A critical review of metacognitive training (MCT) for psychosis: Efficacy, proposed mechanisms of action and significance for functional outcomes

Introduction Despite significant advances in antipsychotic medications, schizophrenia continues to be a highly disabling condition. Many patients go untreated, are treatment resistant or receive inadequate treatment. A large body of work has demonstrated that cognitive biases (e.g., jumping to conclusions [JTC], overconfidence in errors, bias against disconfirmatory evidence) are involved in the formation of delusions in schizophrenia and thus represent a possible target for intervention. The following article provides a critical review of metacognitive training (MCT) for psychosis. Discussion MCT is a variant of cognitive behavioural therapy (CBT) that seeks to both normalize and increase awareness about cognitive processes involved in the emergence of symptoms utilizing strategies that induce doubt in delusions by addressing cognitive biases, while also instilling hope. Randomized controlled trials using blind raters have mainly yielded moderate effects, which in one study were maintained up to three years after treatment. MCT is positively rated by patients signaling that it is useful, fun and the rationale is understood by patients. Further work is needed to clarify whether the JTC bias represents a unique mechanism of action of MCT that may account, in part, for its effects beyond antipsychotic medication. In contrast, overconfidence in errors may be targeted by antipsychotic medications through dopamine modulation as well as through MCT’s cognitive-behavioral strategies. MCT may lead to improvement beyond psychotic symptoms as initial evidence indicates that improvement in the JTC bias contributes to better vocational outcomes and improved social relationships. Conclusion We conclude that MCT represents a promising new direction in intervention research for psychosis that can complement standard treatment approaches.