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Introduction (taken and adapted from the manual)

for references see 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 antipsychotics 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 antipsychotics 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 ten modules targeting common cognitive errors, problem-solving biases as well as emotional problems 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 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” through the use of many examples and exercises. Each respective domain is introduced (e.g., jumping to conclusions) and the fallibility of human cognition is discussed and illustrated. In a second step, the pathological extremes for each cognitive bias are highlighted. 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 based on the situation. 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).

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. As demonstrated in the example below, facial expressions can provide clues to one’s 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 actor Chuck Norris, can also serve as examples).

We wanted to avoid designing a program that is strong on theory but not interesting to its users. 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.

How does MCT work? (part 2)

Figure 2 illustrates our tendency to be misled by stereotypes. For example, many assume that all heavy metal bands are satanic. In reality, heavy metal musicians are as colorful as the 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.

Copyright

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. Steffen Moritz. We request that researchers contact us before conducting empirical trials.