































Graduate Student Journal of Psychology          Copyright 2012 by the Department of Counseling and Clinical Psychology 
2012, Vol. 14               Teachers College, Columbia University 

74 
 

 
Metacognitive Therapy for Major Depressive Disorder: 

Development and Clinical Potential 
 

Ethan Dugas 
Rhode Island College 

 
Adrian Wells and colleagues have developed a metacognitive model of psychological dysfunction 
which shows clinical promise for treating multiple Axis I disorders.  This paper explores the 
fundamentals of this model and the self-perpetuating cycle of counterproductive coping behaviors 
underlying it.  Several therapeutic techniques that have been designed to interrupt this cycle are 
described and contrasted with cognitive behavioral therapy (CBT).  Papageorgiou and Wells’ 
specifications of the general model for rumination and depression are outlined, and empirical tests 
of a clinical metacognitive model of major depressive disorder (MDD) are described.  The 
metacognitive therapy (MCT) treatment package for MDD is summarized.  Finally, evidence from 
recent clinical tests that support the effectiveness of MCT for treating MDD is discussed.  Wells’ 
model appears potent and efficient for reducing anxiety and depression, and his treatment package 
is a novel approach to combating MDD that should be investigated in further studies. 
 

 
Major depressive disorder (MDD) can be particularly 

difficult to treat when faced with certain treatment-resistant 
patients.  Cognitive behavioral therapy (CBT) and its variants 
have become first-line psychological treatments for many 
mood and anxiety disorders, but, when evaluated using the 
Beck Depression Inventory (BDI; Beck, Ward, Mendelson, 
Mock, & Erbaugh, 1961), only 40-58% of depressed patients 
have been found to recover with such treatment (see e.g., 
Dimidjian et al., 2006; Gortner, Gollan, Dobson, & Jacobsen, 
1998), and only one-third to one-quarter of patients so treated 
may remain recovered after 18 months (Roth & Fonagy, 
1996; Teasdale et al., 2000; Wells, 2009).  Furthermore, some 
patients show limited or no response to antidepressant 
medications (Teasdale et al., 2002).  British clinician and 
researcher Adrian Wells has worked with European 
colleagues for decades to develop an alternate, information-
processing model of psychopathology.  It is hoped that 
methods derived from these theories, formalized as the new 
metacognitive therapy (MCT), may provide efficient and 
efficacious treatment packages for acute and relapse 
prevention phases of many Axis I disorders designated in the 
DSM-IV-TR, including but not limited to generalized anxiety 
disorder (GAD) and MDD (Nordahl, 2009; Wells, 2009).   

Metacognition may be conceptualized as an information-
processing capacity encompassing the monitoring, 
interpretation, evaluation, and regulation (or control) of 
mental activities and the contents of consciousness (i.e., 
thoughts), as well as beliefs about one’s ability to effectively 
perform these reflective functions (Papageorgiou & Wells, 
2001a; 2003).  This paper outlines the development and 

                                                 
Ethan Dugas, B.A., Deptartment of Psychology, Rhode Island 

College, Providence, RI. 
Correspondence regarding this article should be addressed to 

Ethan Dugas, Department of Psychology, Rhode Island College, 600 
Mt. Pleasant Ave., Providence, RI 02903.  Email: 
edugas_5609@email.ric.edu 

rationale of Wells’ metacognitive models as well as core 
methods designed to address processing deficiencies and 
counterproductive habits.  Further, this paper will focus on 
elaborations of those models to accommodate rumination, and 
a formulation of MCT that specifically targets depression.  
Contrasts with traditional CBT are highlighted, tests of an 
MDD-specific metacognitive model are reviewed, and recent 
clinical tests of a formalized treatment package are discussed.  
In the concluding section, comparisons are made between the 
MCT approach and “third wave” cognitive behavioral 
therapies which approach cognition similarly but contain 
more humanistic elements.  Lastly, implications of the 
reviewed studies are summarized, and suggestions for further 
exploration of the efficacy of MCT in the treatment of 
depression are presented. 
 

