Metacognitive therapy for OCD

Melchior et al.

Metacognitive therapy for obsessive-

compulsive disorder: A case report
Kim Melchior, MSc
Ingmar H. A. Franken, PhD
Colin van der Heiden, PhD

Obsessive-compulsive disorder (OCD) is a common and disabling

disorder. The most effective psychological treatment for OCD is
currently exposure with response prevention (ERP). Although
ERP is an effective therapy, recovery rates are relatively modest,
so there is room for improvement. Metacognitive therapy (MCT)
for OCD focuses primarily on modifying metacognitive beliefs
about obsessions and compulsions, instead of their actual content.
Based on a few small preliminary studies, there are some indicati-
ons for the effectiveness of MCT for OCD. In the present article,
the metacognitive model and treatment are discussed, as well as
empirical support for its efficacy. Because detailed descriptions of
the application of this treatment modality for patients with OCD
are scarce, the authors report a case study to illustrate the content
of this form of therapy. (Bulletin of the Menninger Clinic, 82[4],
375–389)

Keywords: obsessive-compulsive disorder, metacognitive

therapy, exposure and response prevention

Obsessive-compulsive disorder (OCD) is characterized by ob-

sessions and/or compulsions that cause significant interference
with daily functioning. The lifetime prevalence of this disorder
has been estimated to be 2% (American Psychiatric Association,
2013). Both pharmacological treatment with antidepressant
drugs and specific forms of psychological treatment are effective
Kim Melchior and Colin van der Heiden are at the Outpatient Treatment Centre PsyQ
and Erasmus University Rotterdam, the Netherlands. Ingmar H. A. Franken is at Eras-
mus University Rotterdam, the Netherlands.
Correspondence may be sent to Kim Melchior, PsyQ, Max Euwelaan 70, 3062 MA
Rotterdam, the Netherlands; e-mail: k.vanrossen@psyq.nl (Copyright © 2018 The
Menninger Foundation)

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Melchior et al.

forms of treatment for OCD (Blanco et al., 2006). Meta-analytic

reviews indicate that the psychological treatment of choice for
OCD is exposure and response prevention (ERP; see Rosa-Alcá-
zar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008;
Öst, Havnen, Hansen, & Kvale, 2015; Skapinakis et al., 2016).
In ERP treatment, which is a specific type of cognitive-behav-
ioral therapy (CBT), patients are exposed to anxiety-provoking
stimuli (situations, objects, thoughts) that are avoided and/or
trigger obsessive thoughts, with the instruction to refrain from
engaging in compulsive behavior (Meyer, 1966). This procedure
is based on learning theory, in which classical conditioning is
considered to be responsible for the development of obsessions,
and operant conditioning processes maintain compulsive be-
haviors (Mowrer, 1951).
Although numerous studies have found statistically signifi-
cant change and large symptomatic improvements, the major-
ity of patients still experience distressing OCD symptoms after
ERP. More specifically, although about 60% of treatment com-
pleters achieve recovery, only approximately 25% of patients
are asymptomatic following treatment (Fisher & Wells, 2005).
In addition, approximately 30% of patients with OCD refuse
ERP or withdraw from treatment (Olatunji, Cisler, & Deacon,
2010). So it can be concluded that ERP is efficacious, but that
there is room for improvement. One promising novel approach
is metacognitive therapy (MCT; Wells, 1997, 2000). In the pres-
ent article, the metacognitive model and treatment of OCD are
discussed, using a case example.

The metacognitive model of OCD

Theoretical model
Metacognition refers to thinking about one’s own mental pro-
cesses, beliefs about thinking, and strategies used to regulate
and control thinking processes, such as thought monitoring
(Flavell, 1979). The metacognitive model of OCD concerns two
subcategories of metacognitive beliefs that are supposed to be
fundamental in the maintenance of the disorder: (a) metacogni-
tive beliefs about the significance and consequences of intrusive

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 Metacognitive therapy for OCD

Figure 1. Metacognitive model of OCD (Wells, 1997).

