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© 2009 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
Except as indicated, no part of this book may be reproduced, translated, stored
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mechanical, photocopying, microfilming, recording, or otherwise, without
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Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED PHOTOCOPY LICENSE
These materials are intended for use only by qualified mental health
professionals.
The publisher grants to individual purchasers of this book nonassignable
permission to reproduce all materials for which photocopying permission
is specifically granted in a footnote. This license is limited to you, the
individual purchaser, for personal use or use with individual clients. This
license does not grant the right to reproduce these materials for resale,
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Library of Congress Cataloging-in-Publication Data
Wells, Adrian.
Metacognitive therapy for anxiety and depression / Adrian Wells.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-59385-994-7 (hardcover: alk. paper)
1. Metacognitive therapy. 2. Anxiety disorders—Treatment. 3. Depression,
Mental—Treatment. I. Title.
[DNLM: 1. Cognitive Therapy. 2. Anxiety Disorders—therapy.
3. Depressive Disorder—therapy. WM 425.5.C6 W453m 2008]
RC489.M46W45 2009
616.85′220651—dc22
2008029157Preface
Cognitions count. By now it is well established that thoughts have a
strong impact on emotional and psychological well-being. But consider the
following: You had thousands of thoughts yesterday. Some were pleasant
and some were less so. Where did all those thoughts go?
Thoughts appear and disappear. A central premise of the approach
described in this book is that psychological disorder is the extent to which
some thoughts are extended and recycled and some are simply let go. This
is a process of selection and control of thinking styles, which depends on
metacognition. It is also a matter of how we relate to our own inner experiences.
In cognitive-behavioral theories the content of thought has been
given great importance as determining the presence of disorder. But how
we think about an event, or how we think about a constellation of conversations,
ourselves, and the world around us, is the more profound effect. In
fact, how we respond to thoughts can, and all too frequently does, lead to
emotional suffering.
Over the past 40 years the cognitive-behavioral model has provided
a robust understanding of the impact of cognition on psychological wellbeing,
and led to techniques for treating anxiety, mood, and other disorders.
Like this model, metacognitive therapy (MCT) assumes that psychological
disorder results from biased thinking; however, it provides a
different account of its nature and causes. Earlier approaches have said
surprisingly little about the issue of what gives rise to unhelpful thinking
patterns. It is incomplete to attribute such patterns to the presence
of underlying beliefs about the self and world, such as “I’m vulnerable” or
viii Preface
“I’m a failure.” A negative belief, such as “I’m a failure,” can be the impetus
for a range of responses, such as the deployment of strategies for becoming
a success that might include learning from mistakes, working harder,
developing new skills, or dismissing the belief as simply a thought that is
irrelevant.
Negative beliefs do not necessarily lead to disturbed thinking patterns
and prolonged emotional suffering. Metacognitive theory proposes
that disturbances in thinking and emotion emerge from metacognitions
that are separate from these other thoughts and beliefs emphasized in
cognitive-
behavioral therapy (CBT).
There is something significant about the pattern of thinking seen in
psychological disorder. It has a repetitive, recyclic, brooding quality that is
difficult to bring under control. Earlier theories have tended to say little
or nothing of such qualities and instead have preferred to focus on the
content of thoughts. Earlier approaches have focused on specific irrational
beliefs or shorthand negative automatic thoughts, but this is only a small
feature of cognition and might be of limited importance. For instance,
most patients report long chains of uncontrollable cognitive activity that
hardly fits the description of automatic thoughts. It is control of mental
processes and selection of some ideas for sustained thinking that is at the
heart of emotional suffering. Rather than identifying emotional problems
with automatic thoughts, MCT views troublesome internal states as closely
related to unhelpful processes of worry, rumination, and strategies of mental
control.
At the beginning of my journey leading to MCT, which has taken
over 20 years, it seemed that what might be needed to advance the field
was an account of the factors that control thinking and cause distressing
thoughts to be enriched and extended. I believed that this would depend
on extending the concept of metacognition and its assessment and using
this to formulate the control of attention and mental processes in psychological
disorder.
Metacognition refers to the internal cognitive factors that control,
monitor, and appraise thinking. It can be subdivided into metacognitive
knowledge (e.g., “I must worry in order to cope”), experiences (e.g., a feeling
of knowing), and strategies (e.g., ways of controlling thoughts and protecting
beliefs).*
*I should like to point out that there are important issues of cognitive architecture, the
relative effects of levels of control of attention, and cognitive resource issues that are taken
account of in the theory and are described elsewhere (Wells & Matthews, 1994, 1996). The
metacognitive model assimilates theory and research in these important areas and offers
an explanation of bias and attention effects on task performance. However, this will be of
peripheral interest to most practitioners of MCT, and it is therefore not considered in detail
in this book.
