Metacognitive Approaches to OCD Treatment by Sally Winston, PsyD
Metacognitive therapy is an approach to treating OCD that focuses not on the origins or the reason for OCD symptoms, but on the ways that both obsessions and compulsions are formed, and why they don’t go away on their own. It is not a first-line treatment for OCD and is better suited for those who have already tried ERP (in other words, as a second-line treatment after first-line treatment(s) have been tried).
The word meta-cognition means “thinking about thinking.” By understanding in detail how OCD works, you can then change your relationship with your thoughts and feelings and no longer be tricked into behaving in unproductive ways or having unproductive thoughts. This may include recognizing how fear, disgust, or shame can fuel resistance and reinforce the illusions of danger posed by worrying or unwanted intrusive thoughts, images, or sensations. Metacognitive therapy illuminates how compulsions, avoidance, and ruminations are mistakenly perceived as helpful, making it easier for someone to accept and tolerate temporary discomfort while giving them up.
Metacognitive therapy is individually tailored to each patient. It addresses personal beliefs about thoughts, feelings, and facts, including beliefs about uncertainty, doubts, the power of thoughts, the need for reassurance, and the desire to answer unanswerable questions about the self. It also seeks to take a metacognitive perspective — a shift in focus and attitude which allows you to observe your thinking, feelings, and reactions in real time. You can become unstuck from your obsessions as you learn how to shift your attention without urgency or effort to what matters in the moment. This will help you to refrain from getting entangled or fused with the content of your mind.
Format: Individual therapy in an outpatient or telehealth setting is the most common format for metacognitive therapy, but group therapy can also be based on metacognitive principles. Self-help resources are also available. Metacognitive therapists who treat OCD are keenly aware of how family or significant relationships can influence recovery and will include others in psychoeducation or involvement, with the patient’s agreement. There will often be collaboratively assigned, very individualized homework in the form of thought or behavioral observations or experiments to support recovery.
Finding a Qualified Provider:
Metacognitive therapy is a generic term. Therefore, the first step in finding a provider is to evaluate whether the provider has expertise in treating OCD. This should be followed by a discussion of whether or not a metacognitive approach is an option, or part of the provider's integrated approach. The prospective therapist should be familiar with concepts such as anxiety sensitivity, subtle cognitive compulsions, and paradoxical effort.
It is less important which profession a clinician is (e.g., psychiatry, psychology, social work, counselor) than that they are licensed in their profession and that they have had specialized training specifically in OCD and related conditions.
Who is best suited for this approach?
This approach is particularly well suited to people whose compulsions are primarily mental, or who have tried ERP and found it ineffective. It is also a good starting point for those who are simply bewildered by their OCD of any subtype. A metacognitive approach is also effective for people with co-occurring GAD (generalized anxiety disorder).
Because metacognitive therapies require abstract thinking abilities, they work best with older adolescents through adulthood. Young children may not yet have these abilities. People with co-occurring serious depression, psychotic disorder, or bipolar disorder may not be able to benefit until the depression is treated. Those with a strong trauma history may also benefit from addressing the trauma symptoms prior to direct work with OCD.
Summary of Research Support:
Although metacognitive therapy for OCD has not been studied extensively, a few randomized controlled trials found metacognitive therapy and ERP to have similar efficacy for OCD. Further, metacognitive approaches are grounded in more than 50 years of research on the underlying mechanisms of OCD and how those mechanisms can be modified, so there is reason to think they can be beneficial.