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1Detached Mindfulness Techniques
2The concept of detached mindfulness (DM) was briefly introduced in
3Chapter 1. In this chapter I examine the concept in greater detail and
4describe 10 techniques that can be used to train individuals in the rapid
5and flexible deployment of this metacognitive strategy.
6DM was originally described by Wells and Matthews (1994). It concerns the manner in which an individual relates to his or her cognition and
7the development of flexible control of attention and thinking styles. The
8ATT reviewed in the previous chapter offers a specific strategy designed
9to impact on and improve flexible control of attention and to strengthen
10the ability to disengage from unhelpful ways of relating to inner experiences. DM techniques are focused more on developing meta-awareness in
11the context of suspending conceptual processing and separating self from
12cognitive events.
13I have previously described DM as
14a state of awareness of internal events, without responding to them with sustained evaluation, attempts to control or suppress them, or respond to them
15behaviorally. It is exemplified by strategies such as deciding not to worry in
16response to an intrusive thought, but instead allowing the thought to occupy
17its own mental space without further action or interpretation in the knowledge that it is merely an event in the mind. (Wells, 2005b, p. 340)
18As the name implies, DM has two features: (1) mindfulness and (2)
19detachment. DM consists of both features simultaneously. Let’s address each
20of these components in turn, beginning with mindfulness.
21We use the term “mindfulness” in DM to refer specifically to being
22aware of inner cognitive events, namely, thoughts, beliefs, memories, 
2372 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
24and feelings of knowing. Effectively, the use of the term “mindfulness” is
25intended to refer to metacognitive awareness of thoughts and beliefs where
26attention can be flexibly focused on such inner experiences without being
27locked onto any one of them.
28We use the term “detachment” to refer to two further factors. The first
29and most important dimension of detachment denotes detachment of any
30reactive engagement with the inner event. That is, the person refrains from
31further appraisal of or attempts to cope in response to the inner event. The
32concept of DM contains the antithesis of the CAS. It is about stopping any
33conceptual or behavioral involvement with inner experiences. It consists of
34abandoning worry, rumination, suppression, control, threat monitoring,
35avoidance, or attempts to minimize (nonexistent) threat in response to
36cognition.
37The second component of detachment involves the person experiencing an inner event as an occurrence that is independent of general consciousness of the self (i.e., the individual has a perspective in relation to
38the event in which consciousness is located separately from it). It is as if the
39person is aware of the perspective of the self as an observer of the thought
40or belief. This feature is harder to grasp. Therefore, an example may help
41to illustrate the construct. This example is based on a male patient with
42OCD.
43Therapist: It sounds as if you often have thoughts about contamination.
44Patient: Yes, every time I see a stain I think, “It must be contaminated” or
45“I’m contaminated.”
46Therapist: So how aware are you of repeatedly thinking “It must be contaminated”?
47Patient: I’m always thinking it when I see stains.
48Therapist: Of course. But how often do you stop and consciously reflect
49on the fact that you have had that thought again?
50Patient: I don’t, I just act to prevent harm.
51Therapist: So the first thing you can do is simply to stop and be consciously
52aware of having the thought. That is called mindfulness.
53Patient: Yes, but what if it’s true?
54Therapist: Irrespective of whether it is true or not, it is still a thought.
55Patient: Yes, but I can’t ignore it.
56Therapist: Ignoring the thought isn’t the idea. I want you to become
57aware of it as a thought in your mind that you can observe. I want you
58to become mindful of it.
59Patient: How would I know it is just a thought?
60Detached Mindfulness Techniques 73
61Therapist: What else could it be?
62Patient: Well, it could be true.
63Therapist: Whether it is true or not, it will always be a thought. Whether it
64is true or not, I would like you to practice detachment from it and see
65it as a thought separate from yourself.
66Patient: I’m not sure what you mean.
67Therapist: Can you have the thought “I’m contaminated” right now?
68Patient: Yes.
69Therapist: Look at that stain on the floor. Can you close your eyes right
70now and have the thought “I’m contaminated”?
71Patient: Okay.
72Therapist: Now pay attention to that thought. Don’t do anything to change
73it. Take a step back in your mind and look at the thought and as you do
74so concentrate on where you are as the observer watching that thought
75in your head. Concentrate on what it feels like to be detached from
76that thought. Can you observe that as a thought separate from the
77sense of yourself?
78Patient: Yes, I can.
79Therapist: Can you detach yourself from your thoughts like that in
80future?
81Patient: Yes, but I will still need to wash.
82Therapist: Part of detachment from the thought involves watching it as an
83observer and postponing doing anything else in response to it. How
84long could you postpone washing?
85Patient: I’m not sure.
86Therapist: What about postponing it for an hour to start with?
87In this example the therapist introduces the concept of mindfulness
88in terms of the patient increasing his subjective awareness of the occurrence of thoughts about contamination. This awareness begins to build
89the scaffolding to support the shift from the object mode in which thoughts
90are fused with facts to the metacognitive mode in which thoughts are events
91in the mind. In this process the therapist encourages the patient to refrain
92from evaluating whether or not the thought is a fact by emphasizing that
93it remains a thought irrespective of its validity. The patient’s main task is
94to be aware of the thought as a mental event and to experience it as such.
95The dialogue continues with the introduction of detachment in the form
96of separating the self from the thought and disengaging coping responses
97(i.e., postponing washing).
9874 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
99Aims of DM
100There are several aims in using DM. It can be used to shift patients away
101from the object mode of experiencing and into the metacognitive mode.
102It can be used as a means of interrupting perseverative processing in the
103form of worry and rumination. It can be used to increase executive control
104over the allocation of attention. It also enables patients to escape the influence of thoughts on self-concept.
105The effect of DM is determined by how it is used and the rationale for
106using it. It is imperative that DM is not used as an emotional or cognitive
107avoidance technique or as a means of preventing erroneous feared outcomes. For example, a patient may inappropriately use DM as a means of
108controlling or counteracting the effects of “dangerous thoughts,” a misuse
109that could maintain the mistaken belief that thoughts can cause harm.
110More specifically, the aim is not to teach DM so that it can become another
111form of maladaptive thought control strategies. It is not a means of avoiding
112thoughts. Instead, it is about relating to thoughts and experiencing them
113in a new way that necessitates overt and covert inaction. It is a “do-nothing”
114strategy, the antithesis of coping and the CAS. That is why it is a state of
115“detached awareness.” It is also detached awareness because the process
116of experiencing DM involves disconnection of the sense of self from the
117contents of consciousness as a more profound and deeper experience. This
118latter sense can be particularly useful when the thought or “feeling” that
119intrudes into consciousness is fused with the self-concept.
120Elements of DM
121I have described how DM is a type of inner awareness that occurs in the
122absence of effortful conceptually based self-processing. Specifically, it is
123an awareness of thoughts in which they are experienced as passing events
124in the mind that are distinct from reality and separate from the self. Since
125DM is awareness in the absence of conceptual processing, it requires metacognitive control of analytical and perseverative forms of thinking. DM is
126simply awareness without judgment of the position of the self in relation
127to a mental event. The psychological elements of DM can be isolated and
128conceptualized as involving the following:
1291. Meta-awareness (i.e., consciousness of thoughts).
1302. Cognitive decentering (i.e., comprehension of thoughts as events
131separate from facts).
1323. Attentional detachment and control (i.e., attention remains flexible and not anchored to any one thing).
133Detached Mindfulness Techniques 75
1344. Low conceptual processing (i.e., low levels of meaning-based analysis or inner dialogue).
1355. Low goal-directed coping (i.e., behaviors and goals to avoid or
136remove erroneous threat are not implemented).
1376. Altered self-awareness (i.e., experience of a singularity in consciousness of self as an observer separate from thoughts and beliefs).
138An Information-­Processing Model
139of DM
140Progress in the development of useful experiential techniques is most
141likely to be made by reference to an information-processing analysis of the
142goals and effects of such techniques. DM is based on such an approach.
143In earlier work I have described an information-processing model of DM
144requirements and effects (Wells, 2005b). I briefly summarize that model
145here (see Figure 5.1).
146DM is intended to impact on the CAS and the metacognitive processes
147and knowledge that drive it. DM can be conceptualized as acting on the
148interrelated cognitive and metacognitive subsystems. The metacognitive
149subsystem consists of information about cognition stored as a library of
150knowledge or beliefs that can be accessed to interpret and control thinking. It also consists of a model of the activities of online processing, which
151it monitors and controls in pursuit of the goals of processing. The relationship between the metacognitive and the cognitive subsystems can be
152represented as a flow of information involving monitoring and control, as
153posited by Nelson and Narens (1990).
154The model of the cognitive subsystem held by the metacognitive subsystem is built from the monitoring of events in ordinary cognition (i.e.,
155online processing) and projection of their status into the future in relation to a reference standard. It consists of a current representation of the
156status of ordinary cognition in relation to a set of goals. The model not
157only requires real-time feedback from the online level but the accessing of
158knowledge from long-term memory.
159This specification of the components of and the relations between the
160subsystems leads to hypotheses about the information-processing parameters that have to be met to achieve DM. In this model DM requires the
161following conditions to be present:
1621. Activation of appropriate knowledge (plans) for controlling thinking.
1632. A mental model of the mindfulness state.
1643. Ongoing monitoring and control of that state.
16576 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
166FIGURE 5.1. Metacognitive model of DM grounded in the S-REF framework.
167From Wells (2005b). Copyright 2006 by Springer Science and Business Media.
168Reprinted by permission.
169Meta-subsystem
170u Beliefs
171u Plans
172Model
173Detached Mindfulness
174High meta-awareness
175Cognitively decentered
176Attentional detachment
177Low conceptual activity
178Low goal-directed coping
179CAS
180Low meta-awareness
181Cognitively centered
182Attentional attachment
183High conceptual activity
184High goal-directed coping
185Automatic Processing
186INPUT
187Intrusion Biasing
188Online processing
189Monitoring Control
190Detached Mindfulness Techniques 77
1914. Sufficient attentional resources and flexibility for executive control
192to allow accessing and implementation of DM.
1935. Development of a model of self that is separate from individual
194negative cognitions (beliefs and thoughts).
195This analysis of the features of DM and its requirements sets the stage
196for developing specific DM techniques that are grounded in theory. It also
197means that the effects of different treatment techniques may be formulated
198in terms of this a priori model. For example, the act of identifying automatic thoughts by using a dysfunctional thoughts record might increase
199metacognitive monitoring and allow decentering, thereby strengthening
200metacognitive awareness skills. However, this action might not satisfy the
201other psychological elements of DM, such as attentional detachment, low
202conceptual processing, and low goal-directed coping. The process of interrogating thoughts by directing the patient to rationally question them supports the activation of knowledge (plans) that in turn supports a high level
203of conceptual processing of these thoughts, which is incompatible with
204DM.
205The model (Figure 5.1) and the conditions specified for DM suggest
206that individuals must be able to activate plans for controlling thinking to
207accomplish the desired state. In some instances these plans may be disrupted or not highly developed, meaning that initial training to strengthen
208control plans may be required (e.g., attention training). Most individuals have an intellectual concept of mindfulness but lack the model at the
209metacognitive level to guide them in experiencing this state. Patients’
210acquisition of the model can be achieved by encouraging them to experience focal awareness of their cognitive events (e.g., by counting thoughts,
211engaging in a free-association task—see below). Detachment is facilitated
212by experiential exercises in which individuals practice (1) suspension of
213active conceptual processing and control and (2) experiential awareness of
214self as separate from thoughts. These factors are built into the techniques
215described later in this chapter.
216DM and Other Forms of Mindfulness
217The term “mindfulness” has been used in many different ways in the psychological literature. It has been linked to a state of effortful and conscious
218controlled processing (Shiffrin & Schneider, 1977), a state that is opposite
219to “mindlessness.” Mindlessness is equated with habitual or automatic processing. This characterization is simply another way of differentiating controlled versus automatic processing. It does not implicate metacognition
220and conscious awareness of thoughts themselves as does DM.
