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Effectiveness of a Metacognitive Intervention for Schizophrenia (MCI-S) Program for Symptom Relief and Improvement in Social Cognitive Functioning in Patients with Schizophrenia

  • Mihwa Han
    Affiliations
    Department of Nursing Science, Sunlin University, 30, 36beon-gil, Chogok-gil, Heunghae-eup Pohang-si, Gyeongbuk 37560, Republic of Korea
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  • Kyunghee Lee
    Correspondence
    Correspondence to: K. Lee, DNS, RN, Researcher of Research Institute of Nursing Science, Keimyung University, 1095 Dalgubeol-daero, Dalseo-Gu, Daegu 42601, Republic of Korea.
    Affiliations
    Research Institute of Nursing Science, Keimyung University, 1095 Dalgubeol-daero, Dalseo-Gu, Daegu 42601, Republic of Korea
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Open AccessPublished:July 12, 2022DOI:https://doi.org/10.1016/j.apnu.2022.07.010

      Highlights

      • Metacognitive ability improved through stepwise expansion of perspective
      • Metacognitive intervention for Schizophrenia (MCI-S) reduced delusional thinking in patients with schizophrenia
      • Metacognitive intervention for Schizophrenia (MCI-S) can improve social functioning in patients with schizophrenia

      Abstract

      This study investigated the effectiveness of a metacognitive intervention program for symptom relief and improvement in social cognitive functioning among adults with schizophrenia. The program focused on enhancing metacognition to encourage self-awareness and step-by-step perspective expansion. There were 24 participants in the experimental group and 19 participants in the control group. Delusions decreased, and social cognition and social functioning improved in the experimental group compared to the control group. The program demonstrated utility as a treatment modality, which can be part of an overall program of a mental health promotion institution to improve functioning in patients with schizophrenia.

