Metacognition - Schizophrenia Research

SCHRES-07880; No of Pages 7 Schizophrenia Research xxx (2018) xxx–xxx

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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 b c

Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Roudebush VA Medical Center, Indianapolis, IN, USA Indiana University School of Medicine, IN, USA

a r t i c l e

i n f o

Article history: Received 23 March 2018 Received in revised form 1 June 2018 Accepted 3 June 2018 Available online xxxx Keywords: Psychosis Metacognition Metacognitive knowledge Cognitive insight Metacognitive Therapy

a b s t r a c t In the last two decades years, several interventions have been designed for people with major psychological disorders that all have “metacognitive” in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes “true” metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label “metacognition.” © 2018 Published by Elsevier B.V.

1. Introduction

1.1. Flavell's concept of metacognition

During the last two decades, several ‘metacognitive’ interventions for people with severe psychological problems, including psychosis, have been developed: Metacognitive Therapy (MCT; Wells, 2009), Metacognitive Training (e.g., for people with psychosis) (Moritz et al., 2014) and Metacognitive Reflection and Insight Therapy (Lysaker et al., 2018; Lysaker and Klion, 2017). The starting point of the present review is a lingering debate initiated by Adrian Wells about what constitutes a true metacognitive intervention (Andreou et al., 2018; Capobianco and Wells, 2018; Wells and Fisher, 2011). As we will present in greater depth below, Wells and colleagues assume that only Metacognitive Therapy works at a meta-level, while, for example, Metacognitive Training works on what they call “ordinary cognitions” (Capobianco and Wells, 2018). To provide an answer to this question, one first needs to understand what is meant by the term metacognition. Our review will therefore briefly summarize the original concept devised by Flavell (1979), followed by a summary of the rational and therapeutic mechanisms of each of the three approaches. We will discuss how each treatment maps onto Flavell's original definition as well as their similarities and differences.

The term metacognition was coined by James H. Flavell in the 1970s (Flavell, 1979). While it was originally described as “knowledge and cognition about cognitive phenomena” (p. 906) in Flavell's seminal paper, it is now usually defined more briefly but also more broadly as “thinking about thinking.” The label was new, the concept was not. Flavell's account was built upon earlier research on (memory) “monitoring” (e.g., Hart, 1967) – a term that is still in use – and “knowledge about knowledge” (Tulving and Madigan, 1970). Even Vygotsky (1934) has been credited as one of the originators of research into metacognition (Reynolds and Wade, 1986); according to Spearman (1923; p. 52–53) the roots may even date back to Plato's “cognizing about cognition.” Flavell himself was particularly interested in differences in cognitive monitoring across different stages of childhood and adolescence. As an introductory example to illustrate how metacognitive processes appear in the world, he turned to an earlier study by his group on nursery school, kindergarten, second grade, and fourth grade children who were instructed to learn items to the point of perfect recall (Flavell et al., 1970). Older children, unlike younger children, tended to employ a specific 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, whereas the youngest group failed in most trials despite similar subjective readiness to recall.

⁎ Corresponding author. E-mail address: [email protected] (S. Moritz).

https://doi.org/10.1016/j.schres.2018.06.001 0920-9964/© 2018 Published by Elsevier B.V.

Please cite this article as: Moritz, S., Lysaker, P.H., Metacognition – What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive in..., Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.06.001

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S. Moritz, P.H. Lysaker / Schizophrenia Research xxx (2018) xxx–xxx

