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]

Contents

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. 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

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] [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

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]

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. [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

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Mindfulness is the cognitive skill, usually developed through meditation, of sustaining meta-awareness of the contents of one's own mind in the present moment.

Metacognition is an awareness of one's thought processes and an understanding of the patterns behind them. The term comes from the root word meta, meaning "beyond", or "on top of". Metacognition can take many forms, such as reflecting on one's ways of thinking and knowing when and how to use particular strategies for problem-solving. There are generally two components of metacognition: (1) knowledge about cognition and (2) regulation of cognition. A metacognitive model differs from other scientific models in that the creator of the model is per definition also enclosed within it. Scientific models are often prone to distancing the observer from the object or field of study whereas a metacognitive model in general tries to include the observer in the model.

Acceptance and commitment therapy is a form of psychotherapy, as well as a branch of clinical behavior analysis. It is an empirically based psychological intervention that uses acceptance and mindfulness strategies along with commitment and behavior-change strategies to increase psychological flexibility.

Mindfulness-based cognitive therapy (MBCT) is an approach to psychotherapy that uses cognitive behavioral therapy (CBT) methods in collaboration with mindfulness meditative practices and similar psychological strategies. The origins to its conception and creation can be traced back to the traditional approaches from East Asian formative and functional medicine, philosophy and spirituality, birthed from the basic underlying tenets from classical Taoist, Buddhist and Traditional Chinese medical texts, doctrine and teachings.

<span class="mw-page-title-main">Psychological intervention</span>

In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.

Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. This involves the individual working with the therapist to develop skills for testing and changing beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. A cognitive case conceptualization is developed by the cognitive therapist as a guide to understand the individual's internal reality, select appropriate interventions and identify areas of distress.

<span class="mw-page-title-main">Rumination (psychology)</span> Focused attention

Rumination is the focused attention on the symptoms of one's mental distress, and on its possible causes and consequences, as opposed to its solutions, according to the Response Styles Theory proposed by Nolen-Hoeksema in 1998.

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

A cognitive vulnerability in cognitive psychology is an erroneous belief, cognitive bias, or pattern of thought that predisposes an individual to psychological problems. The vulnerability exists before the symptoms of a psychological disorder appear. After the individual encounters a stressful experience, the cognitive vulnerability shapes a maladaptive response that increases the likelihood of a psychological disorder.

Cognitive emotional behavioral therapy (CEBT) is an extended version of cognitive behavioral therapy (CBT) aimed at helping individuals to evaluate the basis of their emotional distress and thus reduce the need for associated dysfunctional coping behaviors. This psychotherapeutic intervention draws on a range of models and techniques including dialectical behavior therapy (DBT), mindfulness meditation, acceptance and commitment therapy (ACT), and experiential exercises.

Occupational therapy is used to manage the issues caused by seasonal affective disorder (SAD). Occupational therapists assist with the management of SAD through the incorporation of a variety of healthcare disciplines into therapeutic practice. Potential patients with SAD are assessed, treated, and evaluated primarily using treatments such as drug therapies, light therapies, and psychological therapies. Therapists are often involved in designing an individualised treatment plan that most effectively meets the client's goals and needs around their responsiveness to a variety of treatments.

Adrian Wells, CPsychol, is a British clinical psychologist who is the creator of metacognitive therapy. He is Professor of Clinical and Experimental Psychopathology at the University of Manchester, U.K. and is also Professor II of Clinical Psychology at the Norwegian University of Science and Technology.

The metacognitions questionnaire is a self-report scale assessing different dimensions of metacognitive beliefs. Examples of metacognitive beliefs are; "Worry is uncontrollable", "I have little confidence in my memory for words and names", and "I am constantly aware of my thinking". The development of the questionnaire was informed by the Self-Regulatory Executive Function model which is the metacognitive model and theory of psychological disorder. This model is the foundation for metacognitive therapy developed by Adrian Wells.

<span class="mw-page-title-main">Marcantonio M. Spada</span> British academic psychologist (born 1970)

Marcantonio M. Spada is an Italian-British academic psychologist who has studied the role of metacognition in addictive behaviours and operationalised the constructs of "desire thinking" and the "COVID-19 anxiety syndrome". He is currently Professor of Addictive Behaviours and Mental Health and Dean of the School of Applied Sciences at London South Bank University. He is also editor-in-chief of Addictive Behaviors.

Stefan G. Hofmann is a German-born clinical psychologist. He is the Alexander von Humboldt Professor and recipient of the LOEWE Spitzenprofessur for Translational Clinical Psychology at the Philipps University of Marburg in Germany examining Cognitive Behavioral Therapy, especially for anxiety disorders. Since 2012, he has been editor in chief of the journal Cognitive Therapy and Research

Metacognitive training (MCT) is an approach for treating the symptoms of psychosis in schizophrenia, especially delusions, which has been adapted for other disorders such as depression, obsessive–compulsive disorder and borderline over the years. It was developed by Steffen Moritz and Todd Woodward. The intervention is based on the theoretical principles of cognitive behavioral therapy, but focuses in particular on problematic thinking styles that are associated with the development and maintenance of positive symptoms, e.g. overconfidence in errors and jumping to conclusions. Metacognitive training exists as a group training (MCT) and as an individualized intervention (MCT+).

Association splitting is a self-help technique for people with obsessive-compulsive disorder (OCD).

References

  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. 1 2 3 4 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. 1 2 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. 1 2 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. 1 2 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. Springer Verlag. 39 (1). 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". frontiersin.org. 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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