When the topic of psychosis is discussed, a lot of the focus centers on the symptoms themselves. But to fully understand why the hallucinations or the delusions happen, you have to look at what’s happening underneath them.
The ability to reflect on your own thinking and on the world around you is called metacognition. Disruptions in this ability are strongly linked with psychosis and the conditions that feature it. That link can change how symptoms are understood and the way that treatment needs to be structured.
This page covers the connection between metacognition and psychosis, as well as the available treatment approaches. It will explore:
Before we get into the topic of metacognition and psychosis, it first helps to be clear on what psychosis is.
Psychosis is a syndrome where a person’s relationship with reality becomes disrupted. When this happens, symptoms present in different ways, but the most commonly recognized symptoms include:
Psychosis can occur as part of serious mental illness conditions like:
Psychosis can also appear briefly after extreme stress, sleep deprivation, or substance use, so an episode does not always mean one of these conditions is present.
To fully understand the symptoms of psychosis, it’s important to understand the role of metacognition, as metacognition and psychosis are strongly linked.
Metacognition refers to a person’s ability to think about their own thinking. In the context of psychosis, that concept takes on a more clinically important meaning.
Research describes metacognition in psychosis as the ability to form representations of yourself and other people, and to use that understanding to deal with the world around you.[1]
This means being able to pull your thoughts and feelings together and merge them into a story that makes sense for you. Most people do this without noticing, but for a person with psychosis, this capacity is disrupted.
Research comparing metacognitive scores in people with schizophrenia found that metacognitive capacity was much lower in the schizophrenia group compared to the control group.[2]
An important finding from this research was that these metacognitive difficulties were unlikely to be explained solely by hardship or adversity. The control group had also experienced social and medical challenges, yet they did not show the same level of metacognitive impairment.
This suggests that the metacognitive difficulties are closely associated with schizophrenia itself, rather than simply being a consequence of the difficulties of living with the condition.
Metacognitive capacity in psychosis is measured across four different areas, each of which captures a different aspect of how a person relates to their own mental health and the world around them.[3]
This is the ability to think about your own thoughts and feelings.[3] In psychosis, self-reflectivity can be reduced to the point where the person finds it hard to identify what they’re feeling or even why they’re reacting the way they are.[4]
Some people may be aware that something is wrong, but unable to describe what’s happening. The ability to look inward and build a detailed picture of their own mental state is compromised. This makes it harder for the person to communicate what they’re going through.
Understanding others is a key ability, and it’s the capacity to be able to think about what is happening in another person’s mind. It’s sometimes referred to as the theory of mind.[5]
Research has found that these deficits are common in mental health conditions like schizophrenia and are key obstacles in social and work functioning.[5]
If this kind of capacity is impaired, it becomes very difficult to interpret people. For example, a neutral expression might be seen as hostile or a casual comment might feel loaded.
Decentration is the ability to recognize that other people have their own independent perspectives and motivations that are separate from you.[3] If this ability is reduced, then neutral events can feel like they’re personally directed.
For example, a group of strangers laughing might feel like they’re laughing at you personally, even though there’s no evidence to suggest that you are the butt of the joke.
Mastery is the ability to use what you know about yourself to cope with psychological difficulties. It is where the other three areas pay off. For instance, knowing that you tend to spiral at night only helps if you can use that knowledge to plan the evening differently.
If mastery is low, you may recognize that you’re having a hard time but feel powerless to do anything about it.[3]
Overall, the research shows that metacognitive capacity, measured across these four areas, predicts the outcomes of things like:[3]
This means that how well you can reflect on your own mind affects recovery well beyond whether the symptoms themselves improve.
Evidence suggests that two of the most well-known symptoms of psychosis are linked directly to poor metacognition. Below, we explore both delusions and hallucinations.
When the ability to reflect on your own thinking is impaired, unusual beliefs don’t get questioned in the way they might otherwise be. Research on cognitive insight has found that people with psychosis have lower self-reflectiveness and higher self-certainty compared to non-psychiatric controls.[6]
This means the person is less likely to consider that their reading of events could be wrong, and more likely to believe what they feel is accurate.
The metacognitive capacity that would normally allow a person to take a step back and re-evaluate is much weaker and opens the door for delusional beliefs to solidify. A belief that would once have been tested against other explanations then goes unchallenged. The longer this goes on, the more supporting evidence it appears to collect.
Hallucinations, especially auditory ones, have been linked to a failure in a specific metacognitive process called source monitoring.
Research has found that people with schizophrenia who hear voices are more likely to mistake their own thoughts as coming from outside themselves, compared to people with schizophrenia who don’t hear voices.[7]
One cognitive process involved in reality testing—distinguishing “I thought that” from “I heard that”—isn’t working properly. This is part of why the voices carry so much authority. They feel like someone speaking to you in the real world rather than something inside your mind.
