This PhD investigated the efficacy of individual therapies for depression and went on to test metacognitive therapy (MCT) for major depressive disorder (MDD) in individual therapy and in transdiagnostic groups consisting of a range of disordersStudy 1 included a systematic review of meta-analyses comparing the effects of individual therapy for MDD across studies. The findings show small to moderate effect sizes between g=0.25 to d= 0.69 and recovery rates 34% to 47.9% for ITT analyses. However, studies are biased and lack objective definitions of recovery, remission and clinically meaningful change which makes comparisons across studies challenging. Study 2 aimed to test MCT in a single case study with four depressed Danes in an outpatient setting. Three out of four patients reached recovery levels (BDI-II smaller or equal to 8) in only five to eleven sessions and all four patients were recovered at 6-months follow-up. Study 3 involved a large randomised clinical trial (n= 153) in which the effect of MCT was compared to cognitive behaviour therapy (CBT) for MDD. Patients were allocated to up to 24 sessions of treatment and were assessed at pre, post and 6 months follow-up on primary and secondary measures. The mean number of sessions were significantly lower for MCT (5.5; SD = 2.4 versus 6.7; SD = 4.7) and MCT showed a higher completion rate (73.6% versus 65.4%). Both treatments were associated with significant improvements in depression measured with the HDRS and BDI-II. MCT was superior in its effects on the BDI-II and on secondary measures, showing a clear advantage of MCT. . Large ES were detected in both MCT and CBT. Using Jacobson and Truax (1991) criteria revealed that 76% reached recovery levels at post-treatment in MCT whereas 54% reached recovery in CBT. These findings were maintained for both conditions at 6-months follow-up. Study 4 evaluated the effect of MCT in a 6-week treatment protocol for mixed groups of diagnosis in an open trial (n= 131). Significant improvements were observed in outcomes and 85% of patients were reliably improved at post-treatment as measured on the HADS. These findings were maintained at follow- up and the treatment appeared effective in both anxious and depressed cases. In conclusion existing treatments for depression are effective but there is much room for increasing efficacy. MCT appeared more effective than a current treatment of choice; CBT in depression. MCT was also associated with significant improvement in anxiety and depression in patients in a transdiagnostic group setting. The results support the future study and implementation of MCT as an effective treatment option.

Indiana University-Purdue University Indianapolis (IUPUI) / Formal thought disorder (FTD) is a debilitating symptom of psychosis. It is linked to functional deficits and generally demonstrates poor response to interventions. Metacognition has emerged as a potential therapeutic target that may be effective in reducing FTD, as metacognitive deficits and FTD both arise from disruptions in associative thought processes. This study’s primary aim was to determine whether FTD could be reduced with metacognitive therapy. Pre-post changes in FTD severity were assessed using clinician-rated and automated measures in 20 individuals with psychotic disorders who received 12 sessions of evidence-based metacognitive therapy. We also examined whether reductions in FTD were larger when assessed with automated instruments versus clinician-rated measures. Aim two compared associations between FTD and three outcome variables (social functioning, role functioning, metacognition) across FTD-measurement approach. Results indicated that automated FTD, but not clinician-rated FTD, was significantly reduced post-intervention. This effect was more robust within a subsample exhibiting greater levels of FTD. Strength of associations between FTD and outcome variables did not differ across FTD measurement approach. These findings provide initial evidence that a targeted metacognitive intervention can reduce FTD. Effects were strongest for automated instruments, which may be more sensitive to detecting change; however, differences in measurement type did not extend to associations with selected outcome variables. This study provides preliminary support for future efforts to reduce FTD. Large-scale studies with longer intervention periods may further our understanding of the effectiveness of metacognitive intervention on FTD.

