CBT Distinctive Features PDF

Metacognitive
Therapy
Metacognitive therapy is based on the principle that worry and

rumination are universal processes leading to emotional disorder.
These processes are linked to erroneous beliefs about thinking and
unhelpful self-regulation strategies.
Metacognitive Therapy: Distinctive Features is an introduction to
the theoretical foundations and therapeutic principles of metacognitive
therapy. Divided into two parts, Theory and Practice, and using 30 key
points, the authors explore how metacognitive therapy can allow
people to escape from repetitive thinking patterns that often lead to
prolonged psychological distress.
This book is a valuable resource for both students and practitioners
wishing to develop a basic understanding of metacognitive therapy and
how it compares and contrasts with traditional forms of cognitive-
behavioural therapy.
Peter Fisher is a Lecturer in Clinical Psychology at the University of
Liverpool and a Clinical Psychologist with Manchester Mental Health
and Social Care Trust.
Adrian Wells is Professor of Clinical and Experimental Psychopathol-
ogy at the University of Manchester and Professor II in Clinical
Psychology at Norwegian University, Trondheim.
Cognitive-behavioural therapy (CBT) occupies a central
position in the move towards evidence-based practice and is
frequently used in the clinical environment. Yet there is no one
universal approach to CBT and clinicians speak of ®rst-,
second-, and even third-wave approaches.
This series provides straightforward, accessible guides to a

number of CBT methods, clarifying the distinctive features of
each approach. The series editor, Windy Dryden, successfully
brings together experts from each discipline to summarize the
30 main aspects of their approach, divided into theoretical and
practical features.
The CBT Distinctive Features Series will be essential reading for

psychotherapists, counsellors, and psychologists of all orienta-
tions who want to learn more about the range of new and
developing cognitive-behavioural approaches.
Titles in the series:

Acceptance and Commitment Therapy by Frank Bond and Paul
Flaxman
Beck's Cognitive Therapy by Frank Wills
Behavioral Activation Therapy by Jonathan Kanter, Andrew
Busch and Laura Rusch
Constructivist Psychotherapy by Robert A. Neimeyer
Dialectical Behaviour Therapy by Michaela Swales and Heidi
Heard
Metacognitive Therapy by Peter Fisher and Adrian Wells
Mindfulness-Based Cognitive Therapy by Rebecca Crane
Rational Emotive Behaviour Therapy by Windy Dryden
Schema Therapy by Jeffrey Young and Eshkol Rafaeli
For further information about this series please visit

www.routledgementalhealth.com/cbt-distinctive-features
Metacognitive
Therapy
Distinctive Features
Peter Fisher and Adrian Wells

First published 2009 by Routledge
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Simultaneously published in the USA and Canada

by Routledge
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Routledge is an imprint of the Taylor & Francis Group,

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Ø 2009 Peter Fisher and Adrian Wells
All rights reserved. No part of this book may be reprinted or

reproduced or utilised in any form or by any electronic, mechanical,
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sustainable forests.
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

Fisher, Peter, 1968-
Metacognitive therapy : distinctive features / Peter Fisher and
Adrian Wells.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-415-43498-0 (hbk.) ± ISBN 978-0-415-43499-7 (pbk.) 1.
Metacognitive therapy. I. Wells, Adrian. II. Title.
[DNLM: 1. Cognitive Therapy±methods. 2. Mental Disorders±
therapy. WM 425.5.C6 F535m 2009]
RC489.M46F57 2009
616.89©1425±dc22
2008037541
ISBN 0-203-88147-8 Master e-book ISBN
ISBN: 978-0-415-43498-0 (hbk)

ISBN: 978-0-415-43499-7 (pbk)
Contents
Introduction vii
Part 1 THE DISTINCTIVE THEORETICAL FEATURES

OF MCT 1
1 A focus on metacognition 3
2 An information processing model of
psychological disorder 7
3 The cognitive attentional syndrome (CAS) 11
4 Metacognitive beliefs 15
5 Object and metacognitive modes 21
6 Reformulated ABC analysis 23
7 Detached mindfulness 27
8 Executive control and attentional
¯exibility 31
9 Levels of control 33
10 Types of knowledge 37
11 Processes and strategies beyond cognitive
content 39
12 View of self-awareness 41
13 Varieties of change 43
CONTENTS
14 Disorder-speci®c models 45
15 A universal treatment? 55
Part 2 THE DISTINCTIVE PRACTICAL FEATURES

OF MCT 57
16 Conducting therapy at the metacognitive level 59
17 Assessment of metacognition 67
18 Case formulation in MCT 73
19 Meta-level socialization procedures 79
20 Shifting to a metacognitive mode of processing 83
21 Modifying negative metacognitive beliefs 85
22 Modifying positive metacognitive beliefs 89
23 Worry/rumination postponement 93
24 Attention training technique 97
25 Implementing detached mindfulness 101
26 Situational attentional refocusing 107
27 Targeting meta-emotions 109
28 Delivering metacognitively focused exposure 111
29 Developing new plans for processing 115
30 Integrating MCT techniques: a case study 119
Conclusion 127
References 129
Index 135
vi
Introduction
Metacognitive therapy (MCT) originated with Adrian Wells

after he identi®ed a common set of processes in patients suffer-
ing from psychological disorder. The approach developed from
attempts to explain laboratory ®ndings on biases in attention,
and reconcile these with clinical observations of patients who
described particular styles of processing as a means of coping.
These processes were excessive self-focused attention, atten-
tional bias, worry and rumination.
In the late 1980s and early 1990s, the prevailing view was
that attentional bias and worry were automatic processes. It
was also the case that mood and anxiety disorders were linked
to the content of negative thoughts rather than to speci®c styles
of thinking. In contrast to this explanation, attentional bias and
worry were viewed by Wells and colleagues (e.g. Wells &
Matthews, 1994) as linked primarily to the person's conscious
strategies for appraising and dealing with threat. Furthermore,
the content of thoughts was seen as less important than the
style and control of thinking in causing psychological disorder.
Content does matter in MCT but this is the content of meta-
cognition rather than the content of ordinary cognition.
vii
INTRODUCTION
The integration of laboratory ®ndings with clinical observa-

tion culminated in an information processing model of psycho-
logical disorder, the Self-Regulatory Executive Function model
(S-REF; Wells & Matthews, 1994). The S-REF is the generic
basis of disorder-speci®c metacognitive models and the founda-
tion for MCT.
This book describes the key distinctive theoretical and
practical features of MCT and contrasts this approach with
cognitive-behavioural therapy. Although both approaches deal
with cognition, they provide different accounts of how cogni-
tion maintains disorder and they focus on different aspects
of thinking. Speci®cally, MCT asserts that it isn't what people
think that counts, but how.
viii
Part 1
THE DISTINCTIVE
THEORETICAL
FEATURES OF MCT
THEORETICAL FEATURES OF MCT
1
A focus on metacognition
Metacognition is a term used to refer to a speci®c category of

thinking and cognition. It is essentially cognition applied to
cognition. Thinking requires metacognitive factors that monitor
and control it. For instance, the process of memorizing a new
telephone number depends on knowledge of strategies that can
be used to modify memory (e.g. rote rehearsal). It requires the
initiation and regulation of the rehearsal strategy, and depends
on monitoring when it is time to stop rehearsal. In addition, it
requires the subsequent accessing of information that drives
retrieval of the number as and when required. In this small
example of cognition, the act of memorizing requires multiple
aspects of metacognition to make it possible. Beyond this
example, metacognition is involved in the cessation, perpetua-
tion and modi®cation of thinking, which encompasses the
dysfunctional thinking that maintains psychological disorder.
Traditional cognitive-focused treatments such as cognitive-
behaviour therapy (CBT; Beck, 1976) and rational emotive-
behaviour therapy (REBT; Ellis, 1962) emphasize the role of
cognitive bias and distorted or irrational beliefs rather than
the control of thinking. Moreover, these are beliefs outside the
metacognitive domain such as beliefs about the world, and
the social and physical self. For example, Beck (1976) describes
cognitive distortions such as arbitrary inference ( jumping to
conclusions), catastrophizing, and personalization as cognitive
distortions that are evident in negative automatic thoughts.
These are different from the thinking styles that are given central
prominence in metacognitive therapy (MCT; Wells, 2000). In
MCT, maladaptive thinking styles refer to a preponderance of
verbal conceptual activity that is dif®cult to control and occurs
3
MCT: DISTINCTIVE FEATURES
in the form of worry and rumination. These styles can be

