At least four cognitive psychotherapeutic approaches to the treatment of psychosis in schizophrenia currently exist yet each ‘targets’ different aspects of metacognition: ¹

• CBTpsychosis (CBTp) – generally targets individual beliefs
• Metacognitive therapy – targets unhelpful beliefs about thinking styles
• Metacognitive training – targets patients’ awareness of distorted cognitive biases
• Metacognitive reflection insight therapy (MERIT) – targets larger senses of identity.

Furthermore, levels of evidence supporting the merits and efficacy of each approach vary.¹ Here we briefly examine some recent developments in metacognitive approaches within psychotic disorders.

Recent metacognitive approaches

Two recent developments in CBTp are particularly intriguing. Acceptance and Commitment therapy (ACT) for in-patients with psychosis uses innovative mindfulness-based strategies in those experiencing acute psychosis for crisis management and stabilization.²

Although shown effective in randomized, controlled trials (RCTs), ACT in psychosis has not been widely adopted as it is cumbersome to implement requiring one-on-one format and delivery by experienced doctoral-level research therapists. However, a modified strategy, (the REACH study), is being pilot-tested in Providence, Rhode Island, USA, for use in routine inpatient settings.² Initially, 20 patients will be recruited in an open trial to test the new protocol. Following modifications, 90 patients will enter an RCT to compare the simplified ACT with treatment as usual.

Interestingly, this same group developed a storytelling video self-help intervention based on ACT in major depressive disorder (MDD); open-trial results are encouraging.³

Modified ACT has shown promise both in psychosis and in MDD

Virtual bar-rooms help those with high trait paranoia

Virtual reality (VR) studies are also promising. One such study in non-clinical adults with high trait paranoia interviewed after entering a VR bar-room environment identified twelve sub-themes that could form future target areas for VR-assisted CBT (VR-CBT).⁴

Has psychotherapy evolved sufficiently to be tailored to specific patients with psychosis?

Individualized Metacognitive Training (MCT+) is a novel psychotherapy targeting delusional beliefs, such as jumping to conclusions, in those experiencing psychosis.

MCT+ reduces positive symptoms

Researchers in Australia compared cognitive remediation (CR) and MCT+ with CR in an RCT; those receiving four 2-hourly sessions of MCT+ and CR showed significant reductions in delusional and overall positive symptom severity compared to only CR-treated patients; such improvements were maintained at 6-months follow-up.⁵

Improvements in some positive symptoms were maintained at 6-months follow-up

In a similar study, jumping to conclusions bias, a lowered decision threshold and low self-esteem were associated with larger improvements in delusional and overall positive symptom severity over time.⁶

Both studies suggest clinicians can now be helped in selecting those patients in whom MCT+ is most appropriate.

CBT is widely applicable

Culturally-adapted CBTp has also been shown to be feasible as an adjunct to treatment as usual (TAU) in patients with psychosis in lower – or middle-income countries.  A study comparing CBTp adapted for use in Pakistan with CBTp plus TAU reported significantly lower scores in positive and negative symptom scoring scales. ⁷

Is metacognition merely a useful philosophical concept or an accepted clinical practice?

Philosophy or clinical practice?

Which leads us to ask ourselves - is metacognition merely a useful philosophical concept or an accepted clinical practice? Yet to be determined but promising!

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