Going meta on metacognitive interventions

KEYWORDS:

• Metacognitive therapy
• metacognitive training
• cognitive-behavioral therapy
• third wave of CBT
• metacognitive reflection and insight therapy

1. Cognitive-behavioral therapy (CBT) and further developments

Cognitive-behavioral therapy (CBT) is considered the psychological approach with the most empirical support for virtually all major psychological disorders [1]. Yet, CBT is not undisputed. While its effects are large when compared to waiting list control conditions, they are in the small-to-moderate range when the control condition is care-as-usual and high-quality studies are lacking [2]. This may be one of the reasons the field has witnessed the emergence of new treatments over the last few years. The increasing diversity of psychotherapy in the treatment of psychological disorders is paralleled by lingering concerns about the safety and efficacy of psychopharmacological therapy. This diversification of therapy may allow us to learn more about treatment processes in psychotherapy, which could eventually help improve the development of tailored treatments for a broader range of patients with varying needs and preferences. However, this development is not without challenges and at times has fostered a rivalry between proponents of various treatments. The present editorial comments on a recent debate initiated by Adrian Wells [3–5] regarding whether Metacognitive Therapy is fundamentally different from CBT and what constitutes ‘true’ metacognitive treatment. Before doing this, we must disclose potential conflicts of interest: the first author has developed Metacognitive Training, the second author has developed integrative metacognitive psychotherapy focused on recovery, and the third and fourth authors are advocates of CBT-based interventions.

2. Flavell’s concept of metacognition and how it maps onto Metacognitive Therapy and CBT

Adrian Wells and colleagues have posited [5,6] that Metacognitive Therapy adopts a ‘meta-level’ approach, whereas CBT works at an ‘object level’ (‘treatment clearly operates at the cognitive (object-mode) level since the goal is to reality-test ordinary cognitions’ [4, p. 37]). In other publications [3,4], Wells and colleagues further argue that the label ‘metacognitive’ is inappropriate for other metacognitive interventions, such as Meta-cognitive Therapy for Attention Deficit Hyperactivity Disorder [7] and Metacognitive Training for Psychosis [8]. This begs the question: Is Wells’s version of Metacognitive Therapy fundamentally different from CBT and from other metacognitive interventions, such as Metacognitive Training and Metacognitive Reflection and Insight Therapy (MERIT) [9]? To answer this question, we must consult the primary literature as Wells and colleagues neither coined the term ‘metacognition,’ which dates back to the 1970s [10], nor did they introduce the distinction between the meta-level versus the object level [see 11]. Of note, Wells and colleagues’ Metacognitive Therapy was not the first metacognitive intervention; metacognitive programs began as educational programs in the 1980s. For example, the metacognitive training by Kurtz and Borkowski [12] was targeted at fostering more cautious decision-making in impulsive children.

In his review of the meta-memory theory of Nelson and Narens [11], van Overschelde [13] describes the meta-level and the object level as follows:

object level consists of cognitions, which are often associated with external objects (e.g., that thing I see is a dog), and the metalevel consists of cognitions about object-level cognitions (… e.g., why do I keep thinking about that dog?). (p. 47)

Clearly, if one simply replaces ‘dog’ with ‘negative thoughts,’ it is obvious that CBT also adopts a meta-level perspective by identifying and challenging negative thoughts.

According to Flavell, metacognitive knowledge represents one of the four main components of metacognition. We argue that CBT, like Metacognitive Therapy, teaches metacognitive knowledge to patients (core messages of CBT are (1) thoughts are thoughts and should not be treated as facts [14]; and (2) it is not the situation but rather your interpretation of the situation that determines how you feel and think about it). The same is true for other metacognitive interventions, such as Metacognitive Training for Psychosis (its primary goals are to attenuate overconfidence and encourage the seeking of more information when a decision is momentous) and MERIT. Hence, Wells’ statement that CBT only targets ‘ordinary cognitions’ [4, p. 37] is incorrect.

