Metacognitive therapy (MCT; Wells, 2009) continues to gain ground as a treatment for psychological complaints. MCT is theoretically grounded in the self-regulatory executive function model (Wells and Matthews, 1994, 1996), which states that psychopathology arises as a result of a perseverative thinking style called the cognitive attentional syndrome (CAS). The CAS consists of dysfunctional coping strategies that a person employs as an attempt to manage distressful thoughts and feelings. These include worry, rumination, threat monitoring, thought control strategies, avoidance, and reassurance seeking (Wells, 2009). The model proposes that negative thoughts and feelings are temporary in nature, however, when a person responds to these with CAS activity, this may cause extended psychological distress and may inadvertently exacerbate and prolong negative affect. The model further suggests that the CAS arises from a person's positive and negative metacognitive beliefs, i.e., beliefs about cognition. Positive metacognitions are beliefs about the need to engage in CAS activities, e.g., “Worry helps me stay prepared,” whereas negative metacognitions are beliefs about the uncontrollability and dangerousness of thoughts and feelings, e.g., “I have no control over my worry/rumination” and “Feeling like this means I am losing my mind” (Wells, 2009).
In MCT, metacognitive beliefs and processes related to the CAS are identified and modified during treatment. The treatment is manualized, as outlined by Wells (2009). However, flexible application of the manuals is advocated to fit the specific patient's needs. Although MCT targets transdiagnostic processes, the exact case formulation model as well as combination of techniques vary depending on the disorder in question. The first step in therapy is to conceptualize an idiosyncratic case formulation together with the patient, and to socialize the patient to the maintaining processes, including the impact of worry and rumination and the ineffectiveness of current coping strategies. Next, metacognitive beliefs are verbally challenged in Socratic dialogues, and behavioral experiments are used to test and generate change in the person's metacognitive predictions or beliefs about CAS strategies. Main emphasis is laid on challenging the negative beliefs before moving on to challenging the positive metacognitive beliefs. The patient is instructed to postpone worry and rumination processes. The aim is for patient to experience that worry and rumination are processes that can be postponed by disengaging from further processing, that they are harmless, and have no advantages. Specifically designed therapeutic techniques, such as the attention training technique or detached mindfulness (Wells, 2009), are used. The attention training technique (Wells, 1990) is an auditory task that requires the patient to engage in selective attention, divided attention, and attention switching. It is designed to increase the patient's executive control and regain attentional flexibility. In detached mindfulness the patient is instructed to become aware of internal trigger thoughts and detach from them by taking a step back and disengaging any further coping or perseverative processing in reaction to them. The patient practices these new ways of reacting to trigger thoughts in therapy as well as between sessions, and their implementation is proposed to strengthen the patient's ability to disengage from worry and rumination processes. The techniques furthermore challenge the patient's belief that worry and rumination are uncontrollable. Toward the end of therapy focus is on reversing any residual CAS activity. Altogether, MCT aims at increasing the person's experience of attentional control, reducing self-focused attention, and fostering the development of adaptive beliefs and coping strategies.
Several clinical trials have examined the efficacy of MCT. Normann et al. (2014) meta-analytically summarized relevant trials on MCT that were published until early 2014. The authors incorporated 16 trials with patients with anxiety and depression and concluded that MCT is very effective in these populations. It must be noted, however, that only nine of the trials in this meta-analysis were controlled trials and most trials were based on rather small samples. Very recently, Rochat et al. (2018) assessed the efficacy of single-case studies on MCT in a meta-analytic review and also reported that these studies support treatment efficacy of MCT for anxiety, depression, and other psychopathological symptoms. Since the meta-analysis by Normann et al. (2014), several clinical trials on the effect of MCT have been published. Furthermore, the meta-analysis by Normann et al. (2014) focused on depression and anxiety disorders only. To address these limitations, the current study aimed at providing an updated review and meta-analysis on the effect of MCT. The main objective was to investigate whether MCT improves symptoms of psychological complaints on primary and secondary outcome variables in comparison to control conditions. For this purpose, we focused on both uncontrolled as well as controlled trials. With regard to the secondary outcomes, we aimed at assessing whether treatment has an impact on comorbid anxiety or depression as well as metacognitions.
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