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474 – Metacognitive Therapy
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs Counselor Education
Host: Counselor Toolbox Podcast

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• Learn about metacognitive therapy
• Explore the multiple aspects of metacognition
• Practice applying MCT to depression, pain, learned helplessness and other stressful situations
• Distress is a signal that the person is trying to respond to threats to their wellbeing
• Distress is normally reduced by effective coping strategies
• Disorders result when
• The person’s coping skills backfire
• Believe they have no control over their thoughts
• Believe it is in their best interest to keep ruminating. Rumination often focuses on questions that have no easily identifiable answers.
• What if?
• Why do I feel this way?
• Why me?
• What does this symptom mean?
• Metacognitive essentially means “thinking about thinking” and refers to the knowledge and regulation of one’s own cognitive processes
• MCT agrees that prior experiences create schema which influence interpretation of events, however, MCT focuses not on the content of the thoughts but the what the person pays attention to.
• Metacognitive experiences are the reactions people have as a result of their cognitive appraisals
• MCT focuses on disorder specific cognitive biases such as mood congruent memory
• In one study, NFC, acted as the only mediator between treatment and depression recovery
Metacognitive Components
• Metacognitive knowledge refers to declarative knowledge of cognitive processes and includes
• Personal knowledge (e.g., Ways of thinking (rumination, analysis), and personal abilities and limitations) (Mindfulness)
• Negative metacognitive beliefs (distress intolerant thoughts) focus on
• The uncontrollability of thoughts and belief that thoughts need to be controlled
• Rumination
• Threat monitoring
• Unhelpful reactions that backfire (away behaviors)
• Positive metacognitions are beliefs about the need to have the particular beliefs to stay safe or prepared
• Task knowledge (e.g., How to do something (cook, meditate, learn, control thoughts)) (Skills Training)
• Strategic knowledge (e.g., Advantages/disadvantages and applicability of each strategy) (Problem Solving)
Metacognitive Components
• Metacognitive experience is the personal experience and perception of difficulty that accompanies cognitive activity.
• How confident do I feel that I can do it and it will be successful? (Fact-based reasoning vs. Emotional reasoning)
• Metacognitive monitoring and control refers to self-supervision and regulation of the cognitive processes including their ability to plan, monitor, evaluate and regulate their cognitive activities by adjusting task goals, regulating attentional awareness (shot), and selecting cognitive strategies.
• What is the best course of action
• How effective is this course of action
• What needs to be done differently or continued?
Example Application
• (Rumination) If I think about it enough I will find answers.
• How long have you been at it? How much longer will it take?
• What if there is no answer?
• (Need to control thoughts) If I do not control my thoughts I will do something bad.
• How do you know which ones to control?
• What types of bad things have happened by not controlling your thoughts?
Example Intervention
• A à B  C
• A=Critical and unconstructive feedback
• B=They hate me. They don’t consider other perspectives. They are entitled. They aren’t accepting responsibility for their part.
• C=Anxiety, helplessness
• A  M  C
• A=Critical and unconstructive feedback
• B=I need to ruminate to identify all of the ways to defend myself.
• How many ways do you need to think of? When will you have enough?
• Will continuing to ruminate change their opinion?
• Is their opinion truly a threat?
• C=Anxiety, helplessness

• Imagine you have social anxiety and you do not like going to parties because you are worried that you will do something embarrassing and humiliate yourself.
• In MCT, you don’t pay attention to specific thought content. You instead challenge the process that leads to the thought. For example, you could say:
• “Worrying about this does not make it less likely to happen, so I am not going to spend the time worrying.”
• “I have the ability to focus my thoughts on other things.” (tame my monkey mind)

