Metacognitive Therapy to Address Anxiety, Anger and Depression and Increase Mental Health

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody today's presentation on metacognitive therapy. As always, when we go over therapeutic techniques, what we are doing or what I am doing today is just providing you a really high level overview. You are not going to be an expert on metacognitive therapy by the time you get out of today's one hour webinar. However, once you go through, if you learn about it and you think, oh, that could be useful, that could be interesting, then you can delve deeper into finding other resources and other trainings on it. Today we're basically going to learn about metacognitive therapy, the multiple aspects of metacognition, and we're going to talk about what metacognition is and how to apply metacognitive therapy to depression, pain, learn helplessness, and other stressful situations. This particular approach requires something of a paradigm shift in our thinking. So it may be a little challenging, or it was for me, let me just put it that way, a little bit challenging for me to wrap my head around initially and separate it from cognitive behavioral. So I'm going to do my best to differentiate it from cognitive behavioral therapy as we go through today's presentation. Let's start at the beginning. People come to therapy because they're in distress of some sort. Distress is a signal that the person is trying to respond to threats to their well being. Anger, anxiety, depression. You know, those are our distress sort of emotions. It is normally reduced by effective coping strategies. But not everybody has effective coping strategies or there can be hiccups in the system. Disorders result when the person's coping skills backfire. You decide that in order to cope with this situation, you're gonna drink a bottle of wine or go to sleep and just get up tomorrow. Well, both of those examples, while they may help in the very, very short term, they may make the distress go away for the second when you wake up or when you sober up, that problem may still be there. So then the person is left feeling hopeless and helpless because that problem is still there. They tried to make it go away and they don't know how to make it go away. Disorders also result when people believe they have no control over their thoughts. When they believe that, you know, I keep having this thought or I keep telling myself this, we have, you know, those automatic thoughts. Those hecklers in our head sometimes. And when people believe that they have absolutely no control over their thoughts, then they can feel somewhat helpless. If they say, I can't stop worrying, then they're going to feel more helpless and more anxious. They may also develop disorders when they believe it's in their best interest to keep ruminating. Rumination often focuses on questions that have no easily identifiable answers. What if this happens? Think about. It's easiest to give examples of physical disorders. If you have a pain in your stomach, a pain in your side, and you're thinking, well, it could be, you know, I ate something wrong, or it could be irritable bowel, or. But what if. What if it's cancer? What if it's pancreatic cancer? What if it's liver cancer? Better get online and start looking and see what the symptoms of all that kind of stuff are. And if you go online to check out your symptoms, you're almost always going to come up with the most catastrophic results possible, which is going to spin you up into anxiety. When people are depressed, they may say, why do I feel this way? They may be trying to rack their brain for why they feel depressed. It could be cognitions, it could be environment, it could be a neurochemical imbalance because of extended stress or inadequate quality sleep. There's a lot of different reasons why people could feel a certain way. And if they continue to think about it, why do I feel depressed? Then they may get frustrated if they're not coming up with the answer, why me? Why do I feel this way? Why am I depressed? Why am I anxious? Why do I have bipolar disorder? Why me? Why did this happen to me? And sometimes there are no easy answers. You know, you have somebody, I worked with, a gentleman early in my career who was a paranoid, had paranoid schizophrenia, and brilliant, brilliant man, literally was a nuclear physicist, brilliant man. And he could have perseverated on, why me? Why do I have to have this diagnosis? Because he could have theoretically done so many amazing things with his intellectual gifts, but unfortunately, when he had his psychotic break, that kind of put an end to a lot of that. And he could have sat there and perseverated on, why me? Why is this happening? What did I do wrong? And may not come up with an answer, or, what does this symptom mean? And I see this one a lot. Again, with physical issues, especially with people who have chronic pain, does this mean it's getting worse? When people are perseverating or ruminating on these types of thoughts, especially questions that have no answers, it gets frustrating. It Gets exasperating because if you can't come up with an answer, then you can't come up with a solution. Metacognition essentially means thinking about thinking and refers to the knowledge and regulation of one's own cognitive process processes. Now in cognitive behavioral therapy, we talk about the content, we look at specifically these thoughts. What thoughts are you having? Let's take this individual thought, let's dissect it, let's look at whether it is accurate or not. Let's look at any distortions that might be there, yada yada. Metacognitive goes more broadly. Instead of saying, look at each example of overgeneralization, metacognitive says, let's look and see if you have a thinking style that is characteristic