A longitudinal comparison of metacognitive therapy and acceptance and commitment therapy models of anxiety disorders

Complete Reference

Ruiz, F. J., & Odriozola-González, P. (2017). A longitudinal comparison of metacognitive therapy and acceptance and commitment therapy models of anxiety disorders. Anales de Psicología, 33(1), 7-17. https://doi.org/10.6018/analesps.33.1.227041

Study Type

Longitudinal experimental study with between-groups design and mediation analyses.

Background and Theoretical Framework

The present study conducts a longitudinal comparison between two influential theoretical models for understanding and treating anxiety disorders: the Metacognitive Therapy (MCT) model and the Acceptance and Commitment Therapy (ACT) model. Both approaches propose distinct yet potentially complementary mechanisms to explain how anxiety disorders develop and are maintained. The MCT model, grounded in the Self-Regulatory Executive Function (S-REF) model, suggests that anxiety disorders originate in the Cognitive Attentional Syndrome (CAS), characterized by dysfunctional repetitive thinking in the form of worry and rumination. The model proposes that positive and negative metacognitive beliefs about these processes play a central role in the perpetuation of anxiety. In contrast, the ACT model emphasizes the role of cognitive fusion and experiential avoidance in the maintenance of anxiety disorders, proposing that acceptance of internal experiences and values-guided action are fundamental therapeutic mechanisms.

Objectives and Hypotheses

The researchers posed two main hypotheses derived from their interpretations of the MCT and ACT models. First, they expected that, according to the ACT model, the constructs of both models (experiential avoidance and cognitive fusion, on the one hand, and dysfunctional metacognitive beliefs on the other) would longitudinally mediate the effect of metacognitive beliefs on anxiety and stress symptoms. Second, according to the ACT model, they expected that experiential avoidance and cognitive fusion at Time 1 would significantly predict dysfunctional metacognitive beliefs at Time 2, controlling for the effect of anxiety symptoms at Time 1. In other words, the researchers attempted to examine whether experiential avoidance and cognitive fusion can be considered as part of the cognitive attentional syndrome, as proposed by the MCT model.

Method

Participants

The study included 289 participants (59.5% female) with ages ranging from 20 to 82 years (M = 35.38, SD = 8.63). Participants came from Colombia and Spain, with varied educational levels: 7.3% with primary education, 28.2% with secondary education, and 59.9% were university graduates. Thirty-six percent reported having received psychological or psychiatric treatment at some point, and 4.8% reported current psychotropic medication consumption.

Instruments

Acceptance and Action Questionnaire-II (AAQ-II): A measure of experiential avoidance or psychological inflexibility consisting of 7 items assessed on a 7-point Likert scale. The Spanish version used demonstrated adequate psychometric properties.

Beliefs About Thoughts and Feelings Questionnaire (BAFT): A 12-item instrument measuring cognitive fusion with anxious thoughts and feelings. It uses a 7-point Likert scale, and the Spanish version employed in the study demonstrated adequate internal consistency (alpha = .78 to .84) and discriminant validity.

Metacognitions Questionnaire-30 (MCQ-30): A brief version containing five factors: Positive Beliefs about Worry, Negative Beliefs about the Uncontrollability and Danger of Worry, Need to Control Thoughts, Cognitive Confidence, and Cognitive Self-consciousness. It demonstrated adequate internal consistency (alphas from .73 to .87).

Depression, Anxiety and Stress Scale-21 (DASS-21): A 21-item instrument with three subscales (Depression, Anxiety, and Stress), each with 7 items. Participants completed this questionnaire at both assessment points. The data confirm that for the purpose of this study, only the Anxiety and Stress subscales were used.

Procedure

The study used a longitudinal design with two assessment points separated by 9 months. At Time 1 (T1), an anonymous survey was distributed through social media titled "Survey of Psychological Discrepancies in the General Population." Participants responded to self-report questionnaires measuring metacognitive beliefs, experiential avoidance, cognitive fusion, and anxiety and stress symptoms. Nine months later (Time 2, T2), the same participants were invited to complete a second survey containing the same questionnaires and measures, and responses at T1 and T2 were matched according to sociodemographic information.

Data Analysis

Multiple hierarchical regression analyses and mediation analyses were conducted using bootstrapping techniques. Analyses examined longitudinal predictors of changes in variables of interest while controlling for anxiety symptoms at T1. Mediation models were evaluated using Hayes's (2013) PROCESS macro.

Results

Descriptive Data and Internal Consistency

Analysis of internal consistency revealed that all measures used presented adequate reliability: AAQ-II (alpha = .83), BAFT (alpha = .91), MCQ-30 (alphas = .73 to .87), and DASS-21 Anxiety/Stress (alphas = .82 to .89). No statistically significant differences were observed between participants who completed the study and those who did not on any of the study variables.