identi®ed independently of their content, as extended forms of
brooding and dwelling and analysing information.
In contrast to standard CBT that focuses on a wide range of
beliefs about the self and world and says little about metacog-
nitions, metacognitive therapy (MCT) gives metacognitions and
metacognitive beliefs a central role in psychological disorder.
Unlike CBTs, MCT does not assume that distorted cognitions
(i.e. thoughts) and coping behaviours emanate from ordinary
beliefs, but speci®es that thought patterns are the result of
metacognition acting on thinking processes.
Until the advent of metacognitive therapy, research on
metacognition was con®ned largely to the ®eld of develop-
mental psychology and research on human memory. However,
Wells and Matthews (1994, 1996) and Wells (2000) developed a
general theory of psychopathology that explicitly placed
metacognition at centre stage. This approach has led to the
development of MCT that aims to change the way individuals
experience and control thinking, and the beliefs they hold about
cognition. MCT differs from earlier forms of CBT because it
does not focus on beliefs and thoughts about the social and
physical self, or thoughts and beliefs about others and the
environment. Instead, it deals with the way in which people
respond to these other cognitions and the mental processes that
repeatedly give rise to erroneous and unhelpful views of reality.
For example, in cognitive therapy the therapist deals with a
patient's cognition about failure by asking, ``What is the
evidence that you will fail?'' but the metacognitive therapist
asks, ``What is the use in worrying about failure?'' The aim in
MCT is to modify the thinking processes that support biased
failure-oriented processing and the nature of the person's
unhelpful reaction to cognitions of this kind.
If we assume that cognition in psychological disorder is
biased, as do all cognitive and MCT theories, then it is neces-
sary to identify the source of that bias so that it may be treated.
The nature of bias emphasized in CBT, REBT and MCT is
4
different. In the former two approaches it resides in the

schemas or irrational beliefs or in the content of negative
automatic thoughts. In contrast, in MCT the bias occurs in the
style that thinking takes and this is derived from metacognitive
knowledge stored as a library of information and plans or
programmes that direct processing.
The MCT approach proposes that psychological disorder is
linked to a speci®c style of thinking, involving recurrent,
recyclic ideation in the form of worry and rumination and
®xating attention on threat. The bias in processing is therefore
in how the person thinks rather than in what the person thinks.
The content of worry and rumination may show considerable
within-individual variation but the process itself remains a
constant variable. This process arises from and is controlled by
the person's metacognition.
In contrast to this assertion, Beck's schema theory (e.g. 1976)
attributes the control of cognition to more general beliefs,
which are thought to introduce bias, but this bias is in content
rather than in style. Earlier approaches have not attributed a
role to metacognition or differentiated between different think-
ing styles, making MCT distinct in these important respects.
5
2
An information processing model of
psychological disorder
Metacognitive therapy is grounded in an information proces-
sing model of the factors involved in the etiology and main-
tenance of psychological disorder. The model, called the Self-
Regulatory Executive Function (S-REF) model, was originally
proposed by Wells and Matthews (1994) and has been subse-
quently elaborated (Wells, 2000, 2009). As the name of the
model implies, it accounts for psychological disorders in terms
of predominantly top-down or conscious processes and self-
regulatory strategies. According to the model, the person's style
of thinking or coping with thoughts, emotions and stress
back®re, and lead to an intensi®cation and maintenance of
emotional distress. The model draws on distinctions in cogni-
tive psychology between levels of control of attention. It pro-
poses that psychological disturbance is principally linked to
biases in the selection and execution of controlled processes for
appraising and coping with thoughts, threats and emotions. An
individual's strategy for thinking and self-regulation in response
to threat and challenges can prolong emotional suffering or
lead to more transient emotional reactions. Psychological dis-
order develops when the person's style of thinking and coping
inadvertently leads to persistence and strengthening of emo-
tional responses. This occurs principally as a result of extended
thinking which prolongs emotion. A certain pattern of thinking,
called the cognitive attentional syndrome (CAS), is identi®ed as
a causal factor in extending negative thinking in psychological
disorder.
Unlike cognitive-behavioural theory, MCT theory does not
link psychological problems to automatic processing biases or
7
the content of schemas but attributes them to the individual's

conscious strategies. For example, attentional bias, like that
observed in the emotional Stroop task, is not attributed to
activation of schemas or automatic processing but is attributed
to the person's choice of strategy. In psychological disorder,
patients have a strategy of maintaining attention on sources of
threat and engaging in worry-based processing as a means
of coping. Filtering tasks such as the Stroop are thought to
be sensitive to these aspects of processing strategy (Wells &
Matthews, 1994).
The S-REF model is based on three basic levels of cognition:
a level of re¯exive and automatic processes that run with
minimal or no conscious involvement. These processes may
generate intrusions into consciousness that capture attention.
The next level is an online form of processing, which is con-
scious and capacity-limited, responsible for regulating and
implementing appraisal and action. The ®nal level is stored
knowledge in long-term memory. The immediate activities of
the online processing require access to stored knowledge in
order to run. Online processing is guided by knowledge or
beliefs that are metacognitive in nature. Among these levels,
two domains of cognition are important: the metacognitive and
cognitive domains. This overall structure or `àrchitecture'' of
cognition is different from that in traditional CBT, as it maps
onto levels of control of cognition and differentiates between
the content of thoughts and the regulation of thinking, which is
not a distinction made in traditional approaches.
In CBT, there are no levels of attention with a dynamic
interaction between them; instead, there are components of
cognition such as the distinction made between negative auto-
matic thoughts and beliefs or schemas. A schema in CBT is a
memory structure that is synonymous with ideas such as `Ì'm
worthless'' or `Ì'm losing my mind'', which are beliefs thought
to be behind psychological disorder. It is not clear how these
beliefs actually control thinking. In MCT, beliefs like these can
be viewed as outputs of processing and what matters is the style
8
of thinking and metacognition that extends and repeatedly

generates these concepts.
Traditional CBT does not make a distinction between auto-
matic or controlled processing or consider which factors might
lead to the types of appraisal or self-regulatory responses seen in
mental disorders. For instance, it assumes that disorder is linked
to negative automatic thoughts, which are rapid short-hand
negative appraisals such as `Ì'm dying'' or `Ì'm a failure''.
However, metacognitive theory views these types of appraisal as
relatively normal and transient occurrences; they are not the
source of disorder. Instead, S-REF theory asserts that it is the
way an individual responds to such thoughts that determines
whether or not psychological disorder develops. Similarly, a
belief or schema is not thought to be stored in long-term memory
but is simply considered to be another example of a thought that
is reliably triggered and which the person might subsequently
appraise as valid. So beliefs in metacognitive theory are instances
of currently activated thoughts and appraisals of their validity;
beliefs are a product of online processing. The content of
thoughts may be erroneous but the person acts as if a thought is a
direct read-out of reality because of the mode of processing in
which it occurs. Thus, in MCT it is not merely the content of
belief or thoughts that is important but the way an individual
responds to that thought and the individual's processing mode.
We will return to the concept of modes later (Point 5).
To illustrate the idea that the content of thoughts or beliefs
may not be especially important in disorder, we can consider
two individuals who have the same experience and the same
negative automatic thought or belief. Let's assume they are
students who fail an examination and this activates the thought
or belief: `Ì'm a failure.'' One student becomes depressed and
the other experiences only short-term disappointment. How can
this be when they have the same experiences and negative
automatic thought? Traditional CBT cannot answer this ques-
tion because it places all its emphasis on the content of negative
automatic thoughts and beliefs.
9
MCT offers an answer to this conundrum. It states that it

is not the thought itself but the individual's reaction to that
thought (or reaction to a belief ) that determines its emotional
and longer-term consequences for wellbeing. Some individuals
are more resilient than others, which is probably because they
are more ¯exible in their responses to negative thoughts and
emotions. They maintain ¯exible control over their responses
and do not become locked into patterns of sustained processing
of negative information that prolongs emotional distress. Such
¯exibility includes the capacity to modulate activity in low-level
processing structures such as the amygdala, as well as disrupt
and switch out of sustained or extended conceptual processing.
In the S-REF model, a particular style of sustained and
in¯exible responding to thoughts, emotion and threats is
responsible for prolonging and intensifying suffering; this style
is called the Cognitive Attentional Syndrome (CAS).
10
3
The cognitive attentional syndrome (CAS)
According to S-REF theory and MCT, a particular style of

thinking and ways of coping with negative ideas and threat are
a fundamental feature of all psychological disorders. This style,
called the CAS, consists of persistent thinking in the form of
worry and rumination, focusing attention on sources of threat,
and coping behaviours that back®re because they impair
effective self-regulation of thoughts and emotions and learning
of corrective information. If we return to the example of the
students who failed, introduced in Point 2, the one who became
depressed engaged in brooding on the reasons for being a
failure, why it had happened this time and why it had happened
in the past and what this meant about his ability. This form
of conceptual analysis is rumination and it prolongs and
intensi®es negative ideas and emotions. It focuses on analysing
why things happened and what this means; however, in the
misguided pursuit of understanding, it rarely generates useful
solutions or exerts more adaptive control over emotional pro-
cessing. The more adaptive solution is represented by the
response of the student who did not become depressed. This
individual engaged in a short period of brooding but then
decided that the best thing to do was focus on how he could
improve his performance the next time around. In effect, this
student exercised control over his rumination and activated a
different strategy in response to thoughts/beliefs about being
a failure.
Rumination is predominantly past-focused. In contrast, a
similar conceptual process that is also part of the CAS, worry,
is mainly future-oriented. A short-hand means of distinguishing
each process is that rumination seeks answers to ``why''
11
questions, whereas worry seeks answers to ``what if'' questions.

