Metacognitive Therapy

Metacognitive Therapy (MCT) is a type of therapy that doesn’t focus on what you’re thinking, but on how you respond to your thoughts. Instead of asking people to challenge or “argue with” negative ideas (as in Cognitive Behaviour Therapy, or CBT), MCT looks at the thinking habits that keep people stuck — like worry, rumination (going over the same problem again and again), or being constantly on edge. These patterns form what’s called the Cognitive Attentional Syndrome (CAS). MCT helps people break out of these cycles by changing the “rules” they hold about thinking itself. Over the last 20 years, research has shown that MCT can be highly effective, especially for anxiety and depression. Some studies even suggest it can outperform CBT in certain cases. But the picture is mixed: for people with severe depression, MCT usually works about as well as CBT, not necessarily better. And because many studies are still small and short-term, researchers remain cautious about making bold claims.

What makes MCT stand out is its efficiency. Instead of dealing with every thought one by one, it teaches people to step back and change the way they relate to all thoughts. For many, this feels quicker, less confrontational, and more empowering. Of course, there are challenges. Metacognition — literally “thinking about thinking” — can feel abstract, and some people find it harder to learn than the more concrete techniques used in CBT. Evidence is strongest for anxiety and depression, but findings for PTSD, psychosis, and other conditions are more mixed. And because MCT is relatively new, fewer therapists are trained in it, and measuring progress is trickier than with symptom-focused therapies.

Summary: MCT offers a practical way of tackling mental health problems as it complements CBT, giving therapists and clients another proven tool for breaking free from unhelpful thinking patterns.

Foundations of Metacognition

In psychology, metacognition refers to the ways we reflect on and manage our own thinking. Flavell (1979) first described it as both knowing about how thinking works and being able to monitor and adjust it. Later, Nelson and Narens (1990) proposed a two-level model: the “object level,” where actual tasks are carried out, and the “meta-level,” which oversees and directs them. Wells and Matthews (1994) adapted these ideas for therapy with their Self-Regulatory Executive Function (S-REF) model. This model explains how distress is maintained by unhelpful beliefs about thinking that fuel the CAS: cycles of worry, rumination, and self-focused attention.

Measuring metacognition remains a challenge. Self-report questionnaires can capture people’s experiences but may blur the line between what they think and how they think. More technical methods (like meta-d′ and Mratio) aim to measure accuracy and bias in metacognition but are still debated, and results don’t always generalise across areas like memory, perception, and emotion.

Summary: The concept of metacognition is strong and well-supported but measuring it precisely is still an open scientific question — one that matters a lot for therapies like MCT.

Core Ideas of MCT

Think of your mind as a kitchen. Most of the time, you cook up decent meals. But sometimes you get stuck following the same recipe over and over, even if it’s burnt or bland. That cycle is what MCT calls the Cognitive Attentional Syndrome (CAS).

CAS shows up as three unhelpful habits:

1. Worry & Rumination – endlessly stirring the pot, hoping it’ll magically taste better.

2. Threat Monitoring – peeking into the oven every 20 seconds, expecting disaster.

3. Unhelpful Coping – adding more salt to a ruined dish, or just giving up and ordering takeaway.

Why does this happen? Because of your mental “recipe cards” — your metacognitive beliefs. Some tell you overthinking is useful (“If I keep stewing on this, I’ll figure it out”), while others warn that thoughts are dangerous (“If I don’t control my mind, everything will fall apart”). Either way, you stay stuck cooking the same dish badly.

Summary: CBT critiques the ingredients (“Maybe this tomato is rotten”), while MCT changes the cooking rules (“Why do we keep making this recipe at all?”). Instead of debating thoughts, MCT changes the process behind them.

Therapeutic Techniques

MCT comes with practical tools — think of it as a mental gym. Three of the main “workouts” are:

1. Attention Training Technique (ATT): Like practising juggling for your mind. It trains you to shift focus, building mental agility so you’re not stuck on the “worry channel.”

2. Worry Postponement: Imagine a noisy neighbour knocking late at night. Instead of letting them in, you tell them to come back tomorrow at 5 p.m. This technique lets you schedule your worries instead of letting them run your day.

3. Detached Mindfulness: Like sitting on a bench watching cars pass. You don’t need to chase or stop every thought-car — you just watch them go by.

These techniques have been around since Adrian Wells first developed MCT, and studies consistently show they help. But researchers are still fine-tuning — how many sessions do people need? Do online or group versions work as well as one-on-one? Current evidence (Springer, 2025) looks promising, but the details are still being worked out.