of overgeneralization. Metacognitive therapy agrees that prior experiences create schema that influence our interpretation of events. So the past is influencing us now. However, it focuses on not the content of the thoughts, but what the person pays attention to. If somebody has a negative thinking style, a perseverative thinking style, a over generalizing thinking style, an overly personalized thinking style, you get where I'm going with this. Metacognitive experiences are the reactions people have as a result of their cognitive appraisals. So if I have a negative thinking style, I just look at everything through a negative lens and then my reaction to that is going to probably be to be anxious, angry, depressed. Because everywhere I look I'm seeing the negativity, I'm seeing the negative stuff. So metacognition encourages people to become more aware, more mindful of their thinking stuff styles and not get caught up or down in the weeds addressing every single individual cognitive distortion. Because we can have millions of those. Metacognitive therapy says, you know, okay, so when you're feeling depressed, what is your thinking style that you're doing? Metacognitive therapy focuses on disorder specific cognitive biases such as mood congruent memory, which is basically researchers way of saying that metacognitive therapy says when you are in a particular mood, when you are depressed, what things do you tend to notice? It's a depressive thinking style. When you are happy, what do you tend to notice? You know, that's your happy thinking style. And what are the results of those two different approaches to viewing the same content? You know, when you're going to work, think about going to work. We go to work whether we're depressed, we go to work, whether we're angry, we go to work when we're happy. Do you notice different things. When you are in different moods, chances are if you really sit down and think about it, the answer is going to be yes. Unless you intentionally say, ok, I'm in a bad mood, I am going to try to see the good in things today. But our knee jerk response is to see, to notice confirmatory stimuli in the environment. One study on metacognitive therapy indicated that the only mediator between treatment and depression recovery was, you know, if somebody went to treatment, the only factor that really predicted recovery was whether we were able to address their feelings of lack of control. Metacognitive knowledge. Now, there are three components to metacognition. We start out with knowledge, just like we do in treatment plans. Metacognitive knowledge refers to the declarative knowledge of cognitive processes and includes our personal knowledge, so our ways of thinking, knowledge of how we think, and our knowledge of our personal abilities and limitations. And this is really what we would often call mindfulness. Now, within personal knowledge, we can have negative metacognitive beliefs and positive metacognitions. Let's not get too far down in the weeds with that. The biggest issue, I just wanted to throw those terms there because if you start reading about metacognitive therapy, these terms are going to come up negative. Metacognitive beliefs are basically what we have often called distress intolerant thoughts. And they focus on the uncontrollability of our thoughts, rumination and threat monitoring or constantly noticing the threat. There are things that we don't want to have. We don't want to have feelings of uncontrollability. We, we don't want to ruminate, we don't want to feel like we're constantly having to monitor for threats. And we don't want to have coping skills that backfire. When that happens, then we lose a certain amount of self efficacy. When we try to cope with something and it fails, we start to feel that we're powerless to control that situation. So these are all negative beliefs about what's going on. Positive metacognitions are beliefs about the need to have a particular belief to stay safe or prepared. A positive metacognition when it comes to, for example, chronic pain would be I need to constantly scan and be hypervigilant to changes in my pain to make sure that it's not getting worse and becoming cancer. Another part of metacognitive knowledge is task knowledge such as how to do something. And we have a lot of task knowledge such as we know how to cook. In general, you may not know how to make fricassee but you may be able to cook in general. You may know how to meditate or you may not. And people are going to evaluate their task knowledge and if they don't feel competent to do it, then they are going to have more negative metacognitive beliefs. So if you tell a client, well, to deal with your anxiety, why don't we try some meditation? If they don't believe that they have the skills to do it, if they don't have the confidence to do it, then they are going to feel like it's too dangerous. They've already tried other coping skills that have backfired and they may not be wanting to try new ones. We can address this task knowledge component or task skills deficits with skills training. So we look and we identify what strengths a person has, what tasks can they already do in order to cope with whatever it is that they're presenting with, and then what other skills might be helpful and how can we help them learn those skills and develop a sense of confidence that they can implement that tool and it will be effective. The third type of metacognitive knowledge is strategic knowledge. And that is the person's ability to evaluate the advantages and disadvantages of different responses. When I am feeling this way, what are the advantages and disadvantages to reacting this way and the applicability of each strategy? And this really goes to problem solving. Our ability to weigh the options and figure out which