Schizophrenia Research 201 (2018) 20–26

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Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

Metacognition – What did James H. Flavell really say and the implications
for the conceptualization and design of metacognitive interventions
Steffen Moritz a,⁎, Paul H. Lysaker b,c
a
Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
b
Roudebush VA Medical Center, Indianapolis, IN, USA
c
Indiana University School of Medicine, IN, USA

a r t i c l e i n f o a b s t r a c t

Article history: In the last two decades years, several interventions have been designed for people with major psychological dis-
Received 23 March 2018 orders that all have “metacognitive” in their name: Metacognitive Therapy (MCT), Metacognitive Training
Received in revised form 1 June 2018 (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these inter-
Accepted 3 June 2018
ventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what con-
Available online 12 June 2018
stitutes “true” metacognitive treatment, we will first explore the original concept of metacognition as defined by
Keywords:
James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks
Psychosis up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent prob-
Metacognition lems with the label “metacognition.”
Metacognitive knowledge © 2018 Published by Elsevier B.V.
Cognitive insight
Metacognitive Therapy

1. Introduction 1.1. Flavell's concept of metacognition

During the last two decades, several ‘metacognitive’ interventions The term metacognition was coined by James H. Flavell in the 1970s
for people with severe psychological problems, including psychosis, (Flavell, 1979). While it was originally described as “knowledge and
have been developed: Metacognitive Therapy (MCT; Wells, 2009), cognition about cognitive phenomena” (p. 906) in Flavell's seminal
Metacognitive Training (e.g., for people with psychosis) (Moritz et al., paper, it is now usually defined more briefly but also more broadly as
2014) and Metacognitive Reflection and Insight Therapy (Lysaker “thinking about thinking.” The label was new, the concept was not.
et al., 2018; Lysaker and Klion, 2017). The starting point of the present Flavell's account was built upon earlier research on (memory) “moni-
review is a lingering debate initiated by Adrian Wells about what consti- toring” (e.g., Hart, 1967) – a term that is still in use – and “knowledge
tutes a true metacognitive intervention (Andreou et al., 2018; about knowledge” (Tulving and Madigan, 1970). Even Vygotsky
Capobianco and Wells, 2018; Wells and Fisher, 2011). As we will pres- (1934) has been credited as one of the originators of research into meta-
ent in greater depth below, Wells and colleagues assume that only cognition (Reynolds and Wade, 1986); according to Spearman (1923; p.
Metacognitive Therapy works at a meta-level, while, for example, 52–53) the roots may even date back to Plato's “cognizing about cogni-
Metacognitive Training works on what they call “ordinary cognitions” tion.” Flavell himself was particularly interested in differences in cogni-
(Capobianco and Wells, 2018). To provide an answer to this question, tive monitoring across different stages of childhood and adolescence. As
one first needs to understand what is meant by the term metacognition. an introductory example to illustrate how metacognitive processes ap-
Our review will therefore briefly summarize the original concept de- pear in the world, he turned to an earlier study by his group on nursery
vised by Flavell (1979), followed by a summary of the rational and ther- school, kindergarten, second grade, and fourth grade children who were
apeutic mechanisms of each of the three approaches. We will discuss instructed to learn items to the point of perfect recall (Flavell et al.,
how each treatment maps onto Flavell's original definition as well as 1970). Older children, unlike younger children, tended to employ a spe-
their similarities and differences. cific memorization strategy. Moreover, the older children were better
able than the younger ones to predict their own memory performance
in advance. When older children said they were ready to recall a series
of items perfectly, they indeed succeeded in doing so in most trials,
⁎ Corresponding author. whereas the youngest group failed in most trials despite similar subjec-
E-mail address: moritz@uke.uni-hamburg.de (S. Moritz). tive readiness to recall.

https://doi.org/10.1016/j.schres.2018.06.001
0920-9964/© 2018 Published by Elsevier B.V.