      Keywords

      Introduction

      The main psychotic symptoms of schizophrenia destroy an individual's ability to accurately evaluate reality and negatively affect one's quality of life, putting limits on one's social life as well as personal aspects of daily living (
      • Ben-Zeev D.
      • Buck B.
      • Chander A.
      • Brian R.
      • Wang W.
      • Atkins D.
      • Munson J.
      Mobile RDoC: Using smartphones to understand the relationship between auditory verbal hallucinations and need for care.
      ;
      • Jensen G.
      The 2-fold reality: Schizophrenia and the banality of living in 2 worlds.
      ). Auditory hallucinations are a phenomenon in which thoughts from inside a person feel like they are coming from outside of the person. The person subjectively experiences something vividly, although there is no stimulation sensed by the sensory organ (
      • Jensen G.
      The 2-fold reality: Schizophrenia and the banality of living in 2 worlds.
      ). Delusions are when individuals grant meaning to their own thoughts and beliefs even though they run contrary to what is generally accepted or what the person has experienced (
      • Sellers R.
      • Gawęda Ł.
      • Wells A.
      • Morrison A.P.
      The role of unhelpful metacognitive beliefs in psychosis: Relationships with positive symptoms and negative affect.
      ). Patients with schizophrenia often experience hallucinations and delusions, which cause confusion and pain if they do not realize that the hallucinations and delusions are in their own mind and not due to someone or something external to themselves (
      • Prochwicz K.
      A comparison of cognitive biases between schizophrenia patients with delusions and healthy individuals with delusion-like experiences.
      ;
      • Simonsen A.
      • Mahnkeke M.I.
      • Fusaroli R.
      • Wolf T.
      • Roepstorff A.
      • Michael J.
      • Bliksted V.
      Distinguishing oneself from others: Spontaneous perspective-taking in first-episode schizophrenia and its relation to mentalizing and psychotic symptoms.
      ).
      Numerous studies worldwide have investigated the epidemiology of schizophrenia, reporting a lifetime prevalence of 0.3–0.7 % in the general population, and rates in South Korea have been similar to those reported in other countries (
      • Cho S.J.
      • Kim J.
      • Kang Y.J.
      • Lee S.Y.
      • Seo H.Y.
      • Park J.E.
      • Kim H.
      • Kim K.N.
      • Lee J.Y.
      • Sohn J.H.
      Annual prevalence and incidence of schizophrenia and similar psychotic disorders in the Republic of Korea: A national health insurance data-based study.
      ).
      • Fine C.
      • Gardner M.
      • Craigie J.
      • Gold I.
      Hopping, skipping or jumping to conclusions? Clarifying the role of the JTC bias in delusions.
      maintained that the main psychotic symptoms of schizophrenia appear to be due to cognitive bias causing distortion in processing information from the external environment.
      • Lazarus R.S.
      • Folkman S.
      Transactional theory and research on emotions and coping.
      insisted that personal cognitive assessment and the selection of a method to cope with the relationship between humans and the environment determine adaptation or inadaptation. In this regard, the main psychotic symptoms of schizophrenia appear as residual symptoms when patients are in the community rehabilitation stage, and the symptoms should be viewed as something to manage as opposed to the expectation of full recovery (
      • Jensen G.
      The 2-fold reality: Schizophrenia and the banality of living in 2 worlds.
      ).
      The treatment of schizophrenia aims to effectively manage symptoms, integrate the patient into the community, and, to the extent possible, assist the patient in maintaining an independent life in the community (
      • Keepers G.A.
      • Fochtmann L.J.
      • Anzia J.M.
      • Benjamin S.
      • Lyness J.M.
      • Mojtabai R.
      • Lenzenweger M.F.
      The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia.
      ). Although developments in the pharmacological treatment of schizophrenia have been remarkable, pharmacological treatment alone has not prevented a revolving door phenomenon in which rehospitalization frequently occurs (
      • Ciudad A.
      • San L.
      • Bernardo M.
      • Olivares J.M.
      • Polavieja P.
      • Valladares A.
      • Gilaberte I.
      Relapse and therapeutic interventions in a 1-year observational cohort study of nonadherent outpatients with schizophrenia.
      ). To promote the recovery and treatment effects of patients with schizophrenia, there is a need to offer psychosocial interventions alongside pharmacological treatment (
      • Kern R.S.
      • Glynn S.M.
      • Horan W.P.
      • Marder S.R.
      Psychosocial treatments to promote functional recovery in schizophrenia.
      ). As a psychological treatment to reduce psychotic symptoms, cognitive behavioral therapy shows relatively consistent effects, but the effects are not large compared with a control group (
      • Jauhar S.
      • McKenna P.J.
      • Radua J.
      • Fung E.
      • Salvador R.
      • Laws K.R.
      Cognitive-behavioural therapy for the symptoms of schizophrenia: Systematic review and meta-analysis with examination of potential bias.
      ). In addition, various types of interventions, such as cognitive intervention and psychoeducation, have been developed, and the effects of these interventions on psychotic symptoms have been small to moderate (
      • Eichner C.
      • Berna F.
      Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: A meta-analysis taking into account important moderators.
      ;
      • Lejeune J.A.
      • Northrop A.
      • Kurtz M.M.
      A meta-analysis of cognitive remediation for schizophrenia: Efficacy and the role of participant and treatment factors.
      ).
      • Moritz S.
      • Woodward T.S.
      Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention.
      developed metacognitive training based on a cognitive-behavioral model. Metacognitive training consists of increasing the patient's awareness of and control over their cognitive distortions and abnormal behavior.
      • Wells A.
      • Matthews G.
      Attention and emotion: A clinical perspective (Erlbaum).
      argued that a bias towards one's individual way of thinking and response to stress generates a reverse effect, and psychopathy is caused by a self-regulatory executive function (S-REF) model. Further, individuals can solve various mental problems by controlling reactions to their own way of thinking and thoughts through metacognition.
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      argued that the process of repeated worrying and rumination in psychopathy can be controlled by metacognition and developed metacognitive therapy based on the S-REF model. Metacognitive therapy focuses on the details of thought, including negative auto-thinking or irrational beliefs, and views cognition as hierarchical; through upper cognition, namely metacognition, metacognitive therapy focuses on changing one's way of thinking (
      • Fisher P.
      • Wells A.
      Metacognitive therapy: Distinctive features.
      ).
      A metacognition-applied program involves changing the cognitive basis of distorted thought through metacognition, and the program aims to increase insight into one's cognitive distortions. The principle of the program is that patients are not confined to cognitive traps because they learn to observe their thinking and exert metacognitive control (
      • Moritz S.
      • Vitzthum F.
      • Randjbar S.
      • Veckenstedt R.
      • Woodward T.S.
      Detecting and defusing cognitive traps: Metacognitive intervention in schizophrenia.
      ). For patients with schizophrenia, the application of metacognition helps them to see subjective experiences more objectively by expanding their perspective of themselves, others, and situations. To be able to recognize their psychotic symptoms when experiencing them means improvement in insight, which can be connected to interpersonal relationships and improvement in social functioning (
      • Bell V.
      • Raihani N.
      • Wilkinson S.
      Derationalizing delusions.
      ;
      • Chen Q.
      • Sang Y.
      • Ren L.
      • Wu J.
      • Chen Y.
      • Zheng M.
      • Sun H.
      Metacognitive training: A useful complement to community-based rehabilitation for schizophrenia patients in China.
      ;
      • Parker S.K.
      • Mulligan L.D.
      • Milner P.
      • Bowe S.
      • Palmier-Claus J.E.
      Metacognitive therapy for individuals at high risk of developing psychosis: A pilot study.
      ). Such a change is regarded as an essential process for rehabilitating people with schizophrenia (
      • Manoli R.
      • Cervello S.
      • Franck N.
      Impact of insight and metacognition on vocational rehabilitation of individuals with severe mental illness: A systematic review.
      ). When patients recognize their psychotic symptoms in relationships with others, it is referred to as social cognition improvement (
      • Bell V.
      • Mills K.L.
      • Modinos G.
      • Wilkinson S.
      Rethinking social cognition in light of psychosis: Reciprocal implications for cognition and psychopathology.
      ). Social cognition is related to personal and social performance (PSP); realizing how people understand themselves and others encompasses an ability to understand others' behavior and infer their mental state (
      • Fiske S.
      • Taylor S.
      Social cognition: From brains to culture.
      ).
      reported that the social cognition of patients with schizophrenia is related to social functioning and that social functioning and metacognition are uniquely related.
      Recognizing and managing hallucinations and delusions by applying metacognition has been shown to improve PSP, insight, and social cognition (
      • Eichner C.
      • Berna F.
      Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: A meta-analysis taking into account important moderators.
      ). However, the evaluation of the effectiveness of metacognitive programs is necessary to verify a proper intervention method (
      • Philipp R.
      • Kriston L.
      • Lanio J.
      • Kühne F.
      • Härter M.
      • Moritz S.
      • Meister R.
      Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta-analysis (METACOG).
      ). Consequently, this study aimed to develop a metacognitive intervention program to expand the perspectives on self-recognition, others, and situations, focusing on cognitive assessment and a method to cope with psychotic symptoms. The program, Metacognitive Intervention for Schizophrenia (MCI-S), was developed by revising and complementing Metacognitive Training (MCTain) and Metacognitive Therapy (MCTherp) (
      • Moritz S.
      • Woodward T.S.
      Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention.
      ;
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      ). The effectiveness of the MCI-S program was evaluated with regard to symptom relief and functional improvement in patients with schizophrenia.

