Metacognitive Training (MCT; Moritz et al., 2014) is a group intervention that was first released for individuals with psychosis in 2002 (www.uke.de/mct; now available in 37 languages). The intervention has since been adapted for other disorders, including depression (www.uke.de/depression; available in 13 languages), depression in later life (https://clinical-neuropsychology.de/metacognitive-training-for-depression-mct-silver/; available in English and German), bipolar disorder (https://clinical-neuropsychology.de/metakognitives-training-bei-bipolaren-stoerungen/; available in German only), borderline personality disorder (www.uke.de/borderline; available in 8 languages), and pathological gambling (https://clinical-neuropsychology.de/metakognitives-training-bei-problematischem-gluecksspielverhalten/; available in German only). For obsessive-compulsive disorder, there is both a self-help manual (www.uke.de/mymct; available in 7 languages) and a group program (available in German only). Our most recent program is the MCT-acute for patients on acute wards with severe mental illness (https://clinical-neuropsychology.de/metakognitives-training-fuer-das-akutpsychiatrische-setting/; available in English and German).
A common denominator of all MCT programs is a focus on cognitive biases—distortions in the perception, processing, and recollection of information. MCT aims to raise awareness of these distortions by means of playful exercises that convey “aha” experiences to patients. In terms of Flavell’s four-level concept of metacognition, MCT acts at the level of metacognitive knowledge and metacognitive experiences. As with other metacognitive interventions, the goal is that patients learn to take a critical distance from their dysfunctional thoughts and convictions. MCT for psychosis, the most widely used form of MCT, particularly targets the reduction of overconfidence and encourages the gathering of additional information before making important decisions. The promotion of self-esteem is another aim of the MCT as depressive mood not only is a common sequela of being diagnosed with the disorder and the hardship the disorder often inflicts but may also represent a risk/vulnerability factor for the formation of mental illnesses such as psychosis/schizophrenia.
MCT for psychosis can be delivered in a group setting and also in an individual setting (MCT+; www.uke.de/mct_plus). Most of the MCT treatment packages are comprised of 8 to 10 modules.
The manuals and the training material (PowerPoint slides) can be downloaded free of charge via the links above. The training was recently augmented by a smartphone app (for android and iOS) in order to ensure treatment benefits will persist long-term (www.uke.de/mct_app).
Efficacy
There are numerous studies on the feasibility and efficacy of the MCT approach, and MCT for psychosis is included in the official treatment guidelines for schizophrenia/psychosis in Germany (DGPPN, 2019; Lincoln, Pedersen, Hahlweg, Wiedl, & Frantz, 2019) as well as in Australia and New Zealand (Galletly et al., 2016) due to meta-analyses demonstrating its effectiveness (Eichner & Berna, 2016; Liu, Tang, Hung, Tsai, & Lin, 2018; Philipp et al., 2018; Sauvé, Lavigne, Pochiet, Brodeur, & Lepage, 2020). For other versions of MCT randomized controlled studies exist as well (Gehlenborg, Bücker, Berthold, Miegel, & Moritz, 2020; Haffner et al., 2018; Jelinek et al., 2016; S. Moritz, Bernardini, & Lion, 2019; Moritz et al., 2016; Schilling, Moritz, Kriston, Krieger, & Nagel, 2017).
TREATMENT
Like MIT, MCT uses a careful, manualized procedure to foster treatment change. Although the different MCT programs focus on cognitive biases, affective problems are also targeted. Over the years, techniques borrowed from other therapeutic interventions have been incorporated into MCT programs, including acceptance and commitment therapy, cognitive behavioral therapy, and mindfulness-based interventions.
The main goals of all MCT interventions are
- enhanced metacognitive awareness of cognitive biases (e.g., inflated responsibility in obsessive-compulsive disorder; jumping to conclusions in psychosis; mood-congruency effect in depression);
- improvement of affective problems such as low self-esteem;
- normalization by emphasizing the range of cognitive biases from healthy to pathological, stressing the dysfunctionality of exaggerated forms in order to decrease (self)-stigma by improving patients’ and trainers’ understanding of psychopathological states; and
- disputation of dysfunctional self-images and promotion of healthy coping styles.
Treatment can be conducted by psychologists (preferred), psychiatrists, psychiatric nurses, or occupational therapists once they have studied the manual or participated in an online training course (www.uke.de/e-mct). No formal curriculum is required. Training is conducted via PowerPoint slides that the trainers may edit to meet their needs (open source: https://clinical-neuropsychology.de/mct-os/). The group format is open; patients can join the group at any time to ensure feasibility in the long run. The internalization of learning goals is aided by means of homework and smartphone exercises.
