Metacognitive Therapy

Distinctive Features

Peter Fisher, Adrian Wells

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415434980
• eBook ISBN: 9781134108671
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Metacognitive therapy is based on the principle that worry and rumination are universal processes leading to emotional disorder. These processes are linked to erroneous beliefs about thinking and unhelpful self-regulation strategies.

Metacognitive Therapy: Distinctive Features is an introduction to the theoretical foundations and therapeutic principles of metacognitive therapy. Divided into two sections, Theory and Practice and using thirty key points, the authors explore how metacognitive therapy can allow people to escape from repetitive thinking patterns that often lead to prolonged psychological distress.

This book is a valuable resource for both students and practitioners wishing to develop a basic understanding of metacognitive therapy and how it compares and contrasts with traditional forms of cognitive behavioural therapy.

Part 1

THE DISTINCTIVE THEORETICAL FEATURES OF MCT

1 A focus on metacognition

Metacognition is a term used to refer to a specific category of thinking and cognition. It is essentially cognition applied to cognition. Thinking requires metacognitive factors that monitor and control it. For instance, the process of memorizing a new telephone number depends on knowledge of strategies that can be used to modify memory (e.g. rote rehearsal). It requires the initiation and regulation of the rehearsal strategy, and depends on monitoring when it is time to stop rehearsal. In addition, it requires the subsequent accessing of information that drives retrieval of the number as and when required. In this small example of cognition, the act of memorizing requires multiple aspects of metacognition to make it possible. Beyond this example, metacognition is involved in the cessation, perpetuation and modification of thinking, which encompasses the dysfunctional thinking that maintains psychological disorder.

Traditional cognitive-focused treatments such as cognitive-behaviour therapy (CBT; Beck, 1976) and rational emotive-behaviour therapy (REBT; Ellis, 1962) emphasize the role of cognitive bias and distorted or irrational beliefs rather than the control of thinking. Moreover, these are beliefs outside the metacognitive domain such as beliefs about the world, and the social and physical self. For example, Beck (1976) describes cognitive distortions such as arbitrary inference (jumping to conclusions), catastrophizing, and personalization as cognitive distortions that are evident in negative automatic thoughts. These are different from the thinking styles that are given central prominence in metacognitive therapy (MCT; Wells, 2000). In MCT, maladaptive thinking styles refer to a preponderance of verbal conceptual activity that is difficult to control and occurs in the form of worry and rumination. These styles can be identified independently of their content, as extended forms of brooding and dwelling and analysing information.

In contrast to standard CBT that focuses on a wide range of beliefs about the self and world and says little about metacognitions, metacognitive therapy (MCT) gives metacognitions and metacognitive beliefs a central role in psychological disorder. Unlike CBTs, MCT does not assume that distorted cognitions (i.e. thoughts) and coping behaviours emanate from ordinary beliefs, but specifies that thought patterns are the result of metacognition acting on thinking processes.

Until the advent of metacognitive therapy, research on metacognition was confined largely to the field of developmental psychology and research on human memory. However, Wells and Matthews (1994, 1996) and Wells (2000) developed a general theory of psychopathology that explicitly placed metacognition at centre stage. This approach has led to the development of MCT that aims to change the way individuals experience and control thinking, and the beliefs they hold about cognition. MCT differs from earlier forms of CBT because it does not focus on beliefs and thoughts about the social and physical self, or thoughts and beliefs about others and the environment. Instead, it deals with the way in which people respond to these other cognitions and the mental processes that repeatedly give rise to erroneous and unhelpful views of reality. For example, in cognitive therapy the therapist deals with a patient’s cognition about failure by asking, “What is the evidence that you will fail?” but the metacognitive therapist asks, “What is the use in worrying about failure?” The aim in MCT is to modify the thinking processes that support biased failure-oriented processing and the nature of the person’s unhelpful reaction to cognitions of this kind.

If we assume that cognition in psychological disorder is biased, as do all cognitive and MCT theories, then it is necessary to identify the source of that bias so that it may be treated. The nature of bias emphasized in CBT, REBT and MCT is different. In the former two approaches it resides in the schemas or irrational beliefs or in the content of negative automatic thoughts. In contrast, in MCT the bias occurs in the style that thinking takes and this is derived from metacognitive knowledge stored as a library of information and plans or programmes that direct processing.

The MCT approach proposes that psychological disorder is linked to a specific style of thinking, involving recurrent, recyclic ideation in the form of worry and rumination and fixating attention on threat. The bias in processing is therefore in how the person thinks rather than in what the person thinks. The content of worry and rumination may show considerable within-individual variation but the process itself remains a constant variable. This process arises from and is controlled by the person’s metacognition.

In contrast to this assertion, Beck’s schema theory (e.g. 1976) attributes the control of cognition to more general beliefs, which are thought to introduce bias, but this bias is in content rather than in style. Earlier approaches have not attributed a role to metacognition or differentiated between different thinking styles, making MCT distinct in these important respects.