      Methods

      Design

      The study was a pretest-posttest quasi-experimental study with a nonequivalent control group. The MCI-S program was conducted at three community psychosocial rehabilitation facilities located in three regions of Korea. One other facility in a different location was used to recruit participants for the control group. Treatment in a general community rehabilitation program includes case management and standard psychiatric rehabilitation services (referred to as TAU for “treatment as usual”). The study compared the effects of the MCI-S program plus TAU to TAU only. To calculate the sample size needed, G*Power 3.1 was used (
      • Faul F.
      • Erdfelder E.
      • Lang A.-G.
      • Buchner A.
      G* power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
      ). Based on previous studies (
      • Moritz S.
      • Veckenstedt R.
      • Bohn F.
      • Hottenrott B.
      • Scheu F.
      • Randjbar S.
      • Treszl A.
      Complementary group metacognitive training (MCT) reduces delusional ideation in schizophrenia.
      ), the sample size required for a power of 0.80, a significance level of 0.05, an effect size of 0.25, and a two-way ANOVA, 36 participants were required. However, 50 were recruited in consideration of representativeness, the normal distribution, and the dropout rate because the dropout rate reported in previous studies was 31 % (
      • Van Oosterhout B.
      • Krabbendam L.
      • De Boer K.
      • Ferwerda J.
      • Van der Helm M.
      • Stant A.
      • Van der Gaag M.
      Metacognitive group training for schizophrenia spectrum patients with delusions: A randomized controlled trial.
      ). Facilities that had never executed a cognitive behavioral therapy program were contacted to recruit participants. The pre- and post-assessments and a follow-up assessment were performed in the mental health programs where the participants were receiving treatment. All participants completed a pre-assessment questionnaire prior to the beginning of the MCI-S program. Post-assessment occurred immediately after the program ended, and the follow-up assessment was conducted in the fourth week after the post-assessment. The intervention was offered to the control group after the study ended. Approval for the study was received from K University's Institutional Review Board (No. 40525-202004-HR-006-04).

      Participants

      The participants were patients diagnosed with schizophrenia based on DSM-5 criteria and who were registered with the community mental health promotion institutions. Criteria for participation included those aged 18–65, psychiatrically stable and taking antipsychotic medication for three months, who understood the purpose of the study, and agreed to participate by indicating their consent in writing. The exclusion criteria included a history of brain damage, a history of drug abuse within the past three years, and patients with a neurological disorder, including intellectual disability or visual perception disorder. Although the aim was to recruit 25 people for each group, initially 25 participants comprised the experimental group, and 20 participants comprised the control group. One participant in the experiment group dropped out after the fifth session. One person in the control group dropped out before the final assessment. Thus, the analysis included 24 participants in the experimental group and 19 in the control group (Fig. 1).
      Fig. 1
      Fig. 1Participant flowchart. MCI-S, metacognitive intervention for schizophrenia; TAU, treatment as usual.