thoughts and feelings, the so-called fusion beliefs; and (b) beliefs
about the necessity of performing rituals. Three classes of fusion
beliefs are specified: (a) thought-action fusion (TAF; Rachman,
1993) refers to the belief that obsessional thoughts can make
someone do things he or she doesn’t want (e.g., “thinking about
jumping off the bridge will make me do it”); (b) thought-event
fusion (TEF; Wells, 1997) refers to the belief that obsessional
thought can make events happen or mean an event has happened
(e.g., “thinking about a car accident means I will be involved in
such an accident”); and (c) thought-object fusion (TOF; Wells,
2000) refers to the belief that thoughts or negative feelings can
be transferred into objects (e.g., “my feeling of disgust could be
passed into objects and from objects to other people”). Once
activated by a trigger (intrusive thought or image, an urge or
doubt), fusion beliefs give significance to obsessional thoughts,
which provokes worrying and anxiety. Consequently, patients
with OCD engage in ritual behaviors based on a second class of
metacognitive beliefs, beliefs about the necessity of performing
rituals in response to obsessive thoughts (e.g., “I must wash my
hands, otherwise I will never have peace of mind again”). These
rituals are carried out until specific internal rules (instead of ex-
ternal observation) and stop signals are met (e.g., “I must wash

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Melchior et al.

my hands until ‘it feels right’”). A key problem with these ritual
behaviors is that they prevent patients from learning that their
metacognitive beliefs about both intrusions and ritual behaviors
are inaccurate and even backfire by increasing the awareness for
intrusive experiences, as depicted in Figure 1.
There is a growing body of evidence that both thought fusion
beliefs and beliefs about rituals contribute to OCD (see Wells,
2009). For instance, a high correlation has been found between
metacognitive beliefs and OCD symptoms (Myers, Fisher, &
Wells, 2009), and metacognitive beliefs have a predictive value
for OCD symptoms (Wells & Papageorgiou, 1998).

Metacognitive therapy for OCD

Resulting from the metacognitive model, treatment should fo-
cus on modifying patients’ beliefs about the importance of in-
trusive thoughts and the necessity of performing rituals (Fisher
& Wells, 2008). Typically, metacognitive therapy for OCD con-
sists of 10–15 treatment sessions, divided into four treatment
phases as described in Table 1.
Phase 1: Case conceptualization and identification of meta-
cognitive beliefs. In the first sessions, an idiosyncratic metacog-
nitive case formulation is generated to increase patient aware-
ness of metacognitive factors maintaining OCD. Metacognitive
beliefs are identified using the OCD case formulation interview
(Wells, 2009), in which all components of the model (trigger/
intrusion, fusion beliefs, appraisal of the intrusion, beliefs about
rituals, emotions and behavioral responses) are discussed based
on the recent occurrence of an obsessive thought or image. After
the case formulation has been derived, patients are socialized to
the model. This can be achieved by explaining that obsessions
are normally occurring phenomena, by behavioral experiments
to illustrate the counterproductive effect of thought suppression
(e.g., the thought suppression experiment in which the patient is
asked to suppress the thought of a white rabbit, which is rarely
completely successful), or by questioning the consequences of
coping behaviors (e.g., “If your ritual behaviors are helping,
why do you still have a problem with OCD?”). Also, detached
mindfulness (DM) is introduced as an alternative way to engage
with obsessions. In DM, patients are asked to observe their in-

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 Metacognitive therapy for OCD

Table 1. Metacognitive treatment manual (van der Heiden et al., 2016; based on
Wells, 1997, 2009)
Phase Session Topic Techniques
1 Case conceptualization and identify- Administration of the Thought Fu-
ing metacognitive beliefs sion Instrument (TFI) and the
Beliefs About Rituals Inventory
(BARI)
Guided questioning to identify
metacognitive beliefs
Experiments to illustrate effect of
coping behavior
Detached mindfulness
2 Modifying metacognitive beliefs Questioning the evidence of fusion
about obsessive thoughts beliefs
Behavioral experiment to test fusion
beliefs (exposure with response
commission, exposure with
response prevention, or ritual
postponement and adaptive
checking)
3 Modifying metacognitive beliefs Questioning the evidence of beliefs
about ritual behaviors about rituals
Advantage-disadvantage analysis of
ritual behavior
Questioning the advantages of ritual
behavior
Ritual-modulating experiments
Response prevention to test beliefs
about rituals
4 Relapse prevention Relapse prevention
Development of a new plan for deal-
ing with obsessions

trusive thoughts and notice them as “just mental events in the

mind” instead of engaging with them. This can be achieved by
using metaphors, such as a passenger train metaphor, in which
patients are asked to deal with intrusions in the same way they
deal with a train passing through a station as just a bystander
(Wells, 2009).
Phase 2: Modifying metacognitive beliefs about obsessive
thoughts. In the second treatment phase, fusion beliefs are
modified using verbal cognitive restructuring techniques, such