2 An information processing model of psychological disorder

Metacognitive therapy is grounded in an information processing model of the factors involved in the etiology and maintenance of psychological disorder. The model, called the Self-Regulatory Executive Function (S-REF) model, was originally proposed by Wells and Matthews (1994) and has been subsequently elaborated (Wells, 2000, 2009). As the name of the model implies, it accounts for psychological disorders in terms of predominantly top-down or conscious processes and self-regulatory strategies. According to the model, the person’s style of thinking or coping with thoughts, emotions and stress backfire, and lead to an intensification and maintenance of emotional distress. The model draws on distinctions in cognitive psychology between levels of control of attention. It proposes that psychological disturbance is principally linked to biases in the selection and execution of controlled processes for appraising and coping with thoughts, threats and emotions. An individual’s strategy for thinking and self-regulation in response to threat and challenges can prolong emotional suffering or lead to more transient emotional reactions. Psychological disorder develops when the person’s style of thinking and coping inadvertently leads to persistence and strengthening of emotional responses. This occurs principally as a result of extended thinking which prolongs emotion. A certain pattern of thinking, called the cognitive attentional syndrome (CAS), is identified as a causal factor in extending negative thinking in psychological disorder.

Unlike cognitive-behavioural theory, MCT theory does not link psychological problems to automatic processing biases or the content of schemas but attributes them to the individual’s conscious strategies. For example, attentional bias, like that observed in the emotional Stroop task, is not attributed to activation of schemas or automatic processing but is attributed to the person’s choice of strategy. In psychological disorder, patients have a strategy of maintaining attention on sources of threat and engaging in worry-based processing as a means of coping. Filtering tasks such as the Stroop are thought to be sensitive to these aspects of processing strategy (Wells & Matthews, 1994).

The S-REF model is based on three basic levels of cognition: a level of reflexive and automatic processes that run with minimal or no conscious involvement. These processes may generate intrusions into consciousness that capture attention. The next level is an online form of processing, which is conscious and capacity-limited, responsible for regulating and implementing appraisal and action. The final level is stored knowledge in long-term memory. The immediate activities of the online processing require access to stored knowledge in order to run. Online processing is guided by knowledge or beliefs that are metacognitive in nature. Among these levels, two domains of cognition are important: the metacognitive and cognitive domains. This overall structure or “architecture” of cognition is different from that in traditional CBT, as it maps onto levels of control of cognition and differentiates between the content of thoughts and the regulation of thinking, which is not a distinction made in traditional approaches.

In CBT, there are no levels of attention with a dynamic interaction between them; instead, there are components of cognition such as the distinction made between negative automatic thoughts and beliefs or schemas. A schema in CBT is a memory structure that is synonymous with ideas such as “I’m worthless” or “I’m losing my mind”, which are beliefs thought to be behind psychological disorder. It is not clear how these beliefs actually control thinking. In MCT, beliefs like these can be viewed as outputs of processing and what matters is the style of thinking and metacognition that extends and repeatedly generates these concepts.

Traditional CBT does not make a distinction between automatic or controlled processing or consider which factors might lead to the types of appraisal or self-regulatory responses seen in mental disorders. For instance, it assumes that disorder is linked to negative automatic thoughts, which are rapid short-hand negative appraisals such as “I’m dying” or “I’m a failure”. However, metacognitive theory views these types of appraisal as relatively normal and transient occurrences; they are not the source of disorder. Instead, S-REF theory asserts that it is the way an individual responds to such thoughts that determines whether or not psychological disorder develops. Similarly, a belief or schema is not thought to be stored in long-term memory but is simply considered to be another example of a thought that is reliably triggered and which the person might subsequently appraise as valid. So beliefs in metacognitive theory are instances of currently activated thoughts and appraisals of their validity; beliefs are a product of online processing. The content of thoughts may be erroneous but the person acts as if a thought is a direct read-out of reality because of the mode of processing in which it occurs. Thus, in MCT it is not merely the content of belief or thoughts that is important but the way an individual responds to that thought and the individual’s processing mode. We will return to the concept of modes later (Point 5).

To illustrate the idea that the content of thoughts or beliefs may not be especially important in disorder, we can consider two individuals who have the same experience and the same negative automatic thought or belief. Let’s assume they are students who fail an examination and this activates the thought or belief: “I’m a failure.” One student becomes depressed and the other experiences only short-term disappointment. How can this be when they have the same experiences and negative automatic thought? Traditional CBT cannot answer this question because it places all its emphasis on the content of negative automatic thoughts and beliefs.

MCT offers an answer to this conundrum. It states that it is not the thought itself but the individual’s reaction to that thought (or reaction to a belief) that determines its emotional and longer-term consequences for wellbeing. Some individuals are more resilient than others, which is probably because they are more flexible in their responses to negative thoughts and emotions. They maintain flexible control over their responses and do not become locked into patterns of sustained processing of negative information that prolongs emotional distress. Such flexibility includes the capacity to modulate activity in low-level processing structures such as the amygdala, as well as disrupt and switch out of sustained or extended conceptual processing.

In the S-REF model, a particular style of sustained and inflexible responding to thoughts, emotion and threats is responsible for prolonging and intensifying suffering; this style is called the Cognitive Attentional Syndrome (CAS).