This precise aspect of metacognition, the conscious awareness of one's cognitive performance including shortcomings and strengths, is prominent in the neuropsychological literature to the present day (for an early study in the field see Anderson-Parenté, 1994), for example, in descriptions of instances in which neurological and psychiatric patients often lack insight into their cognitive limitations. For neurological patients this has been termed anosognosia (Sunderaraman and Cosentino, 2017). However, according to Flavell, metacognition is more than just comparing subjective versus objective cognitive performance (in fact, such studies had already been performed before him). Flavell (1979) distinguished four components of metacognition that interact in complex ways: (a) metacognitive knowledge, (b) metacognitive experiences, (c) metacognitive goals (or tasks), and (d) metacognitive actions (or strategies). Metacognitive knowledge, the first of the components, is defined as stored world knowledge that has to do with people as cognitive beings and with their diverse cognitive tasks, goals, actions, and experiences (Flavell, 1979). Flavell provides the example of a child who has the belief that unlike many of her friends, she is better at arithmetic than at spelling. Psychopathological examples could be to believe that one is generally incompetent (as in severe depression) versus gifted or in possession of special cognitive skills (as in mania if the belief is unfounded), or in possession of secret knowledge that others try to steal (as in paranoia, again, if unfounded). Metacognitive knowledge can relate to persons, oneself and others, but can also be beliefs about “universal properties of cognition” (p. 907). As we will outline in greater detail below, the former aspect is prominent in the integrative metacognitive model offered by Paul Lysaker, while the latter aspect (e.g., thoughtaction fusion) is central to Metacognitive Therapy by Adrian Wells and colleagues. The second of Flavell's components, metacognitive experiences, are conscious reflections about cognitive processes (e.g., worry that you may fail an exam because you are not good enough; the thought that you have just given a very good presentation). The phases of psychosis can also be framed as metacognitive experiences (Conrad, 1958) such as trema (“stage fright”; the individual has the feeling that something very important is about to happen) or a feeling of “revelation” (or eureka experience) when the delusional belief is finally formed. Metacognitive experiences often act as a prompt for both the third and fourth aspects of metacognition: metacognitive goals and strategies. Flavell provides the example that one senses (i.e., a metacognitive experience) that a certain chapter of a text is perhaps not learned well enough to pass an exam. A purely cognitive strategy would be to read the chapter through once more. Alternatively, you could ask yourself questions about the text and note how well you are able to answer them. The latter would be a metacognitive strategy aimed at the metacognitive goal of assessing one's knowledge, which will give rise to subsequent metacognitive experiences (e.g., surprise, relief, frustration about performance). In her review of Flavell's theory, Livingston (2003) acknowledges that metacognitive and cognitive strategies overlap in that the same strategy could be regarded as either cognitive or metacognitive depending on the goal. According to Livingston, self-questioning while reading would be a cognitive strategy if the purpose is to obtain knowledge while it would be a metacognitive strategy if it is used to monitor what you have read. Since its formal introduction by Flavell, the term metacognition has been well-embraced by the scientific community and soon made its way into psychological textbooks (e.g., Forrest-Pressley et al., 1985). A PubMed search with the keyword metacogniti* resulted in 2773 hits (January 2018), not including numerous theses, books and chapters on the topic. However, it is not without its problems, as some experts have already noted very early (Reynolds and Wade, 1986). It has been criticized as being over-inclusive (“The term metacognition refers to a general concept that subsumes metas for almost any cognitive process imaginable”; Reynolds and Wade, 1986, pp. 307–308), having variable meanings, and being used differently across studies. As a result, the

