Metacognitive Therapy.
Article Type: Book review
Subject: Books (Book reviews)
Author: Hickes, Michael
Pub Date: 01/01/2012
Publication: Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2012 Society for Existential Analysis ISSN: 1752-5616
Issue: Date: Jan, 2012 Source Volume: 23 Source Issue: 1
Topic: NamedWork: Metacognitive Therapy (Nonfiction work)
Persons: Reviewee: Fisher, Peter; Wells, Adrian
Accession Number: 288874188
Full Text: Metacognitive Therapy Peter Fisher & Adrian Wells. (2009). Hove: Routledge.

Reviewing this book was not an easy task. In particular I struggled with the complexity of metacognitive theory, but alongside this there was an intuitive resistance to the extensive use of terminology, abbreviations, models and a foundation based on a technical and 'systems view' of being human. However, as I tried to bracket these reservations I found that many of the underlying ideas increasingly got to me, that the basic phenomenona identified and explored in metacognitive theory (MCT) were insightful and meaningful. I discovered that the 'what' of MCT, even if the narrowness of its perspective in general, and the methodology of its approach in particular, felt deeply inconsistent with the existential tradition, gave me new context and perspective that I feel will be valuable to me in my work as a therapist.

Metacognitive Therapy (MCT) is based on a theory proposed by Wells (1994) and initially formulated to address 'Generalised Anxiety' but subsequently expanded into a more general treatment approach (Wells 2000). MCT is claimed to be of proven effectiveness, based on evidence from a wide range of studies, and the book provides a brief introduction to both the underlying theoretical assumptions of MCT (Part One) as well as its practical features (Part Two). In particular the authors contrast MCT with cognitive-behavioural therapy (CBT), arguing that 'it is not what people think that matters, it is how they think'. Importantly the authors are proposing that MCT is a universal therapy, giving rise to a universal or 'trans-diagnostic' treatment approach.

In Part One key theoretical features of MCT are examined and we are introduced to two ideas in particular: First the Self-Regulatory Executive Function (S-REF) is a term used by the authors to describe what in effect underpins the whole approach: a concern with 'top down' conscious processes and self-regulatory strategies--how an individual responds to thoughts rather than a concern with thoughts themselves, as in CBT. In other words a person's style of thinking or coping with thoughts and emotions which, depending on the control processes for appraising and coping with thoughts and emotions selected by an individual, may either prolong emotional distress and suffering or lead to more transient emotional reactions.

The focus of MCT is therefore on helping a client identify and adjust where their thinking strategy seems to be backfiring and leading to ever-strengthening emotions, where the client is experiencing what seems to be a disproportionate intensification, maintenance and prolongation of emotional distress, and where long-term consequences in relation to their wellbeing occur as a result.

This brings the authors to identify a second key underlying feature of MCT, Cognitive Attention Syndrome (CAS). CAS is the term used to capture an individual's style or strategy for thinking characterised by persistent worry, threat anticipation and how to cope with or avoid threat (future-orientated, asking 'what if) and persistent rumination, the obsessive pursuit of a form of understanding why things happened that rarely generates useful solutions or effective emotional processing (past-focussed, asking 'why'); both strategies, it's claimed, simply result in a prolongation of anxiety and anxious responses, of negative ideas and related emotions, unhelpful coping behaviours and continued deepening distress.

In the context of these two features the authors go on to describe an important distinction between the cognitive and the metacognitive systems, and the implications for MCT. They describe the cognitive as 'object mode' where a thought is experienced as indistinguishable from that which actually takes place in the world; where there is no separation between self as observer and the act of thinking itself. In contrast, events in the mind, i.e. where there is an awareness of a thought, where the individual steps back from a cognitive belief and sees it as a thought in the mind, these are referred to as 'metacognitive'. This differentiation, and the ability to shift mode of thinking from object mode to metacognitive, is highlighted by the authors as a key resource for the individual in challenging and combating the habitual thinking patterns exemplified in CAS.

So MCT focuses on the individuals' reactions to their thoughts; it focuses on the thinking style that gives rise to beliefs. As a result the authors set out a reformulation of the traditional ABC model (on which Beck's CBT, and Ellis's Rational Emotive Behaviour Therapy (REBT) are based). The activating event 'A' is re-assigned as a cognition or emotion (internal trigger) that activates metacognitive beliefs 'M' and the CAS, which then result in emotional consequences, 'C'. The negative beliefs or thoughts, the old 'B', are seen as moderated or caused by 'M'.


The therapist therefore works with a client not on the content of their thoughts but on their beliefs about their thoughts; for instance they may question metacognitive beliefs about the uncontrollability of thoughts, or the need to continuously ruminate (for example they might challenge a hypochondriac by asking what is the point in repeatedly worrying that you have heart disease).