Cognitive Attentional Syndrome
• In MCT, cognitive attentional syndrome (CAS) refers to a tendency to believe thoughts are uncontrollable, rely on ineffective coping skills, ruminate and focus undue attention on threat monitoring
• CAS focuses attention on sources of potential threat
• Increases the sense of danger
• Increases focus of thoughts and awareness on sources of threat
• Prevents noticing the safety features or “threat-free” environment
• Increases intrusions such as memories, intrusive thoughts and potentially nightmares
A-M-C Assessment
• Over the past month what emotional, behavioral and physical symptoms have you noticed?
• Has any thought or situation made you feel worse?
• What thought or feeling did you have when that happened?
• When you had that experience, what happened to your thinking?
• Did you dwell on things? For how long?
• What did you do to try to control the way you felt?
• Did you try to change your thoughts? If so, how?
• Are there advantages to worrying or ruminating?
• Are there advantages to focusing on your thoughts and feelings?
• What do you think will happen if you continue to feel or think like this?
• How much control do you have over your thoughts?
Metacognitions in Pain Management
• Metacognitions about pain related cognitions have been linked to pain intensity, disability, emotional distress, and greater physical dysfunction
• Negative: I cannot stop thinking about my pain. I cannot focus on anything else because of being distracted by my pain.
• Positive: I need to continue to focus on my pain to ensure it doesn’t get worse.
• Participants who reported greater levels of emotional distress also tended to endorse stronger negative meta-cognitive beliefs
• Neuroimaging research showing that catastrophic thinking and specifically rumination on pain activate the brain similar to an anxiety disorder
Pain Application
• Personal knowledge (e.g., Ways of thinking (rumination, analysis), and personal abilities and limitations) (Mindfulness)
• Negative metacognitive beliefs
• The uncontrollability: I can’t stop thinking about the pain
• Rumination: Often thinking about the pain, its negative impact on life
• Threat monitoring: Constantly looking for things that will increase pain and scanning for signs of worsening pathology
• Unhelpful reactions that backfire (If I go to sleep I will wake up and feel better. A few beers will help me relax and stop thinking about it)
• Positive metacognitions: I must stay alert to changes in my pain
• Task knowledge (How to use guided imagery, CPMR, stretching techniques, evaluate ergonomics) (Skills Training)
• Strategic knowledge (Advantages/disadvantages and applicability of each strategy) (Problem Solving)

Depression Application
• Personal knowledge (e.g., Ways of thinking (rumination, analysis), and personal abilities and limitations) (Mindfulness)
• Negative metacognitive beliefs
• The uncontrollability: I can’t stop thinking about all the things I have no control over and how unfair the world is.
• Rumination: Focusing on the things outside of personal control
• Threat monitoring: Constantly looking for things that confirm negative mood bias
• Unhelpful reactions that backfire (If I go to sleep I will wake up and feel better. A few beers will help me feel better)
• Positive metacognitions: ?
• Task knowledge (Nutrition, sleep hygiene, distress tolerance skills, Backward chaining) (Skills Training)
• Strategic knowledge (Advantages/disadvantages and applicability of each strategy) (Problem Solving)

Metacognition and Depression
• Less than 1/3 of patients with depression recover, and relapse rates for those who do recover are estimated to be 50% after 2 years
• In Metacognitive Therapy depression is understood as a consequence of perseverative thinking styles (especially rumination and worry) called the cognitive attentional syndrome (CAS)
• 70–80% of patients with depression were recovered at post-treatment and 6-month follow-up (Hagen et al., 2017).
• The treatment was also associated with large reductions in interpersonal problems
• Why?
• When Sally fails at something, she tends to ruminate on it.
• Uncontrollability of thoughts
• Rumination (What does she ruminate about? Why does she ruminate? )
• Threat Hypersensitivity (In what ways is she hypersensitive to threat? Why is this necessary?)
• When John gets into a fight with his partner he tends to ruminate on it
• Uncontrollability of thoughts
• Rumination (What does he ruminate about? Why does he ruminate?)
• Threat Hypersensitivity (In what ways is he hypersensitive to threat? Why is this necessary?)

• Learned Helplessness as a Metacognitive Target
• Uncontrollability: No matter what I do, the thoughts keep coming back or the situation keeps recurring.
• Rumination: Focusing on all the things I have tried that have failed and the continuing presence of the threat.
• Threat Awareness: Everywhere I turn something bad is waiting.
• Instead of confronting the content, evaluate the utility of these beliefs.
Metacognitive beliefs as psychological predictors of social functioning
• 50% of those with an at risk mental state (ARMS) engaged in 30 h or less of structured activity per week and were considered to be ‘socially disabled’
• Negative beliefs about uncontrollability of thoughts and danger (the situation) was found to predict reductions in structured activity (withdrawal, helplessness)
• Age was found to significantly predict social functioning with younger people experiencing poorer social functioning than older people.
Domain Enhancements of Metacognitive Ability Through Adaptive Training
• An individual with good metacognition is aware of fluctuations in task performance, and appropriately modulates their confidence level
• Two key aspects of metacognitive performance (Fleming & Lau, 2014).
• Efficiency: How accurately do participants discriminate between effective and ineffective strategies. (Problem solving training)
• Bias: Are participants generally more or less confident in a particular strategy or task? (Efficacy enhancement)
• Writing a 50 page thesis
• People can have millions of automatic cognitive distortions. Addressing each one may not be possible.
• Becoming aware of thought patterns, their function, their usefulness and alternatives underlies MCT.
• MCT moves from addressing the content of thoughts (What is being thought?) to the function of those thoughts (Why are the thoughts occurring and are they helpful?)