Why metacognition matters

Dysfunctions in metacognition and mentalising are consistently documented in severe and complex psychiatric disorders, including, but not limited to, schizophrenia, ^{Reference Lysaker, Hamm, Hasson-Ohayon, Pattison and Leonhardt5} personality disorders ^{Reference Semerari, Colle, Pellecchia, Buccione, Carcione and Dimaggio1,Reference Dimaggio, Centonze, Ottavi and Popolo2} and eating disorders. ^{Reference Bora7} Across these conditions, impoverished metacognition predicts psychiatric and functional outcomes, including symptoms, social withdrawal, rigidity and poor adaptation. From a clinical perspective, it stands to reason that patients who cannot articulate their emotions or needs, or imagine how others will respond, will likely lack the flexibility to navigate complex social contexts. Conversely, the capacity to flexibly generate, test and revise representations of one’s own and others’ minds enhances the ability to adapt, repair ruptures and sustain reciprocal relationships in a rapidly changing social world.

Recent developments emphasise that the value of considering metacognition in therapy goes beyond abstract insights – it is an evolving lifespan capacity essential for social and interpersonal functioning, problem-solving, adaptation to challenges and the pursuit of personally meaningful life goals. ^{Reference Dimaggio, Centonze, Ottavi and Popolo2} Therefore, psychotherapy should not only aim to foster reflective understanding within the therapy room, but also equip patients with the tools to apply this awareness in emotionally significant everyday interactions – such as seeking care, recognition or intimacy.

A critique of this stance is that focusing on real-world outcomes blurs the boundaries between clinical and functional improvement, but we contend that a metacognitive approach is consistent with contemporary societal demands for interventions that go beyond symptom reduction and enable individuals to grow through more productive interactions with their social and interpersonal worlds.

Promoting metacognition is also important for enhancing engagement with psychiatric management and medication adherence, particularly in diagnoses such as psychotic or bipolar disorders. Although the concept of insight in psychiatric disorder has a thorny history, promoting awareness of the underlying mental processes that may improve through psychopharmacology can help foster acceptance, engagement and adherence with medication. ^{Reference Lysaker, Hamm, Hasson-Ohayon, Pattison and Leonhardt5} For instance, in managing psychosis, this offers clinicians an alternative framing for medication that sidesteps traditional notions of insight by recasting the patient’s experience, such as ‘When you are under stress, you tend to feel distressed or afraid, and at these times, having experiences such as hearing voices increases your distress even further, creating a toxic cycle. Medication might help you control these experiences, enabling us to discuss strategies to manage your negative thoughts and feelings, and breaking the cycle of distress.’

How psychotherapy creates metacognitive scaffolding

Given that poor metacognition constrains the ability to benefit from therapeutic techniques, the clinician’s first task is to construct a temporary mental framework with the patient whereby reflection becomes safe and emotionally tolerable. As impaired metacognition is a transdiagnostic mechanism, improving metacognition becomes a transdiagnostic target. Individuals with different psychopathologies may benefit when psychotherapy helps them enhance awareness and regulation of mental states. Similarly, different therapeutic approaches that nonetheless incorporate metacognition and mentalising in their protocols may create different routes to therapeutic change.

We propose that the therapeutic relationship functions as a metacognitive scaffold – a space in which the therapist temporarily shares their own integrative capacity to help the patient notice, name and tolerate internal experiences that were previously experienced as confusing, threatening or distressing. Repeated over sessions, this interactive regulation enables patients to begin linking feelings, thoughts, intentions and actions into coherent narratives – transforming fragmented experience into meaning.

When? The metacognitive cycle of change: from awareness to enactment

Within a well-regulated therapeutic relationship, fostering metacognition can facilitate change at multiple levels. With psychiatric symptoms, clinicians can help patients understand the cognitive–affective antecedents of maladaptive behaviours, leading to behavioural change. We illustrate this with three examples, showing that metacognition is not a unitary skill, but a layered process encompassing awareness, differentiation, integration and mastery.

In eating disorders, psychotherapy may promote awareness of triggers for binge episodes. Before treatment, a patient might only report bingeing when ‘confused’ or ‘desperate’. Through metacognitive work, they learn to identify emotions and thoughts occurring before the loss of control that initiates bingeing. This awareness shifts the ‘time stamp’ for identifying maladaptive antecedents, enabling more adaptive coping.

In psychosis, therapists can help patients recognise their thoughts as their own and therefore subject to reflection and revision, while also reconnecting them with agency and desire. This may enhance engagement with rehabilitation, social skills and vocational programmes.

