Name: Anagha Avinash
Tirpude
M.A. Part II
Semester- III
Department of
Applied Psychology
University Of Mumbai
METACOGNITIVE THERAPY
Abstract
Metacognitive Therapy (MCT) is a groundbreaking psychotherapy approach known for its effectiveness
in treating anxiety and depression, potentially surpassing traditional Cognitive Behavioral Therapy (CBT).
It represents a paradigm shift in psychotherapy, rooted in cognitive science and meticulously developed
by Adrian Wells within the context of information processing theory.
Wells and Matthews devised the Self-Regulatory Executive Function (S-REF) model, the cornerstone of
MCT theory. This model highlights the role of metacognitions, or top-down cognitive regulation biases,
as shared causal factors in psychological disorders. MCT's core tenet is that a select set of interventions
can effectively target a wide range of symptoms.
This essay provides a concise overview of MCT, emphasizing its theoretical foundations and efficacy in
treating conditions like Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD),
depression, and Post-Traumatic Stress Disorder (PTSD). Drawing from empirical research, it underscores
the fundamental principles of MCT and its potential as a potent tool in the realm of Cognitive Behavioral
Therapy. Additionally, it evaluates MCT's strengths and limitations and its unique contributions to the
field of clinical psychology.
Introduction
Metacognitive Therapy (MCT) is a form of psychological treatment that has been demonstrated to be
effective and evidence-based. It has been suggested that it may be more effective than traditional forms
of therapy, such as cognitive behavioral therapy (such as that developed by Normann and Morina in
2018). It has been characterized as a cutting-edge approach that has led to a shift in the field of clinical
psychology (Schweiger et al. in 2019).
In the realm of psychotherapy, the landscape is continually evolving as innovative approaches emerge to
address the diverse array of mental health challenges that individuals face. One such approach that has
garnered significant attention and acclaim in recent years is metacognitive therapy (MCT). Developed by
Adrian Wells, MCT offers a unique and promising perspective on understanding and treating
psychological disorders through the lens of metacognition - our thinking about thinking. In this essay, we
embark on a comprehensive exploration of metacognitive therapy, its theoretical foundations,
therapeutic techniques, and the empirical evidence of its efficacy.
Metacognitive therapy is rooted in the premise that it is not the content of our thoughts, but rather the
way we think about our thoughts that plays a pivotal role in the development and maintenance of
psychological distress. This intriguing perspective challenges the traditional cognitive-behavioral model
by emphasizing the importance of metacognitive processes such as worry, rumination, and cognitive
control in shaping emotional and behavioral responses to life's challenges.
Theoretical underpinnings of MCT, as outlined by Wells (2009), propose that dysfunctional
metacognitive beliefs and processes are at the core of various psychological disorders. These beliefs
include cognitive factors like the "cognitive attentional syndrome" and "positive metacognitive beliefs
about worry," which, when addressed, can potentially lead to profound therapeutic transformation.
To embark on our journey of understanding MCT, we will delve into the fundamental principles that
govern this therapeutic approach and explore its unique interventions, including the Attention Training
Technique (ATT) and Detached Mindfulness. We will also examine how MCT compares to other
established therapies, particularly cognitive-behavioral therapy (CBT), and the distinctive advantages it
may offer.
Crucially, this essay will provide an evidence-based perspective on the efficacy of metacognitive therapy.
Drawing from empirical research, including meta-analyses and clinical trials, we will examine the
therapeutic outcomes achieved in conditions such as generalized anxiety disorder, obsessive-compulsive
disorder, depression, and post-traumatic stress disorder.
As we embark on this exploration, it is our aim to offer a comprehensive and informed understanding of
metacognitive therapy. Through the lens of scientific inquiry and clinical practice, we will illuminate the
potential of MCT to revolutionize the way we conceptualize and treat psychological disorders, ultimately
providing new avenues for alleviating human suffering and enhancing mental well-being.
History
Emergence of Metacognitive Theory: The foundation of MCT can be traced back to the development of
metacognitive theory. Adrian Wells, the originator of MCT, began testing mechanisms and concepts of
what would later become the metacognitive model during his doctoral studies in the mid-1980s. His
interest in information processing theory and the role of self-attentional processes in anxiety was
instrumental in shaping the theoretical underpinnings of MCT.
Wells, along with Gerald Matthews, developed the Self-Regulatory Executive Function model (S-REF),
which forms the theoretical basis of MCT. The S-REF model emphasizes the role of metacognition, the
Cognitive Attentional Syndrome (CAS), and metacognitive beliefs in the development and maintenance
of psychological disorders. MCT has evolved and expanded to include a wide range of applications for
various psychological disorders. Wells and his colleagues have conducted numerous empirical studies to
validate and refine the effectiveness of MCT interventions.
