Metacognitive training

1. Introduction

Version followed: group Metacognitive Training for psychosis (MCT; Moritz & Woodward, University Medical Center Hamburg-Eppendorf), current English module set labelled 7.3 with parallel Cycles A and B: 8 core modules plus 2 add-on modules (self-esteem, stigma); and the individualised MCT+ in its 11-unit form as described in the MCT+ multicentre RCT protocol. The full manual (Moritz et al., 2016, VanHam) is not drawn on; module content below comes from the developers' download page, the developers' 2022 overview, the MCT+ protocol and published descriptions of delivery. Variants for depression (D-MCT), OCD (myMCT), borderline personality disorder, bipolar disorder and gambling exist but are not covered here. [source: UKE manual page; Moritz et al. 2022; MCT+ protocol 2016]

MCT is a structured, manualised, mostly group-based cognitive programme for people with psychosis, especially delusions. It does not target the content of delusions head-on. Instead it trains awareness of the thinking styles (cognitive biases) thought to build and maintain delusions: single-cause explanations, jumping to conclusions, inflexibility and bias against disconfirming evidence, social-cognition errors, overconfidence in memory errors and depressive thinking. It uses games, puzzles and everyday examples that show everyone falls into these "cognitive traps". The idea of change: once people see the biases in neutral material, they transfer that awareness to their own beliefs. This lowers their certainty, makes them more willing to consider alternatives and slows their judgements, which loosens delusional conviction indirectly. The developers name reduced response confidence plus openness to alternatives as a key mechanism. Balzan and Galletly describe the aim as planting "seeds of doubt". MCT+ delivers the same bias content one-to-one, combined with CBT for psychosis elements, so it can be applied directly to the person's own symptoms. [source: Wikipedia; Moritz et al. 2022; Balzan & Galletly 2015]

2. Framework

It is a modular programme, not a phased therapy. Group MCT has no clinical phases or progression criteria. It is a rolling cycle of self-contained modules. MCT+ has an ordered sequence of units. [source: Howe & Brown 2015; MCT+ protocol 2016]

Group MCT (core cycle) [source: Howe & Brown 2015; Moritz et al. 2022; UKE manual page; Psychiatria Polska 2009 abstract]

Modules, one per session: (1) Attribution, blaming and taking credit; (2) Jumping to conclusions I; (3) Changing beliefs; (4) To empathise I; (5) Memory; (6) To empathise II; (7) Jumping to conclusions II; (8) Self-esteem and mood. Expanded 10-module version: add (9) Self-esteem and (10) Stigma, run alongside the standard modules.
Two parallel cycles, A and B, cover the same targets with different exercise material. A participant can therefore complete two rounds without repeating items.
Open group: people can join at any module. Each module stands alone.
Frequency and duration: the original Hamburg pilot ran twice weekly. One NHS service ran weekly sessions of about 45 minutes, led by a clinical psychologist. An Indian RCT used twice-weekly one-hour sessions. Group size is not stated in any source. A small group of roughly 3–10 is commonly reported [uncertain].
Materials: slide presentations (PowerPoint/PDF) for each module, a short manual, homework sheets, a yellow card, a red card, a group-rules poster, a flyer and a module overview, the MCT Videosuite clips, and the COGITO app. All are free for non-commercial use and may not be altered.
Each module has three parts: an educational part, practical exercises, and a closing summary with recommendations for daily life. Patient handouts are used between sessions. [source: Možný 2012 abstract]

Who leads, and who joins [source: Moritz et al. 2022; Psychiatria Polska 2009 abstract; Gopal et al. 2019]

Leaders can be psychiatrists, psychologists or psychiatric nurses following the manual. A therapist experienced in running groups with people with psychosis can lead without formal psychotherapy certification. The developers offer optional certified e-learning (e-MCT, about 10 hours, ending in an exam).
Suitable: mild to moderate delusions. Not suitable for the group: severe delusions with unwillingness to engage, marked formal thought disorder, hostility or antisocial behaviour. For acutely unwell people the developers recommend individualised treatment (MCT+) or the briefer "MCT acute" version (available since 2020).