Preface ix
A central idea is that metacognitive factors are crucial in determining
the unhelpful thinking styles seen in psychological disorder that give rise
to the persistence of negative emotions. In its “hard” form, the metacognitive
theory suggests that the irrational beliefs or schemas emphasized by
Albert Ellis and Aaron T. Beck in their respective cognitive theories—or
at least, their persistence and influence—are the products of metacognitions.
Metacognitions direct attention, determine the style of thinking, and
direct coping responses in a way that repeatedly gives rise to dysfunctional
knowledge. This is a dynamic view of beliefs as created by more stable
metacognitions. This view implies that metacognitions, and not their consequences,
should be modified in treatment.
In a “soft” form the theory suggests that metacognitive beliefs exist
alongside other stored beliefs about the self and world, but as separate entities
that are responsible for controlling cognition and making use of other
more general beliefs and knowledge. In this form treatment might retain a
component of challenging traditional beliefs, but it must also deal with the
coexistent metacognitions.
In both its hard and soft forms, the metacognitive approach has
profound implications for treatment. It guides us toward strategies that
enable patients to develop new relationships with their thoughts and
beliefs. Rather than questioning the validity of thoughts and beliefs as in
traditional CBT, it directs the therapist toward changing the metacognitions
that give rise to maladaptive styles of difficult-to-control repetitive
negative thinking. For example, the metacognitive approach to treating
trauma assumes that metacognitive beliefs and control strategies that disrupt
in-built self-regulation are the reasons symptoms do not naturally
subside. The tendency to worry or ruminate, lock attention onto threat,
and cope by avoiding thoughts interferes with a normal adaptation process
and leads to sustained thinking about danger and a persistence of
symptoms.
It follows from this that treatment should consist of removing worry
and rumination, abandoning attentional strategies of threat monitoring,
and helping individuals to experience intrusive thoughts without avoiding
or reacting to them with unhelpful suppression, or with ruminative or
extended thinking strategies. This treatment differs from standard CBT
in that it does not involve challenging thoughts or beliefs about trauma,
or prolonged and repeated exposure to trauma memories. Instead, it consists
of relating to thoughts in a different way, banning resistance or elaborate
conceptual analysis, and suspending maladaptive thinking styles of
worry, rumination, and inflexible threat monitoring. In MCT, beliefs are
challenged—but the focus is on the person’s beliefs about cognition itself.
In treating depression, MCT targets the process of rumination rather
than the content of a range of negative automatic thoughts. Treatment
x Preface
consists of the attention training technique to interrupt repetitive styles of
negative thought and regain flexible control over thinking styles. This is
coupled with challenging negative metacognitive beliefs about the uncontrollability
of depressive thinking, and challenging positive beliefs about
the need to ruminate as a means of coping and finding answers to sadness.
Inevitably, each person who approaches this book will have his or her
own goals in reading it, and his or her own style of processing the material
contained within. The book is a detailed treatment manual and is replete
with therapy techniques grounded in theory. The reader will find interview
schedules for developing case formulations, treatment plans, and
measures to assist in assessment. Many of the ideas will be new, and it is
likely to require experience in applying them to fully appreciate the nature
of MCT. I have tried to omit as much technical terminology as possible,
I hope without losing the scientific and conceptual integrity of the MCT
approach.
Anxiety Disorder Symptoms
內容截圖：
目錄: Contents
Chapte r 1 Theory and Nature of Metacognitive Therapy 1
The Nature of Metacognition 4
Two Ways of Experiencing: Modes 7
The Metacognitive Model of Psychological Disorder 9
The CAS 11
Consequences of the CAS 13
Positive and Negative Metacognitive Beliefs 15
Summary of the Metacognitive Model 17
A Reformulated A-B-C Model 17
A Note on Process-versus
Content-Focused
Therapies 21
Conclusion 22
Chapte r 2 Assessment 23
Operationalizing the A-M-C Model 24
Behavioral Assessment Tests in Anxiety 26
Questionnaire Measures 27
Rating Scales 32
A Seven-Step Assessment Plan 34
Conclusion 35
Chapte r 3 Foundation Metacognitive Therapy Skills 36
Identifying and Shifting Levels 36
Detecting the CAS 39
Using a Metacognitive-Focused
Socratic Dialogue 41
