Cognitive and Behavioral Practice 20 (2013) 301–313www.elsevier.com/locate/cabp

Metacognitive Therapy for Generalized Anxiety Disorder: Nature, Evidence andan Individual Case Illustration

Odin Hjemdal, Roger Hagen, and Hans M. Nordahl, Norwegian University of Science and TechnologyAdrian Wells, Norwegian University of Science and Technology and University of Manchester

Keywanxie

1077© 20Publ

Metacognitive therapy (MCT) is based on over 25 years of research focusing on the processes that contribute to the development andmaintenance of psychological disorders. The approach identifies a common set of processes in psychopathology, and MCT showspromising results in effectively treating a range of disorders. This paper presents the central theoretical tenets of MCT and uses a clinicalvignette to illustrate the structure and techniques of treatment based on Wells's (2009) manual as they relate to a specific case ofgeneralized anxiety disorder.

What Is Metacognition and Why Is It Important?

This paper provides a general introduction to the theoryof metacognitive therapy (MCT) and a more specificoutline of how to useMCT for generalized anxiety disorder(GAD), illustrated with the clinical case of William. In thefinal part of the paper the scientific evidence for MCT inGAD is presented. MCT was developed to address thecontrol of cognition and the strategies and knowledge thatgovern thinking. It contrasts significantly with the theoryand focus of standard CBT.

Metacognition refers to cognition applied to cognitionandmay be defined as any knowledge or cognitive processesinvolved in the appraisal, control, and monitoring ofthinking (Flavell, 1979). In short, metacognition is thinkingabout thinking. Metacognitive theory has distinguishedbetween metacognitive knowledge, which is informationthat individuals have about their own thinking and aboutstrategies that affect it, and metacognitive regulation, whichare the strategies used to change thenature of processing. Inthe metacognitive theory of psychological disorder (Wells,2009; Wells & Matthews, 1994), metacognition is central indetermining the maintenance and control of negative andbiased thinking styles. According toWells, most people havenegative thoughts and beliefs and in most cases thesethoughts and beliefs are transitory mental experiences. The

ords: metacognitive therapy; generalized anxiety disorder;ty; cognition; case study

-7229/12/301-313$1.00/013 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

negative thoughts become a problem because of the way anindividual responds to them. Thus, an important tenet ofmetacognitive therapy, and one of the features distinguish-ing it from traditional CBT, is that neither the content northe subjective validity of thoughts and beliefs are the centralsource of disorder. In basic terms, according to metacogni-tive theory, an individual's metacognitions monitor andcontrol their responses to thoughts, which cause persistenceor perseveration of ideas and maintain psychological andinterpersonal problems.

This supposition can be clearly illustrated in the situationof GAD, where the content of worry shifts around. Thecontent of worry in GAD is not dissimilar from everydayworries experienced by most people. However, peoplewith GAD experience their worry as uncontrollable andexcessive, and it is associated with marked distress. Themetacognitive model provides an explanation of this interms of differences in theway individuals relate to, appraise,and control their worry

The theoretical grounding ofMCT is the Self-RegulatoryExecutive Function Model (S-REF), which emphasizesthe similarities in maladaptive cognitive processing acrossall psychological disorders (Wells, 2000, 2009; Wells &Matthews, 1994, 1996). The S-REF model postulates athinking style called the cognitive attentional syndrome(CAS). InMCT the CAS is a universal feature of psychiatricdisorders and is responsible for prolonging and intensifyingdistressing emotions. The CAS is a thinking pattern ofinflexible self-focused attention (the focus is on self--observation and monitoring of thought processes), persev-erative thinking (in the form of worry and rumination),threat monitoring, and coping behaviors that backfire and

302 Hjemdal et al.

interfere with effective mental control and adaptivelearning.

The CAS is considered to be a problem for psychologicalwell-being because it maintains threat-focused processingand fails to provide information that can modify theindividual's maladaptive appraisals and beliefs. In additionto this, the CAS uses attentional resources that mightotherwise be directed towardmore adaptive responses, andbiases perception and automatic processing in a negativeway. There is a large evidence base supporting the presenceand effects of the CAS in emotional disorders (see Wells,2009, for a review).

The CAS is driven by metacognitive beliefs andmetacognitive knowledge stored in long-term memory,and MCT implies that all disorders are linked to thishigher level of metacognitive beliefs about thinking.These beliefs fall into either positive or negative domains.Positive meta-beliefs concern the advantages of worrying,ruminating, threat monitoring, and controlling cognition(e.g., “Worrying about the future helps me be prepared”).Having positive meta-beliefs alone is not in itself pathogenicbut increases the tendency to worry as a coping strategy,which does not provide the most effective way of managingnegative affect and thoughts. According to MCT, psychopa-thology develops when negative meta-beliefs about loss ofcontrol and danger are activated. These beliefs concern theuncontrollability of worries and rumination andbeliefs aboutthe dangerousness or importance of thoughts. An exampleof a negative metacognition is: “Worrying is out of controland will make me lose my mind.” The patient with GAD canhold bothpositive andnegative beliefs about worrying, whichcause conflicting motivations to sustain or try to avoidnegative thoughts. However, the negative beliefs are mostimportant and lead toworry aboutworry resulting in elevatedand persistent distress. The negative beliefs about theuncontrollability of the process contribute to the use ofunhelpful forms of control or no control at all.

Metacognitive Model of GAD

The metacognitive model of GAD (Wells, 1995, 1997)proposes that when experiencing a negative thought (alsocalled trigger thoughts; e.g., “What if I can't cope with mywork?”), patients with GAD use extended negative thinkingin the form of worry (Type 1 worry) to anticipate and workout ways of how to cope or avoid problems. Most peoplehave positive beliefs about worry, but this is not theproximal feature of GAD. In MCT, the negative beliefsabout worrying are considered to be the main cause ofpathology, although the overuse of worry as a means ofdealing with triggers may produce longer-term difficultiesof impairing emotional processing and be unhelpful in thedown-regulation of emotion. The metacognitive modelproposes thatGADdevelopswhennegativemeta-beliefs are

formed and/or activated. These beliefs fall into twodomains: that worry is uncontrollable and that worry isdangerous for mental or physical well-being. When thesebeliefs are triggered the individual begins to worry aboutworry (Type 2 worry or meta-worry), which leads to anincrease and prolongation of anxiety symptoms. Anxietycan escalate rapidly due to Type 2 worry and occur as panicattacks because of themore imminent threat considered tobe posed by worry itself. In response to meta-worry, theindividual engages in thought-control strategies anddifferent behaviors aimed at reducing worry and/or thethreat it presents.Many of these responses have paradoxicaleffects that interfere with effective mental control and thedevelopment of more adaptive meta-beliefs. For example, aperson with GAD may ask a partner for reassurance, whicheffectively transfers the control of worry to someone else,thus depriving the individual from learning that he or shehas control. In some cases the person will search theInternet for information in an attempt to assuage worry oranxiety, but this can actually increase exposure to ambig-uous and threat-related information—a further triggerfor worrying (e.g., natural disasters, accidents, crime rates,information on specific diseases and accompanying symp-toms). Other unhelpful strategies include trying to suppressthoughts that might trigger worrying and/or having tosustain thinking in order to “think oneself out of worry.”These strategies, described above, simply extend theperson's engagement with negative thoughts. As a conse-quence, such responses reinforce or maintain meta-beliefsabout loss of control and an inability to cope. The MCTmodel is illustrated in Figure 1.