Overview of the Metacognitive Model 
 

Thoughts and beliefs can be considered actual, direct 
experiences of the self and the world, perceived via an “object 
mode” (Wells, 2009).  However, Wells (2009) posits that 
there is also a “metacognitive mode,” wherein thoughts are 
experienced as separate from the self and the world, as if 
observed from a detached perspective.  As such, MCT is 
designed to act on the process of thinking and how thoughts 
are experienced, rather than on challenging the content or 
accuracy of thoughts as CBT might (Wells, 2009; Wells et al., 
2009).  The theoretical underpinnings of MCT lie in Wells 
and Matthews’ self-regulatory executive function model of 
psychological disorders (S-REF; 1996).  In this schema, 
cognitive processes operate on three levels, working from the 
top down to maintain or exacerbate emotional disturbances.  
A meta-system, possessing its own model of cognitive 
processing alongside metacognitive knowledge and beliefs 
that reside in long-term memory, controls and is monitored by 
a particular “cognitive style” of conscious thought and 



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75 
 

behavior processing.  This style, in turn, biases more 
automatic, low-level processing, which feeds back into it. 

A “toxic thinking style” that Wells (2009) refers to as the 
cognitive attentional syndrome (CAS) perpetuates disorder 
through worry and/or rumination, excessive threat-
monitoring, and counterproductive coping behaviors (such as 
avoidance).  The CAS is maintained by positive meta-beliefs 
about its components (e.g., “If I contemplate reasons for my 
negative mood I can find answers”) as well as negative 
beliefs (e.g., “Controlling worry or rumination is 
impossible”).  A typical “A-B-C” model typically espoused 
by CBT might posit that activating triggers, (A), lead to 
schemas or belief manifestations, (B), which lead in turn to 
affective and behavioral consequences, (C).  MCT adds meta-
beliefs and the CAS to step B, in an “A-M(B)-C” 
formulation.  For example, the trigger (A) of being alone 
might lead to affective responses (C) of sadness and 
hopelessness.  However, an intervening belief (B) that “things 
won’t change” may be mediated by metacognitive beliefs 
(M), such as the belief that rumination is necessary for 
change, or that emotions must be directly addressed to 
motivate improvement (Wells, 2009).  These meta-beliefs, 
then, serve to discourage more adaptive ways of coping and 
so unhelpful beliefs are reinforced, in a perseverative loop.  
To overcome the perseverative effects of the CAS, clinicians 
must work to direct patients into a metacognitive mode of 
thinking, facilitating improved executive control and 
cognitive flexibility in order to interrupt and replace 
detrimental processing habits. 

 
Major Techniques Associated with the Model 

 
 One early strategy developed to “unlock” patients from 
their maladaptive thinking styles was the attention training 
technique (ATT; Papageorgiou & Wells, 2000; Wells, 2009).  
The goal of the technique is to aid anxious or depressed 
patients in establishing executive flexibility and disengaging 
from unhealthy levels of self-focused attention.  
Administration consists of explaining the purpose to the 
patient, and then practicing five minutes of selective 
attention, five minutes of rapid attention switching, and a 
brief (1-2 minutes) period of divided attention.  The patient is 
asked to focus exclusively on one of several sounds within 
the room, beyond the room, or in spatial locations behind, in 
front, or to the side; to quickly alternate focus; or to try to 
take in all sounds at once, respectively.  In-session practice 
should continue, but patients are expected to practice alone at 
least once a day.  A key aspect lies in proper understanding – 
ATT should not be used as a coping behavior to eliminate 
negative thoughts.  Instead, thoughts are not to be resisted 
during the procedure, but treated as additional “noises” in the 
mind (Wells, 2009). 

This last concept is a core component of another major 
metacognitive strategy, detached mindfulness (DM; Wells, 
2005).  In the DM state, a patient is mindful or aware of 
“cognitive events” without locking attention onto any in 
particular. This is reminiscent of, but distinct from, the 