      Process of developing the intervention (MCI-S)

      First, the process in which participants view their subjective experience from the metacognitive perspective in handling their main psychotic symptoms is very important. To this end, the content of the program reflecting domestic schizophrenia is essential. Second, patients with schizophrenia have difficulty accepting external stimulations due to their psychotic symptoms (
      • Moritz S.
      • Silverstein S.M.
      • Beblo T.
      • Özaslan Z.
      • Zink M.
      • Gallinat J.
      Much of the neurocognitive impairment in schizophrenia is due to factors other than schizophrenia itself: Implications for research and treatment.
      ). There is a need to compose the content so that feelings of frustration are reduced. Third, a step-by-step approach is needed for participants to understand and apply metacognition. To improve and expand metacognitive ability, self-recognition needs to be conducted first, from which understanding of others and situations is possible. Perspective expansion into others and situations is possible only if metacognition is first applied to oneself.
      The metacognition therapy of
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      is suitable for recognizing one's inner problems and applying metacognition. The metacognitive training of
      • Moritz S.
      • Woodward T.S.
      Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention.
      consists of content to expand metacognition so that three perspectives—oneself, others, and situations—can be viewed, and so it is suitable for the second stage. The researcher of this study applied a metacognitive program step-by-step by integrating the two metacognitive therapies. In the stage where the participant applies metacognition for the first time, recognizes their own symptoms, and views problems as they are, the program's content was based on a revised and complementary version of
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      metacognitive therapy. In the stage where the participant identifies social context from various perspectives based on increased self-recognition, the content of the program was based on a revised and complementary version of
      • Moritz S.
      • Woodward T.S.
      Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention.
      metacognitive training.
      The program was initially reviewed by a group of five experts including a professor of psychiatric nursing, a psychologist, and three mental health workers with experience working in psychosocial rehabilitation programs with patients diagnosed with schizophrenia. The content validity index of the program was calculated (
      • Lynn M.R.
      Determination and quantification of content validity.
      ) for the group of experts. All five rated the items either three or four points (using a four-point scale), indicating the program content was suitable.
      A preliminary evaluation was conducted after experts' verified the program's validity to evaluate the study's applicability. In this evaluation, three patients diagnosed with schizophrenia who were participating in a psychosocial rehabilitation program within a mental health welfare center were selected. They were told the purpose of this study, provided their consent, and participated in a demonstration program lasting three hours on October 15, 2020. By reflecting on the results of this preliminary evaluation, additional examples were added to the program, and this study enabled the participants to easily understand and apply metacognitive perspective.
      The composition of the MCI-S program is shown in Table 1. The program consists of two stages. In the first stage, participants' commitment, anxiety, excessive worry, threat, control of thinking, and avoidance are identified through metacognitive intervention. They realize the wrong use of a metacognitive belief, and the metacognition is revised. In the second stage, in which the participants may experience excessive confidence, self-focus, and commitment generated by characteristic symptoms of schizophrenia, namely attribution bias and hasty concluding, participants begin to recognize others and social situations through metacognitive training. In other words, the program consists of a self-recognition stage and an others and situations recognition stage for step-by-step perspective expansion to be carried out. The most important element in developing the MCI-S program was that patients participating in the program would objectively observe and recognize their own situations in relation to their main psychotic symptoms, accept themselves, and expand their perspective to include others and other possible situations.
      Table 1Composition of the MCI-S program.
      Key objectiveSession (90 min.)ThemeContent
      Realizing my mind1Orientation
      • Introduction to the objectives, content, and progress of the program
      • Self-Attention Rating Scale
      • Checking intricate inner problems and stress
      2Concentration training technique and execution
      • Understanding of metacognition
      • Explanation and execution of attention training technique
      • Understanding of auditory hallucinations and sharing the experience
      3Discerning actual experience and thinking
      • Discerning actual experience and thinking and sharing the experience
      • Viewing thinking in mind by applying metacognition
      4Identifying the differences between worries and reality
      • Identifying my beliefs on worries
      • Understanding difference between worries and reality and sharing the experience
      5Distancing from worries
      • Identifying my worries
      • Understanding the causes and results of worries
      • Distancing from worries using metaphor
      Viewing from diverse perspectives6Putting yourself in someone else's shoes for communication
      • Viewing incidents occurring to me from my own, others', and situational perspectives
      • Recalling the experience of being rejected and finding causes from my own, others', and situational perspectives
      7Not making a hasty decision
      • Explaining the causes and results of the event by looking at the presented picture
      • Finding a way to cope by changing decisions when new evidence is found
      • Interpreting and explaining about experienced events in various ways
      8Outer value and inner value
      • Thinking about others' motivation from diverse perspectives
      • Talking about outer visible and invisible sides (consolidation of strengths)
      Practicing in everyday life9Establishing a plan in everyday life
      • Finding changes in the questions written upon orientation and stress level
      • Prioritizing plans in everyday life by applying metacognition
      10Towards the future
      • Sharing experience to which metacognition is applied
      • Planning to put it into practice in the future
      • Mutually encouraging and sharing feelings and opinions
      MCI­S, metacognitive intervention for schizophrenia.

