Metacognitive Therapy (MCT)

Theory of change

The person changes when they interrupt the CAS, modify the beliefs that govern it and recover a flexible attentional control that allows distress to decay naturally.

Core ideas

1. Psychopathology is maintained by a processing style, not by the mere presence of negative thoughts

   Unpleasant thoughts, images, memories and emotions also appear in people without a disorder and usually subside when they receive no prolonged elaboration. MCT locates the clinical difference in the activation of the CAS: repetitive worry or rumination, attention focused on threat and control strategies that keep negative information accessible and prevent updating. Content helps to recognise the theme of the problem, while process explains its persistence and offers a transdiagnostic target. (Wells and Matthews, 1994, Attention and Emotion; Wells, 2000, Emotional Disorders and Metacognition).

2. Worry and rumination are selected self-regulatory strategies

   Repetitive thinking is activated because the person expects it to allow them to anticipate, resolve, understand, remember or control. This strategic function explains why the CAS can continue despite generating suffering: part of the system considers it necessary. The therapy needs to uncover and modify the beliefs that justify its use, as well as reducing the fear of its consequences. (Wells, 1995, Metacognition and Worry; Wells et al., 2020, Editorial: Metacognitive Therapy: Science and Practice of a Paradigm).

3. Metacognitive beliefs govern the selection and persistence of the CAS

   Positive beliefs favour starting worry, rumination or vigilance, while negative ones turn those processes into signs of uncontrollability, danger or personal meaning. The interaction between the two creates a self-regulatory conflict: the person tries to use a strategy that they simultaneously fear and attempt to control. MCT intervenes on this architecture because modifying one metacognitive belief changes multiple thoughts and situations without restructuring each content separately. (Wells, 2000, Emotional Disorders and Metacognition; Wells and Carter, 2001, Further Tests of a Cognitive Model of Generalized Anxiety Disorder).

4. Meta-worry turns mental activity into an additional threat

   In the GAD model, type 1 worry concerns problems and events, while type 2 worry appraises one's own worry as dangerous or uncontrollable. This second layer intensifies anxiety, vigilance and control efforts and offers a specific explanation of the sense of being trapped by one's own mind. Reducing meta-worry allows the initial intrusion to lose its capacity to trigger escalation. (Wells, 1995, Metacognition and Worry; Davey and Wells, 2006, Worry and Its Psychological Disorders).

5. Distress has a tendency to regulate itself once the processes that prolong it cease

   MCT understands many emotional reactions as responses capable of diminishing and being updated over time. Worry, rumination, vigilance and suppression interfere with that course by keeping threat signals in active processing and restricting contact with new information. Treatment restores the conditions for natural recovery instead of trying to control each emotion directly or eliminate every intrusion. (Wells and Matthews, 1994, Attention and Emotion; Wells et al., 2020, Editorial: Metacognitive Therapy: Science and Practice of a Paradigm).

6. Attention is a trainable control system and a causal lever of change

   Self-focus and vigilance are not regarded as mere symptoms but as operations that select the information available and feed threat appraisals. ATT and situational refocusing train selection, shifting and breadth so that the person can abandon rigid configurations. The relevant learning consists in recovering flexible control, not in using attention as a distraction to produce immediate relief. (Wells, 1990, Panic Disorder in Association With Relaxation Induced Anxiety; Wells, 1997, Cognitive Therapy of Anxiety Disorders).

7. Detached mindfulness changes the mode of processing without suppressing thought

   Detachment maintains awareness of the intrusion and withdraws elaboration, analysis and behavioural response. This stance demonstrates that a thought can be present without becoming a reality, a command or a problem to be solved. Its difference from suppression is structural: suppression monitors and fights the content, whereas detachment allows its existence and frees resources for directing attention elsewhere. (Wells, 2005, Detached Mindfulness in Cognitive Therapy; Wells, 1997, Cognitive Therapy of Anxiety Disorders).

8. Modifying the process takes priority over debating the ordinary content of thought

   The therapy can acknowledge that a worry concerns real matters without entering into an unlimited search for certainty or arguments. The central clinical question is what the person does with the thought, which rule is activated and what effect that response produces. This shift prevents the session from becoming another episode of assisted rumination and directs the work towards mechanisms that can generalise across contents. (Wells, 2000, Emotional Disorders and Metacognition; Wells, 2009, Metacognitive Therapy for Anxiety and Depression).