Buddhism-derived “mindfulness” practice espoused by Thich 
Nhat Hanh, Jon Kabat-Zinn, and adherents, which has been 
described as the nonjudgmental recognition of present 
thoughts, feelings, or sensations, with focus on increased 
attention to and acceptance of immediate experience (Bishop 
et al., 2004; see also Hanh, 1999; Ludwig & Kabat-Zinn, 
2008).  Critically, during DM, a detached perspective 
precludes any conceptual or behavioral engagement with 
thoughts, beliefs, memories, or feelings.  Furthermore, these 
mental events are observed from a separated point of view, by 
imagining a “self” within the mind separate from one’s 
cognitions and consciousness.  This realization of a 
metacognitive mode of thinking can facilitate more flexible 
attention.  Moreover, it supplants the cognitive style of the 
CAS, which consists of self-focused attention and high 
incidence of conceptual processing and coping behaviors, 
with little meta-awareness of thoughts as separate entities 
from the self or reality.  Indeed, one method of facilitating 
this mode with patients involves asking them to conjure a 
mental image of a tiger, allowing it to move freely about the 
mental landscape while observing its behavior, as a metaphor 
for negative thoughts.  Thoughts might also be conceptualized 
as transient events—mere clouds passing through the mind.  
Patients are asked to try to implement DM on their own 
whenever they notice a negative thought, in attempt to derail 
the CAS and prevent the triggering of unhelpful beliefs and 
responses (Wells, 2009).  In this way, ATT and DM work in 
concert to establish flexible attentional control, and to 
eliminate pathological processing of everyday inputs and 
resultant thoughts, without working to eliminate the thoughts 
themselves.   
 
Specification of the Metacognitive Model for Depression 

 
Building on these foundational models and techniques, 

which have been tested in varying forms for many disorders 
including GAD (Wells & King, 2006; Wells et al., 2010), 
posttraumatic stress disorder (Wells & Colbear, 2012; Wells 
et al., 2008), and obsessive compulsive disorder (Fisher & 
Wells, 2008; Rees & van Koesveld, 2008), Papageorgiou and 
Wells (2003; 2009) set about devising and testing a clinical 
metacognitive model specified for depression.  The critical 
feature of the CAS in MDD is rumination, which consists of 
cycling thoughts that revolve around particular themes.  
These thoughts, such as the repeated, negative pondering of 
personal problems or self-worth, may be difficult to disrupt 
(Smith & Alloy, 2009).  While worry has also been associated 
with many individual manifestations of depression, it is 
generally considered to be future- or anticipation-oriented 
(e.g., “What if I never emerge from depression?”).  
Depressive rumination dwells on finding explanations for past 
behavior or present circumstances (“Why am I so 
abnormal?”), which may in turn generate worry about coping 
or surviving in the future (Wells, 2009).   

Papageorgiou and Wells (2001a) employed a semi-
structured interview (derived from a metacognitive profiling 
interview; Wells & Matthews, 1994) to investigate 



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76 
 

metacognitive beliefs in a sample of 14 patients, who were 
diagnosed with recurrent MDD without Axis 1 comorbidity 
using the Structured Clinical Interview for DSM-IV Axis I 
Disorders—Patient Edition (SCID-I/P; First, Spitzer, Gibbon, 
& Williams, 1997).  Depressive symptoms, as assessed by the 
BDI, were at the moderate-to-severe end of the scale (M = 
31.7, SD = 8.9, range = 21-50).  All participants reported 
having ruminated within a few days of the interview, when 
asked to “think about the most recent time in which you felt 
particularly depressed and you were ruminating” (p. 161).  
The authors found that all participants endorsed positive 
beliefs about the necessity or usefulness of rumination, as 
well as negative beliefs that rumination is either 
uncontrollable and self-destructive, or has serious 
interpersonal and social consequences.  These negative 
beliefs were in line with the general S-REF architecture of 
CAS activation and maintenance through perseverative 
negative thinking.  Therefore, therapy based on a specified 
MDD model could target these belief categories directly to 
break the cycle. 

To elaborate, a positive belief such as “I must ruminate 
about the past to make sense of it” might trigger the selection 
of rumination as a coping strategy, which, upon failure to 
help, may produce negative thoughts such as, “Ruminating is 
a sign of weakness.” This, in turn, may serve to deepen the 
ruminative state.  An external trigger such as a verbal insult 
(e.g., “You’re a moron”) could result in positive 
metacognitive beliefs about rumination (e.g., “If I think about 
it, maybe I can be smarter”), followed by a ruminative 
cascade (e.g., “How could I have seemed less dumb all those 
times? Why am I so stupid?”). In addition, negative beliefs 
about rumination (e.g., “I’ll always be useless and can’t think 
myself smarter”) can add more fuel to the depressogenic 
CAS.  In this way, the input, mediated by metacognitive 
beliefs and rumination, leads to such cognitive beliefs as “I’m 
stupid,” or “I’m worthless.”  These beliefs then elicit affective 
responses of sadness or hopelessness, and may generate 
counterproductive behaviors in the future, such as avoiding 
schoolwork or social interaction, which can perpetuate the 
cycle (Papageorgiou & Wells, 2004; Wells, 2009). 
 

