Metacognitive Therapy for Anxiety – Everything You Need To Know


People with anxiety worry about many different things, from their job, exams, families, relationships, finances, health, and the worry itself. Persistent worry, however, leads to symptoms like stress, tension, nervousness, edginess, irritability, difficulty concentrating, insomnia, and muscle aches. 

Since worrying is the core of anxiety disorders, Metacognitive therapy treats anxiety by reducing worry in 8-10 sessions. The content of the worry is not important, but meta-worry and metacognitive beliefs about worry have to be changed for permanent recovery.

Metacognitive therapy (MCT) is a different approach from other treatments because it doesn’t address the content of anxious thoughts and feelings directly. The reason why MCT is very effective in treating emotional disorders like anxiety is because of the theory of emotional self-regulation.

Anxious feelings are naturally very brief. But the amount of time spent worrying is what maintains anxiety. Once you learn to reduce worry, you can expect anxious feelings and symptoms to fade by themselves. MCT teaches you how to reduce worry.

Wells’ metacognitive model of generalized anxiety disorder

The metacognitive model of emotional disorders (also called the Metacognitive Control System Model), was developed by clinical psychologist and professor Adrain Wells from Manchester University.

According to Wells’ metacognitive model of anxiety disorder, the mind is involved in constant self-regulation and usually deals with negative thoughts, feelings, and disappointments on its own. Worrying, along with other unhelpful coping strategies, however, interferes with this process and prolongs anxiety (1).

The mind has a natural ability to regulate negative feelings and thoughts. But that process depends on whether we worry about negative thoughts or whether we leave them alone.

Unhelpful coping strategies that maintain anxiety

People suffering from anxiety disorders like generalized anxiety disorder, OCD, and panic disorder use some or all of these strategies to manage their emotions. These are part of the cognitive attentional syndrome, CAS:

  • Worry
  • Worry about worrying
  • Avoid things, people, and situations that trigger anxiety
  • Monitor for threats internally (looking for signs of anxiety and panic) as well as externally (dangerous and triggering situations)
  • Suppress anxious thoughts by trying not to think about them or make their mind go “blank”
  • Seek reassurance from family and friends, or seek information online
  • Numb or try to calm themselves through alcohol and substances
  • Use distractions like watching too much tv or keeping themselves busy to avoid feelings of anxiety

Anxiety is is maintained by the CAS. Removing CAS will lead to improvement

Example of the metacognitive model of generalized anxiety disorder:

A person suffering from generalized anxiety disorder gets triggered by thoughts like “What if…?”.

“What if I lose my job? How can I pay rent and provide for my family?”

“What if I never succeed in life?”

These types of thoughts are called trigger thoughts

Because of wanting to find solutions, he then starts to worry about his trigger thoughts. He believes that

If I worry, I can anticipate and avoid problems, which is a metacognitive belief.

A metacognitive belief is a belief about how we think. For example, believing that worrying helps prepare for future problems is a positive metacognitive belief.

Because of his metacognitive belief, he responds to his trigger thought, “What if I lose my job?” by worrying about all the possible outcomes (also called type 1 worry):

 “I won’t be able to provide for my family. We have to sell the house. It will be hard to find a place to live….”

At some point during this worry process, physical symptoms like anxiety, tension, restlessness, and feeling on edge appear. 

Because of these symptoms, negative metacognitive beliefs about the uncontrollability and danger of worry get activated: 

My worries have taken control of me (uncontrollability belief)

 I could go crazy with worry (belief about danger).

 Negative metacognitive beliefs activate meta-worry, which is worry about worry. At this point, it gets harder to find a solution to the problem, which was the point of worrying in the first place.

When a person with anxiety no longer believes that he can stop worrying, he relies on other coping strategies like avoidance and reassurance-seeking.

Unfortunately, these strategies backfire and maintain his feelings of anxiety and strengthen his metacognitive beliefs:

 I can’t control worrying. I am going to lose my mind. 

Strengthened metacognitive beliefs lead to many more worry episodes in the future and with that, more coping strategies to stop anxiety. This is how generalized anxiety disorder is maintained according to MCT (2)

Worry about worry is called meta-worry, or type 2 worry: “I am losing control,” “I am going crazy”, I am harming my body”. 


How does MCT treat anxiety

Since CAS and metacognitive beliefs contribute to anxiety, Metacognitive therapy’s goal is to:

  1. Reduce worry that keep the anxiety going
  2. Challenge the metacognitive beliefs that make people believe that worry is harmful and out of their control (2) (3).  
  3. Eliminate unhelpful coping behaviors like avoidance

Does MCT for anxiety work?

Several published studies have tested the effects of MCT, which is recommended as an evidence-based treatment option for anxiety in the UK.

MCT has proven to be very effective and fast for treating anxiety disorders, including Generalized anxiety disorder, panic disorder, and social anxiety disorder. Read this post to learn about how effective MCT is for anxiety and this post that compares MCT to other treaments for anxiety.

What can you expect from treatment with MCT?

  • In therapy, the goal is to experience that you can fully control worry
  • learn the difference between having anxious thoughts and worrying about anxious thoughts
  • learn that it is impossible to lose control over yourself through worrying

Where can I try MCT?

It is very important that you seek an MCT-I certified and experienced therapist to help you overcome anxiety. You can start here.

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  1. Wells, Adrian & Matthews, Gerald. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy. 34. 881-888. 10.1016/S0005-7967(96)00050-2.
  2. Wells A (2008). Metacognitive Therapy for Anxiety and Depression: New York: Guilford Press
  3. Wells, A., Nordahl, H. (2020) Personal communication, Copenhagen
  4. Photo by Aleks Marinkovic – Unsplash
  5. Photo by Sigmund – Unsplash

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