This PhD investigated the theoretical and clinical applications of a meta-cognitive model of psychological disorders in social anxiety. The main objective was to identify potential associations between meta-cognitive knowledge (i.e. meta-cognitive beliefs) and social anxiety. These associations could be direct or indirect via information-processing mechanisms, such as anticipatory processing (AP), focus of attention, and post-mortem processing (PM). The current thesis reports six studies (N = 686).Study 1 explored cross-sectionally the potential contribution of meta-cognitive beliefs about general worry to social anxiety. The results showed that positive and uncontrollability beliefs along with AP were individual positive predictors of social anxiety. Furthermore, these beliefs had an indirect effect on social anxiety through anticipatory processing and the post-mortem. These results prompted further exploration of the nature of meta-cognitive beliefs in social anxiety. Study 2 employed semi-structured interviews to elicit meta-cognitive beliefs that could be specific to social anxiety. High and low socially anxious individuals reported beliefs about anticipatory processing, focusing on an observer perspective (OP) self-image, and the post-mortem. The high socially anxious group reported greater engagement in both AP and focusing on the OP, and spending greater time trying to control AP, OP, and the post-mortem. Moreover, the two groups differed in beliefs about these mechanisms, in coping strategies, and in stop signals. The beliefs elicited informed two new questionnaires that were investigated in Study 3. Each questionnaire revealed three subscales of positive and negative beliefs about AP and about the OP self-image, respectively. The subscales showed good reliability and stability. In addition, the new beliefs revealed further associations with social anxiety. Study 4 investigated whether meta-cognitive beliefs could affect attentional bias in social anxiety. High and low socially anxious individuals completed a dot-probe task with emotional, social and physical words matched with neutral words. The results indicated a potential moderation effect of social anxiety and positive meta-cognitive beliefs on attentional bias. Moreover, meta-cognitive beliefs predicted attentional bias in both social anxiety groups. The above results implicated meta-cognitive beliefs in the maintenance of social anxiety. Study 5 explored whether these beliefs could affect state anxiety in high socially anxious individuals that engaged in either AP or a distraction task prior to giving a speech. The results replicated previous findings that AP was associated with more anxiety compared with distraction. Additionally, uncontrollability beliefs were associated with increased state anxiety before the speech, while positive beliefs interfered with distraction and were associated with the maintenance of anxiety after the speech was over. Finally, Study 6 explored whether a meta-cognitive intervention could be effective in the treatment of social anxiety. In a cross-over design, high socially anxious individuals practiced detached mindfulness and thought challenging prior to giving a speech. The results showed that detached mindfulness was associated with greater reductions in negative beliefs, worry, and the OP. In conclusion, the results of a series of studies support the application of the meta-cognitive model to social anxiety.

Many of the symptoms characteristic of PTSD such as hypervigiliance towards threat, involve attentional processes. The first part of this thesis explored the role of attentional processes in the maintenance and treatment of PTSD. Although general models of anxiety give attentional processes central prominence cognitive models of PTSD (e.g., Foa & Riggs, 1993; Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000) assign an important role to trauma memory and place little or no emphasis on the role of attentional processes in maintaining symptoms. Models of anxiety have suggested that attentional bias is automatic (Mathews & Macleod, 2002) or strategic (Wells & Mathews, 1994). Wells' (2000) Metacognitive Model of PTSD is one of the few models to emphasis thinking style and attention rather then memory. In this model attentional bias is thought to be strategic in nature. The evidence reviewed supports a role of attention in PTSD and suggests it may be beneficial to modify this process. Two different attention techniques based on models of bias are reviewed.The second part of the thesis described a randomized controlled evaluation of attentional training technique (ATT; Wells, 1990) on traumatic stress symptoms in a sample of 60 university students, who had previously experienced a stressful life event. ATT is a technique used in metacognitive therapy to modify the control of attention. Participants were randomly assigned to either an ATT group (n = 29) or a control group (n = 31). An emotional attention set shifting task was included as an objective measure of attention. The results supported the hypotheses, ATT reduced intrusions and negative affect, increased self-report attention flexibility and modified performance on the attention set shifting task. The results are consistent with the metacognitive model of PTSD. Theoretical and clinical implications are discussed and the results add to studies suggesting positive effects of the technique across a range of disorders.The third part critically reflected on methodological and ethical issues from the above research study. The interpretation of the findings is limited by the student population. It is acknowledged that the results are preliminary in nature but it is believed that the study provides useful insights into the role of attentional processes in the development and treatment of traumatic stress symptoms and provides a basis for studies in the future.

<p>Formal thought disorder (FTD) is a debilitating symptom of psychosis. It is linked to functional deficits and generally demonstrates poor response to interventions. Metacognition has emerged as a potential therapeutic target that may be effective in reducing FTD, as metacognitive deficits and FTD both arise from disruptions in associative thought processes. This study’s primary aim was to determine whether FTD could be reduced with metacognitive therapy. Pre-post changes in FTD severity were assessed using clinician-rated and automated measures in 20 individuals with psychotic disorders who received 12 sessions of evidence-based metacognitive therapy. We also examined whether reductions in FTD were larger when assessed with automated instruments versus clinician-rated measures. Aim two compared associations between FTD and three outcome variables (social functioning, role functioning, metacognition) across FTD-measurement approach. Results indicated that automated FTD, but not clinician-rated FTD, was significantly reduced post-intervention. This effect was more robust within a subsample exhibiting greater levels of FTD. Strength of associations between FTD and outcome variables did not differ across FTD measurement approach. These findings provide initial evidence that a targeted metacognitive intervention can reduce FTD. Effects were strongest for automated instruments, which may be more sensitive to detecting change; however, differences in measurement type did not extend to associations with selected outcome variables. This study provides preliminary support for future efforts to reduce FTD. Large-scale studies with longer intervention periods may further our understanding of the effectiveness of metacognitive intervention on FTD. </p>

