What Is “Metacognition” And How Is It Related To OCD?
Below, we’ll review what metacognitions are and how come understanding metacognitions is an important part of overcoming OCD.
The term “metacognition” is just a fancy way of describing our thoughts about our thoughts. We have thoughts about our thoughts all the time and those of us with OCD have A LOT of metacognitions.
Metacognitions powerfully influence how we think, feel, and behave, so understanding what they are and how they work is very useful.
Many of the metacognitions those of us with OCD experience are about our intrusive thoughts. Here are some examples of metacognitions about intrusive thoughts:
· I shouldn’t be having this thought (e.g., I shouldn’t be having the thought of yelling a racial slur).
· Having this thought could mean that something bad is going to happen (e.g., Having the thought that I left the front door open could mean that my door is open and someone will kidnap my pets).
· Having this thought might mean I’m a bad person (e.g., Having the thought that someone else is attractive could mean I’m cheating on my partner and, as a result, I’m a bad person).
· What if I get stuck having this thought (e.g., What if this thought of stabbing someone stays in my mind for the rest of my life)?
· If I get stuck with this thought, I’ll be distracted, feel anxious, and won’t be able to participate in my life.
All the examples above are thoughts about intrusive thoughts. In the first example, you can imagine someone with OCD having the intrusive thought “What if I yell a racial slur” and then having a thought about that thought, such as “Oh my goodness, I just had the thought ‘What if I yell a racial slur?’ I shouldn’t be having that thought. That’s a bad thought to have.”
This is a thought about a thought -- a metacognition.
An Example Of Metacognitions In OCD
To further illustrate this, imagine someone struggling with a pedophilia OCD-related theme area. Someone with a pedophilia OCD-related theme area often has intrusive thoughts and images about molesting a child. Crucially, when they have these intrusive thoughts, they (usually instantly and automatically) have metacognitions ABOUT these thoughts, such as:
· “Maybe having this thought means I actually want to molest a child.”
· “Maybe having this thought means I will inexplicably and uncontrollably molest a child even if I don’t want to.”
These metacognitions then get connected with other thoughts, such as:
· “If I actually want to molest a child, then I’m a terrible person and if anyone ever found out they would be disgusted by me and probably report me to the police.”
· “If I inexplicably and uncontrollably molest a child, even if I don’t want to, then I might scar a child forever as well as getting thrown into jail.”
Needless to say, these thoughts usually activate a lot of painful anxiety and guilt.
As those of us with OCD become more and more accustomed to our intrusive thoughts, and especially as we begin treatment for OCD, we begin to realize more and more that the thoughts are “just our OCD” and “just thoughts”. We begin to learn that even though the intrusive thoughts are abhorrent and / or terrifying, they’re almost certainly not going to happen.
But here’s were OCD get’s really tough for at least two reasons:
· First, as I discuss here, we don’t know very many things 100% for sure. So even if it’s astronomically unlikely I’m a pedophile, I can’t know absolutely for certain.
· Second, I still get stuck with the intrusive thoughts and anxious feelings which get in the way of my life EVEN IF I’m not a pedophile.
The second point is NOT the same as the first. The difference between the first and second point can be hard to grasp. So, let’s spend some time really reviewing it.
The Difference Between An Object Level Fear And A Metacognitive Fear
In OCD, we have two related but distinct fears: Object level fears and metacognitive fears.
Object levels fears are fears about abhorrent or terrible events actually happening in the world. Metacognitive fears are fears about getting stuck with unwanted, distracting thoughts and anxious, painful feelings about the possibility of abhorrent or terrible events actually happening in the world.
Let’s look at some examples that help us understand why object level and metacognitive fears are related but separate.
Imagine Angela. Her OCD-related theme area is a fear of being attacked by terrorists if she goes to a public place. If Angela even thinks about going to a public place, she immediately has “What if” thoughts around the possibility of that public place being attacked by terrorists. She has thoughts and images of the terrible things the terrorists might do to her. These thoughts and images make Angela very scared. True, she “knows” that the chances of a terrorist attack are very, very low. But very, very low doesn’t mean “absolutely zero”. So, a terrorist attack is still possible and that’s scary. As a result, Angela doesn’t leave home unless it’s absolutely necessary.
