Beyond cognitive Therapy

In the last 25 years, many prominent clinical psychological researchers keep elaborating and making evidence-based studies on a new and fascinating clinical psychological model, even looking beyond the already classic CBT model (cognitive behavioral therapy): metacognitive therapy (MCT). The main figures during this process have been Adrian Wells (UK), Hans Nordahl (Norway), Peter Fisher (UK), Odin Hjemdal (Norway), Gerald Matthews (UK, USA), Gabriele Caselli (Italia), Marcantonio Spada (UK) and Roger Hagen (Norway).

It is not kind of interpersonal or verbal treatment meant to be a ‘personal development therapy’, but a high effective and efficient treatment at health insurances or social health systems.

We can say it is an internationally developed clinical model. Its promise regarding effectiveness consists of the many empirical studies supporting this new model for many psychological affections: post-traumatic stress disorder (PTSD), anxiety, depression, addictions, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) and more. Many have intended to classify this model into the so named “third wave therapies’, but the authors avoid this nomenclature.

Firstly, we want to understand what differences this MCT model stands out, and how it implies a theoretical revisionism of the classical CBT model. 

The central hypothesis: 

The MCT essentials assertions are the following: it matters not the content of thinking but the way we link ourselves to them. “Metacognition” means the cognition applied to cognition itself, a mechanism that controls and monitors the emerging contents of our consciousness. It is thinking about thinking. The MCT approach is based in that the emotional disturbances remain due to our metacognitive process (the cognition of cognition) triggers peculiar response patterns on our inner states, which holds negative emotions and reinforce negative ideas too. Let us remember that from the most classical neo-behaviorist tradition, thought can be conceived as an internal behavior.

These whole patters have been called as “attentional cognitive syndrome”, which consists of mental rumination, emotional concerns and worries, an obsessive attention process and dysfunctional behaviors in order to cope with reality.

According to the MCT model, these metacognitive processes in our mind make up the aware self-experience of us and our whole vision of the world, so to speak, it conforms our cosmovision.

The traditional cognitive model (CBT) elaborated by Beck, as well as the known rational emotive behavioral therapy (REBT) created by Ellis, usually state that psychological disorders are caused by thinking’s biases, irrational interpretations and cognitive distortions.

On the other hand, the MCT model emphasizes that it is the attentional cognitive syndrome which keeps focused our mind in concerning ruminations, as well as an obsessive attention process on supposed threats and fears. Unlike classic CBT or REBT therapy models, the MCT model insists not on the thinking’s content but the way we link to our thinking and the beliefs about thinking itself.  The metacognition is a process through which the thinking ‘gets its own sight’; it is an aspect which controls the way the person thinks and reacts regarding an idea, belief or emotion. Metacognition refers to cognition applied to cognition itself and could be defined as any knowledge or cognitive processes involved in the appraisal, control, and monitoring of thinking. Metacognitions have to be with self-knowledge.

Since all persons have negative ideas and feelings, the problem is carried out because of an unyielding and rigid thinking style, excessively and persistently focused on those negative ideas and emotions. 

As a result, the MCT treatment’s goal is changing this dysfunctional coping thinking style.

The MCT core task is not discussing our thinking’s contents in order to carry out a cognitive restructure like in the CBT model (changing contents) but changing the way we relate to our metacognitive processes regardless of our cognitions’ content.

Saying it differently, in classical CBT model the central task is challenging the patient’s content of ideas, and then recheck the reality. In the MCT model, the core task of the clinical intervention is trying to change how the patient reacts to his own ideas. 

Hans Nordahl

Types, domains, strategies and ways of thinking:

According to the metacognitive theory of psychological disorder, there are two kinds of metacognitive ideas: explicit-declarative (mostly verbal expressions) and implicit-procedural ones (not directly verbal, but cognitive rules).

Besides, there would exist two metacognitive domains: positive and negative metacognitions. Positive ones refer to ‘advantages’ of focusing on the cognitive attentional syndrome, e.g.: “it is useful to pay attention to menaces.’ Negative metacognitions regard to beliefs of not taking control over the own ideas, its meaning, importance and real dimension, e.g.: ‘If I cannot remember this information it could be because of brain cancer.’

