Why Metacognitive Therapy is Probably the Best Mental Health Treatment


What is the difference between those who develop anxiety and depression and those who don’t? 

Imagine if you could learn to handle negative thoughts effectively so that you don’t fall into anxiety, depression, and other mental health problems. That is exactly what you will learn from Metacognitive therapy.

Metacognitive therapy (MCT) is a treatment developed by Adrian Wells at the University of Manchester, UK. It is built on an empirical theory about the mind’s ability to heal itself from upsetting life experiences, thoughts, and feelings. 

According to Professor Wells, thinking styles like worry and rumination can interfere with recovery, and reducing them is a goal of MCT.

What is Metacognitive therapy?

Metacognitive therapy, MCT, is a psychotherapy that helps people reduce dysfunctional thinking styles like rumination and worry, and challenge and change metacognitive beliefs that are thought to contribute to these processes.

Metacognitive therapy, MCT, was developed by Adrian Wells, a British clinical psychologist, and professor at Manchester University (1).

After 25 years of research into mental illness, Wells discovered that a factor beneath mental illness is not grief, accidents, sad feelings, or negative thoughts but how we deal with thoughts.

When we ruminate, worry, suppress thoughts, or distract ourselves from them, we put ourselves at risk of developing greater psychological symptoms. Wells and Matthews (1994) identified a pattern of responses to negative thoughts that they called the Cognitive Attentional Syndrome (CAS) (2). CAS is controlled by biased metacognition which includes knowledge about thoughts. This is why the therapy developed is called Meta-cognitive therapy.

In order to reduce CAS requires working on several levels of the metacognitive system and this will take a therapist about 10 sessions.

. You can read about Detached mindfulness in detail in this post.

AMC model reproduced from Wells, A. (2009) Metacognitive Therapy for Anxiety and Depression. Guilford Press.

How does MCT work?

To understand how MCT works, it is important to look at the interactions that happen in the human mind. According to Wells’s S-REF model of the mind (2), the mind works on three levels.

1) A lower level that is unconscious

2) A middle level that is conscious 

3) An upper level, the metacognitive level

Inspired by Wells & Matthews S-REF model – Wells, A., & Matthews, G. (1996)(2)


What happens at the lower level of the mind?

The lower level of the mind is constantly hit by impulses, thoughts, and feelings. This level is reflexive and automatic, and we can’t control it. We can’t control what kinds of thoughts enter the mind.

The brain produces tens of thousands of thoughts every single day. These thoughts are a mix of positive, negative, and neutral thoughts. We have no influence over thoughts like “I am looking forward to the weekend,” “He is really stupid,” and “I am worthless” They appear unconsciously from the experiences that we have every day. But, they are brief, and they will disappear by themselves (5)


“Everyone has negative thoughts and everyone believes their negative thoughts sometimes. But not everyone develops sustained anxiety, depression, or emotional suffering.” 

Adrian Wells, PhD, Clinical Psychologist and founder of MCT

What happens at the middle level of the mind?

The middle level of the mind is conscious and therefore within our control. At this level, we are able to use different strategies for thoughts and feelings that show up during the day (also called the CAS; which are the unhelpful strategies to cope with thoughts like worry, rumination, threat-monitoring, and thought suppression, etc.)

For example, at this level, we can choose to worry about “He is really stupid,” or we can choose to leave that thought alone. If we choose to worry about it, we will cause the thought to stay in our awareness for a longer time.

When negative thoughts stay in the mind too long, they affect our mood and wellbeing.

The strategies that we choose at the middle level are determined by our metacognitive beliefs at the upper level. 

What is the CAS?

CAS stands for the Cognitive Attentional Syndrome and consists of unhelpful coping strategies. There are four main categories:

1) Rumination 

2) Worry 

3) Threat monitoring (looking for bodily symptoms and potential dangers)

4) Inappropriate coping behaviors (avoiding situations, too much sleep/rest, alcohol, binge eating, procrastinating, etc.)

People with mental illnesses use one or more of these strategies in excess. They ruminate for many hours every day, worry, and check their mood. Often, they also try to numb their thoughts with alcohol, sweets, and distractions.

These strategies are used with good intentions. People ruminate to solve their problems and feel better. Or they worry to be prepared. Unfortunately, they will experience the opposite effect because the CAS backfires, and leave people more depressed, anxious, stressed, and confused.  

What happens at the upper level of the mind?

The upper metacognitive level is stored knowledge in long-term memory. Here, our metacognitive beliefs are stored. Metacognitive beliefs activate the CAS to tackle thoughts, feelings, and impulses that show up.

Metacognitive beliefs

Metacognition means thinking about thinking. Metacognitive beliefs are beliefs that shape what we pay attention to. Whether we pay attention to thoughts, feelings, sensations or the world outside of us. Metacognitive beliefs also decide what strategies we use to handle thoughts and feelings. 

There are two types of metacognitive beliefs, positive and negative.

Positive metacognitive beliefs tell us to think more about negative thoughts and feelings because it is useful.

Examples of positive metacognitive beliefs are

Worrying will help me cope

Rumination will help me understand

Negative metacognitive beliefs tell us that specific thoughts and feelings are harmful. Negative metacognitive beliefs also tell us that we cannot control rumination and worry. 

Examples of negative metacognitive beliefs are

My worrying is uncontrollable

I cannot stop ruminating

Worrying is harmful

It is normal to have both positive and negative metacognitive beliefs. But, according to Wells, negative metacognitive beliefs determine more whether someone develops a mental disorder like anxiety.

If we have negative metacognitive beliefs (“I can’t control ruminations. I am going crazy with all this thinking“), we don’t believe that we have a choice but to ruminate and worry. So we keep ruminating for hours and days. And because rumination creates negative feelings, it becomes tempting to use other unhelpful strategies to cope like, for example, distractions and alcohol. 