Formal Tests of Model Fit 
 
 Papageorgiou and Wells (2003) conducted two studies to 
test the fit of this metacognitive model of rumination and 
depression.  In Study 1, 200 adults diagnosed with MDD 
using the Inventory to Diagnose Depression (IDD; 
Zimmerman, Coryell, Corenthal, & Wilson, 1986) completed 
the Ruminative Response Scale (RRS; Nolen-Hoeksema & 
Morrow, 1991; Roelofs et al., 2009). Participants also 
completed Wells and colleagues’ Positive Beliefs about 
Rumination Scale (PBRS; Papageorgiou & Wells, 2001b; 
Watkins & Moulds, 2005), the Negative Beliefs about 
Rumination Scale (split into uncontrollability/harm [NBRS1] 
and interpersonal/social [NBRS2] subscales; Roelofs, 
Huibers, Peeters, Arntz, & van Os, 2008), and a section of the 
Metacognitions Questionnaire (MCQ; Cartwright-Hatton & 

Wells, 1997) concerning self-confidence in cognitive 
functioning. 
 Structural equation modeling supported paths from the 
PBRS to the RRS, which then passed through the NBRS1 and 
NBRS2 in two paths to reach the IDD scores.  In other words, 
positive beliefs about rumination were cross-sectionally 
linked to ruminative tendencies, which were then related to 
depression level through the mediation of negative beliefs 
about rumination.  Cognitive confidence (as measured by the 
MCQ) was proposed to be a depressogenic byproduct, 
feeding back into the model to reinforce both negative beliefs 
about rumination’s interpersonal and social consequences and 
positive beliefs about its value, as part of a vicious cycle.  For 
example, depression can lead to the metacognitive belief, 
“My memory is not very reliable,” which could support the 
negative belief, “My friends and family won’t think I am 
reliable if I continue to ruminate about my past,” and the 
positive belief, “I have to keep ruminating to sort my head 
out.” However, it was unclear if this variable added anything 
substantive to the model, as a reversal of paths such that 
PBRS and NBRS2 influenced metacognitive confidence was 
required to achieve a good model fit, which was not 
significantly better than a model lacking the MCQ variable 
(ΔCFI = .01; Δχ2(2, N = 200) = 1.4, p > 0.05).  Papageorgiou 
and Wells (2003) employed the same assessments with a 
younger, non-clinical sample of 200 psychology students in 
their Study 2.  However, the best model fit differed from that 
in Study 1, with a direct path from rumination to depression 
and no indirect path through negative beliefs about the 
uncontrollability or harm of rumination, possibly reflecting 
less impaired metacognition.  Further, cognitive confidence 
was only non-significantly influenced by PBRS and NBRS2, 
with no influence from depression level itself, presumably 
because of the lower overall levels of depression in the 
sample. 

To better assess causality, Papageorgiou and Wells 
(2009) conducted a prospective test of the metacognitive 
model in a nonclinical sample of 164 students (133 female).  
Participants completed the IDD, RRS, and NBRS (subscales 
1 and 2), and then completed the IDD again 12 weeks later.  
IDD scores at Time 2 were dichotomized into nondepressed 
(59.1%) and borderline-depressed (40.9%) categories (see 
Zimmerman et al., 1986 for symptom severity classification).  
Hierarchical logistic regression showed that, when added to 
the model in Step 1, IDD at Time 1 was a significant 
predictor of depression severity, correctly classifying 72% of 
participants into one or the other category and accounting for 
17-22% of the variance in IDD scores at Time 2.  The 
addition of RRS scores in Step 2 improved variance estimates 
to 21-28%, but did not improve classification accuracy.  
Subsequent addition of NBRS1 and NBRS2 scores resulted in 
73.8% correct classification and accounted for 24-32% of 
IDD score variance.  Importantly, only IDD at Time 1 and 
NBRS1 were significant predictors of IDD severity at Time 2 
when controlling for other factors.  Though RRS score 
approached significance as a predictor, when NBRS1 and 
NBRS2 scores were added in Step 2 in a second analysis, and 



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77 
 

RRS scores were added as Step 3, there was no significant 
improvement in the model. This suggests that effects of 
rumination on depression may be attributable to variance 
shared with negative beliefs about rumination, particularly 
about to its uncontrollability and harmfulness.  While the 
results did generally support the clinical metacognitive 
model, and suggested that metacognitive beliefs predict 
depression level in a way that could be consistent with 
causation, further work must be done to determine whether 
the same results are obtained with a clinical sample and a 
longer retest interval (see also Roelofs et al., 2007; Yilmaz, 
Gençöz, & Wells, 2011). 
 
