S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
ISSN: 2146-9490
JCBPR, 2014, 3: 11-17
11
REVIEW/DERLEME
The Conceptual Foundations of Metacognitive Therapy
1
Sedat BATMAZ1
Uzm. Dr., Psikiyatrist, Mersin Devlet Hastanesi
Abstract
This introductory review article aims to provide the interested reader with an outline of the fundamentals of metacognitive
therapy. Metacognitive therapy (MCT) is an evidence based cognitive behavioural psychotherapy approach with a very
solid theoretical background in understanding and explaining the mechanisms by which any psychological disorder
persists. MCT provides a new perspective for the treatment of psychological disorders by underlining the significance
of how a person thinks, rather than simply focusing on the content of his cognitions. The case formulation and specific
techniques of MCT are the main distinctive features of this therapy approach, which places it in a unique position
among other CBT approaches. These distinctive features are defined throughout the article. A short introduction to the
metacognitive model of psychological disorder, the core features of this therapy, and the specific techniques of MCT are
also summarized. A brief list of clinical scales and treatment plans as well as the order of application of MCT techniques
are also given. This review article aims to underline the theoretical background of MCT, and hopes to provide a glimpse
into the introductory level principles of the application of this therapy approach. (Journal of Cognitive Behavioral
Psychotheray and Research 2014: 3: 11-17)
Keywords: Cognitive therapy, cognition, metacognitive therapy, self-regulatory executive function model, cognitive
attentional syndrome
Özet
Metakognitif Terapinin Kavramsal Temelleri
Giriş düzeyindeki bu gözden geçirme yazısı konuya ilgi duyan okurlara metakognitif terapinin temellerini sunmayı
amaçlamaktadır. Metakognitif terapi (MCT) çok sağlam bir kuramsal arkaplanı olan kanıta dayalı bir bilişsel davranışçı
terapi (BDT) türüdür. Bu yazıda kendini düzenleyici yürütücü işlev (S-REF) modeli hakkında çok kısa bir tanıtımda da
bulunulmaktadır. Ayrıca üstbiliş kavramı tanımlanmakta ve bu yenilikçi terapi yaklaşımının temellerinin altı çizilmektedir.
Makalenin bütününde MCT’nin geleneksel BDT yaklaşımlarından ayırt edici özelliklerine yer verilmektedir. Ruhsal
bozuklukların metakognitif modeli, MCT’nin çekirdek özellikleri ve özgül terapi tekniklerinden de kısaca bahsedilmektedir.
Ayrıca MCT uygulamaları sırasında faydalanılabilecek klinik değerlendirme ölçekleri ve tedavi planları ile tekniklerin genel
olarak uygulanma sırasına da yazıda yer verilmektedir. (Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 2014;
3: 11-17)
Anahtar Sözcükler: Bilişsel terapi, biliş, metakognitif terapi, kendini düzenleyici yürütücü işlev modeli, bilişsel dikkat
sendromu
INTRODUCTION
These are generally the first few questions asked
to the audience when a lecture on the fundamentals
of metacognitive therapy (MCT) is given. Though,
these questions do not in any way imply that MCT
posits that the classical Beckian approach to cognitive behavioural therapy (CBT) (Beck 1976) is based
“Just for a minute, stop to identify how many thoughts
passed through your mind the day before. How many
of them were of negative nature? Did you develop
a psychological disorder due to these negative thoughts?”
1
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S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
on the assumption that negative automatic thoughts
(NATs) are the sole responsible etiological factor in
the development and maintenance of psychological
disorders. MCT is just another CBT approach with
a different way of interpreting the significance of
NATs, and providing a new perspective to the management of psychological disorders (Fisher and Wells
2009).
MCT is an evidence based psychotherapy approach, where the main emphasis lies on the thought processes rather than the content of the thoughts (Fisher
and Wells 2009). Therefore, the therapist aims to focus
on, and modify the processes that underlie the mechanisms which are involved in the development and
maintenance of psychological disorders (Wells 2000;
2009). In very basic terms, the theoretical background
of MCT states that the way how someone thinks, and
controls, or tries to control at least, his behaviours/
attitudes is more important than just what that person
thinks in terms of therapeutic intervention (Fisher and
Wells 2009).