3 The cognitive attentional syndrome (CAS)

According to S-REF theory and MCT, a particular style of thinking and ways of coping with negative ideas and threat are a fundamental feature of all psychological disorders. This style, called the CAS, consists of persistent thinking in the form of worry and rumination, focusing attention on sources of threat, and coping behaviours that backfire because they impair effective self-regulation of thoughts and emotions and learning of corrective information. If we return to the example of the students who failed, introduced in Point 2, the one who became depressed engaged in brooding on the reasons for being a failure, why it had happened this time and why it had happened in the past and what this meant about his ability. This form of conceptual analysis is rumination and it prolongs and intensifies negative ideas and emotions. It focuses on analysing why things happened and what this means; however, in the misguided pursuit of understanding, it rarely generates useful solutions or exerts more adaptive control over emotional processing. The more adaptive solution is represented by the response of the student who did not become depressed. This individual engaged in a short period of brooding but then decided that the best thing to do was focus on how he could improve his performance the next time around. In effect, this student exercised control over his rumination and activated a different strategy in response to thoughts/beliefs about being a failure.

Rumination is predominantly past-focused. In contrast, a similar conceptual process that is also part of the CAS, worry, is mainly future-oriented. A short-hand means of distinguishing each process is that rumination seeks answers to “why” questions, whereas worry seeks answers to “what if” questions. Worry is concerned with anticipating threat and generating ways of either coping with it or avoiding it. So a person may have a quick negative thought: “What if I fail the interview?” and then engage in sustained worry in response to this thought. Worrying is a chain of thoughts in which the person contemplates a range of threatening events and ways to deal with them. So a worry sequence may proceed something like this: “What if I fail the interview… I’d better be prepared…but what if I haven’t prepared the right thing…what should I prepare… I know, I’ll look at the job description…what if they ask about my weaknesses…should I tell them about leaving my last job…what if they think I’m not good enough…what should I tell them…what if I say the wrong thing…what if I get too nervous…?”

The problem with worry as a response to negative ideas or feelings is that it generates a range of threats and increases the sense of danger, leading to anxiety or maintaining an existing anxiety response. Worry and rumination may have other effects on lower levels of processing. In particular, in the metacognitive model of post-traumatic stress disorder (PTSD) (Wells, 2000; Wells & Sembi, 2004a), worry and rumination are thought to disrupt normal in-built recovery processes following trauma, leading to a perpetuation of a sense of threat and to symptoms of PTSD. This is partly because the individual fails to execute the appropriate top-down control over activity in emotion-processing networks in the brain. Instead, resources needed for control are diverted to emotion-laden processes of worry and rumination, which sensitize or sustain activity in emotional networks.

In addition to worry and rumination, the CAS also consists of an attentional strategy of threat monitoring. This refers to fixating attention on threatening stimuli. Often in psychological disorder these are internal events such as thoughts, bodily sensations or emotions. For instance, the obsessional patient monitors for occurrences of certain forbidden or dangerous thoughts; the person with contamination fears monitors for “suspicious-looking” stains on the floor; the person with health anxiety checks his body for signs of disease; and the person with social phobia monitors how they think they appear to others. In each case, threat monitoring increases access to negative information and maintains the sense of threat.

Another important aspect of the CAS is unhelpful coping behaviours, such as avoidance of feared situations, reassurance seeking, trying to control thoughts, using alcohol or drugs, neutralizing behaviours and self-punishment. These strategies backfire for a range of reasons, including the negative effect they have on others, the fact that they prevent exposure to information that can correct erroneous ideas, and that some of them interrupt normal cognitive and biological processes.

The identification of a specific style of thinking (the CAS) sets MCT apart from other forms of CBT because it is more concerned with processes than with content of thought. In MCT, it is not necessary to challenge the content of a thought such as “I’m a failure” but, rather, to help the individual develop an alternative relationship to that thought whilst abandoning the CAS.

A further distinctive feature of MCT is the level of detail used in differentiating between types of human cognition contributing to disorder. It sees negative automatic thoughts as triggers for more sustained worry or rumination and these latter processes are the more proximal cause of disorder. This distinction between varieties of thought is not made in CBT or REBT approaches. Moreover, psychological disorder in MCT is linked to sustained processing and not to the brief instances of thoughts—“automatic thoughts”—that can occur on the periphery of consciousness.

Further important distinctive theoretical features of MCT will emerge in Point 4, as we consider the underlying psychological factors that give rise to the CAS.

4 Metacognitive beliefs

MCT gives prominence to metacognitive beliefs in the development and maintenance of psychological suffering. It holds that a relatively small and specific range of beliefs can explain almost all pathology. This is different from CBT and REBT, in which there are many types of schemas or irrational beliefs. In schema theory, a new schema is formulated whenever it is needed to fit the patient’s presenting problem.

In MCT, positive and negative metacognitive beliefs are important (modification of these beliefs is discussed in Points 21 and 22). Other approaches do not formulate metacognitive beliefs and do not classify the on...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Introduction
• Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF MCT
• Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF MCT
• Conclusion
• References