22178 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
222The heterogenous nature of mindfulness within the psychological
223and treatment literature is evident in the self-report scales developed to
224assess this construct. For example, Brown and Ryan (2003) developed the
225Mindful Attention Awareness Scale (MAAS) to assess the qualities of consciousness associated with well-being. Many of the items appear to assess
226the tendency not to notice information and to behave as if one is on automatic pilot (e.g., “I could be experiencing some emotions and not be conscious of it until some time later”; “I tend to walk quickly to get where I’m
227going without paying attention to what I experience along the way”). These
228items are similar to other psychological concepts such as cognitive failures
229as measured by the Cognitive Failures Questionnaire (Broadbent, Cooper,
230Fitzgerald, & Parkes, 1982), a measure of everyday cognitive and performance errors. In these approaches mindfulness is linked either to levels
231or the efficiency of attentional functioning, but there is limited separation
232between it and related constructs.
233Mindfulness is also fused with concepts such as acceptance (e.g., Hayes,
234Strosahl, & Wilson, 1999), which means taking thoughts as thoughts and
235feelings as feelings without the need to avoid them. This is conceptually
236similar to DM but does not focus specifically on the suspension of worry
237and rumination and on developing a sense of self as separate from beliefs
238although it may separate self from thoughts and feelings.
239Drawing on previous approaches, Bishop et al. (2004) offer an operational definition of mindfulness that has two components: (1) control
240of attention so that it is maintained on immediate experience, thereby
241allowing for increased recognition of mental events in the present; and
242(2) adopting an orientation of curiosity, openness, and acceptance to one’s
243present experiences. The first component is a feature of DM, and implies
244greater metacognitive awareness. However, this definition does not include
245separation of the sense of self from inner events as does DM. The second
246component takes us further away from DM and introduces the concepts of
247curiosity and acceptance. It is not clear how such states are implemented,
248but they are likely to involve active engagement with thoughts, which is not
249a feature of DM.
250Mindfulness has gained prominence as a term equated with Buddhist
251meditation (e.g., Kabat-Zinn, 1994). DM does have some similarity to the
252concepts of mindfulness derived from meditation practices, but it is also
253different from these approaches.
254From the meditation perspective, mindfulness has been described as
255“paying attention in a particular way: on purpose, in the present moment,
256and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). This is a very broad description that partially covers DM and would also capture some features of attention training (Wells, 1990), but omits some of the unique features of DM.
257In the work of Kabat-Zinn (1990, 1994) mindfulness is equated with
258paying attention. Paying attention to the breath is used as a means of focus-
259Detached Mindfulness Techniques 79
260ing on moment-to-moment experience. Such attention offers a means of
261directly experiencing the moment without thinking about it. This includes
262being aware of the thought stream without judging it, cultivating trust in
263the self, and “letting go,” or accepting things as they are. This kind of
264mindfulness is much more general than the concept of mindfulness in
265DM, and despite containing reference to awareness without thinking, it is
266imprecise and somewhat contradictory. In particular, it requires daily practice and focusing on breathing to anchor attention, which suggests some
267kind of body-focused processing. Furthermore, it is difficult to reconcile
268cultivating trust in the self and acceptance with the absence of some form
269of value judgment. The features of mindfulness as practiced in meditation
270appear to conflict with one another and stand apart from the features of
271DM that eschew judgment and body focusing.
272The conceptual and practical differences between mindfulness in DM
273and mindfulness used in these other contexts can be summarized as follows:
274•	 DM does not involve meditation.
275•	 DM does not require extensive and continuous practice.
276•	 DM does not require broader features of mindfulness such as
277increasing present-moment awareness.
278•	 Mindfulness in meditation tends to use body-focus exercises such
279as focusing on the breath to bring attention back to the present if
280it is captured by thoughts. DM does not have body-focused anchors
281for attention.
282•	 DM specifically concerns developing meta-awareness of thoughts
283rather than present-moment awareness.
284•	 Mindfulness has many meanings with a limited consensus. The definition and features of DM are more tightly specified in advance.
285•	 DM separates meta-awareness from detachment.
286•	 DM is specific about the suspension of conceptual processing.
287•	 DM is specific concerning the suspension of goal-directed coping.
288•	 DM is specific in the concept of separation of sense of self from
289mental phenomena.
290It is likely that the effectiveness of techniques will depend on developing strategies grounded firmly in information-processing models that
291specify the more or less adaptive means of achieving mindfulness. The
292principle objective of meditation-derived mindfulness differs from that of
293DM, whose purpose is to modify well-specified metacognitive structures
294and processes that cause psychological disorder. The future development
295of these techniques might be well served by grounding them in a model of
296their requirements and consequences, as might be offered by the metacognitive approach.
29780 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
298Ten Techniques
299This section presents 10 basic techniques that are used in MCT to promote
300a state of DM or components of it. This section is based on an earlier paper
301(Wells, 2005b) describing some of these strategies.
302Metacognitive Guidance
303“Metacognitive guidance” refers to the use of structured questioning to
304promote meta-cognitive self-reflection during exposure to problematic
305situations or stimuli. Useful questions include:
306“Can you look through your thoughts at the outside world?”
307“Can you see your thought and what is going on around you in the
308situation at the same time?”
309“Are you living by your thoughts or by what your eyes reveal?”
310In one case of a patient with washing compulsions the therapist invited
311the patient to enter a situation that activated his distress and urge to wash,
312specifically, walking along the street close to a trash can. First, the patient
313did this without any therapist guidance and was simply told to find a distance from the can that raised some anxiety that was tolerable. Next the
314therapist asked him to move a little closer to the can and provided metacognitive guidance as follows:
315Therapist: How distressed are you feeling right now on a scale of 0–100?
316Patient: Not too bad. I would say 30.
317Therapist: In a moment I want you to take one step forward and move
318closer to the trash can. But as you do that I want you to become aware
319of your inner thoughts. What are you saying to yourself as you step
320closer? Try that now.
321Patient: I really don’t want to do this.
322Therapist: What thought did you have that made you feel that way?
323Patient: I thought it’s probably contaminated with bodily fluids.
324Therapist: Was that a verbal thought or an inner picture?
325Patient: It was a verbal thought: “What if it has bodily fluids on it?”
326Therapist: Good. I want you to take that step closer and watch or listen
327to that verbal thought. See or hear those words in your mind and
328look through them at the trash can to discover the truth about your
329thought.
330Patient: (Takes a step forward.)
331Detached Mindfulness Techniques 81
332Therapist: Well done. Could you experience seeing through your thought
333when you did that?
334Patient: Yes, sort of.
335Therapist: Does that tell you anything about your thought?
336Patient: Well, it’s just a thought. Taking that extra step hasn’t really
337changed anything.
338Therapist: Good. You can learn to relate to your thoughts in a new way
339without avoiding situations. What about taking another step? This
340time look through your thought and ask yourself: “Do my eyes reveal
341to me that I have been contaminated?”
342Patient: (Takes a further step.)
343Therapist: What do your eyes tell you?
344Patient: Well, I can’t see that I’ve been contaminated.
345Therapist: So is it better to live by your thoughts or by what your eyes
346reveal to you?
347Patient: Maybe I shouldn’t be thinking is it or isn’t it contaminated then?
348Therapist: Could you practice looking through your thoughts instead of
349washing each time you have a thought?
350Patient: But when should I wash?
351Therapist: Only before touching food, after eating, or after visiting the
352toilet, but certainly not after having the thought.
353Patient: So you’re saying this is just a thought and I don’t need to wash?
354Therapist: That’s it. Have you been giving this thought too much importance?
355Patient: I’ve been accepting it as true.
356Therapist: Can you practice relating to this thought in a new way from
357now on?
358Free-Association Task
359In this task the therapist asks the patient to sit quietly and watch the “ebb
360and flow” of thoughts or memories that are triggered spontaneously by verbal stimuli. The aim is not to actively think about items or memories but to
361watch the spontaneous events or lack of such events in consciousness. The
362task is introduced in the following way:
363“So that you can become familiar with using detached mindfulness, it
364is helpful to practice in response to spontaneous events in your mind.
365By doing this you can learn to relate to these events in a new way. In
366a moment I will say a series of words to you. I would like you to allow 
36782 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
368your mind to roam freely in response to each word. Do not control or
369analyze what you think, merely watch how your mind responds. You
370may find that nothing much happens, but you may find that pictures
371come into your mind. It doesn’t really matter what happens. Your task
372is to passively watch what happens without trying to influence anything. Try this with your eyes closed. I’m going to say some words now:
373apple, birthday, seaside, tree, bicycle, summertime, roses.
374“What did you notice when you watched your mind?
375“The idea is that you should apply this strategy to your negative
376thoughts and feelings. Just watch what your mind does without getting
377caught up in any thinking process.”
378Tiger Task
379This is a task that our patients particularly enjoy. In this task participants
380are asked to passively observe nonvolitional aspects of imagery as a means
381of experiencing DM. The following instructions are used to implement the
382procedure:
383“So that you can feel what detached mindfulness is like and what you
384need to do to experience it, I want to introduce you to an exercise.
385We call this the ‘tiger task.’ In a moment I’m going to ask you to close
386your eyes and form an image of a tiger. Let’s do that now: close your
387eyes and conjure up an image of a tiger. Do not attempt to influence
388or change the image in any way. Just watch the image and the tiger’s
389behavior. The tiger may move, but don’t make it move. It may blink,
390but don’t make it blink. The tiger may wag its tail, but don’t make it do
391that. Watch how the tiger has its own behavior. Do nothing, but simply
392watch the image, see how the tiger is simply a thought in your mind,
393that it is separate from you and it has a behavior all of its own.”
394Following practice, the therapist then asks the patient about the movements the tiger made and how the image changed: “Did you make the tiger
395move or did it happen spontaneously?” When the patient experiences the
396movements as spontaneous, this is brought to the patient’s attention as an
397experience of DM. The therapist then asks if this process can be applied to
398spontaneously occurring thoughts of a negative kind.
399Suppression–Countersuppression Experiment
400When patients are highly invested in controlling and avoiding particular
401thoughts, and when they erroneously equate the concept of DM with having
402a blank mind, the suppression–countersuppression experiment is particularly useful. In these cases it is important that the therapist distinguishes 
403Detached Mindfulness Techniques 83
404between suppression and DM so that patient misunderstanding and misuse
405of DM is minimized. This technique consists of a brief period of attempting to suppress a target thought contrasted with a subsequent period of
406thought awareness. An example of this technique is given below:
407“It is important that you learn the difference between detached mindfulness and trying to control or avoid thoughts. Trying to stop thoughts
408is a form of active engagement with them since you are trying to push
409them out of your mind. Pushing something is hardly leaving something alone and so this effort backfires and you remain in contact with
410your thoughts.
411“How can you push against a door and not be in contact with it
412by some means? Let’s see this effect in action. For the next 3 minutes
413I don’t want you to think about a blue giraffe. Don’t allow yourself to
414have any thought connected with it, try to push it away. Off you go.
415“What did you notice? Did you think of a blue giraffe?
416“Let’s now try detached mindfulness and see what happens. For
417the next 3 minutes let your mind roam freely and if you have thoughts
418of blue giraffes I want you to watch them in a passive way as part of an
419overall landscape of thoughts. Try that now.
420“What did you notice? How important was the thought of the blue
421giraffe the second time around?”
422The therapist should then discuss how suppression gives thoughts
423extra salience and importance, and how DM can be used to allow thoughts
424to roam freely as passing events in the mind that do not require an active
425response. The procedure may then be repeated asking the patient to
426become aware of being the separate observer of the thought.
427Clouds Metaphor
428In some versions of this task participants were asked to use imagery to
429respond to thoughts: thoughts were to be imagined as printed on clouds
430and allowed to drift across the sky. However, in this form the task involves
431responding to thoughts and then transforming them. As such it is not a
432true version of DM. Another version is now preferred in which clouds are
433simply used as a metaphor to convey the experience of DM. The therapist
434offers the following account:
435“One way to understand detached mindfulness and what it requires
436is to consider experiencing your thoughts as you would experience
437clouds passing you by in the sky. The clouds are part of the Earth’s
438self-regulating weather system, and it would be impossible and unnecessary to try and control them. Try to treat your thoughts and feelings 
43984 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
440like you would treat passing clouds and allow them to occupy their
441own space and time in the knowledge that they will eventually pass
442you by.”