CERTIFICATION
We offer external or internal workshops (see https://clinical-neuropsychology.de/workshop) for all our MCT programs as well as a certified and accredited e-learning course that is provided online in German and English for MCT for psychosis (www.uke.de/e-mct). The online course contains many videos of simulated treatment situations.
GENERAL REFERENCES
[see also MCT websites]
- Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e. V. (DGPPN). (2019). S3-Leitlinie Schizophrenie (S3-guideline schizophrenia). Berlin, Germany: DGPPN.
- 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. https://doi.org/10.1093/schbul/sbv225
- Galletly, C., Castle, D., Dark, F., Humberstone, V., Jablensky, A., Killackey, E., … Tran, N. (2016). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. The Australian and New Zealand Journal of Psychiatry, 50(5), 410–472. https://doi.org/10.1177/0004867416641195
- Gehlenborg, J., Bücker, L., Berthold, M., Miegel, F., & Moritz, S. (2020). Feasibility, acceptance, and safety of Metacognitive Training for problem and pathological gamblers (Gambling-MCT): A pilot study. Journal of Gambling Studies. https://doi.org/10.1007/s10899-020-09975-w
- Haffner, P., Quinlivan, E., Fiebig, J., Sondergeld, L.-M., Strasser, E. S., Adli, M., … Stamm, T. J. (2018). Improving functional outcome in bipolar disorder: A pilot study on metacognitive training. Clinical Psychology and Psychotherapy, 25(1). https://doi.org/10.1002/cpp.2124
- Jelinek, L., Hauschildt, M., Wittekind, C. E., Schneider, B. C., Kriston, L., & Moritz, S. (2016). Efficacy of metacognitive training for depression: A randomized controlled trial. Psychotherapy and Psychosomatics, 85(4), 231–234. https://doi.org/10.1159/000443699
- Lincoln, T., Pedersen, A., Hahlweg, K., Wiedl, K.-H., & Frantz, I. (2019). Evidenzbasierte Leitlinie zur Psychotherapie von Schizophrenie und anderen psychotischen Störungen [Evidence-based guideline for the psychotherapy of schizophrenia and other psychotic disorders]. Göttingen, Germany: Hogrefe.
- Liu, Y.-C., Tang, C.-C., Hung, T.-T., Tsai, P.-C., & Lin, M.-F. (2018). 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, 15(2), 130–139. https://doi.org/10.1111/wvn.12282
- Moritz, S., Bernardini, J., & Lion, D. (2019). Effects and side effects of a transdiagnostic bias modification intervention in a mixed sample with obsessive–compulsive and/or depressive symptoms—a randomized controlled trial. European Archives of Psychiatry and Clinical Neuroscience. https://doi.org/10.1007/s00406-019-01080-3
- 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), 358–366. https://doi.org/10.1016/j.cpr.2014.04.004
- Moritz, S., Stepulovs, O., Schröder, J., Hottenrott, B., Meyer, B., & Hauschildt, M. (2016). Is the whole less than the sum of its parts? Full versus individually adapted metacognitive self-help for obsessive-compulsive disorder: A randomized controlled trial. Journal of Obsessive-Compulsive and Related Disorders, 9, 107–115. https://doi.org/10.1016/j.jocrd.2016.04.001
- Philipp, R., Kriston, L., Lanio, J., Kühne, F., Härter, M., Moritz, S., & Meister, R. (2018). Effectiveness of metacognitive interventions for mental disorders in adults – a systematic review and meta-analysis (METACOG). Unpublished Manuscript (in Revision).
- Sauvé, G., Lavigne, K. M., Pochiet, G., Brodeur, M. B., & Lepage, M. (2020). Efficacy of psychological interventions targeting cognitive biases in schizophrenia: A systematic review and meta-analysis. Clinical Psychology Review, 78, 101854. https://doi.org/10.1016/j.cpr.2020.101854
- Schilling, L., Moritz, S., Kriston, L., Krieger, M., & Nagel, M. (2017). Efficacy of metacognitive training for patients with borderline personality disorder: Preliminary results. Psychiatry Research. https://doi.org/10.1016/j.psychres.2017.09.024
CONTACT
University Medical Center Hamburg-Eppendorf
Department of Psychiatry and Psychotherapy
Clinical Neuropsychology Unit
Martinistrasse 52
20246 Hamburg – Germany
Website: https://clinical-neuropsychology.de/metacognitive_training-psychosis/
Email: moritz@uke.de