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Metacognitive Therapy: Cognition Applied To Regulating Cognition
Adrian Wells - University of Manchester, UK

Abstract. The theory and principles of Metacognitive therapy (MCT) are described and data supporting its effects are summarized. MCT does not advocate challenging of negative automatic thoughts or traditional schemas. It proposes the existence of a universal maladaptive thinking style that causes disorder and focuses on helping patients regulate their cognition more adaptively. It aims to reduce worry and rumination and alter problematic patterns of attention and coping. In doing so it targets underlying metacognition that controls thinking and helps patients develop new ways of consciously experiencing inner events. Data from treatment studies suggest that individualMCT techniques and full treatment are highly effective. Further randomized trials are clearly warranted.
Keywords: Metacognition, metacognitive therapy, anxiety, depression, rumination, worry.

Introduction
Metacognitive therapy (MCT:Wells, 1995) is about how and why people re-generate or extend negative ideas. Processes of perseveration and fixation are thought to lead to psychological disorder. Three of these processes are worry, rumination and threat monitoring. Cognitive-behavioural therapy covers a wide range of orientations and approaches but most of them have a principal focus on mental content. For instance, Beck (1976) describes the content of negative automatic thoughts and schemas as giving rise to emotional disorder. In contrast, the metacognitive approach focuses on mental processes of thinking style, attending and controlling cognition. The bottom-line is this: in CBT, disorder is caused by the content of cognition but in MCT disorder is caused by the way thinking processes are controlled and the style they take. Content is important in MCT but it is the content of metacognition rather than the content of cognition that counts.

Whilst CBT is concerned with testing the validity of thoughts (e.g. ?Where?s your evidence you will have an accident??) MCT is primarily concerned with modifying the way in which thoughts are experienced and regulated (e.g. ?What?s the point in worrying about accidents??). When MCT does focus on testing the validity of thoughts it focuses on metacognitive beliefs
(e.g. ?I have no control over my worries?) rather than on ordinary cognitions (e.g. ?the world is dangerous?). The effectiveness of standard CBT is attributed to a change in metacognitions
and reduction in the Cognitive Attentional Syndrome (CAS) that occur fortuitously during treatment. The theoretical grounding ofMCTis the Self-Regulatory Executive Functionmodel (S-REF:
Wells and Matthews, 1994). It proposes that a thinking style called the Cognitive Attentional Syndrome (CAS) is a universal feature of disorder and is responsible for prolonging and intensifying distressing emotions. The CAS consists of: (1) worry and rumination; (2) threat monitoring; and (3) coping behaviours that are malada- -ptive because they impair flexible self-control or prevent corrective learning experiences. Worry and rumination are predominantly verbal thinking styles in which the person analyses potential threats and attempts to find answers to problems or ways of avoiding danger. These thinking styles often occur in response to initial negative automatic thoughts or intrusions and are conceptualized as a form of coping. The problem with worry and rumination is that they prolong anxiety and negative affect and they focus the individual on ideas and processes that strengthen dysfunctional knowledge. They also interferewith in-built self-regulatory processes needed for emotional processing. Another important feature of theCASis threat-monitoring, which refers to focusing attention on sources of internal or external threat or negative information as a means of coping. This process backfires because it increases awareness of threat and leads to greater negative thoughts and anxiety. For example, a patient with contamination fears described how she was hypervigilant
for stains that could be caused by bodily fluids. This process elevated her sense of threat as she became more aware of how much staining there was in public places. Other coping behaviours that constitute the CAS include avoidance and thought suppression. They are problematic because they are not consistently effective in regulating emotion and thinking, and they fail to provide unambiguous evidence that contradicts erroneous beliefs. For example, the act of suppressing a thought by attempting to remove it from consciousness is likely to activate a self-monitoring plan aimed at detecting the presence or absence of the thought. This can maintain preoccupation with the suppressed topic. There is nowa large evidence-base that self-regulatory strategies, specifically those linked to the CAS (e.g. worry) are associated with vulnerability to emotional disorder and are predictors of traumatic stress (see Wells, 2008 for a review). According to the metacognitive (S-REF) model the CAS is the result ofmetacognition that controls thinking processes. Metacognition is comprised of tacit knowledge or programs and verbally accessible beliefs. Two types of belief are implicated: positive beliefs about the need to worry, ruminate and engage in strategies such as threat monitoring (e.g. ?If I analysewhy I?ve failed I?ll be able to overcomemy depression?), and negative beliefs about the uncontrollability, danger, and meaning of thoughts (e.g. ?My worrying is uncontrollable; if I think bad thoughts I will act badly; some thoughts will make me go insane?). These metacognitions contribute to the extension and fixation on negative thinking.

In summary, thinking styles apart from the content of negative automatic thoughts and standard schemas are important in the development of psychological disorder. The focus is on longer chains of conceptual activity in the form of worry and rumination and strategies of voluntary allocation of attention to threat. These thinking styles emerge from a distinct system of metacognitive beliefs (Wells and Matthews, 1994; Wells, 2000). The negative automaticthoughts of CBT are seen merely as triggers for the true pathological processes (the CAS), and negative beliefs such as ?I?m a failure, I?m vulnerable? are the trigger, products or content of the CAS and not the cause of disorder.


Principles of metacognitive therapy
MCT presents the idea that treatment should be focused at the metacognitive level without the need to challenge the content of negative automatic thoughts or standard schemas. MCT
presents a therapeutic principle that patients need to know both what to do in responseto threat and negative thoughts (i.e. reduce the CAS); and also how best to do it. More
specifically, they need to strengthen flexibility and skills for the regulation of extended thinking.Metacognitive programs or ?how-to? knowledge are shaped through experiencing different
types of relationships with cognition and through manipulating cognitive processes such as the control of attention and worry. MCT therefore incorporates techniques such as attention
training (Wells, 1990), detached mindfulness (Wells and Matthews, 1994; Wells, 2005) and situational attentional refocusing (Wells and Papageorgiou, 1998) to modify and develop the
necessary procedural or ?how to? (i.e. experiential) metacognitions. WhilstMCT is based on the principle that it is beneficial to control thinking, it differentiates
between helpful and unhelpful instances of control. Specifically, it is beneficial to suspend the CAS, but it is often unhelpful to try to remove the content of thoughts from consciousness
(suppression). For example, a patient with generalized anxiety reported that he tried to suppress all health-related ideas since these triggeredworry. This form of control backfired and increased
his preoccupation with themes of illness. When it was successful it was still a problem because it prevented him discovering that worrying was harmless and could not lead to
mental breakdown. His control strategy was inefficient and did not allow him to develop alternative ways of experiencing thoughts or modify his metacognitive beliefs about their
significance.
In MCT the therapist asked him to ban suppressing the content of thoughts, to allow any intrusive thought about health to remain in consciousness, and to postpone any
subsequent worrying that was attached to it. In this way the patient learned to distinguish between the content of consciousness and regulation of the responses to that content.
The therapist used worry postponement experiments and subsequently worry enhancement experiments to challenge negative and positive metacognitive beliefs about the consequences of
worrying.
The MCT therapist works on metacognitive beliefs, such as the belief that thoughts cannot be controlled and the belief in their importance and danger. The therapist challenges
positive beliefs that give rise to unhelpful brooding in the form of worry and rumination and threat-focused attentional processing styles. Techniques from standard CBT can be used,
such as questioning the evidence and behavioural experiments, but they are targeted at the metacognitive belief level rather than the cognitive level. For example, in the metacognitive
treatment of post-traumatic stress (e.g. Wells and Sembi, 2004) the therapist questions the advantages of ruminating about and going over the memory of trauma, and also runs