A new method of therapy called Metacognitive Therapy (MCT) is spreading quickly in Europe but not yet in the US. Early research shows that it’s more effective than Cognitive Behavioral Therapy (CBT), which for decades has been the gold standard of evidence-based therapy.
- In a large study comparing MCT and CBT for depression, metacognitive therapy led to recovery for 74% of people compared to 56% for cognitive behavioral therapy.
- In a long-term study of people with anxiety, 57% of people who had received MCT maintained recovery versus 38% for CBT nine years down the road.
In addition to anxiety and depression, MCT is also being used to treat disordered eating, OCD, trauma, relationship difficulties, and general life stress.
I give a snapshot of MCT’s approach here, and there’s a list of resources at the bottom of the page for those who want more. These tools are accessible for clients and therapists alike.
What is Metacognitive Therapy?
MCT is based on the idea that the suffering associated with anxiety, depression, and other mental health issues is generated and sustained by overthinking. The aim of therapy is to limit the amount of time people spend doing it.
Overthinking shows up as rumination on questions like:
Why did I…?
Why can’t I…?
and
What if…?
Dwelling on “Why” questions tends to lead to depressed mood and “What if?” questions tend to fuel anxiety.
MCT starts by addressing the beliefs people have about their thinking (that’s the “meta” part). Overthinkers hold two beliefs that maintain their ruminating:
- They can’t control their ruminating and/or
- Their ruminating is useful to them (to keep them safe or to solve problems).
MCT sets up behavioral experiments to show people that they can control their ruminating and that they don’t need it. Here’s what that looks like…
MCT versus CBT
A key idea in MCT is that there’s a distinction between a trigger thought (a thought that leads us to ruminate) and how we go to work on it. We don’t often see that these are separate things, but if we investigate a bit, we’ll discover that we don’t have control over the arising of thoughts, but we do have control over whether we go to work on them.
Go to work on means engaging with a trigger thought in any way at all. That includes what we may think of as problem-solving. But solving problems is best done by proactively approaching a problem with a relaxed and creative mindset, which is not the state of mind we’re in when a trigger thought tips us into rumination.
CBT trains a person to analyze and correct their “distorted” thoughts — for instance, by re-framing black-and-white thinking or catastrophizing, or talking back to the inner critic. MCT instead zeroes in on dramatically limiting the amount of time a person works on their trigger thoughts by teaching them to just let their thoughts be there.
Because CBT is focused on confronting cognitive distortions, it doesn’t have much to offer when it comes to things that are basically true. Imagine the person who is distressed about limited finances, a bad relationship, a difficult diagnosis, a high-stakes job — cognitive distortions are not the main cause of their anxiety or low mood. A lot of situations are objectively hard.
Whether we’re in the grips of a distorted thought or we’re in a genuinely tough situation, it turns out if we spend less of our free time dwelling on our thoughts, we feel better. And we’re more likely to take action to change our circumstances or simply get on with enjoying the rest of our lives. Ruminating keeps us frozen in place because it serves as a replacement for effective action.
So, how do we just let our thoughts be there and not go to work on them?
When people first hear about MCT, they have questions about what constitutes overthinking and how to let thoughts lie there. You’ll get a lot of questions answered just by listening to one of the podcasts linked to below. I offer a glimpse here of their process…
How MCT works
By asking you to look at your beliefs about your thinking spells. Do you feel you have the power to stop engaging with your thoughts? Do you feel like your rumination is useful to you? If so, how? Are you afraid that something bad will happen if you stop ruminating?
By asking you to become more aware of your rumination. Do you struggle with low mood but you don’t think you ruminate? MCT says that people who are anxious usually know they’re ruminating because their worried thoughts are front and center in their awareness. People who deal with depression may not be aware that they ruminate — they may just feel bad about themselves. Some people who are anxious may consider their rumination to be important analytical thinking. Either way, often people need to learn first to identify their rumination. Here’s a good article on identifying rumination.
MCT’s behavioral experiments are designed to show us that we are able to control our rumination and that our rumination is not essential to our well-being. You don’t have to take that on faith, you get to try it out and see.
By getting a good feel for the distinction between a thought arising and going to work on it. MCT offers several metaphors to try out:
- Your phone is ringing from someone you don’t want to talk to. You don’t control if the phone rings, but you do control whether you answer it. The challenge is to tolerate the noise of it ringing.
- You have a mosquito bite that itches but you’re refraining from scratching it.
- Picture your mind as a busy train station, all the thoughts coming and going like trains. Most of the thoughts we have in a day arrive and leave fairly quickly. But when a trigger thought comes in, that train stays in the station with the doors open inviting us to get on board. The task is to let the train just sit there while we stay standing on the platform.
The challenge in each of these metaphors is to learn to not engage. Not engaging means: don’t push the thought away, don’t comment on it, don’t do anything with it. Just let it lie there as part of the landscape of your experience in that moment. Here’s an article with more about how to do this.
MCT calls itself “lazy therapy” because they want people to do much less than they normally do with their thoughts. They call this approach detached mindfulness — you’re aware of thoughts, feelings, and memories arising but you don’t follow them, analyze them, or get involved with them.
It’s not important to get exactly right the line between a thought arising and going to work on it. It’s okay that the line is fuzzy sometimes. The main thing is to practice stopping yourself from engaging with a sticky thought. Even if you got on the thought train and it left the station, you can still get off at the next stop.
By trying out behavioral experiments to limit rumination. Here are three:
- Schedule your thinking. Pick a time in the day when you’ll make room for your rumination, maybe 15-20 minutes. It needs to be scheduled and timed. When trigger thoughts come up at other times of the day, say to yourself, “save that for the 3pm thinking session.” Ideally you wouldn’t schedule this for right before bedtime. When your appointed time arrives, do what you usually have done — let your mind go to work on your thoughts as much as you want to.
- Write on your window. Get an erasable marker and write one of your trigger thoughts on your window. Notice how you can focus on the words on the window and you can focus beyond them at the view. Looking through the thought at the view beyond is where we want to get with these thoughts. They are still there, but we aren’t focused on them.
- Exercise your “attentional flexibility.” Sound is apparently the most effective sense to practice with. Wherever you are, listen out for two or three sounds and then practice for several minutes moving your attention from one sound to another at will, as well as focusing wide and letting all the sounds move through you equally. Doing this every day for a few weeks will increase your attentional flexibility which will help you not get glued to sticky thoughts when they arise.
A significant part of MCT is helping a person trouble-shoot these experiments, so if you get stuck, you might like to work with another person who knows this method. The website of the MCT Institute offers online therapy anywhere in the world. I also work with people on how to stop ruminating — feel free to reach out to me. Learning to identify and stop my own rumination has made a huge difference in my life.
To get a more real-time flavor of how MCT works, I highly recommend listening to one of the two podcasts I link to below.
MCT Resources
The website of the MCT Institute has lots of resources.
The Clearer Thinking podcast with psychologist Pia Callesen who has just written a book about MCT for popular audiences.
The Minds & Mics podcast with Pia Callesen.
A 5-minute video interview with Adrien Wells, the psychologist who developed MCT.
A longer video interview with Pia Callesen.
Live More, Think Less: Overcoming Depression and Sadness with Metacognitive Therapy, the new book by Pia Callesen written for a popular audience.
Metacognitive Therapy for Anxiety and Depression, the clinical guide by MCT’s founding psychologist Adrien Wells.
An article in Nature magazine on a clinical trial showing MCT outperforms CBT for depression. (Googling will bring up many more MCT trials from the past five years.)
