I am a professor and head of the clinical neuropsychology working group in the Department of Psychiatry and Psychotherapy at the University Medical Center in Hamburg, Germany. In 2002, our group developed a metacognitive training program (meta = Greek for above/beyond, cognition = derived from Latin for thinking; thinking about thinking). The training can be downloaded at no cost via www.uke.de/mct and is available in 33 languages (for a review see Moritz et al., 20141). For me it is very important that as researchers we serve the public and should not take money for our “inventions.”
MCT is based on the theoretical foundations of the cognitive-behavioral model of psychosis, but it employs a somewhat different therapeutic approach. The program is comprised of eight modules targeting common cognitive biases (i.e., distortions in the processing of information) in psychosis/schizophrenia. These errors and biases, on their own or in combination, may culminate in the formation of false beliefs to the point of delusions (i.e., fixed false beliefs; Garety & Freeman, 20132; Savulich, Shergill, & Yiend, 20123). The sessions aim to raise participants’ awareness of these distortions and to prompt them to critically reflect on, expand upon, and change their current repertoire of problem solving. Since psychosis does not occur instantaneously and suddenly, but is often preceded by a gradual change in the appraisal of one’s cognitions and social environment (e.g., Klosterkötter, 19924), empowering metacognitive competence may act prophylactically to prevent or hinder a psychotic breakdown.
Each module starts with psychoeducational elements and “normalizing” of symptoms. Through presentation of many examples and exercises, each respective MCT topic is introduced (e.g., jumping to conclusions) and the fallibility of human cognition in general is discussed and illustrated. With regard to “normalizing,” we stress that cognitive biases and errors are normal to some degree. To illustrate, according to a study, many Americans believe that they saw Bugs Bunny while visiting Disney Land. This is extremely unlikely, however, as it is a Warner Brothers character and anyone with such a costume would likely be asked to leave by guards within minutes.
In a second step, the pathological extremes for each cognitive bias are highlighted. The participants are introduced to how exaggerations of (normal) thinking biases lead to problems in daily life and sometimes may culminate in delusions. This is illustrated by case examples of people with psychosis, and group participants are given the opportunity to share their own experiences if they feel so inclined. In this way, patients learn to detect and defuse cognitive traps. Dysfunctional coping strategies (e.g., avoidance, thought suppression) are also highlighted in this context, along with ways to replace them with more helpful strategies. In short, the training aims to provide a psychological understanding of psychosis in contrast to the still commonly held view that psychosis is a severe brain disorder, which is not amenable to psychological understanding. While we do not dispute that some patients may have brain deficits, we think that these impairments are often exaggerated5.
Among the problematic thinking styles recognized as potential contributors to the development of delusions are attributional distortions (especially one-sided attributions; module 1), a jumping to conclusions bias (modules 2 and 7), a bias against disconfirmatory evidence (module 3), problems in theory of mind (modules 4 and 6), overconfidence in memory errors (module 5), and depressive cognitive patterns (module 8).
In the last year, we added two modules on self-esteem and dealing with stigma, as a number of studies found that these are the symptoms patients suffer from the most6. Given that patients may experience shame regarding their diagnosis, among many other exercises, we discuss which individuals (e.g. family members, doctors) patients could talk with about the disorder (and which may be less recommended). The labels schizophrenia/psychosis evoke false associations in many people. We therefore provide examples of how to convey information about the disorder in a way that is understandable to people without psychosis. Again, we emphasize that the feelings and ideas of schizophrenia patients are sometimes viewed as extreme, but are often psychologically accessible and understandable. The disorder is neither trivialized nor demonized.
The modules are designed to be administered within the framework of a group intervention program. The main purpose of metacognitive training is to change the “cognitive infrastructure” of delusional ideation. In addition to the module slides, homework is given to participants at the end of each session to encourage engagement in MCT materials outside of sessions. We have now also developed an individualized treatment called MCT+, which can also be downloaded at no cost via www.uke.de/mct_plus.
With regard to research support, in the last two years, two meta-analyses about MCT have been published that show that metacognitive training decreases symptoms and delusions significantly relative to control interventions (Eichner & Berna, 20167; Liu, Tang, Hung, Tsai, & Lin, 20178). As a result, the intervention will be recommended as an evidence-based treatment in the next version of the treatment guidelines for schizophrenia in Germany. The program is not commercially funded by any pharmaceutical company or other enterprise. Rather, we depend fully on federal grants and donations for the development and dissemination of MCT materials. The concept has been adapted for other disorders, including geriatric depression (by the second author), borderline personality disorder, obsessive-compulsive disorder and bipolar disorder. Most of these versions are available at no cost in many languages here.
In the course of time, MCT has been shaped by discussion with clinicians, but feedback from patients and their relatives have also had a large influence on MCT. We would be very interested in your feedback — positive and negative feedback alike is appreciated!
- Moritz, S., Andreou, C., Schneider, B. C., Wittekind, C. E., Menon, M., Balzan, R. P., & Woodward, T. S. (2014). Sowing the seeds of doubt: A narrative review on metacognitive training in schizophrenia. Clinical Psychology Review, 34(4). http://doi.org/10.1016/j.cpr.2014.04.004 ↩
- Garety, P. A., & Freeman, D. (2013). The past and future of delusions research: From the inexplicable to the treatable. British Journal of Psychiatry, 203(5), 327–333. http://doi.org/10.1192/bjp.bp.113.126953 ↩
- Savulich, G., Shergill, S., & Yiend, J. (2012). Biased cognition in psychosis. Journal of Experimental Psychopathology, 3(4), 514–536. http://doi.org/10.5127/jep.016711 ↩
- Klosterkötter, J. (1992). The meaning of basic symptoms for the genesis of the schizophrenic nuclear syndrome. Japanese Journal of Psychiatry and Neurology, 46(3), 609–630. http://doi.org/10.1111/j.1440-1819.1992.tb00535.x ↩
- Moritz, S., Klein, J. P., Desler, T., Lill, H., Gallinat, J., & Schneider, B. C. (2017). Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills? Psychological Medicine, 47(15), 2602–2612. http://doi.org/10.1017/S0033291717000939 ↩
- Moritz, S., Berna, F., Jaeger, S., Westermann, S., & Nagel, M. (2016). The customer is always right? Subjective target symptoms and treatment preferences in patients with psychosis. European Archives of Psychiatry and Clinical Neuroscience, pp. 1–5. http://doi.org/10.1007/s00406-016-0694-5 ↩
- Eichner, C., & Berna, F. (2016). Acceptance and efficacy of metacognitive training (mct) on positive symptoms and delusions in patients with schizophrenia: A meta-analysis taking into account important moderators. Schizophrenia Bulletin, 42(4), 952–962. http://doi.org/10.1093/schbul/sbv225 ↩
- Liu, Y.-C., Tang, C.-C., Hung, T.-T., Tsai, P.-C., & Lin, M.-F. (2017). The efficacy of metacognitive training for delusions in patients with schizophrenia: a meta-analysis of randomized controlled trials informs evidence-based practice. Worldviews on Evidence-Based Nursing. ↩