Metacognitive therapy

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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).


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. Metacognition has been studied for several decades by researchers, originally as part of developmental psychology and neuropsychology.[6][7][8][9] 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.[10][11]

Model of mental disorders[edit]

Self-regulatory executive function model[edit]

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][12] Of particular importance in the model are negative metacognitive beliefs, especially those concerning the uncontrollability and dangerousness of some thoughts.[12] 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[edit]

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 five minutes and see if there is any effect") and strategies such as attentional training technique, situational attention refocusing and detached mindfulness (this is a distinct strategy from various other mindfulness techniques).[13][14][15][16]


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.[17]

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. It concluded, "Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions."[18]

In 2020, a study showed superior effectiveness in MCT over cognitive behavioral therapy (CBT) in the treatment of depression. It summarised, "MCT appears promising and might offer a necessary advance in depression treatment, but there is insufficient evidence at present from adequately powered trials to assess the relative efficacy of MCT compared with CBT in depression."[19]

In 2018–2020, a research topic in the journal Frontiers in Psychology highlighted the growing experimental, clinical, and neuropsychological evidence base for MCT.[20]

A recent network meta-analysis indicated that MCT (and cognitive processing therapy) might be superior to other psychological treatments for PTSD.[21] However, although the evidence-base for MCT is promising and growing, it is important to note that most clinical trials investigating MCT are characterized by small and select samples and potential conflict of interests as its originator is involved in most clinical trials conducted. As such, there is a pressing need for larger, preferably pragmatic, well-conducted randomized controlled trials, conducted by independent trialists without potential conflict of interests before there is a large scale implementation of MCT in community mental health clinics.

See also[edit]


  1. ^ Mulder, Roger; Murray, Greg; Rucklidge, Julia (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. ^ a b c d Wells, Adrian (2011). Metacognitive therapy for anxiety and depression. New York: Guilford Press. ISBN 9781593859947. OCLC 226358223.
  3. ^ Wells, Adrian; Matthews, Gerald (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. ^ a b Wells, Adrian (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. ^ a b Normann, Nicoline; van Emmerik, Arnold A. P.; Morina, Nexhmedin (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. ^ Biggs, John (1 August 1988). "The role of metacognition in enhancing learning". Australian Journal of Education. 32 (2): 127–138. doi:10.1177/000494418803200201. S2CID 145605646.
  7. ^ Brown, Anne L. (1978). "Knowing when, where, and how to remember: a problem of metacognition". In Glaser, Robert (ed.). Advances in instructional psychology. Vol. 1. Hillsdale, N.J.: Lawrence Erlbaum Associates. pp. 77–165. ISBN 9780470265192. OCLC 4136451.
  8. ^ Forrest-Pressley, Donna-Lynn, ed. (1985). Metacognition, cognition, and human performance. Vol. 2: Instructional practices. Orlando: Academic Press. ISBN 978-0122623028. OCLC 11290806.
  9. ^ Shimamura, Arthur P. (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.
  10. ^ Reeve, Robert A.; Brown, Ann L. (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.
  11. ^ Kurtz, Beth E.; Borkowski, John G. (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.
  12. ^ a b Kowalski, Joachim; Dragan, Małgorzata (May 2019). "Cognitive-attentional syndrome – The psychometric properties of the CAS-1 and multi-measure CAS-based clinical diagnosis". Comprehensive Psychiatry. 91: 13–21. doi:10.1016/j.comppsych.2019.02.007. ISSN 0010-440X. PMID 30884400.
  13. ^ Fergus, Thomas A.; Wheless, Nancy E.; Wright, Lindsay C. (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.
  14. ^ Gkika, Styliani; Wells, Adrian (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.
  15. ^ Kowalski, Joachim; Wierzba, Małgorzata; Wypych, Marek; Marchewka, Artur; Dragan, Małgorzata (2020-09-01). "Effects of attention training technique on brain function in high- and low-cognitive-attentional syndrome individuals: regional dynamics before, during, and after a single session of ATT". Behaviour Research and Therapy. 132: 103693. doi:10.1016/j.brat.2020.103693. ISSN 0005-7967. PMID 32688045. S2CID 220669531.
  16. ^ Wells, Adrian (2011). Metacognitive therapy for anxiety and depression. New York, NY: Guilford. ISBN 978-1-59385-994-7.
  17. ^ "Special issue on metacognitive theory, therapy and techniques". Cognitive Therapy and Research. 39 (1). Springer Verlag. February 2015.
  18. ^ Morina, Nexhmedin; Normann, Nicoline (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.
  19. ^ Callesen, Pia; Reeves, David; Heal, Calvin; Wells, Adrian (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.
  20. ^ "Metacognitive Therapy: Science and Practice of a Paradigm | Frontiers Research Topic". Frontiers Media. Retrieved 2019-06-26.
  21. ^ Jericho, Brooke; Luo, Aileen; Berle, David (2021-09-17). "Trauma-focused psychotherapies for post-traumatic stress disorder: A systematic review and network meta-analysis". Acta Psychiatrica Scandinavica. 145 (2): 132–155. doi:10.1111/acps.13366. ISSN 0001-690X. PMC 9539869. PMID 34473342. S2CID 237388505.

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