Worry is concerned with anticipating threat and generating
ways of either coping with it or avoiding it. So a person may
have a quick negative thought: ``What if I fail the interview?''
and then engage in sustained worry in response to this thought.
Worrying is a chain of thoughts in which the person contem-
plates a range of threatening events and ways to deal with them.
So a worry sequence may proceed something like this: ``What if
I fail the interview . . . I'd better be prepared . . . but what if I
haven't prepared the right thing . . . what should I prepare . . . I
know, I'll look at the job description . . . but what if they ask
about my weaknesses . . . should I tell them about leaving my
last job . . . what if they think I'm not good enough . . . what
should I tell them . . . what if I say the wrong thing . . . what if I
get too nervous . . .?''
The problem with worry as a response to negative ideas or
feelings is that it generates a range of threats and increases the
sense of danger, leading to anxiety or maintaining an existing
anxiety response. Worry and rumination may have other effects
on lower levels of processing. In particular, in the metacognitive
model of post-traumatic stress disorder (PTSD) (Wells, 2000;
Wells & Sembi, 2004a), worry and rumination are thought to
disrupt normal in-built recovery processes following trauma,
leading to a perpetuation of a sense of threat and to symptoms
of PTSD. This is partly because the individual fails to execute
the appropriate top-down control over activity in emotion-
processing networks in the brain. Instead, resources needed for
control are diverted to emotion-laden processes of worry and
rumination, which sensitize or sustain activity in emotional
networks.
In addition to worry and rumination, the CAS also consists
of an attentional strategy of threat monitoring. This refers to
®xating attention on threatening stimuli. Often in psychological
disorder these are internal events such as thoughts, bodily
sensations or emotions. For instance, the obsessional patient
monitors for occurrences of certain forbidden or dangerous
12
thoughts; the person with contamination fears monitors for

``suspicious-looking'' stains on the ¯oor; the person with health
anxiety checks his body for signs of disease; and the person with
social phobia monitors how they think they appear to others. In
each case, threat monitoring increases access to negative infor-
mation and maintains the sense of threat.
Another important aspect of the CAS is unhelpful coping
behaviours, such as avoidance of feared situations, reassurance
seeking, trying to control thoughts, using alcohol or drugs,
neutralizing behaviours and self-punishment. These strategies
back®re for a range of reasons, including the negative effect
they have on others, the fact that they prevent exposure to
information that can correct erroneous ideas, and that some of
them interrupt normal cognitive and biological processes.
The identi®cation of a speci®c style of thinking (the CAS)
sets MCT apart from other forms of CBT because it is more
concerned with processes than with content of thought. In
MCT, it is not necessary to challenge the content of a thought
such as `Ì'm a failure'' but, rather, to help the individual
develop an alternative relationship to that thought whilst
abandoning the CAS.
A further distinctive feature of MCT is the level of detail
used in differentiating between types of human cognition
contributing to disorder. It sees negative automatic thoughts as
triggers for more sustained worry or rumination and these
latter processes are the more proximal cause of disorder. This
distinction between varieties of thought is not made in CBT or
REBT approaches. Moreover, psychological disorder in MCT
is linked to sustained processing and not to the brief instances
of thoughts ± `àutomatic thoughts'' ± that can occur on the
periphery of consciousness.
Further important distinctive theoretical features of MCT
will emerge in Point 4, as we consider the underlying psycho-
logical factors that give rise to the CAS.
13
4
Metacognitive beliefs
MCT gives prominence to metacognitive beliefs in the develop-

ment and maintenance of psychological suffering. It holds that
a relatively small and speci®c range of beliefs can explain
almost all pathology. This is different from CBT and REBT, in
which there are many types of schemas or irrational beliefs.
In schema theory, a new schema is formulated whenever it is
needed to ®t the patient's presenting problem.
In MCT, positive and negative metacognitive beliefs are
important (modi®cation of these beliefs is discussed in Points 21
and 22). Other approaches do not formulate metacognitive
beliefs and do not classify the ones that are important. Positive
beliefs concern the advantages of worrying, ruminating, threat
monitoring and controlling of cognition. An example of a
positive metacognitive belief is: ``Worrying about the future
means I'll always be prepared.'' In addition to these positive
meta-beliefs, negative meta-beliefs are also given prominence.
These beliefs concern the uncontrollability of thoughts and
their importance or dangerous consequences. An example of a
negative metacognition is: ``Thinking about X will make me
lose my mind; I have no control over my worrying.''
These metacognitive beliefs give rise to the CAS because they
support persistent worry-based or ruminative thinking styles
and threat monitoring. They also give rise to unhelpful patterns
of cognitive self-regulation, such as attempts to suppress certain
thoughts, but also to failure to disengage mental processes, such
as worry or rumination, that can be controlled (e.g. `Ìf you
believe worry is uncontrollable, do you try to stop it?'').
Different metacognitive beliefs within the domains already
speci®ed are thought to be prominent in speci®c disorders. In
15
generalized anxiety disorder (GAD), the metacognitive model

(Wells, 1995) gives particular importance to negative beliefs
about the uncontrollability of worry and the danger of worry-
ing for physical and psychosocial functioning. Despite the fact
that patients have such negative metacognitive beliefs they also
hold the more normal belief that worrying is advantageous for
anticipating threat and planning coping strategies. MCT is
unique in its emphasis on negative metacognitive beliefs about
worry and the role of negative appraisal of worry as uncon-
trollable and dangerous in the pathogenesis and treatment
of GAD.
In the metacognitive model of obsessive-compulsive disorder
(OCD) (Wells, 1997, 2000), metacognitive beliefs concern the
importance, meaning and danger of having intrusive thoughts.
These beliefs are in the domains of thought±action fusion
(TAF: ``Thinking of jumping off the bridge will make me do
it''), thought±event fusion (TEF: ``Thinking that my partner
will have an accident will make it more likely to happen''), and
thought±object fusion (TOF: ``My bad thoughts can contam-
inate my best possessions and ruin them''). In addition to
fusion-related beliefs about thoughts, in this model, beliefs
about the need to react to thoughts in special ways and perform
rituals are also important. MCT is unique in identifying and
focusing speci®cally on a range of fusion-related beliefs and in
identifying beliefs about rituals.
Concepts that appear similar to metacognitive beliefs also
appear in other speci®c cognitive theories of OCD, but these
are super®cial rather than a substantive point of overlap. For
example, Salkovskis (1985) presents a cognitive model of OCD
in which individuals interpret intrusive thoughts as a sign that
they are responsible for causing or preventing harm. However,
responsibility is a very broad concept that does not speci®cally
de®ne or describe the nature of metacognitions underlying such
appraisals. Rachman (1997) introduced a re®nement of the
responsibility concept and discussed the role of cognitive
distortions in the form of Thought±Action Fusion (TAF). This
16
occurs in two forms: probability and morality TAF. Probability

refers to the idea that having a thought will increase the likeli-
hood of an event, while morality refers to the idea that having a
thought is morally equivalent to performing an unwanted act.
These concepts refer to metacognitive phenomena but view
them as distortions. In metacognitive theory of OCD, which
retains the fusion nomenclature, fusion is conceptualized as a
series of beliefs (TEF, TAF and TOF) as outlined above and no
role is given to the morality dimension. Thus, it can be seen that
there is some overlap between Rachman's concept of fusion and
the beliefs of metacognitive theory but this is minor, while there
is little or no overlap with the concept of in¯ated responsibility
in OCD theory.
The metacognitive model of PTSD (Wells, 2000; Wells &
Sembi, 2004a) is based on the idea that positive metacognitive
beliefs concern the need to engage in repeated thinking about
the trauma, worry about future traumas, focus attention on
threat and suppress intrusive thoughts (e.g. `Ì must worry
about similar events in the future in order to be prepared'').
In addition, there are negative beliefs about the meaning
and consequence of symptoms, such as intrusive thoughts and
memories (e.g. `Ìf I continue to think in this way, I'll lose my
mind''). These metacognitions give rise to persistent recyclic
processing of the trauma and increase attention to threat in a
way that maintains the individual's sense of danger and anxiety
symptoms. Thus, thinking fails to revert automatically to its
usual pre-trauma style. No other theories or models implicate
metacognitive beliefs in PTSD. Moreover, MCT focuses
on modifying the CAS and associated metacognitive beliefs,
whilst other CBT approaches focus on modifying the nature of
trauma memories.
The metacognitive model of depression (Wells, 2009; Wells
& Papageorgiou, 2004) proposes that depression results from
the activation of rumination and maladaptive coping beha-
viours in response to sadness or negative thoughts. Rumination
consists of perseverative negative thinking about the causes and
17
meaning of sadness or depression (e.g. Nolen-Hoeksema, 1991;

