In the third article in this series exploring third wave cognitive behavioural approaches, Jonathan Passmore and Sarah Leach examine the therapeutic approach, metacognitive therapy, and how it can be adapted for use in coaching.
Like second wave approaches, such as Cognitive Behavioural Therapy (CBT), now one of the most widely used evidence-based approaches, third wave approaches can provide alternatives for experienced coaches.
Metacognitive therapy
Metacognitive therapy (MCT), originally developed by Adrian Wells in the early 2000s (Wells, 2009), has become a popular approach within counselling over the last decade. However, like the other third wave approaches explored in this series, the potential value of metacognitive approaches to coaching and specifically applying these ideas to work-based issues and problems hadn’t yet been reviewed.
In this article we review the theoretical basis of MCT, critically review the evidence for its efficacy with clinical populations, and finally reflect on its potential for application in coaching conversations.
Theoretical foundations
The Cognitive Behavioural approach is predicated on a chain of causation often referred to as the ABC model (Figure 1). Under this model the client experiences an activating event (A) which triggers their response. The response however is mediated by the beliefs held by the client (B). This is followed by a response, or consequences (C), such as behaviours.
Figure 1: Traditional second wave CBT process (ABC model)
At this moment in time how much is your attention focused on yourself or on your external environment? Please indicate by giving a number on the scale
First wave behaviouralists argued that as all we can observe is the behaviour, our response must be to work on conditioning the right behaviours. Second wave cognitive behaviouralists, however, argued it was possible to infer cognitions from behaviours. As a result, the Cognitive Behavioural Coaching (CBC) approach focused on working with unhelpful cognitions to create more helpful, evidence-based or rational thoughts to the activating event. MCT adds a new step in this chain. It argues that for those who can reflect or engage in thoughts about their thoughts, there’s also a metacognitive process at work (Figure 2).
Figure 2: Metacognitive process
MCT is theoretically grounded in the self-regulatory executive function model (Wells & Matthews, 1994). The model suggests that psychopathology arises as a result of a perseverative (when people get stuck) thinking style called the Cognitive Attentional Syndrome (CAS). The CAS consists of dysfunctional coping strategies that individuals employ in their attempts to manage distressing thoughts and emotions. These emotions include worry and fear, as well as thoughts such as rumination and threat-monitoring, which can lead to behavioural responses such as avoidance and reassurance seeking.
The model proposes that negative thoughts and feelings are usually temporary. However, when an individual responds to these with a dysfunctional coping strategy, the period of distress is extended and the distress potentially exacerbated.
These dysfunctional coping strategies arise from a person’s positive and negative metacognitive beliefs – their reflections on or beliefs about their own cognitions. These can be categorised into ‘Positive metacognitions’ and ‘Negative metacognitions’. Positive metacognitions are beliefs about the need to engage in specific cognitive processes, eg, the client thinks: “Worry helps me stay prepared.” Negative metacognitions are beliefs held by the client about the uncontrollability or dangerous nature of their thoughts, for example, the client may think, “I have no control over my anxiety.”
The aim of MCT is to help the client identify and modify their dysfunctional coping strategies.
MCT steps
Step 1:
Creating a unique case formulation in collaboration with the client.
Step 2:
The therapist aims to explore with the client the impact of their ruminations, how these are maintained and the effectiveness of their coping strategies.
Step 3:
Explore and challenge through Socratic questions and experiments the client’s metacognitive beliefs. The main emphasis is placed on challenging the negative metacognitive beliefs, such as, “If I think like this, I must be going mad”, before moving to challenge the positive metacognitive beliefs, such as, “If I worry it will help me to perform better.” The patient is invited to postpone their rumination processes by engaging in other tasks such as attention techniques or mindfulness.
