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Letters to the Editor   |    
Meta-Cognitive Therapy Without Metacognition: A Case of ADHD
Adrian Wells, Ph.D.; Peter Fisher, Ph.D.
Am J Psychiatry 2011;168:327-327. doi:10.1176/appi.ajp.2010.10101467
View Author and Article Information
United Kingdom

The authors report no financial relationships with commercial interests.

This letter was accepted for publication in December 2010.

Accepted December , 2010.

To the Editor: In the August 2010 issue of the Journal, Mary V. Solanto, Ph.D., et al. (1) reported promising treatment effects for meta-cognitive therapy on adult attention deficit hyperactivity disorder (ADHD). This treatment combined traditional cognitive-behavioral therapy (CBT) with time management and organization skills training and warrants further evaluation. However, it is important to raise questions concerning the true nature of this treatment and its labeling as a meta-cognitive intervention.

The treatment does not directly attempt to modify metacognition, defined as thoughts or beliefs about cognition and the strategies used to control attention and thinking. It is therefore misleading to refer to this treatment as "meta-cognitive therapy."

Solanto and colleagues' approach was grounded in the cognitive rather than the meta-cognitive domain. This is because it consisted of enabling participants to break down tasks into manageable chunks (a cognitive skill) and to visualize long-term reward along with CBT for depressive and anxious thoughts (manipulating cognitive content).

A meta-cognitive approach to training executive control or attention skills would look very different. Meta-cognitive therapy for ADHD would challenge beliefs about attention, worry, and rumination and train individuals to disengage task-interfering cognitions and resist distraction. Attention skills might be directly facilitated by exercises in the flexible control of attention by methods such as the attention training technique (2).

In contrast, Solanto et al. (1) modify the content of cognition (e.g., challenge negative thoughts and help individuals break tasks down). Although useful, cognition-focused interventions do not examine and directly change the metacognitions that control thinking and give rise to unhelpful patterns of attention. Some evidence exists that cognitive interventions do change metacognition (3), but they do not do this directly or optimally.

Why does any of this matter? Because there is well-defined meta-cognitive therapy (45) for psychological disorders that operates directly on metacognition. It has taken many years for the distinction between CBT and meta-cognitive therapy to be realized (6), and the mislabeling of treatments is a regressive step.

Solanto  MV;  Marks  DJ;  Wasserstein  J;  Mitchell  K;  Abikoff  H;  Alvir  JMJ;  Kofman  MD:  Efficacy of meta-cognitive therapy for adult ADHD.  Am J Psychiatry 2010; 167:958—968
[CrossRef] | [PubMed]
 
Wells  A:  Panic disorder in association with relaxation-induced anxiety: an attentional training approach to treatment.  Behaviour Therapy 1990; 21:273—280
[CrossRef]
 
Solem  S;  Haland  AT;  Vogel  PA;  Hansen  B;  Wells  A:  Change in metacognitions predicts outcome in obsessive-compulsive disorder patients undergoing treatment with exposure and response prevention.  Behav Res Ther 2010; 47:301—307
[CrossRef]
 
Wells  A:  Meta-cognition and worry: a cognitive model of generalized anxiety disorder.  Behav Cogn Psychother 1995; 23:310—320
 
Wells  A:  Metacognitive Therapy for Anxiety and Depression.  New York,  Guilford, 2009
 
Fisher  P;  Wells  A:  Metacognitive Therapy: Distinctive Features.  Hove, UK,  Routledge, 2009
 
References Container
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References

Solanto  MV;  Marks  DJ;  Wasserstein  J;  Mitchell  K;  Abikoff  H;  Alvir  JMJ;  Kofman  MD:  Efficacy of meta-cognitive therapy for adult ADHD.  Am J Psychiatry 2010; 167:958—968
[CrossRef] | [PubMed]
 
Wells  A:  Panic disorder in association with relaxation-induced anxiety: an attentional training approach to treatment.  Behaviour Therapy 1990; 21:273—280
[CrossRef]
 
Solem  S;  Haland  AT;  Vogel  PA;  Hansen  B;  Wells  A:  Change in metacognitions predicts outcome in obsessive-compulsive disorder patients undergoing treatment with exposure and response prevention.  Behav Res Ther 2010; 47:301—307
[CrossRef]
 
Wells  A:  Meta-cognition and worry: a cognitive model of generalized anxiety disorder.  Behav Cogn Psychother 1995; 23:310—320
 
Wells  A:  Metacognitive Therapy for Anxiety and Depression.  New York,  Guilford, 2009
 
Fisher  P;  Wells  A:  Metacognitive Therapy: Distinctive Features.  Hove, UK,  Routledge, 2009
 
References Container
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