Mediation Analyses: Effect of Positive Metacognitive Beliefs

Analyses examined whether experiential avoidance and cognitive fusion mediated the effect of positive metacognitive beliefs on anxiety and stress symptoms. Positive metacognitive beliefs at T1 significantly predicted experiential avoidance at T2, though the direct effect did not reach statistical significance. However, the total indirect effect of positive beliefs on anxiety symptoms was statistically significant (IE = .061, 95% BC CI [-.006, .139]). Regarding stress, positive metacognitive beliefs at T1 significantly predicted cognitive fusion at T2, and cognitive fusion in turn significantly predicted stress symptoms at T2 (IE = .084, 95% BC CI [.024, .212]).

Mediation Analyses: Effect of Negative Metacognitive Beliefs

Analysis of negative metacognitive beliefs revealed a different pattern. Negative beliefs at T1 significantly predicted experiential avoidance at T2 (IE = .215, SE = .087, p = .001), and experiential avoidance predicted anxiety symptoms at T2. The total indirect effect was significant (IE = .104, 95% BC CI [-.040, .001]). The model accounted for 38.9% of the variance in anxiety symptoms at T2. Regarding stress, negative beliefs at T1 significantly predicted both experiential avoidance and cognitive fusion. The model accounted for 38.9% of the variance.

Mediation Analyses: Effect of Beliefs about Need to Control

Beliefs about the need to control thoughts at T1 significantly predicted experiential avoidance at T2 (IE = .212, SE = .089, p = .002) and cognitive fusion at T2 (IE = .368, SE = .078, p < .001). Experiential avoidance significantly predicted anxiety symptoms at T2. The total indirect effect was significant (IE = .112, 95% BC CI [.034, .247]). Regarding stress, the model accounted for 40% of the variance.

Prediction of Changes at T2: Variables at T1

In the final analytical step, researchers examined whether the inclusion of experiential avoidance and cognitive fusion at T1 added incremental variance in predicting negative metacognitive beliefs at T2. Results showed that experiential avoidance at T1 was a significant predictor of negative metacognitive beliefs at T2 (β = .78), explaining 63% of the variance when included with baseline measures of negative beliefs. Only experiential avoidance (β = .22) at T1 was a significant predictor of beliefs about need to control at T2, explaining 56% of the variance. Although inclusion of experiential avoidance and cognitive fusion predicted changes in positive beliefs, these predictors did not add incremental variance.

Discussion

The researchers emphasize that the present study represents the first longitudinal empirical comparison of the key constructs of the MCT model (dysfunctional metacognitive beliefs) and the ACT model (experiential avoidance and cognitive fusion) in predicting anxiety and stress symptoms. The findings provide general support for both hypotheses, although with some important nuances.

Regarding the first hypothesis, results demonstrated a similar pattern of mediation in cases of negative metacognitive beliefs and beliefs about need to control, with experiential avoidance and cognitive fusion serving as significant mediators of the effect of these metacognitive beliefs on anxiety and stress. These results are compatible with both the MCT and ACT models, suggesting that both models may overlap considerably in their key constructs.

However, findings regarding the second hypothesis were less clear. Experiential avoidance at T1 was a significant predictor of negative metacognitive beliefs at T2, although cognitive fusion did not add incremental variance. This pattern suggests that experiential avoidance might be considered a component of the cognitive attentional syndrome according to the MCT model, but cognitive fusion may not be an integral aspect of CAS.

Furthermore, the researchers acknowledge important study limitations. First, all data were obtained using self-report measures, which might artificially inflate relationships between similarly measured constructs. Second, the sample consisted of non-clinical participants, which limits the generalizability of findings. Third, although 106 participants completed the study at both T1 occasions, no differences were found in constructs of interest between completers and non-completers. Nonetheless, longitudinal prospective studies such as this one provide a valuable avenue for exploring the interactions between key concepts of psychological models of anxiety disorders.

The authors conclude that the study supports the validity of both models and suggests that further study of their similarities is warranted. Furthermore, the finding that experiential avoidance at T1 was a significant predictor of negative metacognitive beliefs at T2, but not vice versa when controlling for baseline anxiety levels, suggests that experiential avoidance may be a more fundamental process in the development of these disorders than the MCT model proposes.

Significance and Contribution

This study provides the first longitudinal empirical comparison of key constructs from MCT and ACT models in predicting anxiety and stress symptoms. Its findings suggest considerable overlap between the two theoretical models, with similar mediation patterns where experiential avoidance and cognitive fusion mediate the effect of dysfunctional metacognitive beliefs on emotional symptoms. This evidence contributes to understanding common processes underlying anxiety disorders and provides empirical foundation for integrating complementary theoretical perspectives in clinical research and practice.

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