It is called 'metacognitive experience’ to the kind of feelings and contextual self-made evaluations about the own thinking process. A very depictive example of this could be the worry about worries, which is typical during anxiety disorders.

On the other hand, it exists the ‘metacognitive strategy’, this means the kind of responses that the individual carries out so as to control and self-regulate emotions and thinking. When a person is undergoing some kind of psychological disorder, the self-experience and self-perception implies feeling like losing control. One option is that our mind could try to suppress a disruptive or disturbing idea. Other option is letting go, making focus on other idea or emotion, etc.

Usually we experiment our own thinking like if it was a perception, but not an inner mental event. Our mind uses automatically to experiment these inner mental events like ‘things’ inside the I. Our mind fuses our mental events with the experience from outside. This habitual out of the blue modality, this way of thinking is named as the 'object mode’. Nevertheless, it is feasible to experiment our own cognitions like self-made inner representations and inner events constructed from scratch by our mind. This modality is the ‘metacognitive way’, and we become able to ‘observe’ our own cognitions like if they were split events from the I and the outside world.

Inside the frame of the classical CBT model, the therapist challenges the idea’s content, so the clinical frame takes up into the object mode of thinking. But, working with MCT model supposes to develop new procedural knowledge in order to change the way we feel the cognition, developing an alternative modality of inner experience. The technique so as to develop this new ability is the ‘detached mindfulness’ or the attentional training with designed sounds.  

Mental disorder model: 

Shortly, the classical cognitive model asserts that an event (A) triggers some cognitive mechanisms such as irrational beliefs (B), and this carries behavioral and emotional reactions (C). According to the MCT model, here there are two main things that remain unexplained: 1) why negative beliefs schemas keep themselves linked to negative and repetitive emotions, and 2) what produces uncontrolled cognition patterns that uphold the psychological suffering. 

The MCT model tries to solve this problem putting in the middle of the classical A-B-C model the metacognitive processes.

Here we are giving a very general and sketched out perspective about the MCT model. Its advantages over other models are the possibility of making up a trans dimensional perspective of the psychological affection (exploring feasible common factors to many disorders). This has been explained throughout what the authors call the S-REF basic model: 'self-regulatory executive function model.’ This is kind of further complexity, but basically, the CAS (cognitive attentional syndrome) can consist of a toxic metacognitive style that keeps a person trapped into rumination for a long term, both with repetitive and disturbing experiences, which implies a self-focused attention process with excessive angst and worry, reinforcing dysfunctional emotions. In the classical Beck’s model, the emotional disorder has to be with a negative knowledge; in the MCT model, negative self- knowledge maintains the disturbance. (Matthews & Wells, 1996)

Evidence based findings:

Depression: Depression is the second largest cause of global disability and is a source of major personal suffering, loss of quality of life and risk. Let’s see this chart:

Regarding depression, with MCT clinical approach, 74% of patients compared with 52% in CBT treatment met formal criteria for recovery at post treatment. It has been found that gains are sustained over follow-up periods of 6–12 months. (Callesen, Pia, Reeves, David, Heal, Calvin & Wells, Adrian, 2020)

In this chart we can appreciate the patient’s clinical evolution even after the formal treatment and regarding follow-up:

In a 3 years follow-up, 60% of patients didn’t show any depressive events. (Solem et al., 2019)

Anxiety: Many kinds of therapies try to approach anxiety problems focusing on the nature of reality and the content of thinking.

However, MCT model has showed to be highly effective in comparison with other models, focusing on metacognitive aspects. As Hjemdal et al. say: ‘(…) metacognitive beliefs have a crucial role that intensifies the aversive experience of worry and its threat value. GAD patients use paradoxical or incompatible metacognitive control strategies that reduce their exposure to experiences of self-control and/or contribute to instances of impaired control.’ (Hjemdal et al., 2013)

A study published in 2018 by Open BJPsych, shows that Both CBT and MCT were effective treatments, but MCT was more effective and led to significantly higher recovery rates (65% for MCT and 38% for classical CBT). These differences were maintained at 2-year follow-up. (Nordahl et al., 2018) We should take into account that the higher effectiveness of just classical cognitive therapy vs. pharmacological treatment for social anxiety disorder (for instance Paroxetine), was already known and has been found in many studies. Findings show that cognitive therapy is superior than Paroxetine and placebos trials, but only cognitive therapy is not more efficient than the combination of therapy and Paroxetine. (Nordahl, Vogel, Morken, Stiles, Sandvik & Wells, 2016).

