Metacognitive therapy focuses on removing the CAS and promoting new ways of re- lating to thoughts. To achieve this goal, metacognitions controlling thinking must be modifi ed.
Because metacognitive knowledge and beliefs are represented as plans or programs for thinking and also as propositional information, treatment aims both to build new metacognitive control skills (i.e., strengthen plans) and to change the nature of propo- sitional information. Th ese aims are often interconnected and overlap in the strategies used in treatment. For example, practicing the postponement of chains of worry en- hances control skills and also modifi es erroneous knowledge about loss of self-control.
However, because there are diff erent types of knowledge, individual strategies may not change each type universally. For example, whereas controlling worry may challenge beliefs about its uncontrollability, this will not modify beliefs about its potential dan- ger. In fact, patients may misuse control as avoidance and fail to discover that worry is harmless. Th us, individual treatments are best guided by disorder-specifi c models that delineate the nature and relationship between the types of metacognitive knowledge that operate in each case. Disorder-specifi c metacognitive models have therefore been developed and tested to maximize treatment outcomes.
Th e fi rst task of the therapist is drawing out the individual case-formulation based on the model. Th is is followed by socializing the patient to the model. Here the therapist aims to illuminate the presence of the CAS and to illustrate its eff ects through reviewing examples, questioning its consequences, and conducting socialization experiments.
For example, in the treatment of depression, the therapist asks about responses to fl uctuations in mood/symptoms or negative thoughts and identifi es the nature and du- ration of rumination and the metacognitive beliefs associated with it:
Th erapist (T): What has your mood been like in the last week?
Patient (P): It’s not been a good week, I’ve been feeling dreadful.
T: Was there a trigger for feeling like this?
P: I just woke up with a feeling of dread, and it’s been like that for the past few days.
T: Okay, what was that feeling like? I mean, was it a thought or sensation in your body?
P: I had an argument with my husband, and I just woke up thinking I’ll feel like this forever.
T: Was that the initial thought?
P: Yes.
T: Okay, when you had that thought, what did you then go on to think about?
P: I started to think I would never get over my depression, and how everyone seems bet- ter off than me. But I don’t really have anything to be depressed about. Th ere just seems to be nothing I can do to stop feeling like this.
T: Th at sounds like a long chain of thoughts that we call ruminating. How long did that go on?
P: All morning. I just stayed in bed and carried on going over things in my mind.
T: What happened to your feelings as you did that?
P: Well they just got worse, until I had to get up and take care of things.
T: Have you been ruminating since then?
JWBT357c04_p83-108.indd 87
JWBT357c04_p83-108.indd 87 10/6/10 12:01:37 PM10/6/10 12:01:37 PM
P: Yes, much of the time.
T: If it makes you feel worse, would it be a good idea to reduce the activity?
P: Yes, but how? I’m not sure I can control it, it’s part of my illness.
T: If you could control it, would you feel better?
P: Yes. It would probably help, but I need to fi nd out why I’m like this in the fi rst place.
T: Sounds like you have some beliefs that analyzing yourself will help you.
P: If I can fi nd an answer, then I can do something about it.
T: How long have you been ruminating like this to try and fi nd an answer?
P: For as long as I’ve been depressed; it must be more than four years.
T: Have you been able to fi nd the answer yet?
P: No.
T: Maybe the answer is to stop ruminating. Shall we look at how you can start to do that?
P: But I have no control; it just seems to happen.
T: It’s good you’ve said that, because one of the fi rst things we should look at is your belief that you have no control, as that might get in the way of you practicing new ways of relating to your thoughts.
Following socialization, the next step in treatment is modifying beliefs about un- controllability through a combination of verbal methods such as guided discovery and behavioral experiments. For example, the therapist can ask the patient to start and stop ruminating in the session. Similarly, the therapist can identify occasions when the pa- tient successfully interrupted rumination and question whether the patient can increase the activity. If rumination can be increased, it should be possible to decrease it, too.
Th e concept of detached mindfulness and worry/rumination postponement is then in- troduced. Patients are instructed in acknowledging the presence of a negative thought and then disengaging any sustained worry, rumination, suppression, or coping response. In particular, the patient is instructed to postpone any worry or rumination until a specifi ed 15-minute period later in the day. Th is period is designated as the “worry-time,” but the therapist emphasizes that it is not mandatory to use this period—and, in fact, most pa- tients decide it is not necessary when the time comes. A range of exercises and metaphors is used in MCT to facilitate knowledge and skills of detached mindfulness, although these do not involve the formal practice of meditation. Th roughout this phase of treatment, the therapist monitors the frequency with which detached mindfulness and postponement is practiced and the proportion of negative thoughts to which it is applied.
To facilitate this process, it is often necessary to challenge negative beliefs about uncontrollability and positive beliefs about the need to worry or ruminate. In the treat- ment of some disorders, particularly depression, additional training procedures such as attention training (Wells, 1990, 2007) are used at each session to help patients acquire greater awareness of the control they have over thinking processes so that control is experienced as distinct from the occurrence of individual events. Attention training
consists of focusing on diff erent sounds often presented at a range of locations in space and shifting attention between them. Th e individual is asked to continue following the attention allocation instructions even in the presence and awareness of spontaneous internal events such as thoughts or feelings.
In treating individual disorders, specifi c domains of negative metacognitive beliefs are challenged, such as beliefs about the danger of worrying (in generalized anxiety) and beliefs about the meaning and power of thoughts to cause events (in obsessive- compulsive disorder). Positive metacognitive beliefs about the need to engage in worry, rumination, or other forms of perseverative activity are modifi ed in treatment. One strategy is the strengthening of dissonance between positive and negative metacogni- tions. For instance, the therapist draws attention to the confl ict that exists between the belief that worry is benefi cial and the belief that it can lead to bodily damage or mental breakdown. Specifi c strategies, such as worry mismatch strategies, worry modulation experiments, and paradoxical rumination-prescription techniques, are also used where appropriate (see Wells, 2009). Worry mismatch is a technique in which a recent worry script is written out, with each step in the worry sequence summarized. Th e patient is then asked to describe the events that actually occurred in the situation; this forms a
“reality script.” Th e two scripts are compared, and the therapist helps the patient dis- cover the substantial mismatch that exists between the two. Th e question is then posed:
“If worry does not resemble reality, then what’s the advantage of worrying?” Th e worry modulation experiment consists of asking a person to worry more on some days and ban or postpone worry on others, then to assess the eff ects on outcomes such as quality of work performance or number of mistakes made. In this way, the therapist can help the patient to see that worrying is not helpful and thereby challenges PMC beliefs.
Toward the end of treatment, relapse prevention is undertaken. It consists of review- ing residual metacognitive belief levels and formulating a therapy “blueprint”—a plan for how to respond to negative ideas and emotions in the future. Th e blueprint contrasts the “old plan,” consisting of the CAS, with the new response style, consisting of fac- tors such as low conceptual processing, refocusing on external safety signals, reversal of avoidance, and banning threat monitoring.
Progress in treatment in modifying key elements of the CAS and important meta- cognitions is continuously monitored with self-report scales. Some of these instruments are designed for specifi c disorders (e.g., the Generalized Anxiety Disorder Scale, Major Depressive Disorder Scale, and Obsessive-Compulsive Disorder Scale; Wells, 2008).
Others are more generic, and have been subjected to formal psychometric evaluations (e.g., the Metacognitions Questionnaire 30; Wells & Cartwright-Hatton, 2004).