Metacognition
At this point, it may be essential to define what it is
being referred to by the term metacognition. Metacognition is defined as “cognition about cognition”,
or “thinking about thinking”. Metacognition is important in understanding how cognition operates and in
shaping what someone pays attention to, or in controlling the appraisals and influences behind the types
of strategies one uses to regulate his/her thoughts and
behaviours (Wells 2009). To this end, generally the
analogy of a library is used to clarify any misconception. All the steps involved with the thought processes,
according to this analogy, are represented as someone
entering the library, looking for a specific book, trying
to locate it on the shelves, taking it out, and finally reading the book. Metacognition may be conceptualized
by any of these steps regarding the thought processes
(Flavell 1979). Taking a step further, metacognition
is also classically defined as an orchestra conductor,
where the conductor would be playing the central role
for the selection, appraisal, monitoring and control of
relevant information, i.e. cognitions, for the person
(Wells 2009).
Another point to stress is that metacognition should not give the impression that these processes are
in a hierarchical order positioned above all the classically defined layers of cognition. Rather, metacognitions may be viewed as the deepest structure, driving
the activation of specific cognitions. Maybe an even
better topographical explanation would be where
metacognition is viewed as an overarching process
lying in between all these cognitive layers, rather
than being placed in a deeper structure, or reflected
as closer to the surface. This distinction is essential,
as the therapeutic interventions applied in MCT differ from those of the classical Beckian approach to
therapy, which tends to pursue a trajectory from the
surface level to the core, at least partly, in general
(Beck 1976).
Metacognitive Beliefs, Experiences and
Strategies
Metacognitions consist of beliefs, experiences and
strategies (Wells 2000). Metacognitive beliefs (knowledge) are related to a person’s own thinking style,
and his beliefs about them. These beliefs are further
divided by two subcategories, i.e. explicit (declarative) beliefs, and implicit (procedural) beliefs. These
beliefs are categorized according to whether the belief associated with them can verbally be expressed
or not. In terms of the content, metacognitive beliefs
may either be of positive, or of negative nature. Positive metacognitive beliefs are related to the advantages and benefits of thinking styles (e.g. “Worrying
about the future helps me identify possible threats.”),
whereas negative metacognitive beliefs reflect the
beliefs that some thoughts may be uncontrollable or
dangerous (e.g. “I can not control my thoughts.”).
Metacognitive experiences refer to the appraisals and
feelings a person has regarding his own state of mind
(e.g. worrying about worry, the appraisal of intrusions). Metacognitive strategies reflect the emotional
and cognitive self-regulatory strategies which are involved with the control responses of thoughts and behaviours (e.g. threat monitoring, thought suppression,
emotional avoidance).
The Self-Regulatory Executive Function
Model
MCT has its roots in the Self-Regulatory Executive
Function (S-REF) model. The S-REF model spreads
across three levels which interact with each other and
consists of (1) an automatic information processing
level (low-level processing), (2) a conscious information processing level (cognitive style), and (3) a
library of metacognitive knowledge (meta-system).
The control and maintenance of psychological disor-
S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
ders are affected by these levels in a top-down fashion Details of the S-REF model are explained elsewhere in the literature (Wells and Mathews 1994;
1996; Wells 2000; 2009), and are not the main focus
of this article. Yet, to summarize, in this model, there are four major concepts which are used to explain the reasons for the maintenance of psychological
distress. These four concepts are: (1) the Cognitive
Attentional Syndrome (CAS), (2) metacognitive beliefs, (3) attention/executive control, and (4) mental
modes (Wells 2013). Below, all these four concepts
will be explained in a more elaborate way, focusing on their effects on the metacognitive model of
psychopathology.