443Recalcitrant Child Metaphor
444This metaphor helps the patient to understand the different effects of
445active engagement with thoughts versus detached awareness (mindfulness). The therapist gives the following instruction:
446“You can think of detached mindfulness as similar to the way you
447might deal with a child. How would you manage a child misbehaving
448in a store? You could pay a great deal of attention to the child and try
449to control the child’s behavior. But if the child craves attention this
450response could make things worse. It is better not to actively engage
451with the child but to keep a passive watch over the child without doing
452anything.
453“Your negative thoughts and beliefs are like that child. If you pay
454them a great deal of attention, if you control them or use punishment,
455they misbehave even more. It is better not to try and control or actively
456engage with them, just keep a watching manner over everything. As you
457do this, try to be aware of yourself as the observer of these things.”
458Passenger Train Metaphor
459This is an alternative to the clouds metaphor described above. Here the
460patient is asked to deal with intrusive thoughts and feelings in the same way
461that he or she would deal with an express train passing through a station:
462“It is helpful to think of yourself as a passenger waiting for a train.
463Your mind is like a busy station and your thoughts and feelings are the
464trains passing through. There is no point in trying to stop and climb
465aboard a train that is passing by. Just be a bystander and watch your
466thoughts pass through. There is no point in climbing aboard to be
467whisked away to the wrong place.”
468Verbal Loop
469The repeated presentation of thoughts either by a recording device or
470through repeated vocalization has the effect of decreasing their attentional
471salience and diminishing their meaning because they are experienced
472more as sounds than as inner conveyors of information. This technique is
473presented with a metacognitive rationale as follows:
474Detached Mindfulness Techniques 85
475“I would like you to listen to a recording of your intrusive thoughts [or
476repeat quietly to yourself your thought . . . ]. As you do so you should
477relate to them in a special way. Treat the thoughts as a set of sounds
478and do not engage with them in any other way. They are merely sounds
479in the outside world. Keep in mind as you listen that you are simply
480a listener safe in the knowledge that thoughts are not facts, they are
481simply events in your mind.”
482Detachment: The Observing Self
483We have seen that detachment includes both disengagement of control and
484conceptual processes and experiencing thoughts or beliefs as an observer
485with no further divisible sense of consciousness. It is a core, indivisible, felt
486sense that has no propositional reference and no further point of regression. It is a singular sense of self. In this state the individual is observer of
487the thought and separate from any thought itself.
488This level and experience of DM is accomplished by asking patients
489questions that direct their attention in a particular way during their monitoring of thoughts. These questions are usually incorporated in the above
490experiential techniques to intensify the experience of DM once awareness
491and discontinuation of conceptual processing has been achieved. Specifically the patient is asked during these exercises:
492“Are you the thought or the person observing the thought? Try to be
493aware of your location and what it is like to be the observer. You exist
494entirely separately from thoughts.”
495Or:
496“Are you the belief or the person observing the belief? Try to be aware of
497how your consciousness as the observer is separate from your beliefs.”
498Daydreaming Technique
499It is typically the case that our daydreams are experienced in object mode.
500We become completely immersed in them and live them as momentary
501reality. The practice of shifting to detached observer during daydreaming
502can provide a powerful subjective experience of DM.
503The therapist asks the patient to engage in a pleasant daydream, such
504as driving an exotic car or sipping champagne on a Caribbean beach. Then
505the therapist asks the patient to allow the daydream to continue but to step
506back and be aware of the self in the present as observer of the daydream
507as it unfolds.
50886 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
509Reinforcing DM Using Socratic Dialogue
510On completion of experiential exercises, the therapist reinforces DM during the course of treatment by asking questions when a negative thought or
511belief is activated. These questions include the following:
512“Are you the belief or the person that observes and uses that belief?”
513“Is that thought important or is it a passing event in your mind?”
514“Can you see yourself as separate from that idea?”
515“What are the advantages of practicing being separate from that
516thought?”
517“In future, can you separate your sense of self from the mere occurrence of that thought?”
518Homework
519The application of DM is a task set for homework. The patient is instructed
520to notice the triggers for worry/rumination and unhelpful coping behaviors such as avoidance/suppression (the CAS) and to apply DM to the trigger. Typically, DM is combined with other techniques such as the worry/
521rumination postponement technique (see Chapter 6), which facilitates
522detachment of continued processing from initial intrusions.
523The therapist reviews the range of thoughts to which DM is applied in
524the first few sessions, with a view to increasing this application and enhancing the patient’s awareness of triggers for the CAS. The therapist makes
525careful note that DM is not being inappropriately applied as a coping strategy aimed at preventing erroneous threats.
526In order to determine an effective frequency of the technique, the therapist asks about the proportion of triggers to which DM has been applied.
527As a rough rule of thumb, the therapist aims to achieve a 75% application rate during treatment. The effective use of DM can also be gauged by
528examining scores on the CAS-1 rating scale. In particular, items 1 and 3
529(worry and coping) are indicative of the level of maladaptive engagement
530with internal triggers (i.e., the antithesis of DM).
531Application of DM in MCT
532MCT is not a treatment based on individual techniques. It is quite possible
533to effectively implement MCT without specifically training patients in DM.
534It is important that the therapist does not see this technique or any other 
535Detached Mindfulness Techniques 87
536technique as the mainstay of treatment. However, DM is a component of
537MCT that can act as a catalyst for meta-level change.
538Application of DM early in therapy is recommended in conjunction
539with postponement of worry and rumination (see Chapter 6). Usually the
540technique is introduced in the first or second session but is not intensively
541practiced thereafter. In the treatment of depression we prefer the regular
542practice of the ATT at each session as a more structured and intensive
543means of achieving executive control and with the aim of accomplishing
544important features of DM.
545Throughout its usage the therapist normally tracks the patient’s goals
546in using the technique and monitors examples to ensure that it is used
547appropriately. The therapist should be aware of misuse of DM as a distraction technique, a means of avoiding anticipated threat, and as a means of
548anxiety control.
549A 26-year-old woman undergoing MCT for depression described how
550she had inconsistent results applying DM, stating that “I’m not always
551successful in making my thoughts go away.” A very useful discussion
552followed in which the therapist discovered that she had been inappropriately trying to stop negative automatic thoughts (e.g., “I’m worthless”) rather than applying DM to them and interrupting further conceptual analysis of her failings and weaknesses.
553Later in treatment it may be necessary to ban the use of DM as a prelude to or in conjunction with experiments designed to challenge negative
554beliefs about loss of control and the danger of thoughts and symptoms.
555The continued use of DM can prevent some patients from discovering that
556they cannot lose mental control since they attribute the nonoccurrence of
557the catastrophe to use of the technique.
558Conclusion
559DM is a state of relating to inner thoughts and beliefs in a particular way.
560It is intended to increase flexible control over thinking styles and promote
561the development of a new model of the significance and importance of
562thoughts and beliefs.
563There are several differences and some similarities between DM and
564other mindfulness practices. DM is intended to impact on the CAS and
565enable the development of new metacognitive knowledge. The features
566and information-processing requirements of DM can be specified in the
567context of the metacognitive model.
56888 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
569Ten strategies for achieving DM as part of MCT were described. In
570MCT the therapist uses these techniques most often as part of the early sessions of treatment. They form only a component of the treatment process.
571They should not be considered as intensive training exercises or as procedures that determine the success of the intervention, but instead as useful
572tools that can be used to facilitate metacognitive change and the transition
573between cognitive and metacognitive levels (or modes) of working.
57489
575C hapter 6
576Generalized Anxiety Disorder
577Generalized anxiety disorder (GAD) is the most prevalent anxiety disorder and its core processes represent the elementary processes in all anxiety disorders (e.g., Barlow, 2002).
578GAD is characterized by excessive and difficult-to-control worry combined with several anxiety symptoms. To meet criteria for GAD the individual must exhibit a minimum of two different worry content domains, such
579as health, social, family, or financial worries. The DSM-IV-TR (American
580Psychiatric Association, 2000) diagnostic criteria for this disorder are summarized in Table 6.1.
581Individuals presenting with GAD often state that they have been worriers much of their lives. Worry and anxiety can interfere very significantly
582with their social and/or occupational functioning. The focus of the person’s predominant worry changes over short to long time intervals, but
583the focus is not confined to nor can it be better explained by another Axis
584I disorder. For instance, the worry is not confined to speaking in front of
585a group (as in social phobia), physical illness (as in hypochondriasis), or
586having a panic attack (as in panic disorder). Domain-specific worries like
587these may be better accounted for by another diagnosis.
588Since worry is the key cognitive feature of the disorder, the therapist
589must be able to identify this activity and differentiate it from other types of
590similar mental activity, namely, rumination or obsessional thinking.
591Worry has been defined as a chain of negative thoughts that are predominantly verbal and aimed at problem solving (Borkovec, Robinson,
592Pruzinsky, & DePree, 1983). The chain-like verbal nature of the worry process can be clearly seen in the example given below taken from a patient
593entering our MCT treatment program:
59490 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
595“I was worrying before I even got to work. I thought what if my car
596breaks down, I would be late for the meeting, I would have to make an
597excuse, my supervisor could be angry at me, what if she asks my opinion and I’m not prepared. I was worrying constantly, thinking have I
598done the right thing, have I made a mistake in the report? What if it
599isn’t good enough? They would think I was incompetent. What if they
600regret taking me on? What should I say, what if they ask me something
601I don’t know? It was all too much. I was worrying before and throughout the meeting and when I got back to my office I just couldn’t take it
602anymore. I just lost it and burst into tears.”
603Worry involves catastrophizing and is subjectively difficult to control.
604The process has been viewed as a coping mechanism but the process itself
605can become the focus of worry (Wells, 1995). Such worry about worry is a
606key concept in the metacognitive approach to treating GAD.
607Worry can be described as ego-syntonic, meaning that it is usually
608perceived as characteristic of the self and does not violate the person’s
609self-view. In contrast, other types of persistent negative thinking such as
610obsessional intrusions are ego-dystonic, meaning that they are viewed by
611the person as inappropriate, abhorrent, and disgusting. An example would
612be a religious person having blasphemous thoughts.
613TABLE 6.1. Diagnostic Criteria for GAD
614Criterion A
615Presence of excessive anxiety and worry occurring more days than
616not for at least 6 months. At least two worry topics.
617Criterion B
618The person finds it difficult to control the worry.
619Criterion C
620Anxiety and worry are associated with at least three of the
621following symptoms: restlessness, easily fatigued, concentration or
622memory difficulties, irritability, muscle tension, sleep disturbance.
623Criterion D
624The focus of worry is not confined to another Axis I disorder.
625Criterion E
626Anxiety, worry, or physical symptoms cause significant impairment.
627Criterion F
628Anxiety is not due to substances or a medical condition.
629Note. Summarized from American Psychiatric Association (2000).
630Generalized Anxiety Disorder 91
631In a comparison of normal obsessions and worry several differences
632emerged (Wells & Morrison, 1994). Obsessional thoughts were of shorter
633duration and involved more imagery, while worry was more verbal, more
634realistic, and more voluntary. Another distinction between obsessional
635intrusions and worry is that the former can consist of urges and impulses
636that are not characteristic of worry. Depressive rumination is also egosyntonic in the sense that the person often sees it as a means of understanding feelings and working out problems. Although there are many similarities between anxious and depressive thoughts (Papageorgiou & Wells,
6371999b), there also appear to be some differences. Worry is more futureoriented while depressive rumination focuses more on the past. Worry and
638anxious thoughts involve themes of danger while rumination is concerned
639more with loss, failure, and personal inadequacy.
640The Ubiquity of Worry
641The metacognitive model of psychological disorder assumes that worry is a
642central component of the CAS thought to contribute to all types of pathology. GAD might be considered as the archetypal manifestation of the CAS.
643The application of MCT in this disorder provides a platform for understanding how to conceptualize and treat uncontrollable worry processes
644across a spectrum of disorders.
645Many of the strategies presented in this chapter will find a place in the
646treatment of other disorders, although their precise usage and implementation will need to be adjusted to meet the specification of causal factors in
647disorder-specific case formulations.
