Counselling Psychology Quarterly,

Vol. 17, No. 2, 2004, pp. 223–234

THEORY AND PRACTICE

Current developments of
metacognitive concepts and their
clinical implications: mindfulness-
based cognitive therapy for
depression
NICOLE SCHERER-DICKSON
Anorexia Nervosa Intensive Treatment Team (ANITT), Edinburgh, UK

abstract High relapse and recurrence rate of depression put financial pressure on already
stretched resources for health care. Therefore, the demand for the development of prophylactic
treatments in order to keep patients well, once recovered, has increased during the last decade. The
development of a new therapy manual for group interventions, ‘Mindfulness-based Cognitive
Therapy for Depression’ (MBCT), appears to be one of the first major developments in this
direction. MBCT represents an adaptation of the mindfulness meditation approach into a group
programme for relapse prevention of depression. This paper links the mindfulness approach into
current metacognitive concepts and models of emotional disorders by firstly exploring the limita-
tions of Beck’s schema theory and then describing a more recent multilevel model (interacting
cognitive sub-systems, or ICS) which represents the theoretical foundation for the mindfulness
approach. A description of the MBCT manual is followed by looking at the methodological
limitations of the mindfulness construct and its implications for future therapeutic interventions.
Despite its methodological problems, MBCT appears to be an advanced and cost-efficient
approach to prophylactic interventions to prevent recovered depressed patients from relapse.
Further developments and methodological testing is still required to give the approach an even
more robust foundation.

Within the last 15 years, there has been a widespread and increasing interest in adapting
mindfulness meditation techniques from the Buddhist tradition to clinical programmes

Correspondence to: Nicole Scherer-Dickson, Senior Practitioner (Therapist), ANITT, The

Cottage, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK; e-mail: nicole.schererdickson@lpct.
scot.nhs.uk

Counselling Psychology Quarterly ISSN 0951–5070 print/ISSN 1469–3674 online # 2004 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/09515070410001728253
224 Nicole Scherer-Dickson

for the treatment of medical (Bernhard et al., 1988) and psychological problems such as
anxiety disorders (Kabat-Zinn et al., 1992), whereas its applicability to depression had
not been investigated until recently (Teasdale et al., 2000; Segal et al., 2002).
Different studies on the lifetime course of depression have shown that relapse
and recurrence following successful treatment of major depressive disorder is common
(e.g., Judd, 1997), and the development of new preventative interventions seems to be a
major challenge in the treatment of depression.
Segal et al. (2002) have adapted the mindfulness approach to a clinical programme to
prevent relapse and recurrence of depression, which they have called ‘mindfulness-based
cognitive therapy’ (MBCT). This approach to psychological prophylaxis, based on
current metacognitive concepts on information-processing, was designed as group-skills
training rather than individual psychotherapy and is based on an integration of aspects
of CBT for depression (Beck et al., 1979) and the ‘mindfulness-based stress reduction
programme’ (MBSR) developed by Kabat-Zinn (1990) and colleagues.
This paper explores the MBCT approach, by describing the links between meta-
cognitive concepts and their clinical implications, focusing on their relevance for relapse
prevention of depression.

Metacognition and cognitive theories of emotional disorder

Limitations of the schema theory
Beck’s (Beck et al., 1979) schema theory is a descriptive clinical account of emotional
disorder that has been influential in the cognitive therapy of depression until the present.
The model is based on the premise that emotional disorders, e.g., depression, are linked
with negative automatic thoughts and cognitive distortions which result from the
activation of negative beliefs about the self and the external world.
A number of recent theorists have emphasized the limitations of the schema theory
and have suggested revised frameworks for the conceptualization of cognitive process-
ing in emotional disorder. Teasdale and Bernard (1993) present evidence that negative
thinking may be a consequence rather than the cause of depression and that dysfunctional
attitudes during a depressive episode return to normal after recovery. This is, of course,
not a new view. For example, Alladin (1985) provided evidence from a longitudinal study
that challenged the belief that negative cognitions caused depression and Alagaratnam
(1984) provided an experimental demonstration that induced a depressive cognitive style
in a non-depressed community sample and normalized a depressive cognitive style in a
depressed community sample. Schema theory and cognitive therapy have focused primar-
ily on the content of thoughts and beliefs rather than cognitive processes such as attention
or the regulation of information processing. Moreover, Beck’s schema theory provides
an explanation for the content of people’s thoughts but not their style of thinking. For
example, the content of a specific core belief (‘I am a failure’) can be explained within the
theoretical framework of schema theory by overcritical parents, for instance, who never
praised a person for successes. On the other hand, the model does not give an explanation
for the development of a specific mode of thinking, such as only processing information
 Metacognitive and mindfulness-based CBT 225

that backs up the failure-theme, that is, mistakes the person has made and goals that have
not been achieved.
Wells (2000) considers these issues ‘missing links’ between cognitive theory and
therapy. How people think is an important dimension that has implications on the
maintenance of psychological disorder and recovery.

