Individualized Metacognitive Training (MCT+) Reduces Delusional Symptoms in Psychosis

A Randomized Clinical Trial

Ryan P. Balzan; Julie K. Mattiske; Paul Delfabbro; Dennis Liu; Cherrie Galletly


Schizophr Bull. 2019;45(1):27-36. 

In This Article

Abstract and Introduction


Individualized metacognitive training (MCT+) is a novel psychotherapy that has been designed to specifically target delusional beliefs in people with psychosis. It works by developing an awareness of the implausible content of delusional beliefs, while also targeting the cognitive biases that contribute to their formation and maintenance. It was expected that MCT+ would lead to significantly greater reductions in delusional severity compared to a cognitive remediation (CR) active control condition. A total of 54 patients with a schizophrenia spectrum disorder and active delusions were randomized into four 2-hourly sessions of MCT+ (n = 27) or CR (n = 27). All participants completed posttreatment assessment, and only 2 participants did not complete 6-month follow-up assessment, resulting in MCT+ (n = 26) and CR (n = 26) for final analysis. The primary outcome measures of delusional and positive symptom severity were assessed rater-blind; secondary outcome assessment was non-blinded and included clinical and cognitive insight, the jumping to conclusions (JTC) bias, and cognitive functioning. Participants in the MCT+ condition showed significant reductions in delusional and overall positive symptom severity (large effect) and improved clinical insight (moderate effect) relative to CR controls. In contrast, CR controls showed moderate improvement in problem-solving ability relative to MCT+, but no other cognitive domain. Importantly, these findings were maintained at 6-month follow-up. The study adds further efficacy to the MCT program, and suggests that even brief psychotherapy can help to ameliorate the symptoms of psychosis.


There has been a growing interest over the last decade in non-pharmacological treatments for delusions and other positive symptoms in psychosis. Of these, cognitive-behavioral therapy for psychosis (CBTp) has emerged as the most extensively implemented and studied psychosocial intervention.[1] Recent meta-analyses have reported that CBTp is effective in reducing positive symptoms,[2,3] and may be more effective than other psychological interventions for psychosis.[4] However, recent meta-analyses report that when methodological limitations are taken into consideration (eg, lack of blinding, no control intervention), the therapeutic effect of CBTp is reduced.[5–7] Moreover, other meta-analyses have shown that CBTp may not offer any advantage over other psychosocial treatments in the treatment of delusions specifically.[3,7]

To maximize the efficacy of CBTp, it has been suggested that interventions for psychosis should target the theoretical cognitive and emotional constructs that are responsible for the formation and maintenance of specific symptoms, such as delusions.[7] Metacognitive training for psychosis (MCT) may represent one such intervention. Rather than targeting the idiosyncratic delusions specific to the individual client, this manualized group-based program indirectly targets the cognitive biases that decades of theoretical research has linked to the formation and maintenance of delusional beliefs (eg, overconfidence, belief inflexibility and the jumping to conclusions [JTC] bias).[8] MCT encourages participants to "think about their thinking," raising metacognitive awareness for these biases across several entertaining and collaborative exercises, and thereby indirectly "plants the seeds of doubt".[9,10]

Several randomized controlled trials have shown the efficacy for MCT in reducing delusional severity, even at 3-year follow-up,[11] and 2 recent meta-analyses have concluded that MCT exerts a moderate effect on delusions and positive symptoms.[11,12] However, not all trials have yielded significant improvements for MCT,[13] suggesting that the group program may not be appropriate for all clients with psychosis, particularly those with acute delusions or high levels of paranoia.[14]

Accordingly, an individually administered program of metacognitive training (or MCT+) was developed,[15] which combines the "cognitive bias" focus of group MCT with elements of individual CBTp (Note: MCT+ is no longer referred to as "metacognitive therapy" to avoid confusion with the program developed by Adrian Wells). This hybrid approach allows therapists to simultaneously target the underlying cognitive biases that may be driving delusional content, while tailoring the therapeutic content to specific delusional beliefs, and allowing for greater use of CBTp techniques (eg, thought records, Socratic questioning) compared to the original group program (refer to the MCT+ treatment manual[16] for an in-depth overview). Therefore, MCT+ was developed to maximize the efficiency, yet minimize the potential limitations, of both MCT and CBTp, and maybe a more effective treatment than either of these treatments used in isolation.

Relative to group-based MCT, the evidence-base for MCT+ is still emerging. The only published randomized controlled trial showed that participants who had received MCT+ had significantly lower delusion severity and higher levels of self-reflectiveness (medium effect size), relative to participants receiving an active control intervention.[17] However, these group differences were no longer significant at the 6-month follow-up, which is contrary to the long-term effects typically observed in group-MCT trials.[11,12,18] The authors noted a lower baseline delusion severity in the MCT+ group (despite randomization), which may have led to possible floor effects in this group, or larger regression to the mean in the control group. Moreover, the beneficial effects of MCT+ were more pronounced in a subset of participants who attended a minimum of 4 sessions of either intervention, highlighting the importance of lowering the potential attrition across sessions. One way of doing this is to combine multiple MCT+ modules together into fewer "extended" sessions (eg, 2-h vs 1-h), effectively reducing the number of overall sessions, while ensuring the essential therapeutic content is retained. There is tentative evidence that such extended versions of MCT+ are feasible and may still offer therapeutic benefit to people with psychosis. For example, a recent case study based on 2 individuals with active delusions, each receiving four 2-hourly MCT+ sessions (without concurrent antipsychotic medication), showed a reduction in delusional severity post-intervention.[19] Another small-scale study similarly combined 2 MCT+ modules into a single individually administered module, finding that MCT participants (relative to TAU controls) also exhibited significant decreases in delusional severity, and significant improvements in clinical insight.[20]

The present study is the first independent randomized controlled trial of MCT+ conducted without direct involvement from the co-creators of the program. The primary aim of the study is to determine the efficacy of an extended-session MCT+ protocol in patients with delusions, compared to an active "cognitive remediation (CR)" control condition targeting neurocognitive symptoms. The four 2-hourly MCT+ sessions, delivered over a month, were designed to be flexible, adapting to the client's therapeutic needs while ensuring that "cognitive biases" remained the focus, as per the MCT+ protocol. The primary outcome measure assessing for delusional and positive symptom severity was rater-blinded. It was hypothesized that MCT+ would lead to significantly greater reductions in positive symptoms compared to the CR control condition, which itself would be associated with greater improvements in neurocognitive functioning relative to MCT+.