According to Flavell, the second component of metacognition is metacognitive experience, which is defined as the conscious reflection of cognitive processes (e.g., surprise, relief, or frustration regarding cognitive phenomena such as lapses, intrusions, sudden ideas, etc.). Again, metacognitive experiences are not exclusive to Metacognitive Therapy but are elicited and actively utilized in many cognitive therapies. For example, metacognitive experiences are evoked and examined in CBT when a patient learns about the impossibility of suppressing thoughts during the famous white bear exercise (‘Do not think about a white bear for 1 minute’); they are also used in Metacognitive Training when ‘aha moments’ are experienced by luring individuals into ‘cognitive traps’ to demonstrate the fallibility of human cognition (e.g., high-confident false memories are fostered by showing participants a prototypal scene lacking typical scene-congruent objects, such as a beach with no towels; typically, these missing objects are subsequently falsely remembered). Yet, we agree that Metacognitive Therapy deals with these metacognitive experiences in a more explicit manner than CBT.

We believe that it is counterproductive to overemphasize subtle differences between therapeutic orientations. In fact, many of the techniques of Wells’ Metacognitive Therapy (e.g., demonstrating the dysfunctional consequences of thought suppression and the functional consequences of rumination postponement) are borrowed from existing treatment programs (e.g., CBT, trauma therapy). In turn, mindfulness techniques are increasingly used to enhance cognitive therapies. Instead, we should direct our attention away from broad labels and turn our attention to the most crucial treatment elements. Dismantling studies are necessary to (1) elucidate which processes work effectively for which patients and (2) understand the processes’ positive and negative interactions with other techniques (different elements may exert synergistic effects, whereas others may have no add-on effects because of redundancy). We should also investigate the impact of expectancy effects, particularly when a new technique is portrayed as revolutionary (whether this is true or not (‘snake oil’ marketing)).

In our view, the dispute over what is a ‘true’ metacognitive intervention and whether a metacognitive perspective is superior to a cognitive perspective (as noted above, these differences are hardly defensible) impedes progress in the field. Any ‘narcissism of the little differences,’ as termed by Freud [15], will only weaken evidence-based psychotherapy as a discipline. Indeed, restricting the study of metacognition to a narrow band of highly specific attitudes or beliefs would limit our ability to look at larger links between biological and brain-based activities [16,17].

3. Is everything CBT, then?

It is important to keep in mind that despite the aforementioned similarities, CBT, Metacognitive Therapy, Metacognitive Training, and MERIT have a number of clear differences (e.g., CBT: exposure as a central element, disputation of Beckian emotional biases; Metacognitive Therapy: focus on dysfunctional coping mechanisms, especially worry/rumination and thought suppression; Metacognitive Training: ‘straightening’ disorder-specific cognitive distortions such as overconfidence or jumping to conclusions in psychosis). Applying the same label to all these orientations would create confusion. To be clear, we need to continue scientific debates about which treatment elements are most helpful and which treatment elements are not. Yet, despite conceptual differences, as scientists, we should be united in our efforts to disseminate and refine evidence-based treatments. We should also be happy for every patient who receives an evidence-based treatment, whether or not it is ‘our’ particular approach. Too many patients still do not receive any treatment or the treatment they do receive is ineffective or even potentially harmful (e.g., over-medication or the use of medication alone when psychotherapy or a combination of pharmaco- and psychotherapy is indicated). These practices should be seen as the real enemy.

To conclude, the boundaries between psychotherapeutic approaches are becoming increasingly blurry. Many therapeutic approaches belong to a broader family of psychological interventions (notably CBT). The significance of Metacognitive Therapy lies in its emphasis on metacognitive treatment processes, and we should aim to improve and further develop these processes. However, Metacognitive Therapy clearly does not ‘own’ these processes exclusively. We should be aware that different approaches often have shared change mechanisms and therapeutic techniques. Understanding these commonalities is a good development, one that we as scientists should embrace. Protectionism of terms, techniques, or origins is not helpful. Instead, our efforts should be focused on identifying the processes of change that are associated with specific therapeutic strategies and new ways to improve dissemination.

Declaration of interest

S Moritz developed Metacognitive Training. P Lysaker developed Metacognitive Reflection and Insight Therapy. SG Hofmann and M Hautzinger have published books and articles on cognitive-behavioral therapy. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One reviewer of this manuscript has worked closely with the originator of Metacognitive Therapy. Peer reviewers have no other relevant financial relationships to disclose.

Additional information

Funding

This paper was not funded.