Thousands of thoughts pass through your mind throughout the day. Some are positive, some negative; some may be anxiety-provoking, distressing, or uncomfortable. Most of these thoughts arise spontaneously and disappear after a while.
However, some thoughts do not leave the mind easily and may gradually become more persistent. When a person repeatedly thinks about the same subject, analyses it, or tries to control, suppress, or push the thought out of their mind, the importance of that thought may increase. In many cases, the result of struggling with thoughts is not to reduce them, but to make them more important, even unintentionally.
Metacognitive Therapy (MCT) focuses not only on what a person thinks, but also on how they respond to their thoughts—in other words, how they relate to them. This approach proposes that a common mechanism may play a role across different psychological difficulties, including anxiety, depression, obsessive thoughts, and post-traumatic stress: repeatedly engaging in thinking and analysis, monitoring for internal and external threats, attempting to control emotions or physical symptoms, and continuing these efforts to maintain control. These processes represent different components of a dysfunctional mental cycle.
In the model developed by Adrian Wells, the theorist behind MCT, this cycle is referred to as the Cognitive Attentional Syndrome (CAS), known in Turkish as Bilişsel Dikkat Sendromu (BDS). When CAS is active, the mind loses its flexibility; attention becomes repeatedly caught up in the same threats, the same questions, and the same attempts to maintain control.
Everyone experiences negative thoughts:
“What if something happens?”
“Why do I feel this way?”
“I shouldn’t be thinking about this.”
“What if I lose control?”
“What if the same thing happens again?”
The presence of these thoughts alone does not mean that a person has a psychological problem. What matters is how the mind responds to these thoughts.
Sometimes, when an uncomfortable thought arises, you may be able to let it be without engaging with it too much. In other situations, however, the mind may begin to treat a thought as a threat that needs to be resolved. The person may then analyse the thought, try to suppress it, monitor themselves, scan their emotions, monitor their body, attempt to anticipate potential dangers, mentally simulate threatening scenarios, or repeatedly search their memory for details of past events.
After a while, what becomes truly exhausting is not the thought itself, but this repetitive response system directed towards the thought.
According to MCT, a significant part of psychological entanglement is related to this cycle. The mind may appear to be trying to solve a problem; however, repeatedly worrying, ruminating, scanning for threats, and avoiding them often serve not to resolve the problem, but to keep it going over an extended period.
For this reason, the central question in MCT is:
“When a thought enters the mind, how does the person relate to it?”
This question shifts the focus of the therapeutic process from the content of a thought to the relationship a person has with that thought. The most important factor to consider when trying to understand how you relate to your thoughts is attention. How you use your attention when a thought arises, what you focus on, and how long you remain focused there can provide the answer to the question of “how.”
Metacognitive Therapy is a science-based psychotherapy approach developed by Adrian Wells. According to MCT, the primary factor maintaining psychological difficulties is often not the content of thoughts, but the way a person monitors, evaluates, and attempts to control their thoughts.
Metacognition, in its simplest form, refers to the mind’s knowledge of and regulatory guidance over its own thinking processes. In response to a thought, memory, image, emotion, or physical sensation that enters the mind, metacognition refers to the higher-order system that determines where attention will be directed, what will be analysed, what will be controlled, and which coping strategies will be used.
For this reason, metacognition can be described as the decision-making mechanism that operates in response to thoughts, cognitions, memories, and sensations entering the mind. Metacognitive processes determine how attention is used, how much engagement a person has with a particular thought, and how the mind is regulated.
MCT does not aim to eliminate thoughts or replace all negative thoughts with positive ones. Instead, it teaches individuals to develop a more flexible and distanced relationship with their thoughts. In other words, the goal is to be able to relate differently to the same thoughts when they arise.
For example, a person who develops a fear of driving after being involved in a traffic accident may report that they did not experience significant distress while driving on the same roads before the accident. Before the accident, they may have been able to use their attention more flexibly in traffic—focusing on the road while also listening to music or noticing details in their surroundings.
After the accident, however, their attention may gradually become increasingly focused on signs of threat: speeding cars, sudden braking sounds, possible accident scenarios, physical tension, or thoughts about losing control. In this situation, the problem is not actually the possibility of having another accident; what becomes exhausting is the continuous scanning of attention for danger signals.
When such a process is addressed through MCT in psychotherapy, the person begins to recognise the following:
The aim of MCT is to help reactivate the mind’s natural capacity for self-soothing and self-regulation. For this reason, the therapeutic process focuses not only on reducing symptoms, but also on helping individuals recognise how they manage their mental processes and develop new ways of regulating their minds.