MCT+ (individual) [source: MCT+ protocol 2016; Balzan & Galletly 2015]

Eleven units: (1) case history and alliance; (2) introduction to MCT+ and goals; (3) case formulation; (4) attributional style; (5) decision making and jumping to conclusions; (6) changing beliefs; (7) empathising; (8) memory and certainty of judgement; (9) depression and thinking; (10) self-esteem; (11) diagnosis and relapse prevention.
Dose: the RCT protocol refers to information gathered "over the 6 weeks". In a published case series, a 10-unit version (case history skipped) ran as 4 weekly sessions of 90–120 minutes covering about two units each. The exact session count varies by version [uncertain].
Ordering rule: for a patient with limited insight, case formulation (unit 3) can be moved near the end.
Each unit pairs therapist-led discussion of the topic with worksheet or demonstration exercises.

Moving on [synthesis] Group modules simply rotate. Move a person from group to MCT+ (or the reverse) on clinical grounds: acute symptoms, hostility or inability to tolerate the group point to individual work first; stabilisation points to joining the open group. Offer a second cycle (the other of A/B) when a person found it useful or attended irregularly.

3. Guiding principles

Normalise biases. Everyone makes these thinking errors; frame them as human, not as a deficit. Practical meaning: show the trap with neutral material and point out that most people fall for it, including staff. [source: Moritz et al. 2022; Gopal et al. 2019]
Use a back door, not confrontation. Delusions are not challenged head-on. Practical meaning: work on neutral material first and let participants draw the link to their own beliefs. The aim is to engage people with little insight "without being too confrontational or damaging to the therapeutic alliance". [source: Balzan & Galletly 2015; Gopal et al. 2019]
Sow doubt rather than impose a new belief. Practical meaning: aim for a little less certainty and one more alternative, not for agreement that a belief is false. [source: Balzan & Galletly 2015; Moritz et al. 2022]
Target the process, not the content. Practical meaning: name the thinking style ("jumping", "one cause only", "too sure") rather than debate the facts of a delusion. [source: Wikipedia; Moritz et al. 2022]
Be transparent about why. Each module explicitly says why the group is doing the exercises; this was added after a participant asked. Practical meaning: start every module by stating its purpose and its link to psychosis. [source: Moritz et al. 2022]
Keep it relevant to everyday life. Use games and short case studies tied to daily life. Practical meaning: end each exercise block with "Where does this happen in your life?" [source: Moritz et al. 2022]
Make it playful and engaging. The content is presented playfully as cognitive traps. Practical meaning: keep a light, curious tone; mistakes in the games are expected and welcome. [source: Wikipedia]
Share your own examples. Facilitators and participants share personal experiences. Practical meaning: a brief, safe self-disclosure of your own snap judgement or false memory models that biases are universal. [source: Gopal et al. 2019]
Transfer outside the session. Practical meaning: use homework, the yellow card, the red card and the app every cycle. [source: Moritz et al. 2022; UKE manual page]
Follow the manual and keep the materials intact. Practical meaning: run the slides as supplied; do not alter them or incorporate them into other programmes without asking the authors. [source: UKE manual page]
Start simply. The quick guide says MCT needs little preparation and a group can start even if not everything runs smoothly. Practical meaning: do not delay starting until you feel expert. [source: UKE manual page]
Individualise when needed (MCT+). Practical meaning: for acute, very suspicious or group-averse patients, bring the same bias work to their own examples one-to-one. [source: Moritz et al. 2022; MCT+ protocol 2016]

4. Intervention inventory

Scope note: the manual is not drawn on, so the exercise names and targets come from published module tables (Howe & Brown 2015; MCT+ protocol 2016) and the developers' download page. Step-by-step facilitation detail beyond those descriptions is marked [uncertain] (consistent with published descriptions but not checked against the manual) or [synthesis]. Use the supplied slides, which contain the actual items. [source: Howe & Brown 2015; MCT+ protocol 2016; UKE manual page]

A. Introducing a new participant and running an open group

Purpose: Engage people with little insight and let newcomers join at any module.
Steps: (1) Before the first session, give the flyer or module overview and explain the purpose in plain terms. The developers suggest using these materials to introduce MCT to interested patients. (2) Hang the group-rules poster in the room. (3) In the first session, give each participant the homework sheets, a yellow card and a red card. (4) At each session, welcome newcomers and briefly say what MCT is, because the group is open. [source: UKE manual page; Howe & Brown 2015] (5) Optionally open with a short ice-breaker or relaxation exercise for anxious participants. Howe & Brown suggest this from their experience; it is not part of the programme. [source: Howe & Brown 2015]
Example language (illustrative): "This group is about thinking traps that all of us fall into. We look at puzzles and pictures, see where our minds take shortcuts, and then think about where that happens in daily life."
Watch for: Participants who think they are being told they are "irrational". Reframe as universal traps. Newcomers in the middle of a cycle need a one-line catch-up. [synthesis]

