Inside the therapy room: What to expect over the course of MCT treatment

Inside the therapy room

Metacognitive therapy is a structured, goal-oriented form of therapy with measurable progress. Each session builds on the last, creating a clear roadmap for your progress. Your MCT-therapist will tailor the treatment plan to your specific situation and needs.

Those who’ve been in therapy before tend to describe metacognitive therapy as hands-on and actionable. Unlike traditional therapies that delve into the content of your thoughts, or past experiences, or that use strategies to calm down your nervous system, MCT targets the underlying processes that sustain mental distress. In that way, metacognitive therapy offers a refreshingly different approach from other therapies like CBT and talk therapy.

Treatment with metacognitive therapy typically includes some (or all) of the following steps:

Step 1: Exploring what's keeping your distress going

You'll start by talking with your therapist about the problem you're experiencing. Your therapist will ask you questions about a recent worry or anxiety episode that's typical of the problem you want to address in therapy, to get a clear picture of what you're struggling with.

This involves identifying specific beliefs, thoughts, triggers, and behaviors that fuel your emotional turmoil.

Your therapist will ask questions about what started the episode, and about your thoughts, symptoms, feelings, coping strategies, and your beliefs about how to deal with them. MCT therapists tend to ask different questions than a traditional therapist would ask, questions you might not have been asked before.

By understanding how these elements work together, the therapist can make a model of what's causing and maintaining your distress (this is called a 'case conceptualization'), and create a personalized treatment plan. This model will show how your metacognitive beliefs and the Cognitive Attentional Syndrome (CAS) is feeding your mental distress.

Step 2. Your personal working model‍ shows you how to stop the spirals of mental distress

The next step is to go through your personal metacognitive model together with your therapist to ensure it makes sense to you. This is a framework that is adapted to you, and clearly describes how your current thinking and behavior patterns are responsible for maintaining your emotional distress. The therapist uses guided discovery and practical examples to help you see how your thoughts and behaviors maintain your negative emotions.

You'll soon see how a problem arises not from the thoughts, feelings and symptoms themselves, but rather from how you respond to these thoughts. For example, the problem might be that you spend hours worrying about a thought, and not the fact that you had a negative thought.

Once you grasp the principles of how triggers will only spiral into prolonged anxiety, stress and depression because of your response to them, you'll begin to practice recognizing the triggers that start your rumination cycles, and choose not to respond to them. This is an important foundation for the next step.

Step 3: Relating differently to your thoughts by applying detached mindfulness

Your therapist will help you discover how your response to your thoughts, feelings and symptoms affect their persistence and impact, and help you discover that you have a choice in how you respond to them.

For example, you can choose to leave a worry-thought be, instead of responding with prolonged worry, thought suppression, or avoidance. Choosing not to respond to a trigger thought while being aware of it, is called Detached Mindfulness. This is a key element of metacognitive therapy.

Most people need to experience this in a guided setting before they understand it, so you can expect to spend a bit of time in the first sessions on practical exercises and homework that show you how you can relate more passively to your triggers.

By being more passive with your thoughts and inner experiences, you'll notice that they are just passing events in your mind that can't harm you.

Step 4: Challenging your unhelpful metacognitive beliefs

Your beliefs about your thoughts (your metacognitive beliefs) guide how you ultimately respond to them. If you believe it’s necessary to keep thinking about your depression in order to find a solution, you'll keep ruminating on your problems. If you believe that worrying will help you cope, you'll keep worrying. If you believe that you need to control certain thoughts or that thoughts can harm you, you'll keep trying to control and suppress your thoughts.

And if you believe you can't stop your worry/overthinking, then you're less likely to try stopping it. So your beliefs about your thoughts and how to respond to them are the most important maintaining factor of mental distress.

In MCT, a significant focus is on challenging and critically evaluating these beliefs with dialogue, exercises and homework. You might discover that many of the things that you used to believe about your mind is wrong, and that you can choose more helpful ways to cope with triggers.

Step 5: Practice new ways of relating to triggers

Your therapist will assign homework that challenges you to respond to your triggers differently in your everyday life. This homework helps you rediscover your control over you thinking processes, and your minds natural ability to self-regulate. Of course, you'll probably run into some obstacles here and there. But with each attempt you’ll gain a new experience. 

Together with your therapist you’ll go through the things that went well, and troubleshoot what you found challenging, so you can make the necessary adjustments until you get the hang of it.