The Cognitive Attentional Syndrome
The S-REF model postulates that the CAS is the
main factor underlying psychological disorders (Fisher and Wells 2009). Arising from metacognitive
knowledge and beliefs, and taking the form of worry/
rumination, attentional focusing on threat, and unhelpful coping behaviours that backfire, the CAS has
consequences that lead to the maintenance of negative emotions and strengthening of negative cognitions
(Wells 2009). The CAS determines how the person copes with his negative thoughts, beliefs, and emotions.
The problem here is that the CAS prevents the person
to experience that these negative cognitions or emotions fade away, or decay, if they are not manipulated
by the person (Wells 2013). The CAS is involved with
ideation intended to detect and avoid of possible threats, i.e. threat monitoring and worry; analyzing the
past and questioning the meaning of situations, i.e.
rumination; and dwelling on the past regarding traumatic events, i.e. gap filling (Wells 2013). The CAS is
also related to non-adaptive coping strategies such as
thought suppression, avoidance behaviours, alcohol
and/or substance abuse, self-injury, and safety seeking behaviours (Fisher and Wells 2009). The components of the CAS result in a prolonged emotional
experience, which creates a sense of being stuck, and
further causes a conflict with self-regulatory mechanisms. Consequently, a loss of control over feelings
and cognitions is strengthened. Hence the cage or prison metaphor, which may help with the clients while
explaining them about the nature of the CAS. In this
metaphor, the thought process the person is stuck in
is likened to a cage in order to make the CAS a more
understandable concept.
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(1) Metacognitive Beliefs
These beliefs are only related to the meaning and significance of cognitions, and no further relevance is
sought regarding the content of cognitions. The selection and execution of thinking styles like the CAS rely
on these metacognitive beliefs (Wells 2013). Among
these beliefs, the negative ones are thought to be the
most persistent, and acutely these beliefs increase the
perception of threat, hopelessness or inefficacy (Wells
2013).
(2) Attention/Executive Control
In many psychological disorders, there is a nonadaptive way of attention control (Wells 2013). For
example depressed patients with persistent rumination tend to believe that this thought process is out of
their control, and they give up any effort to stop this.
Moreover, rumination is considered as a solution rather than the problem itself. Therefore, these patients
engage in threat monitoring strategies. Shifting the attentional processes is a main focus during the therapy
offered in MCT.
(3) Mental Modes
Mental modes are structures that define the relationship a person has with his own cognitions (Wells 2013).
Two types of mental modes are of interest, i.e. the
object mode, and the metacognitive mode. The object
mode is the default mode, where cognitions and the
events are processed as synonymous by the person.
On the other hand, MCT aims to bring a new perspective to the client’s way of interpreting the events, by
putting a distance between his thoughts, and himself
and the external world (Wells 2000). To explain the
concept of metacognitive mode to the patient or client, the dream metaphor may be used. This enables
the possibility to deliver the correct message about
the new stance and point of view expected to be reached during the therapy process. The dream metaphor,
where the person is first educated about the concept
of lucid dreaming and asked if he/she ever had, or at
least heard of someone having, this kind of an experience, and then this dream is proposed as a way to look
for when a referral is made to the object mode. As the
reality and the person’s cognitions are fused together
in the object mode, the dream metaphor may be utilized to underscore the similarities between the dreaming process and this particular mode. Then a shift
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S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
may be pursued to the therapy targeted metacognitive
mode, which will enable the person to free himself/
herself from the aforementioned fusion.
Metacognitive Model of Psychological Distress
Although going into detail about the metacognitive
model of all specific psychiatric disorders is beyond
the scope and aim of this introductory review article,
it may be necessary to define a generic metacognitive model of psychological distress for the reader to
understand the therapeutic basis. The roots of MCT
lie in the theoretical background of the S-REF model, which consists of, as disused above, four concepts. These concepts, in differing dominance, are the
main pathological processes in various psychological disorders. In summary, the metacognitive model
of psychological distress starts from a perception of
threat/danger, and this perception is processed in the
object mode. This activates the CAS, and when it is
coupled with ineffective coping strategies, psychological problems emerge. Although this overly simplified model of psychological distress seems to be
transdiagnostic in essence, MCT is applied according
to disorder specific models of the CAS and metacognitive processes (Fisher and Wells 2009).
