Core intervention: Metacognitive therapy

What is metacognitive therapy?

The term "metacognitive" literally means "thinking about thinking" and refers to understanding one's own thinking processes. Metacognitive therapy focuses on the positive and negative beliefs that someone holds about their thinking. For example, beliefs like "I always have to be mentally prepared, or else things will go wrong" or "If I worry too much, I'll lose control." Metacognitive therapy differs from traditional cognitive-behavioral therapy in that it pays less attention to the content of thinking and more to the ideas about thinking itself. The ultimate goal is to have helpful beliefs about one's own thinking.

When is metacognitive therapy used?

Metacognitive therapy is often used for generalized anxiety disorder (GAD), also known as excessive worry disorder, but it has also been proven effective for depression and obsessive-compulsive disorder (OCD). Metacognitive therapy is used when someone has strong unhelpful beliefs about their thinking. An example of a negative metacognition is "worrying is dangerous." The intervention aims to critically examine these beliefs about worrying and invite oneself to view worrying in a different, more nuanced way.

3. You can use the following prompts for this:

• What is the first thing that comes to mind when you start worrying?
• What comes to mind after that?
• How do you feel when you think that way?
• When you have that feeling, what do you think?
• Do you think anything bad could happen if the worries don't stop?
• What is the worst thing that could happen if you don't stop worrying?
• Are you able to stop worrying?
• What do you think about the worrying?
• Do you ever worry about the worrying itself?
• Are there any positive aspects to worrying?
• Do you ever avoid anything to prevent yourself from worrying? Why?
• Are there things you do to prevent or reduce worrying? Why?
• When the worrying starts, how do you deal with it? How do you try to reduce or prevent it?
• Have you ever tried not to worry? What do you do then?

4. Once the metacognitions have been identified, you can choose one of the exercises below to change the beliefs. Some exercises can be done together during a treatment session, while others can be assigned for the client to do at home. You can plan this through the portal or use the app's calendar to schedule it for your client. Give the exercise a clear title and description. Select the date and time, and set a notification so that your client receives a reminder when it's time for the exercise.

Exercises to change beliefs about worrying:

Cognitive techniques to examine and challenge negative metacognitions or perceived dangers:

• Socratic dialogue: Use this technique to explore beliefs about the uncontrollability of worrying. Use a specific situation that triggered worrying.
• Thought record: Use this technique to identify situations that provoke anxiety and the activated cognitions. You can use the Thought record in NiceDay and fill it out during or after the session.
• Worry postponement experiment: With this technique, assess whether worrying can be postponed to test the manageability and controllability of worrying. Ask your client to note down worry topics in the diary in NiceDay. Propose to your client to postpone worrying until a later time, for example, 7:00 PM in the evening. Make clear agreements about the maximum time for worrying (e.g., half an hour) (💡 set a notification).
• Pros and cons: By discussing evidence for and against, you can explore the dangers of worrying together.
• Dissonance technique: Refer to the Metacognitive Model to show both positive and negative cognitions to your client. Discuss how it is possible for positive metacognitions to have negative consequences.
   

Behavioral techniques to test negative metacognitions or perceived dangers:

• Scheduled worrying: This technique aims to examine whether the anticipated dangers come true. Delay worrying until a set time and encourage your client to worry as much as possible during that time.
• Spontaneous worrying: This involves worrying without a specific scheduled time. When worrying arises spontaneously, ask your client to worry as much as possible.
• Mini-research: Your client asks other people how they worry and their thoughts on worrying, worriers, and the dangers of worrying. Also, inquire about how others deal with worrying.
   

Cognitive techniques to examine and challenge positive metacognitions:

• Pros and cons: By discussing evidence for and against, you can make the beliefs more balanced. For example, ask about situations in the past where there was no worrying and how they turned out.
• Retrospective mismatch strategy: Examine which worrying predictions from the past have come true.
   

Behavioral techniques to examine and challenge positive cognitions:

• Prospective mismatch strategy: Make a prediction based on worrying and then investigate whether it came true.
• High vs. low worrying experiment: This technique aims to examine whether worrying leads to more positive events or not. Ask your client to worry as much as possible during one half of the week and as little as possible during the other half. This way, you can explore whether the positive metacognitions actually result in fewer negative events.

Attachment 1. Metacognitive Model Wells

Sources:

1. Keijsers, G. P. J., Van Minnen, A., Verbraak, M., Hoogduin, C. A. L. & Emmelkamp, P., (2017). Protocollaire behandelingen voor volwassenen met psychische klachten. Boom.
2. Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: a systematic review and meta-analysis. Frontiers in psychology, 9, 2211.
3. Van Der Heiden, C. (2012). Cognitieve gedragstherapie voor de gegeneraliseerde angststoornis: een literatuuroverzicht en een gevalsbeschrijving. DTH-Kwartaalschrift voor Directieve Therapieen Hypnose, 32(1), 14.
4. Melchior, K. & Van Der Heiden, C. (2019). Metacognitieve therapie voor de obsessieve-compulsieve stoornis: Theorie, behandeling en implicaties voor de praktijk. Tijdschrift voor gedragstherapie & cognitieve therapie, 4.