The first part of this thesis explores the potential role of metacognitive beliefs and strategies in functional somatic symptoms. Current models (for example, Brown, 2004; Deary, Chalder and Sharpe, 2007) and treatments of functional somatic symptoms focus on cognitive models and cognitive behavioural treatments which show modest treatment effects. A metacognitive account is discussed based upon supervisory regulatory executive function theory (SREF; Wells and Matthews, 1994) and research is systematically reviewed which may support such an account. Current research offers limited indirect support for metacognitive factors playing a role in the difficulties of people suffering from functional somatic symptoms. This paper concludes that further research is needed in this promising area. The second part of the thesis describes a cross-sectional correlational study which examines the relationship of somatic symptom reporting in primary care with metacognitive beliefs, finding a significant association for the first time. Fifty patients were recruited from general practice surgeries took part in the study. Support for the novel Metacognitive Health Questionnaire measure was also found. This measure showed significant associations between health specific metacognitive beliefs and body focussed attention, health preoccupation and distress. This measure also showed significant associations with illness behaviours and thought control strategies. Each of these findings is in line with SREF theory. This study provides preliminary support for the role of metacognition in symptom reporting. The third part of the thesis critically evaluated issues salient to the study including methodologically, supervisory, ethical and clinical issues. The interpretations of the literature review and findings of the research paper are limited by the lack of direct findings to support a metacognitive account, and the cross sectional nature of this study. It is hoped that the prospective study which the research study reported forms part, will offer more robust insights into the role of metacognition in symptom reporting, and that future studies will examine this area further.

Metacognitive therapy (MCT) has been shown to be a promising treatment approach for obsessive-compulsive disorder (OCD). The changeability of metacognitions by (metacognitive) treatment and its relevance to treatment outcome is, however, still unclear. The current study investigates, (1) if treatment with MCT or exposure and response prevention (ERP) in a randomized-controlled pilot trial (n = 24 patients with OCD) changes OCD-specific metacognitions of thought fusion beliefs, beliefs about rituals and stop signals, and (2) if these changes are relevant for the treatment outcome in terms of patient- and therapist-rated OCD symptoms. ANOVA with pretest, posttest and follow-up scores could show that all three metacognitions significantly decreased during both treatments. Regarding thought fusion beliefs, a significant interaction effect indicated a higher decrease after MCT than ERP treatment. In hierarchical regression analyses, changes in stop signals from pre- to post-treatment significantly predicted patient-rating OCD symptoms at post-treatment and follow-up at 3 months after treatment. These changes were even predictive of post-treatment outcome after controlling for general metacognitions and dysfunctional cognitive beliefs. These findings support the assumption thatmetacognitions can change during both treatments and that changes in stop signals might be relevant for the treatment outcome on the symptom level in OCD.

Behavior therapy of obsessive-compulsive disorder (OCD) aims to reduce avoidance, rituals, and discomfort in OCD-relevant situations. The Behavioral Avoidance Test (BAT) measures these behavior-related outcomes in individually challenging OCD-related situations. The association of the BAT with OCD severity measures and its relevance for treatment outcome is, however, still unclear. The current study investigates with a retrospective analysis of a subsample of a pilot study, (1) if reactions on the BAT are related to OCD severity measures in an OCD sample (n = 28), (2) if treatment with two variants of cognitive-behavior therapy (exposure and response prevention vs. metacognitive therapy) changes the BAT scores and (3) if these changes as well as pretreatment BAT avoidance are relevant for OCD treatment outcome as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Participants rated avoidance, ritual, and discomfort in three individually challenging OCD-related situations before and after therapy. For one of these situations, BAT dimensions were rated by the therapist and an independent rater in addition to the patients’ ratings. Correlational analyses found significant correlations between BAT discomfort and OCD severity measures like the Y-BOCS. A repeated measures ANOVA with pre- and posttest scores showed that all three BAT dimensions significantly decreased during both treatments. Hierarchical regression analyses (controlling for Y-BOCS pretest scores) revealed that changes in BAT discomfort as well as pretreatment BAT avoidance scores predicted the Y-BOCS posttest score. These findings suggest that the BAT is a distinct measure of behavior-related outcomes partly being relevant for OCD treatment outcome.