B. Standard module structure (every group session)

Purpose: Keep sessions predictable, transparent and linked to daily life.
Steps: [source: Možný 2012 abstract; Moritz et al. 2022; Howe & Brown 2015] (1) Educational part: introduce the target bias and say explicitly why the group is working on it and how it may relate to psychosis. (2) Practical exercises from the module slides (Cycle A or B). (3) Closing summary with take-home recommendations for daily life, then homework. Starting with a brief recap of the previous module and the homework is the usual structure [uncertain].
Example language (illustrative): "Today's trap is jumping to conclusions. Why bother? Because quick, very certain decisions can lead us to believe things that are not true, and that can be part of how some unusual beliefs start."
Watch for: Running out of time. The slide decks are long, and one review raised doubts about how feasible a full module is in a single session. Prioritise the transfer discussion over finishing every slide. [source: Gopal et al. 2019; synthesis]

1. Module 1: Attribution, blaming and taking credit

Purpose: Target one-sided attributional styles: blaming others for negative events (linked to persecutory ideas) or blaming oneself for them while giving credit away for positive ones (the depressive pattern). Teach multi-cause explanations. [source: Howe & Brown 2015; Moritz et al. 2022]
Steps: (1) Explain attribution: we explain events by ourselves, other people or circumstances. (2) Present everyday scenarios, positive and negative. The materials are based on an attributional-style questionnaire (IPSAQ); do not reproduce the questionnaire. (3) For each scenario, ask the group to generate several possible causes covering self, others and circumstances. (4) Point out that most events have several causes, and that habitually choosing one type of cause has consequences: blaming others breeds conflict and suspicion; always blaming oneself lowers mood. (5) Link to psychosis: single-cause, other-blaming explanations can feed persecutory ideas. (6) Summary and homework. [source: Howe & Brown 2015; Moritz et al. 2022; steps 3–5 sequencing uncertain]
Example language (illustrative): "A friend walks past without saying hello. Let us collect every reason we can think of: something about me, something about them, something about the situation."
Watch for: Participants who list only external, hostile causes. Ask for one cause in each category. It is working when participants spontaneously offer "it could also be…". [synthesis]

2. Module 2: Jumping to conclusions I

Purpose: Target hasty decisions on too little evidence and "liberal acceptance" of implausible explanations. [source: Howe & Brown 2015]
Steps: (1) Discuss everyday situations that invite rash decisions, and their downsides, such as buying the wrong thing, wrongly suspecting someone or falling for fake news. (2) Picture exercise: show pictures that reveal an object gradually, from fragments to a complete image. At each stage, participants say what they think it is and how sure they are. (3) Reveal the answer and look at how early, confident guesses went wrong. (4) Draw the lesson: gather enough information before deciding, especially for important decisions, and notice when you feel certain early. (5) Link to psychosis: deciding on thin evidence can help unusual beliefs form. (6) Summary and homework. [source: Howe & Brown 2015; MCT+ protocol 2016; step order uncertain]
Example language (illustrative): "Before we reveal more: how sure are you, from 0 to 100? … Interesting, several of us were very sure at the second picture and it turned out to be something else."
Watch for: Embarrassment at wrong guesses. Normalise it and have the facilitator guess wrongly too. It is working when people start to say "I'll wait for the next picture". [synthesis]

3. Module 3: Changing beliefs

Purpose: Target belief inflexibility and the bias against disconfirmatory evidence (BADE): holding on to a first interpretation when new information contradicts it. [source: Howe & Brown 2015; Moritz et al. 2022]
Steps: (1) Discuss how beliefs that once seemed obvious can turn out wrong, and the costs of rigid thinking. (2) Cartoon-sequence exercise: show picture stories in reverse order, starting with the last picture, so each new picture adds earlier context. At each step participants judge which of several explanations is most likely and revise as information arrives. (3) Review how first impressions misled and how the full story changed the picture. (4) Lesson: hold off strong judgements until enough evidence is in, and stay willing to revise. (5) Link to psychosis: beliefs that ignore contradicting evidence can become fixed. (6) Summary and homework. [source: Howe & Brown 2015; MCT+ protocol 2016; rating format uncertain]
Example language (illustrative): "With this new picture, does your first explanation still hold up? What would you change?"
Watch for: Participants defending their first choice. Praise revision explicitly. It is working when they lower their ratings for an earlier favourite as evidence changes. [synthesis]