In personality disorders, patients can be scaffolded across multiple aspects of metacognition or mentalising. For instance, those with avoidant presentations can be supported to name emotions and discover their capacity to regulate them. Clinicians can help patients recognise how and when interpretative biases shape interpersonal reactions, and support patients in understanding that intentions, meanings and symbolic cues carry as much weight as concrete behaviours – accordingly reframing teleological thinking. ^{Reference Bateman and Fonagy6} A patient might initially think, ‘I feel bad when people at work ignore me because I’m awkward’, but later realise that distress stems not only from others’ behaviour, but also from interpreting neglect as confirmation of a self-schema: ‘I am flawed and undeserving’, which triggers a specific emotion – shame.

Focusing on metacognition also enables patients to recognise that protective behaviours – avoidance, perfectionism and submission – may initially shield against anticipated neglect or criticism, but ultimately perpetuate distress. Enhancing metacognition thus allows patients to make sense of behavioural experiments and social exposures that improve functioning, relapse prevention and resilience.

Metacognitive growth unfolds through a cyclical process ^{Reference Dimaggio, Centonze, Ottavi and Popolo2} that can guide treatment formulation across disorders:

1. (a) Metacognitive clarification: identifying and verbalising mental states as they emerge. For example, a young man avoids confrontation saying, ‘I do not like tension’, while showing agitation and scanning eye movements – suggesting an unrecognised fear of humiliation. Scaffolding awareness leads to an expanded formulation: ‘I now realise I avoid confrontations out of a deep fear of humiliation that I couldn’t cope with’.

2. (b) Experiential enactment: exploring mental states through emotionally activating techniques (e.g. role-play, imagery, chairwork). The therapist invites the patient to revisit a memory of criticism in imagery; arousal increases, and distress becomes clearer, evoking memories of early abuse. This creates opportunities for rescripting.

3. (c) Behavioural rehearsal: testing new understandings in real-life contexts, monitoring emerging mental states during homework and reflecting on outcomes in session. The patient, now aware that avoidance relates to trauma-based fear rather than shyness, engages in exposure and reprocessing, gradually regaining agency.

Each phase opens a new window of reorganisation, whereby stored memories can be rewritten as new meaning emerges and new structures form. ^{Reference Lee, Nader and Schiller9} Therapists must guide this process with empathic precision – knowing when to amplify or contain affect – so that metacognitive capacity can progressively expand. The therapeutic encounter thus becomes a dynamic laboratory in which individuals learn to think and feel about their own thinking and feeling, practising behavioural regulation through awareness.

Contemporary psychotherapy: from insight to embodied integration

The most effective psychotherapies do not simply provide insight, but foster experiential learning that transforms how individuals use their minds in relation to others. Experiential methods – imagery rescripting, chairwork, role-play – create emotionally salient moments that challenge rigid narratives while maintaining safety. Behavioural experiments then consolidate these discoveries into lived patterns of functioning.

We suggest that one active ingredient of change lies in this recursive movement: on one hand, exploring emotional arousal within a safe relational frame and increasing awareness of mental states; on the other, practising new, healthier behaviours guided by a richer understanding of self and others. This constitutes a metacognitive cycle of change that hypothetically updates both neural and interpersonal representations. ^{Reference Dimaggio, Centonze, Ottavi and Popolo2,Reference Lee, Nader and Schiller9} This cycle also provides a translational bridge between psychotherapy process research and neuroscience models of memory reconsolidation and predictive coding, ^{Reference Bora7} offering a shared language for mind–brain integration.

A potential unifying principle for psychotherapy

Placing metacognition or mentalising ^{Reference Semerari, Colle, Pellecchia, Buccione, Carcione and Dimaggio1,Reference Dimaggio, Centonze, Ottavi and Popolo2,Reference Luyten, Campbell, Allison and Fonagy3} at the centre of psychotherapy bridges traditions that have often competed for theoretical territory, inadvertently holding back progress. What unites effective interventions is not model fidelity, but their capacity to scaffold awareness, integration and flexible use of mental states. This framework provides a common language linking cognitive–behavioural, psychodynamic and experiential approaches while remaining open to empirical validation.

This creates potential for matching patients to the most appropriate therapeutic modality at the optimal time, without reducing psychotherapy to a few evidence-based techniques. By reframing psychotherapy as the cultivation of metacognitive agency, we move from explaining change to facilitating it – a shift that could redefine both clinical training and outcome research.

In emphasising the how, why and when of change, we invite clinicians and researchers to view psychotherapy as a collaborative exercise in metacognitive cultivation – a practise through which minds learn to understand themselves and one another more deeply, allowing human beings to act, relate and flourish with greater freedom and coherence.