648It might be logical to assume that there is something special or
649unique about GAD worry that makes it such a problem for individuals
650suffering from this disorder. The research evidence appears to show that
651this is not the case. The content and nature of GAD worry is very similar
652to normal worry (e.g., Ruscio & Borkovec, 2004). There is, however, one
653way in which GAD worry appears to be markedly different as predicted by
654the metacognitive model. Worry in GAD is associated with more negative
655thoughts and beliefs about worry (Wells & Carter, 2001; Ruscio & Borkovec, 2004).
656Is Worry Controllable?
657Worry is often experienced as difficult to control. This does not mean that
658it cannot be controlled easily. The patient and the MCT therapist need to
659understand the essence of possible and impossible control and effective
660and ineffective strategies.
66192 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
662Worry is a slow conceptual process involving the contemplation of relatively novel future events and ways of coping with them. It is readily modified by feedback from internal or external sources. The conscious strategic
663nature of worry should mean that it is amenable to high levels of volitional
664control even if awareness of such control is low or nonexistent. However, it
665is important to distinguish between intrusive thoughts that might be more
666automatic and involuntary and act as triggers for worry and the sustained
667conceptual nature of worrying itself, which represents a response to such
668intrusions. An aim in MCT is to lessen or stop sustained conceptual-based
669(worry-based) thinking in response to intrusions. This is the type of control
670that the therapist and the patient aim for and not control or suppression
671of the intrusive thoughts that trigger worrying. Furthermore, the control
672of sustained thinking or worry in MCT is used as a means of challenging
673metacognitive beliefs.
674The Metacognitive Model of GAD
675The metacognitive model of GAD (Wells, 1995, 1997) is presented diagrammatically in Figure 6.1. It proposes that people with GAD tend to use
676worrying as their predominant means of anticipating future problems and
677generating ways of coping. Worrying is usually triggered as a coping strategy in response to an intrusive negative thought (e.g., “What if I’m involved
678in an accident?”). This is not necessarily a problem because it is theoretically possible to be a “happy worrier” so long as the person believes that his
679or her work of worry is effective and prevents danger. General worry about
680external events and about social and physical health concerns in response
681to triggers is called “Type 1 worry.” The use of worry as a means of coping
682is linked to positive metacognitive beliefs that most people hold to some
683extent. These include beliefs such as “Worrying helps me avoid problems
684in the future”; “Worry means I’ll be prepared”; and “Worrying helps me
685cope.” However, it is the activation of negative metacognitive beliefs that is
686most important in the transition to GAD.
687GAD develops when the person activates negative beliefs about worrying. Two types of negative belief are important: negative beliefs about the
688uncontrollability of worry and negative beliefs about its harmful or dangerous consequences. The latter category contains beliefs that worry can lead
689to physical (e.g., heart attack), psychological (e.g., mental breakdown), or
690social (e.g., rejection by others) catastrophe. Examples of metacognitive
691beliefs are presented in Table 6.2.
692Once negative metacognitive beliefs are activated, the individual negatively appraises worrying, that is, he or she worries about worry, leading to
693increased anxiety and feelings of being unable to cope. Worry about worry 
694Generalized Anxiety Disorder 93
695is an example of a metacognitive appraisal (an interpretation of a thought
696process). It has been called “meta-worry” or “Type 2 worry” (Wells, 1994)
697to signify that it is the negative appraisal of worry and associated symptoms. Examples of meta-worry are “I’m losing control,” “I’m going crazy,”
698and “I’m harming my body.” Anxiety symptoms are often misinterpreted
699as a sign of the dangerous and damaging effects of worrying that leads
700to a strengthening of negative beliefs and a spiral of immediately intensified anxiety. Panic attacks can occur when such interpretations concern an
701immediate impending catastrophe such as a heart attack or loss of mental
702control.
703Type 2 worry (meta-worry) leads to two further factors that contribute
704to problem maintenance. These are separated out in the model as behavioral
705responses and thought control strategies. The main reason for this is to simplify
706socialization, as we shall see later. In particular, an interesting dynamic in
707the thought control responses used by the patient rewards closer scrutiny.
708FIGURE 6.1. The metacognitive model of GAD. From Wells (1997, p. 204). Copyright 1997 by John Wiley & Sons Limited. Reprinted by permission.
70994 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
710Coping behaviors consist of reassurance seeking, avoidance (though
711this is often subtle), information search (e.g., surfing the Internet), distraction, use of alcohol, and so on. These behaviors maintain negative appraisals and beliefs about worry because they subvert the process of self-control
712by handing control over to external factors. For example, one patient asked
713her husband to telephone her at set times each day to confirm that he was
714safe. Otherwise she would not be able to contain her worry. This process
715prevented her from discovering that she could control her own worries,
716and it therefore maintained her belief in uncontrollability. It also provided a greater range of opportunities for uncertainty when her husband
717was unable to telephone on time, which acted to intensify her triggers for
718worry. Some patients attempt to control or avoid worry by searching for
719information by “surfing the Internet.” One patient described how he had
720recently worried about the appearance of a dark patch of skin on his upper
721arm. As a means of trying to control his worry he had explored information on the Internet about the nature and causes of skin discoloration. He
722had hoped that he would find information that would lead him to worry
723less, but in fact he had discovered dangerous possibilities that he had not
724even thought of, which became the triggers of sustained worry. Thus, some
725strategies backfire and act as further triggers for worrying. Even when they
726do stop worry they prevent the person from discovering that the worry
727process can be suspended by internal means. They also prevent the person
728discovering that even if worry continued it would not lead to negative consequences such as a heart attack or a mental breakdown.
729TABLE 6.2. Examples of Metacognitive Beliefs
730about Worry in GAD
731Positive metacognitive beliefs
732•	 “Worrying helps me cope.”
733•	 “If I worry I’ll be prepared.”
734•	 “Worrying keeps me in control.”
735•	 “If I worry I can anticipate and avoid problems.”
736Negative metacognitive beliefs—Uncontrollability
737•	 “I have no control over worry.”
738•	 “My worries have taken control of me.”
739•	 “I have lost control of my thoughts.”
740•	 “My worries are uncontrollable.”
741Negative metacognitive beliefs—Danger
742•	 “I could lose my mind with worrying.”
743•	 “Worrying will damage my body.”
744•	 “I could go crazy with worry.”
745•	 “I’m going to have a mental breakdown because of worry.”
746Generalized Anxiety Disorder 95
747Another process in the model refers to the patient’s use of thought
748control strategies. There is often an unhelpful use of strategies involving
749suppression of worry triggers and a failure to disengage from the worry process once it is activated. Suppression involves trying not to think thoughts
750that might trigger worrying. So, for example, a person currently concerned
751about his or her performance at work will try to suppress all thoughts about
752work when away from that environment. Unfortunately, suppression is not
753entirely effective and its failure can reinforce beliefs about loss of control
754and/or lead to an increase in the salience of triggering thoughts. The second important process is the individual’s failure to disengage the worry
755process once it is activated. This is made manifest as continuing to think
756through the worry in order to cope, or trying to reassure the self with selftalk. It is a continuation of conceptual activity in which the patient fails to
757interrupt the perseverative coping process. Several factors can contribute
758to this failure. For instance, the person often believes that not worrying
759would be equivalent to not attempting to cope (as worry is a main coping
760strategy) or the person lacks awareness of the control he or she has, assuming, for instance, that the problem is intractable (e.g., worrying is part of
761my personality). Often the individual has had few personal experiences
762of self-control of the worry process that would challenge his or her beliefs
763about its uncontrollability.
764The Model in Action
765A walk-through of the model as it operates in a worry episode will serve to
766illustrate the operation of each of its components.
767A distressing worry episode is triggered by an initial intrusive thought,
768usually in the form of a “What if . . . ?” question (e.g., “What if my partner is
769involved in an accident?”), but sometimes in the form of a negative image.
770This trigger activates tacit positive metacognitive beliefs about the need
771for sustained catastrophic thinking (Type 1 worry) as a means of anticipating and coping with problems. This Type 1 worry immediately leads to
772increases in emotional symptoms, but may subsequently lead to reductions
773in negative emotions if the person satisfies his or her goal of worrying. The
774goal is often the feeling that one will be able to cope or an appraisal that
775most dangerous possibilities have been covered.
776During the worry sequence in GAD, negative beliefs about the uncontrollability and dangerous nature of worry are activated. This leads to negative interpretation of worry (i.e., Type 2 worry) and increased anxiety. At
777this point the person finds it harder to achieve a goal that signals it is safe
778to stop worrying and may begin to see the self as less able to cope.
779Now behaviors and thought control strategies aimed at avoiding worry
780and preventing its negative effects are initiated. Many of these strategies 
78196 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
782are unhelpful or backfire, leading to a preoccupation with and a strengthening of negative beliefs about uncontrollability and danger, so that these
783beliefs are more likely to figure predominantly in future worry episodes.
784An example of this model drawn out for a recent worry episode reported
785by a patient is presented in Figure 6.2.
786Structure of Treatment
787Treatment can be usefully conceptualized as movement through a
788sequence of stages. The number of sessions required to meet each stage
789varies depending on patient and therapist factors. Patient factors are level
790of insight, motivation, and engagement with homework. Therapist factors
791FIGURE 6.2. An idiosyncratic GAD case formulation.
792Generalized Anxiety Disorder 97
793include level of skill and experience in implementing MCT. The sequence
794of stages is as follows:
7951. Case conceptualization
7962. Socialization
7973. Inducing the metacognitive mode
7984. Challenging metacognitive beliefs about uncontrollability
7995. Challenging metacognitive beliefs about the danger of worry
8006. Challenging positive metacognitive beliefs about worry
8017. Reinforcing new plans for processing worry
8028. Relapse prevention
803Treatment typically ranges from five to ten sessions, with the modal
804number of sessions being eight when delivered by therapists with some
805experience of MCT. In the remainder of this chapter the implementation
806of each of these stages is described in detail.
807Case Conceptualization
808Measures
809Tools required during this stage are:
8101. Generalized Anxiety Disorder Scale—Revised (GADS-R)
8112. GAD Case Formulation Interview
8123. Session checklists
813The therapist begins by administering the GADS-R and examines the
814negative and positive metacognitive beliefs endorsed in order to obtain
815a preliminary impression of the types of beliefs that should be amenable
816during formulation. The GADS-R can be found in Appendix 7. This scale
817also provides an impression of the types of behaviors used to avoid worry
818and danger, which can be subtle in GAD. Other measures normally considered that are completed before the session are the Beck Anxiety Inventory (BAI; Beck et al., 1988) and the Beck Depression Inventory II (BDI-II;
819Beck et al., 1996).
820Agenda of the First Session
821The treatment session begins with setting an agenda:
822“In today’s session I would like to explore a recent episode of worry
823in which you became distressed by the worry. In doing this we can
824explore the factors that are keeping your worry problem going and 
82598 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
826begin to examine ways that you can overcome your anxiety. I would
827also like to explain a little more about MCT and what you might expect
828from treatment. Is there anything you would like to put on the agenda
829and talk about today?”
830Generating a Case Conceptualization
831The next step is to proceed with generating an idiosyncratic version of
832the metacognitive model that represents the events in a recent distressing worry episode. It is important that the therapist focuses on an actual
833recent episode rather than trying to conceptualize processes more generally, which can be a major source of in-session drift.
834A straightforward means of generating the case conceptualization is
835to follow a particular sequence of questions. This sequence is depicted by
836the numbering 1–8 in the GAD Case Formulation Interview presented in
837Appendix 11. Each number links a particular interview question to eliciting the material required for each part of the model.
838An example dialogue using these questions is presented below. The
839case conceptualization resulting from these questions is presented in Figure 6.3.
840Therapist: When was the last time you were worried and distressed by
841your worry?
842Patient: It was about 2 weeks ago.
843Therapist: Was that a typical worry episode?
844Patient: Yes, but I didn’t panic on that occasion.
845Therapist: Fine. Let’s look at that worry. Briefly, where were you?
846Patient: I was at home and saw a police car drive by, and then I started
847worrying that one day they could be coming to give me bad news and
848how I couldn’t cope with that.