9. Behavioural experiments function as causal tests of metacognitive beliefs

   A belief about uncontrollability, danger or usefulness is modified more deeply when the person alters the process that supposedly confirms it and observes a different outcome. Postponing worry, giving up vigilance, allowing an intrusion or acting without reassurance seeking generates data that the old plan prevented them from obtaining. The experiment is designed from an explicit prediction and avoids safety behaviours so that the learning can be attributed to the change of strategy. (Wells, 1997, Cognitive Therapy of Anxiety Disorders; Davey and Wells, 2006, Worry and Its Psychological Disorders).

10. The same CAS takes different configurations across disorders

    In generalised anxiety, worry and meta-worry predominate; in depression, rumination; in trauma, the repetitive processing of symptoms and consequences together with hypervigilance; in obsessions, the monitoring and control of intrusions. MCT retains a common theory and adapts triggers, beliefs and behaviours to each presentation, which makes it possible to formulate comorbidity without adding disconnected protocols together. (Wells and Matthews, 1996, Modelling Cognition in Emotional Disorder; Davey and Wells, 2006, Worry and Its Psychological Disorders; Wells et al., 2020, Editorial: Metacognitive Therapy: Science and Practice of a Paradigm).

Influences

• Positivism / Post-positivism
• Beck's cognitive therapy
• Experimental cognitive psychology
• Information-processing theory
• Metacognition
• Models of self-regulation
• The psychology of stress and coping

Key references

• Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273–280.
• Wells, A. (1994). Attention and the control of worry. En G. C. L. Davey y F. Tallis (Eds.), Worrying: Perspectives on Theory, Assessment and Treatment. Wiley.
• Wells, A., y Davies, M. I. (1994). The Thought Control Questionnaire: A measure of individual differences in the control of unwanted thought. Behaviour Research and Therapy, 32, 871–878.
• Wells, A., y Matthews, G. (1994). Attention and Emotion: A Clinical Perspective. Lawrence Erlbaum Associates.
• Wells, A. (1995). Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320.
• Wells, A., y Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy, 34, 881–888.
• Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide. Wiley.
• Wells, A., White, J., y Carter, K. (1997). Attention training: Effects on anxiety and beliefs in panic and social phobia. Clinical Psychology & Psychotherapy, 4, 226–232.
• Wells, A., y Papageorgiou, C. (1998). Social phobia: Effects of external attention on anxiety, negative beliefs, and perspective taking. Behavior Therapy, 29, 357–370.
• Wells, A., y Carter, K. (1999). Preliminary tests of a cognitive model of generalized anxiety disorder. Behaviour Research and Therapy, 37, 585–594.
• Wells, A. (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Wiley.
• Wells, A., y Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy, 32, 85–102.
• Wells, A., y Cartwright-Hatton, S. (2004). A short form of the Metacognitions Questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42, 385–396.
• Wells, A., y Sembi, S. (2004). Metacognitive therapy for PTSD: A preliminary investigation of a new brief treatment. Journal of Behavior Therapy and Experimental Psychiatry, 35, 307–318.
• Wells, A., y Sembi, S. (2004). Metacognitive therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice, 11, 365–377.
• Wells, A. (2005). Detached mindfulness in cognitive therapy: A metacognitive analysis and ten techniques. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23, 337–355.
• Wells, A. (2005). The metacognitive model of GAD: Assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research, 29, 107–121.
• Davey, G. C. L., y Wells, A. (Eds.). (2006). Worry and Its Psychological Disorders: Theory, Assessment and Treatment. Wiley.
• Wells, A. (2009). Metacognitive Therapy for Anxiety and Depression. Guilford Press.
• Wells, A., Welford, M., King, P., Papageorgiou, C., Wisely, J., y Mendel, E. (2010). A pilot randomized trial of metacognitive therapy versus applied relaxation in the treatment of adults with generalized anxiety disorder. Behaviour Research and Therapy, 48, 429–434.