4. Module 4: To empathise I

Purpose: Target theory-of-mind and social-cognition errors: misreading others' feelings and intentions from too few cues. [source: Howe & Brown 2015]
Steps: (1) Discuss how hard it is to know what others feel or intend. (2) Face exercise: show facial expressions and ask what the person feels. Reveal the answer or context and note how often faces mislead. (3) Incomplete cartoon strips: infer what characters feel and think, then add context. (4) Lesson: use several cues (situation, words, behaviour, what you know about the person), not facial expression alone. Ask, or wait for more information, before concluding. (5) Link to psychosis: misreading neutral faces as hostile can fuel suspicion. (6) Summary and homework. [source: Howe & Brown 2015; MCT+ protocol 2016]
Example language (illustrative): "If you only had this face, what would you guess? … Now here is the situation around it. Did that change your guess?"
Watch for: Participants who read threat in neutral faces. Gently ask for alternative readings. It is working when they name context cues before judging. [synthesis]

5. Module 5: Memory

Purpose: Target overconfidence in memory errors: being highly certain about false memories, and too little certainty about correct ones. [source: Howe & Brown 2015; MCT+ protocol 2016]
Steps: (1) Discuss what helps memory (attention, rehearsal, emotional relevance) and what harms it (stress, distraction, time). (2) Normalise false memories: everyone fills gaps with what "should" have been there. (3) Scene exercise: show a complex scene. Later, ask participants to recall or recognise items and spot what was missing, rating their confidence. Some items are plausible but were not present. (4) Reveal the answers. Note that false memories feel real, but correct memories are often more vivid and detailed. (5) Lesson: when a memory is vague, check it with other people or with records before acting on it, and be careful when certain without vivid detail. (6) Summary and homework. [source: Howe & Brown 2015; MCT+ protocol 2016]
Example language (illustrative): "Who remembers the towel on the beach? … There wasn't one. Our minds add what fits. So how could you check a memory you are unsure of?"
Watch for: Shame about memory errors, especially in people with real cognitive impairment. Stress that this is a universal effect. It is working when participants lower their confidence for items they cannot picture clearly. [synthesis] (The example item is illustrative, not taken from the materials.)

6. Module 6: To empathise II

Purpose: Target theory-of-mind errors and need for closure, including confusing what you know with what a character knows. [source: Howe & Brown 2015]
Steps: (1) Discuss the features that guide our inferences about others: context, prior knowledge, language, behaviour. (2) Cartoon sequences: take one character's perspective and judge what that character knows, believes or will do, separating it from what the viewer knows. (3) Discuss the pressure to reach a quick answer and how tolerating uncertainty helps. (4) Summary and homework. [source: Howe & Brown 2015] Version note: the developers' download page recommends the "BADE version" of module 6, described in the manual. Its exact content could not be checked; follow the current manual [uncertain]. [source: UKE manual page]
Example language (illustrative): "We know what is in the box, but does she? What would she think, given only what she saw?"
Watch for: Concrete thinkers who struggle with perspective-taking. Slow down and use one character at a time. [synthesis]

7. Module 7: Jumping to conclusions II

Purpose: Second pass at hasty decisions and liberal acceptance, with new material. [source: Howe & Brown 2015]
Steps: (1) Recap the jumping-to-conclusions trap. (2) Painting-title exercise: show a painting with four candidate titles and decide which is correct, ideally judging each option's plausibility rather than picking at once. (3) Reveal the answer. Discuss how quickly some options seemed right and how implausible options were sometimes accepted too readily. (4) Lesson: weigh all options, look for more information, and rule out options that do not fit. (5) Link to psychosis and daily life (rumours, online claims). (6) Summary and homework. [source: Howe & Brown 2015; rating-per-option format uncertain]
Example language (illustrative): "Before choosing, rate each title: possible, likely, or ruled out. What in the picture supports each one?"
Watch for: Overconfident single choices. Ask "what would make you less sure?" [synthesis]