 S. Moritz, P.H. Lysaker / Schizophrenia Research 201 (2018) 20–26 21

This precise aspect of metacognition, the conscious awareness of concept has blurred boundaries of a number of related concepts such
one's cognitive performance including shortcomings and strengths, is as cognition and social cognition (Andreou et al., 2018). The latter has
prominent in the neuropsychological literature to the present day (for been defined as the mental operations underlying social interactions
an early study in the field see Anderson-Parenté, 1994), for example, to solve social, adaptive problems (Yager and Ehmann, 2006). It deals
in descriptions of instances in which neurological and psychiatric pa- with the question how people store, process, and apply information
tients often lack insight into their cognitive limitations. For neurological about themselves, other people and social situations (Ostrom, 1984)
patients this has been termed anosognosia (Sunderaraman and and is thus partly overlapping with the definition of metacognitive
Cosentino, 2017). However, according to Flavell, metacognition is knowledge given above. Moreover, the components of metacognitive
more than just comparing subjective versus objective cognitive perfor- goals and actions (in delineation to cognitive goals and actions)
mance (in fact, such studies had already been performed before him). remained somewhat elusive in Favell's original text.
Flavell (1979) distinguished four components of metacognition The different developments of the term metacognition are beyond
that interact in complex ways: (a) metacognitive knowledge, the scope of this article, however, as the field is now quite diversified.
(b) metacognitive experiences, (c) metacognitive goals (or tasks), and Most researchers have addressed the early criticism, and the term meta-
(d) metacognitive actions (or strategies). cognition and its most prominent subdomain, metamemory, are now
Metacognitive knowledge, the first of the components, is defined as used as a superordinate category rather than an elementary function.
stored world knowledge that has to do with people as cognitive beings Researchers now invest special efforts to clarify what aspect of metacog-
and with their diverse cognitive tasks, goals, actions, and experiences nition they are concerned with (for an overview about how metacogni-
(Flavell, 1979). Flavell provides the example of a child who has the be- tion can be measured see Dunlosky and Metcalfe, 2009; Dunlosky and
lief that unlike many of her friends, she is better at arithmetic than at Tauber, 2015; Fleming and Lau, 2014), for example, whether
spelling. Psychopathological examples could be to believe that one is metacognitive judgments are operationalized as confidence (Koriat
generally incompetent (as in severe depression) versus gifted or in pos- and Levy-Sadot, 1999; Yeung and Summerfield, 2012), remember-
session of special cognitive skills (as in mania if the belief is unfounded), know (Migo et al., 2012), feeling of knowing (Shimamura and Squire,
or in possession of secret knowledge that others try to steal (as in para- 1986), or other ratings. This is aimed at overcoming the prior Babylonian
noia, again, if unfounded). Metacognitive knowledge can relate to per- speech confusion, which plagues many other fields of psychology as well
sons, oneself and others, but can also be beliefs about “universal (c.f. cognition, neuropsychology, etc.).
properties of cognition” (p. 907). As we will outline in greater detail
below, the former aspect is prominent in the integrative metacognitive 1.2. CBT: a metacognitive intervention?
model offered by Paul Lysaker, while the latter aspect (e.g., thought-
action fusion) is central to Metacognitive Therapy by Adrian Wells and Before turning to metacognitive interventions and how they map
colleagues. onto Flavell's components of metacognition (and whether they deserve
The second of Flavell's components, metacognitive experiences, are the label “metacognitive”), we have to deal with the possibility that
conscious reflections about cognitive processes (e.g., worry that you cognitive-behavioral therapy (CBT) also works at a metacognitive
may fail an exam because you are not good enough; the thought that level. Indeed, borders are blurry and CBT (if not all psychological treat-
you have just given a very good presentation). The phases of psychosis ments) imparts patients with new metacognitive knowledge
can also be framed as metacognitive experiences (Conrad, 1958) such as (e.g., improving drive and increasing social engagement will help to di-
trema (“stage fright”; the individual has the feeling that something very lute negative thoughts). A central and importantly content-unspecific
important is about to happen) or a feeling of “revelation” (or eureka ex- “mantra” of CBT is that thoughts are just thoughts and not facts (for ex-
perience) when the delusional belief is finally formed. Metacognitive ample see Foreman and Pollard, 2011). In fact, even its parent interven-
experiences often act as a prompt for both the third and fourth aspects tion, behavior therapy (BT), can provide fundamental metacognitive
of metacognition: metacognitive goals and strategies. Flavell provides experiences. For example, stress is attenuated after a while when people