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Melchior et al.

as questioning the evidence and searching for counterevidence,

as well as behavioral experiments. In MCT for OCD, three spe-
cific behavioral experiments are used to test fusion beliefs. In
exposure and response commission (ERC), patients are asked
to continue with rituals while holding their intrusions in mind
throughout. In this way, patients can obtain distance from their
intrusions and discover that they are only unimportant events in
their mind instead of subjective realities that must be controlled.
Metacognitively delivered exposure and response prevention or
ritual postponement experiments are goal-oriented and used as
a way of testing fusion beliefs. Finally, adaptive checking can
be used to collect data, instead of getting reassurance, in or-
der to modify a fusion belief. For instance, in case of a TAF
belief, “Thinking I’ve killed someone in a car accident means
that I did,” checking can be used to collect data unambiguously,
showing that the event has not occurred and the thought is only
an irrelevant event in the mind.
Phase 3: Modifying metacognitive beliefs about ritual behav-
iors. In the next phase, metacognitive beliefs about rituals are
challenged, again by using verbal interventions (e.g., question-
ing the evidence and making an advantages–disadvantages anal-
ysis) and behavioral experiments, such as a ritual modulation
experiment. In this experiment, patients are asked to alternate
between more and less ritual behavior with the aim of assessing
its impact on daily life and to test metacognitive beliefs about
the necessity of performing rituals (e.g., “I must perform my
rituals or else I will never find peace again”).
Phase 4: Relapse prevention. In the fourth and final phase,
a new plan for processing in response to intrusive thoughts is
developed. This plan consists of attentional strategies and cop-
ing behaviors opposite to the strategies and behaviors of the old
plan (e.g., applying detached mindfulness instead of worrying
about intrusions). In addition, a relapse prevention plan is de-
veloped, consisting of a summary of the therapy, the case con-
ceptualization, a list of metacognitive beliefs, and an overview
of evidence challenging them.

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 Metacognitive therapy for OCD

Gap between current treatment protocols and MCT

The key theoretical insight underpinning MCT is that disordered
higher order metacognitive processes such as beliefs about the
importance and power of thoughts are responsible for the de-
velopment and maintenance of OCD. As a result, MCT focuses
on the process rather than the content of thinking. Indeed, it
focuses exclusively on challenging metacognitive beliefs about
obsessions or compulsions and makes no attempt to modify
lower order appraisals such as inflated responsibility or perfec-
tionism, as these belief domains are thought to be products of
metacognitive beliefs (Gwilliam, Wells, & Cartwright-Hatton,
2004; Myers & Wells, 2005). The goal is to help patients bring
thinking under flexible control and discover that it is possible
to respond to negative thoughts in more adaptive ways, instead
of replacing obsessive thoughts by reality testing, as in CBT. In
addition to standard reattribution techniques such as Socratic
questioning and behavioral experiments (aimed at metacog-
nitive beliefs!), MCT uses detached mindfulness as a specific
technique to enhance flexible control and choice over reactions
to intrusions. MCT also differs from CBT, and more specifi-
cally from ERP, in that it does not include exposure exercises
aimed at habituation. Instead, behavioral experiments are used
to modify metacognitive processes. One distinct behavioral ex-
periment is ERC, aimed at enabling patients to shift to a “meta-
cognitive mode” of experiencing thoughts with the goal of illus-
trating that their intrusions do not hold any special significance
or meaning (Fisher, 2009).

Metacognitive treatment for OCD: Case conceptualization

Unique manifestation of OCD symptomatology

Thomas is a 57-year-old man referred by his general practitioner
for treatment of his long-lasting fear of contaminating himself
or other people with asbestos. His intrusive thoughts and im-
ages about asbestos contamination are sometimes triggered by
concrete stimuli, such as walking by an old house, but can also
come without an obvious trigger. Thomas believes that having

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Melchior et al.

these obsessive thoughts means he actually is contaminated (an

example of thought-event fusion), resulting in strong feelings of
anxiety. Thomas performs ritual behaviors to remain safe, such
as washing his hands a couple of times when coming home, in
order to reduce the risk of asbestos contamination. Not per-
forming his rituals seems impossible to Thomas, as he believes
he then “will never have peace of mind again” (a metacogni-
tive belief about the necessity of performing rituals). To pre-
vent intrusive thoughts from occurring, Thomas tries to avoid
situations that might trigger his obsessions and displays daily
routines, such as taking a 1-hour shower every evening. Because
he had previously received ERP twice, with only modest and
short-term results, MCT was offered as a new and promising
treatment to Thomas.