Thesis (MEd)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: This study was designed to investigate whether metacognitive instruction could be used to improve the reading comprehension of isiXhosa-speaking English Second Language (ESL) learners in the FET phase. The metacognitive instruction encompassed increasing the learners’ metacognitive awareness, equipping them with metacognitive reading strategies and facilitating the transfer of these strategies to content subjects such as Life Sciences and Geography. The Vygotskian sociocultural theory that accounts for the roles of social, cultural, and historical contexts in comprehending text during academic reading tasks provided an appropriate theoretical framework for conducting the research. The study was comprised of one cycle of action research, framed within a paradigm of praxis. It took place in a high school in a disadvantaged community in the Western Cape Province of South Africa. A qualitative methodology allowed for in-depth insight into the metacognitive habits of ESL learners through various forms of data collection. Eight participants in Grade 10, ranging between 16 and 19 years of age, took part in the study. Their reading comprehension abilities varied, as did their English proficiency. The data were presented as collected in the phases of the action research cycle and summed up in three data processes. Each data set was embedded in the chronological timeline of the study’s progress and discussed in light thereof. Three broad themes were derived from the data, using qualitative content analysis. The data revealed that metacognitive instruction can improve the English reading comprehension of isiXhosa-speaking learners. This was reflected in both the quantitative and qualitative data sets. The quantitative data were used descriptively and interpreted qualitatively, in line with the qualitative methodology. The results of the study indicated that before metacognitive instruction can be successful, language proficiency, basic linguistic skills, and mental representations are crucial. The findings showed that mind mapping and constructing mental representations of the text are two effective metacognitive reading strategies that are easily transferable across the curriculum. They also revealed the strong link between culture and reading practices amongst different population groups. Cultural understandings of concepts such as respect and authority had a profound influence on the learners’ considerations of what it means to learn, read and understand. / AFRIKAANSE OPSOMMING: Hierdie studie het ten doel gehad om te bepaal of metakognitiewe onderrig aangewend kan word ter verbetering van leesbegrip by Xhosasprekende leerders wat Engels Tweede Taal (ETT) in die fase verdere onderwys en opleiding (VOO) neem. Metakognitiewe onderrig het behels om die leerders se metakognitiewe bewustheid te verhoog, hulle dan met metakognitiewe leesstrategieë toe te rus, en hulle laastens daardie strategieë na inhoudsvakke soos Lewenswetenskappe en Geografie te laat oordra. Vygotsky se sosiokulturele teorie het ’n toepaslike teoretiese raamwerk gebied vir die navorsing, wat die rol van sosiale, kulturele en historiese kontekste in teksbegrip gedurende akademiese leestake in ag geneem het. Die studie het uit een siklus aksienavorsing binne ’n praktiese paradigma bestaan. Dit is in ’n hoërskool in ’n benadeelde gemeenskap in die provinsie Wes-Kaap, Suid-Afrika, onderneem. ’n Kwalitatiewe metodologie het deur middel van verskeie vorme van data-insameling diepe insig in die metakognitiewe gewoontes van ETT-leerders gebied. Altesaam agt graad 10-leerders van tussen 16 en 19 jaar, met wisselende leesbegripvermoëns én vaardigheid in Engels, het deelgeneem. Die data is aangebied soos dit in die fases van die aksienavorsingsiklus ingesamel is, en is in drie dataprosesse saamgevat. Elke datastel is op die chronologiese vorderingstydlyn van die studie geplaas en teen daardie agtergrond bespreek. Drie algemene temas is met behulp van kwalitatiewe inhoudsontleding uit die data afgelei. Die data het getoon dat metakognitiewe onderrig wél Xhosasprekende leerders se leesbegrip in Engels kan verbeter. Dít het uit sowel die kwantitatiewe as kwalitatiewe datastelle geblyk. In pas met die kwalitatiewe metodologie, is die kwantitatiewe data beskrywend aangewend en kwalitatief vertolk. Die studie het beklemtoon dat taalbedrewenheid, basiese taalvaardighede en geestesvoorstellings noodsaaklik is vir suksesvolle metakognitiewe onderrig. Die bevindinge toon dat konsepkaarte (“mind mapping”) en die konstruksie van geestesvoorstellings van die teks twee doeltreffende metakognitiewe leesstrategieë is wat maklik op die hele kurrikulum toegepas kan word. Die studie het ook ’n sterk verband tussen kultuur en leespraktyke onder verskillende groeperinge uitgewys. Die kulturele begrip van konsepte soos respek en gesag het ’n diepgaande invloed gehad op wat die leerders onder ‘leer’, ‘lees’ en ‘begryp’ verstaan het.