Metacognitive Training for Psychosis
Welcome to the Metacognitive Training (MCT) for psychosis. This site replaces our former main page www.uke.de/mct which will no longer be updated.
Metacognitive training for psychosis (MCT) is a novel cognitive approach for the treatment of positive symptoms in psychosis and schizophrenia, respectively. Press on your flag below for further information (e.g. theoretical background, administration) and a free version of the MCT in your language (press here for the manual). Below you will find several review articles for download.
Introduction (from the manual)
Why cognitive training for schizophrenia?
Schizophrenia is a complex psychiatric disorder. Its core symptoms are delusions and hallucinations.
The past decade has witnessed a shift in our thinking and treatment of schizophrenia. Psychopharmacological treatment with neuroleptics still represents the primary form of therapy. However, the past deep-rooted reservation against psychotherapy for schizophrenia is now being increasingly questioned. In view of the high numbers of patients who show little or no response to neuroleptics or who discontinue treatment because of side-effects and lack of insight (Byerly, Nakonezny, & Lescouflair, 2007; Elkis, 2007; Voruganti, Baker, & Awad, 2008), the research on complementary psychotherapeutic and cognitive treatment strategies is gaining increasing importance. Cognitive-behavioral treatment, in particular, has proven to be a useful complementary approach to psychopharmacology (Wykes, Steel, Everitt, & Tarrier, 2008).
What is Metacognitive Training?
The present metacognitive training program (*) is based on the theoretical foundations of the cognitive-behavioral model of schizophrenia, but employs a somewhat different therapeutic approach. The metacognitive training program is comprised of eight modules targeting common cognitive errors and problem solving biases in schizophrenia. These errors and biases may, on their own, or in combination, culminate in the establishment of false beliefs to the point of delusions (Freeman, 2007; Moritz & Woodward, 2007). The aim of these sessions is to raise the participants’ awareness of these distortions and to prompt them to critically reflect on, complement, and change their current repertoire of problem solving. Since psychosis is not a sudden and instantaneous incident, but is instead often preceded by a gradual change in the appraisal of one’s cognitions and social environment (e.g. Klosterkötter, 1992), empowering metacognitive competence may act prophylactically on psychotic breakdown.
Homework that is handed to the participants at the end of each session assists with this process. Each module starts with psychoeducational elements and “normalizing“: by means of many examples and exercises the respective domain is introduced (e.g. jumping to conclusions) and the fallibility of human cognition discussed and illustrated. 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 with case examples of people with psychosis, providing the opportunity for group participants to exchange their own experiences if they feel so inclined. 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 of replacing them with more helpful strategies.
How is Metacognitive Training administered?
Among the problematic thinking styles recognized as potential contributors to the development of delusions are attributional distortions (module 1), a jumping to conclusions bias (module 2 and 7), a bias against disconfirmatory evidence (module 3), deficits in theory of mind (module 4 and 6), over-confidence in memory errors (module 5) and depressive cognitive patterns (module 8). Despite good empirical evidence on the validity of these accounts, some of them remain subject to ongoing scientific debate (Freeman, 2007). The modules are 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 recent MCT versions we emphasize the relationship between thinking styles, delusions and psychosis. Previously we were concerned that an overly confrontational and symptom-oriented approach could overstrain participants; however, this concern has proven unfounded. Nevertheless, it is recommended that individual delusional themes be addressed in one-to-one therapeutic sessions. Metacognitive training materials can be adapted for this purpose.
What the MCT is about?
The MCT targets cognitive biases involved in the pathogenesis of psychosis. This figure should illustrate, in an amusing fashion, a core aim of the MCT: Don‘t judge a book by its cover. In other words, don‘t make strong judgments based on little information. In this example: facial expressions can hint at emotions but are not 100% reliable proof - other cues should be considered as well (clearly, this is just an example which is applicable to many other politicians or celebrities who are well-known for their restricted facial expressions, like Danny Trejo or Chuck Norris (actors)).
Figure 1. The many faces of Vladimir Putin
We wanted to avoid designing a theory-driven but dry program. With their interactive and entertaining character, the sessions aim to capture the participants’ attention and exert a sustaied impact. To meet this goal, we have also refrained from incorporating any “drill & practice” tasks. Basic cognitive dysfunctions, such as attentional problems, are not specifically targeted, because these deficits are common in a variety of psychiatric groups, and it remains unclear whether they represent specific vulnerability factors of psychosis. Since most aspects of the program are self-explanatory, the manual is kept fairly short and thus allows for individual variation in training implementation.
(*) Metacognition can be described as “thinking about one's thinking”, and involves the ability to select appropriate responses. It also encompasses the way we appraise and weigh information and how we cope with cognitive limitations.
What the MCT is about II
Figure 2. Oops… aren‘t metal bands all satanic? Don‘t be misled by clichés. Reborn Christian: Dave Mustaine from Megadeth (upper left); Catholic: Tom Araya from Slayer (upper right; led to some controversy as a former album title was titled "God hates us all"; Muslim: Sami Mustafa from Nervecell (lower left); Jewish: Evan Seinfeld from Biohazard (lower right; also has the “Star of David” on his belly). "Black Metal" is as colorful as a rainbow! Some musicians are left wing, others are right wing, some are gay (Rob Halford from Judas Priest), some are religious, some are not… Don‘t judge a book by its cover. Allow yourself to be surprised.
hmm, what about the excessive usage of pentagrams. Truly satanic? Well, then look more closely at the flags of Morocco, Ethiopia and ... Texas!
To err is human! Most of us have prejudices and cognitive biases – whether we are experiencing psychosis or not. The goal of the MCT is to help group members understand these biases – especially those that are particularly pronounced in psychosis, such as jumping to conclusions and overconfidence in errors.
Overviews on current scientific findings demonstrating the efficacy of the MCT
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, 358-366. (Download article)
Moritz, S., Veckenstedt, R., Bohn. F., Köther, U. & Woodward, T. S. (2013).Metacognitive training in schizophrenia. Theoretical rationale and administration. In D. L. Roberts & D. L. Penn (Eds.), Social cognition in schizophrenia. From evidence to treatment (pp. 358-383). New York: Oxford University Press. (Download article)
Moritz, S., Vitzthum, F., Randjbar, S., Veckenstedt, R. & Woodward, T. S. (2010). Detecting and defusing cognitive traps: metacognitive intervention in schizophrenia. Current Opinion in Psychiatry, 23, 561-569.
Moritz, S. & Woodward, T. S. (2007): Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Current Opinion in Psychiatry, 20, 619-625. (Download article)