Research evidence
The past decade has seen widescale research into new third wave approaches, including MCT. The multiple randomised control trials with patients in health settings have been reviewed in a number of meta-analysis studies. Normann et al (2014) concluded that MCT is very effective for specific populations groups, such as those with anxiety and depression. In a second meta-analysis, Rochat et al (2018) confirmed this view, with Normann and Morina (2018) in a third meta-analysis examining MCT’s impact on primary and secondary outcome variables.
The study included 25 trials, where Normann and Morina (2018) noted, “The comparison with waitlist control conditions… resulted in a large effect (Hedges’ g = 2.06)….. in a comparison of MCT to cognitive and behavioral interventions at post-treatment and at follow-up showed pooled effect sizes (Hedges’ g) of 0.69 and 0.37 at post-treatment.” These meta studies provide robust evidence of MCT as a specific treatment for clients managing anxiety.
While these effect sizes are significantly higher than the effect sizes seen in coaching, there are several possible reasons for this, including the severity of presenting issues in therapy compared to coaching. While no data exists for metacognitive coaching (MCC), we hypothesise that using metacognitive approaches with coaching clients would also see lower effect sizes, but that the approach will produce positive results for coaching clients experiencing anxiety and excessive rumination.
Practice
The starting point for translating MCT to coaching is to review the four foundation skills:
- the ability of the coach to understand the different levels of cognition, specifically the difference between metacognition and what is ordinary cognition
- the ability to identify maladaptive cognitions which constitutes the negative and positive CAS
- using Socratic dialogue to help clients explore their cognitive processes
- learning to implement metacognitive interventions, specifically attention training and mindfulness diffusion.
Coaches trained in traditional CBC are experienced in helping clients explore their thoughts, the relationship between their thoughts, feelings and behaviours, and in using tools such as chaining to uncover core beliefs, and Socratic questioning or chair-work to explore illogical or irrational thoughts, while helping clients develop a more evidence-based outlook. This approach encourages the client to engage in reality testing by testing their cognitive distortions through adopting alternative perspectives and by challenging through a rational exploration of the evidence – their thinking.
In contrast, in MCC the coach suspends their own rational mind to join the client in assuming the client’s thoughts may be correct. They then move to explore with the client their thought process though a metacognitive process: that is, helping the client to think about their thinking. This is done by testing out whether the client’s assumptions about the helpfulness of their positive and negative beliefs are borne out by reality.
The belief within MCC is that through enabling clients to become aware of and understand their maladaptive thinking, they’ll more effectively change their mental model of cognition. This exploration is achieved largely through two meta-tools: attention training and detached mindfulness. Let’s look at each in turn and explore one techniques from each.
As we discussed above, some clients are locked into unhelpful thinking patterns they find difficult to break. The traditional behavioural approach results in a wrestling match between their old style of thinking (distorted) and the new challenger (disputation). The result for clients is not a new, effective outlook but a back and forward as the two ideas grapple for control.
Attention Training Technique (ATT)
Wells (2009) suggests Attention Training Technique (ATT) as an intention to reduce this wrestling match. ATT has three components:
- selective attention
- rapid attention switching, and
- diverted divided attention.
Wells has developed a procedure which lasts approximately 12 minutes and can be divided as follows: five minutes for selective attention, five minutes for attention switching and two minutes for divided attention.
Selective attention guides the client’s attention to individual sounds among a variety of competing sounds in different, special locations in their environment. The instruction is to give intense intake intention to specific individual cells while resisting destruction from others.
In comparison, rapid attention switching consists of instructions to shift attention between 10 individual sounds and special locations with increasing frequency. At the beginning of the phase, approximately 10 seconds is devoted to different individual sounds and subsequently the speed of switch is increased to one sound every five seconds. ATT ends with a brief two-minute divided attention instruction in which the client is asked to expand the breadth and depth of attention and attempt to process multiple sounds and location spontaneously.
The technique can be taught within the coaching session, possibly practised during the next session and set as a homework task, with clients invited to repeat the process regularly for review at a future session.