According to Metacognitive Therapy, one of the key mechanisms involved in maintaining many psychological difficulties is the Cognitive Attentional Syndrome. In the English-language literature, this process is referred to as the Cognitive Attentional Syndrome (CAS).
The Cognitive Attentional Syndrome is a repetitive and dysfunctional response system that the mind applies to a thought, emotion, physical symptom, or perceived threat. When this system is active, individuals often believe they are trying to solve a problem; however, rather than generating solutions, their mental processes begin to revolve around the same threat.
CAS/BDS can be understood through three core components:
Child-centred play therapy skills are taught. Parents then conduct special play sessions with their children in the home environment.
Worry is primarily future-oriented: “What if something bad happens?”, “What if I lose control?”, “What if I am caught unprepared?”
Rumination, on the other hand, is more often directed towards the past, oneself, or one’s emotional experiences: “Why do I feel this way?”, “Why did I experience this?”, “I wish I could have changed it.”
When CAS/BDS is active, attention often loses its flexibility. Individuals may begin to lock their attention onto potential signs of threat in the external world, their body, or their mind. A person experiencing panic may monitor their heartbeat; someone experiencing social anxiety may monitor how they appear to others; and someone experiencing depressive rumination may repeatedly check their energy level or whether they “feel good.”
Suppressing thoughts, seeking reassurance, avoiding situations, constantly researching, monitoring the body, or analysing a thought until it is “resolved” may appear to provide relief in the short term. However, when these strategies fail to provide the expected relief, the person may begin to experience their mind as increasingly uncontrollable and threatening.
or this reason, in MCT, the problem is not simply individual negative thoughts. The problem is the mental response system that is repeatedly activated in response to these thoughts—namely, CAS/BDS.
According to MCT, genuine psychological improvement begins when attention that has become stuck starts to regain its flexibility.
The key feature that distinguishes Metacognitive Therapy from other psychotherapy approaches is that it works not only with the content of thoughts, but also with the relationship a person has with their thoughts.
Many therapeutic approaches may focus on understanding the meaning of a person’s thoughts, whether they are accurate, their connection to past experiences, or their emotional origins. This work can be clinically valuable. However, the fundamental question asked by MCT is somewhat different:
Rather than focusing primarily on the question, “How much truth is there in this thought?”, the focus is on the question, “When this thought arises, how does your mind respond?”
According to MCT, what makes a person struggle is often not simply the presence of a negative thought. The primary maintaining mechanism is what the mind does after the thought arises: worrying, analysing, monitoring for threats, attempting to suppress or control the thought, avoiding it, or repeatedly searching for a solution.
CBT and MCT are both evidence-based psychotherapy approaches; however, they operate at different levels. CBT often works with the content, meaning, evidence, and alternative interpretations of thoughts. MCT, by contrast, focuses not on the content of the thought, but on the mental response to the thought, how attention is used, and the metacognitive beliefs that regulate this process.
| Focus in CBT | Focus in MCT |
|---|---|
| The Meaning of the Thought | The Relationship with the Thought |
| “Is this thought true?” | “When this thought arises, how does your mind respond?” |
| Evidence and Counter-Evidence | The Effects of Mental Responses |
| Changing the Meaning of the Thought | Changing the Response to the Thought |
| Content Level | Meta-Level |
| More Functional Thinking | More Flexible Use of Attention and Mental Control |
MCT is a transdiagnostic approach. In other words, rather than focusing on a specific diagnosis, it focuses on common mental mechanisms that recur across different psychological difficulties. Mental health conditions such as anxiety, depression, obsessive thoughts, and post-traumatic stress may present with different symptoms; however, according to MCT, similar processes often play a role in maintaining these difficulties: worry, rumination, threat monitoring, self-monitoring, suppression, and attempts at control.
As a transdiagnostic model, MCT can also explain “recovery” in other therapeutic approaches from a different level. Regardless of which therapeutic approach is used with an individual, if improvement is observed at the end of the process, a corresponding change in attentional processes would also be expected. It is difficult to speak of “recovery” if attention continues to become stuck on the problem in the same way as before. If, following any therapeutic approach, an individual engages in less rumination, monitors for fewer threats, suppresses their thoughts less frequently, uses their attention more flexibly, and experiences a greater sense of control over their mental processes, MCT would interpret this as a change occurring at the metacognitive level.
In MCT, the therapeutic process focuses not on assigning meaning to each individual distressing thought, but on identifying and becoming aware of the cycle the mind enters when these thoughts arise.