Implementation of the MCT Treatment Package for MDD 
 

To support further empirical testing and clinical studies, 
Wells (2009) formalized metacognitive therapy for MDD 
based on the aforementioned techniques and models and 
presented a treatment manual.  First, a patient’s case is 
conceptualized using, primarily, the Major Depressive 
Disorder Scale (MDD-S), which provides insight into positive 
and negative metacognitive beliefs and maladaptive behaviors 
used to cope with depressed mood.  The patient is interviewed 
and a case-specific model of meta-beliefs, ruminative 
behavior, and depressive responses is generated.  The patient 
is then presented with the rationale for rumination being a 
counterproductive coping behavior and is introduced to the 
ATT as a method of improving awareness and control of 
ruminative processes.  Homework is also assigned.  Detached 
mindfulness is then presented and demonstrated, along with 
the suggestion of “rumination postponement.”  This entails 
recognizing when rumination is being triggered, and actively 
deciding to put it off until a specific time later in the day 
(rather than attempting to suppress it directly).   
 Next, negative beliefs about the uncontrollability and 
social stigma of rumination are challenged by showing that 
rumination is interrupted (i.e., controlled) when attention is 
directed away from the self, and that it is not abnormal to 
experience fluctuations in mood or energy level.  Positive 
beliefs are then tackled by investigating whether rumination 
actually helps, or in fact makes things worse (i.e., a cost-
benefit analysis).  Reasoning intended to reinforce the 
disadvantages of rumination is used to help eliminate 
maladaptive threat-monitoring or coping behaviors, and 
actively exploring the consequences of an increased activity 
level is encouraged.  Then, a summary of case-specific 
depressogenic triggers and counterproductive responses is 
presented, and new responses and attentional strategies are 
developed with the patient’s input to replace them.  Finally, 
this plan and summary points from all major steps are 
collected in a therapy blueprint, and booster sessions are 
scheduled for 3 and 6 months later.  Treatment can be 
completed in 5 to 10 sessions at discretion, or a standardized 
8.  Changes in metacognitive beliefs and attentional control 
may be monitored throughout. 

Tests of Clinical Effectiveness 
 
 An initial study of metacognitive techniques for treating 
depression examined only the ATT method.  Papageorgiou 
and Wells (2000) administered the ATT to four physician-
referred adult antidepressant-stabilized patients with recurrent 
MDD (2-4 major depressive episodes; MDEs) and no Axis I 
comorbidity, as diagnosed with the SCID-I/P.  BDI and Beck 
Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 
1988) measures were administered prior to a no-treatment 
baseline period that ranged from three to five weeks 
(depending on patient assignment), before beginning weekly 
ATT sessions, and at follow-up periods of 3, 6, and 12 
months after treatment concluded.  Participants also 
completed the short RRS and the MCQ before and after 
treatment and at follow-up assessments, as well as the 
Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 
1980) and the Private Self-Consciousness Scale (PSCS; 
Fenigstein, Scheier, & Buss, 1975).  The treatment rationale 
was explained to participants at the first session and daily 
homework practice was assigned.  Both BDI and BAI scores 
for all patients fell within the normal range for the general 
population (<10) after 5-8 treatment sessions, with stability 
observed at 3, 6, and 12-month follow-ups.  Readministration 
of the SCID-I/P at 12 months showed no Axis I diagnoses.  
Stable post-treatment improvements were also attained for all 
patients on the ATQ, RRS, PSCS, and MCQ, although the 
study design did not allow conclusions to be drawn about 
whether this was a direct result of ATT or a byproduct of 
reduced depressive symptoms. Furthermore, self-reported 
ruminative behaviors and unhelpful metacognitions were 
consistently reduced and stabilized.  While the results were 
encouraging as to the general efficacy of the ATT for 
reducing pathological depression and anxiety, the weak pre-
test/post-test design and small sample size precluded strong 
conclusions of causality or generalizability. 
 Wells et al. (2009) conducted the first clinical study of a 
complete MCT package targeting depression.  Participants 
were four medication-free or stably medicated adults with a 
SCID-I/P diagnosis of a primary MDE without borderline 
personality disorder (BPD), with no current psychological 
treatment program, and with no CBT during the preceding 
two years.  Participants did not exhibit psychosis, medical 
problems, substance abuse, or suicidality.  Importantly, 
participants had histories of recurrent or persistent MDD 
(three of four suffered from lifelong depression since teenage 
years) and three of four had shown little response to 
pharmacological intervention, in line with profiles suggesting 
poor prognosis for CBT treatment (e.g., Coffman, Martell, 
Dimidjian, Gallop, & Hollon, 2007).  A trained, supervised 
therapist delivered 6-8 weekly MCT sessions of 45-60 
minutes each, according to the treatment guidelines described 
above.  The researchers used a non-concurrent multiple 
baseline design to improve their ability to convincingly 
attribute post-treatment improvement to the MCT package.  
Participants were randomly assigned to baseline periods 
ranging from three to seven weeks in duration.  The Hamilton 



