Decision-making and Metacognition

Workstream 5

Our workstream uses theoretical and experimental methods from cognitive neuroscience to answer questions about metacognition (“thinking about your own thinking”), decision-making, mental capacity and insight, in both healthy and clinical groups. Close links with service user advisors and input from clinicians in the research team ensure the questions studied are relevant and important. Our research focuses on understanding whether and how a quantitative understanding of cognitive processes in the lab can provide relevant context for cases of contested decision-making capacity.


The Mental Capacity Act 2005 (MCA 2005) created statute law describing a legal test to determine whether a person has the “mental capacity” to make a decision for themselves. The MCA 2005 delineates 4 components of capacitous decisional functioning – the abilities to understand the relevant information, to retain it, to use-and-weigh it to generate a choice, and to express that choice. Assessors of mental capacity in healthcare and social care settings therefore need to map the mental states of the people they meet onto these 4 legal components. However, the cognitive underpinning of these 4 functions remains under-specified, the relationships to neuropsychological tests and brain function are unclear and professionals consequently perform capacity assessments in very variable ways.  The use-and-weigh criterion seems particularly tricky to assess, leading to well-founded claims from disability rights organisations that current capacity assessment practices contain a significant degree of subjectivity. 

Our workstream seeks to address this gap by applying methods from cognitive neuroscience to study a critical aspect of decision-making that might be highly relevant for capacity: “metacognition”– or the ability to have knowledge of and reflect on your own thought processes. In this interview, Alex Ruck Keene and Steve Fleming discuss relationships between metacognition, insight and mental capacity.


This workstream is spearheaded by Prof Anthony David at the UCL Institute of Mental Health, with key involvement from the Metalab, led by Dr Stephen Fleming at the UCL Wellcome Centre for Human Neuroimaging and Department of Experimental Psychology. Through theoretical and experimental work, we combine techniques from cognitive neuroscience with experiential research grounded in professional practice. Integral to our work is the input of the McPin Foundation Service User Advisory Group, which has informed us on questions of design and  test-driven our experimental paradigms.

Our work on metacognition is closely allied to that of workstream 4 on insight. Insight may be viewed as a particular kind of metacognition which concerns itself with reflecting upon whether one’s thinking, and resulting beliefs and perceptions, is yielding accurate and useful conclusions. Some clinical psychiatrists would say that decision making capacity is undermined when someone fails to recognize that their thinking is altered. Others disagree, pointing out that the psychiatrist’s determination on insight is subjective and has potential to be abused in legal contexts. We use systematic reviews and empirical studies to scrutinise how insight is used and whether it relates to objective measures of metacognition. Tony David’s ‘King’s Lecture’ on Insight is available here.

Steve Fleming has pioneered measurement of metacognition in the lab. Participants are asked to make a decision and give a self-rating of their confidence that they have decided correctly. We are able to quantify the extent to which that confidence was justified at a given level of performance accuracy, generating a parameter (“meta-d’ ”) with specific neural correlates. Our adapted paradigms enable comparison between healthy and clinical groups, and across the lifecourse, and a gamified metacognitive measure has facilitated measurement of metacognition for people with Parkinson’s Disease and Alzheimer’s and quantification of how specific disorder-related deficits interact with metacognition and insight.

The effects of social influences on an individual’s decision-making form another focus of our work. We undertake theoretical and experimental studies to explore how people use advice and when they may be subject to undue influence from others. We have compared advice-taking behaviours across cultures, in an empirical study with Peking University, China, and we propose that studying advice-taking itself may be useful as a model for the using-and-weighing of options in capacitous decision-making. Collaborating with Prof Francesca Happe’s group, we measuring metacognition in people with autistic spectrum disorder and the neurotypical population to investigate whether people who better understand other people’s minds are also have better metacognition. Finally, we have undertaken a case review with workstream 6, to explore how social pressures may affect decision making capacity in Court of Protection cases.  

Real-world assessment practice is another strand of study for the workstream, using survey and interview methods with health and social care professionals and observational studies of the Court of Protection. This has allowed us to examine the ethical and practical issues of introducing neuroscientific measurement techniques and to make recommendations for improving assessment practices in a variety of settings.

As part of the Dear World Project, Elisa van der Plas and Andrew McWilliams were paired with artists to explore themes of mental illness, decision-making, capacity and vulnerability. Members of the workstream mentor for In2Science and In2Research, helping students from disadvantaged backgrounds to discover and achieve careers in science after school or university.


We are innovating interdisciplinary working in mental health, cognitive neuroscience and law, integrated with service user involvement to pave the way for future functional imaging and neurocomputational studies. We have published our earliest work in peer-reviewed open access journals and are active in public engagement. We have shown that ethical and social aspects of decision-making capacity are amenable to mechanistic study using cognitive science and we are able to measure metacognition and capacity in Alzheimer’s Disease, Parkinson’s Disease and Autism. Our work has more broad ethical and policy implications. We are developing practical recommendations for how mental capacity should best be assessed, and we presented several of our studies and conclusions to the current review panel of the Scottish Mental Health Act.


van der Plas, E., Zhang, S., Dong, K., Bang, D., Li, J., Wright, N.D. & Fleming, S.M. (2022).

Identifying cultural differences in metacognition.

Journal of Experimental Psychology: General, in press

Ariyo, K., et al. (2021)

Insight and equality: A systematic review and meta-analysis of socio-demographic associations

International Journal of Social Psychiatry. August 2021. doi:10.1177/00207640211036174

Ariyo, K., et al. (2021)

Experiences of assessing mental capacity in England and Wales: A large-scale survey of professionals.

Wellcome Open Res 2021, 6:144

David, A. S., & Ariyo, K. (2020)

Insight is a useful construct in clinical assessments if used wisely.

Recent activity

Performing Metacognition, Sarah Carpenter (2021), in collaboration with Bethlem Gallery

As part of the Mental Health and Justice project, artist researcher Sarah Carpenter has been collaborating with clinical researcher Andrew McWilliams whose work focuses on metacognition and...


Workstream 5 supervisory network. Click to enlarge.


Workstream members

Anthony David

Anthony David

Principal investigator

Professor of cognitive neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, KCL. Tony has interests in experimental neuropsychology, neuropsychiatry, insight and decision-making capacity. He will lead on workstream 5 and contribute widely across the research network.

Steve Fleming

Steve Fleming


Principal Research Associate, Wellcome Centre for Human Neuroimaging, University College London. Steve has interests in experimental neuroscience, metacognition and neuroscience and law. He will provide PhD supervision in workstream 5 and contribute to all aspects of the workstream.

Kevin Ariyo

Kevin Ariyo

Core member

PhD student, Department of Psychological Medicine, KCL. Kevin has interests in cognitive neuroscience, decision making and mental capacity law. He will conduct metacognition experiments in workstream 5 and interview clinicians involved in capacity assessment.

Andrew McWilliams

Andrew McWilliams

Core member

Clinical research fellow at King’s College London and the UCL Metacognition Lab, Andrew is a specialist registrar in child and adolescent psychiatry. He is interested in technology solutions to gamify tasks, improving the service user experience, as well as in designing tools which support capacity assessment.

Elisa van der Plas

Elisa van der Plas

PhD student

PhD student at the Wellcome Centre for Human Neuroimaging, University College London. Elisa has interests in decision neuroscience, metacognition and social decision-making. She will conduct research on workstream 5 under the shared supervision of Dr. Stephen Fleming and Professor Anthony David.