the example that one senses (i.e., a metacognitive experience) that a cer- are confronted with a feared stimulus, which can challenge the prior
tain chapter of a text is perhaps not learned well enough to pass an metacognitive belief that the fear will rise to uncontrollable heights if
exam. A purely cognitive strategy would be to read the chapter through one does not withdraw from the situation (“wow, that was easier
once more. Alternatively, you could ask yourself questions about the than I thought”). We can only speculate that if the concept of metacog-
text and note how well you are able to answer them. The latter would nition had made its way earlier from developmental and experimental
be a metacognitive strategy aimed at the metacognitive goal of assessing psychology to clinical psychology, CBT may have already been using
one's knowledge, which will give rise to subsequent metacognitive ex- the prefix “meta,” probably with a hyphen between meta and cognition
periences (e.g., surprise, relief, frustration about performance). In her as CBT mainly targets specific cognitive contents (i.e., “ordinary cogni-
review of Flavell's theory, Livingston (2003) acknowledges that tions” according to Wells, 2009, p. 37). Such a development would
metacognitive and cognitive strategies overlap in that the same strategy have prevented some confusion between cognitive training, which is
could be regarded as either cognitive or metacognitive depending on usually used synonymously with neuropsychological training or cogni-
the goal. According to Livingston, self-questioning while reading tive remediation, and cognitive therapy (however, please note that re-
would be a cognitive strategy if the purpose is to obtain knowledge cently metacognitive adaptations of cognitive remediation have also
while it would be a metacognitive strategy if it is used to monitor been released; see Cella et al., 2015).
what you have read.
Since its formal introduction by Flavell, the term metacognition has 2. Metacognitive interventions
been well-embraced by the scientific community and soon made its
way into psychological textbooks (e.g., Forrest-Pressley et al., 1985). A 2.1. How metacognitive are metacognitive interventions?
PubMed search with the keyword metacogniti* resulted in 2773 hits
(January 2018), not including numerous theses, books and chapters As described, the term metacognition is somewhat vague and bring-
on the topic. However, it is not without its problems, as some experts ing it to any new field will further complicate things and burden bold
have already noted very early (Reynolds and Wade, 1986). It has been claims about what constitutes legitimate or proper “Metacognitive
criticized as being over-inclusive (“The term metacognition refers to a Therapy” (Andreou et al., 2018; Capobianco and Wells, 2018; Wells
general concept that subsumes metas for almost any cognitive process and Fisher, 2011). The developers of Metacognitive Therapy,
imaginable”; Reynolds and Wade, 1986, pp. 307–308), having variable Metacognitive Training, and Metacognitive Reflection and Insight Ther-
meanings, and being used differently across studies. As a result, the apy (MERIT) all argue that their interventions primarily target
22 S. Moritz, P.H. Lysaker / Schizophrenia Research 201 (2018) 20–26

metacognitive processes. We will now go through the different ap- 2.1.1.1. Challenges. In our opinion, Wells and colleagues (over)empha-
proaches one by one and examine to what extent they capture aspects size differences to other therapeutic schools. A central contention is
of Flavell's original concept. In short, we will detail how the focus of that MCT works at a metalevel and CBT at an object level. First, it is de-
Metacognitive Therapy is on metacognitive knowledge about cognition batable if working on contents is really object level. In his review on the
in general (e.g., dysfunctional explicit metacognitive beliefs are chal- model of Nelson and Narens, van Overschelde (2008) explained that the
lenged and replaced), the focus of Metacognitive Training is on “object level consists of cognitions, which are often associated with ex-
metacognitive experience (e.g., disorder-specific cognitive biases that ternal objects (e.g., that thing I see is a dog), and the metalevel consists
are not often conscious to the patient and are made explicit and chal- of cognitions about object level cognitions (e.g., why do I keep thinking
lenged), and the focus of MERIT is mainly on metacognitive knowledge about that dog?)” (p. 47). Clearly, if one replaces “dog” with “negative
about oneself and others. thoughts”, CBT also works at a meta-level, by reflecting on and challeng-
ing negative thoughts. Second, as mentioned, CBT also teaches patients
some “universal properties of cognition” (Flavell, 1979, p. 907), particu-
2.1.1. Metacognitive therapy (MCT) larly that thoughts are not almighty and are not facts, and thus is not
We will start with Metacognitive Therapy, developed by Adrian only concerned with content. Third, a lot of the techniques of CBT are
Wells and coworkers (Fisher and Wells, 2009; Wells, 2012; Wells and used in MCT, perhaps with a different rationale, but it has yet to be
Papageorgiou, 2004), as it is perhaps the most well-known among the shown if the mechanisms are different.
