Two models, three visual treatments.

Metacognitive therapy explores how we relate to thoughts and direct our attention. A central concept is CAS, the cognitive attentional syndrome: persistent worry, rumination and threat monitoring, together with strategies that can keep problems going, such as avoidance and thought control.

MCT Metaphors 04 images

FIG. 01

Attention · Detached mindfulness

The platform

Your mind is like a railway platform. Triggering thoughts and feelings arrive like trains, open their doors, stop for a while, close again and move on. You can notice them without getting on. What you practise is not having to follow every thought further.

Original01·A

Warm tone01·B

Ink01·C

FIG. 01 · THE PLATFORM · ATTENTION TRAINING THOUGHTS PASS · YOU CHOOSE

FIG. 02

Thoughts · Detached mindfulness

The sky

Thoughts shift like clouds across the sky. You can notice them without trying to control their movement.

Original02·A

Warm tone02·B

Ink02·C

FIG. 02 · THE SKY · DETACHED MINDFULNESS YOU ARE THE SKY · NOT THE CLOUDS

FIG. 03

Attentional focus · CAS

The torch

Attention is like your torch. Whatever you shine it on gets more of your attention. You direct the light.

Original03·A

Warm tone03·B

Ink03·C

FIG. 03 · THE TORCH · ATTENTIONAL FOCUS WHERE LIGHT FALLS · WHAT BECOMES REAL

FIG. 04

Avoidance · Anxiety

The beach ball

Holding a beach ball underwater takes constant effort. That is what avoidance does with anxiety — your energy goes into keeping down what wants to rise.

Original04·A

Warm tone04·B

Ink04·C

FIG. 04 · THE BEACH BALL · THE COST OF AVOIDANCE ENERGY SPENT HOLDING DOWN · NOT ON LIVING

MCT Concepts 05 images

FIG. 06

Procrastination · Perfectionism

The mountain

The mountain looks overwhelming from below. Procrastination can mean standing there staring at the summit and staging the pain instead of taking the next step.

Original06·A

Warm tone06·B

Ink06·C

FIG. 06 · THE MOUNTAIN · A PROCESS OF PROCRASTINATION ONE STEP · NOT THE WHOLE SUMMIT

FIG. 26

Worry · Rumination · MCT

A false work order

The worrying thought looks like a task: solve this, work it out, prepare yourself. But the task is made up. No one has issued it. The system produces work orders that lead nowhere.

Original26·A

Warm tone26·B

Ink26·C

FIG. 26 · A FALSE WORK ORDER · RUMINATION NO ONE HAS ISSUED IT

FIG. 25

Intrusive thoughts · Attention · MCT

Spam email

Intrusive thoughts, like spam, do not have to be dealt with, investigated or answered. You do not open every junk email to check whether it is dangerous. The thought does not need to be taken care of to lose its power.

Original25·A

Warm tone25·B

Ink25·C

FIG. 25 · SPAM EMAIL · INTRUSIVE THOUGHTS IT DOES NOT HAVE TO BE OPENED TO BE HARMLESS

FIG. 24

Worry · Avoidance · MCT

Reassurance as a short-acting painkiller

The relief is real. But when worry returns, the need for fresh reassurance can return too. Then the relief is brief, while the pattern remains.

Original24·A

Warm tone24·B

Ink24·C

FIG. 24 · REASSURANCE AS A SHORT-ACTING PAINKILLER THE RELIEF IS REAL · THE PROBLEM REMAINS

FIG. 23

Metacognition · The structure of thinking · MCT

The operating system

MCT looks at the system around thoughts: how we evaluate them, direct our attention and get caught in further thinking.

Original23·A

Warm tone23·B

Ink23·C

FIG. 23 · THE OPERATING SYSTEM · METACOGNITION THE THOUGHTS AND THE SYSTEM AROUND THEM

MCT Exercises and processes 04 images

FIG. 13

Detached Mindfulness · DM · MCT

The tiger exercise

In the tiger exercise, you imagine a tiger and observe the image without trying to control it. It is a way of practising meeting a mental event without going into analysis or control.

Original13·A

Warm tone13·B

Ink13·C

FIG. 13 · THE TIGER EXERCISE · DETACHED MINDFULNESS THE THOUGHT IS REAL AND NOT REAL

FIG. 14

Attentional flexibility · MCT

Autofocus

When we worry, attention can get stuck on possible threats. Autofocus is an image of attention's flexibility: being able to redirect the lens.

Original14·A

Warm tone14·B

Ink14·C

FIG. 14 · AUTOFOCUS · ATTENTIONAL FLEXIBILITY THE LENS CAN BE TRAINED TO MOVE

FIG. 15

Word Association Task · MCT

Word association

A word brings up a thought, an image, perhaps a memory. In the exercise, you notice the associations without analysing or directing them.

Original15·A

Warm tone15·B

Ink15·C

FIG. 15 · WORD ASSOCIATION · WORD ASSOCIATION TASK THE WORDS PASS · YOU DO NOT FOLLOW

FIG. 16

CAS · Cognitive attentional syndrome · MCT

Revving in neutral

Rumination races — but nothing happens. The engine spins without driving anything forward.

