Despite the widespread use of Cognitive Behavioural Therapy (CBT), its success in the treatment of depression can make gloomy reading. Around half of those who receive CBT do not recover.*

This contrasts with the generally higher success rate of CBT for difficulties rooted in anxiety such as Obsessive-Compulsive Disorder (OCD).**

What is it that CBT for depression is missing?

CBT looks at the content of depressed thinking. This means that it asks questions about what people are thinking. The “what” will include themes such as being a failure or believing that the future is hopeless.

What CBT does not do is look at the process of thinking: how we think, specifically how we think about our thinking is important. For all of us, thinking starts with an intrusive thought - something just pops into our heads. We then think about that thought. The technical term for this process is metacognition.

Adrian Wells’ Metacognitive Therapy (MCT) is an approach which is specifically focused on thinking about thinking. The differences between MCT and CBT are important. Look at the following dialogues between a patient and a therapist:

CBT approach

Therapist: “What made you depressed?”

Patient “Dave did not want to come out with me”.

Therapist: “What does that say about you?”

Patient: “I must be boring”.

Therapist: “It seems that you have negative thoughts when this happens. Do you think everyone would feel the same?”

Patient: “No because they would not be bothered”.

Therapist: “So we need to know exactly what you think, when people do not want to meet up with you”.

MCT approach

Therapist: “What made you depressed?”

Patient: “Dave did not want to come out with me”.

Therapist: “What does that say about you?”

Patient: “I must be boring".

Therapist: “It seems that you have negative thoughts when this happens. Let’s look at how you respond to this thought".

Patient: “I try to figure out what is wrong with me”.

Therapist: “How long do you think about this for?”

Patient: “Ages”.

Therapist: “How do you then feel?”

Patient: “Worse".

Therapist: "How does ruminating on this thought serve you?"

Recognising rumination

With MCT we are focussing on questions of how rather than what. How the patient continues to brood about his initial thoughts on the situation with Dave is rumination and his therapist is trying to solve a problem where there is no single identifiable answer. He will continue to do what he feels he has to to solve the problem and will likely become more depressed. Rumination does not work as a problem solving strategy. It is akin to trying to dig yourself out of a hole. It is not a cause of depression, but it is something which makes depression worse. Rumination is a problem because it is something that people believe they cannot stop. The strategies in MCT are focused on providing evidence that it can be stopped.  

CBT looks at the content of a thought but MCT examines what purpose it serves and our reaction to it. In a CBT session a patient may be asked what they would feel like if a scenario they were worrying about were to happen. MCT would bypass this, instead asking a patient how they believe that worrying about this situation would serve them.

MCT like Behavioural Activation looks at our “internal focus of attention”. When we ruminate we are living “in our heads”. The techniques of MCT are a mixture of attention training and mindfulness. They are employed to move this focus of attention from inside of our heads to outside of our heads.

If we are depressed, the CBT approach in talking about “what” we are thinking about can paradoxically make us feel worse. What CBT is missing is an approach to tackling rumination. For people who are depressed, the first approach to take will be to recognise when they are doing it. Once we know that we are ruminating we can focus our attention outwards and in doing so get out of our heads and into our lives.




* only 40-58% of those receiving CBT recover (Dimidjian et al, 2006)

** the success rate of CBT for OCD is between 50 and 75% (Abramowitz, 2006)


Michael O'Sullivan is a Cognitive Behavioural Therapist in the Derbyshire Healthcare Foundation Trust.

Buy Michael's book "A Practical Guide to Working with Depression: A cognitive behavioural approach for mental health workers"