Welcome to the webpage for metacognitive training for psychosis (MCT).
MCT is a novel cognitive approach to the treatment of positive symptoms in psychosis. Click on the appropriate language below for further information (e.g., theoretical background, administration of MCT) and a version of MCT in your language. Before downloading the manual, please participate in a brief survey. Please note that it is possible that not all translations of the manuals have been updated (the most recent version is 6.0).
If you like MCT for psychosis, don’t miss our other treatment packages (click here for more information on MCT for borderline personality disorder, depression, and obsessive-compulsive disorder). A recent meta-analysis reporting a significant overall effect of MCT for positive symptoms, delusions, and acceptance of the intervention can be found here.
Below you will find information on how MCT is used to treat psychosis, several scientific articles to download, links to the manual, how to donate to our research, and copyright information.
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 the understanding and treatment of schizophrenia. Psychopharmacological treatment with neuroleptics still represents the primary form of treatment of schizophrenia. However, past deep-rooted reservations against psychotherapy for the treatment of schizophrenia are 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 becoming increasingly important. 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 it employs a somewhat different therapeutic approach. The 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 the sessions is to raise the 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 is not a sudden and instantaneous occurrence 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 to prevent or hinder a psychotic breakdown.
Homework given to 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, each 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 by case examples of people with psychosis, and group participants are given the opportunity to share 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 to replace them with more helpful strategies.
* Metacognition can be described as “thinking about one’s own 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.
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 (modules 2 and 7), a bias against disconfirmatory evidence (module 3), deficits in theory of mind (modules 4 and 6), overconfidence in memory errors (module 5), and depressive cognitive patterns (module 8). Despite good empirical evidence of the validity of this list, the role of some of these thinking styles in the development of delusions is still subject to ongoing scientific debate (Freeman, 2007).
The modules are designed to be administered within the framework of a group intervention program. The main purpose of metacognitive training (MCT) is to change the “cognitive infrastructure” of delusional ideation. In recent versions of MCT, we emphasize the relationship between thinking styles, delusions, and psychosis. Previously, we were concerned that an overly confrontational and symptom-oriented approach would be stressful for participants; however, this concern has proven unfounded. Nevertheless, it is recommended that individual delusional themes be addressed in one-on-one therapeutic sessions. Metacognitive training materials have been adapted for this purpose (see individualized Metacogntive Therapy).
How does MCT work? (part 1)
MCT targets cognitive biases involved in the pathogenesis of psychosis. Figure 1 illustrates a core maxim of 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—other cues should be considered as well (clearly, many other politicians or celebrities who are well known for their deadpan expression, such as the actors Danny Trejo or Chuck Norris, could also have been used as examples).
Figure 1. The many faces of Vladimir Putin
We wanted to avoid designing a program that is strong on theory but not interesting to use. The interactive and entertaining sessions aim to capture the participants’ attention and have a sustained impact. To meet this goal, we have also refrained from incorporating any “drill and practice” exercises. 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 for psychosis. Since most aspects of the program are self-explanatory, the manual is fairly short, which allows for individual variation in training implementation.
How does MCT work? (part 2)
Figure 2. Don’t judge a book by its cover.
Figure 2 illustrates our tendency to be misled by stereotypes. For example, many of us assume that all heavy metal bands are satanic. In reality, heavy metal musicians are as colorful as a rainbow! Some musicians are left wing, others are right wing, some are gay (e.g., Rob Halford from Judas Priest), some are religious, some are not. . . . Hmm, what about the excessive usage of pentagrams? Truly satanic? Well, maybe not. Look more closely at the flags of Morocco, Ethiopia, and . . . Texas!
Answers to figure 2: Born-again Christian: Dave Mustaine from Megadeth; devout Catholic: Tom Araya from Slayer (this led to some controversy, as the band’s ninth album was titled God Hates Us All); Muslim: Rami Mustafa from Nervecell; Jew: Evan Seinfeld from Biohazard (in fact, he has a tattoo of the Star of David on his stomach).
To err is human! Most of us have prejudices and cognitive biases – whether we are experiencing psychosis or not. The goal of 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.
We have been developing and disseminating MCT free of charge since 2003. We provide a detailed manual, worksheets, and hundreds of slides. The training is available at no cost for students and researchers, but we respectfully ask practitioners/psychotherapists who use the training for a one-time contribution of 30€ (or $30) before downloading the material. This would greatly help defray the costs associated with the program. If MCT is conducted in an institution (e.g., a psychiatric hospital or a general hospital), we ask the institution to send us a one-time contribution of 100€ (or $100). Donate online.
All contributions are considered donations, and we would be happy to send you a receipt.
Selected scientific findings demonstrating the efficacy of 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, NY: 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)
Free use of the material available through this website is permitted with the understanding that any commercial use is prohibited. Copyright restrictions apply (e.g., no manipulation of material, no use of the slides for other purposes without the authors’ prior consent). Giving courses, presentations, and/or workshops on MCT or MCT+, as well as the distribution of certificates for such courses, presentations, and/or workshops, is not allowed without the prior written consent of Prof. Dr. Steffen Moritz. We request that researchers contact us before conducting empirical trials.