Metacognitive therapy

Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation.[1] It was created by Adrian Wells[2] based on an information processing model by Wells and Gerald Matthews.[3] It is supported by scientific evidence from a large number of studies.[4][5]

The goals of MCT are first to discover what patients believe about their own thoughts and about how their mind works (called metacognitive beliefs), then to show the patient how these beliefs lead to unhelpful responses to thoughts that serve to unintentionally prolong or worsen symptoms, and finally to provide alternative ways of responding to thoughts in order to allow a reduction of symptoms. In clinical practice, MCT is most commonly used for treating anxiety disorders such as social anxiety disorder, generalised anxiety disorder (GAD), health anxiety, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) as well as depression – though the model was designed to be transdiagnostic (meaning it focuses on common psychological factors thought to maintain all psychological disorders).

History

Metacognition, Greek for "after" (meta) "thought" (cognition), refers to the human capacity to be aware of and control one's own thoughts and internal mental processes.[6] Metacognition has been studied for several decades by researchers, originally as part of developmental psychology and neuropsychology.[7][8][9][10] Examples of metacognition include a person knowing what thoughts are currently in their mind and knowing where the focus of their attention is, and a person's beliefs about their own thoughts (which may or may not be accurate). The first metacognitive interventions were devised for children with attentional disorders in the 1980s.[11][12] A recent open-access review summarizes differences and similarities of metacognitive therapy, metacognitive training, cognitive-behavioral therapy and metacognitive reflection insight therapy.[13]

Model of mental disorders

Self-Regulatory Executive Function model

In the metacognitive model,[2] symptoms are caused by a set of psychological processes called the cognitive attentional syndrome (CAS). The CAS includes three main processes, each of which constitutes extended thinking in response to negative thoughts. These three processes are:

  1. Worry/rumination
  2. Threat monitoring
  3. Coping behaviours that backfire

All three are driven by patients' metacognitive beliefs, such as the belief that these processes will help to solve problems, although the processes all ultimately have the unintentional consequence of prolonging distress.[4] Of particular importance in the model are negative metacognitive beliefs, especially those concerning the uncontrollability and dangerousness of some thoughts. Executive functions are also believed to play a part in how the person can focus and refocus on certain thoughts and mental modes. These mental modes can be categorized as object mode and metacognitive mode, which refers to the different types of relationships people can have towards thoughts.[2] All of the CAS, the metacognitive beliefs, the mental modes and the executive function together constitute the self-regulatory executive function model (S-REF).[2] This is also known as the metacognitive model. In more recent work, Wells has described in greater detail a metacognitive control system of the S-REF aimed at advancing research and treatment using metacognitive therapy.

Therapeutic intervention

MCT is a time-limited therapy which usually takes place between 8–12 sessions. The therapist uses discussions with the patient to discover their metacognitive beliefs, experiences and strategies. The therapist then shares the model with the patient, pointing out how their particular symptoms are caused and maintained.

Therapy then proceeds with the introduction of techniques tailored to the patient's difficulties aimed at changing how the patient relates to thoughts and that bring extended thinking under control. Experiments are used to challenge metacognitive beliefs (e.g. "You believe that if you worry too much you will go 'mad' – let's try worrying as much as possible for the next 5 minutes and see if there is any effect") and strategies such as attentional training technique and detached mindfulness (this is a distinct strategy from various other mindfulness techniques).[14][15]

Research

Clinical trials (including randomized controlled trials) have found MCT to produce large clinically significant improvements across a range of mental health disorders, although as of 2014 the total number of subjects studied is small and a meta-analysis concluded that further study is needed before strong conclusions can be drawn regarding effectiveness.[5] A 2015 special issue of the journal Cognitive Therapy and Research was devoted to MCT research findings.[16] A 2018 meta-analysis confirmed the effectiveness of MCT in the treatment of a variety of psychological complaints with depression and anxiety showing high effect sizes.[17] And in 2020, a study showed superior effectiveness in MCT over CBT in the treatment of depression.[18]

In 2018–2020, a research topic in the journal Frontiers in Psychology highlighted the growing experimental, clinical, and neuropsychological evidence base for MCT.[19]