Metacognitive concepts and their clinical implications

The term metacognition has been introduced by Flavell (1979) in the context of
developmental psychology to describe the cognitive processes and structures that monitor
and control aspects of cognition. Purdon and Wells (1999) define metacognition as:
‘. . .the aspect of the information processing system that monitors, interprets, evaluates,
and regulates the contents and processes of its own organization’ (p. 71).
Metacognitive regulation processes are active before a distinct thought, e.g., negative
automatic thought, occurs in a person’s mind and regulate how people think. Wells
(2000) describes metacognition as a multi-faceted concept. Moreover, Flavell (1979) and
Moses and Baird (1998) distinguish between three major components of metacognition:
‘metacognitive knowledge’, ‘metacognitive experience’ and ‘metacognitive regulation’.
The first component, ‘metacognitive knowledge’, can be compared with one’s acquired
belief that one is better at arithmetic than at spelling. Furthermore, the construct of
‘metacognitive experiences’ refers to the ‘feeling of knowing’, the intuitive sense that one
knows a certain part of information, although one cannot recall this information at the
moment.
Wells (2000) describes the third component, ‘metacognitive regulation’, as a range
of executive functions, like the allocation of attention, checking and planning, which in
turn reflect either monitoring or control processes. The monitoring process keeps track of
ongoing cognition, whereas the control process modifies cognitive activity, like shifting
attentional focus. Both processes interact with metacognitive knowledge.
Teasdale (1999a) criticizes the concept of ‘metacognitive experience’ and suggests
instead the term ‘metacognitive insight’ (p. 147) to capture the experience of perceiving
thoughts as thoughts and not as a reflection of reality.
Furthermore, metacognition has been conceptualized as a framework that guides
information processing, and explores maladaptive forms of processing that are respon-
sible for emotional vulnerability, such as those typified by rumination and threat
monitoring (Wells and Matthews, 1994). Individuals who ruminate about their situation
are far more likely to relapse into a depressive episode than individuals who deploy more
positive thinking styles. Moreover, patients who suffer from anxiety are more likely to take
threat-related information (e.g., words like ‘ambulance’ or the sound of a fire-engine) into
account than healthy individuals.
Looking at these concepts, it becomes apparent that metacognition controls and
regulates cognition and distortions in thinking that are characteristic for the development
of emotional disorder. It is important to take the influence of metacognitive knowledge
into account as well; that is, a person’s knowledge about his1 ability to perform cognitive
tasks. It follows that the effectiveness of cognitive therapy might be enhanced by strategies
that have an impact on metacognitive regulation and control processes.
226 Nicole Scherer-Dickson

Recent models of the psychopathology, like the ‘interacting cognitive sub-systems’

model (Teasdale and Barnard, 1993), have started to incorporate the role of beliefs about
one’s thoughts and appraisal of these thoughts in the development and maintenance of
emotional disorder.

Interacting Cognitive Sub-systems (ICS)

Teasdale and Barnard (1993) have developed a multi-level model of cognitive proces-
sing in order to overcome some of the limitations in schema theory that were mentioned
earlier. The interacting cognitive sub-systems (ICS) framework (see Figure 1) is based on
a central assumption that the mind works using a number of qualitatively different kinds
of information, or mental codes.
These codes represent distinct aspects of experience on different levels. At the most
superficial level there are three sensory codes representing basic visual, acoustic and pro-
prioceptive (body-state) stimuli. On the next deeper level, repeating patterns of sensory
codes are represented by intermediate and object codes. For example, the sound of the
same word can be spoken with different accents, or the same object can be presented from
different perspectives. On the deepest levels, the interacting cognitive sub-systems model
distinguishes between two kinds of meaning: a specific and a more generic.
Specific meanings are represented by patterns of propositional code, and refer
to specific concepts and the relationship between them, for example, ‘the bread is on
the table’. At this level, meaning is not difficult to understand. However, according to the
interactive cognitive sub-systems framework, such specific meanings have no direct
relationship to emotion production (Teasdale, 1993). This implies that it is possible for

