Do metacognitive beliefs satisfy criteria as mechanisms of change in treatment? A systematic review and evidence synthesis

The Self-Regulatory Executive Function (S-REF) model emphasizes biases in metacognition, and particularly negative metacognitive beliefs, as the central mechanism of persistent emotional distress and disorders. Hence, interventions which effectively modify dysfunctional metacognitions are predicted to create improvement regardless of whether metacognitions are directly targeted or not. With an aim to evaluate the empirical support for metacognitions as a mechanism of change in psychopathology, we conducted a systematic review of the literature focusing on metacognitive change and its relationship to change in outcomes across emotional disorders and therapeutic interventions. Systematic searches were conducted and following PRISMA 2020 guidelines, 27 articles were identified. Results were synthesized and evaluated against established criteria for accurately classifying theoretical predictors as mechanisms of change. Our review shows a consistent association between change in metacognitions, particularly negative metacognitive beliefs, and outcome changes across different mental disorders, outcomes, and interventions. This relationship held even when controlling competing mechanisms such as cognitive beliefs and support the criterion of specificity. However, most of the identified studies lacked the methodological rigor needed (e.g., multiple assessment points during the treatment phase) to draw firm conclusions about metacognitions as a causal mechanism of change. Based on the existing literature, we conclude that metacognition is promising as a candidate to be considered a transdiagnostic mechanism of change of emotional disorders. We provide directions for future research necessary to more definitely determine the role of metacognitive change in psychopathology improvement and recovery. • We evaluated studies on metacognitive beliefs and symptom change during treatment. • We found a strong association between metacognitive- and symptom improvement. • This relationship emerged across diagnostic groups, symptom domains, and treatments. • Change in negative metacognitions seems to be especially important. • Metacognitive- rather than cognitive change reliably correlated with improvement.