Treatment

Assessment
At pretreatment assessment, Thomas’s total score on the Yale–
Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al.,
1995), a clinician-rated semistructured interview for measuring
OCD symptoms, was 21, which can be classified as “moderate”
in comparison with the scores of other OCD patients. On the
Padua-Inventory Revised (Padua-IR; Burns, Keortge, Formea,
& Sternberger, 1996), a self-report scale for measuring OCD
symptoms, Thomas’s pretreatment score was 53, which is “be-
low average” in comparison with the scores of other OCD pa-
tients (van Oppen, Emmelkamp, van Balkom, & van Dyck,
1995).

Interventions
Treatment started with the administration of the OCD case for-
mulation interview. A verbatim fragment from this interview is
shown below.
Therapist: Do you believe your thoughts about being contaminated
with asbestos mean something? (identifying fusion beliefs)

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 Metacognitive therapy for OCD

Thomas: Yes, especially when a specific thought keeps coming, I

become anxious.
Therapist: What does it mean to you when a thought keeps coming
back?
Thomas: When I cannot get rid of a thought, I start to believe that
the thought will warn me.
Therapist: Warn you for what?
Thomas: That what I am thinking has actually happened. That I
really am contaminated with asbestos. That’s what frightens me.
Therapist: How much do you believe that having these thoughts
about being contaminated means you actually are contaminated?
Thomas: At the moment of occurrence, 100%.
Therapist: Did you do anything to prevent contamination with as-
bestos? (identifying behavioral responses)
Thomas: Yes. By washing my hands over and over again.
Therapist: What is the worst that could happen if you shouldn’t do
those things? (identifying beliefs about rituals)
Thomas: Then I can’t relax ever again.
Therapist: How do you know when the contamination is over and
you can stop washing? (identifying stop signals)
Thomas: I have no idea; I stop when I feel that it is okay to stop.

The resulting case conceptualization is displayed in Figure 2.

After the case formulation was derived, psychoeducation
about the metacognitive model and intrusions was given.
The fact that approximately 80% of people experience intru-
sive thoughts occasionally (Rachman & de Silva, 1978) made
Thomas realize that obsessions might not be the main problem,
because this percentage is much higher than the actual number
of patients suffering from OCD. Next, detached mindfulness
was introduced. After 2 weeks of practicing detached mindful-
ness with the passenger train metaphor every day for at least 15
minutes, Thomas noticed that both the duration and the fre-
quency of his obsessive thoughts had lessened.
The second treatment phase turned out to be the most helpful
part of the therapy for Thomas. This seemed mainly due to the
behavioral experiments for modifying fusion beliefs, which are
described below.

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Melchior et al.

Figure 2. Case conceptualization of Thomas's fear of asbestos.

Experiment 1: Adaptive checking experiment. Thomas was

asked to go home when he was having intrusive images of his
house being on fire to check if his house was actually on fire. The
purpose of this experiment was to test his TEF belief, “Thinking
my house is on fire means my house is on fire.” Because he re-
peatedly discovered that his house was not on fire, he concluded
that these images were only events in his mind without actual
meaning or power to cause an event to occur.
Experiment 2: Exposure with response commission experi-
ment. Thomas practiced with washing his hands repeatedly
while holding the obsessive thought “I am contaminated” in
mind throughout his ritual. After a while, Thomas felt silly do-
ing this and experienced a meta-level of the intrusion as “just a
disturbing but meaningless event in my mind.”
Experiment 3: Metacognitively delivered exposure with re-
sponse prevention experiment. Thomas was asked to contami-
nate water with his own old mercury thermometer and then

