Metacognition plays a key role in our everyday lives. How often have you made a shopping list to prevent you from forgetting what to buy when you go to the supermarket? Or think about the last time you were learning something new for an exam. Chances are you engaged in several strategies to help you check your understanding. Re-reading through the text, making notes on the points you are unsure about to revisit later, or asking further questions to deepen your understanding. All of these strategies are just some of the ways in which metacognition impacts our everyday lives and thinking.
Metacognition refers to one’s own awareness of and ability to recognise one’s own thoughts. It is a deeper level of thinking that includes your ability to think about your own thought processes. It acts like an internal guide, alerting you when your memory fails or when your attention wanes, and helps you to take action (for instance, to rehearse information so you will not forget it, or refocus your attention when your mind begins to wander). Therefore, it is unsurprising that training about metacognition – delivered via metacognitive therapy (MCT) – is being used to treat psychological disorders. Individuals receiving MCT for generalised anxiety disorder (GAD), depression, obsessive compulsive disorder (OCD) and Posttraumatic Stress Disorder (PTSD) have all demonstrated reduced symptoms.
MCT has demonstrated promising results for the treatment of PTSD, a psychiatric disorder that can develop once individuals are exposed to a traumatic event. It is expected that individuals will experience stress reaction symptoms in the days following the event, such as intrusive memories of the event, flashbacks, or feeling more on edge. For most individuals these symptoms naturally subside. For some, these symptoms will persist and develop into PTSD.
Previous cognitive models of PTSD focus on the role of cognitive appraisal, and place importance on challenging the content of our irrational beliefs and dysfunctional thinking in order to achieve symptom relief and recovery. Until recently, the beliefs people hold regarding their thoughts has been overlooked by researchers. The metacognitive model, developed by Professor Adrian Wells at the University of Manchester, proposes that the thoughts people have regarding their own cognition can be as harmful as the dysfunctional thoughts themselves.
So, how does MCT apply to individuals suffering with PTSD? According to the metacognitive model, it is the dysfunctional beliefs we hold about our own cognition that perpetuate and maintain PTSD symptoms. Unlike traditional cognitive therapies for PTSD, (e.g. CBT) MCT does not state that distorted thinking or coping strategies rise from ordinary beliefs, but alternatively proposes that thought patterns are a result of metacognition acting on our thinking processes. In the context of PTSD, the metacognitive model proposes that PTSD develops due to a specific style of thinking, such as worry, rumination and fixating attention on sources of threat. The aim of MCT is to not target what the person is thinking, but how the person is thinking.
In line with the metacognitive model, following a traumatic event, it is normal for individuals to experience stress response symptoms, such as intrusive memories and increased arousal (such as heart racing). By experiencing these symptoms it has been argued that an individual is attempting to emotionally process the traumatic event in a way that promotes future coping. This response forms part of an inbuilt reflective adaptation process (RAP) which aims to develop new procedures (metacognitions) for controlling cognition and plans for dealing with future threats.
According to the model, the RAP process continues uninterrupted and symptoms tend to reduce naturally. However, it is thought that a certain pattern of thinking called the cognitive attentional syndrome (CAS) plays an integral role in disrupting the RAP process by extending negative thinking patterns that prolong emotion. The CAS consists of three processes: worry, rumination and threat monitoring. Hence, PTSD develops when individuals maintain attention on threat and engage in worry-based strategies as a way of coping. The CAS is driven by maladaptive metacognitive beliefs, such as positive (‘Worrying helps me cope.’) and negative (‘My worrying is dangerous for me.’, When I start worrying I cannot stop.’) beliefs about worry, as well as maladaptive positive and negative metamemory beliefs. Metamemory refers to the way in which people assess the content of their own memories; it is not the memory itself but the judgements and assessments that we make about our own memories.
Maladaptive metamemory beliefs include both positive (‘I need to remember the event perfectly to work out who was to blame.’) and negative (‘Gaps in my memory are preventing me from getting over it.’, ‘I need to remember the event perfectly to know who was to blame.’) beliefs about what it means to have gaps in our memory. The metacognitive model proposes that it is these maladaptive metacognitive beliefs, alongside the persistent use of maladaptive thought control strategies which serve to maintain a sense of threat and maintain symptoms of PTSD. A recent study found that individuals, who hold pre-existing maladaptive metacognitive beliefs about worry (their thoughts are uncontrollable) prior to trauma exposure were more likely to report PTSD symptoms in response to a traumatic event that they experienced. They also found that negative metamemory beliefs (‘Gaps in my memory are preventing me from getting over it.’) maintained PTSD symptoms over time (12 weeks). This study highlighted the important role of maladaptive metacognitive beliefs in predicting and maintaining PTSD symptoms – which has never been evidenced before.
The metacognitive model of PTSD suggests that recovery can be achieved by targeting the maladaptive metacognitive beliefs that serve to increase anxiety and maintain a threat-focused mode of processing. Rather than addressing the content of dysfunctional thoughts which may emerge in the aftermath of a trauma, clinicians should look at exploring the metacognitive beliefs individuals hold in relation to their cognition – mainly around worry and rumination strategies. This is substantially different to alternative cognitive theories of PTSD, as these models give special emphasis to disturbances in memory (disorganised memory or failure to incorporate corrective information into existing autobiographical memory) and the content of dysfunctional thoughts and beliefs surrounding the traumatic event, the self or the world, as a cause of PTSD. Individuals receiving treatment for PTSD based on these alternative theories are required to engage in techniques such as thought challenging and imaginal reliving of the trauma (reliving the traumatic event from the beginning to the end with a therapist) in order to achieve recovery.
This can be an extremely distressing and difficult process. MCT does not require individuals to engage in these types of techniques because MCT states that it is the way in which individuals relate to their thoughts and symptoms that is the driver for change (symptom relief). Further, MCT stems from the premise that psychological symptoms (intrusions) following a traumatic event are a normal response, compared to other cognitive therapies which view symptoms as an abnormal response. Encouraging individuals to interpret their symptoms as an abnormal reaction to trauma is likely to heighten anxiety and further perpetuate any maladaptive metacognitive beliefs. It may also work to maintain mental health stigma and reduce help-seeking behaviours among individuals who may be experiencing such symptoms.
This is an important issue for trauma-exposed individuals, particularly first responders who are frequently exposed to high levels of trauma within their jobs. A recent survey found that police officers are reluctant to seek help for work-related mental health issues due to mental health stigma. The metacognitive model offers a more nurturing approach which normalises the experience of symptoms in the aftermath of trauma and focuses on reducing unhelpful coping strategies and tackling maladaptive metacognitions which maintain a current sense of threat.
The metacognitive model of PTSD is still gathering evidence. However, it does provide a promising avenue for future research. Some key unanswered questions remain such as, the role of metacognition in the prevention of PTSD. Previous studies have highlighted the role of pre-existing maladaptive metacognition in predicting PTSD symptoms. Therefore, it is plausible that training individuals to adopt more adaptive metacognitive beliefs prior to trauma exposure could help dampen the psychological effects of trauma. It is impossible to predict when someone will be exposed to a traumatic event within the general population. However, first responders and military personnel, by the nature of their roles, are frequently exposed to high levels of trauma on a daily basis. Therefore, training these individuals in the role of metacognition at the beginning of their service is likely to promote adaptive metacognitive beliefs and help boost psychological resilience, to help dampen the effects of any future trauma exposure.
Danielle Hett is a PhD Student at Loughborough University. Her PhD is focused on developing preventative interventions for PTSD within military populations.
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