AMFM is here to help you or your loved one take the next steps towards an improved mental well-being.
One of the most interesting findings in psychosis research is that better insight into having a psychotic condition is associated with higher rates of depression.
This is known as the insight paradox, and it’s one of the most important considerations in the study of metacognition and psychosis.
A meta-analysis found that global insight was associated with depression in schizophrenia, with the relationship also featuring internalized stigma and hopelessness.[8]
This suggests that realizing that you have a serious mental illness, without the metacognitive capacity to make meaning from that awareness, can be damaging rather than helpful.
For example, a person who gains insight into something about themselves, but doesn’t have the mastery skills to apply it, may become more demoralized. Psychoeducation is paced carefully, because information about the diagnosis is received very differently depending on whether the person has the tools to do something with it.
This means that treatment for psychosis has to take a different approach when it comes to psychoeducation.
Different strategies target metacognition and psychosis, with each approach working from a slightly different angle.
Metacognitive reflection and insight therapy (MERIT) is an individual psychotherapy that focuses on helping the person build a stronger narrative about themselves and their experiences.
MERIT doesn’t teach skills in the traditional therapeutic sense and doesn’t try to correct the person’s thinking.[9] Instead, the sessions are molded around the person’s own agenda. This means it encourages them to reflect on their own experiences and consider other perspectives.
Eventually, the idea is that the person slowly develops the metacognitive capabilities that psychosis has disturbed.
Trials that include MERIT have shown improvements in both metacognition and symptoms compared to usual treatment, but the evidence base is still growing.[9]
Metacognitive therapy is another potential psychotherapy treatment approach for psychosis. MCT focuses on the beliefs people hold about their own thinking, like the belief that worry is uncontrollable, and works to change the thinking style that fuels those beliefs.[9]
If MERIT focuses on building the skills needed to reflect on your own mind, MCT focuses on changing the specific beliefs about thinking that keep the symptoms going.
Metacognitive therapy is different from metacognitive training, which we cover next. They are sometimes abbreviated the same as MCT, so if you’re researching treatment approaches, it helps to know which one a source means.
Metacognitive training is a group-based intervention that targets the cognitive biases that are usually seen in those with psychosis.[9] This could be biases like jumping to conclusions or overconfidence in their own judgments.
Evidence for metacognitive training is promising, with research showing that it reduced delusions and hallucinations and showed improvements in self-esteem and general functioning.[9]
The standard treatment process for psychosis involves both therapy and medication. The approaches explained in the last section complement standard treatment, rather than replacing it entirely. A patient will still be prescribed antipsychotic medication and undergo cognitive behavioral therapy for psychosis (CBTp), with metacognitive approaches added to support recovery.
For example:
This combination enables a more comprehensive treatment plan that targets the main areas that psychosis disrupts.
As long as the person with psychosis is well enough for it, outpatient psychiatric treatment can often work well. But there are situations that call for a higher level of treatment and support.
If psychotic symptoms have persisted despite medication and outpatient therapy, or daily functioning has broken down, a residential setting may be the correct next step.
Residential treatment provides an environment where the main focus is recovery. This means the more difficult aspects of treatment, like metacognitive work, can get sustained attention without distractions.
Building the skills needed to reflect on your own mind and those around you isn’t something that can happen in one or two outpatient sessions a week. It requires a more focused therapeutic setting where these skills can be practiced throughout the day.
A residential program also allows for medication to be monitored and perhaps even adjusted in real time.
For those with psychosis who have found that outpatient care has reached its limits, residential care can provide what is needed.
A Mission For Michael (AMFM) provides treatment for adults experiencing various conditions. Psychosis support is a phone call away – call 866-478-4383 to learn about our current treatment options.
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If you, or your loved one, is living with psychosis and the current treatment approach hasn’t been producing positive results, it may be time to explore a different treatment direction.
At AMFM (A Mission For Michael) Mental Health Treatment, our clinical team is experienced in working with complex psychiatric presentations where standard outpatient psychiatric treatment has reached its limits. We focus on the wider picture, rather than just symptom management alone, and help with the metacognitive disruptions that may be fueling psychosis.
We offer an intimate, focused mental health treatment experience for adults in home-like settings that are carefully maintained to be peaceful, comfortable spaces. The full spectrum of care is available, including residential and outpatient treatment programs. Our team believes in treatment persistence and will personalize your treatment plan so you can achieve lasting, life-changing outcomes.
Our locations in California, Minnesota, and Virginia accept insurance and are in-network with most major providers. To check your insurance coverage for mental health care, simply complete our confidential online verification form or call us at 866-478-4383.
If anything on this page sounds like what you or your family have been living with, take it as a prompt to act. Reach out to us if you would like to start the admissions process or learn more about how we can support your mental well-being. Our compassionate team is available 24/7 to answer your questions and provide guidance with no obligation.
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