Metacognitively Focused Verbal Reattribution 48
Metacognitively Delivered Exposure 50
Conclusion 55
xiv Contents
Chapte r 4 Attention Training Techniques 56
Overview of the ATT 57
Rationale for the ATT 59
Credibility Check 60
Self-Attention
Rating 60
Basic Instructions for the ATT 61
Patient Feedback 63
Homework 63
Troubleshooting 64
Outline of the First ATT Session 65
Case Example 66
Situational Attentional Refocusing 68
Conclusion 69
Chapte r 5 Detached Mindfulness Techniques 71
Aims of DM 74
Elements of DM 74
An Information-Processing
Model of DM 75
DM and Other Forms of Mindfulness 77
Ten Techniques 80
Reinforcing DM Using Socratic Dialogue 86
Homework 86
Application of DM in MCT 86
Conclusion 87
Chapte r 6 Generalized Anxiety Disorder 89
The Ubiquity of Worry 91
Is Worry Controllable? 91
The Metacognitive Model of GAD 92
The Model in Action 95
Structure of Treatment 96
Case Conceptualization 97
Socialization 102
Bridging from Socialization
to Metacognitive Modification 104
Questioning Uncontrollability Beliefs 105
Detached Mindfulness and Worry Postponement 106
Challenging Uncontrollability Beliefs 108
Challenging Danger Metacognitions 110
Behavioral Experiments 115
Challenging Positive Metacognitive Beliefs 117
New Plans for Processing 121
Relapse Prevention 123
GAD Treatment Plan 123
Contents xv
Chapte r 7 Posttraumatic Stress Disorder 124
CAS in PTSD 125
Metacognitive Beliefs 127
The Metacognitive Model of PTSD 128
The Model in Action 130
Structure of Treatment 132
Case Conceptualization 133
Socialization 136
Presenting the Treatment Rationale 137
Detached Mindfulness and Rumination/
Worry Postponement 138
Application of DM and Rumination/
Worry Postponement 143
Generalization Training 145
Eliminating Other Maladaptive Coping Strategies 145
Attention Modification 146
Residual Avoidance 151
New Plans for Processing 151
Relapse Prevention 152
PTSD Treatment Plan 153
Chapte r 8 Obsessive–Compulsive
Disorder 154
Overview of MCT: Object Level versus Meta Level 154
Two Types of Metacognitive Change 157
The CAS in OCD 157
Metacognitive Beliefs 160
Stop Signals 161
The Metacognitive Model of OCD 162
The Model in Action 165
Structure of Treatment 167
Case Conceptualization 167
Socialization 172
Presenting the Treatment Rationale 174
Engagement: Normalizing and Destigmatizing 174
Detached Mindfulness 175
Increasing Compliance with ERP and ERC 179
Challenging Specific Metacognitive Beliefs
about Thoughts 180
Behavioral Experiments 182
Contamination Fears: A Special Case? 186
Modifying Beliefs about Rituals 188
Behavioral Experiments and Beliefs about Rituals 191
New Plans for Processing: Stop Signals and Criteria
for Knowing 192
xvi Contents
Relapse Prevention 194
OCD Treatment Plan 194
Chapte r 9 Major Depressive Disorder 195
Rumination and Depressive Thinking 196
The CAS in Depression 198
The Metacognitive Model of Depression 199
The Model in Action 201
Structure of Treatment 203
Case Conceptualization 203
Socialization 208
Enhancing Motivation 209
Helping Patients Understand the Role of Behaviors 210
Attention Training 211
Detached Mindfulness and Rumination Postponement 211
Implementing DM Techniques 212
Modifying Negative Metacognitive Beliefs 213
Modifying Positive Metacognitive Beliefs 217
Modifying Threat Monitoring 218
Maladaptive Coping with Mood Fluctuation 219
New Plans for Processing 219
Relapse Prevention 221
Fear of Recurrence 221
A Note on Suicidality and Self-Injury
222
Depression Treatment Plan 222
Chapte r 10 The Evidence for Metacognitive Theory and Therapy 223
The Existence and Consequences of the CAS 223
Metacognitive Beliefs 228
Interim Summary 232
Causal Status of the CAS and Metacognitions 233
Does Metacognition Contribute to Disorder
above Ordinary Cognition? 234
Model Testing: Data from Path Analyses
and Structural Equation Modeling 236
Summary of Evidence on Theory 238
The Evidence on Treatment 239
Conclusion 246
Chapte r 11 Concluding Thoughts 247
Specifications of a Transdiagnostic Treatment 250
A Universal Formulation 251
Neurobiology and MCT 255
MCT in a Wider Context 256
Closing Remarks 258
Contents xvii
Appendices 259
Metacognitions Questionnaire 30 (MCQ-30) 261
Meta-Worry Questionnaire (MWQ) 264
Thought Fusion Instrument (TFI) 265
Attention Training Techniques Summary Sheet 266
Self-Attention
Rating Scale 267
CAS-1 268
Generalized Anxiety Disorder Scale—Revised
(GADS-R) 269
Posttraumatic Stress Disorder Scale (PTSD-S) 271
Obsessive–Compulsive
Disorder Scale (OCD-S) 273
Major Depressive Disorder Scale (MDD-S) 275
GAD Case Formulation Interview 277
PTSD Case Formulation Interview 278
OCD Case Formulation Interview 279
Depression Case Formulation Interview 280
GAD Treatment Plan 281
PTSD Treatment Plan 283
OCD Treatment Plan 286
Depression Treatment Plan 289
New Plan Summary Sheet 292
References 293
Index 303