Skip to main content Accessibility help

Metacognitive training for schizophrenia spectrum patients: a meta-analysis on outcome studies

  • B. van Oosterhout (a1), F. Smit (a2) (a3) (a4), L. Krabbendam (a5), S. Castelein (a6) (a7), A. B. P. Staring (a8) and M. van der Gaag (a4) (a9)...

Metacognitive training (MCT) for schizophrenia spectrum is widely implemented. It is timely to systematically review the literature and to conduct a meta-analysis.


Eligible studies were selected from several sources (databases and expert suggestions). Criteria included comparative studies with a MCT condition measuring positive symptoms and/or delusions and/or data-gathering bias. Three meta-analyses were conducted on data gathering (three studies; 219 participants), delusions (seven studies; 500 participants) and positive symptoms (nine studies; 436 participants). Hedges’ g is reported as the effect size of interest. Statistical power was sufficient to detect small to moderate effects.


All analyses yielded small non-significant effect sizes (0.26 for positive symptoms; 0.22 for delusions; 0.31 for data-gathering bias). Corrections for publication bias further reduced the effect sizes to 0.21 for positive symptoms and to 0.03 for delusions. In blinded studies, the corrected effect sizes were 0.22 for positive symptoms and 0.03 for delusions. In studies using proper intention-to-treat statistics the effect sizes were 0.10 for positive symptoms and −0.02 for delusions. The moderate to high heterogeneity in most analyses suggests that processes other than MCT alone have an impact on the results.


The studies so far do not support a positive effect for MCT on positive symptoms, delusions and data gathering. The methodology of most studies was poor and sensitivity analyses to control for methodological flaws reduced the effect sizes considerably. More rigorous research would be helpful in order to create enough statistical power to detect small effect sizes and to reduce heterogeneity. Limitations and strengths are discussed.