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 Metacognitive therapy for OCD

spray this “contaminated” water everywhere in the therapist’s

office without performing any ritual behavior. At first, intrusive
thoughts about contamination emerged, meaning that the of-
fice actually was contaminated (TEF). However, after a while
Thomas realized that there were no actual signs of contami-
nation, which he considered to be evidence for the alternative
thought “the problem is only thoughts about contamination,
not contamination itself.” Again, Thomas concluded that in-
trusive thoughts about contamination were only meaningless
events in his mind.
Although his metacognitive beliefs about rituals were not tar-
geted at this point in treatment, both Thomas’s ritual behaviors
in reaction to obsessive thoughts and his avoidance behavior
were reduced after the second phase of therapy. In the third
phase, an advantage–disadvantage analysis of his daily rituals
without a clear relation to obsessive thoughts, such as shower-
ing for more than 1 hour every day, revealed that the amount
of time spent on rituals was most important to Thomas, and
outweighed the advantages. When the therapist asked Thomas
why he still had problems with OCD if his rituals made him feel
comfortable, Thomas realized that his rituals did not help him
overcome his OCD. This notion was reinforced by carrying out
a ritual modulating experiment, which is described below.
In a ritual modulating experiment, Thomas was asked not
to take a shower for one evening (Day 1), whereas he was al-
lowed to perform his ritual the next day (Day 2), in order to test
his belief that not performing his rituals will cause him terrible
distress and a sleepless night. On both days, he monitored his
degree of distress and his ability to sleep. Thomas reported be-
ing distressed both nights, the first night because of not being
allowed to take a shower and the second night because of the
amount of time spent on his ritual behavior. On both nights,
Thomas slept through the night, leading him to the conclusion
that he does not need his rituals in order to sleep. He further
noticed that on Day 1, he spent his free time watching a movie,
which made him feel happy, whereas he did not have time for
relaxing activities on Day 2 because of his time-consuming rit-

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Melchior et al.

ual. The credibility of his belief, “I need to perform my rituals,

otherwise I will never have peace of mind,” lowered to zero.
Finally, the therapist and Thomas worked on a relapse pre-
vention plan. The most important element in his old plan for
dealing with obsessions was “trying to get rid of the thought,”
which was driven by his fusion belief: “If I cannot get rid of a
thought, then it will happen.” Adaptive checking while holding
the obsessive thought in mind was the most helpful strategy for
Thomas, because this convinced him that obsessive thoughts by
themselves had no meaning or power. Other strategies in his
new plan were applying detached mindfulness and reading his
advantage–disadvantage analysis to remember that performing
rituals is not necessary in order to relax.

Treatment outcomes
After treatment, Thomas no longer fulfilled the DSM-IV diag-
nostic criteria for OCD as assessed by the SCID-I. Scores on
the OCD self-report measures decreased from 21 (moderate)
to 1 (very low) on the Y-BOCS and from 53 (below average)
to 20 (very low) on the Padua-IR. In terms of clinically sig-
nificant change, Thomas was classified as asymptomatic on the
Y-BOCS (the most stringent criterion for defining recovery; Ja-
cobson & Truax, 1991) because his posttreatment score on this
measure met criteria for reliable change (a minimal reduction of
10 points on the Y-BOCS) and was below the cutoff score of 7,
which indicates an absence of OCD symptoms (Fisher & Wells,
2005). Interestingly, scores on two questionnaires measuring
OCD-specific types of metacognitions also decreased substan-
tially. On the Thought Fusion Instrument (TFI, Wells, Gwilliam,
& Cartwright-Hatton, 2001), a self-report questionnaire mea-
suring fusion beliefs, Thomas’s score decreased from 590 at the
start of treatment to 130 after treatment. On the Beliefs About
Rituals Inventory (BARI; McNicol & Wells, 2012), Thomas’s
score decreased from 44 to 19. Together, these results suggest
that the correction of metacognitive beliefs is the specific vehicle
that is responsible for the treatment gains. Treatment gains were
maintained at 3-month follow-up.

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 Metacognitive therapy for OCD

Conclusions

Results and impact on field

In the case of Thomas, MCT appeared to be an efficacious treat-
ment for OCD. This is in line with preliminary evidence from
pilot studies supporting the efficacy of MCT for OCD, showing
significant and large decreases on both OCD-specific and gen-
eral outcome measures, as well as high recovery rates (Fisher
& Wells, 2008; Rees & van Koesveld, 2008; van der Heiden,
van Rossen, Dekker, Damstra, & Deen, 2016). However, fur-
ther research comparing MCT to other active treatments for
OCD is necessary to study the relative effectiveness of this in-
novative treatment. Therefore, we recently set up a randomized
controlled trial (RCT) with a pretest-posttest 6- to 30-month–
follow-up design to compare MCT with ERP, the current gold
standard for OCD patients.

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