Marcantonio Spada is a Professor of Addictive Behaviours and Mental Health in the School of Applied Sciences where he is also the Head of the Division of Psychology and Deputy Lead of the Centre for Addictive Behaviours Research. He will be speaking at iCAAD London 2019 on: New directions for the treatment of problem drinking: Targeting metacognitive change. He has also written a blog for us on the same topic which serves to prepare us for his talk next year.

Over to Marcantonio:

Cognitive-Behavioural Therapy (CBT) is one of the treatments of choice for problem drinking, however it is not without limitations. One such limitation is that CBT does not elucidate why only a small proportion of individuals who engage in alcohol use end up losing control of their behaviour. A further limitation is the failure to establish if cognitions, such as irrational beliefs and expectancies, play a causal role in the aetiology and development of problem drinking rather than simply being an epiphenomenon of the latter. These structural weaknesses may explain CBT’s moderate effectiveness for problem drinking when compared to other forms of treatment, including medical management, treatment as usual, or active psychosocial treatments. In addition, treatment effects for CBT for problem drinking appear to diminish over time.

Together will several colleagues, I have been arguing (over the last twenty years) that a possible reason for CBT’s lack of efficacy in the treatment of problem drinking is that it does not directly tackle metacognitive change. In other words, restructuring of cognitions (the staple intervention in CBT) does not directly bring to metacognitive change. So why is it important to modify metacognitive level structures? The answer is straightforward: These structures play a fundamental role in maintaining the cognitive-affective states which in turn are likely to lead to problem drinking. In other words, if we do not modify metacognitive structures, the effort of re-appraising cognitions may be, to a large degree, in vain. This may explain, why residual symptoms are often present following CBT for problem drinking in turn increasing the likelihood of relapse. These residual symptoms include ‘dangerous’ internal experiences such as craving, obsessional thoughts about alcohol use, and the perception of lack of control over the mind and behaviour.

So, what metacognitive structures (not modified directly by CBT) may be fuelling these residual symptoms and preventing cognitive-affective change? These are metacognitive beliefs, extended thinking (desire thinking, rumination and worry), thought suppression, and metacognitive monitoring. Metacognitive beliefs are beliefs we hold about our cognitive experiences and ways of controlling such experiences. For example “I need to control my thoughts at all times” or “Having thought X means I am weak”. These beliefs have been found to be powerful predictors of problem drinking because they are linked to the activation of extended thinking and thought suppression which paradoxically heighten the same experiences we are trying to control. Metacognitive monitoring refers to the ability to monitor internal states as a guide to knowing if an internal goal has been met (for example if enough alcohol has been consumed in relation to the goal of feeling relaxed). Alcohol disrupts attentional processes and neurological systems linked to ensuring metacognitive control.

Targeting the above metacognitive structures, therefore, may be crucial in potentiating treatment outcomes. The treatment options for achieving metacognitive change are several. A primary goal, if working within a metacognitive framework, would be to socialise clients (known as ‘metalevel socialisation’) to the role of metacognitive structures in maintaining their difficulties with alcohol use. This means a specific focus on how: (1) extended thinking (desire thinking, rumination, and worry) deepens distress and may lead to uncontrolled alcohol use; (2) failures of metacognitive monitoring lead to alcohol overuse; and (3) extended thinking about alcohol use and other alcohol-related thoughts (including thought suppression) increase negative affect and the possibility of further use. Let’s look at the various techniques which can be used to bring about metacognitive change.

Metalevel Socialisation and Detached Mindfulness

Shifting to a metacognitive mode and developing detached mindfulness creates new forms of awareness of cognitive-affective states. This helps clients see that the occurrence of these states is less important than the relationship they have to them. Detached mindfulness strategies (developed by Adrian Wells and Gerald Matthews in 1994) are aimed at helping the client move to the observing stance (the metacognitive mode) with respect to cognitive-affective states. Detached mindfulness comprises two features: (1) mindfulness—an awareness of one’s internal experience; and (2) detachment—separation of sense of self from internal experience and the suspension of any extended thinking or coping activity in response to internal experience. Detached mindfulness is not a symptom management technique; it is intended to facilitate engaging in an array of flexible responses to internal events. It involves encouraging clients to observe their cravings, images, memories, and thoughts without trying to control or change them. Detached mindfulness strategies are introduced using metaphors, Socratic dialogue, and direct experiential techniques.

