sense can be made from it. Taken together, these findings highlight the diverse experiences people have with their experience of psychosis and how it affects their life story. In other words, psychosis impacts life narratives in diverse ways and, as related to therapeutic interventions, must be addressed in a personalized manner.
Regarding the second aim, we identified diverse therapeutic methods that utilized narrative elements. While all approaches included narrative elements, life stories were utilized towards differing goals. For instance, narratives in MERIT promote metacognitive growth towards a more integrated sense of self. Narratives in trauma-focused work often aim to help patients understand, process, and integrate their trauma memories. However, NET allows space for patients to discuss both trauma and positive memories to promote a more balanced narrative identity. This is similar to interventions that aim to reduce self-stigma (e.g., NECT) by widening identity beyond illness. Lastly, some types of art therapy that promote narrative reflection, as reviewed here, allowed patients to practice another part of their identity through art-making (i.e., their artist identity). Given that narrative approaches appeared in a range of diverse methods, it is suggested that narrative evolution can be facilitated in various ways. For example, a psychotherapist may offer talk therapy which emphasizes the joint discussion of life stories. MERIT, a narrative-focused integrative psychotherapy, is one example of a therapy that utilizes life stories directly and explicitly. Importantly, in traditional psychotherapy approaches, narratives may be explored through written or verbal accounts and in individual or group settings. In fact, numerous therapies reviewed here (e.g., MERITg, NECT) are group-based therapies, suggesting that narrative work can be successfully completed in group settings. Some studies discussed adaptations that may assist people in identifying narratives, for example, utilizing the surrounding environment in telehealth or even an Electronically Activated Recorder as an accessible way to identify narratives and possibly improve the joint patient-therapist understanding of life narratives. Narrative psychotherapies reviewed here also differed in level of structure or manualization. For example, studies ranged in number of sessions, from around two sessions to fifty-two. However, many emphasized the greater number of sessions which is in line with the National Institute for Health and Care Excellence (NICE) guidelines for psychosis treatment (Kuipers et al., 2014). Although some level of flexibility is likely important for these treatments, research suggests that manualized or structure treatments can support narrative recovery. As explored here, art therapy is an alternative way to elicit narratives (i.e., distinct from psychotherapy) through the exploration of life stories with visual arts, suggesting that verbal, written, or visual accounts of narratives can improve outcomes. Overall, these results suggest that a range of methods can be used to elicit narratives and to personalize therapy for people to direct their own treatment according to their needs and preferences.
Several studies discussed sense of self as an outcome in psychotherapy, which may be connected to narrative identity. For many, narrative approaches seemed to provide an opportunity for people to explore parts of themselves that had been lost, forgotten, or not integrated. In MERIT, self-reflectivity is one of the four domains of metacognition, which measures the ability to integrate information about oneself in complex ways. MERIT involves the discussion and integration of life stories, which is largely directed by the patient. Other therapies focused on helping patients identify and integrate more varied parts of themselves. As discussed above, this might mean integrating trauma memories or working with an overidentification with illness identity. Self-stigma therapies addressed the changes in identity that often occur when stigma becomes internalized, including thoughts that one is dangerous, incompetent, or cannot be trusted. Art therapy, in contrast, allowed patients to participate in creative outlets to expose themselves to, and potentially develop, the “artist” part of themselves. While talk therapy asks patients to use written or spoken words to describe experiences and attempt to make sense of them, art does not typically require verbal language, or as in poetry, using language outside of traditional linguistic rules. Art can reduce distress by allowing expression via visual representations or immersive activities that allow movements and sensory experiences. In addition, art can be a way for people to experience themselves outside of language or pre-reflective states. For example, Mitchell and Meehan (2022) discussed how an implicit sense of time is essential to the minimal sense of self, such as fundamental sensory experiences, which can be disrupted for people with schizophrenia. This may be especially helpful for people who are in a state of fragmentation that interferes with verbal communication, or are specifically experiencing alexithymia, poverty of speech, or other expressive deficits. Although art therapy is not traditionally categorized as a narrative therapy, it may be a helpful approach to elicit narratives in alternative ways when clinically appropriate (e.g., alternatives to verbal language or direct discussion of psychological problems). Overall, results suggested that narrative approaches promoted sense of self and narrative identity in a flexible manner that supported individualization and self-directed recovery.