choice is going to best serve us in the moment. Metacognitive experience is the personal experience and perception of difficulty that accompanies cognitive activity so we can think, hey, I'm anxious. One of those skills that I've learned that might be helpful in dealing with this anxiety is meditation. And I feel fully confident that I can implement that because I've practiced it, I've rehearsed it, and that it will help me feel less anxious. So great. So what is the metacognitive experience with those thoughts that we just had? Probably pretty confident, pretty calm, pretty motivated to try. The third metacognitive component is monitoring and control and refers to the self supervision and regulation of the cognitive processes, including planning, monitoring, evaluating and regulating their cognitive activities by adjusting task goals, regulating attentional awareness, and selecting cognitive strategies. Perfect example. I am a great big old sissy when it comes to getting a shot. I hate needles beyond belief, but you got to get your flu shot, you got to get shots occasionally and I have to figure out how to deal with that. So monitoring and control. I'm going back through. Let's go back up here so we can just follow it through. Negative metacognitive beliefs. The uncontrollability of thoughts. I have this fear that thoughts or fear of shots, that it's going to hurt. So I may ruminate on the fact that, oh, I've got to go get that shot, it's going to hurt, my arm is going to hurt for the whole next day, blah, blah, blah, blah, blah. And threat monitoring, you know, looking around and wondering, you know, is this particular practitioner going to be one that's good at giving shots or am I going to feel like I just got stabbed with a great big old butcher knife or something? So those are the negative metacognitive beliefs that may be going through my head before I get a shot. My task knowledge, how to do something. I've gotten a shot before, I've survived it before. So I know that task knowledge and the advantages and disadvantages, well, I can evaluate and say, you know what? Ruminating on the fact that this is gonna hurt ain't gonna solve the problem. Okay, so my metacognitive experience is telling me that, okay, this was unpleasant before, but I've gotten through it before. Monitoring and control. When you go to get a shot, a lot of times they say, don't look. Why? Because if you look, then you tend to tense up. You tend to expect the pain, you tend to focus on the pain. If you're not looking, then you tend to not tense up as much. They also tell you to focus on relaxing because if you tense up that muscle, then you're probably going to have more bruising and more soreness and more yada, yada, yada. Well, so I know what the skills are. I need to not look and I need to relax. And that means engaging whatever skills I have to to help me relax. So that's the best course of action. That's the cognitive strategy I'm going to use. If I continue to think about how much it's going to hurt, I ain't going to relax. So I need to think about anything else. And that's one way that's an example of metacognition. I can focus on the negatives or I can focus on what I can control in the situation. What do you think is going to be more helpful? What. What do you think is going to make me feel more efficacious? Example application. When we think about rumination, sometimes people will ruminate on things. You know, why me? What's causing this? Yada, yada. And in their mind, in the back of their mind, the Meta concepts or metacognition. Going along with this is if I think about it long enough, I'll find the answer. So one of the things we can posit is, okay, you know, you've been thinking about this for a long time and you've been telling me that you keep thinking about it and you keep trying to find answers. How long have you been at it and how much longer is it going to take for you to find that answer? And what if there is no answer? You know, you might be going forever. So encouraging people to look at the effectiveness and of what they're doing and the consequences of it. Another example would be people's belief that they need to control my thoughts. If I don't control my thoughts, I will do something bad. And this struck me rather poignantly, if you will, working with people who have postpartum depression, and particularly with women with postpartum depression. And I can tell you I had this experience myself. My postpartum depression was bad enough that I would have images of doing very horrible things to my child. Completely ego dystonic. They scared the bejesus out of me, which is the difference between postpartum psychosis, in which the person sees absolutely nothing wrong with that and, and postpartum depression, having those thoughts and it being terrifying. So that was kind of the upside to being terrified at my own thoughts. But yeah, it was terrifying and I felt like I couldn't control those images sometimes. And so in metacognitive therapy, the practitioner would say, you know, how do you know which thoughts to control? How do you know which ones are the ones that you want to let through and which ones you want to make sure don't come through at all? Who knows? And what types of bad things have happened by not controlling your thoughts? When you've had those thoughts, what's happened? What bad things have happened? Have you followed through on any of it? And obviously this is on a case by case basis. If you're dealing with somebody who's in a fluoride psychotic episode, you know, you're going to have more difficulty helping them with metacognition. But it is important to help people recognize that sometimes these thoughts will come and they're transient and they are unpleasant, but do they make you do something bad and encourage them to really look