Metacognitive Therapy

Metacognitive Therapy (MCT) is a recent development in understanding the causes of mental health problems and in treating them. The approach is based on a specific theory proposed by Wells and Matthews (1994), initially used to treat Generalised Anxiety and subsequently expanded as a general treatment approach (Wells, 1995, 2000). The approach is backed by scientific evidence from a wide range of studies. Metacognition is the aspect of cognition that controls mental processes and thinking. Most people have some direct conscious experience of metacognition. For instance, when unable to remember a name a person may feel sure that the name is stored in memory.

This gives rise to a metacognitive state that occurs as a strong feeling called the ‘tip-of the tongue-effect.• This is an example of metacognition working to inform the person that an item of information is somewhere in memory even though the person is unable to remember it. Metacognition can even go further by retrieving this name and pushing into consciousness often when least expected. Although we are aware of some metacognition operating like in this example, most of the metacognitions that control our thinking and conscious experience operate in the background.

One of the features of psychological disorders such as anxiety or depression is that thinking becomes difficult to control and biased in particular ways that lead to a worsening and maintenance of emotional suffering. Many patients report that they feel that they have lost control over their thoughts and behaviours. Another important feature is that the persons thinking and attention becomes fixed in patterns of brooding and dwelling on the self and threatening information. Metacognitive therapy recognises this change in thinking patterns and believes it is very important. It gives it a name: the Cognitive-Attentional Syndrome (CAS).

This pattern consists of worry, rumination, fixation of attention on threat, and coping behaviours that the person believes are helpful but many of which backfire and keep emotional problems going. The CAS is controlled by metacognitions and it is necessary to remove the CAS by helping patients develop new ways of controlling their attention, new ways of relating to negative thoughts and beliefs, and by modifying metacognitive beliefs that give rise to unhelpful thinking patterns. This approach has been developed into specific ways of understanding and treating disorders such as generalised anxiety disorder, post-traumatic stress, obsessive-compulsive disorder, social anxiety, depression, and health-anxiety.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is a psychological treatment approach that has been applied effectively to a wide range of mental-health problems. It is the most supported psychological treatment with over 300 published studies. It is recommended by the National Institute of Clinical Excellence (NICE) for anxiety disorders and depression and it has other effective uses across many mental health problems.

CBT is based on the principle that psychological distress results from distortions and biases in the way an individual interprets events. These give rise to negative meanings and maintain and strengthen unhelpful beliefs. In addition the way an individual behaves can generate problems by interfering with effective problem solving, by disrupting self-regulation and by preventing exposure to corrective learning experiences. For example, avoidance of a feared object prevents a person discovering that the object presents no real danger and erroneous beliefs about harm remain unchanged and anxiety persists.

CBT contains a range of specific models and approaches to treating disorders. Treatment based on disorder-specific models, and many of these are now available, is preferred. Treatment for anxiety and depression typically lasts 12-14 sessions, and the therapist works with the client to examine and modify negative thoughts, biases and behaviours that underlie symptoms. Homework is a part of treatment and often consists of recording thoughts, changing patterns of behaviour, activity scheduling, and conducting ‘behavioural experiments to test distorted beliefs.

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