concept has blurred boundaries of a number of related concepts such as cognition and social cognition (Andreou et al., 2018). The latter has been defined as the mental operations underlying social interactions to solve social, adaptive problems (Yager and Ehmann, 2006). It deals with the question how people store, process, and apply information about themselves, other people and social situations (Ostrom, 1984) and is thus partly overlapping with the definition of metacognitive knowledge given above. Moreover, the components of metacognitive goals and actions (in delineation to cognitive goals and actions) remained somewhat elusive in Favell's original text. The different developments of the term metacognition are beyond the scope of this article, however, as the field is now quite diversified. Most researchers have addressed the early criticism, and the term metacognition and its most prominent subdomain, metamemory, are now used as a superordinate category rather than an elementary function. Researchers now invest special efforts to clarify what aspect of metacognition they are concerned with (for an overview about how metacognition can be measured see Dunlosky and Metcalfe, 2009; Dunlosky and Tauber, 2015; Fleming and Lau, 2014), for example, whether metacognitive judgments are operationalized as confidence (Koriat and Levy-Sadot, 1999; Yeung and Summerfield, 2012), rememberknow (Migo et al., 2012), feeling of knowing (Shimamura and Squire, 1986), or other ratings. This is aimed at overcoming the prior Babylonian speech confusion, which plagues many other fields of psychology as well (c.f. cognition, neuropsychology, etc.). 1.2. CBT: a metacognitive intervention? Before turning to metacognitive interventions and how they map onto Flavell's components of metacognition (and whether they deserve the label “metacognitive”), we have to deal with the possibility that cognitive-behavioral therapy (CBT) also works at a metacognitive level. Indeed, borders are blurry and CBT (if not all psychological treatments) imparts patients with new metacognitive knowledge (e.g., improving drive and increasing social engagement will help to dilute negative thoughts). A central and importantly content-unspecific “mantra” of CBT is that thoughts are just thoughts and not facts (for example see Foreman and Pollard, 2011). In fact, even its parent intervention, behavior therapy (BT), can provide fundamental metacognitive experiences. For example, stress is attenuated after a while when people are confronted with a feared stimulus, which can challenge the prior metacognitive belief that the fear will rise to uncontrollable heights if one does not withdraw from the situation (“wow, that was easier than I thought”). We can only speculate that if the concept of metacognition had made its way earlier from developmental and experimental psychology to clinical psychology, CBT may have already been using the prefix “meta,” probably with a hyphen between meta and cognition as CBT mainly targets specific cognitive contents (i.e., “ordinary cognitions” according to Wells, 2009, p. 37). Such a development would have prevented some confusion between cognitive training, which is usually used synonymously with neuropsychological training or cognitive remediation, and cognitive therapy (however, please note that recently metacognitive adaptations of cognitive remediation have also been released; see Cella et al., 2015). 2. Metacognitive interventions 2.1. How metacognitive are metacognitive interventions? As described, the term metacognition is somewhat vague and bringing it to any new field will further complicate things and burden bold claims about what constitutes legitimate or proper “Metacognitive Therapy” (Andreou et al., 2018; Capobianco and Wells, 2018; Wells and Fisher, 2011). The developers of Metacognitive Therapy, Metacognitive Training, and Metacognitive Reflection and Insight Therapy (MERIT) all argue that their interventions primarily target



metacognitive processes. We will now go through the different approaches one by one and examine to what extent they capture aspects of Flavell's original concept. In short, we will detail how the focus of Metacognitive Therapy is on metacognitive knowledge about cognition in general (e.g., dysfunctional explicit metacognitive beliefs are challenged and replaced), the focus of Metacognitive Training is on metacognitive experience (e.g., disorder-specific cognitive biases that are not often conscious to the patient and are made explicit and challenged), and the focus of MERIT is mainly on metacognitive knowledge about oneself and others.

2.1.1. Metacognitive therapy (MCT) We will start with Metacognitive Therapy, developed by Adrian Wells and coworkers (Fisher and Wells, 2009; Wells, 2012; Wells and Papageorgiou, 2004), as it is perhaps the most well-known among the three approaches. MCT is usually carried out in 8–12 face-to-face sessions and is meant by Wells as an economic (and in his view, more effective) alternative to CBT (Hagen et al., 2017; Wells and Fisher, 2016), based on a meta-analysis of five direct comparison studies with mainly small samples (Normann et al., 2014). More recently, the approach has been extended to group settings (Papageorgiou and Wells, 2014). MCT is rooted in the Self-Regulatory Executive Function (S-REF) model (Wells and Matthews, 1994). In part, the terminology is borrowed from the metamemory model of Thomas Nelson and Louis Narens, who distinguished between an object level and a meta-level (Nelson and Narens, 1990). Wells and colleagues locate the cause of psychological disorder at the metacognitive level and not at the object level (i.e., cognitive content). MCT is designed to change dysfunctional (positive or negative) beliefs (i.e., metacognitive knowledge) about thinking (e.g. “worrying helps me to find the cause of my problem” or “worrying is uncontrollable and I might go mad”) and impart the patients with new insights/metacognitive knowledge about their cognitive apparatus (e.g., rumination is not helpful; suppressing thoughts will only strengthen them). The approach is transdiagnostic and the basic model is applied to very different psychological disorders such as depression, anxiety, and obsessive-compulsive disorder, and more recently to psychosis (Morrison et al., 2014; Wells, 2011; Wells et al., 2010). The authors assume the presence of a cognitive attentional syndrome (CAS) in patients with psychological disorders which includes three core processes that can be described as extended dysfunctional thinking in response to negative thoughts: worry/rumination, threat monitoring and coping behaviors that backfire. These are maintained by patients' (dysfunctional) metacognitive beliefs that these strategies are helpful when in fact they impede healthy function. Flavell (1979) already noted that metacognition can also do harm, for example by enhanced self-attention and rumination about thoughts (e.g., “Think of the feckless obsessive, paralyzed by incessant critical evaluation of his own judgments and decisions”, p. 910). One of the key mechanisms of action in this form of therapy are exercises that challenge dysfunctional metacognitive beliefs and strategies, which prompt metacognitive experiences (e.g., surprise, enlightenment). Some of the strategies of MCT are borrowed from the arsenal of cognitive therapy, such as using principles of the Socratic dialogue, rumination postponement, variants of the “white bear exercise” (Wegner et al., 1987) where one should not think about a white bear, elephant or else), and innovative variants of the “safe exercise” from trauma therapy (to lock away or treat negative thoughts like external objects) in the tradition of mindfulness, where attention is paid non-judgmentally. The latter technique is called “detached mindfulness” (Wells, 2005) and is a central element of MCT. Another important exercise is the attention training technique (Fergus et al., 2014; Papageorgiou and Wells, 2000), which is aimed at reducing self-focused attention.