at that? Comparing cognitive behavioral and metacognitive therapy. In cognitive behavioral, something happens. Somebody gets critical unconstructive feedback. Somebody is just nasty to them, okay? That's the activating event. They get upset, they feel anxious and helpless. And they're like, out of feeling, out of control. Their automatic beliefs, this person hates me. They don't consider other perspectives. They feel entitled, and they aren't accepting responsibility for their part in this situation. Okay, so there can be a lot of beliefs that go along with it. And in cognitive, behavioral, we would examine each one of those beliefs for their validity, you know, how accurate are they, and for their effectiveness, you know, even if they are valid, you know, is this thought helping me in some way? In what way is this thought, you know, contributing to helping me feel empowered? In metacognitive therapy, same person gets unconstructive feedback. They feel anxious, helpless, powerless. They're like, just everywhere I turn, I'm always, you know, with this person, I am never able to get it through the goalpost. You know, it's always not good enough or it's never good enough. Okay, so the metacognitive therapist would say, what is the thought process that is going on in your mind? Characterize the beliefs that you're having. Instead of telling me each individual belief, characterize the beliefs and tell me why you're thinking about them. Why are you going down this train of thought? And the person may say, I need to think about it. I need to ruminate to identify all the ways to defend myself against this person's criticism. Okay, so again, how many ways do you need to think of and when will you have enough ways? When will you have enough information in your arsenal? Will continuing to ruminate change their opinion? You know, anything that you think of to defend yourself, is that going to change that person's opinion? You know, sometimes. No. Sometimes people are just going to have a differing opinion, and nothing you say is going to make any difference. Is their opinion truly a threat to you? There can be. A colleague could have a differing opinion about how to treat a client. Doesn't mean yours is wrong necessarily. Doesn't mean theirs is wrong, necessarily. Is their opinion a threat to your ability to practice? Does it mean you're a bad therapist? Well, no, it means that you have different approaches. Imagine you have social anxiety and you don't like going to parties because you're worried that you'll do something embarrassing and humiliate yourself in metacognitive therapy, Again, we're not paying attention to that specific thought content. We're not having them identify every automatic belief they're having. Instead, we're challenging the process that leads to the thought. And the process for that person might be worrying about this prepares me in some way. It helps me be ready for handling this. And then they may go, well, you know, I don't really see the purpose in worrying about it. So they may switch their thought process to saying, worrying about this does not make it less likely to happen. So I'm not going to spend the time worrying or. And I have the ability to focus my thoughts on other things. And in other approaches, we may refer to this as taming our monkey mind, Encouraging people to recognize that, yes, worry may pop in, but we don't have to greet it with a handshake and give it a big hug and not let it go. We can let thoughts just like clouds come in, make their pretty little picture or devastating little picture and then float out and that's all. We don't have to hang on to them remembering. You know, a lot of people think about thoughts as, oh my gosh, I'm having this thought over and over and over again and it's stuck in my head. And I encourage them to think about other thoughts that they've had that didn't stick. You know, they got up from the living room and went into the kitchen to do something, and before they even got to the kitchen, they forgot what they got up to do. We've all had those moments. Well, that was a thought too. So what's the difference between the thoughts that stick and the thoughts that one ear and out the other? Helping people recognize that thoughts don't have to stick around. And when they do, a lot of times we're holding on to them. And. And the question is, why are we holding on to them? Not what are the thoughts we're having, but what is the benefit to holding on to this thinking pattern? In metacognitive therapy, cognitive attentional syndrome, or cas, refers to a tendency to believe thoughts are uncontrollable, rely on ineffective coping skills, ruminate and focus undue attention on threat. Monitoring constantly or nearly constantly scanning for threats and scanning for evidence to support our feelings. I feel anxious, therefore it must be dangerous, therefore I must find evidence that it's dangerous. That's kind of backwards. We really want to see the evidence before we have the feeling. Cognitive attentional syndrome focuses attention on sources of potential threat, which increases our sense of danger. If we are intentionally paying more attention to the threats, we are going to feel more helpless, more hopeless, more anxious, more dysphoric. It increases focus of thoughts and awareness on sources of threats. So not only do we have this just general overriding sense of anxiety and danger, and, you know, our HPA axis is on overdrive, but we're noticing any indication, including microaggressions, that could contribute or could support our feelings. Instead of letting our feelings be reactions to facts, we are finding facts to support our feelings. It's a small difference. It seems like a semantic difference, but it makes a big difference in the long run. Focusing on threats prevents noticing