Empirical Support for the Model

There is substantial empirical evidence supportingthis model. This section provides a brief summary of theevidence (see Wells, 2009, for a more detailed review).

The negative effects of worrying for emotional andcognitive self-regulation have been demonstrated. Borkovec,Robinson, Pruzinsky, and DePree (1983) showed that briefperiods of worrying led to greater anxiety, more depressivesymptoms, and more negative thoughts in high comparedwith low worriers. It was also demonstrated that despitesuffering with the negative consequences of worry, peoplewith GAD had positive beliefs about worry (Borkovec,Hazlett-Stevens, & Diaz, 1999; Borkovec & Roemer, 1995).York, Borkovec, Vasey, and Stern (1987) also demonstratedthat participants had more negative thought intrusions afterthe induction of worry than after a neutral condition.

Following exposure to the stress of watching a dis-tressing video, brief periods of induced worrying havebeen shown to be associated with an increase in intrusivethoughts about the stressor over 3 days (Butler, Wells, &Dewick, 1995; Wells & Papageorgiou, 1995). The use of

Figure 1. The metacognitive mode of generalized anxietydisorder. From Wells (1997), p. 204; published by Wiley;reproduced with permission licence number 2927550880379.

303MCT for GAD

worry to cope with thoughts is also associated with a rangeof emotion disorder symptoms (Wells & Davies, 1994).

An important tenet is that negative metacognition iscentral to the development of pathological worry as seen inGAD, and several studies have examined this assertion.Wells andCarter (1999)measuredworry aboutworry (Type2 worry) and Type 1 worry and demonstrated that theformer was a stronger correlate of pathological worry scoresthan the latter. In a subsequent studywith the sole emphasison worry about the danger of worry belief, the frequency ofType 2 worry discriminated those individuals meetingthreshold for GAD from individuals classified as havingsomatic anxiety or no anxiety (Wells, 2005a, 2005b; 2006).This effect could not be attributed to differences in theoverall frequency ofworrying since the effect remainedwhenthe frequency of Type 1 worry was statistically controlled.

There are some initial indications that the positiveassociation betweenType 2 worry and pathological worryingmay be stable across different ethnic groups. Nuevo,Montorio, and Borkovec (2004) replicated the study ofWells and Carter (1999) and extended it by examining therelationship betweenmeta-worry and worry severity in olderSpanish adults. Meta-worry consistently emerged as asignificant positive correlate of pathological worry and theamount of interference from worrying, relationships thatpersisted even when trait-anxiety and Type 1 worryfrequency were statistically controlled.

Prospective studies address the causal status ofmetacognition. However, only one unpublished studyhas examined this in GAD. Nassif (1999, Study 2)

examined the longitudinal predictors of pathologicalworry and GAD over a period of 12 to 15 weeks.Meta-worry, but not Type 1 worry (assessed at Time 1),predicted the later development of GAD. Furthermore,negative beliefs about the uncontrollability and danger ofworry measured at Time 1 predicted the later develop-ment of GAD, and this effect remained when trait-anxietyand Type 1 worry frequency assessed at Time 1 werepartialled-out. These findings clearly need to be replicat-ed in order to draw firmer conclusions.

In the MCT model of GAD, the disorder results frommeta-worry linked to negative metacognitive beliefs. Thus,there should be evidence that negative beliefs aboutworrying are significantly associated with GAD and shoulddistinguish GAD from other disorders. Several studiesconfirm this prediction (Cartwright-Hatton & Wells, 1997;Davis & Valentiner, 2000). Wells and Carter (2001)compared patients with GAD against gender-matchedpatients with social phobia, panic disorder, and nonpatientcontrols. The GAD group could be distinguished fromthe other groups in endorsing significantly higher negativemetacognitive beliefs in two domains: (a) uncontrollabilityand danger and (b) need for control focusing on negativeconsequences of not controlling thoughts. Differencesin beliefs about uncontrollability and danger remainedwhen the frequency of Type 1 worry was statisticallycontrolled.

A study by Ruscio and Borkovec (2004) is especiallyrelevant in addressing the issue of the importance ofworry versus metacognitions about worry in GAD. Thestudy is notable for examining the differences betweenindividuals who were high worriers but did not have GADand those that met criteria for GAD. The results showedthat worry was similar across both groups, but significantdifferences emerged in two separate negative beliefdomains: beliefs about the uncontrollability of worryand beliefs about the danger of worrying.

Despite the emphasis given to negative metacognitivebeliefs, positive beliefs are also viewed as contributing tothe inflexible use of worrying as a coping strategy, but thisis not necessarily unique to GAD and is a feature of themetacognitive account of general stress vulnerability(Wells & Matthews, 1994). Interview studies and ques-tionnaire data support this assertion (Cartwright-Hatton& Wells, 1997; Davey, Tallis, & Capuzzo, 1996; Wells &Papageorgiou, 1998). Individuals with GAD and thosewithout do not show significant differences in theendorsement of positive meta-beliefs about worrying(e.g., Cartwright-Hatton & Wells, 1997; Wells, 2005a,2005b), but these beliefs are positively correlated withworry tendencies. Thus, it could be useful to challengethese positive meta-beliefs as a general stress preventionstrategy and to increase flexibility in responses to stressand negative thoughts.

304 Hjemdal et al.

MCT for GAD

The first step in MCT is to generate a case conceptual-ization based on themodel described above. This forms thebasis of interventions aimed to reduce unhelpful copingstrategies, bringing worry under effective control andmodifying metacognitive beliefs. The second step is tosocialize the patient so that he or she learns that theproblem is not worry itself, but the patient's own beliefsabout worry. Metacognitive beliefs are modified throughexperiencing new types of relationships with cognitiveprocesses. In the case of GAD, the focus is on the cognitiveprocess of worry, which typically is perceived as a persistentand an uncontrollable process. MCT applies techniquessuch as detached mindfulness (Wells & Matthews, 1994; Wells,2005a, 2005b) and worry postponement experiments. Thesestrategies are used to replace the ineffective mental controlstrategies used by patients. Take the example of trying tosuppress thoughts, which has the paradoxical effect ofincreasing their frequency, and thus often contributes to aperception of loss of control. Detached mindfulness andworry postponement are strategies that give the clientincreased awareness of control and ultimately change theclient's relationship with the cognitive process of worry andwith negative thoughts that trigger the experience. Thegoal is to increase effective control over worry and tochallenge beliefs about its uncontrollability. However, theMCT therapist goes on to ensure that the patient is willingto try and lose control of worry later in treatment tochallenge other metacognitions concerning the danger-ousness of worrying.