First, the individual’s difficulty is formulated in terms of the problem they are experiencing, the triggering thought, the mental responses to that thought, and the resulting emotional and behavioural consequences. This helps the individual begin to recognise not only what they are thinking, but also how their mind responds after the thought arises.
The therapeutic process focuses on the following areas:
Recognising the Mental Cycle
Worry, rumination, threat monitoring, suppression, avoidance, and attempts at control are identified and distinguished from one another.
Working with Metacognitive Beliefs
Rigid metacognitive beliefs such as “If I worry, I will be prepared,” “I can find a solution if I analyse this,” “I cannot control my thoughts,” and “These feelings are dangerous” are explored.
Increasing Attentional Flexibility
The individual learns to use their attention more flexibly rather than focusing exclusively on threats, the body, emotions, or thoughts.
Developing a New Relationship with Thoughts
The aim is not to suppress thoughts, empty the mind, or ignore the problem. Instead, the aim is to help the individual discover that when a distressing thought arises, they do not have to respond to it with the same repetitive pattern every time.
As this awareness increases, the influence of the CAS/BDS cycle decreases. The mind no longer has to treat every distressing thought as a threat that needs to be resolved.
During the therapeutic process, MCT-specific methods such as Detached Mindfulness, the Attention Training Technique, postponement exercises for worry and rumination, meta-level dialogue, and behavioural experiments may be used. However, the purpose of these techniques is not simply to practise exercises; it is to increase flexibility in the individual’s mental processes, strengthen their sense of mental control, and enable them to manage the mind’s natural flow in everyday life.
Metacognitive Therapy can be used for a range of psychological difficulties, particularly when repetitive thinking, threat monitoring, attempts to control thoughts, and patterns of getting mentally stuck are prominent.
As this awareness increases, the influence of the CAS/BDS cycle decreases. The mind no longer has to treat every distressing thought as a threat that needs to be resolved.
During the therapeutic process, MCT-specific methods such as Detached Mindfulness, the Attention Training Technique, postponement exercises for worry and rumination, meta-level dialogue, and behavioural experiments may be used. However, the purpose of these techniques is not simply to practise exercises; it is to increase flexibility in the individual’s mental processes, strengthen their sense of mental control, and enable them to manage the mind’s natural flow in everyday life.
Metacognitive Therapy is based on the S-REF model developed by Adrian Wells and identifies the Cognitive Attentional Syndrome (CAS/BDS) as one of the key mechanisms that maintain psychological difficulties. Within this model, the goals of treatment are to reduce CAS/BDS, modify metacognitive beliefs, and strengthen metacognitive control.
In a randomised controlled trial involving individuals with Generalised Anxiety Disorder, MCT was compared with CBT. Both approaches were found to be effective; however, the recovery rate was reported as 65% in the MCT group compared with 38% in the CBT group. The difference was also reported to be maintained at the two-year follow-up.
Longer-term follow-up studies have also provided evidence that the effects of MCT can be sustained. In a nine-year follow-up study, the recovery rate was reported as 57% in the MCT group and 38% in the CBT group, while the rate of re-diagnosis with Generalised Anxiety Disorder was lower in the MCT group.
These findings suggest that MCT is not limited to an approach aimed solely at short-term relief; rather, it may contribute to more lasting changes in the way individuals soothe and regulate their minds.
Dr. Ali Engin Uygur has completed international Metacognitive Therapy training provided by Adrian Wells and Hans Nordahl and is an MCT-I-approved Advanced Metacognitive Therapist and Supervisor. As one of the first therapists in Türkiye to work in the field of Metacognitive Therapy, he has been engaged in clinical practice, training, and supervision in MCT since 2015. Dr. Uygur also serves as a supervisor in the international Metacognitive Therapy training programs offered through MCT-I.
He was the first therapist in Türkiye to apply Metacognitive Therapy in a group therapy format and also conducted the first online group applications of Metacognitive Therapy for individuals with cancer.
Dr. Uygur is also an ISST-approved Schema Therapist and conducts work on the use of metacognitive skills within the Schema Therapy approach.
In the therapeutic process, Dr. Ali Engin Uygur’s MCT approach is not based solely on the use of techniques and exercises. Instead, it focuses on helping individuals understand their mental processes, recognise the CAS/BDS cycle, work with rigid metacognitive beliefs, and develop more flexible ways of using their attention.
The aim of this approach is not to eliminate distressing thoughts entirely, but to help individuals discover that they can respond to these thoughts differently when they arise.
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