8. Module 8: Self-esteem and mood

Purpose: Address depression, which is common in psychosis, and depressive thinking patterns. [source: Howe & Brown 2015; Moritz et al. 2022]
Steps: (1) Psychoeducation on the causes, symptoms and treatment of depression. (2) Identify typical depressive thinking patterns, such as overgeneralisation, selective attention to the negative, black-and-white thinking and "should" statements. (3) Practise replacing them with more balanced thoughts using examples. (4) Discuss strategies to boost self-esteem and mood. (5) Summary and homework. [source: Howe & Brown 2015; MCT+ protocol 2016 for steps 2–3]
Example language (illustrative): "'I fail at everything.' Is there a more balanced way to say that, one you could actually believe?"
Watch for: Disclosure of hopelessness or suicidal thoughts. Follow your service's standard risk-assessment procedure after the session. [synthesis]

9. Add-on module: Self-esteem

Purpose: Address low self-esteem. The expanded 10-module version runs it in addition to the standard modules. [source: Wikipedia; Moritz et al. 2022; UKE manual page]
Steps: The group module's content is not drawn on [uncertain]. The MCT+ self-esteem unit, which plausibly overlaps, (1) presents self-esteem as largely self-determined, (2) discusses how psychotic symptoms can affect self-esteem in either direction, (3) explores how voice content may mirror inner conflicts, using an "inner critic" versus "well-meaning companion" metaphor, and (4) has the person list personal strengths. [source: MCT+ protocol 2016]
Example language (illustrative): "What would a well-meaning companion say about the same situation your inner critic is commenting on?"
Watch for: Participants unable to name any strengths. Let the group offer observations, or start with small, concrete ones. [synthesis]

10. Add-on module: Stigma

Purpose: Address public stigma and self-stigma linked to psychosis. [source: Wikipedia; Moritz et al. 2022]
Steps: Content is not drawn on [uncertain]. The MCT+ relapse-prevention unit covers coping with the diagnosis, including disclosure in social settings, which indicates the likely focus. [source: MCT+ protocol 2016] As a working outline [synthesis]: discuss common stereotypes and their inaccuracy, notice when one has taken them on oneself, and weigh the pros and cons of disclosure in specific settings.
Watch for: Distress from past discrimination. Validate it before moving to coping. [synthesis]

11. Yellow card

Purpose: A pocket prompt for checking one's thinking in daily life. [source: UKE manual page]
Steps: Give each participant a card at the start. The card prompts three checks: what is the evidence? are there other ways to see it? am I overreacting, even if things are as they seem? Practise using it on a recent example in the group. [source: UKE manual page; practice step synthesis]
Example language (illustrative): "Next time you feel sure someone is against you, take out the card and go through the three questions before you act."
Watch for: Whether participants report actually using it. Ask at the start of each session. [synthesis]

12. Red card

Purpose: Crisis planning. [source: UKE manual page]
Steps: Each participant writes the names and phone numbers of people and services who can help in a crisis. Check that the numbers are current. [source: UKE manual page; check step synthesis]
Watch for: People with no personal contacts. Help them list services, and link with their care coordinator. [synthesis]

13. Homework sheets

Purpose: Transfer from the session to daily life. [source: UKE manual page; Možný 2012 abstract]
Steps: Hand all participants the homework sheets after the first session. Set the homework that matches each module, and review it at the next session. [source: UKE manual page; review step uncertain]
Watch for: Low completion. See section 5.

14. Supporting media: MCT Videosuite and the COGITO app

Purpose: Videos illustrating cognitive biases serve as visual aids in sessions. The COGITO app (formerly "MCT and More") sends daily self-help exercises at times the user chooses, with favourites, personalisation and user-added exercises. [source: UKE manual page; Moritz et al. 2022]
Steps: Show the relevant clip when introducing a bias. Help interested participants install the app and pick one or two notification times. [source: Moritz et al. 2022]
Watch for: Paranoid concerns about phones or apps. Make the app optional. [synthesis]

15. Format variants: MCT acute, negative-symptom adaptation and remote delivery

MCT acute: a briefer version for acute exacerbations, available since 2020. Its content is not drawn on [uncertain]. [source: Moritz et al. 2022]
Negative-symptom adaptation: a modified version based on Swanson and colleagues' work, available from the MCT website. Its content is not drawn on [uncertain]. [source: Moritz et al. 2022; Wikipedia]
Remote delivery: groups were run over video during COVID-19. [source: Moritz et al. 2022]
Single-module brief version: Balzan et al. (2014) tested a one-session programme combining jumping-to-conclusions and BADE content. [source: Gopal et al. 2019]

