Metacognitive Training Project

Background: Metacognition, or “thinking about thinking1” is a key aspect of psychotic experiences and recovery in Psychosis-Spectrum Disorders2 (PSD). Metacognition is associated with symptom severity3, cognition4 and mood5; and can predict outcomes (including wellbeing and functioning6–8). Cognitive models suggest metacognition is required to understand psychotic symptoms9. Metacognitive therapy for PSD encourages metacognitive reflection about, and re-appraisal of, psychotic symptoms10. Improvements in metacognition translate to better engagement of patients in their personal recovery plan11. Current metacognitive therapies require specialised training of a qualified therapist, and are therefore costly to implement and difficult access. Metacognitive training, however, aims to be a brief intervention, that can be implemented online, at a time and place to suit the individual. There are therefore clear benefits to online metacognitive training, when engagement and attendance at in-person therapy reduces according to a number of inter-personal12 and psychosocial factors13–16.

In healthy adults, computerised metacognitive training provided feedback on metacognitive judgements, and half hour weekly session for 8 weeks improved their metacognitive accuracy17. In PSD, RCTs demonstrated that in-person cognitive training and metacognitive therapy have a positive impact on cognition and functioning in PSD10-11 but no study has examined the impact of online metacognitive feedback on metacognition in PSD. Further, there is no evidence in clinical or control groups about whether feedback about metacognitive accuracy can improve clinically relevant measures of metacognition.

Objectives: This study will continue to co-develop metacognitive training with individuals with lived experiences of PSD and investigate the impact of the brief, online, training on metacognitive accuracy, and clinically relevant metacognitive judgements. If successful, this would be a low-cost intervention to support recovery and engagement with recovery plans in PSD, alongside medication and Cognitive Behavioural Therapy (CBT).

Project Plan:

The training module has been developed alongside public involvement partners (PIPs) with lived experience of PSD. The training is based on work published by Carpenter (201917) with healthy adults, however PIPs identified the feedback format was confusing and demotivating. The present study will continue to work with PIPs to ensure that training instructions, feedback format, and functionality are acceptable. The project will launch once ethical approvals are granted. The main study build is complete ahead of ethical approval.

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2.       Lysaker, P. H. et al. Metacognition and schizophrenia: The capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months. Schizophr. Res. 122, 124–130 (2010).

3.       Trauelseh, A. M. et al. Metacognition in first-episode psychosis and its association with positive and negative symptom profiles. Psychiatry Res. 238, 14–23 (2016).

4.       Nair, A., Palmer, E. C., Aleman, A. & David, A. S. Relationship between cognition, clinical and cognitive insight in psychotic disorders: A review and meta-analysis. Schizophr. Res. 152, 191–200 (2014).

5.       Palmer, E. C., Gilleen, J. & David, A. S. The relationship between cognitive insight and depression in psychosis and schizophrenia: A review and meta-analysis. Schizophr. Res. (2015). doi:10.1016/j.schres.2015.05.032

6.       O’Connor, J. A. et al. Can cognitive insight predict symptom remission in a first episode psychosis cohort? BMC Psychiatry 17, (2017).

7.       Wright, A., Fowler, D. & Greenwood, K. Influences on functional outcome and subjective recovery in individuals with and without First Episode Psychosis: A metacognitive model. PSYCHIATRY Res. 284, (2020).

8.       Wright, A. C., Davies, G., Fowler, D. & Greenwood, K. Three-Year Follow-Up Study Exploring Metacognition and Function in Individuals With First Episode Psychosis. Front. PSYCHIATRY 10, (2019).

9.       Garety, P. A., Kuipers, ” E, Fowler, D., Freeman, D. & Bebbington, P E. A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31, (2001).

10.     Moritz, S. & Woodward, T. S. Metacognitive training for schizophrenia patients (MCT): A pilot study on feasibility, treatment adherence, and subjective efficacy. Ger. J. Psychiatry 10, 69–78 (2007).

11.     Lysaker, P. H. et al. Metacognition and recovery in schizophrenia: From research to the development of metacognitive reflection and insight therapy. J. Exp. Psychopathol. 10, (2019).

12.     Bourke, E., Barker, C. & Fornells-Ambrojo, M. Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis. Psychol. Psychother. Theory, Res. Pract. 94, 822–853 (2021).

13.     Nosé, M., Barbui, C. & Tansella, M. How often do patients with psychosis fail to adhere to treatment programmes? A systematic review. Psychol. Med. 33, 1149–1160 (2003).

14.     Killaspy, H., Banerjee, S., King, M. & Lloyd, M. Prospective controlled study of psychiatric out-patient non-attendance: Characteristics and outcome. Br. J. Psychiatry 176, 160–165 (2000).

15.     Lincoln, T. M. et al. Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis. Psychiatry Res. 216, 198–205 (2014).

16.     Richardson, T. et al. Predictors of disengagement from cognitive behavioural therapy for psychosis in a National Health Service setting: A retrospective evaluation. Br. J. Clin. Psychol. 58, 440–451 (2019).

17.     Carpenter, J. et al. Domain-general enhancements of metacognitive ability through adaptive training. J. Exp. Psychol. Gen. 148, 51–64 (2019).