the safety features or threat freeness of an environment. You could be looking around and if you are hyper vigilant, then you may be noticing, you know, the person that comes in in the door that has their hoodie on still. You may notice you know different sources of threat, but you may fail to notice the hundred other people in the restaurant that are pleasantly eating. You may fail to notice the police officers that are on lunch break over there that could probably handle anything that happened, you know, that was not anticipated. We tend to focus on the things that are uncontrollable and things that are threat related instead of looking and going, well, what resources do I have in this area? And focusing on threat increases intrusions such as memories, intrusive thoughts, and potentially nightmares. If we're regularly focusing on threats, then we are noticing more negative things. That is going to remind us of situations in the past where unpleasant things have happened. And when we go to sleep, some of that stuff is still bouncing around in our mind, which can trigger having nightmares and night terrors. In the metacognitive assessment questions that you might ask over the past month, what emotional, behavioral and physical symptoms have you noticed? Okay, that's a pretty standard question. Has any thought or situation made you feel worse? Okay, now we're getting to triggers. What thought or feeling did you have when that happened? So if you had a thought that made you feel worse and then you had another thought that I'm so frustrated that I can't stop thinking about that, you know, so a thought follows a thought. Or if a situation happened and maybe your best friend didn't call you back when they said they would, or they canceled plans on you, that situation happened and you felt bad. You felt you were wondering if you were going to be, if you were being rejected, if they were unhappy with you, maybe they were mad. So what thought or feelings did you have that followed that? And it's probably not one thought, probably not one feeling. It was probably a cascade of things and rumination and looking back and double checking over, you know, the past week or month to see, okay, let me look for sources of threat. Let me look for something that I did that may have made this person mad at me. When you had that experience, what happened to your thinking? Did you dwell on things for how long? Did you dwell on the fact that the person canceled dinner plans with you? Did you try to, what did you do to try to control the way you felt? You know, did you have a glass of wine? Did you call another friend and decide to go out anyway? What is it that you did? Did you try to change your thoughts? If so, how? What are the advantages to worrying or ruminating? Did you sit there and just continue to worry over, you know, is this person mad at me? Or ruminate over the fact that, how dare they cancel? What was the advantage to that? Are there advantages to focusing on your thoughts and feelings? Were there advantages to focusing on how you were feeling and how you were reacting and then getting mad at yourself for reacting the way you were reacting? In acceptance and commitment therapy, he calls this dirty discomfort. It's our reaction to our reaction. So sometimes people will feel angry, and that's what he calls clean discomfort. And then they start feeling guilty that they got angry. And then they start feeling angry at themselves for getting angry and angry at themselves for feeling guilty. So all of these other feelings start arising out of the initial experience. We want to ask the person, are there advantages to focusing on these feelings and, you know, holding on to them? Instead of asking yourself, what is a different strategy I can use? What do you think will happen if you continue to feel or think like this? And how much control do you have over your thoughts, helping people recognize that just like feelings are natural, they'll come in, it's what you do with them. You can feel an unpleasant feeling. You can feel anger. Anger tells us there might, doesn't mean there is. There might be a threat. Check it out, see if there is. If there is, handle it. If there isn't, ask yourself what you need to do to improve the next moment. If you have a thought that comes into your mind, the same sort of thing asking yourself, just recognizing, just like a feeling happens, a thought happens, it pops in your mind, okay, you have a reaction to that thought. You may get angry, you may feel guilty, you may be like, oh, crap, this thing again. Whatever you feel, you feel. But at that point you radically accept it. And then you say, okay, what is the best course of action? Thoughts will come and go. We can't turn our brain off and say, I can't have this thought. But there are all kinds of strategies we can use to address thought patterns, metacognitions and pain. Metacognitions about pain related cognition. So our thoughts about our pain related thoughts have been Linked to pain intensity, disability, emotional distress, and greater physical dysfunction. Going back to those positive and negative metacognitions. Negative metacognitions include I cannot stop thinking about the pain. I can't focus on anything else because I'm being distracted by my pain. Everything comes back to my pain. So we're thinking about the pain constantly. Positive metacognition. Why would I want to focus on the pain? I need to continue to focus on my pain to ensure it doesn't get worse. That way, as soon as it starts to get worse, I can tell the doctor how effective is that in helping you live the kind of life that you want to live? Sitting there and looking for minute changes in your pain, that takes a lot of time and energy. Is that how you want to spend your time and energy? Participants who