Attention deficit hyperactivity disorder (ADHD): MCT therapy model has proven to be effective as a treatment way and a viable psychosocial intervention for ADHD. It is nowadays well-known that ADHD, once thought to be exclusively a childhood disorder, uses to persists into adulthood, affecting approximately 4% of the U.S. adult population and generating significant impairment in academic, occupational, social, and emotional functioning. He we see a chart comparison between MCT therapy and standard supportive therapy for ADHD (Solanto et al, 2013):

In 2018, after 25 independent studies, Normann & Morina asserted in a meta-analysis review that the findings indicate MCT is an effective treatment for a wide range of psychological disorders. To date, strongest evidence exists for anxiety and depression disorders.

Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions.

 Posttraumatic Stress Disorder (PTSD): The MCT model for PTSD does not require exposure and has shown to be as effective as other treatments such as EMDR approach.

So to speak, MCT does not use exposure or reliving of trauma memories and this could be advantageous in reducing the aversiveness to the treatment by both the patient and the therapist. It is said by Nordahl, Halvorsen, Hjemdal, Ternava & Wells (2018): 'The metacognitive beliefs are hypothesized to underlie an unhelpful response style consisting of worry, rumination and threat monitoring, and other coping behaviours such as attempting to fill gaps in memory. These response styles prevent cognition and arousal returning back to basal levels of processing a threat-free environment. In effect PTSD symptoms are maintained because these factors prolong threat-related processing and interfere with the downregulation of subcortical arousal. In contrast to EMDR, MCT does not involve prescribed exposure exercises or restructuring of negative trauma-related memories.'

Addictions: Metacognitions play a major role in substance use disorders. This has been specifically studied by Spada & Wells (2010). A positive association has been observed between beliefs about the need to control thoughts and alcohol consumption. In further research, evidence has been found that these same beliefs related to lack of cognitive confidence (the conscious assessment of one's cognitive functioning in the presence or absence of an objective cognitive deficit) predicted the classification as problem drinking. Beliefs about the need to control thoughts predict drinking levels and relapses in problem drinkers.

Positive meta-cognitions about drinking (e.g., "drinking helps me control my thoughts") can be conceptualized as a specific form of alcohol expectation related to drinking as a means of controlling cognition and emotion.

From a metacognitive standpoint, such beliefs are believed to play a central role in motivating individuals to engage in the use of alcohol as a means of cognitive-affective regulation. Negative metacognitions of alcohol use refer to the perceived lack of executive control over behavior (e.g., "my drinking persists no matter how I try to control it") and the negative impact of alcohol use on cognitive functioning ("drinking will hurt my mind"). This mentioned academic research was the first study to empirically demonstrate that individuals with alcohol dependence report significantly higher scores on meta-cognitions of alcohol use than problem drinkers and also than nondrinkers.

This empirically based hypothesis led to the so-called "three-phase formulation" to explain problematic alcohol consumption with supported empirical data (Spada, Caselli, Wells, 2012). In the three-phase formulation: 1) during the pre-alcohol use phase, alcohol-related triggers (such as cravings, images, memories, or thoughts), activate positive metacognitive beliefs about thinking, which lead to thinking about that same desire, rumination, and worry, or their combination. 2) The activation of the latter leads to an escalation of negative cravings and emotions, reinforcing negative metacognitive beliefs about the need to control thoughts and increasing the likelihood of alcohol consumption. Positive metacognitive beliefs about alcohol use and their reduction in metacognitive control contribute to the deregulation of alcohol use itself. 3) Over time, as the drinking problem becomes more severe, negative metacognitive beliefs about the uncontrollability of alcohol use and alcohol-related thoughts arise, contributing to the persistence of unregulated alcohol use. In the post-drinking phase following the activation of positive metacognitive beliefs about post-event rumination, the affective, cognitive, and physiological consequences of unregulated alcohol consumption become the subject of rumination again. This, in turn, leads to a paradoxical increase in negative affect and alcohol-related thoughts, along with the strengthening of negative metacognitive beliefs about such thoughts. Finally, intermittent attempts to suppress alcohol-related thoughts increase the likelihood that alcohol will be used again as a means of achieving self-regulation.

