Emotional aspects of metacognition in anxious rumination: Clues for understanding the psychotherapy process

Current theorizations of the therapeutic relationship assume that this broad concept depends on mutual and continuous interactions between the patient and therapist and their individual characteristics (Horvath, 2001). One of these characteristics, metacognition, has recently acquired great importance in clinical psychology and has been recognized as an essential skill for the therapeutic relationship development (Dimaggio, Semerari, Carcione, Nicolo, & Procacci, 2007). The aim of the present study was to systematically examine the metacognition construct and its connection with the therapeutic relationship in a patient with a neurotic ruminating attitude who had a descriptive diagnosis of anxiety disorder not otherwise specified. A total of 82 sessions of a weekly psychodynamic psychotherapy were coded with the Metacognition Assessment Scale-Revised version (Carcione et al., 2010) and Psychotherapy Process Q-Set (Jones, 1985); subsequently, they were evaluated through time series analyses. Results showed that the patient's understanding of the other's mind and mastery abilities improved with time. With respect to the association between metacognitive functioning and the therapeutic relationship, results showed a significant positive effect of an authentic and empathic relationship on the patient's mastery abilities. On these grounds, we then reasoned that the above association might depend on the specific metacognitive function. Results confirmed this hypothesis and showed that the emotional side of metacognition, rather than the cognitive side, was associated with the empathic relationship. Overall, these findings suggest that improvement in the therapeutic relationship leads to a better comprehension of the patient's emotional state, which may in turn have a positive effect on the patient's coping strategies.