Several approaches were integrative and included the use of life stories alongside other methods. It is likely that other methods interact to promote narrative evolution, for example, specific therapist interventions. A systematic review by Mellado et al. (2024) discussed psychotherapy methods that transform life stories through dialogue or intersubjectivity. The authors highlighted therapeutic methods that were in line with the current study results such as a trusting therapeutic environment, emotional reflection, and shared emotional experiences. In the current study, the concept of having a safe space to express oneself was important across modalities. Intersubjectivity is an important concept in MERIT, which is seen as a facilitator for metacognitive growth (Hamm et al., 2022; Hasson-Ohayon et al., 2017, 2020). In addition, research focused on both MERIT and trauma-based approaches (i.e., TF-CBTp and NET) found that emotion expression positively impacted changes in narrative identity through reconnecting and exploring emotions within life stories. Taken together, these results suggest that a strong therapeutic relationship and focus on emotion may be important aspects of psychotherapy that emphasize life stories which may then result in greater changes in personal narratives and narrative identity.
It was notable that different interventions reported a range of positive outcomes. As we reviewed a wide range of treatments, outcomes were specific to the method or specific treatment. For example, because MERIT is a metacognitively oriented therapy, metacognition was often the primary outcome. Trauma-focused approaches are focused on traumatic events and thereby reduce trauma or PTSD symptoms. Despite this, our results highlighted several outcomes that may be common across narrative-oriented approaches. Several studies mentioned personal recovery, or the concept of recovery defined by the individual person. This makes sense given that narrative therapy is a personalized approach focused on each person’s unique story. However, this may also mean that it can be difficult to measure outcome or change for each person if their definition of personal recovery is different. Qualitative studies with open-ended questions may be especially beneficial to explore how interventions help people beyond pre-determined outcome measurement. Several studies also mentioned agency, autonomy, or self-efficacy as an outcome and/or mechanism of change. As mentioned above, people with psychosis tend to have fragmented or “stuck” life stories, which can impede goal-directed activity because they are unsure about their purposes, possibilities, and place in the world. If a person engages in narrative-focused psychotherapy, they may begin to integrate life stories and form a more nuanced understanding of themselves and their place in the world. This may result in them having a better idea of who they are and what they want for themselves, potentially leading them to make personalized decisions that are beneficial and fulfilling for them. It was notable that studies did not specifically use a measure of narrative change to assess narrative evolution or changes in narrative identity. Future research may identify or further develop measures that assess aspects of narrative change that appear to be relevant across approaches, such as agency and self-experience.
Results are in line with a recent systematic review that focused on studies analyzing correlates and mediators of post-traumatic growth (Ng et al., 2021), which has implications for narrative identity and narrative psychotherapy. Post-traumatic growth refers to positive changes that may emerge following challenging or traumatic experiences. As discussed above, the experience of psychosis can be traumatic and potentially impactful on narrative identity. From a narrative perspective, this growth occurs through revising and reconstructing one’s life story in ways that foster meaning, agency, self-understanding, and possibilities for the future. For example, one scoping review found that post-traumatic growth after a first episode of psychosis often included themes related to making positive lifestyle changes, developing positive character traits, forming connections with others, and integrating the experience of psychosis into one’s sense of self (Jordan et al., 2017). Of note, authors found that meaning in life, coping self-efficacy, personal identity and strength, receiving support, opportunities and possibilities, perspective shift, and relationships are related to post-traumatic growth. Future research investigating narrative psychotherapy may specifically evaluate post-traumatic growth, which may be relevant to outcomes.
Our study additionally raises questions for factors that may interfere with narrative evolution or disrupt narrative identity. Two qualitative studies mentioned factors in psychiatric care that can disrupt recovery or narrative identity (Lawrence et al., 2021; Van Sambeek et al., 2023). A major factor was treatments overly focusing on illness identity/engulfment or symptoms. As mentioned above, fragmentation is a core problem for people with psychosis, and therapists must not reinforce it by focusing on only one part of a person’s identity (Hamm et al., 2017). Treatment approaches may integrate opportunities for meaning making (e.g., making sense of symptoms in the context of one’s life) to address this issue. In addition, stigma can interfere with recovery and therapeutic dialogue with either therapist or patient limiting their expectations of the patient and impeding the opportunity to explore diverse life stories (e.g., outside of their patient role). It is also possible that symptoms or cognitive processes interfere with the ability to jointly discuss narratives with a therapist. For example, a patient that is focused on an entrenched delusion may be unable or unwilling to discuss life stories outside the delusion (e.g., childhood memories). Alternatively, painful emotions such as fear or shame may make it challenging for a person to think clearly and may lead to the fragmentation of narratives and disorganization. The integrated model of metacognition proposes that people with psychosis tend to have low levels of metacognition which may further interfere with narrative identity (Lysaker et al., 2022). Therefore, utilizing metacognitive interventions may be especially helpful in facilitating self-reflectivity and narrative evolution even when the patient can only offer fragmented narratives or has disorganized speech (Lysaker & Klion, 2017). This also raises the question of whether there is a sequence that may be useful in therapy before focusing on life stories, in order to make the discussion of narratives more fruitful. Given that the therapeutic relationship is consistently reported by patients as paramount in therapy (L. A. Faith et al., 2024), it seems important to first establish rapport with a patient. As trust is being established, the therapist may simultaneously evaluate any factors that are affecting the discussion of life stories so they can be addressed (e.g., traumatic memories, emotional dysregulation, etc.).