      Research procedures

      The program consisted of 10 sessions for 10 weeks, once a week, and 90 min per session. There were 5–10 people in each group. The first 20 min involved reviewing the details learned in the previous session. The next 50 min involved the content to be learned and the related activity. The last 20 min focused on sharing feelings and opinions about the session and providing guidance on the tasks to be completed for the next session. The content of the program included the following: nickname and self-introduction, Self-Attention Rating Scale presentation, the practice of attention training technique, discernment of actual experience and one's own thinking, the difference between worry and reality, distancing from worries (
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      ), putting yourself in someone else's shoes or communication, not making hasty decisions, outer and inner values (
      • Moritz S.
      • Woodward T.S.
      Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention.
      ), and establishing a plan to practice in everyday life. Each session started with completing a self-attention rating scale (
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      ). The purpose of the scale is to self-check their level of concentration so that they are better able to focus their attention (
      • Wells A.
      Metacognitive therapy for anxiety and depression.
      ). Then, the program was executed in which the participants shared their experiences after various examples of the session topic were explained to them. A workbook containing each session's content and an activity report was distributed to each participant in advance, and printed materials were offered in each session so that the participants could remember metacognition principles and program content.

      Data collection

      The participants completed self-report items regarding their demographic information, insight, and social cognition. Participants' primary psychotic symptoms and personal and social performance were evaluated by specialized mental health professionals that consisted of two mental health nurses, two mental health social workers, and one mental health clinical psychologist. These professionals included two men and three women with a mean age of 39.8 years and 11 years and six months of experience working in the mental health sector. The specialized mental health professionals had, on average, worked in their current position for seven years and four months and reported having a mean caseload of eight individuals. They completed the questionnaire assessing the participants' primary psychotic symptoms and personal and social performance following the one-on-one interviews. Before completing the scale, the surveys were completed after conducting at least four interviews and receiving training on the assessment and guidance from a clinical psychologist until κ = 0.80 or higher was achieved for their inter-rater reliability.

      Measures

      Psychotic symptoms

      Psychotic symptoms were assessed using the 17-item Psychotic Symptom Rating Scale (
      • Haddock G.
      • McCarron J.
      • Tarrier N.
      • Faragher E.
      Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS).
      ), which includes 11 auditory hallucinations items and six delusion items. Items are rated using a 5-point Likert scale (scored 0–4). Higher scores indicate more severe psychotic symptoms.
      • Haddock G.
      • McCarron J.
      • Tarrier N.
      • Faragher E.
      Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS).
      reported Cronbach's alphas of 0.88 and 0.94 for the hallucinations and delusions subscales, respectively. In this study, Cronbach's α was 0.95 and 0.93 for the same subscales, respectively.

      Personal and social performance

      The Personal and Social Performance (PSP) Scale was developed by
      • Morosini P.L.
      • Magliano L.
      • Brambilla L.
      • Ugolini S.
      • Pioli R.
      Development, reliability and acceptability of a new version of the DSM-IV social and occupational functioning assessment scale (SOFAS) to assess routine social functioning.
      and assessed the extent to which aspects of personal and social functioning are being affected by psychopathology. Four dimensions are assessed by the scale: difficulty in socially useful activities including work and school, personal and social relationships, disability level including self-care, and disturbing and aggressive behaviors. Each dimension consists of a single question that is responded to using a six-point scale (from “No symptoms” to “Very severe”). A total score can be derived that ranges from 1 to 100. Higher scores indicate a higher degree of severity in PSP. In the present study, the internal consistency was α = 0.76.

      Insight

      Insight was measured using Beck's Cognitive Insight Scale (
      • Beck A.T.
      • Baruch E.
      • Balter J.M.
      • Steer R.A.
      • Warman D.M.
      A new instrument for measuring insight: The Beck cognitive insight scale.
      ). This tool consists of 15 items: nine items on self-reflection and six on self-certainty. Items are responded to using a four-point Likert scale. The score is derived by subtracting the score for self-certainty from the self-reflection score; higher scores indicate greater cognitive insight. In the present study, Cronbach's α was 0.82.

      Social cognition

      Social cognition was measured with the Hinting Task developed by
      • Corcoran R.
      • Mercer G.
      • Frith C.D.
      Schizophrenia, symptomatology and social inference: Investigating “theory of mind” in people with schizophrenia.
      . This tool is a self-report questionnaire devised to test the ability to infer the real intention concealed in indirect discourse. Participants respond to questions about the speaker's intention after reading a story composed of a short conversation between two people. If the participant gives a correct answer, they receive two points. If the answer is incorrect, the participant receives an opportunity to answer again by receiving a hint. They receive one point if the answer is correct or zero points if incorrect. Higher scores indicate higher social cognition.
      • Ng R.
      • Fish S.
      • Granholm E.
      Insight and theory of mind in schizophrenia.
      reported Cronbach's α = 0.80. The Cronbach's α = 0.89 in this study.

      Statistical analyses

      The data were analyzed using SPSS/WIN 20.0 Program (IBM Corporation, Armonk, NY). Demographic characteristics were analyzed to determine the frequency, mean, and standard deviation. Cronbach's α was used to determine the reliability of the measures. For the test of normality, the Shapiro-Wilk test was used. To test for homogeneity between groups, the independent t-test, chi-square test, Fisher's exact test, and Mann-Whitney U test were used depending on the status of the normal distribution. To evaluate the program's effect, delusions and aggressive behavior with non-homogeneous pre-check results were controlled for as covariates. Differences between the groups according to the lapse of time were analyzed using two-way repeated-measures ANCOVAs or Friedman and Wilcoxon signed-ranks test. Statistical significance was set at p < .05.

