What Metacognitive Exposure and Response Prevention Is Teaching Us (That Bion Already Knew)

A recent randomised controlled trial by Exner et al. (2024), published in the Journal of Anxiety Disorders, compared Metacognitive Exposure and Response Prevention (MERP) to standard ERP. MERP integrates exposure tasks with structured attention to how patients relate to their intrusive thoughts—inviting a form of thinking-about-thinking.

The study found that MERP was non-inferior to ERP in reducing OCD symptoms, and significantly better at reducing anxiety by end of treatment. While both therapies were effective, MERP appeared to offer something additional: a shift not just in behaviour, but in mental stance.

At UITS, we welcome the rigour of this study—but its conclusions come as no surprise. For us, MERP confirms a position we’ve held for years, one rooted in the work of Wilfred Bion: that the task of therapy is not just to reduce symptoms, but to restore the mind’s ability to bear and process experience.

MERP’s invitation to “watch the mind working” echoes Bion’s emphasis on alpha-function—the capacity to transform raw, intolerable mental content into something that can be thought about. This is particularly relevant for adolescents whose intrusive thoughts carry a moral weight or persecutory quality. For them, exposure without reflection can feel mechanistic or even violent. MERP slows the encounter down. It restores reverie.

This is why we ask: not just what is the intrusive thought—but what psychic work is it doing?

Not just is the compulsion weakening?—but can this mind now think more freely?