Short Answer… More Options –
We have over 50,000 thoughts per day. Which ones should we pay attention to and which ones should we view as background noise? Which ones do we act upon and which ones do we ignore or laugh about? How do we determine whether our responses to our thoughts are helping us in the long run? The answers to those types of questions reveal some of our metabeliefs – our thoughts about our thoughts. Metacognitive therapy (MCT) focuses on identifying and changing specific cognitive patterns that are maintaining unwanted symptoms.
MCT is a type of cognitive behavioral therapy which researchers have found to be effective for treating OCD. Although there is less evidence supporting its efficacy than there is for ERP, it appears to be roughly equal in its impact. I’m not interested in debating the merits of one approach over another; I am simply glad to have more evidence based options to help my clients. And not only is it supported by rigorous research, I’ve personally witnessed positive impacts of MCT for some of my clients with OCD over the years. Below are a couple examples of unique contributions of MCT.
MCT provides an interesting conceptualization of OCD, especially in regards to the role of obsessions. As it turns out, roughly 67% of people report experiencing obsessions – thoughts, images, or impulses that are intrusive, repetitive, and themed. Obsessive thinking is fairly common. However, only about 2% of people have OCD. Why is that? The MCT model suggests that people with OCD have different metabeliefs, which play a role in how they react to the obsessions. MCT researchers also propose that those with OCD experience more intense emotional responses to obsessions, which leads to strengthening metabeliefs surrounding obsessions. In other words, the strong feelings of fear, disgust, etc can be a signal to pay more attention to the obsessive thought or believe it is true. For example, a person may implicitly think, “My fear about the obsession means that I need to do something to neutralize it.” Or, “Thinking about committing a sin, means I did it.” So, one of the goals in MCT is learn to recognize the role of these mental processes using a strategy referred to as Detached Mindfulness, and gradually come to accept that obsessive thoughts are a simply part of human existence. Even before I knew anything about MCT, I was aware that those clients who developed a different mental relationship with their obsessions got better (or was it vice versa?). MCT makes that process more explicit.
MCT also offers some slightly different approaches for exposure based interventions. The technique used in MCT is referred to as Exposure and Response Commission. In addition to habituating to the situation or event, the goal is to change beliefs about the value and necessity of the rituals. I could ask a client, “What will or could happen if you do not engage in the ritual?” The answer to that question will reveal metacognitive beliefs that can be directly tested using exposure as part of a behavioral experiment. So instead of focusing on watching subjective units of distress (SUDS) come down over time as the metric, we focus instead on observing changes to the credibility of beliefs and the value or necessity of the ritual. I can specifically recall a client who was unwilling to change his hand washing rituals due to fear of contracting HIV. However, he was willing to experiment with thinking different thoughts to himself while still ritualistically washing his hands. He quickly concluded that his hand washing ritual not as valuable. His success with that process was a turning point in his therapy, and eventually led him to have more courage to make significant changes.
In my humble opinion, MCT is not a replacement for ERP, nor is it a competitor. Instead, I view MCT is a way to shift the focus more towards the mental or cognitive aspects of recovery the process. For some clients, this is more acceptable, and therefore works better.
P.S. Yes, the lines in the Muller-Lyer Illusion graphic are exactly the same size.
Jim Carter, Ph.D. Specialty Behavioral Health
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