Metacognitive Interventions for Delusions in Schizophrenia

Metacognitive Training (MCT), an approach developed by Steffen Moritz, PhD, and colleagues at the University of Hamburg, Germany, is a group-based psychotherapeutic approach to treating both positive and negative symptoms of schizophrenia, and particularly delusions.1 It comes in a module format, with each module targeting common cognitive errors and problem-solving biases, such as jumping to conclusions, bias against confirmatory evidence, and overconfidence. The approach is available at no cost in 37 languages.2

People with schizophrenia have structural brain abnormalities that make it particularly challenging for them to adopt new thought patterns, even when evidence contradicts their cognitions. In turn, this impinges their ability to override delusions. Indeed, one functional magnetic resonance imaging study showed an imbalance in how the brain networks in people with schizophrenia respond to evidence, which could underlie the structural cause of delusions.3 Specifically, according to some experts, people with schizophrenia have an imbalance in the neurotransmitters involved in reacting to sensory processing, including dopamine, glutamate, and serotonin. This can result in them becoming overwhelmed by sensory information, leading to information being processed in a way that both causes and maintains delusions.

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The purpose of MCT is to enhance metacognitive competence in patients, an awareness of their “cognitive traps” and the ability to critically reflect on, expand on, and alter their current problem-solving mechanisms. This approach improves the ability of these patients to integrate evidence that contradicts a belief, a process that is essential to the revision of delusions. As Dr Moritz said, MCT works by “sowing the seeds of doubt, decreasing overconfidence in judgements, and encouraging patients to collect more information.”

Individualizing MCT
The need for psychiatrists to personalize metacognitive interventions has led to an extension of MCT, known as MCT+, which is individual rather than group based. According to Dr Moritz, MCT+ is “like a ‘buffet,’ where clinicians can choose according to the symptoms and preferences of patients. If self-esteem and depression are a big issue in patients, these might be targeted before cognitive biases and delusions are dealt with.” There is a high prevalence of negative cognitions about the self in people experiencing delusions, and it can be therapeutically productive to tackle these issues in efforts to reduce delusions.4

Part of individualized care is being empathic about cultural diversity. Variations in cultural factors that influence cognitive processes such as introspection, evaluation of beliefs, and certainty about beliefs are plausible causes of differences in how individuals interpret reality.5 For example, a recent study evaluating the relationship between cortical thickness and cognitive insight in Indian patients with schizophrenia found differences in how cultural factors affect their cognitive insight when compared with current literature about patients with schizophrenia from a Western society. The researchers concluded that although Western societies cultivate constructs of introspection and openness to feedback, these were isolated entities for their Indian participants.5 Ultimately, the way metacognition is taught within MCT+ needs to account for individual cultural differences.

“MCT and MCT+ have been culturally adapted, but clinicians may wish to make further changes,” says Dr Mortiz, adding that the paradigm also seems to work for extreme religious beliefs.6 Although there are few data targeting how patients’ religious beliefs affect their MCT sessions, it is important for psychiatrists to take religious factors into consideration when implementing MCT because religious beliefs may affect treatment efficacy similar to cultural attitudes.

How effective is MCT?

Although patients with schizophrenia are often prescribed treatment with antipsychotics that substantially reduce delusions, the effects wear off if patients stop taking them. This is often the case because of the unfavorable adverse effect profiles of these medications and the difficulty of remembering to take medication. In contrast, MCT can teach cognitive life skills that will help patients for the rest of their lives. As such, complementing a medication regimen with MCT, and particularly MCT+, has the potential to combat delusions in the long-term.

The efficacy and acceptability of MCT is supported by numerous studies, with one recent meta-analysis finding metacognitive interventions to be more effective for people with schizophrenia than the commonly used cognitive remediation (CR).7 Although CR focuses on improving neurocognitive abilities such as attention, working memory, and cognitive flexibility, it fails to target the underlying cause of delusions, which are not a typical executive function.

Further support for MCT is provided by a study examining metacognitive capacity at the time patients experience their first episode of psychosis and 3 years later. Self-reflectivity was significantly correlated with the expressive component of negative symptoms, such as blunted affect, poor rapport, and alogia, indicating that negative symptoms partially emerge as a response to patients experiencing a separation between themselves and others.8 Applying the principles of MCT has the potential to alleviate cognitive fragmentation by teaching patients over time that their delusions aren’t real.

Addressing unmet needs

While the efficacy of MCT to combat delusions in schizophrenia is becoming largely accepted within psychiatry, there remains an unmet need to individualize the training. With its modularized format, MCT is easy to individualize. Indeed, MCT has become an open source that clinicians can download and edit to meet the needs of their patients.

The future of shrinking delusions in schizophrenia is one that is patient-centric and culturally sensitive. Therefore, it is no surprise that interest in the approach is gaining pace. In Germany and Australia, it is now recommended for the treatment of schizophrenia, and to further raise its long-term efficacy, an app with daily exercises has been developed (MCT & More).9


1. Moritz S, Vitzthum F, Randjbar S, Veckenstedt R, Woodward TS. Detecting and defusing cognitive traps: metacognitive intervention in schizophrenia. Curr Opin Psychiatry. 2010;23(6):561-569.

2. Mortiz S. Metacognitive Training (MCT) for Psychosis available in 35 languages. Accessed June 4, 2019.

3. Lavigne K, Menon M, Woodward TS. Functional brain networks underlying evidence integration and delusions in schizophrenia Schizophr Bull. doi:10.1093/schbul/sbz032

4. Collett N, Pugh K, Waite F, Freeman D. Negative cognitions about the self in patients with persecutory delusions: An empirical study of self-compassion, self-stigma, schematic beliefs, self-esteem, fear of madness, and suicidal ideation. Psychiatry Res. 2016;239:79-84.

5. Jacob A, Shukla A, Thonse U. Cultural differences and neural correlates of cognitive insight in schizophrenia. Schizophr Res. 2019;S0920-9964(19)30171-30179.

6. Moritz S, Lasfar I, Reininger KM, Ohls I. Fostering mutual understanding among muslims and non-muslims through counterstereotypical information: an education versus metacognitive approach. Int J Psychol Relig. 2018;28(2):103-120.

7. Philipp R, Kriston L, Lanio J. Effectiveness of metacognitive interventions for mental disorders in adults-a systematic review and meta-analysis (METACOG). Clin Psychol Psychother. 2019;26:227-240.

8. Austin S, Lysaker PH, Jansen JE, et al. Metacognitive capacity and negative symptoms in first episode psychosis: evidence of a prospective relationship over a 3-year follow-up [published online, February 27, 2019]. J Exp Psychopathol. doi:10.1177/2043808718821572

9. Moritz S, et al. Welcome to the “MCT & More” App. Accessed June 4, 2019.