849Therapist: Okay, I need to slow things down. What was the first thought
850that went through your mind when you saw the police car? Was it a
851“What if . . . ?” question or an image of something bad happening?
852Patient: I think it was more like: “What if my husband has been killed?”
853Therapist: So that was the trigger, an initial “what if” thought about your
854husband.
855Patient: Yes, and I thought how bad it would be.
856Therapist: So it sounds as if you were into the worry now. What did you
857then go on to worry about?
858Patient: I thought what if I couldn’t manage the children on my own, how 
859Generalized Anxiety Disorder 99
860would I cope with the finances, what if I ended up alone, how could I
861deal with those things?
862Therapist: So it sounds as if you were deeply into worry. What happened
863to your emotions when you were worrying like that?
864Patient: I felt terrible, I was tearful, restless, tense, I felt anxious.
865Therapist: When you were feeling anxious and you were worried, did you
866think anything bad could happen because of the way you were thinking and feeling?
867Patient: I’m not sure.
868Therapist: What was the worst that could happen if you continued to feel
869and think like that?
870FIGURE 6.3. GAD case formulation arising from the dialogue.
871100 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
872Patient: That’s terrible, I don’t want to get into that. When you get into
873that you think you’re going to lose your mind and that’s when panic
874sets in.
875Therapist: When you’re really worried do you think you could go crazy?
876Patient: Yes.
877Therapist: Do you have any other negative thoughts about your worries
878and anxiety?
879Patient: I think I could damage my body, especially my heart, if I go on
880like this.
881Therapist: Why don’t you stop yourself worrying if it’s so harmful?
882Patient: I can’t, I have no control.
883Therapist: So it sounds like you have some beliefs about worry. That it is
884uncontrollable, that it can make you lose your mind, and that it can
885damage your heart, is that right?
886Patient: Yes.
887Therapist: How much do you believe it is uncontrollable on a scale from
8880 to 100%?
889Patient: Ninety percent.
890Therapist: How much do you believe it can make you lose your mind?
891Patient: Seventy percent.
892Therapist: How much do you believe worry can damage your heart?
893Patient: Seventy percent.
894Therapist: These sound like negative beliefs about worry. Can I ask you,
895do you have any positive beliefs about worry? That is, do you think
896worry is helpful in any way?
897Patient: It means I can be prepared, it helps me be aware of problems,
898and it helps me do a good job.
899Therapist: How much do you believe that?
900Patient: I believe all of those things about 70 percent.
901Therapist: When you were worrying on this occasion did you do anything
902to stop yourself worrying?
903Patient: I talked to my mother about it to get some reassurance. She is
904good, as she gets me to look at it logically.
905Therapist: Anything else, such as avoiding things, or searching for evidence to put your mind at rest?
906Patient: I avoid watching the news and reading newspapers as there’s
907always something to worry about.
908Therapist: I want to ask you about two other things in response to wor-
909Generalized Anxiety Disorder 101
910rying thoughts. Do you try not to think certain thoughts in case they
911trigger a worry?
912Patient: Yes, I try not to think about illness and accidents.
913Therapist: Okay. Have you ever decided not to respond by worrying when
914you have a negative thought like that?
915Patient: No, I feel I’m right to worry about it, that it wouldn’t be good
916otherwise. I have to think about these things, otherwise I won’t be able
917to deal with them.
918Therapist: Okay, I’ll put that in the model too. Let’s call it “continuous
919thinking.”
920A Note on Eliciting Metacognitions
921Metacognitive beliefs concerning uncontrollability and danger are at center stage in the case conceptualization and treatment. It is crucial that
922these can be effectively elicited. Novice MCT therapists sometimes find
923it difficult to elicit negative metacognitive beliefs, often because they are
924implicit in the patient’s description. While negative beliefs about danger are
925typically present, negative beliefs about uncontrollability are always present.
926For example, a patient stated that he had no negative beliefs about worrying, just that worrying made him feel bad. The therapist asked him why he
927didn’t reduce his worrying if it made him feel so bad, to which the patient
928replied that he couldn’t because he had no control. As this example shows,
929uncontrollability beliefs are an implicit part of this patient’s problem.
930A strategy for eliciting negative metacognitions consists of asking
931about the disadvantages of worrying. The disadvantages correspond to
932negative beliefs. Asking about the advantages of worrying can provide a
933means of eliciting positive beliefs about the activity.
934The therapist might also find it useful to ask about the “worst consequences scenario” to determine negative beliefs about worry. An example
935of a worst consequences question combined with an exploration of meanings follows:
936Therapist: How do you feel when you’re worried?
937Patient: I feel stressed and anxious.
938Therapist: What’s the worst that could happen if you continued to worry
939like that?
940Patient: I’d really lose it.
941Therapist: What do you mean by “really lose it”?
942Patient: I don’t know really, it would be taken out of my hands.
943Therapist: What’s the worst way of losing it?
944102 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
945Patient: I’d crack up or something.
946Therapist: What would that look like?
947Patient: I’d have a breakdown and be paralyzed with worry.
948Therapist: Do you believe that worry can cause a breakdown?
949Patient: Yes, if I go on like this.
950Socialization
951The process of socialization has effectively begun while the therapist systematically traces out the components of the case conceptualization. However, the next step is more explicit in explaining the mechanisms in the
952model. The therapist proceeds by sharing the diagrammatic case formulation (or, better still, this has been mapped out already in real time on a
953marker board). The following steps are usually followed:
954Step 1: Sharing the Conceptualization
955The therapist explains briefly how the model works:
956“Looking at the diagram we have mapped out, it is possible to see some
957important factors that help us understand the causes of your worry
958problem. On this occasion your worry was triggered by an initial intrusive thought [state patient example], and you went on to worry about
959what this would be like and how to deal with the situation if it happened [point to Type 1 worry]. This was associated with feeling anxious [trace link between Type 1 worry and anxiety]. But that wasn’t the
960end of things because you then began to worry about what you were
961thinking and feeling. We call this ‘worry about worry’ or Type 2 worry
962[point to Type 2 worry]. On this occasion you thought [state patient’s
963Type 2 worry]. What effect did thinking that have on your anxiety?
964“So you see that part of your problem is worry about worry and
965the negative beliefs you have about worrying. This is directly increasing your anxiety. You have also developed some other coping behaviors that may not actually help [point to behaviors box in the case formulation]. For example, have these things worked yet, have you been
966able to overcome your worry problem? It these things don’t work, what
967does that lead you to believe about the controllability of worry?
968“There are also some interesting thought control strategies that
969you use. You try not to think thoughts that might trigger worrying. You
970also don’t seem to interrupt the worry process consistently when it is
971activated. If you allow yourself to engage in continued thinking, does
972that give you the sense that you can control it?
973Generalized Anxiety Disorder 103
974“Apart from your negative beliefs you also have some positive
975beliefs about worry. We will deal with these later. But let me ask you
976now, Do you think that having positive beliefs about worry might contribute to a persistence of worrying?
977“So you see how your problem is maintained by what you believe
978about worry and the strategies you use to control it. We need to change
979these things in treatment so that you can recover.”
980Step 2: Hypothetical Questions
981Hypothetical questions are then used as a means of illustrating the contribution of metacognitive beliefs to the problem:
982“I can illustrate the role of beliefs about worry by asking you a question. If you believed that worry was only a good thing to do, how
983much of a problem would worry be?”
984“If you suddenly discovered that you could control worry, how much of
985a problem would remain?”
986“If you discovered that worry could not harm your mind or body,
987would worry be so distressing?”
988Step 3: Dissonance (Two-Minds Strategy)
989A further means of conveying the message that beliefs about worry are central to the problem is by illustrating how metacognitive beliefs place the
990patient in a no-win situation that can only lead to the process of difficultto-control worry:
991“It appears that you are in two minds about worry. On the one hand
992you believe it is a beneficial thing to do, but on the other hand you
993believe it is uncontrollable and harmful. How easy is it for you to stop
994worrying so long as you are in two minds about it?”
995Or:
996“As we have seen you are in two minds about worry. Are two minds
997better than one in this instance? What problems do two minds create?”
998Step 4: Question the Effects of Behaviors
999By questioning the effects of behavior the therapist can help patients discover that their self-regulatory behaviors have not been effective. This act
1000of discovery allows the therapist to pose an important question that leads 
1001104 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1002neatly into the first therapy exercise of applying DM and worry postponement. Questions to use are as follows:
1003“How effective have your behaviors been in getting rid of worry in the
1004long term?”
1005“What have your behaviors enabled you to discover about the controllability of worry?”
1006“Your inability to control worry could mean it is uncontrollable, but
1007could it also mean you have been using the wrong strategies to
1008control it? Have you thought about it like that before?”
1009Step 5: Suppression Experiment
1010Next, a suppression experiment is used to illustrate how some thought control strategies are counterproductive or ineffective and do not provide useful information about worry. Here the patient is asked to suppress a neutral
1011thought. The experiment is normally introduced with very little rational in
1012the following way:
1013“Let’s see how some of your strategies might not be helpful. We can try
1014with a neutral thought. Let’s assume that you worry about blue rabbits. For the next 3 minutes I want you to stop yourself from having
1015any thoughts of blue rabbits. What ever you do you must not think of
1016a blue rabbit in any shape or form. Off you go.
1017“Okay, you can stop now. What happened when you tried to suppress that thought?”
1018Typically, the patient reports that the suppressed thought occurred. This
1019result can then be used to illustrate how trying to suppress worry triggers
1020is not very effective. The therapist can ask, “If it is not effective, what does
1021this lead you to believe about the controllability of worry?”
1022In some instances the patient is able to suppress the target thought.
1023In such cases the therapist should simply ask, “It seems that you could suppress the thought. Is that something you can do with all of your worry triggers?” The answer to this question can be used to show how the strategy is
1024not consistently effective.
1025Bridging from Socialization
1026to Metacognitive Modification
1027As the process of initial socialization draws to an end the patient should be
1028asked to summarize what he or she has learned about the cause of worry.
1029The therapist gives a brief description of the nature of MCT as follows:
1030Generalized Anxiety Disorder 105
1031“Treatment will focus on examining more effective ways of responding
1032to your thoughts that trigger worry so that you can discover that worry
1033is not uncontrollable. We will then try to deal with the negative beliefs
1034that you hold about the danger of worry. These beliefs give rise to high
1035levels of anxiety so we should deal with them soon. Later in treatment
1036we will look at the positive beliefs you have about worry and a range of
1037alternative ways of responding to negative thoughts.”
1038Questioning Uncontrollability Beliefs
1039The next stage is the use of verbal reattribution to explore and weaken
1040beliefs about the uncontrollability of worry. Discussion of modulating
1041influences on worry is used to provide evidence that worry is subject to
1042control and can be readily displaced by alternative processing demands.
1043For example, the therapist asks:
1044“What happens if you are worrying and the telephone rings and you
1045answer the phone? What happens to your worry?”
1046“If worry truly is uncontrollable, how does it ever stop?”
1047The latter question can elicit some intriguing answers. As the following dialogue illustrates, the therapist should attempt to carefully explore
1048the patient’s concept of control and distinguish control of worry from suppression of thoughts:
1049Therapist: How much do you believe worry is uncontrollable?
1050Patient: Eighty percent.
1051Therapist: If worry truly is uncontrollable, how does it ever stop?
1052Patient: It doesn’t, unless the thing I was worried about is no longer
1053there.
1054Therapist: So what happens to your worry when you sleep?
1055Patient: It’s there even when I’m asleep. I wake up feeling tired.
1056Therapist: Is feeling tired the same as worry?
1057Patient: No, no, it’s different, I suppose.
1058Therapist: So if worry is uncontrollable, how do you ever sleep?
1059Patient: Well, sometimes sleep is difficult, but I suppose it does stop.
1060Therapist: Yes, that’s right. What happens to your worry if you have to
1061do something important like answer the telephone? Does it stay the
1062same?
1063Patient: No, it’s very much switched on and off.
1064106 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1065Therapist: That’s right. So does that suggest worry is uncontrollable?
1066Patient: No, I do have some control. But maybe not over big worries.
1067Therapist: Well, we need to examine what we mean by “control.” You can’t
1068always control initial thoughts that trigger worry, but you can choose
1069not to engage in the extended worry process that follows. And that’s
1070what I’d like us to look at next.