METACOGNITIVE THERAPY FOR MAJOR DEPRESSIVE DISORDER 
 

78 
 

Rating Scale for Depression-17 (HRSD-17; Hamilton, 1960; 
1967) and SCID-I/P were administered at pretreatment, 
posttreatment, and 3- and 6-month follow-ups.  Weekly 
ratings on the BDI, BAI, and a custom measure of rumination 
were collected.  Questionnaire packages containing the RRS, 
PBRS, NBRS, and MCQ-30 (a short form of the MCQ; Wells 
& Cartwright-Hatton, 2004) were mailed weekly, and all self-
report measures were completed at follow-ups.   
 Participants showed relatively stable BDI scores during 
the baseline phase, with an average pretreatment score of 
24.30 (SD = 5.77), and no longer met criteria for MDD at 
treatment completion (M = 6.50, SD = 3.87).  One 
participant’s dysthymia and another’s GAD also became 
subclinical by 6-month follow-up.  Scores on the RRS, PBRS, 
NBRS, and MCQ scales were also substantially reduced, with 
post-treatment levels maintained at follow-ups, suggesting 
that MCT does affect metacognitive and cognitive-process 
variables underlying depression.  An application of stringent 
criteria to BDI scores requires that recovered patients should 
no longer meet diagnostic criteria for depression and should 
have BDI scores ≤ 8 (Frank et al., 1991).  If diagnostic 
criteria are not met but BDI scores are above 8, patients may 
be considered improved.  All participants were improved 
post-treatment and at follow-ups, with three  recovered at 
post-treatment and 3-month follow-up, and two recovered at 
6-month follow-up.  HRSD-17 remission criteria require 
scores ≤ 7 for at least three consecutive weeks, while 
recovery requires scores ≤ 7 for four months with two-week 
assessments (Rush et al., 2006).  Adjusting the criteria to the 
timeline of their study, the authors determined that all four 
participants were in remission after treatment and at 6-month 
follow-up, and three of four were in remission at 3-month 
follow-up.  Three of four participants showed consistent 
remission and could be considered recovered.  The 
researchers concluded that the treatment, though relatively 
brief, was well-tolerated, and achieved high compliance and 
marked improvements in depressive symptomology, despite 
the presence of potentially CBT-resistant cases.  The very 
small sample was a clear limitation, but there is room for 
optimism in planning larger controlled trials for depressed 
samples with varying circumstances.  Additionally, multiple 
therapists would allow for measurement of the influence of 
skill on treatment outcomes, and adherence to manual 
guidelines could be more formally assessed.  
 In a promising study, Nordahl (2009) compared the 
efficacy of treatment by a brief MCT package to that of CBT.  
Though the author had formal training and fifteen years of 
experience with CBT, he had no previous experience with 
MCT and proceeded using a generalized formulation of the 
treatment derived from available literature on attention 
training (Wells, 1990), an early manual for GAD treatment 
(Wells, 1997), and a general therapy manual (Wells, 2000).  
Participants were 30 patients with varied diagnoses 
undergoing treatment at a Norwegian university outpatient 
facility.  The majority of patients had been stabilized on 
SSRIs or SNRIs, and 50% had diagnoses of recurrent MDD, 
while 42% presented with an anxiety disorder according to 