      Results

      Regarding the characteristics of the sample, 69.8 % were men, and the mean age was 45.44. The mean age for when schizophrenia occurred was 23.88. The average number of hospital admissions was 4.86, and all participants were taking antipsychotic medication. Most were unmarried (79.1 %), living with their family (60.5 %), and had a high school level of education (60.5 %). According to the pre-homogeneity test results, there were no significant differences between the experimental and control groups in their general characteristics (Table 2).
      Table 2Pre-homogeneity test of the participants (N = 43).
      CharacteristicCategory/rangeTotal (n = 43)Experimental group (n = 24)Control group

      (n = 19)
      χ2/t/Up
      n (%) or M ± SDn (%) or M ± SDn (%) or M ± SD
      GenderMale30(69.8)18(75.0)12(63.2)0.710.401
      Female13(30.2)6(25.0)7(36.8)
      Age (years)45.44 ± 0.4347.42 ± 10.3542.95 ± 10.261.410.166
      Age of onset (years)23.88 ± 6.4722.71 ± 5.2425.37 ± 7.65−1.290.205
      No. of admissions to psychiatric hospital4.86 ± 4.215.79 ± 5.133.68 ± 2.26201.50
      Mann-Whitney's U test.
      0.508
      Marital statusUnmarried34(79.1)17(70.8)17(89.5)2.28
      Fisher's exact test. PSP, Personal and Social Performance Scale.
      0.610
      Married4(9.3)3(12.5)1(5.3)
      Other5(11.6)4(16.7)1(5.3)
      Living situationAlone8(18.6)7(29.2)1(5.3)5.70
      Fisher's exact test. PSP, Personal and Social Performance Scale.
      0.089
      Family26(60.5)13(54.2)13(68.4)
      Other9(21.0)4(16.7)5(26.3)
      EducationMiddle school6(14.0)2(8.3)4(21.1)1.52
      Fisher's exact test. PSP, Personal and Social Performance Scale.
      0.555
      High school26(60.5)15(62.5)11(57.9)
      University or higher11(25.5)7(29.2)4(21.1)
      Auditory hallucinations0–258.30 ± 8.108.96 ± 8.227.47 ± 8.09222
      Mann-Whitney's U test.
      0.882
      Delusions0–176.02 ± 5.157.83 ± 5.313.74 ± 3.98121
      Mann-Whitney's U test.
      0.009
      PSP30–8063.91 ± 10.9361.25 ± 12.1167.26 ± 8.392−1.840.073
      Socially useful activities2–52.86 ± 0.833.00 ± 0.832.68 ± 0.82175.50
      Mann-Whitney's U test.
      0.166
      Personal and social relationship1–52.77 ± 0.942.96 ± 0.992.53 ± 0.84162
      Mann-Whitney's U test.
      0.084
      Self-care1–52.40 ± 0.902.29 ± 0.992.53 ± 0.77208.50
      Mann-Whitney's U test.
      0.612
      Disturbing and aggressive behaviors1–41.44 ± 0.731.29 ± 0.751.63 ± 0.68153
      Mann-Whitney's U test.
      0.026
      Insight−5–123.23 ± 3.192.58 ± 3.094.05 ± 3.22−1.510.136
      Social cognition0–167.95 ± 4.398.83 ± 4.456.84 ± 4.171.490.142
      a Mann-Whitney's U test.
      b Fisher's exact test. PSP, Personal and Social Performance Scale.
      Pretest assessment results indicated there were no significant differences between the two groups in auditory hallucinations, insight, social cognition, and difficulty in socially useful activities, including work and school, personal and social relationships, and self-care. However, the two groups differed significantly in delusions and disturbing and aggressive behaviors (Table 2).
      Before checking the program effects, according to the Shapiro-Wilk test, auditory hallucinations, delusions, and the four dimensions of PSP (socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors) did not comply with the normal distribution. Therefore, the Friedman test and Wilcoxon signed-rank test were conducted. As for the variables confirmed to comply with the normal distribution, the psychotic symptoms whose pre-check result was not homogeneous and disturbing and aggressive behaviors were controlled as covariates in the two-way repeated-measures ANOVA.
      Auditory hallucinations decreased in both the experimental and control groups, and the difference between the two groups was not statistically significant. Delusions decreased in both the experimental and control groups, and the difference between the two groups was statistically significant.
      Regarding PSP, the interaction with time was significant, but the change in PSP over time in the two groups was not significant. Difficulty in socially useful activities and difficulty in personal and social relationships decreased over time in both groups, and the difference between the two groups was significant. Although difficulty in self-care decreased over time in both groups, the difference between the two groups was not significant. The experimental group's disturbing and aggressive behavior did not show a statistically significant decrease, whereas there was a significant decrease in the control group. However, the difference between the two groups was not significant (Table 3).
      Table 3Main psychotic symptoms and personal and social performance (N = 43).
      VariableGroupPre-testPost-testFollow-upSourceF/χ2p
      M ± SDM ± SDM ± SD
      Auditory hallucinationsExperimental8.96 ± 8.223.92 ± 5.523.63 ± 5.1515.77
      Friedman test.
      <0.001
      Control7.47 ± 8.083.42 ± 6.933.11 ± 6.1217.24
      Friedman test.
      <0.001
      0.114
      Wilcoxon signed-rank test.
      DelusionsExperimental7.83 ± 5.315.46 ± 5.634.75 ± 4.999.43
      Friedman test.
      <0.001
      Control3.74 ± 3.981.47 ± 3.041.11 ± 2.4419.93
      Friedman test.
      0.001
      <0.001
      Wilcoxon signed-rank test.
      Personal and Social Performance (total scale)Experimental61.25 ± 12.1070.83 ± 11.4275.04 ± 9.73Group2.940.094
      Control67.26 ± 8.3970.95 ± 4.0871.42 ± 2.79Time2.520.096
      Group × Time13.45<0.001
      Socially useful activitiesExperimental3.00 ± 0.832.79 ± 0.932.42 ± 0.9215.52
      Friedman test.
      <0.001
      Control2.68 ± 0.822.00 ± 0.471.89 ± 0.3121.78
      Friedman test.
      <0.001
      0.001
      Wilcoxon signed-rank test.
      Personal and social relationshipsExperimental2.96 ± 0.992.63 ± 0.872.25 ± 0.9821.73
      Friedman test.
      <0.001
      Control2.53 ± 0.842.00 ± 0.332.00 ± 0.0013.52
      Friedman test.
      0.001
      <0.001
      Wilcoxon signed-rank test.
      Self-careExperimental2.29 ± 0.991.92 ± 0.921.58 ± 0.8312.11
      Friedman test.
      0.002
      Control2.53 ± 0.771.74 ± 0.561.84 ± 0.5017.90
      Friedman test.
      <0.001
      0.126
      Wilcoxon signed-rank test.
      Disturbing and aggressive behaviorsExperimental1.29 ± 0.751.13 ± 0.441.08 ± 0.405.20
      Friedman test.
      0.074
      Control1.63 ± 0.681.11 ± 0.311.05 ± 0.2218.20
      Friedman test.
      <0.001
      0.469
      Wilcoxon signed-rank test.
      a Friedman test.
      b Wilcoxon signed-rank test.
      As for insight, there were no significant findings. However, there was a significant group-by-time interaction for social cognition. There was more improvement in social cognition in the experimental group (Table 4).
      Table 4Insight and social cognition (N = 43).
      VariableGroupPre-testPost-testFollow-upSourceFp
      M ± SDM ± SDM ± SD
      InsightExperimental2.58 ± 3.092.92 ± 4.103.21 ± 4.42Group0.640.430
      Control4.05 ± 3.223.74 ± 2.623.21 ± 2.52Time1.390.255
      Group × Time0.230.795
      Social cognitionExperimental8.83 ± 4.4413.08 ± 3.3414.25 ± 2.23Group3.900.056
      Control6.84 ± 4.168.79 ± 5.438.26 ± 5.34Time0.410.617
      Group × Time9.920.001

