In this presentation, Professor Spada will outline the metacognitive approach to the conceptualisation and treatment of problem drinking. The presentation will be highlighting the role played by metacognitive beliefs, extended thinking and thought suppression in the development and escalation of problem drinking. Professor Spada will also review the type of interventions used in Metacognitive Therapy for the treatment of problem drinking and their efficacy.

1. New directions for the treatment of problem
drinking: Targeting metacognitive change
iCAAD Conference
London, May 2019
Marcantonio Spada
London South Bank University

2. “Maybe CBT does not provide a comprehensive
framework for conceptualizing and treating
alcohol problems”
A September 1999 intrusive thought
Background

3. • CBT only has modest treatment effectiveness
and high relapse rates
• Residual symptoms are often present
increasing the likelihood of relapse
• ‘Dangerous’ internal experiences such as
craving
• Obsessional thoughts about alcohol use
• Perception of lack of control over the mind and
behaviour
Background

4. • What cognitive structures (not addressed by
CBT directly) may be fuelling these residual
symptoms?
• Metacognitive structures
• Metacognitive beliefs
• Repetitive negative thinking
• Thought suppression
• Metacognitive monitoring
Background

5. • These 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”
• “Having thought X means I am weak”
• “If I worry I will be prepared”
• “If I ruminate I will understand”
• These beliefs have been found to be powerful predictors
of psychopathology (Wells, 2000; 2013)
• Activate and maintain unhelpful coping responses to
intrusive thoughts such as rumination, worry, thought
suppression, threat monitoring and avoidance
Metacognitive beliefs

6. • The role of metacognitive beliefs in psychopathology has
been explored using the Metacognitions Questionnaire
(MCQ; Cartwright-Hatton & Wells, 1997; Wells &
Cartwright-Hatton, 2004)
• The questionnaire consists of five distinct factors
• Positive beliefs about worry
• Negative beliefs about thoughts concerning
uncontrollability and danger
• Cognitive confidence
• Beliefs about the need to control thoughts
• Cognitive self-consciousness
Metacognitive beliefs

7. Metacognitive beliefs
• Studies using the MCQ have found that
• Beliefs about the need to control thoughts predict
alcohol use independently of anxiety and
depression (Spada & Wells, 2005)
• Beliefs about the need to control thoughts and
cognitive confidence predict category membership
as a problem drinker (Spada, Zandvoort & Wells,
2007)
• Beliefs about the need to control thoughts predict
drinking status and alcohol use in problem drinkers
following CBT (Spada, Caselli & Wells, 2009)

8. 3 Months 6 Months
B SE Wald p Class
(%)
B SE Wald p Class
(%)
Step 3 64.3 70.0
QFS .00 .01 .12 .72 -.01 .01 .74 .40
BDI -.01 .04 .20 .66 -.05 .05 1.14 .28
STAI .06 .04 2.70 .10 .08 .04 4.18 .04
MCQ-4 .10 .05 4.67 .03 .12 .05 5.66 .02
X2
13.70 .01 15.01 .00
3 Months 6 Months 12 Months
β t P β t p β t p
Step 3
QFS .25 2.1 .04 .09 .81 .42 .13 1.1 .30
BDI .08 .47 .64 -.02 -.11 .90 .05 .28 .78
STAI .07 .44 .66 .21 1.2 .21 .17 1.0 .31
MCQ-4 .31 2.6 .01 .39 3.3 .00 .31 2.6 .01
r2
.24 .12 .22
F Change 6.8 .01 10.9 .00 6.6 .00
Spada, M. M., Caselli, G. & Wells, A. (2009). Metacognitions as a predictor of drinking status and level of alcohol use
following CBT in problem drinkers: a prospective study. Behaviour Research and Therapy, 47(10), 882-886.
Metacognitive beliefs

9. Chi-Square=8.24, p=.69; CFI=1.00; RMSEA=.00; 54% of variance explained
Metacognitive beliefs
Spada, M. M., Moneta, G. B. & Wells, A. (2007). The relative contribution of metacognitive beliefs and
expectancies to drinking behaviour. Alcohol and Alcoholism, 42(6), 567-574.

