Investigating the Relationship Between Insight and Metacognition in Anxiety Treatment: Results from an Online Imagery Rescripting Intervention

Background Imagery Rescripting (IR) has shown promise in reducing anxiety symptoms and improving coping skills, but who benefits most may depend on individual factors. Insight refers to recognizing symptoms as abnormal and in need of treatment, while metacognitive beliefs are beliefs that people hold about their own thoughts, such as beliefs about their uncontrollability or danger. Both may shape treatment outcomes. Objective This study examined pre-post changes in insight and anxiety symptoms following an unguided online self-help IR intervention, as well as the association between insight and metacognition. Methods Three hundred and four participants completed pre- and post-intervention measures of anxiety, insight, and metacognition, with a one-week follow-up. Results Higher pre-intervention anxiety was associated with better clinical insight, and this relationship was stable through follow-up. Anxiety symptoms decreased substantially from pre- to post-intervention; changes in insight were smaller and mixed across measures. Contrary to our initial hypothesis, better pretreatment clinical insight was associated with higher post-intervention anxiety, after controlling for baseline anxiety. Higher insight was associated with more unhelpful metacognitive beliefs; however, metacognitive beliefs did not predict anxiety outcomes or moderate the relationship between insight and anxiety, and none of the subscale-level interactions met the pre-specified significance threshold. Conclusions Findings highlight the relevance of insight to anxiety outcomes but provide no evidence that metacognitive beliefs moderate this relationship. Subscale-level patterns were not reliable and require investigation in adequately powered studies with pre-specified hypotheses.