      Discussion

      This study involved the development and evaluation of a metacognition program for patients with schizophrenia (MCI-S). Using a pretest-posttest quasi-experimental design with a nonequivalent control group, the study examined whether participants had a decrease in main psychotic symptoms and improvement in social cognitive functioning. The results indicated that the program effectively reduced delusions and increased personal and social performance and social cognition.
      Auditory hallucinations in both the experimental and control groups continuously decreased; however, the difference in the decrease did not differ between the two groups. Our results are consistent with
      • Philipp R.
      • Kriston L.
      • Lanio J.
      • Kühne F.
      • Härter M.
      • Moritz S.
      • Meister R.
      Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta-analysis (METACOG).
      systematic review and meta-analysis that showed metacognitive training with patients with schizophrenia compared to standard psychological treatments bordered on significance with regard to symptom severity as the outcome variable. As opposed to the results for auditory hallucinations, the difference in the reduction of delusional symptoms in the experimental group was significant. This finding is similar to the results of
      • Moritz S.
      • Veckenstedt R.
      • Bohn F.
      • Hottenrott B.
      • Scheu F.
      • Randjbar S.
      • Treszl A.
      Complementary group metacognitive training (MCT) reduces delusional ideation in schizophrenia.
      , in which participation in a metacognition program was associated with a reduction in delusional symptoms in 150 hospitalized patients and outpatients.
      PSP scores increased over time in both groups but not significantly; however, there was a group-by-time interaction effect indicating that there were significant differences between the two groups over time. There was more improvement in PSP in the experimental group compared to the control group.
      • Morrison A.P.
      • Pyle M.
      • Chapman N.
      • French P.
      • Parker S.K.
      • Wells A.
      Metacognitive therapy in people with a schizophrenia spectrum diagnosis and medication resistant symptoms: A feasibility study.
      similarly did not find a significant increase in PSP in their study of metacognition therapy for patients with schizophrenia. However, they did not include a control group in their study.
      • Fischer M.W.
      • Dimaggio G.
      • Hochheiser J.
      • Vohs J.L.
      • Phalen P.
      • Lysaker P.H.
      Metacognitive capacity is related to self-reported social functioning and may moderate the effects of symptoms on interpersonal behavior.
      found a significant correlation between metacognition and PSP and that PSP had a negative correlation with main psychotic symptoms; in consideration of this, they recommended using metacognition as an intervention. Given that the experimental group's PSP improvement was remarkable compared to TAU, and delusions significantly decreased, it was confirmed that changes in delusions and PSP occurred through the MCI-S program.
      In the four areas of PSP that were assessed, there was significant improvement in socially useful activities and in personal and social relationships in both the experimental and control groups, and the differences between the two groups were significant. Consequently, the MCI-S was found to be effective in improving personal and social relationships.
      • Kawata A.K.
      • Revicki D.A.
      Psychometric properties of the personal and social performance scale (PSP) among individuals with schizophrenia living in the community.
      reported that socially useful activities and personal and social relationships correlated with psychotic symptoms of schizophrenia. Given the results of the present study, it appears a reduction in main psychotic symptoms is concomitant with improvements in aspects of personal and social functioning.
      With regard to self-care, there was steady improvement in the experimental group, whereas, in the control group, there was improvement over the 10-week period, then a slight decrease in self-care from posttest to follow-up four weeks later. Nonetheless, although both groups improved significantly, there was no significant difference in self-care improvement between the two groups. It may be that self-care improvement through metacognitive training alone is unreasonable for patients with schizophrenia. To improve self-care ability, it may be necessary to also use more concrete methods.
      Disturbing and aggressive behaviors decreased in the experimental group, but the change was not significant, whereas there was a significant decrease in the control group. However, the difference between the two groups was not statistically significant.
      Insight continuously increased from pretest to follow-up in the experimental group, whereas insight continuously decreased in the control group. However, the change was not significant for either group, and the group-by-time interaction indicated no significant differences between the two groups over time. Although there was no significant difference between the two groups, there was an unexplainable difference in insight scores between the two groups. It would be expected that the MCI-S program would increase insight, but a decrease in insight in participants receiving TAU warrants further investigation.
      Social cognition improved in both groups, and the difference in improvement between the two groups was significant. There was more improvement in the experimental group over time. The results are consistent with a previous study in which metacognitive training included 18 participants diagnosed with schizophrenia; it was confirmed that participants' social cognition improved (
      • Moritz S.
      • Kerstan A.
      • Veckenstedt R.
      • Randjbar S.
      • Vitzthum F.
      • Schmidt C.
      • Woodward T.
      Further evidence for the efficacy of a metacognitive group training in schizophrenia.
      ).
      • Dark F.
      • Scott J.G.
      • Baker A.
      • Parker S.
      • Gordon A.
      • Newman E.
      • Penn D.L.
      Randomized controlled trial of social cognition and interaction training compared to befriending group.
      reported a high correlation between social cognition and PSP. Similarly, in the present study, there were concomitant improvements in both social cognition and PSP in the experimental group compared to the control group. Thus, the changes in PCP and social cognition in the experimental group can be viewed as meaningful or having clinical significance.

      Strengths and limitations

      A strength of this study is that it was an intervention study that included a control group to test the effects of metacognitive improvement on main psychotic symptoms, personal and social performance, insight, and social cognition. The study provides support for MCI-S as a program for patients with schizophrenia that can be integrated into community rehabilitation programs. The program can be used as a basis for developing a metacognitive program for diverse patient populations. However, the study has limitations with regard to generalizability. The study had a small sample size, and experimental participants were from three facilities in different areas of South Korea. Other limitations concern the study's internal validity: its small sample size can affect the accuracy of the findings; there was no control group at each facility for comparison; there was a lack of homogeneity in the delusion and aggressive behavior on the PSP; and a self-report assessment was used, which may be affected by social desirability bias.
      There is a need for further research on the MCI-S with a larger sample size. Follow-up assessments should be conducted at three, six, and 12 months to determine the program's lasting effects. In addition, patients with schizophrenia show very diverse cognitive damages depending on the progress of the disease. It would be important to evaluate the MCI-S program effects given the diversity of cognitive characteristics. Cultural diversity is an important consideration as well. A program reflecting domestic schizophrenia is essential; there is a need to present experiences that the participants can relate to using various examples in consideration of cultural background. Lastly, further research is needed to investigate the relationship between metacognitive beliefs and various psychosocial factors that have yet to be examined.

      Funding

      This research was funded by the National Research Foundation of Korea ( 2020R1A2C1009207 ). The funding source had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

      Declaration of competing interest

      None.

      Acknowledgment

      We warmly thank the patients who voluntarily participated in the study despite the pandemic of COVID-19.

      Appendix A. Supplementary data

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