International Classification of Diseases, 10th Revision (ICD-
10; World Health Organization, 1992) criteria.  The rationale 
for the study was that a generalized, cost-effective 
implementation of MCT that targets the trans-diagnostic CAS 
might compare favorably to standard treatment practices in a 
head-to-head trial, particularly in an unfavorable, 
heterogeneous clinical setting.  As in Wells et al. (2009), 
exclusion criteria included severe BPD, psychosis, serious 
medical problems, substance abuse, and suicidality.  A two-
group between- and within-subjects pre-post test design was 
employed, with patients randomly assigned to receive either 
MCT or CBT.  Measures included the BDI and BAI, as well 
as Wells’ Anxious Thoughts Inventory (AnTI; Wells, 1997), 
which was designed to assess changes in worrying and meta-
worrying (worrying about the uncontrollability and danger of 
worrying).  Because patients resumed standard facility 
treatment programs following the study, follow-up data could 
not be collected.  MCT treatment lasted an average of 7.5 
sessions, employing the ATT, DM practice, worry/rumination 
postponement, and the challenging of negative and positive 
beliefs about worrying and ruminating.  Homework was 
assigned at each session.  CBT followed a similar structure, 
but averaged 10 sessions and consisted of traditional activity 
scheduling, identification and challenge of automatic negative 
thoughts and schemas, and self-monitoring and diary-keeping 
homework (following Beck, Emery, & Greenberg, 1985, for 
anxiety; Beck, Rush, Shaw, & Emery, 1979, for depression). 
 One-way ANCOVAs controlling for pretreatment 
measures showed significant differences in posttreatment BAI 
scores between MCT and CBT groups (F(1,23) = 4.35, p = 
.05, η2 = .16), significant differences in AnTI-assessed meta-
worry (F(1,23) = 6.20, p = .02, η2 = .21), and non-significant 
difference in BDI scores.  Posttreatment uncontrolled CBT 
effect sizes (Cohen’s d) compared equably or favorably with 
those from a study with a similar patient group treated with 
CBT (Westbrook & Kirk, 2005) that was chosen as a 
benchmark, Though all effect sizes were very large, MCT 
effect sizes were higher for both BAI scores (d = 2.25 vs. 1.74 
for CBT) and BDI scores (d = 1.31 vs. 1.21 for CBT).  
Though this MCT package did not show a treatment 
advantage over CBT in this clinical sample, it performed 
equally well and outperformed it for anxiety reduction. Also, 
this is despite the fact that an implementation of MCT 
specifically tailored to depression was not used, nor Wells’ 
(2009) recent diagnosis-general formulation.  Further, it is 
possible that the meta-worry measured and reduced in this 
study, or beliefs about worry, may overlap with beliefs about 
rumination as the two constructs have been shown to be at 
least somewhat related, and were conceptually combined in 
the original S-REF model (Nolen-Hoeksema, 2000; Wells, 
2009; Wells & Matthews, 1996).  Nordahl concluded that 
MCT may provide an efficient and accessible form of trans-
diagnostic treatment that is potentially favorable to CBT.  
Ratings of treatment adherence and independent diagnostic 
assessment could strengthen future findings. 
 
 



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79 
 

Conclusion 
 

In sum, Adrian Wells and colleagues have developed a 
robust model of metacognitive and emotional dysfunction, 
with well-defined components that can be targeted and treated 
individually to break perseverative cycles of anxiety and 
depression.  Disorders such as MDD present a disorder-
specific form of cognitive attentional syndrome (CAS) that 
acts as a toxic go-between connecting metacognitive 
beliefs—which are at the top of the self-regulatory executive 
function (S-REF) model—with the low-level processing of 
basic inputs.  This syndrome forms the core of a perseverative 
cycle (Wells & Matthews, 1996; Wells, 2009).  Dysfunctional 
metacognitions include positive thoughts about the need to 
engage in unhelpful coping behaviors such as rumination, and 
negative thoughts about the consequences of doing so that can 
increase the behavior’s damage.  The attention training 
technique (ATT) and detached mindfulness (DM) can be 
practiced to strengthen executive control and direct one’s 
attention away from the self, allowing for more effective 
interruption and delaying of rumination, and for the 
consideration of thoughts from a detached perspective.  In 
contrast to CBT’s emphasis on content, metacognitive 
therapy aims to switch patients into a “metacognitive mode” 
of thinking and challenge their thought processing and 
attentional fixation.  MCT targets the rationale behind 
positive and negative meta-beliefs, as well as threat-
monitoring and coping behavior. 