Wells and Matthews (1994) introduced the concept of 'detached mindfulness' (DM) to define the antithesis of CAS, and developed DM as a component of MCT aimed at helping shift a client from object mode to metacognitive mode. Mindfulness refers to being aware of the occurrence of a thought or belief, detachment involves a combination of both suspending response to that thought and separating sense of self from that thought.

The authors go on to describe how, in their view, psychological change is constrained by CAS--characterised by both a loss of executive control of top-down processing and a constant focus of attention on threat--which in turn results in a severe limitation in ability to correct faulty ideas in feared situations. Distinctive techniques, such as Attention Training Technique (ATT) (Wells, 1990) and Situational Attention Refocusing (SAR) (Wells & Papageorgiou, 1998), are consequently used to help a client counteract excessive self-focus, utilise external focussing and reverse maladaptive attentional strategies in stressful situations.

Unlike CBT, metacognitive theory is grounded in information processing theory. The authors refer to the Self-Regulatory Executive Function (S-REF) that comprises three levels of 'cognitive architecture'; low level automatic processing, conscious strategic processing and stored metacognitive knowledge. Differentiation and inter-relationship between these levels and understanding their respective roles is seen as axiomatic to effective treatment.

Metacognitive theory also differentiates metacognitive knowledge from other knowledge about self and the world, as well as the way it is represented, and the authors describe metacognitive knowledge as more like a set of programmes that direct thinking and action (Wells & Matthews 1994). Consequently, change requires engaging with alternative plans for processing, and treatment will include training clients in the specific application of new ways of thinking and coping that are opposite to CAS; with the aim of developing the clients knowledge base to support new responses in future.

In MCT, 'disorder' is therefore conceptualised as a function not of cognitive content of thoughts and beliefs, as in CBT and REBT, but of processes such as preservative thinking, attentional focus, and internal control strategies that are counter-productive and result in patterns of excessive worry or rumination; the approach is focused on helping a client restore flexible control over thinking where cognitive content is purely the material used by these processes.

The S-REF includes a distinctive definition and perspective on self-awareness, and emphasizes that all forms of self-awareness are not necessarily conducive to positive mental health outcomes. In particular the authors point out that chronic and inflexible self-focused attention (an element of self-awareness) is a key activator of CAS, and that it is the type of awareness that matters, specifically awareness of thoughts or beliefs as passing events in the mind that do not require any response--an adaptive form of awareness not focused on coping but on allowing attention to be freely allocated to observing thoughts without processing these further.

In Part Two, the distinctive practical features of MCT are explored and the authors offer a range of practical tools associated with this approach. Beginning with the assessment of metacognition, subsequent chapters address case formulation, modification of negative and positive metacognitive beliefs, attentional training techniques, detached mindfulness, meta-emotions and focused exposure, including succinct examples of case formulations for disorders such as General Anxiety Disorder, Obsessive Compulsive Disorder and Post Traumatic Stress Disorder.

As mentioned above, in MCT detached mindfulness refers to how individuals respond to mental events: worries, intrusive images, negative thoughts and memories, it involves discontinuation of any further cognitive or coping response to thoughts. Two techniques are suggested, free association and the tiger task. In free association clients are asked to passively notice their negative thoughts, worries, intrusions and feelings, while in the tiger task clients are asked to bring an image of a tiger to mind and watch the image without attempting to influence the image. Detached mindfulness is used in conjunction with rumination postponement as a means to diminish preservative thinking, modify maladaptive attentional strategies and eliminate dysfunctional coping behaviours.

Meta-emotions refer to emotions about emotions, much like thoughts about thoughts (i.e. metacognition). For instance it is suggested that we can be ashamed of a temper tantrum, enjoy a moment of bittersweet melancholy, and so on. A depressed client who has anxiety about positive emotional states and their sustainability (an example of a meta-emotion) might be asked what happens to their emotions, whether they continue for ever or fluctuate, or whether the client has experienced an emotion that lasted for ever, with the aim of helping the client see that the emotions fade and are replaced by other emotional states.

In concluding this book the fundamental objection I was left with was the way in which MCT views and works with a clients' difficulties with living in terms of a diagnostic disorder within a systems-based architecture, and presumes to be able to rectify the system and know what is best for the client. As Rollo May once warned, whenever you perceive a person merely as a particular diagnostic disorder you have 'defined for study everything except the one to whom these experiences happen, everything except the existing person him [or her] self' (May, 1986: p25).


May, R. (1983/86). The Discovery of Being: Writings in Existential Psychology. New York: W.W. Norton

Wells, A. (1990). Panic Disorder in Association with Relaxation-Induced Anxiety: An Attentional Training Approach to Treatment. Behavior Therapy, 21: 273-280

Wells, A. & Matthews, G. (1994). Attention and Emotion, a Clinical Perspective. Hove: Erlbaum

Wells, A & Papageorgiou, C. (1998). Social Phobia: Effects of External Attention on Anxiety, Negative Beliefs and Perspective Taking. Behavior Therapy, 29: 357-370

Wells. A, (2000). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Chichester: Wiley.
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