three approaches. MCT is usually carried out in 8–12 face-to-face ses-
sions and is meant by Wells as an economic (and in his view, more effec- 2.1.2. Metacognitive Reflection and Insight Therapy (MERIT)
tive) alternative to CBT (Hagen et al., 2017; Wells and Fisher, 2016), Flavell breaks metacognitive knowledge into three areas: person,
based on a meta-analysis of five direct comparison studies with mainly task, and strategy. MERIT best relates to the person category, which
small samples (Normann et al., 2014). More recently, the approach has Flavell defines as follows: “The person category encompasses every-
been extended to group settings (Papageorgiou and Wells, 2014). MCT thing that you could come to believe about the nature of yourself and
is rooted in the Self-Regulatory Executive Function (S-REF) model other people as cognitive processors. It can be further subcategorized
(Wells and Matthews, 1994). In part, the terminology is borrowed into beliefs about intraindividual differences, interindividual differ-
from the metamemory model of Thomas Nelson and Louis Narens, ences…” (Flavell, 1979, p. 907). MCT was first developed for a range of
who distinguished between an object level and a meta-level (Nelson psychological disorders and later applied to psychosis; in contrast,
and Narens, 1990). Wells and colleagues locate the cause of psycholog- MERIT was initially developed for psychosis and later applied to other
ical disorder at the metacognitive level and not at the object level disorders. As reviewed by Lysaker and Lysaker (2010), a broad range
(i.e., cognitive content). MCT is designed to change dysfunctional (pos- of literature suggests that the first-person experience of schizophrenia
itive or negative) beliefs (i.e., metacognitive knowledge) about thinking involves to some degree the experience of loss of a previously coherent
(e.g. “worrying helps me to find the cause of my problem” or “worrying and cohesive sense of self. Specifically, schizophrenia may be associated
is uncontrollable and I might go mad”) and impart the patients with with the disintegration of previously integrated and complex senses of
new insights/metacognitive knowledge about their cognitive apparatus self and others, thus leaving persons with a fragmented understanding
(e.g., rumination is not helpful; suppressing thoughts will only of themselves and others with which to make sense of life and psychiat-
strengthen them). ric challenges. MERIT, as well as closely related variants which use sim-
The approach is transdiagnostic and the basic model is applied to ilar models of metacognition (Bargenquast and Schweitzer, 2014;
very different psychological disorders such as depression, anxiety, and Dimaggio et al., 2015; Inchausti et al., 2017), was designed to help pa-
obsessive-compulsive disorder, and more recently to psychosis tients become better able to bring together the small pieces of informa-
(Morrison et al., 2014; Wells, 2011; Wells et al., 2010). The authors as- tion about their experience of themselves and others (e.g. awareness of
sume the presence of a cognitive attentional syndrome (CAS) in patients specific isolated thoughts and feelings) into an integrated sense of who
with psychological disorders which includes three core processes that they and others are as unique beings in the world, and to then use that
can be described as extended dysfunctional thinking in response to neg- knowledge to make sense of and respond to psychological and social
ative thoughts: worry/rumination, threat monitoring and coping behav- challenges (Lysaker and Klion, 2017). MERIT is a staged approach. The
iors that backfire. These are maintained by patients' (dysfunctional) metacognitive capacity of patients is assessed continuously and inter-
metacognitive beliefs that these strategies are helpful when in fact ventions are offered at the level of which patients are capable. As pa-
they impede healthy function. Flavell (1979) already noted that meta- tients develop greater levels of metacognitive capacity, interventions
cognition can also do harm, for example by enhanced self-attention are tailored to match those higher levels. The ultimate therapeutic
and rumination about thoughts (e.g., “Think of the feckless obsessive, mechanism is asserted to reflect the practice of metacognitive acts as
paralyzed by incessant critical evaluation of his own judgments and de- optimal levels which spur increasing gains over time in a manner that
cisions”, p. 910). is likened to physical therapy (Lysaker and Klion, 2017; Van
One of the key mechanisms of action in this form of therapy are Donkersgoed et al., 2014).