Fig. 1. Interacting cognitive subsystems (ICS): the relationship between sensory, intermediate, and
meaning codes (AC, Acoustic; VIS, Visual; BS, Body-state; MPL, Morphonolexical; OBJ, Object;
PROP, Propositional; IMPLIC, Implicational). (From Teasdale & Barnard, 1993.)
 Metacognitive and mindfulness-based CBT 227

a person to talk about specific emotion-related meanings without necessarily experiencing

any of the associated emotions.
The more generic level of meaning is presented in a pattern of implicational code,
and corresponds to schematic mental models of experience. Implicational meanings are
implicit, but explicit general knowledge, such as predictions and attributions, can
be extracted from them. These generic meanings are associated with intuitive and holistic
feelings, and do not have a value that can be tested. Only implicational meanings are
directly linked to emotion.
According to Teasdale (1993), the interactive cognitive sub-systems approach
captures an important distinction between ‘emotional’, ‘gut-level’ meanings and ‘intel-
lectual’, ‘rational’ meanings.
Putting these two kinds of meaning into the context of metacognition, ‘metacognitive
knowledge’ corresponds to specific Propositional meanings and the relationship between
concepts. We do not have to experience knowledge at this level, it can be acquired
via verbal input or by reading books. As mentioned earlier, Teasdale (1999a) makes a
distinction between ‘metacognitive knowledge’ and ‘metacognitive insight’ rather than
‘metacognitive experience’. According to the interactive cognitive sub-systems model,
‘metacognitive insight’ is represented at the level of schematic, Implicational meanings.
Changes at this level cannot be acquired by learning from books but requires some
form of experiential learning.
The therapeutic consequences of maintenance, vulnerability and relapse of depres-
sion within the ICS framework will have a strong influence on the integration of the
mindfulness approach into relapse prevention of depression.

Maintenance, vulnerability and relapse of depression within the

framework of the Interactive Cognitive Subsytems Model (ICS)
Maintenance, vulnerability and relapse of depression
Within the framework of the interactive cognitive sub-systems model, emotional reactions
occur at the level of Implicational meanings when emotion-related schematic models
are produced. A depressed emotional response is generated when depressogenic
models are produced. Maintenance of a depressed state relies on repeated generation
of self-perpetuating processing configurations, like ruminative, negative, self-focused
cognitive thinking. Teasdale and Barnard (1993) refer to this self-perpetuating configu-
ration as ‘depressive interlock’ which is experienced by a person as a stream of negative
automatic thoughts. Other types of information, like processing bodily information, e.g.
sleep disturbance, can maintain the ‘depressive interlock’. The depressed person experi-
ences discrepancies between the current perceived state of the self (low mood) and the
desired state (uplifted mood up), and tries to reduce depression by understanding the
cause of discrepancy. Teasdale and Barnard (1993) suggest that the depressed person
employs ruminating or pondering over personal inadequacies (‘I am worthless’, ‘I am a
failure’) as a cognitive strategy to reduce the experienced discrepancy. This again
maintains the discrepancies between present and desired state and leads to perpetuating
rather than reducing depression. Segal et al. (2002) refer to this mode of mind as the
228 Nicole Scherer-Dickson

‘doing mode’ (p. 70) because as soon as the individual realizes he feels depressed, he
wants to feel better and ruminating, as his chosen cognitive strategy makes the unwanted
emotion worse. It remains an assumption that people who have already experienced a
depressive episode in their past might fall easier into the self-perpetuating, ruminative
thinking style than others.
This shows that the concept of a ‘depressed interlock’ seems to have an important
impact on understanding the process in relapse of recovered depressed patients.