Nolen-Hoeksema et al., 1993). These processes are linked to
positive metacognitive beliefs about the advantages of rumi-
nation (e.g. ``Thinking about why I feel sad will help me to
recover'') and negative beliefs about the uncontrollability of
depressive thoughts and experiences (e.g. `Ì have no control
over my depressive thoughts; they are a sign of disease''). These
beliefs lead to a persistence of ruminative thinking styles and
the preference of rumination-focused responses to sadness over
and above alternative low levels of conceptual activity and
increased behaviours. There are sharp contrasts between Beck's
schema theory of depression (e.g. Beck et al., 1979) and the
MCT approach. The beliefs emphasized in schema theory are in
the domains captured by the concept of the negative cognitive
triad. They consist of negative beliefs about the self, the world
and the future. These beliefs are not a feature of the metacog-
nitive model and are seen as the content or product of rumi-
nation. Only MCT gives a fundamental role to beliefs about
rumination.
The metacognitive beliefs in other disorders such as social
phobia and panic-disorder similarly lead the individual to
activate cycles of worry or rumination and to focus attention
on threat because of the advantages that this is believed to
bestow. However, in each case there is also the belief that these
thinking processes are uncontrollable. Each of these beliefs
contributes to the persistence of the CAS and to the main-
tenance and strengthening of distress. For example, the person
with social phobia believes that it is helpful to worry about
possible mistakes or about creating a favourable impression in
the future as a means of ensuring good outcomes. But such
worry is often appraised as uncontrollable, and each of these
beliefs contributes to a persistence of the activity and to high
levels of anxiety.
It follows, from the analysis described above, that major
differences exist between the MCT approach to beliefs and CBT
theories that are based on schemas or concepts of irrational
18
beliefs. REBT identi®es a speci®c set of beliefs that are primarily

in the social domains of acceptance, relationships and personal
performance. Schema theory effectively posits an unlimited
number of beliefs that seem to best ®t the disorder presented. In
contrast, MCT implies that all disorders can be linked to a
higher level of metacognitive beliefs about thinking and that
these fall into positive and negative content categories. The
negative category is further reduced to a content of uncon-
trollability and danger, whilst the positive domain concerns
the advantages of worry, rumination and attentional threat-
monitoring strategies. These belief domains do not feature in
other cognitive-behavioural or ``new-wave'' therapies. Further-
more, MCT speci®es that metacognitive beliefs about uncon-
trollability and danger of cognition are present in most types of
psychological disorder.
So far we have described beliefs as verbal propositions but,
unlike CBT or REBT, MCT states that beliefs may not actually
be best conceptualized only in this way. They are considered to
exist as procedures or plans for processing (Wells & Matthews,
1994). Thus, a cognitive belief such as `Ì'm worthless'' may be
the output of a metacognitive plan that controls processing.
The plan or programme repeatedly generates this output in
certain situations. A metacognitive belief such as, `Ì must
worry in order to avoid problems in the future'' is a marker for
the programme that supports the process of worrying.
Therefore it is necessary to modify the plan itself in therapy
and not simply challenge the output or the marker. As a result,
MCT incorporates procedures that modify the person's style of
processing, such as the focus of attention, style of thinking, and
method of coping in problematic situations when the plan is
normally activated. In this way, new plans for controlling pro-
cessing can be developed that increase ¯exibility in responses
and can override the old thinking pattern.
Experiential exercises involving manipulations of attention
and awareness, and changing the relationship individuals have
with their thoughts provide a means of establishing new plans
19
for reacting to inner events triggered by problematic situations.

In other words, tacit metacognitive knowledge, i.e. plans,
control processing and are formulated and addressed in treat-
ment. Such treatment is provided not through verbal chal-
lenging methods but through experiential strategies of using
cognition differently. For example, in the treatment of trauma
the therapist asks patients to allow intrusive thoughts to come
and go without engaging with them, and in anxiety-provoking
situations helps patients to focus attention on benign or safety-
related information rather than potential danger.
20
5
Object and metacognitive modes
A distinctive theoretical feature of MCT is the idea that cog-

nition can be separated into cognitive and metacognitive
systems and that processing can be cognitive or metacognitive
in nature. This division raises the possibility that a person can
experience thoughts in different modalities. Thoughts can be
experienced as external events that are indistinguishable from
events that actually occur or they can be experienced as simply
events in the mind. In metacognitive therapy, the former mode
of experiencing thoughts is called the object mode, whilst the
latter is called the metacognitive mode (Wells, 2000). For
example, an individual suffering from contamination obsessions
repeatedly has the thought; `Ìt's contaminated with faeces''
when encountering stains in public places. This person is in
object mode and does not differentiate between the thought and
the perception of the stain. In metacognitive mode, this person
would be aware of the thought and see it as separate from the
stain and as an event in the mind. In this way the problem is
transformed from one of contamination everywhere to one of
giving thoughts too much importance and fusing them with
reality.
When an individual experiences a negative thought or belief,
such as `Ì'm worthless'', it is typically experienced in object
mode; it is taken as a piece of direct data. The person is
therefore likely to respond to it by analysing why they are
worthless and how they can gain more worth. However, this
belief could also be experienced by the person in metacognitive
mode. In this mode, the individual steps back from the belief
and sees it as a thought in the mind. This shifting of modes is
thought to be a valuable resource that increases ¯exibility in
21
responses to negative ideas that can buffer against the activa-

tion of habitual patterns of thinking typi®ed by the CAS. In
other forms of CBT, there is objecti®cation of thoughts too, in
so much as they are interrogated and reality-tested, but the
individual does not directly experience the thought as an object
in the mind. This direct experiencing is necessary to strengthen
the metacognitive plans that control cognition.
In object mode, thoughts are experienced as direct percep-
tions and there is no separation between self as observer and
the act of thinking itself. Even questioning the validity of a
thought, a common practice in CBT, may not counteract this
mode of processing. For instance, an individual who thinks,
``What if I'm not prepared?'' may be led to question the
evidence for this appraisal. In so doing, the person imbues the
thought with greater objectivity; it is a concept that may or may
not be accurate. The individual may not enter a complete
metacognitive mode and learn that thoughts are internal events
that do not need to be responded to with further thoughts.
Instead, they learn that all negative thoughts need to be
evaluated for reality; the idea being that, `Ì cannot trust some
thoughts; which ones can I trust?''
22
6
Reformulated ABC analysis
The metacognitive model's analysis of psychological disorder is

focused ``downstream'' or `ùpstream'' of that of CBT or
REBT. In CBT or REBT, the therapist focuses on negative
automatic thoughts or irrational beliefs. In MCT, the therapist
focuses on the individual's reactions to thoughts and beliefs or
the thinking style that gives rise to beliefs. Reference to the
ABC model, on which Ellis' REBT and Beck's CBT are based,
provides one way to understand this difference.
In these original examples, `À'' refers to an antecedent or
activating event that leads to activation of a belief (Ellis) or a
negative automatic thought (Beck) designated as ``B'', which in
turn leads to an emotional consequence, ``C''.
In Wells' MCT, the activating event `À'' is speci®cally re-
designated as a cognition (a thought or belief ) or emotion
which leads to the activation of metacognitive beliefs, ``B'', and
the CAS, which gives rise to emotional consequences, ``C''. In
this schematic, the ordinary negative beliefs or thoughts (``B'')
are moderated by or caused by ``M''.
This gives rise to a different formulation of a problem, as
illustrated in Figures 1(a) and (b).
What does this mean in terms of treatment? It means that
the therapist focuses on beliefs about thoughts rather than
beliefs about other types of event. For example, in hypochon-
driasis the CBT therapist focuses on challenging conviction in
thoughts that are misinterpretations of bodily symptoms (e.g.
``What's your evidence that you have heart disease?''). How-
ever, in MCT the therapist questions the patient about the need
to continuously appraise symptoms in this way (e.g. ``What's
the point in repeatedly worrying that you have heart disease?'').
23
Figure 1a ABC analysis