10. Repetitive negative thinking 1: Worry
“Worry is characterised by a chain of
thoughts and images negatively affect-laden
and relatively uncontrollable; it represents an
attempt to engage in mental problem-
solving on issues whose outcome is
uncertain but contains the possibility of one
or more negative outcomes” (Borkovec et al.,
1983)

11. Repetitive negative thinking 2: Rumination
Why do I feel so
bad?
Why did this
happen to me?
Why can’t I
handle things
better?
What does this
mean about me?
What am I
doing to deserve
this?
What will others
think of me?

12. • Voluntary process involving the elaboration of
a desired target (Caselli & Spada, 2010)
• Imaginal prefiguration
• “I imagine myself involved in the desired activity
as if it were a movie”
• Verbal perseveration
• “If I were not practice the desired activity for a
long time, I would think about it continuously”
• Target=activity, object or state
Repetitive negative thinking 3: Desire thinking

13. • Worry is associated with alcohol use in
problem drinkers (Smith & Book, 2010)
• Rumination increases craving in alcohol
dependent drinkers (Caselli et al., 2013)
• Rumination prospectively predicts drinking
status and alcohol use in problem drinkers
(Caselli et al., 2010)
Repetitive negative thinking: The evidence

14. 3
Months
6
Months
12
Months
β t p β t p β t p
QFS .11 .99 .32 .10 .92 .36 .12 1.08 .29
BDI .18 1.44 .15 .05 .40 .69 .10 .86 .39
RRS-R .27 2.31 .02 .50 4.62 .00 .42 3.77 .00
Caselli, G., Ferretti, C., Leoni, M., Rebecchi, D., Rovetto, F. & Spada, M. M. (2010). Rumination as a predictor of
drinking behaviour: a prospective study. Addiction, 105(6), 1041-1048.
Repetitive negative thinking: The evidence

15. • Desire thinking
• Is present across the continuum of addictive behaviours
(Spada et al., 2015)
• Appears to mediate the relationship between craving and
challenge responses in experimental conditions (Frings et
al., 2018)
• Its activation (Caselli & Spada, 2016) brings to
• Increases in sense of deprivation (fixing attentional focus)
• Increases in accessibility of target-related information
(cognitive content)
• Increases in ‘on-line’ conviction in dysfunctional cognitive
beliefs (e.g. “I deserve it”, “I can stop whenever I want”)
• Biases in decision-making through the neglect inhibitory-
related information
Repetitive negative thinking: The evidence

16. -- Desire thinking hadDesire thinking had
a significant effect ona significant effect on
craving followingcraving following
manipulationmanipulation
- This effect was- This effect was
independent ofindependent of
baseline levels ofbaseline levels of
craving and desirecraving and desire
thinking as well asthinking as well as
perceived stressperceived stress
changes during thechanges during the
manipulationmanipulation
Caselli, G., Soliani, M. & Spada, M. M. (2013). The effect of desire thinking on craving: an experimental
investigation. Psychology of Addictive Behaviors, 27(1), 301-306.
Repetitive negative thinking: The evidence

17. Repetitive negative thinking: In summary
Rumination
Why?
Worry
What if?
Desire thinking
If only…
Self-focussed
attention

18. Repetitive negative thinking: Function
‘How and
now?’ should
be the
question…
Not ‘What
if?’, ‘Why?’,
and ‘If only’
Non action
should be the
alternative to
‘How and
now?’
The Prefrontal Cortex is involved primarily in the dynamic representation of multiple
future and past events in problem-solving situations

19. • Thought suppression in alcohol dependent
patients brings to hyper-accessibility of content
(Klein, 2007)
• Thought suppression is linked to the depletion of
neurocognitive resources needed for urge
regulation (Garland et al., 2012)
• A greater use of thought suppression is associated
with a greater use of alcohol (Bowen et al., 2007)
Thought suppression

20. • Metacognitive monitoring = the ability to monitor
internal states as a guide to knowing if an internal
goal has been met (Spada & Wells, 2006)
• Alcohol disrupts attentional processes (Steele &
Josephs, 1990) and neurological systems linked to
meta-level processing (Nelson et al., 1998)
• Not attending to internal change in cognition is
associated with alcohol use (Spada & Wells,
2006)
Metacognitive monitoring

21. • Psycho-education on repetitive negative thinking
and thought suppression
• Re-appraising metacognitive beliefs
• Uncontrollability of thoughts
• Utility of alcohol use for cognitive regulation
• Thought action fusion
• Deprivation/craving vs. desire thinking
• Rumination and worry as potentiators of negative affect
• Postponement of repetitive negative thinking
• Attention training
• Detached mindfulness
• Enhancement of metacognitive monitoring
• Cooking metaphor, stop signal homework, postponement of
alcohol use, interspersion of alcohol use
What metacognitive interventions?