Attention Modification

Direct attention modification strategies are also a key component to achieve metacognitive change. In 1990 Adrian Wells developed the Attention Training Technique (ATT), which aims to improve the individual’s executive control over the allocation of attention and prioritisation of attentional processing. This strategy involves asking clients to focus on a visual fixation point and to keep their gaze on this point. While doing this, clients are directed to focus their attention on individual sounds among an array of seven or more sounds and spatial locations. They are instructed to identify individual sounds, then to rapidly switch attention between them, and finally to divide attention among them. ATT therefore emphasises that no matter what thoughts or inner or outer events occur, these are examples of “noise” that individuals can learn to see as separate from their thinking.

A second strategy developed in 2000 by Adrian Wells is called Situational Attentional Refocusing (SAR). SAR entails, when used for tackling problem drinking, encouraging clients to purposefully direct their attention to alcohol cues and refrain from any extended thinking of pleasant alcohol-related memories and images (e.g., focusing on how many drinks they have consumed rather than images of how pleasurable the next drink will be – this would be an example of ‘desire thinking’). An important application of SAR during alcohol use is to enhance metacognitive monitoring. The aim is to correct the failure of monitoring caused by alcohol use before more profound, chemical-induced failure occurs. The client is asked to focus on the impact of alcohol use on internal states as a drinking episode unfolds. This can be mapped as a timeline, helping clients see how they can choose to discontinue alcohol use as soon as they achieve a desired goal (e.g. feeling more relaxed) or in response to an external cue (e.g., quantity), whichever is most appropriate or occurs first.

Modifying Metacognitive Beliefs

When aiming to achieve metacognitive change, negative metacognitive beliefs are usually tackled first, as they tend to maintain patterns of extended thinking. Examples of negative metacognitive beliefs include “Anxious thoughts will lead me to lose control of my mind”, “My craving experiences never stop”, and “Thoughts of using alcohol make me do it”. Strategies for tackling negative metacognitive beliefs include de-catastrophising their significance through verbal reattribution (e.g. “What is the evidence for and against the idea that your experience of craving needs to be controlled?” and “Could it not be allowed to stay there as long as it needs to stay?”), strategies that directly change extended thinking (interventions aimed at interrupting desire thinking, rumination, and worry such as postponement) and practicing detached mindfulness.

Positive metacognitive beliefs (e.g., If I ruminate about the fact I used alcohol, my mood will lift because I will understand”, “If I worry, I will find a solution and be prepared ahead of the next time I may use alcohol” or “Using alcohol will help me gain control of my mind”) are linked to the activation of extended thinking. Modifying these beliefs starts with verbal reattribution, such as an advantages-disadvantages analysis (e.g., “What are the advantages and disadvantages of thinking that drinking helps you gain control or that worrying prepares you?”). This is followed by the exploration of better methods for achieving the advantages highlighted. Continuing with a similar theme, clients can be asked to explore the effectiveness of their chosen strategies in achieving their goal.

In addition to these interventions, clients are asked to conduct behavioural experiments to test their metacognitive beliefs. For example, clients often present with a metacognitive belief that if they experience a cognitive-affective state (e.g., a craving), they need to act on it. An experiment is typically devised in which clients apply detached mindfulness and postponement when confronted with the state. After this experiment, clients are encouraged to reflect on their reactions and their predictions regarding the power or persistence of the trigger.

Development of New Plans for Processing

As the metacognitive stance is strengthened, clients are encouraged to identify the coping strategies they typically use and then not engage in them, substituting these with healthy alternatives. This is done initially in session and then between sessions when clients experience cognitive-affective states associated with alcohol use. For example, clients are encouraged to enter situations that trigger craving or discomfort and to apply a new set of strategies that have been learned and consolidated in treatment.

Some Concluding Thoughts

There may be reasons why relapse rates in CBT for problematic alcohol use are high. One of the reasons is that CBT does not explicitly address the role of metacognitive change in the development and maintenance of problem drinking. Evidence of the effectiveness of targeting metacognitive change in the treatment of anxiety and depression indicates that the time may have come to address metacognitive structures in the treatment of problem drinking.

Written by Professor Marcantonio Spada