Source: Wells (2009, p. 17). Copyright 2009 by Guilford Press. Reprinted
by permission.
Figure 1b AMC analysis

by permission.
The MCT question reveals metacognitive beliefs about uncon-

trollability of thoughts and positive beliefs about the need to
misinterpret symptoms and worry about health in order to
remain safe. The MCT therapist challenges these metacogni-
tions and explores alternative ways of relating to symptoms
that do not necessitate worry or misinterpretations.
24
In the AMC analysis, metacognitions may repeatedly gener-

ate other instances of negative thoughts or beliefs as, for
instance, an output of worry or rumination sequences. So a
trigger may be an intrusive mental event, which primes meta-
cognitions that guide processing in a way that generates the
more conscious negative appraisals that would normally be
classed as thoughts or beliefs.
25
7
Detached mindfulness
Because the CAS links disorder to styles of responding to

thoughts and beliefs, an aim of treatment is to develop alterna-
tive styles of responding to these inner events. As we have seen,
the CAS refers to a state of processing consisting of worry,
rumination, threat monitoring, suppression and other maladap-
tive coping behaviours. Wells and Matthews (1994) introduced
the term ``detached mindfulness'' (DM) to refer speci®cally to
an alternative state of processing that is the antithesis of the
CAS and also aims to shift the patient from object-mode to
metacognitive mode of processing.
As the name suggests, detached mindfulness comprises two
features: mindfulness and detachment. Mindfulness simply
refers to being aware of the occurrence of a thought or belief;
this is essentially developing and activating meta-awareness.
The second component is detachment. This refers to two
factors: (a) the suspension of any conceptual or coping activity
in response to the thought, and (b) the separation of sense of
self from the thought. A wide range of techniques and strategies
has been developed to help individuals acquire the metacog-
nitive skills necessary to deploy the state of DM (e.g. Wells,
2005). However, DM is not intended to be a symptom manage-
ment, avoidance or coping strategy; it is intended to increase
the array of ¯exible responses to thoughts, beliefs and feelings
when they are activated.
The range of strategies developed includes metacognitive
guidance, the free-association task, the tiger task and the use of
metaphors in treatment (see Point 25 for a discussion of these
strategies).
27
Detached mindfulness has no parallel with techniques used

in earlier forms of CBT. However, mindfulness meditation
techniques have recently been used as strategies for treating
relapse prevention in mindfulness based cognitive therapy for
depression (e.g. Teasdale et al., 2000).
DM may overlap a little with the concept and practice of
mindfulness meditation. There are minor similarities in that
both are intended to reduce or suspend evaluative types of
processing. However, they differ substantially because DM is
speci®cally aimed at suspending continued conceptual proces-
sing of thoughts, whereas meditation involves a more general
`àcceptance'' of all events. Mindful meditation is also linked to
adopting an inquisitive stance in relation to events, but it is
dif®cult to reconcile the idea of non-judgemental processing
with acceptance and inquisitiveness that rely on high-level
interpretative processes. Meditation is practised over many
weeks or years, but DM is applied to speci®c instances of
thoughts and can be developed in minutes. Mindfulness medi-
tation often involves using focusing of attention on internal
anchors such as the breath, but DM does not require this type
of body-focused attention. Moreover, such self-attention is
eschewed because of the risk of its contributing to self-focused
processing con®gurations that are part of the CAS. Meditation
is not speci®cally designed to modify pathological mechanisms
and processes, as is the case with DM.
Detached mindfulness in MCT was developed speci®cally to
produce cognitive and metacognitive effects considered helpful
on the basis of metacognitive theory. In contrast, mindfulness
meditation pre-dates any theory of psychological disorder and
was subsequently embraced by theorists wishing to reduce
depressive rumination. Thus, DM is developed from a theory of
rumination and worry, whereas mindfulness meditation is
based on Buddhist practices.
Whilst DM is a component of MCT, it is not necessary or
suf®cient. It is used as a technique that helps patients develop
an alternative relationship with cognition without triggering the
28
CAS and with a view to enhancing metacognitive control. The

technique is speci®c to MCT and does not feature in other
forms of CBT, which prefer to challenge thoughts rather than
disengage further processing from them.
29
8
Executive control and attentional
flexibility
In metacognitive theory, psychological disorder is linked to a
loss of cognitive resources and attentional ¯exibility. This is
a problem because psychological change and the control of
cognition require processing resources, yet these are constrained
by the CAS. Loss of resources and executive control means that
individuals have de®ciencies in the top-down control or sup-
pression of activity in lower-level and more re¯exive emotion
processing networks in the brain (i.e. amygdala). In addition,
focusing attention on threat limits the person's access to
information that can correct faulty ideas in feared situations. It
follows that it would be bene®cial in treatment to develop
techniques that recover resources, increase ¯exible (executive)
control over processing and enhance the ¯ow of corrective
information into processing. With this goal in mind, techniques
such as Attention Training (Wells, 1990; see Point 24) and
Situational Attentional Refocusing (Wells & Papageorgiou,
1998; see Point 26) have been developed as part of MCT.
Attention Training Technique (ATT) consists of external
attentional focusing on multiple auditory stimuli and has selec-
tive attention, attention switching and divided attention com-
ponents. It is practised during discrete practice sessions rather
than applied as a coping technique. Empirical evidence sup-
ports the ameliorative effect of the technique on anxiety and
depression (see Wells, 2006, for a review). For example, in
experimental studies using case series, ATT has been associated
with improvements in symptoms in panic disorder (Wells et al.,
1997), hypochondriasis (Papageorgiou & Wells, 1998), and
recurrent major depression (Papageorgiou & Wells, 2000). It
31
also appears to be associated with neurobiological changes

consisting of reductions in amygdala activity in depressed
patients (Siegle et al., 2007). Attention training is often referred
to in the ``new-wave'' CBTs such as Acceptance and Commit-
ment Therapy (ACT; Hayes et al., 1999), but it is not the same
thing as ATT (see Point 24).
A different attentional technique used in MCT is Situational
Attentional Refocusing (SAR; e.g. Wells & Papageorgiou,
1998). It is used to redirect attention during exposure to threat-
ening or anxiety-provoking situations. The aim is to increase the
¯ow of new and adaptive information into awareness so that
the individual is better able to update and modify her erroneous
beliefs. For instance, in social phobia individuals turn atten-
tion inward onto themselves when entering a feared social
situation. This is part of their threat-monitoring and coping
strategy, as they fear presenting an unfavourable impression.
This attentional style impairs the processing of external infor-
mation that would be valuable in challenging negative beliefs
about other people, such as the belief that everyone is staring
at them. In order to modify dysfunctional beliefs, it is necessary
to modify the direction of attention during exposure so that it
is focused on other people in the environment. Thus, the use of
exposure in metacognitive therapy does not depend on repeated
or prolonged exposures but depends on controlling cognition
during exposure to maximize the ef®ciency of new learning.
SAR is also applied in MCT for trauma, where the individual's
attentional style changes following a traumatic event. Threat
monitoring after trauma often consists of focusing on potential
sources of danger in the environment, which increases the
perception of current danger and maintains anxiety. In order for
cognition to return to its usual state of processing, the therapist
works with the patient to identify and modify the focus of
attention using techniques such as prescribing the detection
of neutral stimuli and safety signals in the environment.
32
9
Levels of control
Self-Regulatory Executive Function (S-REF) metacognitive

theory differs from the theories of Beck and Ellis and most
other cognitive approaches to psychopathology in being
grounded in information processing theory. It has a cognitive
architecture, meaning that it has an overall structure that
differentiates knowledge or beliefs, online (attentionally
demanding) conscious processing and automatic low-level
emotional processing, and the nature of relationships between
them. This is important because the relationship between these
factors is likely to be a source of disorder and may be more
important than the content of negative thoughts or social
beliefs. Whilst Beck's schema theory uses terms associated with
information processing approaches, such as schema and atten-
tion bias, it really focuses on cognitive content rather than
explaining in detail how information is transmitted, the form it
takes, how it passes through levels from stimulus to response
and how levels of cognition are connected. This level of expla-
nation is required for true information processing accounts and
is described to a greater degree in the S-REF model.
The S-REF represents cognition within a three-level
architecture: (1) low-level automatic processing networks that
process information re¯exively and outside awareness and
incorporate primitive emotion-processing networks; (2) a level
of conscious strategic processing that requires processing
resources, is largely conscious, and is responsible for interpreting
and implementing strategies; and (3) a level of stored knowledge
that is metacognitive in nature and guides the nature of
processing.
33
Differentiating between levels and describing the interrela-

