There is a new type of therapy on the block and it’s called “metacognitive”. It can help with social anxiety disorder, generalized anxiety disorder (GAD), health anxiety, obsessive compulsive disorder (OCD) and depression. But what is it and how does it work? That’s what we’ll explore in this article.
We live in a world of cognitive behavioural therapy
Today, mental health therapy is dominated by cognitive behavioural therapy (CBT). There is good reason for this: CBT is the most clinically effective treatment we have for most issues. It delivers results and does this in a cost effective way, which is a big advantage for healthcare providers.
However, CBT is not effective for everyone. A meta-analysis (a study that takes the results of lots of other studies and pools them together) published in 2015 suggested that CBT was becoming less effective.
And everyone gets along with it. At the local support group I run, Anxiety Leeds, it is common for people to have been through several rounds of CBT and still not achieved the results they want.
Because of this, new therapies are being developed. There are a wide range of these: acceptance & commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT) and the topic at hand, metacognitive therapy.
A very short history of metacognitive
I won’t bore you with an in-depth history. But it is important to note that metacognitive is a young field.
The primary driver behind it is a British clinical psychologist named Adrian Wells. He is Professor Clinical and Experimental Psychopathology at the University of Manchester and co-founder of the Metacognitive Institute.
The standard textbook on the subject, Metacognitive Therapy for Anxiety and Depression, was only published in 2011.
Therefore, it is still early days to say how effective metacognitive will prove to be in the long-term. However, early results are very promising. A 2014 meta-analysis published by the Anxiety and Depression Association of America (ADAA) concluded “MCT is effective in treating disorders of anxiety and depression and is superior compared to waitlist control groups and CBT”.
Okay, but what is it?
Metacognitive essentially means “thinking about thinking”. The theory is that we have a set of beliefs about the way we think, and that these beliefs are incorrect.
For example, we have positive beliefs about worry:
- “Worrying keeps me safe”
- “It is useful to focus my attention on threat monitoring”
And we have negative beliefs about our thinking:
- “I cannot change”
- “I have no control over my thoughts”
- “I could damage my mind by worrying”
The problem with these beliefs is that when we believe that worrying keeps us safe and that we cannot change the way we think, even if this is only subconscious, we are unlikely to make a positive change.
Therefore, the idea of metacognitive therapy is to challenge these “meta” beliefs. If we can reduce our subconscious beliefs that we need worry, or that we cannot get rid of worrying, we will be more motivated and find it easier to tackle the worries themselves.
How does it compare to CBT?
Metacognitive therapy (MCT) is another layer up from cognitive behavioural therapy. In CBT, we are dealing we thinking. In MCT, we are dealing we thinking about thinking.
Let’s illustrate this with an example.
Imagine you have social anxiety and you do not like going to parties because you are worried that you will do something embarrassing and humiliate yourself.
In CBT, we would challenge the thought. We would ask ourselves “what are the changes this will actually happen” and “are the consequences as bad as I imagine?” When we challenge the thought, we realise that the changes of it happening are low and that even if it did happen, the social consequences would not be that bad: people would laugh at us but then forget about it.
In MCT, we are a step removed from this. We don’t even give the thought attention. Rather than challenging the thought itself, we challenge the process that leads to the thought. For example, we could say to ourselves:
“Worrying about this does not make it less likely to happen, so I am not going to spend the time worrying.”
“I have already spent time worrying about this. I have no new information, so further worrying will not be productive and will only make me unhappy.”
This process of refusing to engage with the thought is called detached mindfulness. Like any therapy technique, it takes practice and repetition to see the benefit.
What do the exercises involve?
Much like CBT, MCT comes with homework. There are various exercises that help us challenge our invalid beliefs. Each one is designed to challenge a specific belief, either positive or negative.
An example is attention training technique. This is an exercise designed to challenge the belief that “I have no control over my thoughts”.
In the exercise, you are given a series of sounds to focus your attention on. You then switch your attention between the different sounds as instructed. The idea is that you demonstrate to yourself that you can control your attention, and that you therefore have control over your thoughts.
In this aspect, MCT is similar to mindfulness. Many mindfulness-based exercises have you focus your attention in different stimulus or different areas of the body. And, in both cases, the exercise is not designed to suppress anxious or negative thoughts. Rather, you should allow the thoughts to enter your mind but refuse to engage with them.
MCT has already shown itself to be a promising therapy for tackling anxiety, OCD and depression.
Whether it will replace other therapies in the long-term is unclear. It seems more likely that will form a toolset alongside mindfulness and cognitive behavioural therapy. Different people respond to different things and so having all options available is likely to produce the best outcomes.
Like other therapies, challenging your metacognitive beliefs is hard and takes practice. However, the long-term effects can produce significant benefits.