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2.1.1.1. Challenges. In our opinion, Wells and colleagues (over)emphasize differences to other therapeutic schools. A central contention is that MCT works at a metalevel and CBT at an object level. First, it is debatable if working on contents is really object level. In his review on the model of Nelson and Narens, van Overschelde (2008) explained that the “object level consists of cognitions, which are often associated with external objects (e.g., that thing I see is a dog), and the metalevel consists of cognitions about object level cognitions (e.g., why do I keep thinking about that dog?)” (p. 47). Clearly, if one replaces “dog” with “negative thoughts”, CBT also works at a meta-level, by reflecting on and challenging negative thoughts. Second, as mentioned, CBT also teaches patients some “universal properties of cognition” (Flavell, 1979, p. 907), particularly that thoughts are not almighty and are not facts, and thus is not only concerned with content. Third, a lot of the techniques of CBT are used in MCT, perhaps with a different rationale, but it has yet to be shown if the mechanisms are different. 2.1.2. Metacognitive Reflection and Insight Therapy (MERIT) Flavell breaks metacognitive knowledge into three areas: person, task, and strategy. MERIT best relates to the person category, which Flavell defines as follows: “The person category encompasses everything that you could come to believe about the nature of yourself and other people as cognitive processors. It can be further subcategorized into beliefs about intraindividual differences, interindividual differences…” (Flavell, 1979, p. 907). MCT was first developed for a range of psychological disorders and later applied to psychosis; in contrast, MERIT was initially developed for psychosis and later applied to other disorders. As reviewed by Lysaker and Lysaker (2010), a broad range of literature suggests that the first-person experience of schizophrenia involves to some degree the experience of loss of a previously coherent and cohesive sense of self. Specifically, schizophrenia may be associated with the disintegration of previously integrated and complex senses of self and others, thus leaving persons with a fragmented understanding of themselves and others with which to make sense of life and psychiatric challenges. MERIT, as well as closely related variants which use similar models of metacognition (Bargenquast and Schweitzer, 2014; Dimaggio et al., 2015; Inchausti et al., 2017), was designed to help patients become better able to bring together the small pieces of information about their experience of themselves and others (e.g. awareness of specific isolated thoughts and feelings) into an integrated sense of who they and others are as unique beings in the world, and to then use that knowledge to make sense of and respond to psychological and social challenges (Lysaker and Klion, 2017). MERIT is a staged approach. The metacognitive capacity of patients is assessed continuously and interventions are offered at the level of which patients are capable. As patients develop greater levels of metacognitive capacity, interventions are tailored to match those higher levels. The ultimate therapeutic mechanism is asserted to reflect the practice of metacognitive acts as optimal levels which spur increasing gains over time in a manner that is likened to physical therapy (Lysaker and Klion, 2017; Van Donkersgoed et al., 2014). More so than Metacognitive Therapy and Metacognitive Training, MERIT is highly tailored to the individual both in terms of the techniques and goals. With respect to illness concept, MERIT allows persons to evolve a personally meaningful idea about recovery and to decide what steps they could take to achieve and ultimately managing their own recovery. The focus is on understanding the individual as a complex and multifaceted being with a unique history and unique set of hopes, wishes and dreams. A MERIT therapist typically will ask a patient, ‘What do you want me to understand?’ before asking ‘What do you want me to do?’ Therapeutic alliance is conceptualized as the basis for shared reflection as the creation of meaning is the essential focus. The therapeutic relationship is thus characterized as necessarily nonhierarchical in nature. Structurally, MERIT is thus an integrative framework that assists practitioners, from a range of perspectives, to tailor their practice in