It may be useful to distinguish MCT from several 
conceptually related approaches to therapy, sometimes 
popularly designated “third wave” cognitive behavioral 
therapies, which share a focus on acceptance or a mindfulness 
concept derived from Buddhist traditions, as described earlier 
(Hanh, 1999; see Bhanji, 2011, for discussion).  Like MCT, 
these treatment programs emphasize patients’ interpretations 
of and reactions to their thoughts, rather than attempting to 
modify cognitions directly.  However, Wells considers MCT 
an extension of traditional CBT in that it targets specified 
psychological mechanisms that perpetuate depressive 
symptoms (Wells et al., 2009).  In contrast, Mindfulness-
Based Cognitive Therapy (MBCT; Segal, Williams, & 
Teasdale, 2012; see Piet & Hougaard, 2011, for review) was 
developed primarily to aid in relapse prevention (see e.g., 
Teasdale et al., 2002).  Attention to the “present moment” is 
practiced in MBCT to facilitate awareness of self-defeating 
thinking, and to promote acceptance of transient negative 
thoughts and disengagement from them before they can 
induce a depressive episode (Scherer-Dickson, 2004).  The 
approach of Acceptance and Commitment Therapy (ACT; 
Luoma, Hayes, & Walser, 2007; see Ruiz, 2010, for review) 
is a similar one, focusing on the power of language and de-
emphasizing negative self-judgments (Bhanji, 2011).  
Dialectical Behavior Therapy (DBT; Dimeff & Koerner, 
2007; Linehan, 1993) shares similar ideas about cognitions 
and acceptance, but is more oriented to address emotional 
dysregulation and behavioral extremes, given its original 
development as a treatment for BPD (see Kliem, Kröger, & 

Kosfelder, 2010, for review).  MCT is distinct in its 
philosophy of logically challenging counterproductive 
cognitions without a spiritual emphasis or an overt focus on 
personal acceptance.  Instead, it employs a precise, 
customizable model of how metacognition can malfunction, 
and emphasizes cognition over affect.  It is possible that this 
more mechanistic approach could be advantageous for 
patients whose circumstances or personalities may make them 
less amenable to the humanistic elements of third wave 
therapies. 

Evidence has accumulated for a clinical metacognitive 
model of depression and clinical tests have begun.  Wells et 
al. (2009) showed that an MCT package targeting depression 
may be effective even for difficult cases with recurrent or 
chronic MDD that have not responded to medication and may 
be unlikely to benefit from traditional CBT, and observed 
promising stability at follow-ups.  Nordahl (2009) showed 
that even a diagnosis-general MCT package may be 
comparably effective and favorably efficient to CBT in 
treating depression, in a head-to-head study with patients of 
varying diagnoses.  These promising results should motivate 
coordinated effort in the future to better determine MCT’s 
potential, including implementation of the depression-
targeting MCT treatment package with expert training and 
supervision in a well-controlled head-to-head study.  It would 
also be useful to examine the efficacy of MCT for patients 
with distinct depression diagnoses and histories (e.g., chronic 
MDD, dysthymia or double depression, single MDE, etc.), 
and compare responses to treatment.  This could allow for 
deconstruction of the clinical metacognitive model and its 
techniques with respect to current depressive nosology, and 
facilitate comparison with CBT and other therapies across 
case presentations.  Research groups evaluating other 
therapeutic techniques and their treatment outcomes could 
consider adopting one or more of Wells’ measures of 
metacognitions and beliefs about rumination in their studies 
as additional variables. 

Metacognitive therapy may have the potential to treat and 
stabilize depressive symptoms in a straightforward, resource-
efficient manner. Increasingly recognized and respected in 
Europe, MCT has yet to garner mainstream support in North 
America but warrants more extensive investigation. 
 

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