reported greater levels of emotional distress or also tended to endorse stronger negative metacognitive beliefs. Interestingly, they did some neuroimaging on these same patients and found that catastrophic thinking, specifically ruminating about their pain, activated the brain in similar ways to an anxiety disorder. So these thoughts about pain and the uncontrollability of pain and, and focusing on the losses as a result of the pain triggered those emotional centers in the brain that are the same as anxiety. So what does that say? That tells me that our HPA axis, when we're focusing on pain, our HPA axis is ramping up. It's preparing us to fight or flee pain applications. So personal knowledge, our ways of thinking and personal abilities and limitations. Going back to mindfulness with negative metacognitive beliefs, the person may be saying, I can't stop thinking about the pain. I may be ruminating, often thinking about the pain and its negative impact on life. So things we want to challenge. When somebody says, I can't stop thinking about the pain, asking them what is the effect of that? When you are constantly thinking about the pain and encouraging them to notice times when they have done something different, when they have thought about something different, not necessarily specific things about the pain, but when they've thought about something completely different, like going to Disney World, threat monitoring, constantly looking for things that will increase pain and. And scanning for signs of worsening pathology. That's one of those negative metacognitive beliefs that can be really exhausting. So how much time do you need to spend scanning and maybe encouraging them to have a trial of only scanning periodically instead of scanning all the time for pain and constantly noticing small changes in their pain, noticing twice a day when they get up in the morning, when they Go to bed at night or something and then gradually weaning down from there. Unhelpful reactions that backfire with people in chronic pain. If I go to sleep, I'll wake up and I'll feel better. I've heard a lot of patients who have chronic migraines may use this particular strategy and a lot of times they wake up and they don't feel better and then they feel even more helpless because they're like, I don't know how to make it go away or a few beers will help me relax and stop thinking about it. Well, a few beers may help you relax a little bit, but a lot of times it's not going to change your cognitions at all. So again, somebody tries a strategy to try to help themselves feel better and it didn't work. Positive metacognitions. Again, I must stay alert to changes in my pain. Task knowledge for pain. How to use guided imagery. This is a strategy we know works for non pharmacological intervention for pain. If we tell somebody, let's use, you know, try using guided imagery, well, that sounds great, but what is their skill level with it and what is their confidence that it will work? They need to have both in order for it to be effective. They need to have confidence in their abilities and confidence in the intervention. Cued progressive muscular relaxation stretching techniques and how to evaluate their ergonomics for chairs and beds and things that might be contributing to their pain. These are all potential tasks or interventions that could help with their pain. But if they don't have the belief that it'll work or the confidence in their ability to implement these things, they're not going to really change the metacognitive picture and strategic knowledge. Advantages and disadvantages and applicability of each strategy. For example, stretching techniques might be really helpful, but if you are on the metro, probably not going to be able to get a mat out and lay down and do stretching. That's obviously an exaggerated example, but the person needs to have knowledge of what works for them in which situation. Ice and heat, for example. Perfect example. I will have pain sometimes in my neck. I have tmj, I grind my teeth a lot and a lot of times doctors will say, you know, put heat on it to help relax the muscles. Heat for me doesn't seem to do nearly as well as ice and ice is my friend. So from a strategic point of view, I know that one of the ways to address pain is ice or heat. And I know the types of pain for me strategically that ice works better. So I Have confidence in my ability to choose the right intervention and that that intervention will work. Let's apply it to depression. When people are depressed, they may have uncontrollable thoughts or seemingly uncontrollable thoughts. I can't stop thinking about all the things I have no control over and how unfair the world is. Just I can't stop thinking about it. And we really need to help them focus on the word can't. You know, not necessarily each specific thought, but the fact that they feel like they can't control their thoughts at all. It's challenging. You know, learning to tame that monkey mind takes a lot of practice. But encouraging them to chart, to notice when they're able to stop that thought even for five minutes, even for 10 minutes, or to switch their thinking to something, to an alternative for a minute, 5 minutes, 10 minutes, and get some relief, encouraging them to start noticing positive, small changes, incremental changes. We are not going to go help have somebody go from being a person who gets bad news and just ruminates on it for hours or days to somebody who doesn't do that at all overnight. What I want them to be able to do is to notice when they're starting to ruminate and feel like they have some strategies where they can identify their thoughts, recognize them, and then choose whether to keep holding on to those thoughts and keep ruminating, or choose alternate strategies. Rumination. For a lot of