MCT has integrated findings from empirical research on attention, metacognition, and emotional
processing. This integration has contributed to the development of specific MCT interventions and
techniques. Ongoing research in the field of MCT has led to the development of new interventions, the
refinement of existing techniques, and the exploration of its applicability to a wider range of
psychological conditions.
MCT has also been integrated with other therapeutic approaches, such as mindfulness-based
interventions and cognitive-behavioral therapy, to enhance its effectiveness in treating various
psychological disorders.
Theoretical underpinning
Metacognitive therapy (MCT) is grounded in a well-defined theoretical framework that sets it apart from
traditional cognitive-behavioral therapies. The key theoretical underpinnings of MCT include:
At the heart of MCT is the concept of metacognition, which refers to thinking about thinking. MCT posits
that it is not the content of our thoughts but how we think about our thoughts that plays a central role
in psychological distress. This metacognitive awareness includes processes like rumination, worry, and
cognitive monitoring.
Adrian Wells, the originator of MCT, developed the Metacognitive Model of Psychological Disorder. This
model suggests that individuals with psychological disorders, such as anxiety and depression, exhibit
dysfunctional metacognitive beliefs and engage in unhelpful metacognitive processes that contribute to
their distress.
The CAS is a critical concept in MCT. It comprises perseverative negative thinking patterns, including
rumination, worry, and threat monitoring. These processes are viewed as counterproductive and
exacerbating psychological disorders.
MCT emphasizes the role of metacognitive beliefs, which are beliefs about one's thoughts and thinking
processes. These beliefs can be positive (e.g., "Worrying helps me prepare") or negative (e.g., "I can't
control my thoughts"). Wells argues that these beliefs are central to the development and maintenance
of psychological disorders.
The Role of Attention and Information Processing in Metacognitive Therapy
Adrian Wells, the pioneer of Metacognitive Therapy (MCT), initiated his exploration of the metacognitive
model during his doctoral studies in the mid-1980s. His interest lay in information processing theory and
the significance of self-attentional processes in understanding anxiety. This work was influenced by
earlier research by Duval and Wicklund, Carver and Scheier, Fenigstein, and others who had
demonstrated the effects of heightened self-focused attention in various psychological disorders.
Wells argued that attentional processes and thinking styles, such as excessive worry, should receive
more attention in the development of psychological disorder theories. Traditional psychotherapies like
Cognitive Behavior Therapy (CBT) and Rational Emotive Behavior Therapy (REBT) had primarily focused
on the content of thoughts and schemas, largely overlooking the role of attention.
Historically, attention's role in clinical models was seen mainly as a result of bottom-up processes
influenced by emotions, personality traits, or external factors. For instance, in test anxiety, attention
was thought to be diverted from task-focused processing due to excessive worry. Additionally, Duval
and Wicklund's theory of self-awareness posited that attention could be directed either inward towards
the self or outward towards the environment, with inward self-focus linked to self-consciousness and
social anxiety.
Despite these insights, there was a lack of a comprehensive theory linking attention bias for threats, self-
focus, attention resource limitations, and psychological disorders. Wells recognized the potential
benefits of developing such a theory.
In the 1980s, research began to explore the relationship between attention bias and emotions more
extensively, influencing the field of psychopathology. Studies by Mathews and MacLeod indicated that
anxiety patients exhibited an attentional bias toward threat-related stimuli, attributed to underlying
negative schemas. Similarly, Wells and Matthews in the late 1980s and early 1990s emphasized the
importance of experimental research on attention and emotion in developing robust theories of
emotional disorders.
They argued that individuals' self-beliefs are not just passive data, but they involve strategic conscious
processes that regulate attention and cognition. They conducted an extensive review of the literature
and proposed the Self-Regulatory Executive Function model, which became the foundation for MCT.
Adrian Wells' early research laid the groundwork for MCT by highlighting the significance of attention
and information processing in understanding psychological disorders. These insights continue to shape
the field of psychotherapy and contribute to our understanding of how metacognition plays a crucial
role in therapeutic interventions.
The Self-Regulatory Executive Function Model (S-REF) in Metacognitive Therapy
The Self-Regulatory Executive Function (S-REF) model, also referred to as the metacognitive model of
psychological disorders, was developed by Adrian Wells and Gerald Matthews in the mid-1990s. It aimed
to distinguish between different levels of control of attention and map how these levels of processing
influence psychological disorders. Existing theories, such as schema theory, were criticized for lacking
specific details about cognitive processes contributing to emotional problems.
In the S-REF model, a central concept is the "cognitive attentional syndrome" (CAS), a cluster of
processes activated under stress or threat, leading to psychological disorders. CAS includes
perseverative negative thinking patterns like excessive worry, rumination, threat monitoring, and
unhelpful coping behaviors such as thought suppression, which hinder effective self-regulation. Elevated
self-focus, like private self-consciousness, was seen as an indicator that an individual might develop this
syndrome.
