What is metacognitive therapy?

We all have disturbing thoughts sometimes - thoughts that makes us feel anxious or depressed. That's perfectly natural. Usually we are able to accept these thoughts as part of life and we can actively dismiss them or just allow them to take their course and fade away. But sometimes, some people struggle to do this. They are unable to dismiss or let these thoughts go. That can then lead to sustained anxiety, depression, or emotional suffering.


The cognitive attentional syndrome (CAS)


People who struggle to deal with disturbing thoughts tend to display the same kind of metacognitive pattern. It's called the CAS and it prolongs and intensifies negative emotional experience. The CAS consists of:

  1. Worrying and rumination. These are long chains of predominantly verbal thought. Worrying might involve the person attempting to answer What if . . . ? questions which often have little relationship with the true probability of dangerous events. Rumination seeks to answer questions that often do not have a single or identifiable answer, such as Why me? or Why do I feel this way?

  2. Threat monitoring. This involves fixating attention on perceived threat. For example, an individual traumatized in a robbery scans the environment for potential danger. A patient with low self-esteem monitors for signs that people might not like her

  3. Unhelpful thought control strategies (eg, thought suppression) and other forms of behaviour (eg, avoidance or substance abuse) that prevent adaptive learning

'The problem isn’t really that I have negative thoughts about myself, it’s how I’ve been reacting to them. I’ve discovered that I’ve been pouring coal on the fire. I just didn’t see that process before.'


But why do some people display the CAS pattern and not others?


This question is answered by looking at someone's metacognitive beliefs. These are you beliefs about their own thinking, and there are two types:


First, there are 'positive' metacognitive beliefs about the need to engage in aspects of the CAS:

If I worry about my symptoms, I won’t miss anything important

If I think about my failings and analyze why they occurred, I will be able to become a better person

If I think about my depression it will make me angry which is better than feeling sad

Focusing on danger will keep me safe


Second, there are negative metacognitive beliefs about the uncontrollability, dangerousness, or importance of thoughts feelings:

I have no control over my mind

my anxiety could make me go crazy

If I have violent thoughts I will act on them against my will

Being unable to remember names is a sign of a brain tumor


These beliefs are a key influence on the way people respond to negative thoughts and emotions. They are a driving force behind the toxic thinking style that leads to prolonged

emotional suffering.


Dysfunctional metacognitive strategies


Metacognitive strategies are the responses made to try to control and alter unwanted experiences. Sometimes the strategy may be to attempt to suppress certain thoughts through positive thinking or distraction. But this is unlikely to help as it prevents the person from engaging in functional emotional processing, such as getting used to and reducing the power of a thought or emotion through repeated exposure. It also has the danger of increasing a feeling of loss of control if you are unable to consistently suppress unwanted thoughts.


Other strategies may include focusing attention toward threat in an attempt to be prepared. This may include analyzing experiences to find answers, or to trying to predict what might happen in the future so as to avoid problems. The problem with this strategy is that it maintains a sense of threat.


So, how does the MCT therapist help?


Traditional Cognitive Behavioural Therapy (CBT) addresses an individual’s thoughts and beliefs in order to identify dysfunctional content. For example, a CBT therapist might identify that a client is becoming distressed because of the dysfunctional thought, 'I’m worthless'. The CBT therapist might then try to address this by challenging the thought with a question like, 'What's the evidence that you're worthless?'.


Metacognitive Therapy (MCT) is also interested in identifying someone's dysfunctional thoughts, but only because it helps to get deeper - to the metacognitions which tell us about underlying dysfunctional processes. To take the example above, the MCT therapist would also identify the dysfunction 'I’m worthless' thought. However, instead of addressing the thought itself the therapist would then try to address the metacognition underlying it, perhaps by asking, 'What is the point in evaluating your worth?'


The ultimate aim is to dismantle the CAS. That is, to reduce the extent of worry and rumination, to lessen threat monitoring, to change unhelpful coping strategies. Just like in CBT, this is achieved largely through questioning and guided discovery. But the discovery is about the processes which stem from metacognitive beliefs and strategies that are leading to distress.


Some examples of MCT questioning


In each case below a dysfunctional metacognitive belief is in bold, and the kind of questions that the metacognitive therapist might use to reframe the the belief is underneath in italics


If I worry, I will be prepared

Is it possible to be prepared without worrying?

Is it possible to worry about everything that could happen?

Does worry give a balanced view of the future or a biased one?

What are the disadvantages of dwelling on that thought?


Focusing on danger will keep me safe

How do you know which danger to focus on?

Is it the danger you see or the one you don’t see that will catch you out?

Could focusing on danger make you less safe because you forget the usual

things?


I must control my thoughts

How do you know which ones to control?

Is it possible to control all of your thoughts?

Could controlling your thoughts stop you from finding out the truth about

them?