The Efficacy of Metacognitive Skills Training in the Context of Forensic Psychiatric Care

Does Group-Based Metacognitive Skills Training Reduce Jumping to Conclusions Bias of Patients With Psychotic Disorders in the Context of Forensic Psychiatric Care

Deficiencies in social cognition are part of the core symptomatology of psychotic disorders. And deficiencies in social cognition, the closely related concept of metacognition, and, for example, paranoid attitudes are all associated with violence. The link between social cognition and violence is also observed through rehabilitation, as both group-based Social Cognition Interaction Training (SCIT) and group-based Metacognitive Skills Training (MCT) have reduced violent behavior in patients with psychotic disorders. Thus, a better knowledge of social cognition and its rehabilitation in psychotic disorders can help to reduce risky behavior and to rehabilitate the significant social difficulties often found in psychotic disorders. This research study aims to examine factors underlying the efficacy of group-based MCT.

The goal of the metacognitive skills training group developed by Moritz and partners is to strengthen the social and metacognitive skills of the patients participating in the group. The group consists of 10 sessions during which exercises and discussion are emphasized. The themes of the group sessions are, for example, jumping to conclusions -bias, empathy, and memory. Detailed information is available from the MCT website (https://clinical-neuropsychology.de/metacognitive_training-psychosis/). Overall there is meta-analysis-level evidence for the moderate effectiveness of MCT on positive symptoms of psychotic illnesses, such as delusions. Prior studies have argued that the unique factor underpinning MCT's efficacy is its impact on various cognitive biases, and that participating in the group especially reduces patients' tendency to jump to conclusions, which is a cognitive style associated with delusions and deficits in social perception and reasoning. As delusionality is related to the risk of violence, these results form a logical link between jumping to conclusions, delusionality, and violence.

But the results regarding the effectiveness of MCT are still somewhat conflicting, and studies seem to be of varying quality. Additional longitudinal research and research related to the jumping to conclusion bias are also needed. The hypothesis regarding this study is that the MCT group reduces patients' tendency to jump to conclusions. These reductions are presumed to be associated in one-year follow-up with fewer mood symptoms, delusions, paranoia, and more psychological flexibility.

Study Overview

• Status: Recruiting
• Conditions: Psychotic Disorders; Schizophrenia; Schizoaffective Disorder; Psychotic Depression; Delusional Disorder
• Intervention / Treatment: Behavioral: Metacognitive Skills Training (MCT); Other: Treatment as usual

Detailed Description

Based on their multi-professional treatment plan in the Vanha Vaasa hospital, participation in the MCT group intervention is offered to patients who could benefit from it. The intervention under investigation is part of the standard care of the hospital. Participation does not prevent participation in other forms of rehabilitation, and patients can participate in the group even if they don't participate in the study. Being part of the control group does not prevent participation in the intervention group, but being part of the control group might delay participation. When these are in conflict, treatment takes precedence over research.

Data is collected until the sample size is satisfactory (at least 20 to 25 patients). Patients in the MCT condition are compared to patients (n=30) and controls (n=30) measured with a psychological test battery not completing the group. The test battery is the same for all the groups. It consists of valid tasks measuring neurocognition, social cognition, and psychiatric symptoms and a task for measuring the tendency to jump to conclusions. Patients in the group condition are tested before the group and nine months after the group has concluded. For both control groups testing interval is one year.

The comparison between the groups (intervention group, patient controls, and non-patient controls) is done by comparing the rate of change in the tendency to jump to conclusions. This comparison is done with regression analysis. If minor differences and equal variances are assumed (delta of slope 0.1), the power of the comparison is around 0.57. If larger differences are assumed (delta of slope 0.5), the power of the comparison approaches 1. In a previous study, a medium-sized comparative difference between patients in MCT condition and patients in cognitive remediation condition was found.

To avoid problems with multiple testing, the differences in magnitudes of mood symptoms, delusions, paranoia, and psychological flexibility after the delay are assessed with MANOVA. In a recent meta-analysis, the observed effect of MCT on delusions was high medium (g=0.69). The observed effect on negative symptoms was small but significant (g=0.23). Consequently, the expected power of the MANOVA ranges from 0.48 to 0.99. Direct comparisons are made with discriminant analysis with identical power estimates. Univariate ANOVAs can also be used, but with much worse power estimates, when controlling for multiple testing.