tionship between them is important because it allows con-
sideration of the roles of automatic highly-learned responses,
low-level (sub-cortical) emotional processes, and how they
interact with conscious processes in contributing to psycholo-
gical disorder. The approach therefore has implications for
research on neurobiological processes. For instance, it proposes
links between strategic processing and activity in emotional-
processing circuits and structures in the brain that can be tested
and modi®ed. One implication is that the CAS blocks adequate
top-down control of emotional processing; thus removing the
CAS should provide a means of restoring control and allowing
emotional processing to run its normal course and be modu-
lated effectively. This is a basic supposition of MCT for post-
traumatic stress disorder.
The distinction between levels and speci®cation of their
interrelationship locates disorder predominantly at the level of
strategic or conscious processes linked to metacognitive beliefs.
Thus, MCT theory differs from early cognitive accounts of bias
in emotional disorder (e.g. Williams et al., 1988) by empha-
sizing the effect of strategic online processes rather than auto-
matic biases in attention. It differs from Beck's (1976) cognitive
theory in that it does not equate cognitive biases and distortions
with the activity of schemas, but with the style of conscious
processing which draws from metacognition. Similarly, it attri-
butes bias effects observed in tasks such as the emotional
Stroop test (e.g. Mathews & Macleod, 1985) to strategy-related
processes such as maintaining attention on sources of threat
(threat monitoring), rather than to automatic processes. This
has implications for developing treatments of bias: it means
that the therapist should modify the metacognitive beliefs that
support threat-monitoring strategies and patients should be
instructed in using alternative attentional responses.
The use of ATT and SAR and the focus on modifying
metacognitions controlling attention are distinctive features of
MCT. When attentional strategies are used in CBT or stress-
34
management treatment approaches, they concentrate on

employing distraction from thoughts, emotion or pain experi-
ences as a coping technique. In contrast, attention modi®cation
in MCT is designed and delivered with the goal of removing
the CAS, strengthening metacognitive control and improving
access to new information for updating knowledge.
35
10
Types of knowledge
We have already seen how the metacognitive approach differ-

entiates metacognitive knowledge from other knowledge about
the self and the world. Another area of contrast with other
cognitive theories is the way in which knowledge is represented.
CBT and REBT refer to the semantic content of knowledge and
express their respective schemas or irrational beliefs in verbal
declarative form (e.g. `Ì'm worthless'' and `Ì must be approved
of by virtually everyone in order to be worthwhile''). This is a
useful heuristic, but metacognitive theory acknowledges that
knowledge is not likely to be represented in this way in the
cognitive system, and it may be more useful to think of
knowledge as a set of programmes or plans that direct thinking
and action (Wells & Matthews, 1994, 1996). In essence, these
are metacognitive programmes for guiding processing, and in
this sense constitute a proceduralized knowledge base. The
marker for these procedures would be declarative statements
such as `Ì must worry in order to avoid harm'', but this
declarative belief would be closely linked to plans for guiding
the activity of the processing system in the implementation of
worrying. In this scenario the modi®cation of beliefs should not
only include verbal challenging of the level of conviction in
metacognitions but also provide individuals with alternative
plans for processing.
For example, the prevention of relapse in anxiety and
depression would not only focus on checking for and modifying
residual levels of conviction in declarative beliefs, as would be
the case in standard CBT, but would also involve training
patients to implement new ways of thinking and coping in
response to negative thoughts, beliefs and emotions. However,
37
these are not just any type of new response. It is not an issue of
generic training in relaxation or social skills, for instance, but is
speci®c training in responses that are opposite to the CAS and
any new strategy learned must not be used to avoid or prevent
erroneous threat. By shaping and practising new responses, the
individual develops the knowledge base or programme to
support these new responses in the future.
A distinctive feature of MCT, therefore, is the incorporation
of a training component that helps patients strengthen new
plans for regulating cognition and action. This typically consti-
tutes part of relapse prevention and distinguishes MCT from
other treatment approaches that train anxiety reduction, social
interaction, assertiveness or other types of skill.
38
11
Processes and strategies beyond cognitive
content
As we have seen, a key difference between MCT and the
approaches of CBT, behaviour therapy and REBT is that it
does not focus on the content of thoughts and beliefs. The only
exception is reserved for focusing on the content of meta-
cognitive beliefs. In CBT, the therapist is concerned with the
content of negative automatic thoughts and invites the patient
to reality test this content. Cognitive distortions or thinking
errors are identi®ed in thoughts and beliefs but this is an
extension of examining content. This emphasis on content
stands in contrast to the predominant focus of MCT, which is
on thinking style or cognitive processes.
In MCT, disorder is viewed as a function not of cognitive
content but of processes such as perseverative thinking, atten-
tional focus, and internal control strategies that are counter-
productive. Perseverative processes are patterns of recyclic
conceptual activity that most commonly take the form of worry
or rumination. These processes can have virtually any content
and it is necessary in MCT to arrest these processes and restore
¯exible control over thinking. However, MCT is not about
suppressing thought content; it is about interrupting a parti-
cular process and learning to relate to thoughts without the
need to engage in sustained processing or goal-directed coping.
The metacognitive approach views attention as a central
process in pathology. The strategy of threat monitoring is an
important feature of the CAS. This strategy is not seen as an
automatic function of the person's general beliefs (e.g. `Ì'm
vulnerable''), as in schema-based cognitive therapy, but is
viewed as linked to metacognitive beliefs that control attention.
39
As described in Point 10, the modi®cation of attention through

discrete exercises and the situational deployment of new
attention strategies in stressful situations is a distinctive feature
of MCT. The aim is modi®cation of metacognitions that con-
trol attention in the service of strengthening executive control
and improving access to new information that can modify
knowledge.
In the ``pure'' version of MCT theory, cognitive content is
viewed as the material used by processes and modi®ed by
processes. It is the processes that are seen as the core elements
of pathology, but these draw on metacognitive content for
guidance rather than on any other content of cognition. The
range of processes implicated in MCT theory is wider than in
schema theory. Furthermore, the link between processes and
the content of the person's knowledge is made explicit. In
schema theory, processes or ``biases'' are largely a feature of
content rather than separate factors of cognitive style, as is the
case in MCT.
40
12
View of self-awareness
The S-REF model views self-awareness as a complex multi-

faceted variable. This sets the approach aside from most other
theories and treatments of psychopathology. Often self-
awareness is equated with positive mental health outcomes
and is a factor reinforced in treatment. The metacognitive
approach does not correspond with this view of self-awareness.
First, it views self-focused attention (a component of self-
awareness) as a generic marker for activation of the CAS,
particularly when self-attention is chronic and in¯exible.
Second, it views a particular type of self-awareness speci®cally
involving awareness of thoughts as most useful in treatment.
However, high degrees of attention given to one's body and
public and private self-concept are thought to be deleterious.
This is a marker for excessive preoccupation and self-analysis
that is a feature of the CAS.
The MCT therapist is cognisant that even awareness of
thoughts is not free of potential toxic effects. This awareness
may re¯ect ``threat monitoring'', as in cases of OCD or PTSD,
where individuals fear the occurrences of particular types of
thought and monitor them as a means of preventing harm.
Unlike most other psychotherapeutic approaches, MCT
signals the necessity to delineate further the nature of awareness
of thoughts that is conducive to positive health outcomes. It
suggests that the type of awareness that is bene®cial is speci-
®cally not linked to goal-directed harm avoidance. It is aware-
ness of thoughts or beliefs as passing events in the mind that do
not require any response. Adaptive self-awareness is ¯exible and
not directed at coping but allows attention to be freely allocated
to observing thoughts without further conceptual processing.
41
It is recognized that self-awareness can be bene®cial when it

is ¯exible, controllable and applied appropriately in a way that
does not compromise self-regulation, belief change and per-
formance. Most therapy approaches equate self-awareness to
positive health outcomes without de®ning the kind of self-
awareness that is and is not bene®cial.
42
13
Varieties of change
As the foregoing discussion has begun to elucidate, metacog-

nitive therapy opens up a range of new possibilities for thera-
peutic change that do not ®gure in traditional CBT. Unlike the
focus of traditional treatment on reality-testing the content of
negative thoughts and beliefs about the self and the world, MCT
focuses on modifying cognitive processes. These are not the
processes buried in the content of thoughts (e.g. arbitrary,
inference, catastrophizing) as in Beck's CBT, but are the styles
of worry, rumination and threat monitoring. MCT aims to sus-
pend these processes, not to test their content against the facts.
The main point at which challenging content enters MCT is
when the therapist works on underlying metacognitive beliefs
about thoughts ± a level of working that is not a feature of
earlier CBTs. Treatment uses verbal reattribution methods and
behavioural experiments to challenge positive and negative
metacognitive beliefs.
Because MCT is based on a distinction between metacog-
nitive and cognitive levels of processing, and the two systems
supporting them, it asserts that there are two ways of relating to
thoughts and beliefs. Previously, in Point 5, we saw that these
are labelled the modes. This distinction gives rise to a type of
change that directly alters the individual's experience of his own
mental events. It is useful to change the way a person experi-
ences and relates to his thoughts and beliefs. Speci®cally, it
suggests these can be experienced as objects in the mind that are
moved outside the sense of the observing self, as would be the
goal in detached mindfulness (see Point 7).
Finally, an important variety of change involves the
strengthening of control and ¯exibility of cognition. This does
43
not mean improving the ability to avoid unwanted thoughts.