16. MCT+ unit 1: Case history and alliance

Purpose: Understand the person's problems and build a working relationship. [source: MCT+ protocol 2016]
Steps: (1) Clinical interview on current problems, symptoms and past treatment. (2) Use worksheets to identify delusions and hallucinations, how certain the person is about them, and related interpersonal or coping difficulties. (3) Explore motivation, and attend to the therapeutic relationship. [source: MCT+ protocol 2016]
Example language (illustrative): "What has been most troubling for you lately? … And how sure are you, from 0 to 100, that it is happening the way you describe?"
Watch for: Conviction ratings, which give a baseline for later doubt. Suspicion of the therapist. [synthesis]

17. MCT+ unit 2: Introduction and goals

Purpose: Explain the programme and agree goals. [source: MCT+ protocol 2016; Balzan & Galletly 2015]
Steps: (1) Explain MCT+ and its main strategies. (2) Set personal goals; a published example is reducing paranoia in public places. (3) List the person's symptoms and how distressing they are or were. [source: MCT+ protocol 2016; Balzan & Galletly 2015]
Example language (illustrative): "What would you like to be different at the end of our sessions? Something you could notice in daily life."
Watch for: Goals framed only as "make them stop". Translate into goals within the person's control. [synthesis]

18. MCT+ unit 3: Case formulation (fire metaphor)

Purpose: Build an individual vulnerability-stress model. [source: MCT+ protocol 2016]
Steps: (1) Explain the metaphor: vulnerability factors are like wood or coals, a triggering stressor is the spark, and symptom-reducing interventions are the fire extinguisher. (2) Fill it in with the person's own vulnerabilities, triggers and helpful strategies. (3) If insight is limited, move this unit near the end of therapy. [source: MCT+ protocol 2016]
Example language (illustrative): "What do you think piled up the wood for you? What was the spark last time? And what has helped put things out?"
Watch for: Rejecting an illness model. Use the person's own words, such as "stress" or "crisis", and defer the unit if needed. [synthesis]

19. MCT+ units 4–8: Individualised bias work

Purpose: Apply the six bias topics (attribution, decision making/jumping to conclusions, changing beliefs, empathising, memory and certainty) to the person's own experiences. [source: MCT+ protocol 2016; Balzan & Galletly 2015]
Steps: For each unit: (1) therapist-led discussion of the bias, with demonstration exercises from the materials. These are the same types as in the group (a card trick for attribution, line drawings that become progressively clearer, reversed picture stories, picture-based guessing of feelings, complex scenes for memory errors). (2) Fictional examples, then personal ones. (3) Reality testing: recall everyday events that seem to support the belief and consider other explanations for them. (4) Socratic weighing of the pros, cons and consequences of a view. (5) Practical rules: gather enough evidence before deciding; collect several social cues before inferring intent; check vague memories with others or with records. [source: MCT+ protocol 2016; Balzan & Galletly 2015]
Example language (illustrative): "Last week you said the neighbour's cough was a signal. Using what we did today, what other explanations could there be? How sure are you now?"
Watch for: Pushing too hard on the delusion. Keep the stance non-confrontational. Progress shows as a drop in conviction ratings and more alternatives offered by the person. [source: Balzan & Galletly 2015; synthesis]

20. MCT+ unit 9: Depression and thinking

Purpose: Address depression-related thought distortions and low self-perception. [source: MCT+ protocol 2016]
Steps: Identify the person's black-and-white thinking and "should" statements, then practise more balanced replacements on their own examples. [source: MCT+ protocol 2016]
Watch for: Suicidality. Assess risk using your service's standard procedure. [synthesis]

21. MCT+ unit 10: Self-esteem

Purpose: Strengthen self-esteem. [source: MCT+ protocol 2016]
Steps: (1) Present self-esteem as largely self-determined. (2) Discuss how psychotic symptoms can raise or lower self-esteem. (3) Explore whether voice content mirrors inner conflicts, using the inner critic versus well-meaning companion metaphor. (4) Identify personal strengths. [source: MCT+ protocol 2016]
Watch for: Grandiose ideas that prop up self-esteem. Handle them gently, since challenging them can lower mood. [synthesis]