The model suggests that CAS results from an interaction between higher-level controlled processing and
lower-level automatic processing, particularly involving self-relevant information and emotional
regulation. It differentiates between declarative beliefs (e.g., "I'm worthless") and procedural beliefs
that guide processing and have a metacognitive function. General negative beliefs (e.g., "People think
I'm a failure") were considered to result from processing routines guided by metacognitions.
Wells proposed the existence of negative (e.g., "I have lost control of my worrying") and positive (e.g.,
"Worrying means I'm ready to cope with anything") metacognitive beliefs driving CAS responses. Unlike
other cognitive models, the S-REF model emphasizes the role of cognitive architecture, distinguishing
reflexive low-level processing from top-down motivated strategies.
The model identifies a cognitive attentional syndrome characterized by biased perseverative negative
processing as a coping strategy, emphasizing that the level at which a cognitive bias operates
determines the type of treatment needed. Individual differences in self-focused attention were
considered markers for CAS, which is a common mechanism across psychological disorders.
Wells and Matthews argued that it's not the content of thoughts but rather the perseveration in
response to negative thoughts (CAS) that causes and maintains psychological disorders. Consequently,
they advocated for developing techniques that help individuals effectively regulate the CAS. In the S-REF
model, psychological disorder is linked to maladaptive metacognitive beliefs and overuse of negative
thinking strategies, suggesting that treatment should focus on flexible mental control rather than fixing
skill deficits or challenging cognitive content.
Over the years, Wells continued to refine the S-REF model based on experimental data and clinical
application, detailing the inner structure of higher-order cognitive functions and the role of
metacognitive components in regulating the CAS.
Attention training technique
The attention training technique in Metacognitive Therapy (MCT) is a therapeutic approach that focuses
on modifying how individuals allocate their attention to their thoughts and the external environment.
This technique aims to help individuals break free from unproductive patterns of rumination and worry
by training them to shift their attention away from their thoughts and onto more constructive and task-
focused activities.
Detached mindfulness
Detached mindfulness is a key component of Metacognitive Therapy (MCT). It involves cultivating a
state of mindfulness where individuals observe their thoughts, emotions, and experiences from a
detached and non-judgmental perspective. This mindfulness practice helps individuals develop
metacognitive awareness and gain distance from their thoughts, reducing rumination and worry.
Effectiveness of MCT
Metacognitive Therapy (MCT) has gained recognition as an effective therapeutic approach for various
psychological disorders, including anxiety disorders (Generalized Anxiety Disorder or GAD), Obsessive-
Compulsive Disorder (OCD), depression, and Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder (GAD): MCT has shown promise in the treatment of GAD. It focuses on
reducing excessive worry, a hallmark symptom of GAD, by addressing maladaptive metacognitive beliefs
and processes related to worry.
A systematic review and meta-analysis by Normann and Morina (2018) found that MCT was significantly
more effective than control conditions in reducing symptoms of GAD. Several studies have also
demonstrated positive outcomes in reducing GAD symptoms using MCT techniques.
Obsessive-Compulsive Disorder (OCD): MCT addresses cognitive processes and beliefs associated with
OCD, such as the need for excessive checking or compulsive rituals. It aims to modify metacognitive
beliefs about the significance and control of obsessive thoughts.
A study by Myers, Fisher, and Wells (2009) demonstrated that MCT was effective in reducing OCD
symptoms, and this approach has gained attention as a valuable addition to traditional OCD treatments.
Depression: MCT targets cognitive processes associated with depressive rumination and negative
thinking patterns. It aims to modify metacognitive beliefs that perpetuate depression.
Studies have shown that MCT is effective in reducing depressive symptoms. For example, Wells and
Papageorgiou (1998) found that MCT reduced depressive symptoms and prevented relapse in patients
with recurrent depression.
Post-Traumatic Stress Disorder (PTSD): MCT targets maladaptive metacognitive beliefs and processes
related to PTSD symptoms, including intrusive thoughts and avoidance behaviors.
Empirical studies have indicated that MCT can be effective in treating PTSD. A case study by Hagen et al.
(2017) demonstrated the potential of MCT for reducing PTSD symptoms in individuals with complex
trauma histories.