Rather, this means improving control of attention, which acts
as a general-purpose resource for prioritizing cognition and
action under stressful conditions and attenuating unwanted
activity in lower-level processing networks. When a person can
control attention they can choose to shape the version of reality
inhabited. Attention is the basis of consciousness and of learn-
ing about the self and the world.
In summary, metacognitive theory presents a range of
targets for change that distinguish the approach from other
treatments. It implies that it is possible and bene®cial to
change: (1) thinking style, (2) content of metacognitions, (3)
modes and the nature of experiential awareness of cognition,
and (4) strength of executive (attentional) control.
44
14
Disorder-specific models
So far we have discussed generic features of the metacognitive

model and universal aspects of treatment. However, disorder-
speci®c models have been developed and evaluated that are
based on the generic S-REF model. The disorder-speci®c
models are aimed at capturing the content of metacognitions
and the nature of processes that are more speci®c to a par-
ticular disorder (see Wells, 2000, 2009). For instance, in
generalized anxiety disorder metacognitive beliefs concern
positive beliefs about the usefulness of worry whilst negative
beliefs concern the uncontrollability and danger of worrying.
Both types of belief exist but it is the negative metacognitive
beliefs that are the more proximal cause of GAD. In obsessive-
compulsive disorder, the metacognitions concern the themes of
thought±event fusion (TEF), thought±action fusion (TAF) and
thought±object fusion (TOF). In TEF, thoughts are believed to
have the power to increase the probability of events (e.g.
``Thinking about accidents will make them happen''). In TAF,
thoughts are believed to increase the likelihood of committing
unwanted acts (e.g. ``Thinking of stabbing someone will make
me do it''). In TOF, the belief is that thoughts and feelings can
be transferred into objects or contaminate or spoil them in
some way (e.g. `Ìf I have impure thoughts whilst reading, my
thoughts will pass into my books and I won't be able to study
in the future'').
In depression, metacognitive beliefs focus around positive
beliefs about rumination as a means of coping with sadness,
and negative beliefs about the uncontrollability and causes of
depressive thoughts and feelings. Post-traumatic stress disorder
(PTSD) is linked to positive beliefs about worrying as a means
45
of anticipating and avoiding future danger, positive beliefs

about the bene®ts of analysing the traumatic event to reach
understanding or apportion blame, and negative beliefs about
the meaning and consequences of experiencing intrusive
thoughts and recollections of the event.
Two models will now be described in more detail to illustrate
the processes and speci®c metacognitions involved in depression
and PTSD. Each of these models and the others alluded to in
this section form the basis of generating personal case formu-
lations that are shared with patients as the basis of conducting
treatment. MCT proceeds on an individual case formulation
basis.
Metacognitive model of depression

The metacognitive model of depression (Wells, 2009) is depicted
in Figure 2. The person with depression responds to negative
thoughts and feelings of sadness with activation of positive
metacognitive beliefs about the need to ruminate as a means of
dealing with sadness and negative thoughts/beliefs. It is typi-
cally believed that rumination will lead to a greater under-
standing and the discovery of solutions to feelings of sadness or
thoughts of personal failure or defectiveness.
Rumination consists of chains of thoughts in which the
person asks questions such as, ``why, what does it mean, if only,
why me, will it ever end . . .?'' and so on. This process rarely
produces answers but focuses the individual more intensely on
feelings and memories of failure or negative events and this
maintains sadness. At some point in this process the depressed
person develops and subsequently activates negative beliefs
about depressive thoughts and symptoms. These involve beliefs
about the uncontrollability of thoughts and feelings (e.g. `Ì
have no control over my thinking; depression is an illness in my
brain beyond my control''). These beliefs lead to further nega-
tive thoughts, such as thoughts about hopelessness and beha-
viours such as social withdrawal, which maintain depression
46
Figure 2 Metacognitive model of depression

by permission.
and rumination. Another process also contributes to depres-

sion. With repeated rumination and depression the person
begins to lose awareness of the activity of ruminating. This
reduced meta-awareness interferes with the ability to identify
and interrupt ruminative responses so that they persist in their
cycle of depression unchecked. Furthermore, because the
47
person believes rumination is helpful and may lead to an

answer to depression, the process is not spontaneously recog-
nized as the toxic process that it really is. There are other
changes in behaviour such as reduced activity levels and coping
through use of alcohol that back®re and increase negative
thoughts that trigger rumination or provide more time and
space for rumination.
A case example will serve to illustrate the model. A 31-year-
old woman presented to services reporting multiple depressive
episodes over the last eight years. Her current episode of
depression had lasted for approximately 18 months. She could
not identify any speci®c life triggers for her depression, but
she had been unable to return to work for the past 11 months.
The therapist questioned her about how she used her time
during a typical day and selected yesterday as the reference
point. The patient explained how she carried on with some
daily chores but she felt tired and unmotivated most of the
time and on some days found it easier to remain in bed. She
described feelings of sadness on waking in the morning, and of
thinking `Ìt will never improve''. These feelings and thoughts
are identi®ed as a trigger in the metacognitive model and case
conceptualization.
The therapist then asked about the type of thoughts the
patient had in response to this trigger and discovered that she
spent all morning ruminating and analysing why she felt this
way and trying to work out why she was ``different''. The
patient described how this process of rumination occurred
about 80 per cent of the time. Asking about the advantages of
engaging in this type of thinking activity as a means of
exploring positive metacognitive beliefs, the therapist discov-
ered that the patient believed that rumination helped because it
acted as a form of punishment that might cause her to become
angry and break out of depression. Paradoxically, however, the
patient also believed that she had limited control over both her
thinking and her emotions and did not see that the process of
rumination was a central factor in maintaining her suffering.
48
In this case example, we can see each of the important

aspects of the metacognitive model: there are positive and
negative metacognitive beliefs about thinking; the CAS is
evident as rumination; and unhelpful coping is apparent in the
form of self-punishment, anger and, on some days, remaining
in bed.
Treatment consisted of sharing the case formulation, intro-
ducing strategies that enabled her to disengage from negative
thoughts and feelings and postpone and eventually ban rumi-
nation. Treatment challenged metacognitive beliefs, and helped
her learn new ways of responding to sadness and negative
thoughts in the future.
There are very few similarities between this approach to
depression and cognitive-behavioural approaches. Traditional
CBT would formulate the problem in terms of the content of
negative automatic thoughts and focus on challenging the
validity of thoughts centring on the ``cognitive triad'' (negative
thoughts about self, the world and the future). In contrast,
MCT does not concern itself with the content of such thoughts
and does not reality-test them. It views these thoughts as the
trigger for rumination or as an output of rumination and it
focuses on changing the process of continued thinking rather
than any speci®c content of thinking. Both approaches might
use activity scheduling, but in CBT the goal would be to
increase mastery and pleasure, whilst in MCT this would be to
counteract inactivity, which is seen as a maladaptive coping
behaviour that provides time for rumination. MCT would
challenge beliefs about rumination and depression, but CBT
would challenge general schemas (beliefs) about the world, the
future or the self (e.g. `Ì'm worthless''). Another important
difference is that MCT would utilize speci®c techniques that are
not a part of CBT, such as attention training, detached mind-
fulness, and metacognitively-focused behavioural experiments
that change the way the person relates to thoughts and feelings.
In some respects, CBT activities such as keeping thought
diaries, interrogating the reality of negative thoughts and
49
identifying the thinking errors they contain would be seen by

the MCT practitioner as engaging in excessive thinking
processes that are not far enough removed from the CAS.
Metacognitive model of post-traumatic stress