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order to enhance metacognition. MERIT is based on several core assumptions including the notion that recovery from psychosis is possible and likely, regardless of how ill, disorganized or demoralized patients are, and that patients are active agents in their own recovery. MERIT is defined by eight elements, each of which can be delivered within a session regardless of the unique dilemma a patient is experiencing. Each element describes a therapist behavior (e.g. attention to patient agenda, eliciting a personal narrative or reflecting on the experience of session) that assists adults with psychosis in recapturing metacognitive abilities that are atrophied, damaged, or previously never attained. Each element can further be measured and used to establish fidelity. MERIT does not offer prescribed activities to be performed in a certain order. It is explicitly not a step-by-step guide. Therapists are guided by the eight elements to make meaning with patients and integrate and use information about themselves and others in increasingly complex ways. Regarding the concept of metacognition itself, the treatment relies on what they refer to as the integrative model of metacognition (Lysaker and Hasson-Ohayon, 2018). This frames metacognitive processes as making it possible for persons to have access to a sense of self and others within the flow of life. It proposes that metacognition is a spectrum of activities which, at one end, enable an awareness of specific thoughts, wishes and feelings, while at the other end, involve processes that allow reflective and embodied experience to be integrated into a larger complex sense of oneself and others (Lysaker and Dimaggio, 2014). In this model, both ends of the spectrum are suggested to influence each other. For example, one might interpret a discrete experience of an emotion in light of one's large sense of oneself while one's larger sense of self should be influenced by discrete emotional experiences. As does Metacognitive Training (see below), it incorporates new concepts of metacognition such as the division of metacognitive activities into different phenomena based on their foci as proposed by Semerari et al. (2003) as well as the emphasis on metacognitive acts as necessarily intersubjective in nature (Cortina and Liotti, 2010; Hasson-Ohayon et al., 2017). MERIT shares with the practices of second wave CBT an interest in identifying cognitions, but it differs in its interest in the quality of those cognitions and concern about their absolute correctness. Like third wave CBT, such as mindfulness and ACT, MERIT also focuses on persons' relationship to their experience. However, it aims at a joint reflection about self-experience in the moment, as it is occurring between the therapist and patient and as it has unfolded across patients' personal narratives. Unlike ACT, MERIT de-emphasizes abstractions and looks to the larger complex web of meanings, which span a unique life as the context necessary for understanding any abstraction a person might hold onto in the moment (Lysaker and Hasson-Ohayon, 2018). In MERIT the primary mechanism of change is joint reflection between the patient and therapist which is keyed to the patient's metacognitive capacity in the moment. If the patient is at best able only to notice but not connect different activities in their mind, the therapist joins them at this level and seeks to merely name and think about these discrete phenomena. As patients become better able to synthesize information (e.g. see connections between thoughts and feelings within the flow of life and to connect different eras of their lives in terms of the struggles they have faced) therapists similarly join them at this level. In MERIT it is assumed that as patients think about themselves and others at their maximal metacognitive capacity they will develop over time increased metacognitive capacities. Change is assessed using the Metacognitive Assessment Scale Abbreviated (Lysaker and Klion, 2017). Finally, moving in the opposite direction of MCT, after being developed and tested empirically with patients with psychosis, MERIT has been applied to other conditions including borderline personality disorder (Vohs and Leonhardt, 2016). 2.1.2.1. Challenges. There are several limitations of this approach. First, it is explicitly an integrative therapy and it is unclear to what extent the use of its principles by a cognitive therapist would result in something