22. MCT+ unit 11: Diagnosis and relapse prevention

Purpose: Cope with the diagnosis and prevent relapse. [source: MCT+ protocol 2016]
Steps: (1) Discuss coping with the diagnosis, including disclosure in social settings and possible illness course. (2) Draw up an emergency plan; the red card can be used here. (3) Identify early warning signs, involving relatives where possible, since they often notice signs first. (4) Pull together what was learned across the sessions. [source: MCT+ protocol 2016; red-card link synthesis]
Example language (illustrative): "What were the first small changes last time, before things got bad? Who around you would notice them?"
Watch for: Fatalism about the diagnosis. Balance it with what the person has learned to do. [synthesis]

5. Handling problems

The developers publish a separate "tips for dealing with difficult therapy situations" download. It is not drawn on, so most guidance below is marked [synthesis]; check it against that document. [source: UKE manual page] [uncertain]

Acutely psychotic, very severe delusions, marked thought disorder, hostility. These people do not fit the group. Offer individual MCT+ or MCT acute first, and bring them into the group once they are more settled. [source: Moritz et al. 2022]
Anxiety about the group, or a paranoid participant wary of others. Open with a brief ice-breaker or relaxation exercise. [source: Howe & Brown 2015, as their suggestion] Let the person sit near the door, allow them to watch without speaking, and offer a pre-group individual meeting. [synthesis]
Participant uses an exercise to "prove" the delusion, or brings delusional content into the group. Do not debate it in front of the group. Acknowledge the experience, return to the thinking style ("Let us see which trap we might all fall into here"), use the yellow-card questions, and offer to discuss it individually afterwards. Shield other members from detailed delusional material. [synthesis]
Participant challenges the point of the exercises ("this is childish"). Explain the rationale transparently, as the developers built in after exactly such a question. Link the game to a real-life cost of the bias. [source: Moritz et al. 2022; synthesis]
Stuck: no transfer from games to own beliefs. Use everyday, non-delusional examples first, such as misjudging a text message. Ask "has this ever happened to you?" rather than "is your belief an example?" Consider adding MCT+ sessions for personal application. [synthesis; MCT+ rationale from MCT+ protocol 2016]
Overconfidence in the room ("I never make mistakes"). Let the exercises do the work: show the confidence rating against the result without comment, and model your own error. [synthesis]
Dominating or disruptive members. Refer to the group-rules poster, give structured turns, and talk privately after the session. Persistent hostility meets the published exclusion criterion, so move the person to individual work. [source: UKE manual page for rules poster; Moritz et al. 2022; rest synthesis]
Overwhelm, or slide decks too long. Cut the number of exercise items rather than the transfer discussion. Slow down for participants with cognitive impairment. The feasibility of full modules has been questioned in some settings. [source: Gopal et al. 2019; synthesis]
Non-adherence (homework, attendance). The group is open and the modules stand alone, so missed sessions can be made up in the next cycle (A/B). Keep homework short, review it briefly without judgement, and use the yellow card and COGITO prompts as low-effort alternatives. [synthesis]
Rupture: participant feels mocked or exposed by wrong answers. Repair it directly. Restate that everyone, staff included, falls for these traps. Avoid singling anyone out; use group-level rating rather than individual answers when people are sensitive. [synthesis]
Mood drop or suicidal ideation (module 8 or the self-esteem module). Follow standard risk assessment and the service's protocol after the session; check the red card is complete; inform the care team. [synthesis]
Stigma distress or harmful disclosure (stigma module, MCT+ unit 11). Explore the pros and cons of disclosure for the specific setting, without pushing either way. [synthesis; disclosure topic from MCT+ protocol 2016]
Medication or diagnosis disputes. MCT is offered as an add-on. Do not make engagement conditional on accepting a diagnosis. In MCT+, defer the case formulation (fire metaphor) for people with low insight. [source: MCT+ protocol 2016; rest synthesis]
Fidelity drift (adding or editing slides). The materials may not be altered without consulting the authors. Make adaptations in delivery, not in the slides. [source: UKE manual page]

Sources

Sources:

Books cited (not drawn on):

Moritz, S., Bohn, F., Veckenstedt, R., Hottenrott, B., & Woodward, T. S. (2016). Metacognitive Training for schizophrenic patients (MKT): Manual. Hamburg: VanHam.
Moritz, S., Krieger, E., Bohn, F., & Veckenstedt, R. (2017). MKT+: Individualisiertes metakognitives Therapieprogramm für Menschen mit Psychose. Berlin: Springer.

Not drawn on, cited via the sources above: Moritz et al. (2014), Sowing the seeds of doubt, Clinical Psychology Review 34(4); Balzan et al. (2014), single-module MCT. [uncertain]

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