For Angela, the object level fear is the fear of her actually being attacked by terrorists if she goes to a public place.
Now, let’s contrast Angela’s object level fear with her metacognitive fear. Her metacognitive fear is that, if she goes to a public place, she will get stuck with unwanted, distracting thoughts and the related anxious, painful feelings EVEN IF the terrorists never attack.
To further illustrate the differences between object level and metacognitive fears, imagine a well-meaning friend trying to reason with Angela. “Come on, Angela, this is just your anxiety talking. There’s basically no chance that terrorists will attack the Starbucks. You’ll be fine!”
Angela already knows the statistics about terrorist attacks. She knows the chances are very low. But not zero. So, the “What if” doubt is still there and Angela’s object level fear remains.
However, even though Angela knows that the chances of actually being attacked by a terrorist at Starbucks is very low, the chances of her getting stuck with unwanted, distracting thoughts and related anxious, painful feelings about the possibility of being attacked by terrorist is VERY HIGH.
Why do we say that Angela’s chances of getting stuck with unwanted, distracting thoughts and related anxious feelings about the possibility of being attacked by a terrorist are very high? Because she’s ACTUALLY EXPERIENCED getting stuck with the thoughts and feelings most of the times she’s gone to a public place EVEN IF she’s never actually been attacked by terrorist.
Another way of stating this is: How many times has Angela actually been attacked by terrorists? Zero. But, how many times has Angela been stuck with the unwanted, distracting thoughts and anxious, painful feelings about the possibility of being attacked by terrorists? ALL THE TIME!
And getting stuck with unwanted, distracting thoughts and anxious, painful feelings really can damage Angela’s life EVEN IF the terrorists never attack.
Imagine how hard it would be for Angela to have a conversation with her friend at Starbucks while, the entire time Angela was trying to have a conversation, she was having scary thoughts and images of terrorists barging through the front door with guns and knives. That doesn’t sound like a very good time EVEN IF the terrorists never arrive.
Understanding The Difference Between Object Level and Metacognitive From A Different Angle
Let’s continue to reinforce this idea from a different angle. Imagine it this way:
Imagine that Angela goes to Starbucks with a friend and tries to have a conversation. Unfortunately, sitting at the table with Angela and her friend is Mr. OCD, who is a harmless fellow with a giant bullhorn. Every thirty seconds or so, Mr. OCD screams full force into the bullhorn “ANGELA, TERRORISTS ARE GOING TO KILL YOU!” Even if Angela is ENTIRELY convinced that it’s very unlikely she’s imminently going to die, it can STILL be REALLY HARD to have a conversation with a friend while someone is screaming on a bullhorn right next to you.
In this case, one of the things that’s painful about OCD is the possibility that the message being screamed (“Angela, terrorists are going to kill you!”) on the bullhorn could be true (the object level fear). But the other thing that’s really painful about OCD is the SUPER LOUD NOISE from the bullhorn, that’s distracting and painful, whatever the message or content of that noise.
We could imagine someone screaming into a bullhorn in a language we can’t understand STILL being distracting and painful.
Reinforcing The Difference Between Object Level And Metacognitive From Yet Another Angle
Imagine I’m working with Erica, whose primary OCD-related theme area is that she’ll contract a deadly germ from the environment.
Erica’s object level fear is actually contracting a deadly germ in the environment and then dying. She “knows” the chances of this happening are very low, but they aren’t zero. So, she avoids going out, wears gloves, and frequently washes and showers for longer and longer periods of time.
Erica’s metacognitive fear is getting stuck with unwanted, distracting thoughts and related anxious, painful feelings about the possibility of contacting a deadly germ in the environment EVEN IF she never ACTUALLY contacts a deadly germ.