The fundamental distinction between classical
CBT theories and the metacognitive model can best
be understood at the level of the formulation of cases
(Fisher and Wells 2009). In MCT, the activating event
is designated as a cognition or emotion, i.e. A, which
lead to the activation of metacognitive beliefs, and
the CAS, i.e. B, which further gives rise to emotional
consequences, i.e. C. In this model, B is moderated,
or even caused by, metacognitions, and the CAS, i.e.
M. This reformulated ABC analysis is termed as the
AMC analysis in MCT (Fisher and Wells 2009; Wells
2000).
Application of Metacognitive Therapy:
The Basics
During MCT, the therapist aims to change the aforementioned concepts of the S-REF model. Any MCT
lasts for around 12 sessions, and at each session the
most significant emphasis is on the CAS and the
metacognitions of the client. The therapist tends to
focus on the thought processes and the reactions of
the client to those processes more often than on the
content of the client’s cognitions. In MCT, forming
a new relationship with the cognitions and the effec-
tive control of the CAS are the primary therapeutic
targets. When these targets are reached, an effective
treatment is also deemed to have been provided. Also
the difference between non-adaptive coping styles
and more effective ways to reduce distress are discussed with the client. There may be some behavioural
experiments to test the positive and negative metacognitive beliefs. Although Socratic questioning may
be utilized during the interview, the main purpose of
this kind of questioning would rarely be to do reality
testing about the NATs. Socratic questioning is thought to be used as a mediator to shift the client to the
metacognitive mode of processing (Wells 2013). The
only instances when reality testing is of importance
may be when the therapist hopes to question the reality of the metacognitive beliefs. To help the client
shift to the more effective metacognitive mode, metaphors, guided discovery or experiential techniques
may be of particular use.
The Order of the Application of the
Metacognitive Techniques During MCT
In general, the therapist follows a sequential path to
apply the techniques of MCT. Although there may be
some differences between specific disorders, and also
depending on the particular client, a general timeframe for order of the application of metacognitive techniques would be as follows (Wells 2005; 2007; 2009;
2013):
(1) Engagement of the client to treatment, and forming a therapeutic alliance
(2) Psychoeducation about the disorder, and the treatment, specifically MCT
(3) Shifting the patient to the metacognitive mode
(4) Experiential (executive control) strategies to overcome the effects of the activated CAS
(5) Changing non-adaptive coping strategies with
more effective ones
(6) Dealing with, and challenging the uncontrollability beliefs of cognitions or emotions
(7) Dealing with, and challenging the significance or
dangerousness beliefs of cognitions or emotions
(8) Dealing with, and challenging positive metacognitive beliefs
(9) Relapse prevention strategies, and termination of
the therapy
S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
The Core Principles of MCT
MCT, like many other psychotherapy approaches, has
its unique principles which have been discovered by
empirical research, or later on developed via clinical
observation, that could be summarized as follows
(Wells 2009):
(1) Any negative emotional reaction, e.g. anxiety or
depression, is considered as a signal that points
out to the discrepancy between self-regulation and
of threats to well-being.
(2) These negative emotions are generally self-limiting, because the person incorporates some coping
strategies to overcome them.
(3) If these emotional experiences become persistent
for some reason, then one might talk about a psychological disorder.
(4) The main reason for the persistence of such negative experiences is dependent on the thinking
styles, and the behavioural reactions, i.e. strategies, of the person.
(5) These non-adaptive styles and reactions result in
the activation of the CAS, and this is evident
throughout all psychological disorders.
(6) The CAS consists of components that are closely
related to worry, rumination, threat monitoring,
ineffective thought control strategies, avoidance
behaviours, etc.
(7) The CAS is an outcome of erroneous metacognitive beliefs, which are involved with the control
and appraisal of cognitions and emotions.
(8) The CAS is responsible for the prolonged and
intensified negative emotional experiences.
(9) MCT primarily targets, therefore, the CAS and the
relevant metacognitions.
Specific Techniques in MCT
Sometimes classified among the so-called third wave
of CBT approaches, though according to Wells himself this would be a misclassification, MCT also uses
many of the wide range of classical CBT techniques.
