If you walk into a Metacognitive Training group for psychosis, you might mistake it for a slightly unusual classroom. There is a projector, a set of slides, a friendly facilitator, and a group of people working through brain teasers and visual puzzles together. There is very little discussion of individual symptoms. This is the point. Metacognitive Training (MCT), developed by Steffen Moritz and colleagues at the University of Hamburg in the early 2000s, takes a sideways approach to psychosis: rather than working on the content of any particular delusion or voice, it trains the underlying thinking habits that make psychotic thought patterns sticky.
Metacognitive Training is an 8-to-10-session manualised group (or individual) programme that uses exercises and examples to target cognitive biases — jumping to conclusions, overconfidence in errors, attributional bias, and others — that contribute to delusional thinking.
What "metacognition" means here
Metacognition is "thinking about thinking" — the awareness of how our minds work, where they are reliable, and where they reliably go wrong. MCT teaches participants that all human brains have systematic biases, that these biases can be learned and noticed, and that catching them in real time can interrupt the cascade that turns a stray suspicion into a fixed delusional belief.
The full programme is freely available in dozens of languages from the University Medical Center Hamburg-Eppendorf at clinical-neuropsychology.de. The fact that it is free, manualised, and available globally has made it one of the most-implemented psychological interventions for psychosis in the world.
The cognitive biases MCT targets
Jumping to conclusions
One of the most replicated findings in psychosis research is that people with delusions often reach conclusions faster and on less evidence than controls. The classic test is the "beads task" (Garety and colleagues, 1991): participants see beads drawn from a hidden jar and must decide which of two jars they came from. People with delusions tend to decide after one or two beads where controls wait for five or six. MCT exercises directly illustrate this and invite participants to slow down and demand more evidence.
Bias against disconfirmatory evidence
Once a belief has formed, people with psychosis often weight new evidence asymmetrically — strongly noting evidence that supports the belief and dismissing evidence that contradicts it. MCT exercises model this bias and teach participants to deliberately seek and weigh disconfirmatory evidence.
Attributional bias
People with persecutory delusions often show an exaggerated tendency to blame negative events on the deliberate actions of others (rather than chance or their own role). MCT exercises explore alternative explanations for ambiguous social situations.
Overconfidence in errors
People with psychosis sometimes hold incorrect memories or judgments with extreme confidence. MCT exercises demonstrate this in low-stakes domains (visual puzzles, memory tasks) so participants can experience their own overconfidence in a non-threatening way.
Theory of mind difficulties
Subtle difficulties in inferring others' mental states can contribute to social misinterpretation. MCT includes exercises on reading facial expressions and social context.
Mood and self-esteem
Later modules address depression and low self-esteem, which often drive delusional themes.
How a session typically runs
An MCT session is about 45 to 60 minutes. The facilitator presents the bias of the week, walks through visual examples, asks the group what they would conclude, then reveals the actual answer (which is often surprising). Discussion is light and humorous; the format is deliberately non-threatening. Participants are not asked to share symptoms or apply the lessons to their own delusions in the room. The transfer happens later, on the participants' own time.
Why this format works
- Non-threatening — no one has to disclose their own beliefs in the group
- Group format reduces stigma — participants see they are not alone
- Concrete and visual — easier to engage with than abstract belief discussion
- Skills generalise — once you notice yourself jumping to conclusions about beads, you can notice it about your neighbours
- Cheap to deliver — group format, manualised, free materials
What the evidence shows
The MCT evidence base is now substantial. A 2018 meta-analysis by Eichner and Berna in Schizophrenia Bulletin (indexed at PubMed) reviewed 15 trials and found small-to-moderate effects on positive symptoms and on jumping-to-conclusions bias, with effects sustained at follow-up. Several individual trials have shown reductions in delusional severity comparable to standard CBTp at lower delivery cost.
Two practical features make MCT distinctive: the effects appear to be at least partially mediated by changes in the underlying cognitive biases, supporting the theoretical model; and the gains tend to be durable, with several follow-up studies showing maintained benefits at 6 to 12 months and sometimes longer.
How MCT relates to standard CBTp
MCT and CBTp are complementary. Standard CBTp tends to be individual, longer (16 to 26 sessions), and focused on specific symptoms and personal formulation. MCT is shorter, group-based, and focused on cross-cutting thinking habits. Many services use both. NICE includes psychological interventions broadly in its psychosis recommendations and does not single out MCT, but Germany, the Netherlands, and several other countries have included MCT formally in their guideline recommendations.
An individual variant: MCT+
An individual version called MCT+ integrates the same cognitive bias work with personalised symptom-focused work, blending MCT and CBTp elements. This is used when a patient cannot attend group or when the symptom-focused work needs more depth.
Who it suits
- People with persistent positive symptoms, particularly delusions
- People who would not engage with individual symptom-focused therapy
- People in early intervention services where a group programme is feasible
- People who want a non-stigmatising entry point to psychological work
Limitations
- Less direct work on individual delusional content
- Less individualised formulation
- Group format is not for everyone
- Effects on negative symptoms are smaller than on positive symptoms
Finding MCT
The MCT materials are free at clinical-neuropsychology.de and can be delivered by any trained mental health professional. In the UK, several Early Intervention in Psychosis teams use it. In the US, availability is patchier but growing, particularly in academic medical centres. Some peer support organisations have begun offering peer-led MCT-inspired groups.
For people considering this work
If individual CBTp is unavailable or unappealing, a Metacognitive Training group may be a good entry point. The format is gentler, the time commitment lower, and the skills carry over into other work later. It is not a replacement for medication or for individual therapy when that is needed, but it is one of the best-supported group interventions in modern psychosis care.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.