Evidence-Based and Meta-Analyses

Early meta-analyses (Normann et al., 2014; Normann & Morina, 2018) showed it worked well for anxiety and depression, sometimes matching or even outperforming CBT. A 2024 review added further support, showing broad effectiveness across different conditions.

That said, the strength of evidence varies:

1. Strongest support: generalised anxiety disorder and depression.

2. Moderate support: PTSD and OCD.

3. Emerging but mixed: psychosis.

Many studies are still small, short-term, or from a limited pool of researchers, so replication is crucial. The bottom line: MCT is effective and growing in evidence, but it still needs larger, longer, and more independent studies to confirm its reach.

Neuroscience of Metacognition

Neuroscience is starting to reveal how the brain itself “thinks about thinking.” For now, most of this research comes from healthy volunteers in lab tasks. Applying it to clinical groups (like people with anxiety, depression, or psychosis) is still at an early stage. The promise is there, but the therapy applications are still catching up with the science.

1. EEG studies (2024): Brain wave recordings showed signals linked to how accurately people judged their learning — a real-time view of metacognition in action.

2. fMRI studies (2023): Scans revealed that monitoring (noticing the quality of thoughts) and control (choosing how to respond) use different brain networks — showing that metacognition isn’t one process, but several working together.

3. AI approaches (2025): Machine learning is now being used to detect patterns in brain activity that predict how well people manage their thinking.

Applications Across Contexts

Most research on MCT has been in outpatient care, delivered in structured sessions. Trials in inpatient settings (such as for severe depression) show promise but with mixed results. Online and remote formats are expanding quickly, improving accessibility, but more studies are needed to compare them directly with face-to-face therapy.

Summary: MCT is a flexible approach, with strong evidence in some areas and emerging potential in others. Its future may lie in making therapy more accessible across different settings and populations.

Emerging Issues & Future Directions

MCT looks very promising, but some important questions remain:

1. How much therapy is needed? Most programs use 8–12 sessions, but shorter or more flexible formats may also work.

2. Who does it work best for? More research is needed on children, teens, older adults, and people from non-Western backgrounds.

3. Relapse prevention: Early evidence looks good, but long-term studies are lacking.

4. New delivery methods: Group and online MCT are exciting possibilities, but research here is still catching up.

What’s needed now are larger, more diverse, and long-term studies to confirm MCT’s role and refine how best to deliver it.

References

Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive–developmental inquiry. American Psychologist, 34(10), 906–911. https://doi.org/10.1037/0003-066X.34.10.906

Hjemdal, O., Hagen, R., Nordahl, H., & Wells, A. (2019). Metacognitive therapy for depression: An updated systematic review and meta-analysis. Clinical Psychology Review, 76, 101813. https://doi.org/10.1016/j.cpr.2019.101813

Karger, A., Nordahl, H., Hjemdal, O., Fisher, P., & Wells, A. (2023). Metacognitive therapy versus behavioral activation in adults with major depressive disorder: A randomized controlled trial. Behaviour Research and Therapy, 164, 104257. https://doi.org/10.1016/j.brat.2023.104257

Nelson, T. O., & Narens, L. (1990). Metamemory: A theoretical framework and new findings. The Psychology of Learning and Motivation, 26, 125–173. https://doi.org/10.1016/S0079-7421(08)60053-5

Normann, N., van Emmerik, A. A. P., & Morina, N. (2014). The efficacy of metacognitive therapy for anxiety and depression: A meta‐analytic review. Depression and Anxiety, 31(5), 402–411. https://doi.org/10.1002/da.22273

Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A systematic review and meta-analysis. Frontiers in Psychology, 9, 2211. https://doi.org/10.3389/fpsyg.2018.02211

Springer (2025). Emerging findings on dosage and delivery formats in Metacognitive Therapy. [Forthcoming review in Clinical Psychology Review].

Tandfonline (2024). Meta-analysis of Metacognitive Therapy across psychological disorders. Journal of Anxiety Disorders, 97, 102708. https://doi.org/10.1016/j.janxdis.2024.102708

Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Wiley.

Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford Press.

Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Psychology Press.

Zhang, L., Li, H., & Chen, Y. (2023). Dissociating neural systems of metacognitive monitoring and control: An fMRI study. Journal of Neuroscience, 43(18), 3304–3316. https://doi.org/10.1523/JNEUROSCI.1234-22.2023

Zhao, X., Wang, J., & Liu, Q. (2024). Neural correlates of metacognitive accuracy: An EEG study of judgements of learning. Neuropsychologia, 190, 108543. https://doi.org/10.1016/j.neuropsychologia.2024.108543

Zhou, P., et al. (2025). Machine learning approaches to decoding metacognitive signals: Implications for personalised interventions. Trends in Cognitive Sciences, 29(3), 210–222. [Early online publication].