people with depression, they focus on things outside of their personal control, which contributes to their feelings of hopelessness and helplessness for threat monitoring. They're constantly looking for things that confirm that negative mood bias. They're depressed, so they're noticing things that are depressing. They're noticing the ads on TV for the animal shelter. They're noticing the fact that it's raining outside today. They're noticing, you know, all of the things that confirm their mood instead of noticing other things, unhelpful reactions that backfire. If I go to sleep, I'll wake up and feel better. A few beers will help make me feel better. A lot of people turn to alcohol and sleep. And with depression, sleeping typically throws that circadian rhythm further out of whack, which contributes to more low energy and apathy. And alcohol, we know, also messes with those neurotransmitters and can contribute to worse anxiety and depression. From a task knowledge perspective, we can help people develop a greater toolbox, if you will, to handle depression so they feel like they're going in forearmed, if you will. We can help educate them about the importance of nutrition, sleep, hygiene, distress tolerance, sleep skills and backwards chaining, for example, in order to address their depression. And again, they need to not just know these things in concept, they need to be able to explain them, to apply them, and have confidence that using these strategies will help them feel better. And that's where we come in as therapists to help them develop these skills, rehearse them in session, practice them between sessions, and then process it the following session. Less than a third of patients with depression actually recover. And relapse rates for those who do recover are estimated to be 50% after two years. So even the ones that do recover, 50% of them have already relapsed. In metacognitive therapy, depression is understood as a consequence of perseveratory thinking styles, especially rumination and worry. 70 to 80% of patients who went through metacognitive therapy for depression were recovered at post treatment and six month follow up. So they hadn't gone out for the full two years, but they had gone out for six months and people were still maintaining their gains. Interestingly, the treatment was also associated with a large reduction in interpersonal problems. So the question is why? And when you think about it, it really makes sense. When you take somebody out of that negative mindset, constantly worrying, constantly scanning for threats, and in an apathetic or dysphoric mood, then they are probably going to want to engage with other people. There's probably going to be less withdrawal, there's probably going to be more positive interpersonal interactions. So yeah, it totally makes sense that when somebody starts feeling better, it'll often have positive effects on their relationships. Some more examples, when Sally fails at something, she tends to ruminate on it. She may focus on those uncontrollable thoughts. She thinks that she is a failure. She thinks that nobody's gonna like her, she thinks that she's gonna get fired. She starts having all of these thoughts that just start bombarding her brain. One of the techniques in dialectical behavior therapy, as most of you are probably aware, is distress tolerance. And one of the benefits of distress tolerance is helping people switch their thoughts, helping people start thinking about something else. So these thoughts that keep bombarding them, instead of noticing them and hooking onto them and nurturing them, you're saying, yeah, you know that all that stuff can go on over there. I'm going to focus over here, I'm going to focus on activities, comparisons, contributing emotions. The opposite. Help me, I can never do the acronym in my own head. Pushing away positive thoughts and sensations that can help you Quit thinking about these thoughts. That can help just move your attention, turn your attention, not addressing a particular thought, but just completely turning your attention away from that worry and threat. Rumination. When John gets into a fight with his partner, he tends to ruminate on it. We've probably had clients like this. The uncontrollability of his thoughts, wondering what's going to happen, getting angry that his partner didn't see things the way he did. Whatever it is with rumination, we want to ask him, what does he think about, you know, after they get into a fight? Tell me what types of things you are thinking about. What types of things do you tell yourself? And let's listen to that dialogue for a few minutes, and then let's try to characterize that dialogue. Maybe it's an abandonment dialogue, maybe it is over generalization. There are a lot of different dialogues that we can have and our automatic beliefs, you know, we can categorize into those different kind of bins, if you will. So we want to look at those bins. Those are the metacognitions, abandonment, failure, loss, that we want to evaluate and help John recognize this thinking style that he has and where it's coming from. If he has abandonment issues, you know, from the past, then when they get into a fight, he may fear that this person is going to abandon him as well. And that may trigger those ruminative, ruminatory, whatever, that may trigger a lot of rumination. And we want him to recognize how it makes sense in a certain way, where this is coming from, if we can identify it, what the effects are? How does this benefit you to ruminate on the possibility of abandonment? What would be an alternate strategy you could use? You could use for your energy? Instead of ruminating on, you know, all the reasons this person might abandon you or how your life will be over if this person abandons you, what could you focus your