that was similar to what would happen when an existential or psychodynamic therapist used those same principles. Second, work on MERIT has yet to really explore the complexity of experiences which have to be integrated and the extent to which it is an automatic activity. Much of what is focused upon is the embodied experience of intersubjective encounters, and a challenge that remains for MERIT is to be able to describe how persons move from increased awareness of embodied experience of intersubjective encounters to a more coherent narrative of their lives and an account of others as having their own unique perspectives. Third, sense of self requires the availability of multiple elements of self in an evolving manner (Lysaker and Lysaker, 2008). Work is therefore needed to describe how MERIT actually promotes self-experience which, more than becoming increasingly integrated, is also fundamentally dialogical and flexible. 2.1.3. Metacognitive Training for psychosis and other psychological disorders The label Metacognitive Training first surfaced in the midst of the 1980s in the context of children's education (e.g., Kurtz and Borkowski, 1987), which has remained a prominent scope of research (Abd-El-Khalick and Akerson, 2009; Casselman and Atwood, 2017; Teong, 2003). The present review will confine itself to its application in people with psychological disorders. The idea of Metacognitive Training for psychosis was borne in the early 2000s. Two recent meta-analyses have confirmed its efficacy for the treatment of positive symptoms/delusions (Eichner and Berna, 2016; Liu et al., 2018) and it is now recommended as a treatment for psychosis by the Australian Psychiatric Association as well as the German Psychiatric Association and the German Psychological Association (e.g., Galletly et al., 2016). The goal was to correct cognitive biases in psychosis, that is, distortions in the way an individual perceives, interprets and recollects information. At that time, knowledge about these biases was still in its infancy (Garety and Freeman, 1999) but indicated that people with psychosis jump to conclusions (JTC), show marked incorrigibility, and are overconfident in their false judgments (for more recent reviews see Garety and Freeman, 2013; Moritz et al., 2017b). Importantly, awareness of these biases is poor in many patients (e.g., Moritz et al., 2016): they often regard their decision-making as rather rational and even hesitant (Freeman et al., 2006). Accordingly, Metacognitive Training aims to generate or raise metacognitive awareness for these over-arching biases in a gentle, non-insulting manner (e.g., implicit behavior/cognition becomes metacognitive knowledge; Moritz et al., 2014). Similar to MCT by Wells, Metacognitive Training tries to improve metacognitive knowledge of patients (e.g. knowledge that many patients with schizophrenia tend to jump to conclusions or are overconfident) by corrective experiences that give rise to strong metacognitive experiences (“aha moments”). It also picks up a long tradition of metacognitive research that goes back to Asher Koriat (Koriat, 2002; Koriat and Levy-Sadot, 1999) who regards confidence/doubt as being at the heart of metacognition (see also Yeung and Summerfield, 2012). A central aim of Metacognitive Training for psychosis is thus to “sow the seeds of doubt,” that is, patients are encouraged to attenuate their confidence if evidence is not sufficient and collect more information before momentous decisions are made (Moritz et al., 2014). Unlike the claim by Capobianco and Wells (2018) that the “intervention is clearly a cognitive behavioral approach that deals with the content of negative thoughts” (p. 161), the cognitive bias modules of the metacognitive group training for psychosis primarily work at the metacognitive level and keep the level of personal content at a minimum. In fact, Metacognitive Training for psychosis avoids in-depth discussions of delusional contents in order to engage patients who are not willing to talk about their psychotic experiences, often due to suspiciousness, ambivalence and shame (such issues are dealt with in individualized CBT or MCT+, see below). From the view point of basic research, things became complicated because the concept was increasingly “watered down” by incorporating