• Study Type: Interventional
• Enrollment (Estimated): 85
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Leo Kuutti, MA; Phone Number: +358 029 524 3058; Email: leo.kuutti@vvs.fi
• Study Contact Backup: Name: Alice Keski-Valkama, PhD; Phone Number: +358 029 524 3055; Email: Alice.keski-valkama@vvs.fi

Study Locations

• Finland
  • Vaasa, Finland
    • Recruiting
    • Vanha Vaasa Hospital
    • Contact: Leo Kuutti; Phone Number: +358295243058; Email: leo.kuutti@vvs.fi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria (patients):

• Willingness to participate in a scientific study
• Diagnosis of a psychosis spectrum disorder
• Finnish language skills due to questionnaires and psychological tests being in Finnish

Exclusion Criteria (patients):

• Psychosis that severely deteriorates the ability to function
• Cognitive problems that severely deteriorate the ability to function
• Guardianship established for personal matters

Inclusion Criteria (non-patient controls):

• Willingness to participate in a scientific study
• Self-assessed sufficient Finnish language skills due to questionnaires and psychological tests being in Finnish

Exclusion Criteria (non-patient controls):

• Diagnosis of a psychosis spectrum disorder
• Cognitive problems that severely interferes with functioning

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention group; Patients with a psychosis spectrum disorder participating in the group-based metacognitive skills training and receiving treatment as usual	Behavioral: Metacognitive Skills Training (MCT); The goal of the metacognitive skills training group developed by Moritz and co. is to strengthen the social and metacognitive skills of the patients participating in the group. The group consists of 10 sessions during which exercises and discussion are emphasized. The themes of the group sessions are, for example, jumping to conclusions -bias, empathy, and memory. Detailed information is available from the MCT website (https://clinical-neuropsychology.de/metacognitive_training-psychosis/). Overall there is meta-analysis-level evidence for the moderate effectiveness of MCT on positive symptoms of psychotic illnesses, such as delusions. Prior studies have argued that the unique factor underpinning MCT's efficacy is its impact on various cognitive biases, and that participating in the group especially reduces patients' tendency to jump to conclusions, which is a cognitive style associated with delusions and deficits in social perception and reasoning.; Other: Treatment as usual; Medicinal treatment deemed appropriate by the attending physician, psychiatric ward treatment, and others forms of treatment recommended to the patients based on their treatment plans (e.g., work therapy, dialectical behavior therapy, talk therapy)
Active Comparator: Patient controls; Patients with a psychosis spectrum disorder receiving standard long-term care in the hospital	Other: Treatment as usual; Medicinal treatment deemed appropriate by the attending physician, psychiatric ward treatment, and others forms of treatment recommended to the patients based on their treatment plans (e.g., work therapy, dialectical behavior therapy, talk therapy)
No Intervention: Non-patient controls; Control group consisting of test subjects without a diagnosis of psychosis spectrum disorder

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Jumping to conclusions bias	The bias is measured using a revised version of the beads task. This is a test of optimal performance, meaning that both low and high scores can be problematic.	For the intervention group, the measurement is done before the group and nine months after completion. For the control groups, the time interval is one year.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Paranoia and psychotic experiences	Paranoia and psychotic experiences assessed with the Symptoms Checklist 90 self-report questionnaire. The scale for paranoia goes from 0 to 24 with higher scores meaning worse outcome. The scale for psychotic experiences goes from 0 to 40 with higher scores meaning worse outcome	For the intervention group, the measurement is done before the group and nine months after completion. For the control groups, the time interval is one year.
Mood symptoms	Mood symptoms assessed with Symptoms Checklist 90 self-report questionnaire. The sum for scales measuring depression and anxiety goes from 0 to 92 with higher scores meaning worse outcome.	For the intervention group, the measurement is done before the group and nine months after completion. For the control groups, the time interval is one year.
Psychological flexibility	Psychological flexibility assessed with the the comprehensive assessment of acceptance and commitment therapy processes - Short Form (CompACT-8) self-report questionnaire. The total CompACT score ranges from 0-48, with higher scores indicating greater psychological flexibility: The ability to attend and adapt to situational demands in the pursuit of personally-meaningful longer-term goals.	For the intervention group, the measurement is done before the group and nine months after completion. For the control groups, the time interval is one year.

Collaborators and Investigators

• Sponsor: University of Jyvaskyla
• Collaborators: Vanha Vaasa Hospital
• Investigators: Principal Investigator: Raimo Lappalainen, PhD, University of Jyväskylä

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2023
• Primary Completion (Estimated): December 1, 2026
• Study Completion (Estimated): December 1, 2026

Study Registration Dates

• First Submitted: August 15, 2023
• First Submitted That Met QC Criteria: August 21, 2023
• First Posted (Actual): August 22, 2023

Study Record Updates

• Last Update Posted (Actual): May 14, 2024
• Last Update Submitted That Met QC Criteria: May 13, 2024
• Last Verified: May 1, 2024

More Information

Terms related to this study

• Keywords: Violence; Social Cognition; Forensic Psychology; Metacognitive Skills Training; Forensic Psychiatry
• Additional Relevant MeSH Terms: Schizophrenia Spectrum and Other Psychotic Disorders; Schizophrenia; Psychotic Disorders; Mental Disorders; Schizophrenia, Paranoid
• Other Study ID Numbers: VVSJYUMCT01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Ownership of the data will reside with the University of Jyväskylä and Vanha Vaasa Hospital. The data are managed by the Ph.D. student, the PI, and the rest of the research team. Other researchers can use the data; however, it requires a research plan and the permission of the research team. Principally, the Ph.D. student, the PI, or someone from the research team will be one of the co-authors in all publications written from the data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No