1071Detached Mindfulness
1072and Worry Postponement
1073Socialization should have begun to shift the patient to a metacognitive perspective (level) of viewing the problem. At this stage of treatment it is useful to check that the patient understands that the problem is one of beliefs
1074about worry and unhelpful strategies for regulating thoughts.
1075The next step is building on the suppression experiment and developing the skills of DM. In Chapter 5, we saw a range of techniques for
1076inducing DM. The strategy used in the treatment of GAD is identifying the
1077trigger, applying DM to it, and postponing the worry process that normally
1078follows the trigger.
1079This can be thought of as a means of decoupling intrusions from
1080the control of subsequent processing so that the patient develops greater
1081metacognitive flexibility. Furthermore, this is used as part of a subsequent
1082behavioral experiment to test negative metacognitive beliefs about the
1083uncontrollability of worry.
1084Detached Mindfulness
1085With reference to the suppression experiment and/or the ineffectiveness
1086of coping strategies, the therapist should remind the patient how trying
1087to control initial triggers for worrying has not been effective in overcoming the problem. What is required is a new approach that can enable the
1088patient to discover the truth about the uncontrollability of worry. The following questions are used to introduce this stage:
1089“Have you ever decided not to worry in response to a triggering
1090thought?”
1091“Have you ever tried to hold in mind a trigger and just leave it alone?”
1092“Have you ever seen your negative thoughts as merely events passing
1093through your mind?”
1094After setting the scene in this way, the therapist instructs the patient
1095about applying DM to thoughts. This is typically practiced with neutral 
1096Generalized Anxiety Disorder 107
1097thoughts and then followed by DM’s application to two or three typical
1098worry triggers. The therapist introduces the exercise in the following
1099way:
1100“We have seen how trying to control triggering thoughts doesn’t provide a long-term solution to worry. It’s time to try something new,
1101something called detached mindfulness. This will enable you to
1102develop a new relationship with your thoughts and discover the truth
1103about worry. In a minute I will ask you to have a thought about a tiger
1104and allow the thought to exist in its own space in your mind. I’d like
1105you to just watch the thought and do nothing to control it or influence
1106it in any way.
1107“Okay, can you have the thought now? Just watch the tiger. You
1108may notice that it is moving, but don’t make it move. You may notice
1109the thought fades, but don’t make it fade. You may notice other
1110thoughts but they should not be of your deliberate making. Just watch
1111the thought in a detached way.”
1112After approximately 2 minutes the therapist should determine if the
1113task was successfully implemented. If there were difficulties, these difficulties should be explored and corrected. For instance, some patients report
1114that they were unable to “hold onto” the thought. This problem should
1115be discussed as an indication that the person was trying to do something
1116with the thought, which is not the objective of the exercise. It is helpful to
1117gently remind the patient that the objective is to watch the thought in a
1118detached way no matter what happens. The task should be repeated or an
1119alternative DM strategy such as free association (see Chapter 5) should be
1120implemented until the patient has the necessary experience.
1121The next step is application of the technique to a recent worry trigger.
1122First the therapist identifies a recent trigger in the following way: “Think
1123about your most recent worry. What was the triggering thought?” At this
1124point a negative image or What if . . . ? thought is pinpointed. The therapist
1125proceeds to repeat the DM procedure for this trigger:
1126“I’d like you to bring to mind that worry trigger. Allow the trigger to be
1127in your mind but do nothing with it. Don’t push it away, and don’t try
1128to reason with it and work it out. It’s only a thought.”
1129Worry Postponement Experiment
1130After the experience of applying DM, the idea of postponing the worry process that is normally connected with triggering thoughts is introduced as a
1131means of enhancing DM but also as a means of challenging the belief that
1132worry is uncontrollable. In doing so it is crucial that the therapist makes 
1133108 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1134a clear distinction between thought suppression (which is undesirable) and
1135worry postponement. The following explanation is normally given:
1136“For homework I would like you to apply detached mindfulness to each
1137of your triggering thoughts. Then follow this with postponement of
1138any worry or thinking-through process. Perhaps you can say to yourself: ‘There’s a worry thought, I don’t need to dwell on this and activate my worry now, I’ll wait and do that later.’ Then later in the day I’d
1139like you to set aside a time when you can take time to worry through
1140that thought. That time should be restricted to 10 minutes, and not be
1141just before bedtime. The worry time is not compulsory—most people
1142forget to do it—so I’m not suggesting that you must try to use that
1143time. By using worry postponement you can test out how uncontrollable worry really is. Have you ever used a strategy like this before?
1144“It is important that you know the difference between thought suppression and postponing your worry. I’m not asking you to not think
1145a thought. The thought that acts as a trigger can still be in your mind,
1146but you choose not to engage your thinking and reasoning process.
1147For example, you may have a trigger about work, something like ‘What
1148if I can’t cope?’ I don’t want you to try and suppress thoughts like that.
1149Say to yourself, ‘There goes a worry trigger. I’m going to leave it alone
1150and not deal with it now. I’ll deal with it later.’ The thought can remain
1151and you choose not to deal with it with your usual worry response. Can
1152you see what I’m asking you to try? This is an experiment to see how
1153uncontrollable worry truly is.”
1154The therapist then takes a belief rating in uncontrollability and does
1155so again after a week of implementing the experiment for homework. Note
1156that an index of belief change in the uncontrollability domain can also be
1157obtained from the sessional administration of the GADS-R.
1158Challenging Uncontrollability Beliefs
1159Verbal Methods
1160Further challenging of belief about uncontrollability is achieved by reviewing counterevidence. For instance, the therapist asks what happens to the
1161patient’s worry if he or she is distracted by the doorbell or needs to answer
1162the door? Or if his or her child requires urgent attention? The therapist
1163aims to show how worry is displaced by these competing demands and
1164therefore must be responsive to the patient’s responses and priorities. The
1165therapist also asks what happens to worry when the person sleeps, which
1166is further evidence that it is subject to control. (Note: sleep disturbance 
1167Generalized Anxiety Disorder 109
1168caused by worry is not evidence that worry cannot be controlled. It is simply the case that the patient has not used appropriate control.)
1169Loss-of-Control Experiments
1170Refinements of the worry postponement experiment are required to fully
1171modify beliefs about uncontrollability. In the next stage, treatment progresses to “pushing worry” in two contexts: during a postponed worry
1172period and during a worry episode. The aim is to provide unambiguous
1173evidence that worry cannot become uncontrollable even when the patient
1174tries to lose control.
1175The loss-of-control experiment is best introduced and first practiced
1176during a treatment session. This reduces patient fear associated with implementing the procedure for homework, thereby facilitating compliance.
1177In the session, the therapist asks the patient to think of a recent or current worry, and then to begin worrying about it with the aim of worrying
1178as intensely as possible to test if it is possible to lose control of the activity.
1179The procedure is introduced as follows:
1180“You’ve discovered that worry isn’t uncontrollable by using worry postponement. But what would happen if a really big worry came along?
1181How much do you believe you could lose control?
1182“It is important to be sure that you cannot actually lose control of
1183worry. One way to do this is to deliberately push your worrying. Can
1184you think of a current or recent worry?
1185“I’d like you to dwell on that worry and to engage your worry
1186process, worry as much as you can, really catastrophize and try to lose
1187control of the activity. Off you go, try that now.”
1188It is then suggested that the loss-of-control experiment be practiced
1189for homework during a postponed worry period and then again at the
1190actual time that a worry trigger is experienced. Some patients feel confident enough to go straight into pushing worry during a worry episode
1191and so pushing worry in a postponed period can be omitted. As with all
1192behavioral experiments, the therapist monitors belief change throughout
1193this procedure by using verbal ratings of belief in uncontrollability and/or
1194the self-report index relevant to this provided by the GADS-R.
1195Some patients question the usefulness of pushing worry in the treatment session or discount the experience as “artificial” and not capable
1196of providing evidence about real worry. This is only natural because the
1197situation is contrived and is simply used to reinforce the need to practice
1198the procedure for homework in order to test beliefs in real situations. The
1199therapist should be aware of the possibility that resistance of this kind may 
1200110 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1201be a sign of avoidance and that the procedure should be implemented
1202anyway.
1203Challenging Danger Metacognitions
1204Once beliefs concerning the uncontrollability of worry have been effectively challenged, as indicated by scores of zero or as close to zero as possible on the GADS-R, it is appropriate to move on to challenging dangerrelated metacognitions.
1205Verbal and behavioral reattribution methods are used to weaken and
1206modify danger-related metacognitions. Several verbal strategies are used
1207before introducing behavioral experiments. These verbal methods involve
1208(1) strengthening dissonance, (2) questioning the evidence, (3) exploring
1209counterevidence, (4) questioning the mechanism, and (5) providing new
1210information.
1211Strengthening Dissonance
1212When positive beliefs about the usefulness of worry are evident from the
1213outset of treatment, they provide an opportunity to emphasize the conflict
1214that exists between such beliefs and metacognitions concerning danger.
1215Dissonance induction has the potential to change any side of the equation:
1216it may lead to a weakening of positive or negative beliefs. The following
1217questions are useful for this purpose:
1218“You seem to believe that worrying has advantages but also that it is
1219harmful. How can both be true?”
1220“Is it true that worry is good and bad in equal measure?”
1221“If worrying is harmful, how can you also believe that it helps you
1222cope?”
1223“Have you ever thought that worry might not be useful or harmful,
1224and that it is irrelevant?”
1225Questioning the Evidence
1226The therapist questions the evidence that the patient has to support negative danger-related metacognitive beliefs. Worry is often equated with the
1227concept of stress. Because the patient believes that stress is harmful, he or
1228she also believes that worry is harmful. When this is the case we have found
1229it helpful to discuss how stress and worry are different entities. One way to
1230do this is to show how worry is a coping strategy in response to stress and
1231negative thoughts. Therefore it is not equivalent to stress but is instead a
1232response to stress.
1233Generalized Anxiety Disorder 111
1234Further discussion should focus on the fact that there is limited evidence that psychological stress is directly damaging. The relationship
1235appears to be subtle and mediated by appraisals of control and aspects
1236of personality. The stress response can be seen as part of a wider anxiety
1237response that represents a survival mechanism for dealing with threat. If
1238stress was harmful, natural selection would have selected out vulnerable
1239individuals. Some specific questions that therapists can use during this
1240phase of treatment are:
1241“How do you know that worry is harmful?”
1242“How long have you been worrying? Have you come to harm yet?”
1243“How many people on your street do you estimate worry, and how
1244many have become mentally or physically ill as a result?”
1245“Would your belief that worry is dangerous stand up in a court of law
1246given the state of evidence?”
1247We have found the book The Truth about Stress (Patmore, 2006) to be a
1248useful resource for those who wish to explore the stress myth further with
1249their patients.
1250Generating Counterevidence
1251We saw above how the therapist might draw the patient’s attention to counterevidence by questioning how long the patient has been a worrier, and
1252whether or not psychological or physical catastrophes have occurred as a
1253consequence. This maneuver can backfire insomuch that the patient may
1254have health issues that he or she mistakenly attributes to worry. In these
1255circumstances it is necessary to show how worry and the health issues might
1256be correlated, but that this does not mean worry causes health problems
1257(i.e., that the patient worries about his or her health because of health
1258symptoms: poor health leads to worry, but this does not mean that worry is
1259the cause of poor health).
1260Observations that contradict predictions based on danger-related
1261beliefs should be explored. One strategy is to ask the patient if he or she
1262knows anyone else who is a worrier, and to ask if that person has suffered
1263significant physical and mental health problems as a consequence.
1264We have seen how worry is often equated with stress. The belief that
1265stress or worry is harmful can be challenged by asking the patient to think
1266of people who are exposed to intense stress, for example, race car drivers
1267or soldiers in combat training. These situations are likely to activate high
1268levels of anxiety and worry, and yet these people do not show physical or
1269psychological breakdown as would be predicted if the patient’s beliefs were
1270accurate. Direct counterevidence can be cited such as the finding that the
1271incidence of civilian psychological disorder decreases in wartime.