exercises that challenge dysfunctional metacognitive beliefs More so than Metacognitive Therapy and Metacognitive Training,
and strategies, which prompt metacognitive experiences MERIT is highly tailored to the individual both in terms of the tech-
(e.g., surprise, enlightenment). Some of the strategies of MCT are niques and goals. With respect to illness concept, MERIT allows persons
borrowed from the arsenal of cognitive therapy, such as using prin- to evolve a personally meaningful idea about recovery and to decide
ciples of the Socratic dialogue, rumination postponement, variants what steps they could take to achieve and ultimately managing their
of the “white bear exercise” (Wegner et al., 1987) where one own recovery. The focus is on understanding the individual as a com-
should not think about a white bear, elephant or else), and innova- plex and multifaceted being with a unique history and unique set of
tive variants of the “safe exercise” from trauma therapy (to lock hopes, wishes and dreams. A MERIT therapist typically will ask a patient,
away or treat negative thoughts like external objects) in the tradi- ‘What do you want me to understand?’ before asking ‘What do you
tion of mindfulness, where attention is paid non-judgmentally. The want me to do?’ Therapeutic alliance is conceptualized as the basis for
latter technique is called “detached mindfulness” (Wells, 2005) shared reflection as the creation of meaning is the essential focus. The
and is a central element of MCT. Another important exercise is the therapeutic relationship is thus characterized as necessarily non-
attention training technique (Fergus et al., 2014; Papageorgiou hierarchical in nature.
and Wells, 2000), which is aimed at reducing self-focused Structurally, MERIT is thus an integrative framework that assists
attention. practitioners, from a range of perspectives, to tailor their practice in
 S. Moritz, P.H. Lysaker / Schizophrenia Research 201 (2018) 20–26 23

order to enhance metacognition. MERIT is based on several core as- that was similar to what would happen when an existential or psycho-
sumptions including the notion that recovery from psychosis is possible dynamic therapist used those same principles. Second, work on MERIT
and likely, regardless of how ill, disorganized or demoralized patients has yet to really explore the complexity of experiences which have to
are, and that patients are active agents in their own recovery. MERIT is be integrated and the extent to which it is an automatic activity. Much
defined by eight elements, each of which can be delivered within a ses- of what is focused upon is the embodied experience of intersubjective
sion regardless of the unique dilemma a patient is experiencing. Each el- encounters, and a challenge that remains for MERIT is to be able to de-
ement describes a therapist behavior (e.g. attention to patient agenda, scribe how persons move from increased awareness of embodied expe-
eliciting a personal narrative or reflecting on the experience of session) rience of intersubjective encounters to a more coherent narrative of
that assists adults with psychosis in recapturing metacognitive abilities their lives and an account of others as having their own unique perspec-
that are atrophied, damaged, or previously never attained. Each element tives. Third, sense of self requires the availability of multiple elements of
can further be measured and used to establish fidelity. MERIT does not self in an evolving manner (Lysaker and Lysaker, 2008). Work is there-
offer prescribed activities to be performed in a certain order. It is explic- fore needed to describe how MERIT actually promotes self-experience
itly not a step-by-step guide. Therapists are guided by the eight ele- which, more than becoming increasingly integrated, is also fundamen-
ments to make meaning with patients and integrate and use tally dialogical and flexible.
information about themselves and others in increasingly complex ways.
