A brief interview with Prof. Adrian Wells on the distinctive features of Metacognitive Therapy (MCT).
1. Dear Prof. Wells, could you outline the core features of the Metacognitive Theory and Therapy approach to psychological disorders?
Metacognitive Theory of psychological disorders is based on the principle that most psychological disorder is caused by a pattern of extended thinking. This pattern is called the Cognitive Attentional Syndrome (CAS). It is made up of chains of verbal thought in the form of worry and rumination, a pattern of focusing attention on threat and coping strategies that have paradoxical effects. Rather than terminating negative thinking they extend it.
The CAS is driven by underlying beliefs about thinking which fall into two braod categories of positive beliefs (e.g. I must worry in order to cope) and negative beliefs (e.g. Some thoughts are dangerous).
Metacognitive Therapy focuses on removing the CAS in response to negative thoughts and experiences by raising awareness of this process and improving the selective control of it. In so doing it also challenges the underlying metacognitive beliefs. By the end of treatment clients are more flexible in their response to negative ideas and less reliant on fixed patterns of thinking and mental control as a means of coping with emotional experience.
2. What are the main differences from previous CBT approaches?
MCT is radically different from earlier CBT. For one thing at the core of the theory is the idea that thoughts are not really that important. Instead it is the persons reaction to thoughts that counts. This is the opposite message to that in CBT, where negative automatic thoughts are central to disorder.
MCT is also different in that it focuses on thought styles and mental regulation rather than the content of thoughts. It does not reality-test thoughts or general beliefs about the self and world. The focus in MCT is reducing the CAS. In fact the act of interrogating and challenging thoughts could be seen as analogous to the CAS: it is another form of extended thinking and does not directly produce the kind of metacognitive change thought to be necessary in MCT.
In MCT beliefs are the focus of intervention but these are only the metacognitive beliefs and not other ‘schemas’. These other schemas are seen very much as the triggers for the CAS or the output of that process and are therefore ‘epiphenomena’.
Of course CBT is a ‘shape shifter’ and it continuously incorporates concepts from other theories and techniques. CBT has begun to use principles from metacognitive therapy. The problem with this is that boundaries are blurred and it becomes difficult to usefully define what CBT is. Furthermore, the combining of CBT and MCT treatment techniques is likely to be problematic as they are based on conflicting messages concerning how clients should relate to and manage their thoughts. I have described the principles and techniques of MCT and how these differ from traditional CBT in my recent treatment manual: Metacognitive Therapy for Anxiety and Depression published by Guilford Press which is available in Italian by the publisher Eclipsi.
3. The concept of metacognition is used by various approaches that highlight different facets (e.g. self-reflection skills, mentalization, empathy). What do you think of these conceptualizations of metacognition as metacognitive functions instead of meta-beliefs?
It seems to me that metacognition is becoming a buzz word, and in my reading of some other approaches it is clear that the authors are not using the term correctly or in the same way. For example, treatments that largely consist of standard cognitive therapy techniques and focus on cognition rather than beliefs about cognition or on mental control have been labelled as metacognitive. There is a high degree of misunderstanding of the concept. It is important to keep in mind that it is a multi-faceted construct. You asked about self-reflection, this may not be metacognitive at all. For example, thinking about how one could improve one’s golf swing is not a metacognition. It is not thinking about thinking. However, thinking about how one might improve one’s memory is metacognitive self-reflection. The issue with constructs such as empathy and mentalization is that they are ‘fuzzy’ or non-specific concerning metacognition, in some instances they capture metacognition whilst at other times they don’t.
You also asked me about metacognitive functions and beliefs. As I said metacognition is multi-faceted: there are metacognitive strategies such as trying to control thoughts with suppression, beliefs such as the positive and negative beliefs about thoughts, and metacognitive experiences such as appraisals of mental states and felt-senses such as the ‘tip of the tongue effect.’ There are likely to be metacognitive ‘functions’ that are not amenable to direct conscious experience but act on cognition more automatically. Progress in this area in my view depends on the development of models that distinguish these components and can specify their effects on disorder within a multi-level cognitive system. That was my aim over 20 years ago and the basis of the metacognitive model that was described in our 1994 book: Attention and Emotion.
4. From your point of view could MCT be considered a third wave approach and if so where is it positioned?
I don’t like the term ‘third wave’ because it doesn’t convey any information. Instead it seems to suggest that there is a new movement but gives no indication of the differences that exist between the treatments that form this movement. I would not view MCT as part of what I understand to be the third wave therapies (ACT and MBCT) because it does not draw on meditation practices. In fact some aspects of meditation such as increased self-focus, re-directing attention, and the imagery techniques would not be the recommended means of achieving change in MCT.
5. One of the most relevant techniques proposed by MCT is Detached Mindfulness. What are differences and overlaps between detached mindfulness and the concept of mindfulness as proposed by mindfulness based cognitive therapies?
Detached mindfulness refers to a specific and well defined state that we introduced in 1994. By mindfulness we mean awareness of thoughts, that is to say specifically metacognitive awareness and the ability to distinguish a negative thought form a subsequent worry or rumination response to that thought. By detachment we mean stopping or disconnecting any response to that thought, and in a more profound way experiencing the self as separate from a thought as simply an observer of it. This is much more specific than the construct of mindfulness as it is used in meditation. Different practitioners of meditation have different descriptions of what they mean by mindfulness. It may be awareness of the breath, of present moment experience or consist of a non-judgemental stance. It seems to me that one of the limitations with the meditation based approaches to developing treatment is likely to be that they lack a sufficiently rigorous model and that these constructs lack precision to connect sufficiently well with pathological processes. Having said this, I must also point out that detached mindfulness is a technique that has a specific aim and that it is not a mandatory component of MCT.
6. Is MCT a treatment focused on emotional disorders or may it be applied to a broad range of psychological disorders (e.g. personality disorders) and with which differences?
MCT is a generic treatment that in principle can be applied to a wide range and perhaps all psychological disorders. There are groups of researchers testing the treatment in anxiety disorders, depression, psychosis, eating disorders, addictions, borderline personality, and the psychological consequences of physical health problems. We have tended to proceed using disorder specific models that capture the nature and effects of the CAS and metacognitions in each disorder. However, it is also possible to formulate on a more generic level using a transdiagnostic version of the model. This can be a useful starting point in developing more specific forms of an intervention.
7. What will be the future developments of MCT approach? Are there any issues or areas which remain uncovered?
New areas are being explored right now and are set to expand in the future. These areas include applications to new client groups such as children and adolescents and further developments in the areas of personality disorders and psychosis. One area that we have recently begun to explore is group based MCT treatment which holds the possibility of brief and highly cost-effective treatment options. Areas yet to be explored are the neurocognitive correlates of MCT techniques such as attention training and detached mindfulness. It is encouraging to see controlled and comparative trials of the treatment appearing in the literature and there are several large scale studies of this kind underway that will yield results soon. For readers interested in recent work and finding out more I would recommend checking out the information and updates on our website: www.mct-institute.com