Implications for relapse prevention in depression

Following this, Teasdale et al. (1995) suggest that the central goal of relapse prevention
based on the interactive sub-systems model is to help patients to disengage from these
ruminative, self-perpetuating thinking modes when they feel depressed and, speaking in
terms of the interactive cognitive sub-systems framework again, to replace depressogenic
schematic models. Moreover, interventions to reduce relapse should normalize the
pattern of thinking that becomes active in mild negative affect, like feeling sad. Therefore,
interventions should not be aimed at eliminating sad or depressed mood but rather
preventing the establishment of the perpetuating, ruminative cycle. Teasdale et al. (1995,
pp. 30–31) distinguish between two different strategies to achieve this: (1) redeploying the
cognitive resources necessary to maintain the interlock, and (2) promoting the production
of alternative schematic models that are related to depressogenic topics but are not
depressogenic themselves. In the context of metacognition, it seems that depressive
interlock can be prevented by experiencing negative thoughts through ‘metacognitive
insight’ as ‘just thoughts’, rather than as reflections of reality. This means that instead
of changing the content of thoughts like in Beckian cognitive therapy, Segal et al. (2002)
are of the view that interventions of relapse prevention should lead to changes in a
patient’s relationship to his thoughts in order to establish a ‘metacognitive insight’ mode.
So patients shift their perspective of negative thoughts and experience them as ‘passing
events in the mind’ (Segal et al., 2002, p.38) rather than as valid reflections of the self.
Segal et al. (2002) refer to this mode of mind as the ‘being mode’ (p. 73) and present the
opposite of the ‘doing mode’ as mentioned earlier. In the ‘being mode’, the focus is on
‘accepting’ and ‘allowing’ what is, without any pressure to change it.
These findings led to the development of alternative approaches in relapse preven-
tion, such as training patients at risk for depression to de-centre or distance themselves
from their negative thoughts. Moreover, such skills should fill up the cognitive space that
would otherwise be filled up with ruminative thoughts.
Based on these findings, those of Linehan (1993) in the treatment of border-
line disorders with mindfulness mediation techniques and Kabat-Zinn’s (1990) pro-
gramme of mindfulness-based stress reduction, Segal et al. (2002) developed their
programme of mindfulness-based cognitive therapy for relapse prevention in depression.

Mindfulness-based cognitive therapy for depression

Teasdale et al. (2002) developed mindfulness-based cognitive therapy (MBCT) as a group
intervention programme designed to train recovered depressed patients to disengage
 Metacognitive and mindfulness-based CBT 229

from depressogenic thinking that may lead to relapse according to the interactive cognitive
sub-systems model. MBCT is based on an integration of aspects of cognitive behavioural
therapy for depression (Beck et al., 1979) with components of the mindfulness-based stress
reduction programme (MBSR) developed by Kabat-Zinn (1990) and colleagues. Segal
et al. (2002) state that MBCT ‘. . .unites for the first time what are commonly thought
of as Eastern meditative practices and perspectives . . . with Western psychological
epistemologies and practices . . . in a new and seamless synthesis’ (p. vii).

‘Mindfulness’-approach: background
The concept of mindfulness originates in Buddhist meditative practice. Kabat-Zinn
(1994) describes mindfulness as follows: ‘Mindfulness means paying attention in a
particular way: on purpose, in the present moment, and non-judgementally’ (p. 4).
Staying mindful means being aware of the ‘here and now’ and accepting whatever life
might bring. This is also about accepting that not only positive events happen in life but
negative events are an essential part of life as well. ‘Paying attention’ can be described as
follows: in Western societies quite often people do different things at the same time, like
eating and watching TV or reading. Within the Buddhist tradition, staying mindful means
being fully aware what one is doing at a particular moment.
Combining these Eastern meditation practices with Western psychotherapy
approaches, Linehan (1993) incorporated mindfulness meditation techniques as an essen-
tial component in the treatment of patients with borderline personality disorder (Dialec-
tical Behaviour Therapy, DBT). Moreover, Kabat-Zinn (1990) and colleagues have
developed a mindfulness-based stress reduction programme at the University of
Massachusetts Medical Centre. This stress-reduction and relaxation programme entails
training in methods for voluntary deployment of attention based on mindfulness medita-
tion. This approach has been shown to be efficient in the treatment of anxiety disorders
(Kabat-Zinn et al., 1992) and medical problems like psoriasis (Bernhard et al., 1988).
On the background of the Buddhist concept of mindfulness the MBSR programme
and cognitive therapy, Segal et al. (2002) developed an eight-session group programme in
order to prevent relapse in recovered depressed patients.