Regarding the concept of metacognition itself, the treatment relies 2.1.3. Metacognitive Training for psychosis and other psychological
on what they refer to as the integrative model of metacognition disorders
(Lysaker and Hasson-Ohayon, 2018). This frames metacognitive pro- The label Metacognitive Training first surfaced in the midst of the
cesses as making it possible for persons to have access to a sense of 1980s in the context of children's education (e.g., Kurtz and
self and others within the flow of life. It proposes that metacognition Borkowski, 1987), which has remained a prominent scope of research
is a spectrum of activities which, at one end, enable an awareness of spe- (Abd-El-Khalick and Akerson, 2009; Casselman and Atwood, 2017;
cific thoughts, wishes and feelings, while at the other end, involve pro- Teong, 2003). The present review will confine itself to its application
cesses that allow reflective and embodied experience to be integrated in people with psychological disorders.
into a larger complex sense of oneself and others (Lysaker and The idea of Metacognitive Training for psychosis was borne in the
Dimaggio, 2014). In this model, both ends of the spectrum are suggested early 2000s. Two recent meta-analyses have confirmed its efficacy for
to influence each other. For example, one might interpret a discrete ex- the treatment of positive symptoms/delusions (Eichner and Berna,
perience of an emotion in light of one's large sense of oneself while one's 2016; Liu et al., 2018) and it is now recommended as a treatment for
larger sense of self should be influenced by discrete emotional experi- psychosis by the Australian Psychiatric Association as well as the Ger-
ences. As does Metacognitive Training (see below), it incorporates man Psychiatric Association and the German Psychological Association
new concepts of metacognition such as the division of metacognitive ac- (e.g., Galletly et al., 2016). The goal was to correct cognitive biases in
tivities into different phenomena based on their foci as proposed by psychosis, that is, distortions in the way an individual perceives, inter-
Semerari et al. (2003) as well as the emphasis on metacognitive acts prets and recollects information. At that time, knowledge about these
as necessarily intersubjective in nature (Cortina and Liotti, 2010; biases was still in its infancy (Garety and Freeman, 1999) but indicated
Hasson-Ohayon et al., 2017). that people with psychosis jump to conclusions (JTC), show marked in-
MERIT shares with the practices of second wave CBT an interest in corrigibility, and are overconfident in their false judgments (for more
identifying cognitions, but it differs in its interest in the quality of recent reviews see Garety and Freeman, 2013; Moritz et al., 2017b). Im-
those cognitions and concern about their absolute correctness. Like portantly, awareness of these biases is poor in many patients
third wave CBT, such as mindfulness and ACT, MERIT also focuses on (e.g., Moritz et al., 2016): they often regard their decision-making as
persons' relationship to their experience. However, it aims at a joint re- rather rational and even hesitant (Freeman et al., 2006). Accordingly,
flection about self-experience in the moment, as it is occurring between Metacognitive Training aims to generate or raise metacognitive aware-
the therapist and patient and as it has unfolded across patients' personal ness for these over-arching biases in a gentle, non-insulting manner
narratives. Unlike ACT, MERIT de-emphasizes abstractions and looks to (e.g., implicit behavior/cognition becomes metacognitive knowledge;
the larger complex web of meanings, which span a unique life as the Moritz et al., 2014). Similar to MCT by Wells, Metacognitive Training
context necessary for understanding any abstraction a person might tries to improve metacognitive knowledge of patients (e.g. knowledge
hold onto in the moment (Lysaker and Hasson-Ohayon, 2018). In that many patients with schizophrenia tend to jump to conclusions or
MERIT the primary mechanism of change is joint reflection between are overconfident) by corrective experiences that give rise to strong
the patient and therapist which is keyed to the patient's metacognitive metacognitive experiences (“aha moments”). It also picks up a long tra-
capacity in the moment. If the patient is at best able only to notice but dition of metacognitive research that goes back to Asher Koriat (Koriat,
not connect different activities in their mind, the therapist joins them 2002; Koriat and Levy-Sadot, 1999) who regards confidence/doubt as
at this level and seeks to merely name and think about these discrete being at the heart of metacognition (see also Yeung and Summerfield,
phenomena. As patients become better able to synthesize information 2012). A central aim of Metacognitive Training for psychosis is thus to
(e.g. see connections between thoughts and feelings within the flow “sow the seeds of doubt,” that is, patients are encouraged to attenuate
of life and to connect different eras of their lives in terms of the struggles their confidence if evidence is not sufficient and collect more informa-
they have faced) therapists similarly join them at this level. In MERIT it tion before momentous decisions are made (Moritz et al., 2014). Unlike
is assumed that as patients think about themselves and others at their the claim by Capobianco and Wells (2018) that the “intervention is
maximal metacognitive capacity they will develop over time increased clearly a cognitive behavioral approach that deals with the content of
metacognitive capacities. Change is assessed using the Metacognitive negative thoughts” (p. 161), the cognitive bias modules of the
Assessment Scale Abbreviated (Lysaker and Klion, 2017). metacognitive group training for psychosis primarily work at the
Finally, moving in the opposite direction of MCT, after being devel- metacognitive level and keep the level of personal content at a mini-
oped and tested empirically with patients with psychosis, MERIT has mum. In fact, Metacognitive Training for psychosis avoids in-depth dis-
been applied to other conditions including borderline personality disor- cussions of delusional contents in order to engage patients who are not
der (Vohs and Leonhardt, 2016). willing to talk about their psychotic experiences, often due to suspi-
