What is Metacognitive Therapy (MCT)

Written by Brant Maclean

What is Metacognitive Therapy? 

Metacognitive therapy (MCT) is a time-limited psychotherapy that treats mental health disorders by targeting metacognitive processes and metacognitive beliefs. Metacognition refers to how a person thinks about thinking; that is, the processes by which a person thinks (such as worry, rumination, thought suppression, and threat monitoring). MCT contends that mental health disorders are maintained by these maladaptive, inflexible metacognitive processes, which are referred to, in a broad sense, as the cognitive attentional syndrome. The Cognitive attentional syndrome is maintained by one’s beliefs about the metacognitive processes that comprise it. These metacognitive beliefs can either be positive, such as the belief that attempting to suppress one’s unwanted thoughts is an effective strategy to manage them; or negative, such as the belief that worry will drive one insane.

How is Metacognitive Therapy Different to Cognitive Behavioural Therapy (CBT)? 

Whilst CBT deals with changing what one thinks, Metacognitive therapy focuses on changing how one thinks. For example, if a person with depression were to present with persistent cognitions that regard themselves as a failure, a metacognitive therapist would not seek to challenge the veracity of such cognitions like a CBT therapist but would rather seek to alter how the person metacognitively responds to such thoughts, such as by interrupting their rumination on them through detached mindfulness.

Moreover, whilst both therapies target belief systems, metacognitive therapy targets negative and positive metacognitive beliefs, whereas CBT focuses on automatic thoughts, which stem from one’s core beliefs (overarching beliefs one has about themselves, the world, and others). For example, a person with a diagnosis of generalised anxiety disorder (GAD) may hold the negative metacognitive belief that worry can drive them insane, which in turn maintains Type II worry (worry about worry). They may simultaneously hold a positive metacognitive belief that worry is helpful, which maintains Type I worry (worry about hypotheticals and future events).

Is Metacognitive therapy an Evidence-Based Therapy? 

MCT is an effective treatment for anxiety and depressive disorders. There is also evidence for the treatment of OCD and PTSD. MCT is particularly effective for generalised anxiety disorder (GAD); it has outperformed CBT in terms of symptom reduction and recovery rates in various randomised controlled trials. 

Techniques of Metacognitive Therapy

MCT uses various techniques to alter the cognitive attentional syndrome and metacognitive beliefs. Here is a cursory sample:

• Attention training: attention training involves regularly completing exercises in which one's attention is fixed on one sound among many, alternating between focusing on a single sound, and rapidly switching between sounds. Attention training disrupts the cognitive attentional syndrome and grants one greater attentional flexibility. 

•  Detached mindfulness: In stark contrast to metacognitive processes like rumination, worry, and thought suppression, detached mindfulness involves 'doing nothing' in response to thoughts. For example, instead of trying to suppress intrusive thoughts or force oneself to stop worrying, one simply watches one's thoughts passively without attempting to change them. As with attention training, detached mindfulness disrupts the cognitive attentional syndrome. 

•  Socratic dialogue and behavioural experiments: As in CBT, Socratic dialogue and behavioural experiments can be utilised to change beliefs. However, in MCT, they are applied to metacognitive beliefs instead of automatic thoughts, dysfunctional assumptions, and core beliefs.

References: 

Hagen, R., Hjemdal, O., Solem, S., Kennair, L. E. O., Nordahl, H. M., Fisher, P., & 

Wells, A. (2017). Metacognitive Therapy for Depression in Adults: A Waiting List Randomized Controlled Trial with Six Months Follow-Up. Frontiers in Psychology, 8, 31-31. https://doi.org/10.3389/fpsyg.2017.00031

Nordahl, H. M., Borkovec, T. D., Hagen, R., Kennair, L. E. O., Hjemdal, O., Solem, 

S., Hansen, B., Haseth, S., & Wells, A. (2018). Metacognitive therapy versus cognitive–behavioural therapy in adults with generalised anxiety disorder. BJPsych Open, 4(5), 393-400. https://doi.org/10.1192/bjo.2018.54

Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A 

systematic review and meta-analysis. Frontiers in Psychology, 9, 2211-2211. https://doi.org/10.3389/fpsyg.2018.02211

Rawat, A., Sangroula, N., Khan, A., Faisal, S., Chand, A., Yousaf, R. A., Muhammad, N., & Yousaf, H. (2023). Comparison of metacognitive therapy versus cognitive behavioral therapy for generalized anxiety disorder: A meta-analysis of randomized control trials. Curēus (Palo Alto, CA), 15(5), e39252-e39252. https://doi.org/10.7759/cureus.39252 

Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford Press.

Wells, A., Walton, D., Lovell, K., & Proctor, D. (2015). Metacognitive therapy versus prolonged exposure in adults with chronic post-traumatic stress disorder: A parallel randomized controlled trial. Cognitive Therapy and Research, 39(1), 70-80. https://doi.org/10.1007/s10608-014-9636-6