Basically, metacognitive beliefs (both positive and negative) lead to unhelpful thinking patterns (ruminating, worrying, suppressing thoughts, analyzing) and other unhelpful strategies (drinking, distracting oneself, withdrawing, picking fights, etc.). 

Wells (5)

What can we learn from the metacognitive model of the mind?

The metacognitive model of the mind (called the S-REF model and later developed as the Metacognitive Control System Model, Wells 2009) emphasizes that worrying and rumination are active and voluntary strategies that can be brought under control if people’s metacognitive strategies and beliefs are changed.

Why is that important?

Controlling rumination and worry and changing unhelpful metacognitions will help people recover from mental disorders like anxiety and depression, and other issues like OCD, social phobia, and low self-esteem.

What is self-regulation?

According to Wells (5), the mind is involved in constant self-regulation and usually deals with negative thoughts, feelings, and disappointments. He uses the metaphor that the mind can usually heal itself the same way the body can heal a broken arm. Thoughts, images, and impulses visit us shortly but will disappear again. Unless we grab on to them by ruminating and worrying (and through other CAS strategies). When we do that we interfere with this self-regulation.  

Photo by Diana Polekhina – Unsplash

How can I recover from mental illness with MCT?

Self-regulation is a natural ability that happens without our help. So to recover from mental disorders, you need to reduce the CAS and start believing that you have control over how much you worry and ruminate.

Metacognitive therapy helps people recover from mental illness by:

  • Reducing unhelpful strategies like rumination, thought suppression, and worry
  • Modifying metacognitive beliefs (from “I can’t control ruminations” to “I decide when to ruminate”)
  • Using attention flexibly (so that you choose what you want to pay attention to in a situation)

It is important to visit an MCT-I certified therapist to make sure that you receive quality MCT therapy. You can find MCT-I certified therapists here and here.

Summary slideshow

Is Metacognitive therapy another type of Cognitive therapy?

Although MCT deals with cognition (which means thinking), MCT is not just another layer on top of Cognitive-behavioral therapies (CBT). Usually, newer cognitive therapies that deal with thinking are categorized as third-wave therapies(3) (the first wave focused on classical conditioning, operant learning, and behaviorism, and the second wave focused on using cognition and information processing, like CBT).

According to Capobianco & Nordahl(3), MCT is not a third-wave cognitive therapy because it is based on an information processing model, which differs significantly from third-wave therapies. Third-wave therapies are typically based on theories that are rooted outside of psychology, for example, philosophy and Buddhism.

Third-wave therapies don’t have a clear theoretical understanding of what causes and maintains mental illness, something that MCT clearly defines(3).

The difference between MCT and CBT

Cognitive-behavioral therapy (CBT) views negative thoughts as the reason why people develop anxiety and depression. However, everyone has negative thoughts and CBT can’t answer the question of why some people can dismiss negative thoughts naturally, while others get anxiety and depression (10). However, the theory behind MCT answers this question by proposing that biased metacognitions make it difficult for people to recover from negative thinking.

Go to this post and this post if you want to read more about the difference between MCT and CBT.

The science behind MCT

Metacognitive therapy is supported by a lot of research (6). There is clear evidence of the effects of that CAS and the importance of metacognition. Data(7) shows that when people reduce rumination and worry, they recover from mental issues like anxiety, depression, OCD, and even low self-esteem.

Metacognitive therapy can create more changes in thinking than cognitive behavioral therapy, CBT (8) (9). This is consistent across a range of anxiety, mood, psychotic, and addiction-related disorders. 

If you are interested in reading about the research proving the effectiveness of MCT, go to his post.


  • Extended thinking like rumination and worry contribute to psychological symptoms.
  • Metacognitive therapy helps to reduce rumination and worry through specifically designed techniques.
  • Metacognitions lie beneath unhelpful thinking patterns and are a focus of treatment in MCT.  


  1. Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Lawrence Erlbaum Associates, Inc.
  2. Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy, 34(11-12), 881–888. https://doi.org/10.1016/S0005-7967(96)00050-2
  3. Lora Capobianco, Henrik Nordahl (2022) A Brief History of Metacognitive Therapy: From Cognitive Science to Clinical Practice. Cognitive and Behavioral Practice, Available online at www.sciencedirect.com
  4. Wells, A., (2009). Metacognitive therapy for anxiety and depression. Guilford press.
  5. Wells A, Capobianco L, Matthews G and Nordahl HM (2020) Editorial: Metacognitive Therapy: Science and Practice of a Paradigm. Front. Psychol. 11:576210. doi: 10.3389/fpsyg.2020.576210
  6. Normann & Morina, The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis, Front. Psychol., 14 November 2018 | https://doi.org/10.3389/fpsyg.2018.02211
  7. Solem, S.,  Wells, A.,  Kennair, L. E. O.,  Hagen, R.,  Nordahl, H., &  Hjemdal, O. (2021).  Metacognitive therapy versus cognitive–behavioral therapy in adults with generalized anxiety disorder: A 9-year follow-up study. Brain and Behavior,  11, e2358. https://doi.org/10.1002/brb3.2358
  8. Callesen, P., Reeves, D., Heal, C. et al. Metacognitive Therapy versus Cognitive Behaviour Therapy in Adults with Major Depression: A Parallel Single-Blind Randomised Trial. Sci Rep 10, 7878 (2020). https://doi.org/10.1038/s41598-020-64577-1
  9. Fisher, P., & Wells, A. (2009). Metacognitive therapy: Distinctive features. Routledge/Taylor & Francis Group.

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