The feasibility and acceptability of metacognitive therapy in a forensic setting: a case report of chronic paranoid schizophrenia with persistent depressive symptoms

Abstract

There is increasing evidence that metacognitive therapy (MCT; Wells, 2009) results in significant benefits in various disorders, including depression and psychosis, and may even surpass the efficacy of cognitive behavioral therapy (CBT), currently recommended in treatment guidelines. The implementation of advanced new forms of treatment, and especially research into the effectiveness of these new treatments, is often more challenging in forensic psychiatric treatment and with difficult-to-treat patients. The evidence on the effectiveness of psychological interventions in this population is still limited and research on MCT in this context is non-existent. As a first step in evaluating MCT’s feasibility and acceptability in this context, this paper describes a case example of the treatment of persistent depressive symptoms of chronic paranoid schizophrenia augmented with MCT in a forensic mental health setting. In addition to treatment as usual, i.e. medication, regular conversations with a designated nurse, and a social skills group, 18 weekly sessions of MCT following a depression treatment plan, targeting rumination/worry, attentional control, metacognitive beliefs, and dysfunctional behaviors, were delivered. The same person conducted the assessments and therapy. Clinically significant reductions in depressive symptoms and delusions were observed, assessed at pre- and post-therapy. In addition, a prominent decline in rumination, dysfunctional metacognitive beliefs and coping behaviors took place. Although the specific contribution of MCT cannot be established, it is concluded that MCT may be a useful supplement to treatment options in the treatment of difficult-to-treat patients and in a forensic setting.