Studies of treatment mechanism have examined the eff ects of manipulating attention, presenting mental sets that facilitate metacognitive change, and have explored metacog- nitive belief change as a predictor of treatment response.
In social phobia, the threat monitoring component of the CAS is marked by exces- sive self-focus on performance and embarrassing symptoms. Wells and Papageorgiou (2001) tested the eff ects of exposure on individuals with social phobia when it was pre- sented under two conditions. One condition asked patients to shift to external attention focus (counteracting threat monitoring), while the other used a habituation rationale and asked patients to stay in the situation for the same planned period of time. Th e metacognitive condition involving attention refocusing was superior to the comparison condition in reducing anxiety and negative beliefs.
In a study of patients with obsessive-compulsive disorder, Fisher and Wells (2005) used a similar approach. Th ey asked patients to listen to a loop tape of their obsessional thoughts under a habituation exposure condition or a condition that emphasized meta- cognitive change. Th e metacognitive condition was superior at reducing distress, urge to neutralize, and negative beliefs.
Two studies have evaluated metacognitive change as a predictor of treatment outcome. Solem, Halland, Vogel, Hansen, and Wells (2009) showed that change in
metacognitive beliefs predicted improvement in symptoms in obsessive-compulsive pa- tients receiving exposure therapy, but change in non-metacognitive dysfunctional beliefs (responsibility, perfectionism, etc.) did not. Spada, Caselli, and Wells (2009) found that metacognitive beliefs predicted drinking status across follow-up after a course of CBT in problem drinkers.
FUTURE DIRECTIONS
Because MCT is based on an information processing model that specifi es a cognitive architecture involving metacognitive and subcortical emotional processes, it should be possible to map these processes and linkages in the human brain. Developments in dynamic imaging techniques should be used to determine the neurological correlates of metacognitive techniques and measures. Moreover, the impact of strategies such as de- tached mindfulness and attention training should be explored. Th e model predicts that these techniques should increase executive control and be associated with reductions in activity in areas of the limbic system under exposure to threat or negative stimuli.
Of critical importance, future studies should aim to examine the eff ects of treat- ments, including conventional CBTs, on metacognition and on the role of metacogni- tion as a mediator of treatment outcome. Because the MCT model is multidimensional, incorporating various features of metacognition, studies may seek to determine which components carry most treatment eff ects. Is it change in the content of metacognitive beliefs or the enhancement of metacognitive control as indexed by fl exibility in atten- tion, for example? Th e MCT approach provides a range of possibilities that go beyond concepts of simply enhancing metacognitive awareness or reality-testing the content of cognition.
Th e development of mindfulness and acceptance approaches in CBT has drawn greater attention to the multifaceted nature of aspects of cognition that are not always susceptible to reality testing. Th e use of meditation-based mindfulness has been one answer to the problem of high relapse following CBT for depression. But this is only one type of approach. Grafting new techniques onto existing treatments might provide a solution, but an alternative is to go for a complete rethinking of the fundamental therapeutic approach. MCT and some of the other approaches in this book attempt to do just that. Th ey each ask diff erent questions, and the one asked by MCT is specifi - cally: “What is it that controls thinking?” If we agree that biased cognition is a cause of disorder, it is rather surprising that it has taken the fi eld so long to address the questions of what gives rise to bias, and more importantly, what gives some but not all thoughts their continued salience.
Does the incorporation of mindfulness-based theory and strategies represent a para- digmatic change within the fi eld of CBT? In my view it could, but as it currently stands it probably does not. Th is is because mindfulness approaches serve as an extension of CBT and have not forced a more fundamental change in the treatment. Furthermore, the goals of meditation-based mindfulness are far from fi xed, which could threaten its
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progression. Sometimes it is viewed as an anxiety management technique, other times as a relapse prevention strategy, and others as a distraction from worrying. Without a coherent psychological framework for understanding the eff ects and for developing the use of mindfulness meditation, it can hardly be viewed as paradigmatic. In contrast, techniques such as ATT and detached mindfulness, as used in MCT, do not borrow from the meditation tradition; they have a specifi c theoretical origin grounded in modi- fying well-specifi ed psychological mechanisms. However, they are still simply techniques used in MCT and do not in themselves constitute a paradigm change.
It is important to look beyond individual techniques at the empirical and theoretical basis of an approach to judge how well it explains pathology and gives rise to new forms of practice. As far as MCT is concerned, others shall judge its paradigmatic standing in the fi eld. I would contend that it is radically diff erent from the earlier content-based approaches in CBT and from the behavioral approaches, both of which have neglected metacognition, extended thinking, and intentions and goals in the person’s selection of some thoughts over others.
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