The current study has limitations worth mentioning. We chose a narrative review to highlight an underdeveloped research area and contribute to theoretical and clinical developments. We hope this review can provide a critical review using our areas of expertise. However, this review was not comprehensive. A future systematic review may be warranted once the literature expands. Many of the studies included were small pilot or feasibility studies. Future research would benefit from randomized trials, larger studies, and a greater number of qualitative analyses to examine subjective recovery factors. Studies most often reported treatments offered alongside psychiatric medication. Recent studies are beginning to explore the effectiveness of psychosocial interventions without medication (Bighelli et al., 2024). More research is needed to identify how narrative approaches may be used with patients who are unmedicated. In addition, our review was limited by the search terms we used. It is likely that there are therapy approaches that may include narratives but do not necessarily make that an explicit focus of their approach or protocol. For example, psychodynamic therapy may include the discussion of life stories but do not explicitly describe this as part of the approach. In addition, recent research that appeared in our search is imbalanced by the type of approach. Specifically, the majority of studies included were focused on MERIT, while other approaches had more limited research. This overrepresentation likely reflects MERIT’s unique alignment with the present search strategy, as it was developed specifically for psychosis and directly targets the integration of fragmented experiences into coherent personal narratives as a mechanism of recovery.
In conclusion, this study summarized the current literature related to a range of narrative-based psychotherapy approaches for people with psychosis. Narrative approaches for this population is a growing area of research, and results reinforce its use to support self-directed recovery. Across therapeutic methods, narrative approaches contributed to sense of self, meaning making, and the expansion of a more varied narrative identity (e.g., a more complex and integrated identity). Some approaches were established, with expansion into new adaptations and populations (e.g., MERIT and NECT), while others were newer interventions. Specifically, trauma-focused narrative interventions are particularly promising, with early research supporting feasibility and efficacy. Unexpectedly, art therapy appeared to be a useful method to evoke life stories, oftentimes without using verbal language. The range of techniques found supports the idea that narrative approaches may be integrated with a range of methods and theoretical orientations, depending on the patient’s needs and goals. The therapeutic relationship and therapist interventions, not surprisingly, were reported as mechanisms of change in several studies. In addition, patient agency and changes in emotional experience was both a mechanism and outcome. These findings support the idea that meaning making and self-directed recovery are important elements of therapy that contribute to recovery from psychosis (e.g., L. A. Faith & Wiesepape, 2026). There were several studies that support the feasibility and acceptability of narrative-based approaches for people with psychosis, and continued research is needed for this promising approach. We hope these findings are helpful for therapists that may be considering narrative-focused approaches. Future research may evaluate mechanisms of change, patient perspectives, and barriers to narrative evolution.

Author Contributions

Conceptualization, L.A.F., C.N.W. and J.M.R.; methodology, L.A.F. and C.N.W.; validation, L.A.F., C.N.W. and J.M.R.; investigation, L.A.F. and C.N.W.; writing—original draft preparation, L.A.F., C.N.W. and J.M.R.; writing—review and editing, L.A.F., C.N.W. and J.M.R.; project administration, L.A.F. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
CBTCognitive-Behavioral Therapy
EARElectronically Activated Recorder
MERITMetacognitive Reflection and Insight Therapy
MERITgGroup-based MERIT
NECTNarrative Enhancement and Cognitive Therapy
NETNarrative Exposure Therapy
SELFSelf-Concept and Engagement in Life
TF-CBTpTrauma-Focused Cognitive-Behavioral Therapy for Psychosis

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