Yet, in a differing frequency, and for different purposes. There are also some specific techniques for this
approach. Some may be listed as follows (Wells 1990,
2005, 2007, 2013, Papageorgiou and Wells 1998,
2000, Wells and Papageorgiou 2001, Fisher and Wells
2005, 2009):
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(1) Dealing with metacognitive beliefs, and reality
testing of them where appropriate
(2) Postponement of worry or rumination
(3) Attention training technique
(4) Detached mindfulness
(5) Metacognitively delivered exposure
Detailed descriptions of these techniques is far beyond the scope of this introductory article, and the
interested reader is directed to the works of Wells
(2000, 2009).
Metacognitive Therapy for Clinical or Research
Purposes: Scales
MCT is an evidence-based psychotherapy approach,
and offers disorder specific treatment manuals. MCT
is currently being offered as a treatment approach
to many psychological disorders, including Major
Depressive Disorder, Generalized Anxiety Disorder,
Obsessive Compulsive Disorder, and Post-Traumatic
Stress Disorder. Research is still underway in a variety of other disorders. Disorder specific and generic
rating scales, such as the Metacognitions Questionnaire 30 (MCQ-30) (Wells and Cartwright-Hatton
2004), Meta-Worry Questionnaire (MWQ), Thought
Fusion Instrument (TFI) (Wells et al. 2001), SelfAttention Rating Scale, CAS-I, Generalized Anxiety
Disorder Scale – Revised (GADS-R), Post-Traumatic
Stress Disorder Scale (PTSD-S), Obsessive Compulsive Disorder Scale (OCD-S), Major Depressive
Disorder Scale (MDD-S), as well as treatment plans
and case formulation interviews are readily available for the therapist to implement during the sessions
(Wells 2009). These scales may help clarify the diagnosis, and also provide feed-back about the progress
of the client during the follow-up period. There are
also many other rating scales available to rate the frequency and severity of the components of the CAS
or metacognitions, e.g. Positive Beliefs About Rumination Scale (PBRS) (Papageorgiou and Wells 2001),
Negative Beliefs About Rumination Scale (NBRS)
(Papageorgiou et al. 2008), Penn State Worry Questionnaire (PSWQ) (Wells and Papageorgiou 1998),
Thought Control Questionnaire (TCQ) (Wells and
Davies 1994), Anxious Thoughts Inventory (AnTI)
(Wells 1994).
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S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
Summary
MCT provides a new perspective for the treatment
of psychological disorders by underlining the significance of how a person thinks, rather than simply
focusing on the content of his cognitions. MCT is an
evidence-based and effective CBT approach, with a
very strong theoretical background in understanding
and explaining the mechanisms by which any psychological disorder persists. The main target of MCT lies
in attempts to inhibit the CAS, and help the client find
more effective control strategies. Although MCT has
disorder specific treatment plans, most of the techniques used in MCT may be utilized transdiagnostically
(Wells 2009; Wells and Matthews 1994; Fisher and
Wells 2009). The case formulation and specific techniques of MCT are the main distinctive features of
this therapy approach, which places it in a unique position among the CBT approaches (Fisher and Wells
2009).
ACKNOWLEDGMENTS
Parts of this article are based on my presentation at the
49th National Psychiatric Congress organized by the
Psychiatric Association of Turkey, held in Izmir, on
September 25, 2013. I would like to acknowledge the
unique contribution of Professor M. Zihni SUNGUR,
MD whose ideas are the main component behind the
topographical description of metacognitions. Further,
I would like to thank the anonymous reviewers, who
were of great inspiration with their positive feedback
regarding the previous drafts of this article. There are
no conflicts of interest to declare.
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S. Batmaz/Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi 3 (2014) 11-17
Yazışma adresi/Address for correspondence:
e-mail: [email protected]
Alınma Tarihi: 07.12.2013
Received: 17.12.2013
Kabul Tarihi: 15.02.2014
Accepted: 15.02.2014
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The Conceptual Foundations of Metacognitive