Original16·A

Warm tone16·B

Ink16·C

FIG. 16 · REVVING IN NEUTRAL · COGNITIVE ATTENTIONAL SYNDROME MAXIMUM POWER · ZERO MOVEMENT

Intensive Short-Term Dynamic Psychotherapy — works with what happens in the moment between patient and therapist. Feeling, anxiety and defences. The triangle of conflict as a map.

ISTDP Concepts 05 images

FIG. 07

Feeling · Anxiety · Defences · ISTDP

The triangle of conflict

Feelings arise. Anxiety manifests in the body. Defences are activated. Where in the triangle are you right now?

Original07·A

Warm tone07·B

Ink07·C

FIG. 07 · THE TRIANGLE OF CONFLICT · FEELING · ANXIETY · DEFENCES WHERE IN THE TRIANGLE ARE YOU?

FIG. 09

Relationship patterns · Transference · ISTDP

The triangle of persons

Early relationships can shape patterns that recur in present-day relationships. In the therapeutic relationship, they can become visible as they happen.

Original09·A

Warm tone09·B

Ink09·C

FIG. 09 · THE TRIANGLE OF PERSONS · RELATIONSHIP PATTERNS EARLY · PRESENT-DAY · THE THERAPEUTIC RELATIONSHIP

FIG. 17

Defences · Avoidance · ISTDP

The side door

The door offered avoidance, without a decision.

Original17·A

Warm tone17·B

Ink17·C

FIG. 17 · THE SIDE DOOR · AUTOMATISED AVOIDANCE THE DOOR OPENED BEFORE THE CHOICE WAS MADE

FIG. 18

Breakthrough · Resistance · ISTDP

Unlocking

In ISTDP, unlocking describes a breakthrough to feelings and memories previously kept away. Here it takes the form of a quiet click — the right key, at the right moment.

Original18·A

Warm tone18·B

Ink18·C

FIG. 18 · UNLOCKING · BREAKTHROUGH A QUIET CLICK

FIG. 19

Anxiety · Signal · ISTDP

Anxiety as a signalling system

Anxiety can signal that something is stirring strong or conflicting feelings. In ISTDP, we explore the connection and how anxiety is expressed in the body. If it becomes overwhelming, it needs to be regulated.

Original19·A

Warm tone19·B

Ink19·C

FIG. 19 · ANXIETY AS A SIGNALLING SYSTEM THE SIGNAL AND THE BODY’S REACTION

ISTDP Metaphors 04 images

FIG. 08

Defences · Protection · Cost · ISTDP

Defence as a wall

The wall has protected you from what was once too painful. But the same wall that keeps pain out also keeps out closeness, grief, anger — and the light on the other side.

Original08·A

Warm tone08·B

Ink08·C

FIG. 08 · DEFENCE AS A WALL · PROTECTION AND PRISON THE WALL PROTECTS · THE WALL SHUTS OUT

FIG. 10

Anxiety · Feeling · Signal · ISTDP

The smoke and the fire

Anxiety is the smoke — visible, tangible, hard to breathe through. In this image, the fire is a feeling that gives rise to anxiety. We need both to understand the feeling and to attend to the anxiety.

Original10·A

Warm tone10·B

Ink10·C

FIG. 10 · THE SMOKE AND THE FIRE · ANXIETY AND FEELING THE SMOKE IS NOTICED · THE FIRE IS SENSED

FIG. 11

Defences · Vitality · Cost · ISTDP

Defence as a fire extinguisher

The fire extinguisher works — it puts out the discomfort quickly. But it does not only put out the pain. It also puts out the warmth, the closeness, the anger, the love. What is alive.

Original11·A

Warm tone11·B

Ink11·C

FIG. 11 · THE FIRE EXTINGUISHER · THE COST OF DEFENCE IT PUTS OUT THE PAIN · AND THE WARMTH

FIG. 12

Intellectualisation · Experience · ISTDP

The menu instead of the meal

You can describe the feeling exactly — know what it is called, where it comes from, why it is there. But there is a difference between reading the menu and eating the meal. The experience is not the same as the description.

Original12·A

Warm tone12·B

Ink12·C

FIG. 12 · THE MENU INSTEAD OF THE MEAL · INTELLECTUALISATION THE DESCRIPTION IS NOT THE EXPERIENCE

ISTDP The work in therapy 03 images

FIG. 20

Resistance · Defences · ISTDP

Resistance as a lid

Heavy, rusty, familiar. The work is not about forcing it open, but about understanding why it is there.

Original20·A

Warm tone20·B

Ink20·C

FIG. 20 · RESISTANCE AS A LID HEAVY · RUSTY · FAMILIAR

FIG. 21

Self-observation · Defences · ISTDP

Turning the weapon on yourself

In this image, anger has turned inward. What could have been directed at someone else becomes an attack on the person themselves.

Original21·A

Warm tone21·B

Ink21·C

FIG. 21 · TURNING THE WEAPON ON YOURSELF SEE THE DEFENCE FROM WITHIN

FIG. 22

Alliance · Collaboration · ISTDP

Therapist and patient on the same side

Therapist and patient look in the same direction. The therapeutic alliance is about exploring together what is happening, working with the defences that cause difficulties and finding a possible way forward.

Original22·A

Warm tone22·B

Ink22·C

FIG. 22 · THERAPIST AND PATIENT ON THE SAME SIDE BOTH LOOKING IN THE SAME DIRECTION