The treatment adheres to a particular sequence:case conceptualization and socialization are followed by(1) shaping meta-awareness of the distinction betweenthoughts that act as triggers and the worry response andlearning new meta-level responses; (2) challenging beliefsabout the uncontrollability of worry; (3) challengingbeliefs about the danger of worry; (4) modification ofpositive beliefs about worry; and (5) relapse prevention.

The GAD treatment usually consists of 10 to 12treatment sessions administered in weekly 50-minutesessions (see Wells, 2009, for a detailed session-basedtreatment plan). These are the main elements of MCT.What follows is an illustration of MCT as applied to the caseof William.

The Case of WilliamAssessment

Using the ADIS-IV, William (see Robichaud, 2013-thisissue, for the clinical case presentation) receives a primaryAxis I diagnosis of GADwith a severity rating of 6 (on a 0 to 8scale). The diagnostic assessment also indicates that he isexperiencing some depression, which is a common comor-bid problem for individuals suffering from GAD (see, e.g.,Moffitt et al., 2007). It is typical to assess anxiety and

depressive symptoms prior to and during treatment, and inthe case ofWilliam this is done by using the BeckDepressionInventory (Beck & Steer, 1993b) and the Beck AnxietyInventory (Beck & Steer, 1993a), which are completed priorto each therapy session. Additional scales that might beuseful, particularly pre- and posttreatment, are the Metacog-nitions Questionnaire (MCQ-30; Wells & Cartwright-Hatton,2004) and the Penn State Worry Questionnaire (PSWQ;Meyer, Miller, Metzger, & Borkovec, 1990).

It is very important to assess the degree to which theclient endorses positive and negative meta-beliefs. Whenworking with GAD using MCT, the Generalized AnxietyDisorder Scale–Revised (GADS-R; Wells, 2009), a self--report instrument, is used. The GADS-R assesses howdisturbing worries have been for the last week, and howmucheffort the patient has used in controlling worries. Thesame scale also measures levels of positive and negativemetacognitions, which is essential for the metacognitivetherapist, along with the extent of typical maladaptivebehaviors used by the patient to cope with or to avoid worry.Using the GADS-R in every session gives the therapist agood overview of the client's current level of positive andnegative meta-beliefs, along with the use of maladaptivecoping behaviors. It therefore contributes to targeting thefactors that are currently the most important to work withat each stage of treatment.

Case Formulation in MCT for GAD

MCT treatment is described in the treatment manualsby Wells (1997; 2009) and always starts with a collaborativecase formulation. The main aim of the case formulationis to capture the metacognitive beliefs that maintain theproblemalongwith theuse ofmaladaptive copingbehaviorsand avoidance.MCThas a structured and usually sequentialway of doing this, and follows a case formulation interview(Wells, 2009), as illustrated in Figure 1.

The case formulation starts by identifying the triggerthat starts a worry episode (1). A trigger in MCT is alwaysan internal intrusive thought, often in the form of a “Whatif. . . ?” question, but also sometimes occurs in the form ofa negative image. The therapist typically tries to examinethese triggers by asking questions such as, “What was thefirst thought you had when you started to get anxious orstarted to worry?” After the therapist has found the triggerfor the worry episode, he then explores the thoughtsfollowing this trigger (Type 1 worry) by asking, “Whenyou had this initial thought, what kind of thoughtsfollowed?” and “For how long did you worry?” (2). Thiskind of Type 1 worry leads to an increase or persistence ofnegative emotions and symptoms. The therapist assessesthese symptoms (3) by asking the patient, “When youhave these thoughts, how do they make you feel(emotionally and physically)?” (4). During the worryepisode, negative beliefs about worrying are activated. To

305MCT for GAD

explore these, the therapist looks for negative interpre-tation of worry (Type 2 worry). Specific questions areagain used: “When you had these thoughts and feelings,did you think something bad could happen as a result ofworrying and feeling this way?” “What's the worst thingthat could happen?” These Type 2 worries reinforcenegative beliefs of uncontrollability (5a) and danger (5b).These negative meta-beliefs are further explored with thepatient by asking, “Since worrying seems to be such aproblem for you, why don't you just stop it?” “Do youthink that worrying is uncontrollable in any way?” “If so,howmuch do you believe that worrying is uncontrollable ona scale from 0 (not at all) to 100 (completely uncontrollable)?”The negative beliefs about danger are further examined byasking: “Do you believe that worrying is harmful in any way?”“Do you think that worry may be harmful to your body or toyour mind? If so, how much do you believe this on a scalefrom 0 (not at all harmful) to 100 (very harmful)?”Althoughpatients suffering from GAD always hold negative beliefsabout worry, but also hold positivemeta-beliefs (6). To assessthese positive meta-beliefs the therapist asks the followingquestions: “Are there times that you believe that worry maybe useful in some way?” “Do you think that worrying couldhelp you cope?” “Does worry help you foresee problems andavoid them?” “Are there any advantages of worrying?”Finally, the therapist elicits the coping strategies (7) andthought control strategies (8a and 8b) used by the patient tocope with worry episodes. This part of the formulation isachieved by using questions such as, “When you startworrying, what do you do to try and stop it?” Probe questionshelp the patient to answer this: “Do you avoid situations,distract yourself, ask for reassurance, and sleep more or lessthan normal, use alcohol, medication or other drugs?”Thought control strategies are typically examined by askingthe patients the following (8a): “Do you also usemore directstrategies like controlling your thoughts by trying to suppressyour thoughts, like trying not to think certain thoughts ortrying to control them in other ways?” The therapist alsoasks: “Have you tried to interrupt worry by deciding notto engage in these thoughts?”

MCT Case Formulation for WilliamWilliam describes several worry domains but primarily

his trigger thoughts are linked to his health, family, andwork. A trigger (1) for William is, “What if I develop aserious illness?” This trigger is followed by Type 1 worry(2) as a stream of thoughts (What if my wife had troublehandling all the bills if I died? What will happen to my kids, willthey cope? What will my family do if they would have no money?Will they have to move? Will they suffer?). This kind of Type 1worry can last for a long period of time. William worriesmore or less all the time and every day as a reaction to hisdifferent trigger thoughts. These different worries give riseto several emotional and physical symptoms (3). He

describes that it is difficult for him to focus and concentrate.In MCT one often finds that these difficulties are related tothe ongoing worrying process. William also has difficultiesfalling asleep, feels tired all the time, and is irritable at workand at home. He experiences muscular tension, stomachproblems, feels restless, anxious, and reports a lowmood asa reaction to his worries. When William is asked about hisType 2 worry—for example, “When you have thesethoughts and feelings, did you think something bad couldhappen as a result of worrying and feeling this way?”—hemay report that he is afraid that he will go crazy related tointense levels of worry and anxiety. In MCT, these negativemetacognitive beliefs are important. Here William believesthat he could go crazy (a danger belief about worry) andthere is also the implicit or explicit belief that his worry isuncontrollable because it could lead to anxiety and losinghismind (4). Hemay think that because his worries seem tobe always present and difficult to stop (because he spendsabout 75% of his waking day worrying), that this is powerfulevidence that they are uncontrollable (5a). In metacogni-tive therapy it is important to assess how much he believesthat the worries are uncontrollable, it would not be unusualfor this belief to be around 75%. He worries that he maygo crazy, and in metacognitive therapy we often find thatpatients actually worry that their worries will contribute tomaking them “lose their minds” (5b). Despite having thesenegative meta-beliefs about worrying described above,William continues to believe that there are advantages tomanaging worry withmore thinking time (6). In particular,he worries about something happening to him, andresponds by making a plan for the family's finances. Hisexcessive planning has taken on proportions that interferewith the family's other activities. In the metacognitiveapproach the therapist interprets this as a positivemeta-belief, common among GAD patients (i.e., “I mustmake a plan or I won't be able to stop worrying”).Unfortunately, the planning process is another form ofextended thinking. In effect, William is trying to stopworrying by thinking more, when he needs to reduce theamount of thinking in response to negative ideas.

William also uses other coping strategies (7): procras-tination, seeking reassurance from others, and checkingfor information on the Internet, among other things. Healso describes using thought control strategies, such astrying to distract himself from worrying in addition tosuppressing his thoughts (8a). In particular, the thought,“What if I develop a serious illness?” triggers worrying.Most clients have never tried not to engage with triggers ofthis kind, and it is something new to them. It is thereforecentral to explore if William has ever experienced notengaging with the triggers and thoughts that normallylead to a worry episode (8b). The metacognitive caseformulation for William is presented diagrammatically inFigure 2.

(1) What if I develop a serious illness?

(2). What if my wife had trouble handling all the bills if I died? What will happen to my kids, will they cope? What if they would have no money?

(4). I will have a nervous breakdown if I don’t stop to worry

(5a). Worrying is uncontrollable 75% (5b). Worrying will make me go crazy

(6). Worrying will help me solve problems in life. Worrying will help me cope better. Worrying will help take the right decisions.

(3).

Anxiety, muscle tension,concentrationproblems,fatiguesleeplessness,stomachdistress,irritable,restlessness low mood

(8).

a. Distracting himself from thoughts

b) Never tried not to engage with trigger thoughts with more thoughts (e.g. arguing with himself if the worry is "true")

(7).

Excessive checking, reassurance,procrastination, make others take the decisions for him, search internet for information, double checking,

Figure 2. The metacognitive case formulation for William.

306 Hjemdal et al.

Socialization to the Model

The socialization process starts with sharing the caseconceptualization with the client. William would beexpected to view the case formulation a good fit withhis view of his problems, and likely had no additionalinformation to add at this point. After the case formulationhad been shared, some important facilitating questionswere asked in order to develop his metacognitive under-standing of the problem.

• “How much of a problem would worrying be for youif you knew that you could control your worries?”

William may have answered that if he could becertain that he could control his worries, they wouldnot be a problem.

• “If you were certain that you could not go crazy orhave a nervous breakdown due to worrying, how big aproblem would worrying be for you?” William mayhave answered that if he was 100% sure that worryingwould not give himanervous breakdown, hewould bereassured that his problem was not that dangerous.

• “If there were only advantages to worrying, wouldworrying be a problem for you? Would yourecommend worrying to your spouse and family?”

307MCT for GAD

William said his major problem was that hethought that worrying could be dangerous andthat he felt no control over his worries. Williamwould be expected not to recommend worrying as astrategy to anyone. It is useful that the client realizesthe contradiction between positive and negativemeta-beliefs about worry. Questions such as thefollowing are posed: “Are you aware of the fact thatyou have both negative and positive beliefs aboutworry? What do you think are the effects of holdingboth types of beliefs?”

• Questioning how it is possible to simultaneouslyhave both positive and negative meta-beliefs aboutworrying can begin to build a new perspective forthe client. To such a question,William likely answeredthat he had never considered the contradictionbetween having both positive and negative beliefsregarding worrying as a strategy. He would beexpected to be a bit puzzled by this. The therapistcan ask ifWilliam felt trapped in a circle of continuousworry and anxiety that was difficult to break out off.Holding both positive and negative beliefs aboutworry could contribute to keeping him trapped in anegative circle of continuous worry and anxiety.

• The coping strategies the patient uses when anxiousare often maladaptive because they only temporarilyreduce anxiety or they increase it. Asking questionsthat illustrate the effect of other coping strategies istherefore central. For example, “How does excessivechecking work for you? Do you become less worried?If so, does checking have a lasting or a temporaryeffect?”WhenWilliam took the time to reflect on this,he discovered that his checking behavior led to anincrease in his anxiety levels, which was contradictoryto his goal for using this behavior. Experiencingparadoxical effects when using different kinds ofcoping behaviors can be useful in exploring in themetacognitive model.

• In addition to his coping strategies, William was askedif he had ever tried to suppress thoughts: “Do you evertry not to think particular thoughts?” “And how wellhas this worked for you?” William had used suppres-sion to deal with his worries. He likely stated that itworked occasionally, but when questioned whetherthis effect was short lived, he admitted that it had nothelped him deal with his problems in the long run.

The socialization would be expected to improveWilliam's insight into the effects of his coping strategiesand the role of beliefs about worry. It began to open upsome new perspectives and alternative ways of thinkingabout his worries and his thinking about thinking. Thiscreated a foundation for proceeding with conducting anexperiment to check the effect of using suppression as a way

to cope with his worries. Such an experiment would beintroduced in the following manner: “Let us explore howthought suppression would work. For the next minute, Iwould like you not to think of a white giraffe. Try your verybest not to think of it, and suppress it as hard as you can.”This is a task that most clients find difficult to achieve. If theclient confirms that it was possible to suppress thoughts, thetherapist asks if the client had to allocate a lot of effort and ifthe client found it strenuous to suppress this particularthought. This way the therapist can illustrate that suppres-sion is a strategy that usually backfires by either increasingthe frequency of a particular thought or demanding a lot ofmental resources in order to block thoughts. Usually, as inWilliam's case, he found that he could not suppress thethought, and this was used to show how his own strategycould contribute to the belief that his worry was uncontrol-lable. The therapist offered an alternative interpretationto William in order to explore this further: “Perhaps yourworry is not uncontrollable, but that you are using strategiesthat do not work? Would you be interested in exploringsome other strategies? Have you ever tried not to engagewith your worrying thoughts?”Most clients have not tried todisengage from their worry process, and if they state thatthey have tried, it is important to explore how. For example,there are important differences between mindfulnesstechniques and the techniques of “detached mindfulness”used in MCT.

Detached Mindfulness

Early in therapy it is important that the client understandsand starts to differentiate between trigger thoughts andworrying. This is a new way of relating to trigger thoughts, inwhich the person is helped to become an objective observerof their thoughts.

The trigger thoughts typically occur spontaneously,which in most cases lead to worry and rumination as acoping response. One of the main goals of MCT is toincrease the client's ability to let trigger thoughts come andgo without engaging in them (this experience is calleddetached mindfulness; Wells, 2009; Wells & Matthews,1994). Detached mindfulness is not related to meditationtechniques or to focusing on the presentmoment. Detachedmindfulness strictly refers to being aware of inner cognitiveevents and thoughts without responding to them. The termdetachment refers to two factors: (a) the disengagement of anyactive response to the inner event and (b) experiencing theevent as separate from the self. That is, the person is helpedto become aware of the self as an objective observer ofthoughts but separate from them.

In order to develop detached mindfulness, it is useful togive the client experiences that approximate and achievethe state. Wells (2005b) described 10 different techniquesthat facilitate the development of detached mindfulness.

308 Hjemdal et al.

Williamused the free association task, the cloudsmetaphor,and the passenger train analogy, with the cloud and thetrain metaphors introduced first in order to socializeWilliam to the concept. In the clouds metaphor, thoughtsare likened to clouds floating in the sky. It would be futile totry to push the clouds away and to try to control theirmovements in order to change the weather. Triggerthoughts should be treated in the same way, left alone totake care of themselves. In the train analogy, the client isasked, “When you are waiting for a train, do you climbaboard every one that enters the station? Thoughts are liketrains. Where would you end up if you climbed on boardall of them?”

William was then asked to try the free association task(Wells, 2005a, 2005b). In this task, the therapist said aloud aseries of neutral words: green, water, sun, walking, bicycle,holiday, chocolate. William's task was to let his mind wanderfreely without trying to control thoughts, and to just observehis mental experiences in a detached manner. With anincreased ability to observe and not engage with thoughts,the free association taskwas gradually expandedbydroppingin trigger words. Here, William was asked to treat triggerwords in the same way as neutral words. In this way, Williamgrasped the concept of detached mindfulness and howthis was very different from his normal way of reacting tothoughts with worrying and planning.

It is important that clients understand the differencebetween detached mindfulness and suppression, and on aregular basis in treatment the therapist asks the client todescribe how he uses detached mindfulness to ensure it isnot being confused with thought suppression. Initially,many clients have difficulty distinguishing the two.

Challenging Uncontrollability: The WorryPostponement Experiment

The experiment of not thinking of a white giraffe makesthe patient aware that thought suppression is an inefficientstrategy for controlling thoughts. Detachedmindfulness is astrategy to disengage from trigger thoughts.However, whenthe chain of thoughts (worry or rumination) has started,William found it difficult to control this chain of thoughts,reporting that when he started worrying about healthissues, he could go on for hours, with suppressing thoughtsor distraction not working very well. In order to dealwith his worrying and begin to challenge uncontrollabilitybeliefs about worrying, the therapist introduced the worrypostponement experiment. As part of the worry postpone-ment experiment a specific worry period was established. IfWilliam felt that he needed to engage in worrying orrumination, he would do so between 6:00 and 6:15 P.M. eachday. It may be beneficial to restrict worrying to a specificplace, but MCT does not regard it as essential. Most GADpatients find that when the pre-set worry period arrives,

they do not need to worry, or the worries that they had atsomepoint during theday are no longer relevant. Using theworry period to worry is something that very few actuallydo, but postponing the worrying to this period is essential.With increased awareness of the ability to postpone worries,the client's erroneous beliefs that worry is uncontrollableare weakened.

The rationale for worry postponement was deliveredstressing that following detached mindfulness Williamshould postpone his worries whenever they occurred.“Just simply say to yourself, here is a worrying thought, Iwill not deal with this now, but return to it later if it is stillrelevant.” The therapist emphasized that this was anexperiment to test William's belief that worry was uncon-trollable. Ratings in his uncontrollability belief were takenin the session and then again at the next session after thishomework task.

Most patients are surprised to find that they canpostpone worrying. William may have found it difficult topostpone worries at first between sessions and startedworrying about his inability to postpone them. He reportedusing postponement of worries 60% of the time whenworries occurred. However, on exploration it became clearthat he was still trying to suppress his worries and anxiousthoughts. He was trying to get rid of them, because hefound some of his thoughts were frightening and depress-ing. The therapist therefore returned to explore the conceptof detached mindfulness using exercises in the session,which increased William's ability to simply observe thoughtswithout engaging in them. Several behavioral experimentsof worry postponement can also be undertaken in thesessions, in order to give William the experience of thistechnique. William was asked to bring on a trigger thoughtand activate the worrying process. The therapist thereafterasked William to postpone his worries for 10 minutes toexplore what would happen. During the 10-minute periodWilliam and the therapist focused on a different theme inthe therapy. At the end of this period the therapist returnedtoWilliam's worries, checking if William had worried duringthe last 10 minutes. In this way William discovered that hehad control and his worries faded without him tryingactively to get rid of them. Although in-session experimentsmay be somewhat different from the everyday experiencesof the worry process between sessions, the in-sessionexperiences can make it easier for William to understandworry postponement between the treatment sessions.For homework he was asked to postpone his worry until6:00 P.M. each day, and he was instructed that the “worrytime” was not mandatory.

Postponement of worry also facilitates changing from aprimarily internal focus to an external focus. So rather thanfocusing on his thoughts and worries, William graduallychanged his focus to what was going on around him. Theexternal focus made it easier to take part in everyday life

309MCT for GAD

and concentrate on the tasks at hand. Within a few sessionshewould be expected tohave increased theuse of detachedmindfulness and worry postponement to 80% of his triggerthoughts and the occurrence of worrying. Furthermore, hisbelief in the uncontrollability of worry had also decreased.

Uncontrollability: Verbal ReattributionWe have already described how the use of detached

mindfulness and worry postponement is a valuable way togive patients new metacognitive experiences and tochallenge their beliefs about the uncontrollability of worry.The goal inMCT is to reduce uncontrollability beliefs to 0%or as close to this as possible.Williamperceived his worries asongoing and always present. He stated at the beginning oftherapy (when doing the case conceptualization) that hisworries were highly uncontrollable (75%). In order tofurther challenge William's belief about uncontrollabilitythe therapist engaged him in a meta-level Socratic dialogue:“What happens to your worries if the doorbell rings, or oneof the children urgently needs medical attention or thephone rings?” and explored if this was evidence that hecould “choose to worry” and therefore it was under hiscontrol. This line of questioning continued with asking ifthere were times he didn't worry in response to thoughts,and the therapist helped him to see that he had experiencedthis in treatment already with the worry-postponementexperiment.

Uncontrollability: The Loss of Control ExperimentFurther work was needed in order to reduce William's

belief that worries were uncontrollable, and a newbehavioral experiment called “losing control” was under-taken. In this experiment, William was asked to specifywhat losing control would mean for him. He had specificexpectations that he would not be able to go to work or takecare of the family. The therapist asked William how “losingcontrol of his worrying” could be observable in the sessionsfor both of them. William might have expected that hewould start talking gibberish. He was therefore encouragedby the therapist to try to lose control of his worry in thesession. He was asked to activate a trigger, worry about it asusual, and try his very best to lose control. William was notsuccessful in losing control, and he was quite surprised thatone of his big fears did not happen as a consequence ofletting worry run freely. His belief in worry beinguncontrollable would likely be reduced to 5%, after thisexperiment. Then the losing control experiment wasassigned as homework. The therapist and William plannedhow to run the experiment at home. The therapist wentthrough William's previous experiences, which indicatedthat he had not lost control at any point in his life. Theycollectively summed up the results of the in-sessionexperiment, and also repeated what losing control wouldlook like. William was anxious about doing the experiment,but decided that it would be a good test, and wanted to do it

the very same day in the afternoon. In the next sessions hereported that he experienced increased control, and hisanxiety was markedly reduced, which was also indicated asa decrease on the scores on the BAI and GAD-S.

WorkingWithNegativeMetacognitionsRelated toDanger

A significant proportion of GAD patients worry aboutthe danger of worrying. InWilliam's case he worried that hewould go crazy from the experience of intense anxietybrought on by worrying. By questioning the evidence of therelation between worry and becoming crazy, William wasasked how long he had been worrying and if he had lost hismind at any point during this time. He confirmed that hehad never lost his mind, and he also stated that he couldn'tthink of anyone who had lost their mind as a result toworrying. To test his belief further, a behavioral experimentwas set up in therapy. In this experiment William was askedto try to worry in the session to such an extent that he wouldlose his mind. As in the behavioral experiment describedearlier, the therapist and William specified how it would bepossible to observe that he was crazy. He might haveworried that he would lose his mind, start running around,crying uncontrollably, run out of the therapy room andfinally would be admitted to a mental hospital. Williamagreed to test if worrying could make him go crazy in thesession, and to make this even worse he had to worry outloud. His level of anxiety prior to the experiment wasrelatively high, and he might report that it felt uncomfort-able for him to test this out, but he did not go crazy.Through this experiment William could discover thatalthough worrying felt uncomfortable, it was not dangerousfor his mental health. His belief of becoming crazy fell tozero. The “going crazy” experiment was given as home-work, with much the same rationale and preparation as the“losing control” experiment. A reduction of this metacog-nition further reduced his anxiety levels.

Working With Positive Metacognitions Related to Worry

When the negative meta-beliefs were reduced to0% – 5%, the treatment turned to challenging William'spositive metacognitions. William had expectations thatworrying would help him solve problems in his life, that itwould help him cope better, and that worrying would helphim make the right decisions in how to live. These positivebeliefs were challenged using such questions as, “What isyour evidence that worrying is helpful?” “Has the worryingreduced your anxiety?” Even though William's answer tothese questions was likely no, he would be expected tostill believe that worry could be helpful in some way.Williamwas therefore challenged to take part in a worry-mismatchexperiment (Wells, 2007). The retrospective version of thisprocedure was tested first. William was asked to remember arecent situation where he hadworried about the outcomeof

310 Hjemdal et al.

the situation. He chose a recent visit to the doctor, where hehad worried quite a bit about having a serious illness beforethe visit. A detailed description of the content of the worriesinvolved in the trip to thedoctor was written downon the leftside of a sheet of paper. On the right side of the paperWilliam had to write down in detail what actually happenedat the doctor's office. There is typically a huge discrepancybetween the descriptions on the left and the right. Williamwas asked by the therapist how useful worrying seemed tohim if it is was not closely matched to reality.

In order toworkon thepositivemeta-beliefs even further,he was asked to do another test before the next session. Hewas asked to conduct a worry-modulation experiment (Wells,2009) consisting of increasinghis worry for oneday and thenminimizing it on the second day (using detached mindful-ness and worry postponement), in order to compare whichof these two days were the most pleasant and productive forhim. At first the idea of increasing his worries would likely bea bit puzzling to William. But the therapist reminded himthat worrying was what William had been doing for manyyears, and that by increasing his worry for a day, the therapistsimply meant that William was to return to his old habitof worrying about most things, and maybe increase theproportion of worry a bit compared to what he used to do.William would be expected to return to the next sessionreporting that the day he worried less was the better of thetwo. He did not find it difficult to increase worry because hehad extensive experience with worrying; however, he foundit curious to try to worry more as the therapy focuses onreducing the amount of worrying. The therapist can thenquestion if there are any advantages to worrying. Williamlikely concluded that this experience illustrated that therewere no positive consequences of worrying, and after that hewould be expected to no longer have any remaining positivebeliefs that worry had any advantages or could be usefulfor him.

Working With Avoidance Strategies and UnhelpfulCoping Strategies

William used several unhelpful strategies to cope with hisworry. Among these strategies (see description in the caseformulation) were excessive checking, reassurance, procras-tination, searching the Internet for information, arguingwith himself if the worry was "true," and trying to distracthimself from worry thoughts. One by one these unhelpfulcoping strategies were challenged and questioned intherapy. For example, when searching the Internet forinformation on health issues, did this reduce or increase hisfocus of attention on possible threats? After thinking aboutthis for a while William became certain that searching theInternet could make him more anxious, and that thisstrategy just kept the worry process going. He thereforeagreed that he would try to drop this unhelpful coping

strategy for a week, and whenever he got the urge to searchthe Internet for information, he would postpone it (similarto his postponement of worries earlier in therapy). Havingtested this out for a week, William would be expected toreturn to the session feeling calmer and with less anxietyregarding his health-related worries, and would agree todrop his checking behavior. Toward the end of thetreatment the therapist askedWilliam if seeking reassurancefrom others actually reduced his levels of anxiety in the longrun, and if it permanently reduced his anxiety levels.

Reassurance seeking is a complex social behavior that isunder volitional control. Patients may be reluctant to stopthis strategy if they continue to believe it is helpful. Byreviewing the usefulness of this strategy with the patient,and illustrating that it has not led to a long-term reductionin worry, the metacognitive therapist increases the motiva-tion to try to change this strategy and try new strategies andbehaviors. Furthermore, the therapist helps the patientto discover that it is a source of further processing andtherefore another example of extended thinking. Williamexperienced temporary reductions of his anxiety when hereceived reassurance, yet the anxiety always returned. As anexperiment he agreed to drop seeking reassurance fora week. He came back the following week, and haddiscovered that he had experienced little anxiety and feltthat he could control his worry onhis own. Based on this, hewould be expected to conclude that reassurance seekingwas a strategy that increased his anxiety, which was contraryto his initial belief, and therefore decided to drop thisstrategy in the future.

Relapse Prevention

In this last phase of treatment the therapist workedwith William to construct a “therapy blueprint,” examinedhis worries about relapse, and worked on residualnegative and positive metacognitive beliefs endorsed onthe GAD scale (GAD-S).

The blueprint consisted of a summary of William's caseformulation and strategies he had found useful in learningto relate to negative thoughts in a new way. It alsomade useof the old plan/new plan worksheet (Wells, 2009), in whichhis old response to a negative thought was summarized anda new response written in detail (see Table 1 for a morethorough description). He was asked to refer to this as asummary reminder of the new strategies he shouldimplement in the future. In addition, there was a smallresidual positive belief that it was necessary to plan ahead inorder to avoid worrying. The therapist identified this andused a Socratic approach to helpWilliam reinforce the ideathat he had alternative and more direct means of reducingworry that did not require overthinking. A booster sessioncan be planned 3 months after the last treatment sessionin order to check on the client's progress.

Table 1Therapy Blueprint for William

My triggers:

• What if I will get a serious illness?• What if something happens to my family?• What if I do something wrong?

Old plan: New plan:

Thinking style:

• If I have a negative thought, thenworry about it to find out whatcould happen and how to avoid it

• If I have a negative thought, cover allthe negative possibilities so I amprepared for the catastrophe

Thinking style:

• If I have a negative thought, just leave italone and wait to see what happens

• If I have a negative thought, just letit fade away

Behavior:

• When I am worried search forevidence that is supporting orcounteracting my worrying

• When I am worried, askothers to reassure me

Behavior:

• If I am worried, don't search for evidence,just stop the thought process(but do not suppress the thought)

• If I am worrying, then ban asking forreassurance and just let the worry ebb away

Attention focus:

• Look for danger, soI am prepared

• Focus on my thoughts andbody to find out what is going on

Attention focus:

• Ban threat monitoring, it just makes me worry• Focus on the world outside me and

continue what I'm doing to findout what I can achieve

Reframe:

• My trigger thoughts are best left alone. If so, they will just fade away.• I control my worries, they do not control me.• Do more novel things, break my old routine without thinking so much.

311MCT for GAD

Outcome Studies of MCT in GAD

Different treatment trials have reported promisingresults for MCT. The first was an open trial in which Wellsand King (2006) reported an 87.5% recovery rate atposttreatment, as well as a 75% rate at 6 and 12 monthsfollow-up using formal criteria on the STAI. In arandomized trial the effects ofMCTwere compared againstthe effects of applied relaxation. In this study there was an80% standardized recovery rate for MCT on a measure ofpathological worry (PSWQ) compared to 10% for appliedrelaxation at posttreatment (Wells et al., 2010). The gains inMCT were maintained at 12-month follow-up. However, alimitation of these earlier studies is their small sample size.

A recent large independent randomized controlledtherapy trial found that both MCT and a variant of intol-erance of uncertainty therapy (IU) were effective (van derHeiden et al., 2012). The within-group posttreatment effectsizes forMCTwere 2.39 (PSWQ) and 2.01 (STAI) compared

with 1.43 (PSWQ) and 1.42 (STAI) in IU treatment. At6-month follow-up the effects were 2.38 (PSWQ) and 2.0(STAI) followingMCT compared with 1.6 (PSWQ) and 1.56(STAI) in the IU condition. The authors reported a supe-riority ofMCT over IU treatment on several of themeasures.

Fisher (2006) has computed recovery rates measuredby PSWQ scores across different treatment trials for GAD atposttreatment and 1-year follow-up. In this analysis the ratesfor MCT were 80%, and 70% respectively, compared with46%, and 53% respectively for CBT, 48% and 64% for IUand 37% and 38% for applied relaxation. The results appearto show that MCT is an effective treatment. Consistent withthese data MCT and IU are treatments now recommendedin the updated NICE guidelines for (NHS Evidence, 2012).

Conclusions

In this paper we have described Wells's metacognitivemodel and treatment of GAD, illustrated in the case of

312 Hjemdal et al.

William (Robichaud, 2013-this issue). The model is basedon the principle that worry is not effectively regulated inGAD, because of the effects of metacognition on mentalcontrol and extended thinking. In particular, metacogni-tive beliefs have a crucial role that intensifies the aversiveexperience of worry and its threat value. GAD patients useparadoxical or incompatible metacognitive control strat-egies that reduce their exposure to experiences ofself-control and/or contribute to instances of impairedcontrol. The patient does not have a deficit or absence ofcontrol; rather, beliefs about control are unhelpful andstrategies used to cope with worries and negative thoughtsare counterproductive. It should be noted that MCT is notsimply a matter of gaining “better” control, because themodel emphasizes the importance of using experiences intherapy to challenge beliefs about the uncontrollability ofworry and beliefs that worry is dangerous. The metacog-nitive therapist is cautious not to convey the idea thatworry must be controlled; instead, the aim is to show thatthoughts are insignificant for further processing, andthe individual has a choice about how to respond to histhinking.

This approach contrasts with other approaches thatfocus on reality testing the content of worry, involveproblem solving of concerns, or distinguish between typesof worry that should be analyzed and responded to or not.In each of these other approaches the therapist may insome cases be seen to be dealing with the problem ofexcessive thinking with more thinking. MCT suggestsinstead that treatment should focus on reacting tonegative ideas by reducing the reliance on worrying andthinking and by ultimately doing little or nothing inresponse to negative thoughts. This contrasts withmeditation or relaxation strategies, which countenanceresponding to thoughts with changes in attention,breathing exercises, and with CBT, which focuses onworry exposure or challenging schemas concerninguncertainty.

References

Beck, A. T., & Steer, R. A. (1993a). Beck Anxiety Inventory manual.San Antonio, TX: Psychological Corporation.

Beck, A. T., & Steer, R. A. (1993b). Manual for the Beck DepressionInventory. San Antonio, TX: Psychological Corporation.

Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983).Preliminary exploration of worry: Some characteristics andprocesses. Behaviour Research and Therapy, 21, 9–16.

Butler, G., Wells, A., & Dewick, H. (1995). Differential effects of worryand imagery after exposure to a stressful stimulus: A pilot study.Behavioural and Cognitive Psychotherapy, 23, 45–56.

Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry andintrusions: The Meta-Cognitions Questionnaire and its correlates.Journal of Anxiety Disorders, 11, 279–296.

Davey, G. C. L., Tallis, F., & Capuzzo, N. (1996). Beliefs about theconsequences of worrying.Cognitive Therapy andResearch, 20, 499–520.

Davis, R. N., & Valentiner, D. P. (2000). Does meta-cognitive theoryenhance our understanding of pathological worry and anxiety?Personality and Individual Differences, 29, 513–526.

Fisher, P. L. (2006). The efficacy of psychological treatments forgeneralized anxiety disorder? In G. C. L. Davey & A. Wells (Eds.),Worry and its psychological disorders: Theory, assessment and treatment(pp. 359–378) Chichester: Wiley.

Flavell, J. H. (1979). Metacognition and cognitive monitoring: A newarea of cognitive-developmental inquiry. American Psychologist,34(10), 906–911.

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990).Development and validation of the Penn State worry question-naire. Behaviour Research and Therapy, 28, 487–495.

Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D.,Gregory, A. M., & Poulton, R. (2007). Depression and generalizedanxiety disorder: Cumulative and sequential comorbidity in a birthcohort followed prospectively to age 32 years. Archives of GeneralPsychiatry, 64(6), 651–660.

Nassif, Y. (1999). Predictors of pathological worry. Unpublished M.Phil.thesis. University of Manchester, UK.

Nuevo, R., Montorio, I., & Borkovec, T. D. (2004). A test of the roleof metaworry in the prediction of worry severity in an elderlysample. Journal of Behavior Therapy and Experimental Psychiatry,35(3), 209–218.

Robichaud, M. (2013). Cognitive Behavior Therapy Targeting Intol-erance of Uncertainty: Application to a Clinical Case ofGeneralized Anxiety Disorder.Cognitive and Behavioral Practice,20, 251–263 (in this issue).

Ruscio, A. M., & Borkovec, T. D. (2004). Experience and appraisalof worry among high worriers with and without generalizedanxiety disorder. Behaviour Research and Therapy, 42,1469–1482.

van der Heiden, C., Muris, P., & van der Molen, H. T. (2012).Randomized controlled trial on the effectiveness of metacogni-tive therapy and intolerance-of-uncertainty therapy for general-ized anxiety disorder. Behaviour Research and Therapy, 50(2),100–109.

Wells, A. (1995). Metacognition and worry: A cognitive model ofgeneralized anxiety disorder. Behavioural and Cognitive Psychotherapy,23, 301–320.

Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manualand conceptual guide. Chichester, UK: Wiley.

Wells, A. (2000). Emotional disorders and metacognition: Innovativecognitive therapy. Chichester, UK: Wiley.

Wells, A. (2005a). The Metacognitive Model of GAD: Assessment ofmeta-worry and relationship with DSM-IV Generalized AnxietyDisorder. Cognitive Therapy and Research, 29, 107–121.

Wells, A. (2005b). Detached mindfulness in cognitive therapy: Ametacognitive analysis and ten techniques. Journal of RationalEmotive & Cognitive Behavior Therapy, 23(4), 337–355.

Wells, A. (2006). The metacognitive model of worry and generalizedanxiety disorder. In G. C. L. Dawey & A. Wells (Eds.),Worry and itspsychological disorders. Theory, assessment and treatment (pp. 179–199).Chichester, UK: Wiley.

Wells, A. (2009).Metacognitive therapy for anxiety and depression. New York:Guilford Press.

Wells, A., & Carter, C. (1999). Preliminary tests of a cognitive model ofGeneralized Anxiety Disorder. Behaviour Research and Therapy, 37,585–594.

Wells, A., & Carter, K. (2001). Further tests of a cognitive model ofGeneralized Anxiety Disorder: Metacognitions and worry in GAD,panic disorder, social phobia, depression, and non-patients.Behavior Therapy, 32, 85–102.

Wells, A., & Cartwright-Hatton, S. (2004). A short form of themetacognitions questionnaire: Properties of the MCQ-30. BehaviourResearch and Therapy, 42(4), 385–396.

Wells, A., & Davies, M. (1994). The Thought Control Question-naire: A measure of individual differences in the control ofunwanted thought. Behaviour Research and Therapy, 32,871–878.

Wells, A., & King, P. (2006). Metacognitive therapy for GeneralizedAnxiety Disorder: An open trial. Journal of Behavior Therapy andExperimental Psychiatry, 37, 206–212.

Wells, A., & Matthews, G. (1994). Attention and emotion: A clinicalperspective. Hove, UK: Erlbaum.

313MCT for GAD

Wells, A., & Matthews, G. (1996). Modelling cognition in emotionaldisorder: The S-REF model. Behaviour Research and Therapy, 32,867–870.

Wells, A., & Papageorgiou, C. (1995). Worry and the incubation ofintrusive images following stress. Behaviour Research and Therapy,33, 579–583.

Wells, A., & Papageorgiou, C. (1998). Relationship between worry,obsessive-compulsive symptoms and meta-cognitive beliefs. BehaviourResearch and Therapy, 36(9), 899–913.

Wells, A., Welford, M., King, P., Papageorgiou, C., Wisely, J., & Mendel,E. (2010). A pilot randomized trial of metacognitive therapy vs.applied relaxation in the treatment of adults with generalizedanxiety disorder. Behaviour Research and Therapy, 48, 429–434.

York, D., Borkovec, T. D., Vasey, M., & Stern, R. (1987). Effects of worryand somatic anxiety on thoughts, emotion and physiologicalactivity. Behaviour Research and Therapy, 25(6), 524–526.

Address correspondence to Odin Hjemdal, Department of Psychology,Norwegian University of Science and Technology, N-7491 Trondheim,Norway; e-mail: odin.hjemdal@svt.ntnu.no.

Received: February 19, 2012Accepted: January 6, 2013Available online 19 February 2013