For the practice, the coach may need to ensure sounds can be heard from different locations. These might be a ticking clock, a radio and a mobile phone generated sound from a timer, or involve opening a window to allow bird song or traffic and external noises to enter. The coach thus needs to plan in advance if they anticipate using ATT to ensure everything is in place.
Progress can be monitored over time using the Self Attention Scale, with the client, answering the scaling question prior to the first use of ATT, then after a period of home use, and finally at the end of the coaching intervention (see Figure 3).
Figure 3: Scaling assessment
At this moment in time how much is your attention focused on yourself or on your external environment? Please indicate by giving a number on the scale
-3 -2 -1 0 +1 +2 +3
Entirely externally focused Equal Entirely internally focused
The second recommended practice is detached mindfulness (DM) techniques. DM has two features, first, mindfulness and second, detachment. The benefits of mindfulness are well known (Hall, 2013).
Detachment has two aims. The first is to help the client refrain from appraisal of the situation, and in so doing reduce worry, rumination and threat monitoring. The second is to encourage the client to experience an inner event as an occurrence that is independent of general consciousness of them self. It is as if the person is aware of their perspective of the self, as an observer of the thought or belief. One way to illustrate this is the tiger technique.
Tiger Task
The coach invites the client to engage in an experiment, by bringing to mind a tiger and observing its behaviour. The client is invited to close their eyes and bring to mind a tiger. The coach asked the client not to influence or change the image of the tiger in any way but simply to watch the tiger in their mind and observe its behaviour.
The tiger may move or stand still. It may blink or look straight ahead. It may shake its tail or keep it still. The client is invited to note how the tiger has its own behaviour while being reminded to do nothing but simply watch the tiger. At the end of the task the client is invited to reflect on the exercise: “Did you make the tiger move, or did it happen spontaneously?” Through discussion, the client recognises the tiger moved without direction and was separate from the direct thoughts or cognitive instruction of the client’s mind.
Applying MCC
As can be seen in the description of MCC and the tools that can be applied, there’s much similarity between this approach and mindfulness and acceptance and commitment coaching. The real value of MCT, and its adaptation for coaching, is the ability to work with clients who bring high levels of anxiety to coaching, helping them to explore this, through observation of their metacognitions and sharing with them techniques they can use outside the session to more effectively manage these experiences.
Conclusion
The evidence over the past decade has shown MCT is an effective intervention for anxiety-based conditions. While no research has yet been conducted on non-clinical populations, we believe, based on case study experiences of using the approach with clients, that MCC has potential for transfer from clinical populations to others at work and home who experience anxiety.
- Next issue: Acceptance and Commitment Coaching
References
- L Hall, Mindful Coaching, Kogan Page, 2013
- H M Nordahl, T D Borkovec, R Hagen, L E Kennair, O Hjemdal and S Solem, ‘Metacognitive therapy versus cognitive-behavioural therapy in adults with generalised anxiety disorder’, in BJPsych Open, 4, 393-400, 2018. https://doi.org/10.1192/bjo.2018.54
- N Normann, A A Emmerik and N Morina, ‘The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review’, in Depress. Anxiety, 31, 402-411, 2014.
https://doi.org/10.1002/da.22273 - N Normann and N Morina, ‘The ffficacy of metacognitive therapy: A systematic review and meta-analysis’, in Frontiers in Psychology, 2018. Retrieved 2 April 2021 from:
https://doi.org/10.3389/fpsyg.2018.02211 - J Passmore and S Leach, Third Wave Cognitive Behavioural Coaching, Pavilion Publishing, 2022
- L Rochat, R Manolov and J Billieux, ‘Efficacy of metacognitive therapy in improving mental health: a meta-analysis of single-case studies’, in Journal. Clinical. Psychol. 74, 896-915, 2018. https://doi.org/10.1002/jclp.22567
- A Wells, Metacognitive Therapy for Anxiety and Depression, Guilford Press, 2009
- A Wells and G Matthews, Attention and Emotion: A Clinical Perspective, Psychology Press, 1994