1272112 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1273Questioning the Mechanism
1274and Searching for Counterevidence
1275One way to challenge beliefs about the harmful consequences of worry is
1276to question the mechanism that links worry to negative outcomes. Often,
1277this will be the first time that the patient has explored such issues. This
1278process alone, when it yields insight into the absence of an explanation,
1279can weaken negative beliefs. The therapist aims to challenge the existence
1280or validity of any mechanism. Useful basic questions include:
1281“What’s the mechanism by which worry causes [insert idiosyncratic
1282danger outcome]?”
1283“How does worry cause harm to the body?”
1284“How does worry cause harm to the mind?”
1285Typically, these questions are answered with reports of symptoms.
1286For example, a 53-year-old woman undergoing MCT for GAD was asked
1287by her therapist, “How does worry harm the body?” She answered,
1288“It increases blood pressure, and I know that high blood pressure is
1289associated with heart problems.” The therapist went on to make a distinction between chronically elevated blood pressure that poses a cardiac risk and the transient increases in blood pressure associated with
1290worry and exercise. By drawing parallels between the effects of worry
1291and exercise, the therapist was able to show how transient increases
1292might actually improve cardiac resilience.
1293When there are fears concerning the negative effects of worry/anxiety on the body involving cardiovascular events, it is useful to explore the
1294mechanism by which anxiety influences physiology as a means of eliciting disconfirmatory evidence. For instance, a patient was concerned that
1295worry would lead to heart damage. His fear was based on the observation
1296that whenever he was worried and anxious he noticed changes in his heart
1297rhythm. The therapist explored the effect of anxiety on the production
1298of adrenaline and using guided discovery helped the patient to see how
1299adrenaline could be used to save life in the event of a heart attack as follows:
1300Therapist: Do you know why your heartbeat changes when you’re anxious?
1301Patient: Because I’m scared.
1302Therapist: That’s right, and when you’re scared what substance does your
1303body produce that makes your heart beat faster?
1304Patient: Is it adrenaline?
1305Generalized Anxiety Disorder 113
1306Therapist: That’s it, you produce adrenaline, which acts on your body
1307so that you can survive danger. Have you seen those medical dramas
1308where they have to start someone’s heart following a heart attack?
1309Patient: Yes.
1310Therapist: What do they do to restart someone’s heart?
1311Patient: They give electric shocks.
1312Therapist: That’s right. And what do they inject directly into the heart?
1313Patient: Adrenaline.
1314Therapist: That’s right. So do you think they would do that if adrenaline
1315could damage the heart?
1316Patient: No.
1317Therapist: So you can see that adrenaline can save your life. Even if you
1318have had a heart attack and your heart is probably weaker as a result,
1319adrenaline can save your life. Do you think doctors would use adrenaline if it was going to make matters worse?
1320Patient: No, I see what you mean. So adrenaline is not going to harm me
1321then?
1322Therapist: What do you think now that we have examined some of the
1323counterevidence?
1324Patient: No, it probably won’t, it could even be a good thing.
1325Therapist: Can you think of anything else that increases your heart rate.
1326Patient: Like exercise, you mean?
1327Therapist: Yes, good example. Would you say that exercise is bad for your
1328heart?
1329Patient: No, it’s recommended as something that can protect against
1330heart disease.
1331Therapist: That’s right. So can you see how an increase in heart rate is not
1332good evidence that your heart will be damaged by worry.
1333The evolutionary perspective can be a valuable tool in counteracting
1334negative beliefs about worry and anxiety/stress. The therapist uses guided
1335discovery to help the patient explore how evolution would have extinguished a tendency in which worry or stress disadvantaged the organism
1336through adversely affecting psychological or biological well-being. The following transcript illustrates the use of this technique:
1337Therapist: Think about the evolution of humans. Do you think early environments were stressful for our ancestors?
1338Patient: Yes, they must have been.
1339114 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1340Therapist: In what way do you think they were stressful?
1341Patient: I guess there was a lot that people didn’t know back then. So
1342many things that we don’t worry about today would be the source of
1343stress.
1344Therapist: I’m sure you’re right. Do you think that there was a lot to worry
1345about?
1346Patient: Yes, much more than there is today.
1347Therapist: So if worry and stress caused mental illness, do you think
1348humans would have evolved and still be around as a species today?
1349Patient: No, probably not.
1350Therapist: So, looking at some of the counterevidence, how much do you
1351believe that worry is harmful to your mental health?
1352The evolutionary strategy can be usefully coupled with the survival
1353mechanism explanation, in which the therapist presents information that
1354the anxiety response is part of the person’s built-in survival mechanism.
1355Such a mechanism would not be effective if it caused dangerous outcomes
1356such as mental or bodily breakdown. The following transcript illustrates
1357this approach:
1358Therapist: Do you think there could be advantages to anxiety?
1359Patient: No, I just don’t want to have it. If I could worry without the anxiety that would be one solution because the anxiety is damaging me.
1360Therapist: Have you heard of the fight-or-flight response?
1361Patient: I think so, but I’m not sure.
1362Therapist: It’s part of a person’s built-in survival mechanism and anxiety plays a central role. When a person is exposed to danger, his
1363or her anxiety is activated. This leads to changes in thinking and in
1364bodily arousal that prepare the person to take emergency action. For
1365instance, the heart beats faster and blood is redirected away from
1366the gut and to the muscles to supply them with more oxygen. You
1367may have noticed that your thinking speeds up and so on. This is to
1368help the person fight or to run away from the situation. So you can
1369see anxiety is there to help you survive danger. Do you think it would
1370have served humans so well as a survival response if it harmed them
1371in some way?
1372Patient: No, I don’t suppose so. I hadn’t thought that anxiety could be
1373helpful.
1374Therapist: Can you think of any other ways that anxiety could be helpful?
1375Generalized Anxiety Disorder 115
1376Patient: What, you mean for survival?
1377Therapist: I was thinking more about whether some anxiety could improve
1378performance.
1379Patient: Well, I’ve heard that athletes try not to be too relaxed before
1380competing.
1381Therapist: That’s right, being anxious or psyched-up can actually improve
1382performance. So maybe that’s some further evidence that anxiety is
1383not bad for you.
1384Behavioral Experiments
1385The preceding section examined some of the common verbal reattribution techniques used to weaken negative beliefs concerning the danger
1386of worry. Dealing with these techniques should be followed by the use of
1387behavioral experiments that consolidate what the patient has learned and
1388test his or her specific predictions. The therapist should not assume that
1389verbal strategies alone are sufficient to produce the complete and stable
1390changes in a patient’s negative metacognitive beliefs that are required in
1391treatment.
1392Behavioral experiments should be a consistent and mandatory component of treatment. Five examples of the behavioral experiments commonly used in MCT to challenge negative beliefs are given in the examples
1393that follow.
1394Minisurveys
1395A 51-year-old patient was very concerned that his worry was abnormal and a
1396sign that his mind was weak and vulnerable. He believed that his worry was
1397a warning that he was “losing his ability to think.” The therapist discussed
1398with him possible ways to test his belief that his worry was abnormal and a
1399sign that he must be losing his ability.
1400It was decided that a useful way for the patient to find out would be
1401to interview four people and ask them questions about worry. It was reasoned that if the patient’s worry was abnormal then other people would
1402report worrying little and having no difficulty controlling their worries.
1403Three questions were generated: (1) “Do you ever worry?,” (2) “Do you
1404ever have difficulty controlling worry?,” and (3) “How often do you worry?”
1405The patient was asked to interview some people whom he thought hardly
1406ever worried and some whom he thought might worry a lot. The therapist also agreed to ask three people the same questions. When asked what
1407responses he predicted, the patient stated that he thought most people 
1408116 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1409would say they did not worry and if they did it would not be frequent and
1410not associated with difficulties in control.
1411The results of the survey were a great surprise to him. He had asked
1412his wife about worry and was shocked to discover that she worried more
1413than he did. Indeed, she found her worry uncontrollable at times, but she
1414did not have GAD. The results changed his belief that he was abnormal
1415and losing his ability to think. He concluded that this was further evidence
1416that he simply worried too much about worry.
1417Going-Crazy Experiment
1418In a treatment session with a 27-year-old woman the therapist asked,
1419“What is the worst that will happen if you worry more?” The patient
1420replied that she would “have a mental breakdown.” The therapist asked
1421what the symptoms of a mental breakdown would be like and discovered that the patient had a particular fear of schizophrenia. The
1422therapist explored how the patient might know that she had schizophrenia, to which the patient explained that she would develop visual hallucinations.
1423An experiment was run in which the patient was asked to worry about
1424a recent concern during the therapy session and to increase her worry to its
1425maximum degree to test if she could induce hallucinations. She found that
1426hallucinations did not occur, a finding that reduced her belief level from
142765% to 30%. The therapist asked what was keeping the remaining belief
1428going. The patient replied that she had not experienced any physical symptoms like she would if she was anxious. Further exploration revealed that
1429the patient’s main physical symptoms were racing thoughts and tightness
1430in her arms. The therapist refined the experiment and asked the patient
1431to worry intensively while exercising and tensing her arm muscles to determine if this caused hallucinations. After trying this experiment her belief
1432fell to 20%. The remaining belief was tackled by asking the patient to conduct homework in which she deliberately pushed her worry higher the next
1433time she felt anxious.
1434Damaging the Body with Worry
1435A 31-year-old patient believed that he could damage his body with worry.
1436He believed that he could induce a heart attack. After establishing that
1437the patient was in good physical health and there was no risk for him to
1438perform vigorous exercise, the therapist asked him to worry while jogging
1439around the outside of the clinic. The patient predicted that this would lead
1440to physical collapse or even to a heart attack.
1441After this experiment the patient’s belief in worry damaging his body
1442dropped by 30%.
1443Generalized Anxiety Disorder 117
1444Evaluating Effects of Worry on the Body
1445When patients believe that worrying can have damaging effects on the
1446body the therapist first weakens this belief by reviewing the evidence and
1447counterevidence. Next the therapist runs a behavioral experiment to evaluate the effects of worry on bodily reactions.
1448A patient was concerned that worry could harm her body. Her evidence
1449for this belief was that worry could increase her heart rate. The therapist
1450took her pulse under three conditions of (1) light exercise, (2) sitting in a
1451chair having neutral thoughts, and (3) sitting having worrying thoughts.
1452The results showed that exercise led to an increase in heart rate but there
1453was little difference in her heart rate between worrying and having positive
1454thoughts. This result was used as evidence against the idea that worrying
1455had a marked effect on her body.
1456The therapist refined the experiment by asking the patient what would
1457happen to her heart rate if she worried while exercising compared to exercising without worry. The patient predicted that her heart rate should be
1458much higher, at least 20 beats per minute higher when she worried. The
1459therapist asked the patient to do 10 step-ups while worrying, then 10 while
1460not worrying, and compared the patient’s pulse rate in the two conditions.
1461The patient discovered that there was little difference in rate between the
1462two conditions. This discovery was successful in challenging her belief.
1463Challenging Positive Metacognitive Beliefs
1464The model specifies that positive metacognitive beliefs about worry are
1465normal and not specific to pathology. However, the problem in GAD is that
1466patients lack the flexibility of selection and implementation of a range of
1467strategies for dealing with intrusive thoughts and emotion. That is, positive
1468beliefs in GAD monopolize the style of processing in response to negative
1469thoughts and emotions. In turning the spotlight on positive metacognitive
1470beliefs, the therapist is normally entering the final third of treatment. Positive beliefs become the focus only after negative beliefs about uncontrollability and danger have been effectively challenged.
1471The modification of positive beliefs is considered important as a means
1472of freeing up the patient’s capacity to use alternative means of responding to internal events, and to increase motivation to break the habit of
1473responding with extensive conceptual activity. Strong positive beliefs may
1474serve as a vulnerability following treatment as they underlie a continuation
1475or reinstatement of worry responses.
1476Several strategies have been developed in MCT to weaken positive
1477beliefs. These include standard verbal reattribution techniques, the specific mismatch strategy, and worry modulation experiments.