energy on doing that might help improve the next moment and might help you improve your relationship with that person. Learned helplessness can also be a metacognitive target. When people have a sense of learned helplessness, they focus on the uncontrollability. They may tell themselves things like, no matter what I do, the thoughts keep coming back or the situation keeps reoccurring. Well, that could be true. However, does focusing on it change the situation? When I lived in Florida, no matter what I did, occasionally we'd have a hurricane come through, and there was nothing I could do about it. Did sitting there worrying about whether the hurricane was going to hit, every time a hurricane was headed Towards Florida. Did that do any good? Did that help me in any sort of way? And the answer is no. You know, I can say for me the answer was no. We had our preparations in place, we had all of our extra supplies. You know, sitting there and continuing to worry did no good. So recognizing that ruminating on things that I had no control over was not a good use of energy, focusing on all the things I tried in the past and have failed at and the continuing presence of the threat, you know, well, getting a hurricane to turn doesn't really help. There's not much you can do there. But rumination, coping with different situations, making sure that you have a plan is going to be helpful in certain situations. For the uncontrollable threat awareness. With learned helplessness, people often feel like everywhere I turn something bad is waiting. Instead of confronting the content and say, let's talk about every bad thing you see. Evaluate the utility of these beliefs. Yes, there are bad things, there are really crappy things going on in the world all the time and I can focus on those, but is that going to do me any good? Is my worrying about it gonna change those events? There was unfortunately another mass shooting yesterday. Does my worrying about mass shootings do any good? Does my ruminating and perseverating on the fact that there was a mass shooting, does it change the fact that it happened? No. Does it help me be any more prepared? No. So what is a better use of my energy? 50% of people at risk in an at risk mental state or arms often engage in 30 hours or less of structured activity per week and are considered to be socially disabled. Negative beliefs about the uncontrollability of thoughts and danger was found to predict reductions in structured activity through withdrawal and helplessness. When people feel like the world is dangerous, their thoughts are dangerous, they can't control anything, they tend to withdraw, not try stay in their comfort zone. Interestingly though, in this study, age was found to significantly predict social functioning with younger people having poorer social functioning than older people. So younger people had a less tolerance for the distress, which is a target or a benchmark that we can work on for prevention, Helping people develop more distress tolerant cognitive strategies. Individuals with good metacognition are aware of fluctuations in their task performance and appropriately modulate their confidence level. They may start doing something, they think they've got it and they start doing something and they're like crap, I don't know what I'm doing here or this isn't working. And they can figure out at that point, guess I Better switch and try a different strategy. However, people with poor metacognition don't recognize that and they'll continue to keep trying to do it even though they're not doing it correctly or not doing it effectively. People can have millions of automatic cognitive distortions. It just, it happens. Addressing each one of these may not be possible. You can do ABC worksheets till you're blue in the face. But with metacognitive therapy, instead of looking at each individual cognitive distortion, you're looking at themes or modes of thinking. Becoming aware of thought patterns, their function, their usefulness and alternatives are what underlie metacognitive therapy. Metacognitive therapy moves from addressing the content of thoughts, the what is being thought to the function of those thoughts. Why are these thoughts occurring and are they helpful? Okay, so I hope that made sense. I know it was a big paradigm shift to really get away from the content of thoughts to thinking about just in general, you know, are you having a negative approach to your thinking? Are you having Using overgeneralization? A lot of people use certain cognitive distortions as a thinking style. They overgeneralize most things and it's important to help them see that they're using that or they're using a very external locus of control, a very internal locus of control to help them identify or characterize helpful and unhelpful thought patterns for them. There is a book on metacognitive therapy. You can go on books.google.com and take a look at that to get a little bit more information. It they only have like 30 pages that are available on Google Books. There are Several studies on PubMed, most of which I link to in this presentation. They don't get too far into the meat and potatoes of actually how to do it. They just talk about its effectiveness. So if you're really interested in mct, check out that book. I also have a couple of short videos that will be out on the website. Yeah, hopefully before the end of the week that use some metacognitive strategies more practically and provide you some activities that you can use in individual or group therapy. So keep a Lookout on our YouTube channel for those videos to be released and I will see you on Tuesday. You. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of therapy notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. 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