Metacognitive Therapy for Social Anxiety Disorder

“Try to pose for yourself this task: not to think of a polar bear, and you will see that cursed thing come to mind every minute.”

Fyodor Dostoevsky, Winter Notes on Summer Impressions, 1863

In anticipation of a feared social situation, many people with social anxiety disorder (SAD) experience some form of negative thinking.

“What if they notice my anxiety?”

“What if they reject me?“

“I can’t give this presentation, I’m too nervous.“

“People will ridicule me if I make a mistake.“

Traditionally, cognitive behavioral therapy (CBT) argues that negative thoughts like these are the reason why people develop psychological problems, such as anxiety disorders and depression (e.g., Beck, 1976; Ellis & Harper, 1961).

However, when we think about it critically, we realize that most people are familiar with negative thoughts of this kind, but not all of us are affected by mental health conditions.

So, what determines whether or not these thoughts lead to a psychological disorder, such as SAD?

Metacognitive therapy proposes a fresh perspective.

It Is Not What People Think, But How They Think

Adrian Wells (2009), Professor of Clinical and Experimental Psychopathology at the University of Manchester, argues that what regulates people’s emotional experiences and their ability to control them is not what they think, but how they think.

He has coined the term metacognition, which refers to beliefs about thinking.

For example, you may hold the belief that it is helpful to worry about future social situations, as this may prepare you for all the things that could possibly go wrong.

In this case, Wells argues, it is not so much about the specific content of your thoughts (e.g., “What if they reject me?“), but rather about the process in which your thoughts are engaged: worrying.

Let’s have a look at how these two different points of view are handled in therapy.

Traditional CBT vs Metacognitive Therapy

As mentioned above, traditional CBT argues that thoughts related to danger lead to anxiety and can eventually cause a disorder (Beck, 1976).

Based on this idea, therapist and patient team up to explore the specific content of the patient’s thoughts.

“I’m sure they will reject me.”

“I am not worthy of love and acceptance.”

Once identified, these thoughts are treated as fallible hypotheses and are critically examined for their accuracy and usefulness.

Metacognitive theory, in contrast, argues that such negative thoughts do not cause anxiety disorders (Wells, 1995).

Instead, it points out the crucial role of metacognitions (ideas about thinking) for the development of mental health conditions, such as social phobia (Wells, 2009).

According to this theory, inaccurate metacognitions tend to lead to maladaptive thinking styles, and these are the underlying reason for disproportionate emotional responses, such as those found in people with social anxiety.

Therefore, metacognitive therapy tries to identify the patient’s maladaptive ideas about thinking.

This can be achieved by focusing on the thought processes the patient engages in when experiencing intense emotional reactions, such as anxiety or shame.

For example, people with SAD tend to ruminate excessively about past social mishaps, driven by the underlying belief (metacognition) that this will help them avoid similar social situations in the future.

Let’s have a look on the most common metacognitions of people with social anxiety.

“I can prepare myself for the worst-case outcomes by playing them through in my mind repeatedly.” – Anticipatory anxiety

“Analyzing in detail my performance in past social situations and dwelling on embarrassing situations will improve my future performance.” – Rumination

“Being alert to my physical arousal and external threats in social situations will help me control them.” – Heightened self-awareness and threat-focus

“It is possible and beneficial to avoid certain thoughts.” – Thought-suppression

If you suffer from social phobia, you probably identify with one or several of the above convictions.

According to metacognitive therapy, these faulty metacognitions cause and maintain your social anxiety, as they lead to the so-called cognitive attentional syndrome.

By the way, if you want to learn more about traditional (and quite effective) CBT for social anxiety, you should click here to go to our article on this topic. It will help you get a comprehensive understanding of this widely used treatment approach.

Cognitive Attentional Syndrome & Social Anxiety

Maladaptive thinking styles, such as engaging in excessive rumination or trying to suppress anxiety-provoking thoughts, tend to lead to a specific way of thinking.

Wells and Mathews (1996) have coined the term cognitive attentional syndrome to refer to it.

As the cognitive attentional syndrome is linked to unhelpful thought processes, it is seen as the main reason why some people get trapped into certain emotions (such as anxiety in social situations), while other people can move on relatively quickly when facing them (Wells, 2009).

For example, people with public speaking anxiety tend to get trapped in their feelings of nervousness, as they pay close attention to their physical arousal and try to consciously reduce it.

These attempts, which are driven by the metacognition that they are useful and will reduce anxiety, are the reason why their anxiety exacerbates rather than subsides.

Since faulty, inaccurate, and unhelpful metacognitions lie at the very root of the cognitive attentional syndrome, they are the main target in metacognitive therapy.

What Is Metacognitive Therapy?

Metacognitive therapy (Wells, 2007) proposes a shift in focus: Away from negative thoughts about oneself, others, and the world, and towards our beliefs about the usefulness of certain thinking styles.

It suggests an examination of the ideas we have about our own thinking, such as “It is helpful to worry about the future“, or “It is important to control my thoughts”.

Wells points out that patients can regain a good level of control over their emotions if they learn to accept intrusive and automatic thoughts.

He recommends that you critically examine your metacognitions and adjust them accordingly if you feel they are inaccurate and harmful.

The following questions can help you get started with this task:

• Is it really helpful to worry excessively about everything that can go wrong, or does it get to a point where it only increases your anxiety?
• Do you really benefit from ruminating endlessly about past social faux-pas?
• Does it make sense to focus on your physical arousal and external social threats rather than actively engaging in the social situation?
• Do your attempts to suppress specific thoughts work? What if you allowed them to arise and shifted your focus back to the social situation?

However, to really bring about significant and lasting change, we recommend you start a therapeutic process.

To learn more about your options, click here to check out our eBook that provides a complete overview and summary of effective psychotherapies for social anxiety.

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