ciousness, ambivalence and shame (such issues are dealt with in indi-
2.1.2.1. Challenges. There are several limitations of this approach. First, it vidualized CBT or MCT+, see below).
is explicitly an integrative therapy and it is unclear to what extent the From the view point of basic research, things became complicated
use of its principles by a cognitive therapist would result in something because the concept was increasingly “watered down” by incorporating
24 S. Moritz, P.H. Lysaker / Schizophrenia Research 201 (2018) 20–26

elements from CBT and other therapeutic schools that were deemed original definition by Flavell which helps us see that each of these treat-
compatible. A main reason was because patients with psychosis deem ments legitimately captures important aspects of the concept of meta-
emotional problems a priority in treatment (Byrne et al., 2010; cognition. Metacognitive Therapy focuses on persons' orientations to
Kuhnigk et al., 2012; Moritz et al., 2017a), more so than working on hal- what they believe, MERIT focuses on larger senses of identity, and
lucinations and delusions (Moritz et al., 2017a). Metacognitive Training focuses on awareness of mental processes.
In recent years, a number of metacognitive trainings were devised This review also raises a range of essential questions and issues. For
for other disorders including depression, borderline personality disor- instance, other cognitive treatments such as CBT also deal with
der and obsessive-compulsive disorder (Jelinek et al., 2016; Moritz metacognitive phenomena; distinctions between CBT (and other treat-
et al., 2010; Schilling et al., 2015). These adaptations are rooted in the ments) and those reviewed here are yet to be firmly delineated and ex-
setup and presentation mode of the Metacognitive Training for psycho- plored. These treatments and their study also finally reorient us to
sis: pdf-concerted PowerPoint slides which are almost self-explanatory, theory and the need for more complex and responsive models of the
an open group, and engaging in humorous exercises aimed to provide age-old question of how persons understand themselves and reflect
corrective “aha moments” (i.e., metacognitive experiences). These upon and respond to experience in a way that is unique to them but
disorder-specific versions have been intended as hybrids, to amalgam- which can also be understood by others.
ate a CBT and Metacognitive Training approach. With respect to their
contents, they are very close to prior CBT interventions and the devel- Role of funding source
opers explicitly see Metacognitive Training, even Metacognitive Train- No external funding.
ing for psychosis, as variants of CBT. As we have speculated before, the
founders of CBT may have called their approach “meta-cognitive” if
Contributors
the latter term had been popular already. As described, Wells regards Both authors have written and proof-read the manuscript.
working on a cognitive level as superfluous. In the opinion of the devel-
opers of Metacognitive Training, the specific contents of thoughts are
Conflict of interest
meaningful. Jumping to conclusions and overconfidence may perhaps
Both authors are developers of metacognitive interventions that are dealt with in the
explain why one has fixed false beliefs but may not explain why one manuscript.
feels persecuted by the CIA versus becomes a religious extremist. Con-
tents are associated with the biography and specific experiences (in-
Acknowledgement
cluding worries) of patients and are thus not random. Elucidating why We would like to thank Drs. Ryan Balzan and Lukasz Gaweda for comments on an ear-
a patient has certain specific thoughts may lead to new metacognitive lier version of the manuscript.
experiences and thus improve metacognitive knowledge. Still, it is un-
fortunate that Metacognitive Training and Metacognitive Therapy References
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