Obsessive compulsive Disorder (OCD): MCT focuses on changing, by reworking subjective plans of action and cognition, the strategies that patients use to guide their behavior and processing. Treatment challenges not only metacognitive beliefs about thoughts, but also the way individuals relate to their intrusive thoughts themselves. This gives rise to new techniques, which propose to go beyond the perhaps already classic Exposure Prevention Response with Exposure Response Commission and another new ways of treating this disorder. (Wells, 2009)

   

Sources: 

·      Callesen, Pia, Reeves, David, Heal, Calvin & Wells, Adrian. (2020) Therapy in Adults with Major Depression: A Parallel Single-Blind Randomised Trial. Sci Rep 10, 7878 (2020). https://doi.org/10.1038/s41598-020-64577-1

·      Fisher, Peter & Wells, Adrian. (2009) Metacognitive Therapy. Distinctive Features. New York: Routledge. 

·      Hjemdal et al., Metacognitive Therapy for Generalized Anxiety Disorder: Nature, Evidence and an Individual Case Illustration, Cognitive and Behavioral Practice (2013). http://dx.doi.org/10.1016/j.cbpra.2013.01.002

·      Matthews, Gerald & Wells, Adrian. (1996). Modelling cognition in emotional disorder: The S-REF Model. Behav. Res. Ther. Vol. 34, No. 11/12, pp. 881-888, Elsevier Science. 

·      MCT Institute website: https://mct-institute.co.uk

·      Nordahl, H.M., Halvorsen, J.Ø., Hjemdal, O. et al. Metacognitive therapy vs. eye movement desensitization and reprocessing for posttraumatic stress disorder: study protocol for a randomized superiority trial. Trials 19, 16 (2018). https://doi.org/10.1186/s13063-017-2404-7

·      Nordahl, H.M., Vogel, P., Morken, G., Stiles T., Sandvik, P., Wells, A. (2016) Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial.  Psychother Psychosom 2016; 85:346–356.  https://doi.org/10.1159/000447013

·      Nordahl, Hans et al. (2018) Metacognitive therapy versus cognitive–behavioural therapy in adults with generalized anxiety disorder. BJPsych Open 4, 393–400. doi: 10.1192/bjo.2018.54

·      Normann, N & Morina, N. (2018) The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis. Front. Psychol. 9:2211. doi: 10.3389/fpsyg.2018.02211

·      Solanto, Mary et al. (2010) Efficacy of Meta-Cognitive Therapy for Adult ADHD. Am J Psychiatry 2010; 167:958–968. Elsevier Science. 

·      Solem S, Kennair, Hagen R, Havnen A, Nordahl HM, Wells A, and Hjemdal, O. (2019) Metacognitive Therapy for Depression: A 3-Year Follow-Up Study Assessing Recovery, Relapse, Work Force Participation, and Quality of Life. Front. Psychol. 10:2908. doi: 10.3389/fpsyg.2019.02908

·      Spada, Marcantonio, Caselli, Gabriele & Wells, Adrian. (2012) A Triphasic Metacognitive Formulation of Problem Drinking. Clinical Psychology and Psychotherapy. DOI: 10.1002/cpp.1791

·      Spada, Marcantonio, Wells, Adrian. (2010) Metacognitions across the continuum of drinking behaviour. Elsevier. Personality and Individual Differences 49 (2010) 425–429. 

·      Wells, Adrian. (2009) Metacognitive Therapy for Anxiety and Depression. New York: The Guilford Press.