The eight-session programme and its empirical evidence

MBCT programme (Segal et al., 2002). The aim of the mindfulness-based cognitive
therapy programme is to teach individuals to recognize and disengage or de-centre from
ruminative, negative patterns of thought during times of potential relapse. Patients will
learn to change into a different mode of mind that will less likely lead to relapse.
To achieve this shift in thinking mode, skills are used to change attention and awareness
in different ways, e.g. by using mindfulness-meditation techniques. Thus, the emphasis
in MBCT is no longer on the content, but rather on how negative thoughts are
experienced.
The programme is restricted to working with recovered depressed patients.
Moreover, Segal et al. (2002) stress the importance that therapists need to have some
230 Nicole Scherer-Dickson

experience with mindfulness practice themselves, as questions from patients experiencing

problems can not always be answered by knowledge retrieved from manuals.
The mindfulness-based cognitive therapy-programme was designed as a group pro-
gramme rather than an individual therapy to increase cost-efficiency. Class sizes can be
between 12 (Segal et al., 2002) and 30 (Kabat-Zinn, 1990). The programme entails
two-hour weekly sessions over a period of 8 weeks. Segal et al. (2002) have also arranged
for four follow-up classes during the year after finishing the programme.
The first four sessions of the 8-week programme focus on teaching patients to
pay attention, be ‘mindful’, in everyday situations. Teasdale et al. (2000) use the
metaphor of driving a car on a familiar route without realizing that one is actually driving
(‘autopilot’). The shift of attention is from ‘autopilot’-driving to ‘mindful’-driving. The
‘raisin-exercise’ (Segal et al., 2002, p. 103) is an example for teaching individuals to pay
attention to a simple object like a raisin: holding it, smelling it, looking at it and finally
chewing and tasting it. Furthermore, patients are taught, with reference to their body and
their breathing, if they notice their mind wandering, to bring it back to focus. Participants
also learn to become aware that negative thoughts and feelings can occur when the mind
wanders. Within sessions 5–8, patients learn to become more vigilant for mood shifts and
then move on to learn to handle them, for example by shifting their attention to their
breathing and then to their whole body in order to ‘pause’ before dealing with difficulties,
e.g., negative thoughts. This way of coping-response in difficult situations indicates some
flexibility as it is to be expected that participants deal with these problems in different
ways. Furthermore, participants are encouraged to identify their own individual ‘warning’
signs and prepare action plans for how to cope with negative thoughts and emotions
during difficult situations in the future.

Empirical evidence. In order to investigate the effectiveness of the mindfulness-based

approach to prevent relapse in depression, Teasdale et al. (2000) have randomized 145
recovered depressed patients to continue only ‘treatment as usual’ (e.g., consult family
doctor) or to receive mindfulness-based cognitive therapy for depression in addition.
Relapse of depression was assessed over a 60-week period and the results showed that
for patients with three or more depressive episodes in the past, MBCT reduced the risk
for relapse, whereas for patients with only two depressive episodes there was no change.
Teasdale et al. (2000) interpret these results as clinically significant because the relapse
rates of the group at high risk of recurrence (three or more episodes in the past) had been
halved.
Moreover, Teasdale et al. (2002) investigated the hypothesis that ‘metacogni-
tive awareness’ can prevent the relapse of depression. ‘Metacognitive awareness’ can be
understood as a form of ‘metacognitive insight’ as described earlier and refers to the act of
experiencing thoughts as thoughts in the moment they occur; that is, objectifying them.
Increasing metacognitive awareness involves changing the relationship to thoughts and
feelings. Teasdale et al. (2002) found that cognitive therapy as well as mindfulness-based
cognitive therapy, increases metacognitive awareness and reduces depressive relapse as a
result of this. Both approaches seem to encourage a shift in one’s relationship to negative
thoughts rather than a change of the thought itself.
 Metacognitive and mindfulness-based CBT 231