Corresponding author
* Address for correspondence: B. van Oosterhout, GGzE, PO Box 909, 5600 AX, Eindhoven, The Netherlands. (Email:
Hide All
Abdel-Hamid, M, Lehmkamper, C, Sonntag, C, Juckel, G, Daum, I, Brune, M (2009). Theory of mind in schizophrenia: the role of clinical symptomatology and neurocognition in understanding other people's thoughts and intentions. Psychiatry Research 165, 1926.
Aghotor, J, Pfueller, U, Moritz, S, Weisbrod, M, Roesch-Ely, D (2010). Metacognitive training for patients with schizophrenia (MCT): feasibility and preliminary evidence for its efficacy. Journal of Behavior Therapy and Experimental Psychiatry 41, 207211.
Balzan, RP, Delfabbro, PH, Galletly, CA, Woodward, TS (2014). Metacognitive training for patients with schizophrenia: preliminary evidence for a targeted, single-module programme. Australian and New Zealand Journal of Psychiatry 48, 11261136.
Bennett, K, Corcoran, R (2010). Biases in everyday reasoning: associations with subclinical anxiety, depression and paranoia. Psychosis 2, 227237.
Bentall, RP, Rowse, G, Shryane, N, Kinderman, P, Howard, R, Blackwood, N, Moore, R, Corcoran, R (2009). The cognitive and affective structure of paranoid delusions: a transdiagnostic investigation of patients with schizophrenia spectrum disorders and depression. Archives of General Psychiatry 66, 236247.
Briki, M, Monnin, J, Haffen, E, Sechter, D, Favrod, J, Netillard, C, Cheraitia, E, Marin, K, Govyadovskaya, S, Tio, G, Bonin, B, Chauvet-Gelinier, JC, Leclerc, S, Hode, Y, Vidailhet, P, Berna, F, Bertschy, AZ, Vandel, P (2014). Metacognitive training for schizophrenia: a multicentre randomised controlled trial. Schizophrenia Research 157, 99106.
Burns, AM, Erickson, DH, Brenner, CA (2014). Cognitive–behavioral therapy for medication-resistant psychosis: a meta-analytic review. Psychiatric Services 65, 874880.
Colbert, SM, Peters, ER (2002). Need for closure and jumping-to-conclusions in delusion-prone individuals. Journal of Nervous and Mental Disease 190, 2731.
Colbert, SM, Peters, ER, Garety, PA (2010). Delusions and belief flexibility in psychosis. Psychology and Psychotherapy: Theory, Research and Practice 83, 4557.
Craig, JS, Hatton, C, Craig, FB, Bentall, RP (2004). Persecutory beliefs, attributions and theory of mind: comparison of patients with paranoid delusions, Asperger's syndrome and healthy controls. Schizophrenia Research 69, 2933.
Cuijpers, P, Driessen, E, Hollon, SD, van Oppen, P, Barth, J, Andersson, G (2012). The efficacy of non-directive supportive therapy for adult depression: a meta-analysis. Clinical Psychology Review 32, 280291.
Duval, S, Tweedie, R (2000). Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455463.
Erawati, E, Keliat, BA, Helena, N, Hamid, A (2014). The influence of metacognitive training on delusion severity and metacognitive ability in schizophrenia. Journal of Psychiatric and Mental Health Nursing 21, 841847.
Favrod, J, Maire, A, Bardy, S, Pernier, S, Bonsack, C (2011). Improving insight into delusions: a pilot study of metacognitive training for patients with schizophrenia. Journal of Advanced Nursing 67, 401407.
Favrod, J, Rexhaj, S, Bardy, S, Ferrari, P, Hayoz, C, Moritz, S, Conus, P, Bonsack, C (2014). Sustained antipsychotic effect of metacognitive training in psychosis: a randomized-controlled study. European Psychiatry 29, 275281.
Fernyhough, C, Jones, SR, Whittle, C, Waterhouse, J, Bentall, RP (2008). Theory of mind, schizotypy, and persecutory ideation in young adults. Cognitive Neuropsychiatry 13, 233249.
Ferwerda, J, de Boer, K, van der Gaag, M (2010). Metacognitive training for patients with psychotic vulnerability [in Dutch]. Directieve Therapie 30, 263279.
Fine, C, Gardner, M, Craigie, J, Gold, I (2007). Hopping, skipping or jumping to conclusions? Clarifying the role of the JTC bias in delusions. Cognitive Neuropsychiatry 12, 4677.
Freeman, D (2007). Suspicious minds: the psychology of persecutory delusions. Clinical Psychological Review 27, 425457.
Freeman, D, Startup, H, Dunn, G, Cernis, E, Wingham, G, Pugh, K, Cordwell, J, Mander, H, Kingdon, D (2014). Understanding jumping to conclusions in patients with persecutory delusions: working memory and intolerance of uncertainty. Psychological Medicine 44, 30173024.
Garety, PA, Freeman, D, Jolley, S, Dunn, G, Bebbington, PE, Fowler, DG, Kuipers, E, Dudley, R (2005). Reasoning, emotions, and delusional conviction in psychosis. Journal of Abnormal Psychology 114, 373384.
Garety, PA, Hemsley, DR, Wessely, S (1991). Reasoning in deluded schizophrenic and paranoid patients. Biases in performance on a probabilistic inference task. Journal of Nervous and Mental Disease 179, 194201.
Garety, PA, Kuipers, E, Fowler, D, Freeman, D, Bebbington, PE (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31, 189195.
Higgins, JP, Thompson, SG, Deeks, JJ, Altman, DG (2003). Measuring inconsistency in meta-analyses. British Medical Journal 327, 557560.
Janssen, I, Versmissen, D, Campo, JA, Myin-Germeys, I, van Os, J, Krabbendam, L (2006). Attribution style and psychosis: evidence for an externalizing bias in patients but not in individuals at high risk. Psychological Medicine 36, 771778.
Jauhar, S, McKenna, PJ, Radua, J, Fung, E, Salvador, R, Laws, KR (2014). Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry 204, 2029.
Kaney, S, Bentall, RP (1989). Persecutory delusions and attributional style. British Journal of Medical Psychology 62, 191198.
Kinderman, P, Bentall, RP (1997). Causal attributions in paranoia and depression: internal, personal, and situational attributions for negative events. Journal of Abnormal Psychology 106, 341345.
Kumar, D, Zia Ul Haq, M, Dubey, I, Dotivala, KN, Veqar Siddiqui, S, Prakash, R, Abhishek, P, Nizamie, SH (2010). Effect of meta-cognitive training in the reduction of positive symptoms in schizophrenia. European Journal of Psychotherapy and Counselling 12, 149158.