elements from CBT and other therapeutic schools that were deemed compatible. A main reason was because patients with psychosis deem emotional problems a priority in treatment (Byrne et al., 2010; Kuhnigk et al., 2012; Moritz et al., 2017a), more so than working on hallucinations and delusions (Moritz et al., 2017a). In recent years, a number of metacognitive trainings were devised for other disorders including depression, borderline personality disorder and obsessive-compulsive disorder (Jelinek et al., 2016; Moritz et al., 2010; Schilling et al., 2015). These adaptations are rooted in the setup and presentation mode of the Metacognitive Training for psychosis: pdf-concerted PowerPoint slides which are almost self-explanatory, an open group, and engaging in humorous exercises aimed to provide corrective “aha moments” (i.e., metacognitive experiences). These disorder-specific versions have been intended as hybrids, to amalgamate a CBT and Metacognitive Training approach. With respect to their contents, they are very close to prior CBT interventions and the developers explicitly see Metacognitive Training, even Metacognitive Training for psychosis, as variants of CBT. As we have speculated before, the founders of CBT may have called their approach “meta-cognitive” if the latter term had been popular already. As described, Wells regards working on a cognitive level as superfluous. In the opinion of the developers of Metacognitive Training, the specific contents of thoughts are meaningful. Jumping to conclusions and overconfidence may perhaps explain why one has fixed false beliefs but may not explain why one feels persecuted by the CIA versus becomes a religious extremist. Contents are associated with the biography and specific experiences (including worries) of patients and are thus not random. Elucidating why a patient has certain specific thoughts may lead to new metacognitive experiences and thus improve metacognitive knowledge. Still, it is unfortunate that Metacognitive Training and Metacognitive Therapy carry very similar names, a problem that also plagues many cognitive and mindfulness programs. Yet, the term “Metacognitive Training” was already around since the mid-1980s (e.g., Reeve and Brown, 1985). In one of these intervention studies, children receiving Metacognitive Training were (among other goals) trained in the necessity of working slowly and carefully, which exerted positive effects on cognition and impulsivity (Kurtz and Borkowski, 1987). This very aspect is also captured by Metacognitive Training for psychosis. The individualized format of psychosis intervention is not a training but a proper face-to-face therapy, which was abbreviated as MCT+ (e.g., Moritz et al., 2011) to differentiate it from Wells' Metacognitive Therapy. Likewise, the self-help format for OCD (Moritz et al., 2010; Moritz and Hauschildt, 2016) is called myMCT, again in an attempt to reduce confusion. 2.1.3.1. Challenges. As described, Metacognitive Training has incorporated elements from other therapeutic approaches, especially CBT. Without studies that examine the efficacy of its specific components it is not possible to decide whether the metacognitive elements or other components lead to symptom improvement. The training programs for depression and OCD share many formal aspects with the original Metacognitive Training for psychosis but are strongly rooted in the theoretical foundations of CBT. Another problem is the short duration of Metacognitive Training for psychosis which may not be sufficient for severe mental illness. 3. Conclusion The concept of metacognition has a long history and has spurred novel basic and clinical research. Despite shortcomings of the concept, it has led to the development of sophisticated therapies that address metacognitive deficits. Prominent examples include Metacognitive Therapy by Wells, Metacognitive Training by Moritz and Woodward, and MERIT by Lysaker. While all treatments target metacognition, each offers a different definition of the term, and each is very different in structure. To make sense of this state of affairs we reviewed the

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original definition by Flavell which helps us see that each of these treatments legitimately captures important aspects of the concept of metacognition. Metacognitive Therapy focuses on persons' orientations to what they believe, MERIT focuses on larger senses of identity, and Metacognitive Training focuses on awareness of mental processes. This review also raises a range of essential questions and issues. For instance, other cognitive treatments such as CBT also deal with metacognitive phenomena; distinctions between CBT (and other treatments) and those reviewed here are yet to be firmly delineated and explored. These treatments and their study also finally reorient us to theory and the need for more complex and responsive models of the age-old question of how persons understand themselves and reflect upon and respond to experience in a way that is unique to them but which can also be understood by others. Role of funding source No external funding.

Contributors Both authors have written and proof-read the manuscript.

Conflict of interest Both authors are developers of metacognitive interventions that are dealt with in the manuscript.

Acknowledgement We would like to thank Drs. Ryan Balzan and Lukasz Gaweda for comments on an earlier version of the manuscript.

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