22. Preliminary evidence: Mechanisms
• Key findings
• Metacognitive beliefs as prospective predictors of
alcohol use (Spada et al., 2015; Hamonniere &
Varescon, 2018)
• Induction of desire thinking leads to increased
distress and urge to use alcohol in alcohol use
disorder patients (Caselli, Gemelli & Spada, 2016)
• Detached mindfulness leads to significantly
weakened meta-appraisal and metacognitive
beliefs compared to a brief exposure in Alcohol
Use Disorder (Caselli et al., 2016)

23. Preliminary evidence: Single case series
• Metacognitive Therapy for Alcohol Use
Disorder (Caselli, Martino, Spada & Wells,
2018)
• First five consecutively assessed individuals who
met the following criteria
• Primary diagnosis of Alcohol Use Disorder
• Age 18–65 years
• Absence of borderline personality disorder and concurrent
psychological treatment
• No evidence of physical withdrawal syndrome, progressive
cerebral traumas or severe cognitive deficits
• Not actively suicidal and medication free
• No concurrent substance use (apart from nicotine) in the
previous 6 months

24. Preliminary evidence: Single case series
• Measures
• Alcohol Use Disorders Identification Test
Consumption (AUDIT-C; Bush et al., 1998)
• Hospital Anxiety and Depression Scale (HADS;
Zigmond and Snaith, 1983)
• Positive Alcohol Metacognitions Scale (PAMS; Spada
and Wells, 2008)
• Negative Alcohol Metacognitions Scale (NAMS;
Spada and Wells, 2008)
• Penn Alcohol Craving Scale (PACS; Flannery et al.,
1999)
• Quantity Frequency Scale (QFS; Cahalan et al., 1969)
• Cognitive Attentional Scale – Alcohol (CAS-A)

25. WEEKS MONTHS
Preliminary evidence: Single case series

26. Preliminary evidence: Single case series

27. The present and beyond
• More research is needed on
• Longitudinal comparative predictive power of key
metacognitive variables
• Interaction of mechanisms of change
• Adolescents and relapse prevention
• A clinical model and protocol is being
finalised (Wells, Caselli & Spada, in prep.)
• Trials are planned to (hopefully) showcase the
relative and additive effectiveness of
Metacognitive Therapy for Alcohol Use
Disorder

28. • There may be reasons why relapse rates in CBT
for problem drinking are high
• One of the reasons is that CBT does not explicitly
address the role of metacognitive structures
• The CBT model will need modification if
outcomes are to improve or…
• It may need to be supplanted by new forms of
treatment which target metacognitive change:
Metacognitive Therapy
Concluding thoughts

29. Metacognition in addictive behaviours team
• Dr Gabriele Caselli, Studi Cognitivi and Sigmund Freud University
• Professor Adrian Wells, University of Manchester
• Dr Ana Nikčević, Kingston University
• Dr Bruce Fernie, King’s College London
• Dr Giovanni Maria Ruggiero, Studi Cognitivi
• Dr Sandra Sassaroli, Studi Cognitivi
• Professor Ian Albery, London South Bank University
• Dr Francesca Martino, Studi Cognitivi
• Professor Alessio Vieno, Universita’ di Padova
• Dr Claudia Marino, Universita’ di Padova
• Professor Fabien Gierski, Université de Reims Champagne-Ardenne
• Dr Giovanni Moneta, London Metropolitan University
• Chiara Manfredi, Studi Cognitivi
• Daniela Rebecchi, Studi Cognitivi
• Antonella Gemelli, Studi Cognitivi

30. Thank you
Marcantonio Spada
spadam@lsbu.ac.uk
www.marcantoniospada.com
https://www.researchgate.net/profile/Marcantonio_Spada