Case study
A 32-year-old woman named Susan had a lifelong history of anxiety and depression and was described
as a treatment resistant case. Susan had received diagnosis-specific CBT at three separate periods, one
lasting 10 months and another lasting 14-16 months, and had attended CBT group therapy for anxiety
disorder without significant effect. She had used medication at two different time periods, but did not
use medications when starting MCT-treatment or over the course for therapy
Susan reported ongoing concerns related to attending work and social meetings, social anxiety,
tiredness, exhaustion, and excessive worries concerning finances and physical health
The patient met diagnostic criteria for SAD, GAD, F33.1 MDD, F42.2 OCD, and F40.2 specific phobia at
the start of treatment and received 8 individual 50-minute therapy sessions of MCT in an in-patient
setting over 8 weeks Diagnostic evaluation was undertaken using the Mini-International
Neuropsychiatric Interview and Symptom Checklist-90. Treatment was paid by the Norwegian national
health service and individual therapist had 2 years of formal clinical training in MCT.
Limitations
Metacognitive Therapy (MCT) is a promising therapeutic approach, but like any treatment modality, it
has its limitations.
MCT is not as widely available as some other therapeutic approaches, such as Cognitive-Behavioral
Therapy (CBT). Training in MCT may be limited, and not all mental health professionals are familiar with
or trained in this approach.
While MCT has shown effectiveness for various psychological disorders, it may not be equally suitable
for all individuals or all types of disorders. Its primary focus on metacognition may not address the full
range of symptoms in some cases.
Although there is evidence supporting the short-term efficacy of MCT, more research is needed to
ascertain its long-term effects and whether treatment gains are sustained over time.
MCT is often used in conjunction with other therapeutic modalities, and it may not be suitable as a
stand-alone treatment for some individuals with complex comorbid conditions.
The applicability of MCT to individuals from diverse cultural backgrounds may be limited, as it may not
account for culturally specific expressions of psychological distress.
MCT primarily focuses on metacognition and may not provide extensive tools for addressing emotion
regulation and processing, which are critical components of some psychological disorders.
It's important to note that while MCT has its limitations, it also has demonstrated efficacy and can be a
valuable addition to the repertoire of therapeutic approaches. The choice of therapy should be based on
an individual's specific needs, preferences, and the nature of their condition.
Criticism
While MCT as a whole has garnered empirical support, some specific techniques or interventions used
within MCT may not have extensive empirical backing. Critics argue that more research is needed to
establish the effectiveness of these techniques.
MCT can be conceptually challenging for some clients due to its emphasis on metacognition. Critics
argue that this complexity might limit its accessibility, especially for individuals with lower cognitive
functioning or educational backgrounds.
MCT primarily focuses on metacognition and may not provide extensive tools for addressing emotional
processing and regulation. Some critics argue that this limitation may be inadequate for individuals with
high emotional dysregulation.
MCT is primarily designed for common mental health conditions like anxiety and depression. Critics
suggest that its applicability to severe mental illnesses, such as schizophrenia or bipolar disorder, is
unclear and requires further investigation.
MCT is often used in conjunction with other therapeutic modalities. Critics argue that this raises
questions about its efficacy as a stand-alone treatment and whether it can produce lasting effects
without additional therapies.
Some critics argue that MCT may not be adequately adapted for individuals from diverse cultural
backgrounds, potentially neglecting culturally specific expressions of psychological distress.
Training in MCT may not be readily available to all mental health professionals. Critics highlight the need
for wider dissemination and training opportunities.
Conclusion
In conclusion, MCT stands out as a cutting-edge approach to psychotherapy, providing a novel and
promising way to understand and treat psychological disorders. Established on the basis of the meta-
cognitive model, it emphasizes the role of psychokinesis in the formation of emotional and behavioral
reactions to distressful thoughts. While MCT has been shown to be effective in treating a variety of
psychological conditions, such as Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder
(OCD), depression, and Post-traumatic Stress Disorder (PTSD), it is subject to limitations in its
accessibility, its applicability to serious mental disorders, and its cultural adaptability. Furthermore,
certain critics have questioned the empirical basis for certain MCT techniques, but MCT still has great
potential as an invaluable tool in the therapeutic toolbox. With its emphasis on psychokinesis and
attention training, MCT offers a novel perspective on psychological disorders, and further research and
development of its techniques can further improve its efficacy and expand its scope. As we look to the
future, MCT provides a promising opportunity to explore new ways to understand and alleviate human
suffering.
References
Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford Press.
Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A systematic review and
meta-analysis. Frontiers in Psychology, 9, 2211.
Papageorgiou, C., & Wells, A. (2003). An empirical test of a clinical metacognitive model of rumination
and depression. Cognitive Therapy and Research, 27(3), 261-273.
McEvoy, P. M., & Mahoney, A. E. J. (2012). To be sure, to be sure: Intolerance of uncertainty mediates
symptoms of various anxiety disorders and depression. Behavior Therapy, 43(3), 533-545.
Fisher, P. L., & Wells, A. (2009). Metacognitive therapy for obsessive-compulsive disorder: A case series.
Journal of Behavior Therapy and Experimental Psychiatry, 40(4), 402-412.