See also

References
  1. Mulder R, Murray G, Rucklidge J (December 2017). "Common versus specific factors in psychotherapy: opening the black box". The Lancet. Psychiatry. 4 (12): 953–962. doi:10.1016/S2215-0366(17)30100-1. PMID 28689019.
  2. Wells A (2011). Metacognitive therapy for anxiety and depression. New York: Guilford Press. ISBN 9781593859947. OCLC 226358223.
  3. Wells A, Matthews G (November 1996). "Modelling cognition in emotional disorder: the S-REF model". Behaviour Research and Therapy. 34 (11–12): 881–8. doi:10.1016/S0005-7967(96)00050-2. PMID 8990539.
  4. Wells A (12 December 2019). "Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health". Frontiers in Psychology. 10: 2621. doi:10.3389/fpsyg.2019.02621. PMC 6920120. PMID 31920769.
  5. Normann N, van Emmerik AA, Morina N (May 2014). "The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review". Depression and Anxiety. 31 (5): 402–11. doi:10.1002/da.22273. PMID 24756930. S2CID 205736364.
  6. Moritz S, Lysaker PH (November 2018). "Metacognition - What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions". Schizophrenia Research. 201: 20–26. doi:10.1016/j.schres.2018.06.001. PMID 29903626. S2CID 49215109.
  7. Biggs J (1 August 1988). "The role of metacognition in enhancing learning". Australian Journal of Education. 32 (2): 127–138. doi:10.1177/000494418803200201. S2CID 145605646.
  8. Brown AL (1978). "Knowing when, where, and how to remember: a problem of metacognition". In Glaser R (ed.). Advances in instructional psychology. 1. Hillsdale, N.J.: Lawrence Erlbaum Associates. pp. 77–165. ISBN 9780470265192. OCLC 4136451.
  9. Forrest-Pressley DL, ed. (1985). Metacognition, cognition, and human performance. Vol. 2: Instructional practices. Orlando: Academic Press. ISBN 978-0122623028. OCLC 11290806.
  10. Shimamura AP (June 2000). "Toward a cognitive neuroscience of metacognition". Consciousness and Cognition. 9 (2 Pt 1): 313–23, discussion 324-6. doi:10.1006/ccog.2000.0450. PMID 10924251. S2CID 15588976.
  11. Reeve RA, Brown AL (September 1985). "Metacognition reconsidered: implications for intervention research". Journal of Abnormal Child Psychology. 13 (3): 343–56. doi:10.1007/BF00912721. hdl:2142/17676. PMID 4045006. S2CID 37033741.
  12. Kurtz BE, Borkowski JG (February 1987). "Development of strategic skills in impulsive and reflective children: a longitudinal study of metacognition". Journal of Experimental Child Psychology. 43 (1): 129–48. doi:10.1016/0022-0965(87)90055-5. PMID 3559472.
  13. Moritz S, Klein JP, Lysaker PH, Mehl S (September 2019). "Metacognitive and cognitive-behavioral interventions for psychosis: new developments". Dialogues in Clinical Neuroscience. 21 (3): 309–317. doi:10.31887/DCNS.2019.21.3/smoritz. PMC 6829173. PMID 31749655.
  14. Fergus TA, Wheless NE, Wright LC (October 2014). "The attention training technique, self-focused attention, and anxiety: a laboratory-based component study". Behaviour Research and Therapy. 61: 150–5. doi:10.1016/j.brat.2014.08.007. PMID 25213665.
  15. Gkika S, Wells A (February 2015). "How to deal with negative thoughts?: a preliminary comparison of detached mindfulness and thought evaluation in socially anxious individuals". Cognitive Therapy and Research. 39 (1): 23–30. doi:10.1007/s10608-014-9637-5. S2CID 19147462.
  16. "Special issue on metacognitive theory, therapy and techniques". Cognitive Therapy and Research. Springer Verlag. 39 (1). February 2015.
  17. Normann N, Morina N (2018). "The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis". Frontiers in Psychology. 9: 2211. doi:10.3389/fpsyg.2018.02211. PMC 6246690. PMID 30487770.
  18. Callesen P, Reeves D, Heal C, Wells A (May 2020). "Metacognitive Therapy versus Cognitive Behaviour Therapy in Adults with Major Depression: A Parallel Single-Blind Randomised Trial". Scientific Reports. 10 (1): 7878. Bibcode:2020NatSR..10.7878C. doi:10.1038/s41598-020-64577-1. PMC 7217821. PMID 32398710.
  19. "Metacognitive Therapy: Science and Practice of a Paradigm | Frontiers Research Topic". frontiersin.org. Frontiers Media. Retrieved 2019-06-26.

Further reading
  • Wells A, Fisher PL, eds. (2016). Treating depression: MCT, CBT and third wave therapies. Chichester, UK; Malden, MA: Wiley-Blackwell. doi:10.1002/9781119114482. ISBN 9780470759059. OCLC 908699035.CS1 maint: ref=harv (link)
  • Wells A, Simons M (2014). "Metacognitive therapy: thinking differently about thinking". In Hofmann SG (ed.). The Wiley handbook of cognitive behavioral therapy. Chichester, UK; Malden, MA: Wiley-Blackwell. pp. 107–130. doi:10.1002/9781118528563.wbcbt06. ISBN 9781118533208. OCLC 843010463.CS1 maint: ref=harv (link)
  • Herbert JD, Forman EM (2011). "The evolution of cognitive behavior therapy: the rise of psychological acceptance and mindfulness". In Herbert JD, Forman EM (eds.). Acceptance and mindfulness in cognitive behavior therapy: understanding and applying the new therapies. Hoboken, NJ: John Wiley & Sons. pp. 1–25. doi:10.1002/9781118001851.ch1. ISBN 9780470474419. OCLC 612189071.CS1 maint: ref=harv (link)
  • Fisher PL, Wells A (2009). Metacognitive therapy: distinctive features. The CBT distinctive features series. London; New York: Routledge. ISBN 9780415434980. OCLC 229466109.CS1 maint: ref=harv (link)
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