Kuokkanen, R, Lappalainen, R, Repo-Tiihonen, E, Tiihonen, J (2014). Metacognitive group training for forensic and dangerous non-forensic patients with schizophrenia: a randomised controlled feasibility trial. Criminal Behaviour and Mental Health 24, 345357.
Langdon, R, Still, M, Connors, MH, Ward, PB, Catts, SV (2013). Attributional biases, paranoia, and depression in early psychosis. British Journal of Clinical Psychology 52, 408423.
Liberati, A, Altman, DG, Tetzlaff, J, Mulrow, C, Gotzsche, PC, Ioannidis, JP, Moher, D (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Medicine 6, e1000100.
McKay, R, Langdon, R, Coltheart, M (2007). Jumping to delusions? Paranoia, probabilistic reasoning, and need for closure. Cognitive Neuropsychiatry 12, 362376.
Moritz, S, Kerstan, A, Veckenstedt, R, Randjbar, S, Vitzthum, F, Schmidt, C, Heise, M, Woodward, TS (2011 a). Further evidence for the efficacy of a metacognitive group training in schizophrenia. Behaviour Research and Therapy 49, 151157.
Moritz, S, Veckenstedt, R, Andreou, C, Bohn, F, Hottenrott, B, Leighton, L, Kother, U, Woodward, TS, Treszl, A, Menon, M, Schneider, BC, Pfueller, U, Roesch-Ely, D (2014). Sustained and “sleeper” effects of group metacognitive training for schizophrenia: a randomized clinical trial. JAMA Psychiatry 71, 11031111.
Moritz, S, Veckenstedt, R, Bohn, F, Hottenrott, B, Scheu, F, Randjbar, S, Aghotor, J, Kother, U, Woodward, TS, Treszl, A, Andreou, C, Pfueller, U, Roesch-Ely, D (2013). Complementary group metacognitive training (MCT) reduces delusional ideation in schizophrenia. Schizophrenia Research 151, 6169.
Moritz, S, Veckenstedt, R, Randjbar, S, Vitzthum, F, Woodward, TS (2011 b). Antipsychotic treatment beyond antipsychotics: metacognitive intervention for schizophrenia patients improves delusional symptoms. Psychological Medicine 41, 18231832.
Moritz, S, Woodward, TS (2005). Jumping to conclusions in delusional and non-delusional schizophrenic patients. British Journal of Clinical Psychology 44, 193207.
Moritz, S, Woodward, TS (2007). Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Current Opinion in Psychiatry 20, 619625.
Morrison, AP (2001). The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy 29, 257276.
National Institute of Clinical Excellence (2009). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Update). National Institute of Clinical Excellence: London, UK.
Naughton, M, Nulty, A, Abidin, Z, Davoren, M, O'Dwyer, S, Kennedy, HG (2012). Effects of group metacognitive training (MCT) on mental capacity and functioning in patients with psychosis in a secure forensic psychiatric hospital: a prospective-cohort waiting list controlled study. BMC Research Notes 5, 302.
Rocha, NB, Queiros, C (2013). Metacognitive and social cognition training (MSCT) in schizophrenia: a preliminary efficacy study. Schizophrenia Research 150, 6468.
Ross, K, Freeman, D, Dunn, G, Garety, P (2011). A randomized experimental investigation of reasoning training for people with delusions. Schizophrenia Bulletin 37, 324333.
So, SH, Garety, PA, Peters, ER, Kapur, S (2010). Do antipsychotics improve reasoning biases? A review. Psychosomatic Medicine 72, 681693.
Tarrier, N, Wykes, T (2004). Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behaviour Research and Therapy 42, 13771401.
Turner, DT, van der Gaag, M, Karyotaki, E, Cuijpers, P (2014). Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. American Journal of Psychiatry 171, 523538.
Van Dael, F, Versmissen, D, Janssen, I, Myin-Germeys, I, van Os, J, Krabbendam, L (2006). Data gathering: biased in psychosis? Schizophrenia Bulletin 32, 341351.
van der Gaag, M (2006). A neuropsychiatric model of biological and psychological processes in the remission of delusions and auditory hallucinations. Schizophrenia Bulletin 32 (Suppl. 1), S113S122.
van der Gaag, M, Hoffman, T, Remijsen, M, Hijman, R, de Haan, L, van Meijel, B, van Harten, PN, Valmaggia, L, de Hert, M, Cuijpers, A, Wiersma, D (2006). The five-factor model of the Positive and Negative Syndrome Scale II: a ten-fold cross-validation of a revised model. Schizophrenia Research 85, 280287.
van der Gaag, M, Valmaggia, LR, Smit, F (2014). The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis. Schizophrenia Research 156, 3037.
van Oosterhout, B, Krabbendam, L, de Boer, K, Ferwerda, J, van der Helm, M, Stant, AD, van der Gaag, M (2014). Metacognitive group training for schizophrenia spectrum patients with delusions: a randomized controlled trial. Psychological Medicine 44, 30253035.
Versmissen, D, Janssen, I, Myin-Germeys, I, Mengelers, R, Campo, JA, van Os, J, Krabbendam, L (2008). Evidence for a relationship between mentalising deficits and paranoia over the psychosis continuum. Schizophrenia Research 99, 103110.
Walston, F, Blennerhassett, RC, Charlton, BG (2000). “Theory of mind”, persecutory delusions and the somatic marker mechanism. Cognitive Neuropsychiatry 5, 161174.
Woodward, TS, Moritz, S, Menon, M, Klinge, R (2008). Belief inflexibility in schizophrenia. Cognitive Neuropsychiatry 13, 267277.
Wykes, T, Steel, C, Everitt, B, Tarrier, N (2008). Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin 34, 523537.
Young, HF, Bentall, RP (1997). Probabilistic reasoning in deluded, depressed and normal subjects: effects of task difficulty and meaningful versus non-meaningful material. Psychological Medicine 27, 455465.
Zimmermann, G, Favrod, J, Trieu, VH, Pomini, V (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research 77, 19.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

van Oosterhout supplementary material
Figures S1-S6

 Word (61 KB)
61 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed