Metacognitive Therapy for Anxiety and Depression Adrian Wells
Contents
Chapter 1 Theory and Nature of Metacognitive Therapy
Chapter 3 Foundation Metacognitive therapy skills
Chapter 4 Attention training techniques
Chapter 5 Detached Mindfulness technique
Chapter 1 Theory and Nature of Metacognitive Therapy
Its not that we have unpleasant\unhelpful thoughts but its how we react to them
“I’m a failure” do I ruminate, ignore it, go and read a book on self improvement? Then what’s the effect of my reaction
Then you might ask what the purpose and effects of your strategy might be
MC on both the specific thought, and the thinking process: I have a great memory, powerful thoughts, I can’t ignore them. I must think through them to find an answer.
MC experiences: I’m going to lose control because of my worrisome thoughts, because I already experience my thoughts as a losing of control
MC Strategies. On the basis of an MC then a strategy may emerge, e.g. suppress thoughts, focus on negative events and worry about them.
Object mode of thought as thought fusion where thought isn’t distinguished from direct experience of self or world. So as I think, I’m experiencing my self or the world as it is, I see through the filter of my thought which colours the world\self and I accept it as it is, rather than seeing a thought as a representation (good\bad\right\wrong) of the world
MC mode thought as a representation of world\self
With MCT you don’t challenge the initial thought but rather you aim to experience a shift in MC mode, which is a skill which takes practice.
Detached mindfulness: detachment from acting on the thought, and to distinguish self from thought, i.e. disidentification.
DM=
Meta-awareness (i.e., consciousness of thoughts).
Cognitive decentring (i.e., comprehension of thoughts as events separate from facts).
Attentional detachment and control (i.e., attention remains flexible and not anchored to any one thing).
Low conceptual processing (i.e., low levels of meaning-based analysis or inner dialogue).
Low goal-directed coping (i.e., behaviours and goals to avoid or remove erroneous threat are not implemented).
Altered self-awareness (i.e. experience of a singularity in consciousness of self as an observer separate from thoughts and beliefs).
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
Two types of CAS. Cognitive attentional syndrome
Negative: I can’t control my thoughts, I could go crazy, not cope because of my thoughts
Positive: I need to worry so I don’t miss anything
Perseverative thought
What if? (possible threats)
Why do\does (meaning of events)
As much as this is the thinking style, it can move the attentional system onto threat.
Worrying can block emotional processing: engagement of PFC, connecting emotional situation to other situations historic and futural which dissipate the energy, as with memory processing.
Worrying focuses on potential danger (to keep self safe) but is not related to the probability of things happening. It perpetuates fear, uncertainty, and self doubt (to keep self safe), maintains a sense of threat.
Rumination seeks answers to question that do not have a single or identifiable answer such as why me. It perpetuates uncertainty, self doubt, maintains a sense of threat.
Worry and rumination take up energy that can be used in engaging with valued activities that booster sense of self worth, efficacy and valued activities. Worry and rumination pay attention and you get to experience bad things so this then starts to define your world. Again the more you think of it, the more intrusive thoughts you might get.
Thought control strategies prevent exposure and habituation to unpleasant thoughts, plus you get the enhancement and rebound affect. Failure of thought control can be interpreted as loss of control.
Ruminating as attempting to feel so bad I snap out of it.
Worrying as worrying to get to a feeling I can worry so much I can cope with anything (?)
Avoidance and substance to manage emotions reduces an individuals belief in their ability to cope.
CAS is controlled by erroneous beliefs about thinking positive and negative, which on the surface seem reasonable but come with other clauses that make them unhelpful.
So the thought is reasonable is some possibly exceptional situations, the problem comes in its scope, its application to a wide range of situations.
If I worry I will be prepared ( I need to be prepared for everything)
Meta beliefs about thoughts
Thoughts and Action = show my desire, mean I will do things
Thoughts are uncontrollable
Thoughts and Effects=can make bad things happen(me lose control, harm my body)
ABC of antecedent, belief, consequence=standard CBT model
MCT A=>(MรณB)=>C
A is a trigger of a standard thought
CAS as the network of thoughts, behaviour, attentional style that relate\enable metacognitive beliefs. I must work out why I had the problem to make sure I don’t have it again. So CAS would be focus on the problem. Ruminate. Don’t do other things.
MCT as process focussed. Trigger, beliefs, process and outcome
CAS as a pattern of thinking that causes psychological disorder.
Aim to experience thoughts in a detached way so that some choice can be given tot hem and how to respond to them.
cognitive attentional syndrome =CAS
Chapter 2 Assessment
AMC= Internal antecedent=> Meta beliefs and CAS=>Emotional consequences
Start on the emotions consequences
Emotional Consequences (C) “Thinking back over the past 2 weeks, what has your mood/anxiety been like?” “What physical symptoms have you noticed?” “What changes have you noticed in your behaviour?” “Have you had any thoughts of harming yourself?” (Consider risk assessment and deterrents if warranted.)
Activating Inner Event (A) 5. “Has anything or any situation made you feel worse?” 6. “What was the initial thought or feeling you had at the time?” 7. “Thinking back to the last time you felt more anxious/depressed, what happened to trigger it? Can you identify an initial thought or feeling that you had?” 8. “Has there been a time when you were more wrapped up in thinking about your problem? What was the thought that started that the last time it happened?”
The CAS and Metacognitions (M) 9. “When you had that experience, what happened to your thinking?” 10. “Did you worry or dwell on things? How long did that last?” 11. “Did you pay more attention to what was troubling you? What was that like?” 12. “Did you do anything to control the way you felt? What did you do?” 13. “Did you do anything to change your thoughts? What did you do?” 14. “Did you try not to think certain things or avoid anything?” 15. “Are there any advantages to worrying or ruminating? What are they?” 16. “Are there any advantages to focusing on thoughts/feelings? What are they?” 17. “How does focusing your attention on threat help?” 18. “What would happen if you didn’t control your thoughts/emotions?” 19. “What’s the worst that could happen if you continue to feel [or think] like this?” 20. “How much control do you have over your worries or depressive thoughts?”
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
Chapter 3 Foundation Metacognitive therapy skills
4 skills
1. Distinguish different levels of cognition, primary or meta
2. Identify maladaptive cognitive processes in the CAS
3. Use meta cognitive Socratic dialogue
4. Implement metacognitive exposure
The CAS=worry, rumination, threat monitoring and counterproductive coping behaviour. Counter productive coping behaviour=thought suppression, avoidance, emotional control
Does the clients attention get stuck on an particular thing which can be the basis for threat monitoring. (what’s the difference between threat monitoring and worry\rumination\brooding). Threat monitoring checking body for lumps, checking room for contamination.
With worry\rumination the first 3 thoughts might be useful, the 300,000 after that not.
CAS is a set of psychological processes that includes repetitive negative thinking (worry and rumination), threat monitoring, and associated unhelpful behavioural and cognitive strategies; it is derived from metacognitive beliefs, either positive (e.g., “If I ruminate I will understand my situation”) or negative (e.g., “I cannot control my ruminative thoughts”). While moments of negative self-appraisal are relatively brief in most people, the prolonged occurrence of negative emotions and negative self-appraisal in some people is due to recurring activation of CAS
When does the preservative thinking start and when does it stop, trigger and brake
What keeps the thinking going (I have to solve this problem, if I don’t think about it I wont be safe)
Threat monitoring: checking how I feel (unpleasant emotions\thoughts is the threat)
There will be metacognitions (positive and negative) about
1. Threat monitoring
2. Rumination
3. Worrying
4. Brooding
The goal of exposure in MCT varies: it is used both to modify beliefs and to strengthen alternative and more adaptive processing. Three types of metacognitively delivered exposure are used to (1) facilitate belief change in general, (2) specifically challenge metacognitive beliefs, and (3) promote adaptive processing of trauma.
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
CBT ERP reality tests the content of beliefs or aims to habituate to anxiety. MCT aims to reality test MC.
When you prepare ERP for mct, then you look at both the belief to be challenged and the coping behaviour that prevents its disconfirmation
Chapter 4 Attention training techniques
Inflexibility of attention due to repeated focus on threat, self, and perseverative cognitive process. ATT is not a mechanism to avoid painful stimuli by focusing on positive\neutral stimuli. Rather they are there to strengthen MCs that regulate thinking.
So strength my attentional shifting challenges a belief of I can’t stop thinking and gives me the ability to stop thinking.
ATT uses sound, directs attention at non self focused events and is not a way to move attention of unpleasant symptoms.
ATT has three components
1. Selective attention
2. Rapid attention switching
3. Dividing attention
Takes 12 mins, with 5 mins for 1 and 2 and 2 mins for 3.
The spatial geography is used, notice sounds on the right side, close to, far away and on the left side. Focus on one visual point whilst you are doing this
ATT is practiced when not in a state of anxiety. It is not aimed at changing mood rather increasing skills and challenging beliefs.
Dimensions of attention: Selectivity, switching, parallel processing and capacity requirements.
The aim of ATT is to interrupt preservative self focussed processing, it is not an avoidance or symptom management strategy.
ATT consists of 3 components
1. Selective attention 5 min
2. Rapid attention 5 min
3. Divided attention 2min
Selective attention
Guide attention to sound in near field, far, left and right. Pay intense attention but if distracted, just return.
Rapid attention switching.
Shift focus between sounds with increasing speed, ending up with a switch every 5 seconds.
Divided attention
Pay attention to multiple sounds in multiple locations.
Use 6-9 sounds with spatial locations, some may be potential sounds, so you are listening to a location.
Use three sounds in the consulting room, two sounds outside near distance, 2 more sounds in the far distance. Near distance as outside the room, within the building, far is outside the building.
Rationale for the ATT
The aim here is not to get a blank slate, intrusions are treated as additional noise. Be aware of the intrusion but direct your attention where you want.
ATT as increasing your awareness of your focus of attention and to strengthen your control over it.
Basic instructions for the ATT
“I would like you to focus your gaze on a dot that I have placed on the wall. Throughout the exercise try to keep your eyes fixed on the dot. I’m going to ask you to focus your attention on different sounds inside this room and outside of this room. I will ask you to focus your attention in different ways. It doesn’t matter if thoughts and feelings come into your mind. The aim is to practice focusing your attention no matter what you might become aware of. “To begin with, focus on the sound of my voice (S1). Pay close attention to that sound. No other sound matters. Try to give all of your attention to the sound of my voice. Ignore all of the other sounds around you. You may hear them but try to give all of your attention to the sound of my voice. Focus only on the sound of my voice. No other sound matters. Focus on this one sound. “Now turn your attention to the sound I am making as I tap on the desk (S2). Pay close attention to that sound, for no other sound matters (pause). Try to give all of your attention to the tapping sound (pause). Closely monitor the tapping sound (pause). If your attention begins to stray or is captured by another sound, refocus on the tapping sound (pause). No other sound matters. Give this one sound all of your attention (pause). Continue to monitor this sound and if you are distracted return your attention to it (pause). “Now focus on the sound of (S3; e.g., the ticking of a wind-up timer) (pause). Pay close attention to that sound, for no other sound matters (pause). Try to give all of your attention to the sound of the timer (pause). Closely monitor the sound the timer makes (pause). If your attention begins to stray or is captured by another sound, refocus on the timer (pause). No other sound matters. Give this one sound all of your attention (pause). Continue to monitor this sound and if you are distracted return your attention to this sound as soon as you can (pause). “Now focus your attention on sounds that you might hear outside of this room, but nearby. Focus on the space outside and behind you (S4). Pay close attention to that space and try to detect sounds that might occur there [if there are specific sounds, the therapist draws attention to them]. Even if there are no sounds keep your attention on that space. Try to give all of your attention to it (pause). Closely monitor for sounds there (pause). If your attention begins to stray or is captured by a sound elsewhere, refocus on that place. No other sound matters. Give all of your attention to that place and what you might hear there. Continue to monitor and if you are distracted return your attention to it (pause).” The instructions in the above paragraph are repeated for additional sounds (S5-7) and/or spaces (e.g., on the left, on the right, and in the far distance). “Now that you have identified and practiced focusing on individual sounds and locations I am going to ask you to quickly shift your attention between them as I call them out (pause). First, focus on the tapping sound (S2), no other sound matters (pause). Switch your attention and focus on what you might hear behind you in the near distance (S4) (pause). Pay close attention to (S4), no other sound matters. Now turn your attention to (S7), no other sound matters (pause). Turn your attention again this time to the sound of the timer (S3) (pause). Now switch and focus on the tapping sound (S2) (pause). Now focus on (S6) (pause), now on the sound of (S5) (pause), (S4) … (S2) … (S3) …, etc. “Finally, I want you to expand your attention. Make it as broad and deep as possible. Try to absorb all of the sounds and all of the locations that you have identified at the same time. Try to focus on and be aware of all of the sounds both inside and outside of this room at the same time (pause). Covertly count the number of sounds that you can hear at the same time (pause). Try to hear everything simultaneously. Count the number of sounds you can hear this way. “This concludes the exercise. How many sounds were you able to hear at the same time?”
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
ATT needs to be practiced once-twice a day for 12 minutes.
ATT is mental fitness, it is not a way to cope with unpleasant thoughts\emotions.
If they come up, be aware of them, and pay attention to what’s important to you after that.
Situational attentional refocusing.
So change attention to something which will reduce negative beliefs. So SA everyone is looking at me, so pay attention to other peoples hair and eyes.
Scanning for danger, then pay attention to safety.
ATT is designed to increase executive co ntrol and to interrupt perseverative self-focused processing,
SAR is intended to increase access to disconfirmatory information and to correct attentional strategies that are counterproductive in situations (i.e., it modifies threat-monitoring aspects of the CAS).
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
Chapter 5 Detached Mindfulness technique
DM techniques are focused more on developing meta-awareness in the context of suspending conceptual processing and separating self from cognitive events.
a state of awareness of internal events, without responding to them with sustained evaluation, attempts to control or suppress them, or respond to them behaviourally. It is exemplified by strategies such as deciding not to worry in response to an intrusive thought, but instead allowing the thought to occupy its own mental space without further action or interpretation in the knowledge that it is merely an event in the mind. (Wells, 2005b, p. 340)
Mindful: being aware not locked in on any one thing, and detached no reactive engagement, acting, judging, suppress
DM: There is an observing self and then there is the internal event.
Aim with DM to move from object mode in which thoughts are fused with facts to the metacognitive mode in which thoughts are events in the mind.
Wells, Adrian. Metacognitive Therapy for Anxiety and Depression . Guilford Publications. Kindle Edition.
Mindful is controlled processing, mindless is automatic processing.
DM differs from mindfulness in that DM has the aspect of separation of self from internal event.
Mindfulness means paying attention without thinking, so attention to sensation. It aims to anchor attention then to be mindful.
DM doesn’t have body focussed anchors
DM separates meta-awareness from detachment.
DM suspends conceptual and goal directed processing\coping
Ten techniques
Metacognitive guidance
So put in exposure situation and ask these questions:
“Can you look through your thoughts at the outside world?” “Can you see your thought and what is going on around you in the situation at the same time?” “Are you living by your thoughts or by what your eyes reveal?”
Aim is to separate the thought and the world
Free association task
Sit quietly and watch the ebb and flow of thoughts and memories that are triggered by verbal stimuli
Therapist says random words
You allow your mind to wander freely in response to each word. Don’t control or analyse just watch how your mind responds. Nothing much may happen or something. The aim here is to just watch what your mind does in response to these words.
Tiger task
participants are asked to passively observe nonvolitional aspects of imagery as a means of experiencing DM.
Close your eyes, form a picture of a tiger, the tiger can move but don’t make it move, watch what happens. See how the tiger is a thought in your mind. Notice how the thought has a behaviour of its own
Hmm
DM shows that thoughts are not the world, that we are not our thoughts, and that thoughts can have a will of their own.
Suppression-counter suppression experiment
Try to suppress a target thought and contrast with a period of thought awareness
Pink elephant.
Trying to suppress it, leaves you in contact with it.
So try to suppress it what happens, then allow your mind to wander freely and just watch what happens and if a pink elephant comes up , so notice that.
How important was the pink elephant between the two exercises.
Suppression increase importance
Can you push against a door and not be in contact with it
Clouds metaphor
Think of thoughts and feelings like clouds in the earths self regulating system, and let them occupy their own space, knowing they will move of their own accord
Recalcitrant child metaphor
Shows active engagement vs detached mindfulness
Child misbehaving in a store, try to control it but it craves attention and may get worse
Thoughts like children if you try and control them they can misbehave even more.
Passenger train metaphor
As a passenger waiting for a train, imagine your thoughts as trains passing through, no point in joining the train and whisked away to wrong place.
Verbal loop
Listening to a verbal representation of your thoughts, can change your relationship to them, it can diminish their meaning and salience as they are experienced as sounds, rather than as inner conveyors of information. Record your intrusive thoughts
Detachment: the observing self
Whilst any of the above tasks are being performed ask are you the thought, or the person observing the thought, try to be aware of the location of the observer and the thought.
Daydreaming technique
When we daydream we become our daydreams, we identify for them, as opposed to being a detached observer.
So have a day dream, imagine being on holiday but then step back and be the observer of the day dream as it unfolds (how??)
Distressing thoughts
Are you the thought, or the observer of the thought?
Does the thought pass, do you as observer remain
Can you see yourself as separate from the idea