Limitations and implications for future developments

Despite the efficacy of the mindfulness approach, it entails theoretical limitations which
still need to be investigated and might lead to further clinical developments in cognitive
therapy.
A conceptual and empirical review on mindfulness training as a clinical intervention
by Baer (2003) emphasizes the amount of methodological problems during the research
studies as a major limitation of this approach. The author criticizes that most studies
examining the effects of mindfulness training interventions used pre-post design but no
control groups. Moreover, TAU (treatment as usual) consisted of medical or unspecified
psychotherapy approaches which does not allow the comparison of the effects of mind-
fulness interventions with specific psychological approaches. Bishop (2002) questions the
positive results of the Teasdale et al. (2000) study by arguing that, the combination of two
forms of treatment – the mindfulness approach together with aspects of cognitive therapy –
makes it difficult to draw conclusions about the effectiveness of the mindfulness approach
in prevention of depressive relapse as such. Moreover, Bishop (2002) refers to problems
with the conceptualization of mindfulness. Up to now, Western descriptions of the
construct have been consistent with the Buddhist tradition which does not go beyond
a descriptive nature. There have been no attempts to develop definitive criteria of
the construct, and descriptive qualities of the mindfulness approach have not been
operationalized. Different individuals might experience a state of ‘mindfulness’ in dif-
ferent ways which makes the determination of the criteria that are responsible for
preventing patients from relapse of depression more difficult. As the construct has not
been defined as such, there is no evidence so far to support its validity. Bishop (2002)
argues that to prove the effectiveness of mindfulness-based techniques in psychotherapy, a
conceptual definition is needed before its validity is tested. In this vein, Baer (2003)
postulates the necessity of more randomized control trials to clarify whether observed
effects are due to mindfulness interventions of to confounding factors such as placebo
or passage of time.
Furthermore, Wells (2000) criticizes the theoretical background of the ‘mindfulness’
approach, the interactive cognitive sub-systems model, and states that one of its greatest
limitations is the Implicational code concept and its circularity as it is difficult to define
exactly what it means and where to locate implicational meaning in the information
processing context. Moreover, the present author argues that the concept of ‘mindful-
ness awareness’ fails to describe which components of self-awareness improve or
worsen emotional disorders. Wells (2000) presents an alternative model of self-regulatory
information processing (the self-regulatory executive function, S-REF) which overcomes
the limitation of the interactive cognitive sub-systems model by placing metacognition and
attention in the centre of development of emotional disorders rather than Implicational
meanings (e.g., ICS).
The S-REF model by Wells is consistent with the schema theory, but incorporates
aspects of cognitive architecture (different levels), regulation of attention and other meta-
cognitive components of cognition with the individual’s schema or stored knowledge.
Well’s (2000) S-REF approach seems to provide different clinical implications for
cognitive-behaviour therapy as it underlines the importance of restructuring maladaptive
232 Nicole Scherer-Dickson

metacognitive beliefs as well as non-metacognitive beliefs or schemas. Such restructuring

requires new therapeutic tools in order to monitor and then modify metacognitive
processes. One example of these new tools is ‘metacognitive profiling’ (Wells, 2000, p.
107) in order to identify metacognitions like meta-beliefs, coping strategies, attention or
memory that are activated in stressful situations. Wells (2000) and colleagues have also
developed three different metacognitions questionnaires, for example, the Thought
Control Questionnaire (TCQ) (Wells, 2000, p. 113), to assess and monitor metacognition
in patients during their treatment. Besides monitoring metacognitions, Wells (2000)
presents two different techniques to restructure cognition, i.e., modify attention (Attention
Training Technique (ATT) and Situational Attention Refocusing (SAR)), which seem to
have some similarity with the ‘mindfulness’ approach without the focus on meditation.
Wells seems to have developed a theoretical model of self-regulation mechanisms in
emotional disorder that is important for the future development of cognitive theory. This
model seems to create the ‘missing link’ between cognitive theory and therapy that Wells
(2000) had identified and might form a base for the advancement of cognitive therapy in
the future.

Conclusion
New models developed on the basis of findings in cognitive sciences and cognitive
theories about information processing and emotional processing (see Rachmann, 1980;
Teasdale, 1999b) seem to have a major impact on the understanding of the development
and maintenance of emotional disorders.
As outlined in this paper, these new models of cognitive processing have clinical
implications for cognitive therapy beyond the framework of Beck’s schema theory (Beck
et al., 1979). Besides the development of mindfulness-based cognitive therapy for
the prevention of relapse of depression (Segal et al., 2002), Wells (2000) has developed
a range of different interventions focusing on the metacogitive aspects of the emotional
disorders that have to be further developed and tested.
Looking at the models and theories outlined in this paper, one may conclude
that changing the relationship people have to their way of thinking as opposed to simply
changing the content of their thoughts, has a major impact on therapy outcome and
relapse prevention.
Mindfulness-based cognitive therapy for depression seems to be a cost-efficient treat-
ment programme for relapse prevention as it teaches patients skills to identify high-risk
situations (e.g., rumination) and accept the way they are thinking by changing their
attitude towards their thoughts. The programme seems to empower vulnerable patients to
break the cycle of the lifelong course of recurrent depression.
The high relapse rates for depression underline the importance of prophylactic
treatment during periods that fall between acute depressive episodes. Group pro-
grammes, like the one presented, could have a major impact on health services as they
are cost-efficient and seem to work especially well with recovered patients that are very
likely to relapse.
 Metacognitive and mindfulness-based CBT 233

Note

1. For simplicity, persons/patients in the text are referred to as ‘he’ throughout.

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