1478118 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1479Verbal Reattribution
1480The therapist usually begins this part of treatment by questioning the evidence supporting the advantages of worrying. This step is introduced in
1481the following way:
1482“We have examined your negative beliefs about worry, and you’ve been
1483able to discover that worrying is controllable and harmless. We should
1484now turn our attention to the positive beliefs you hold about the usefulness of worry. Such beliefs support the continued overuse of worry
1485as a coping strategy. We should now look toward expanding and maintaining the new ways you have learned of relating to your thoughts.”
1486The therapist challenges the patient’s beliefs by questioning the evidence supporting them and reviewing counterevidence. Some examples of
1487typical questions are as follows:
1488“Do you have any evidence that worrying is helpful?”
1489“What is the mechanism that leads worry to be helpful?”
1490“Have you ever done something and not been able to worry? What was
1491the outcome?”
1492“What happens to your concentration when you worry?” (“How does
1493that fit with worry being helpful?”)
1494“What happens to your mood when you worry? So how helpful is worrying?”
1495“If worrying is effective for avoiding problems, it must mean that people who worry often must have fewer problems in their life. Is that
1496right?”
1497“How often do situations turn out the way your worry depicted them?
1498So if worry exaggerates reality, how useful can it really be?”
1499“Does worry let you look at things from all angles, including the positive? If it is biased, how useful is it in helping you?”
1500An example of using these questions during treatment with an older
1501patient with GAD is represented in the following dialogue:
1502Therapist: What do you think is the main benefit of worrying?
1503Patient: It means I won’t make major mistakes. I can avoid them.
1504Therapist: Do you have any evidence that worrying stops you from making mistakes?
1505Patient: Well, I’ve been a worrier most of my life and I suppose I haven’t
1506made any really big mistakes.
1507Therapist: Have you been able to worry about everything in your life?
1508Generalized Anxiety Disorder 119
1509Patient: No, I don’t suppose it’s everything.
1510Therapist: So, have the things you haven’t worried about been a mistake?
1511Patient: No. Sometimes you can be pleasantly surprised by the things you
1512don’t anticipate.
1513Therapist: So what’s your evidence that worry is necessary to stop you
1514from making mistakes?
1515Patient: I suppose there isn’t any. But it might help sometimes.
1516Therapist: What’s the mechanism that makes worry help sometimes?
1517Patient: Well, I might be correct in anticipating a problem.
1518Therapist: How often do situations turn out exactly like you anticipated?
1519Patient: Sometimes they do.
1520Therapist: So they are exactly how you anticipated them, is that right?
1521Patient: No, maybe not, because worry is so negative.
1522Therapist: That’s right. Does worry paint an accurate picture or is it
1523biased in some way?
1524Patient: It’s pessimistic, so it’s not really realistic.
1525Therapist: That’s right. So how much do you believe worry is helpful in
1526preventing mistakes?
1527Patient: It probably isn’t very useful.
1528Worry-Mismatch Strategy
1529The worry-mismatch strategy is designed to illustrate how the content of
1530worry does not fit closely with the nature of reality. This strategy is not
1531principally a means of challenging the content of worry (although it may
1532have that effect), but instead a means of challenging the validity of beliefs
1533about the usefulness of worry (metacognitions).
1534There are two types of mismatch strategy, the retrospective mismatch
1535and the prospective mismatch. Both strategies involve obtaining a detailed
1536patient description of the content of steps in his or her worry process, and
1537then comparing these steps with a description of the events as they actually occurred in a situation. This strategy can be implemented for a past
1538event (retrospective mismatch) or for a forthcoming event (prospective
1539mismatch).
1540In the retrospective version, the therapist first identifies a recent situation that the patient was exposed to and had worried about beforehand.
1541The therapist elicits a detailed description of the content of the steps
1542involved in the worry episode and writes them out in one column of a
1543two-column table. This column is headed “Worry Script.” The steps in the 
1544120 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1545worry sequence are elicited by the therapist repeatedly asking, “And then
1546what did you think or worry about?” Alternatively, the therapist repeats
1547“What if that happens?” at each step until no new information is generated.
1548In the next column, headed “Reality Script,” the therapist writes
1549a description of the true sequence of events in the worry situation. The
1550therapist repeatedly asks, “And what actually happened in the situation?”
1551The therapist then directs the patient to assess the level of agreement or
1552“fit” between the two scripts, emphasizing the discrepancy that exists. The
1553technique is rounded off by the therapist asking, “If worry does not closely
1554match reality, how useful can it really be?” An example of a completed
1555mismatch script can be seen in Table 6.3.
1556The therapist uses the prospective mismatch when a patient is intending to engage in a future activity but is currently worrying about it. It is
1557also useful when the patient avoids situations because the thought of entering them causes him or her prolonged worry. In these circumstances the
1558worry script is written out in a treatment session and then for homework
1559the patient is asked to enter the avoided or worried-about situation and
1560later to write out the reality script and bring it along to the next session. At
1561that session the therapist and the patient retrieve the worry script from the
1562file and write out a more detailed reality script based on the patient’s notes
1563for comparison with the worry script.
1564Worry Modulation Experiments
1565If positive beliefs about worry are accurate and worry is helpful, then it
1566logically follows that increases and decreases of worry in the patient’s
1567life should have an observable effect on outcomes. Since the patient has
1568TABLE 6.3. A Completed Mismatch Script
1569Worry script Reality script
1570Situation: Visiting friends for a few days
1571Trigger: “What if I arrive late?”
1572“I’ll miss the train.”
1573“I will arrive last of all.”
1574“Everyone will be drunk.”
1575“I won’t be able to join in.”
1576“I’ll get anxious.”
1577“I’ll have to leave.”
1578“I’ll end up on the streets.”
1579“I’ll be lost.”
1580“Someone will attack me.”
1581“I could die.”
1582“I arrived early.”
1583“Not many people were there.”
1584“I had some great food and wine.”
1585“I met a couple of really nice guys.”
1586“I’m looking forward to visiting my
1587friends again next month.”
1588Generalized Anxiety Disorder 121
1589already experienced decreasing the extent of worry earlier in treatment,
1590the effect of this decrease on outcomes can be questioned by the therapist
1591to weaken positive beliefs:
1592“We might already have some evidence that can address the issue of
1593whether worrying is helpful. Can you think back to earlier in treatment when you postponed your worry? Did you find that unhelpful?
1594Did you find that you coped less well or things didn’t work out when
1595you worried less?”
1596This questioning can be followed by an experiment in which worry
1597is increased and decreased with the specific aim of assessing its impact
1598on daily outcomes such as work performance, coping, and daily events. In
1599order to facilitate the experiment, the therapist should operationalize with
1600the patient observable signs of worrying being helpful and not worrying
1601being unhelpful. The aim is to test the prediction that not worrying will
1602result in poorer outcomes than worrying.
1603For example, a patient who believed “Worrying means I’ll perform
1604better” was asked to worry more on the first day at work after the treatment session, and then to ban worry on the next day to see if there was
1605a difference in her performance. At the following treatment session
1606the therapist asked the patient if she had noticed any difference in
1607performance on the two days in question. The patient reported that
1608there was no difference. She had realized that she was a cautious person in any case and that worrying did not improve her performance.
1609New Plans for Processing
1610Once negative and positive metacognitive beliefs have been effectively
1611modified, the final step of treatment, which contributes to relapse prevention, is consolidation and strengthening alternative metacognitive plans
1612(proceduralized—“experiential”—knowledge) that can control responses
1613to intrusive thoughts/stress.
1614Proceduralization of replacement plans requires repeated practice of
1615new processing strategies. That the patient maintains awareness of the perseverative process is particularly important, since changes in content can
1616mask the fact that the process is still intact.
1617For example, a patient reported that she no longer worried like she
1618used to. However, she wanted to talk with the therapist about something that was bothering her. She went on to disclose that she had
1619seen a movie about someone undergoing therapy who recovered
1620memories of childhood abuse. After seeing this movie the patient was 
1621122 METACOGNITIVE THERAPY FOR ANXIETY AND DEPRESSION
1622analyzing her own experiences to try and work out if the source of her
1623GAD could be that she had been abused but had repressed memories
1624of the abuse.
1625The therapist helped her to see that this analysis of whether she
1626might have been abused was just another manifestation of worry/
1627rumination: the reason she felt the way she did was because she was
1628still engaging in the worry process. This patient continued to hold on
1629to persistent positive beliefs about the usefulness of worry and analytical thinking as a strategy for finding solutions to negative feelings. She
1630needed further strengthening of skills for recognizing and detecting
1631the worry process (irrespective of content) as part of her alternative
1632plan for processing. The alternative plan for processing would become
1633detecting of the worry process, applying detached mindfulness to the
1634triggering thought, and allowing emotions to ebb and flow without
1635trying to understand them.
1636A range of alternative plans for processing can be built up. Some
1637examples of strategies commonly used as components of new plans are
1638given in Table 6.4. It is important to note that this part of treatment is
1639only implemented after successful modification of negative beliefs about
1640danger because alternative plans should not inadvertently become sources
1641of avoidance.
1642TABLE 6.4. Examples of Components Used in New Plans
1643Old plan New plan
16441. “If I have a negative thought, then
1645worry about what could happen and
1646how to avoid it.”
1647“If I have a thought, then leave it alone
1648and wait and see what happens.”
16492. “If I have a negative thought, then
1650cover all possibilities so I’m not taken
1651by surprise.”
1652“If I have a negative thought, then
1653imagine one thing positive rather than
1654covering all possibilities.”
16553. “If I’m worried, then focus on evidence
1656supporting or counteracting my
1657worries.”
1658“If I’m worried, then don’t search for
1659any evidence; simply stop the thought
1660process.”
16614. “If I need to do something new, then
1662try to stop thoughts of danger.”
1663“If I need to do something new, then
1664allow thoughts to ebb and flow like
1665tides.”
16665. “If I’m worried, then use alcohol to
1667help me cope.”
1668“If I’m worried, then avoid alcohol (push
1669worry if I need to prove it’s harmless).”
16706. “If I’m worrying, then ask my partner
1671for reassurance.”
1672“If I’m worrying, then ban asking for
1673reassurance.”
16747. “If I do anything novel, then try to
1675anticipate problems before doing it.”
1676“Do more novel things; break my routine
1677without giving much thought first.”
1678Generalized Anxiety Disorder 123
1679Relapse Prevention
1680Relapse prevention consists of reviewing residual scores on metacognitive
1681variables that are hypothesized as constituting continued vulnerability.
1682In GAD negative beliefs about uncontrollability and danger concerning
1683thoughts are a proximal cause of GAD. The therapist should check that
1684these beliefs are at 0% or as close as possible to this level. More extensive
1685evaluation of such metacognition is therefore recommended in the last
1686two treatment sessions by close scrutiny of the GADS-R and administration
1687of further tools such as the Meta-Worry Questionnaire and the MCQ-30. If
1688residual beliefs in these domains persist, then further modification should
1689be attempted by returning to and refining the strategies used earlier in
1690treatment.
1691A further cause of subsequent problems is the continued use of worry
1692or rumination as a coping strategy. It is important that the therapist checks
1693for other subtle forms of ongoing patient worry that are activated in situations and emphasizes awareness and abandonment of this process. The
1694presence of remaining positive beliefs about worry should be explored in
1695this context. If necessary, further work should be undertaken to modify
1696them.
1697Avoidance of situations and other behaviors such as reassurance
1698seeking or information search are markers for residual beliefs about the
1699uncontrollability and threat imposed by emotions such as anxiety. These
1700responses should be identified and reversed before termination of treatment.
1701Finally, the therapist and the patient work on writing out a therapy
1702blueprint, which contains a summary of information about GAD and worry,
1703an example of the case formulation, the results of behavioral experiments
1704to test negative and positive metacognitions, and the new plan for dealing
1705with stress/intrusions.
1706Booster treatment sessions can be scheduled for 3 and 6 months after
1707treatment as an opportunity to monitor patient gains and reinforce the
1708knowledge and strategies he or she has acquired.
1709GAD Treatment Plan
1710An overall 10-session treatment plan for implementing MCT in GAD is presented in Appendix 15. This is intended as a guide to treatment structure
1711and content and should be applied flexibly as individual circumstances
1712require. The plan should be implemented with direct reference to the
1713strategies described in this chapter.