How many times has Erica actually contacted a deadly germ in the environment? Probably never. But how many times has she been stuck with the unwanted, distracting thoughts and related anxious, painful feelings about the possibility of contacting a deadly germ in the environment? ALL THE TIME. Every day. For hours!
So, imagine a friend of Erica telling her, “Erica, come on, be realistic! You’re chances of contacting a deadly germ are so, so low!” Just like with Angela, Erica already “knows” this.
Imagine, though, that Erica’s friend said “Erica, come on, be realistic! You’re chances of getting stuck with unwanted, distracting thoughts and related anxious, painful feelings are so, so low!”
That’s just FALSE. Although Erica’s probably never contacted a deadly germ, she’s been stuck with the thoughts and feelings about the possibility of contacting a deadly germ THOUSANDS of times.
Once again, we can see that the object level fear is very unlikely but the metacognitive fear has happened countless times!
And From One More Angle
OCD with a sensorimotor theme area involves an individual who gets “stuck” noticing his or her bodily functions, such as blinking, breathing, heartbeat, or swallowing. This can become very distressing. And, much of the time, if you ask someone with a sensorimotor theme area what their fears are, they’ll tell you that their fears are getting stuck with the unwanted object of awareness and the related anxious, painful feelings.
Note: Someone with sensorimotor OCD is often not concerned that noticing their blinking or their swallowing is a sign of some impending health concern. Frequently, they’re afraid that the awareness of these bodily functions will become stuck and, as a result, get in the way of them being able to focus on the things they want to enjoy in life.
For example, they might report, “I’m so scared that I’ll keep noticing my swallowing and not be able to ever enjoy any other activity again without being stuck with the awareness of my swallowing.”
In cases like these, the individual is afraid of getting stuck with unwanted and distracting objects of awareness. They are afraid of getting stuck, possibly forever, with intrusive thoughts, related anxious, painful feelings, and the impact this would have on their lives. It’s hard to have a clearer example of a metacognitive concern than that!
What Does All This Mean For OCD Treatment?
When working with my clients, I frequently remind them that, during exposure and response prevention treatment, we’re practicing at least two skills. The first skill we’re practicing is distress tolerance. That’s the ability to allow the intrusive thoughts and related anxious feelings to be present without trying to make them go away. This skill is related to accepting uncertainty and the willingness to take calculated risks.
The second skill we’re practicing is cognitive flexibility. That’s the ability to have unwanted, distracting intrusive and the related anxious, painful feelings present AND STILL participate in other activities.
For example, consider an example of an exposure for Julie who experiences hit-and-run OCD. After driving her car (and not doing any checks or avoidances), Julie comes back to my office. She reports to me, “William, I’m super scared right now. There were pedestrians everywhere and I heard tons of bumps while I was driving. I’m having the thought that I might have run someone over and not realized it.”
“Great work” I reply, “And what do we say to the intrusive thoughts during an exposure?”
“We say the thoughts can be there as long as they need to” Julie says, “In fact, we’re going to try to keep the thoughts there. So, if the thoughts drift off, I’m going to pull them back. I just keep in contact with the thought I might have hit someone with my car.”
“Wonderful! And what do we say to your body during an exposure?” I ask.
“I tell my body that it can feel however it needs to feel for however long it needs to feel it and it’s understandable I’d have these anxious feelings because I have OCD and it’s a scary idea to think about running someone over and not realize it.”
“Great! And, finally, tell me, Julie, how come, later during our exposure, we’re going to play some chess together? Wouldn’t that be bad because it’s a distraction technique?”
“We’re going to play chess because that’s a way of practicing cognitive flexibility. By playing chess, I’m showing myself that I can participate in a complex cognitive task even while I ALSO am purposefully holding on to the distracting, anxiety producing thought that I might have run someone over.”
“Outstanding!”
Just like riding a bike, the more Julie practices her distress tolerance and cognitive flexibility skills, the easier and easier these skills become. Our goal is to have Julie practice these skills enough that she finds herself using them automatically. During this process, Julie will begin to notice that her intrusive thoughts start making her less and less anxious and that her intrusive thoughts start showing up less and less.