disorder
Post-traumatic stress disorder (PTSD) is the persistence of
particular clusters of symptoms (arousal, avoidance, re-
experiencing) for longer than one month following exposure
to a stressful event. In most instances symptoms subside within
this time but in a signi®cant minority of cases they persist. The
metacognitive model of PTSD (Wells, 2000; Wells & Sembi,
2004) is based on the idea that it is the activation of the CAS
that leads to the persistence of symptoms because it interferes
with control of emotional processing. The metacognitive model
of PTSD is presented in Figure 3. In this model, traumatic
events lead to symptoms of increased arousal, intrusive
thoughts and startle sensitivity that are part of the person's
in-built Re¯exive Adaptation Process (RAP). The RAP is a
low-level emotional processing function that serves to bias
processing and action as a means of facilitating the acquisition
of new routines for cognition and action in the future.
Normally, symptoms subside as the RAP runs its course and
the individual uses ¯exible executive control over it.
However, activation of the CAS inhibits ¯exible control over
the RAP and inadvertently fuels the processing of threat and
the running of the continued anxiety programme. In particular,
worry about threats in the future maintains the sense of danger
and anxiety, and rumination about the trauma maintains
preoccupation with trauma memory. Strategies such as threat
monitoring (e.g. hypervigilance for people who resemble an
attacker) increase the perception of potential dangers in the
environment, which maintains a state of anxiety. Behaviours
such as thought suppression (e.g. trying not to think about the
trauma) or avoiding reminders of the event prevent the
50
Figure 3 Metacognitive model of PTSD

by permission.
development of ¯exible control over thinking, and strategies

such as suppression can back®re and increase the salience of
thoughts.
The CAS is linked to metacognitive beliefs that include
positive beliefs about worry, rumination, threat monitoring and
thought control (e.g. `Ìf I worry about being attacked in the
future, I'll be prepared; I must keep a look-out for danger in
order to prevent accidents''). Negative metacognitive beliefs
concern the signi®cance of intrusive thoughts and memories
and lead to a sense of continued danger from symptoms
51
themselves (e.g. ``Thinking about what happened is out of

control; I'm losing my mind'').
In summary, as a result of the CAS the individual strength-
ens the sense of current threat, which maintains anxiety and
interacts with the effects of the RAP, giving rise to routines for
processing that are con®gured towards detecting potential
dangers and reacting rapidly to them. Threat-related processing
is not brought under appropriate ¯exible control and so cogni-
tion does not return to the usual state of processing a relatively
benign environment.
The metacognitive model differs markedly from other cog-
nitive and behavioural models of PTSD (e.g. Ehlers & Clark,
2000; Foa & Rothbaum, 1998). Most of these models give
special emphasis to disturbances of memory as the cause of
PTSD. For instance, it is argued that disorganized memory or
failure to incorporate corrective information in memory struc-
tures is responsible for symptoms. The metacognitive approach
does not hold that either memory disorganization or incomplete
memory is important. It suggests that most people have
incomplete memories and the hub of the problem is the person's
post-trauma thinking style (the CAS) under the in¯uence of
metacognitive beliefs.
MCT for PTSD differs extensively from all other cognitive
and behavioural treatments. Almost no exposure or imaginal
reliving of trauma memories is used in MCT because the
mechanism of change is not thought to be change in memory
organization, content or habituation to memories. There is no
restructuring or rescripting of memories, as would be the case in
some types of CBT. There is no challenging of thoughts or
beliefs about the trauma or the world. Instead, treatment focuses
on developing an idiosyncratic version of the model. Using
this formulation, the therapist proceeds to use strategies that
reduce worry and rumination. This includes detached mindful-
ness, worry and rumination postponement experiments, chal-
lenging positive beliefs about the need to worry and ruminate,
challenging negative beliefs about symptoms, and modifying
52
unhelpful threat-monitoring strategies. These techniques do

not appear in other cognitive and behavioural treatments of
PTSD.
53
15
A universal treatment?
There are now many different types of CBT, some of which are
linked to well-speci®ed and evidence-based models and others
that are not. One of the limitations of CBT is that it is possible
to specify any new schema that seems to ®t a particular new
disorder or presentation. In contrast, MCT is based on a more
tightly de®ned set of variables and beliefs and all disorder can
be explained with reference to a small set of pre-speci®ed
factors. This means that MCT theory is more parsimonious. It
also implies that it may be possible to treat the CAS directly in
all disorders, giving rise to a universal or trans-diagnostic
treatment approach (Wells, 2009; Wells & Matthews, 1994). It is
not clear at this stage whether it would be possible to dispense
entirely with the disorder-speci®c models and these may be
retained for optimal treatment effects. However, a universal
treatment might be applied to all disorders as a starting point
and then disorder-speci®c modules guided by individual models
might then be used as needed. In contrast, the growth of
different CBT models has led to an emphasis on the differences
between disorders rather than on their similarities and it is
unlikely that a universal CBT could emerge from this arena.
55
Part 2
THE DISTINCTIVE
PRACTICAL
FEATURES OF MCT
PRACTICAL FEATURES OF MCT
16
Conducting therapy at the metacognitive
level
The fundamental distinctive feature of metacognitive therapy is
the explicit focus on modifying metacognitive beliefs and pro-
cesses in order to achieve therapeutic change. In other words,
MCT concentrates on changing how the patient thinks by
altering beliefs about cognition. This is in direct contrast to
CBT, which is concerned with the content and product of
dysfunctional information processing and therefore the goal is
to modify the output of unhelpful thinking (Clark, 2004). The
CBT therapists' targets of change include systematic errors,
negative automatic thoughts, and core beliefs. In essence, CBT
works predominantly at the content or cognitive level, whereas
MCT operates at the process or metacognitive level.
Working at the metacognitive level requires the therapist to
look beyond the content of ordinary cognition. To accomplish
this goal, the MCT therapist must keep in mind the three
components of the cognitive attentional syndrome (CAS) ±
perseverative thinking, maladaptive attentional strategies and
unhelpful coping behaviours ± and be able to detect and modify
each aspect of the CAS during the process of therapy. This
gives rise to a very distinctive way of conducting therapy.
To illustrate, imagine you are working with a patient and a
sudden affect shift occurs. The CBT therapist might ask, ``What
just went through your mind?'' in order to elicit a negative
automatic thought (NAT). The primary goal would be to
modify the content of the NAT, or belief in that content, by
helping the patient label the cognitive distortion it contains, or
by helping the patient to evaluate the evidence and counter-
evidence for the NAT with the goal of generating alternative
59
appraisals. Working with the content of thoughts in this way is

effectively operating in the object mode, as discussed earlier
(Point 5).
The MCT therapist may ask the same initial question, but
would make no attempt to modify the content of the NAT
because these thoughts are viewed as either a trigger for
rumination, or the consequence of a rumination chain. The
therapist is therefore interested in the positive metacognitive
beliefs that direct the person to select rumination as a coping
response and the negative beliefs that make it unlikely the
person will interrupt the ruminative process. Modifying these
two types of metacognitive belief helps the MCT therapist
achieve their therapeutic target of enabling patients to select a
non-ruminative response to NATs. In addition, the aim is for
patients to realize that such thoughts are simply events in the
mind that do not require any form of further conceptual
processing.
The difference between working with content in the tradi-
tional way and working on the metacognitive level can be
further illustrated by comparing CBT and MCT in relation to
the following excerpt of ruminative thinking:
I'm alone . . . nobody cares about me . . . why don't my

friends or family ring me . . . is this sadness ever going to
end? . . . what am I going to do . . . I've felt this way for
years . . . I wish I could stop crying . . . nothing works out
for me . . . I keep failing . . . why am I so useless?
In this brief rumination sequence, there are a range of negative

automatic thoughts, cognitive distortions, possible core beliefs
and attributional errors, and therefore the CBT therapist has to
decide which cognitive component to target ®rst. The CBT
therapist might begin by asking, ``What is your evidence for the
belief that nobody cares about you? Do you have any counter-
evidence against this thought?'' As previously discussed, CBT
essentially proceeds by reality-testing the content of cognition.
60
In contrast, the MCT therapist would ask, ``Do you think that
there are better ways of responding to the thought Ì'm
alone'?'', with the goals of increasing awareness of the dis-
advantages of ruminating in response to a negative thought and
shifting the patient to a metacognitive mode of processing.
In the above rumination chain, there is a rapid transition
from a relatively benign thought, `Ì'm alone'', to being `ùse-
less''. This is the type of transition that commonly occurs when
a CBT therapist conducts a downward arrow. The downward
arrow consists of repeatedly questioning what a thought means
if it were true and is believed to uncover core beliefs. We
suggest that, when a person ruminates, they are effectively
conducting their own version of a downward arrow. This is
problematic because the person is continually generating nega-
tive beliefs about themselves, the world and the future. The
MCT therapist would help the patient to identify and label the
ruminative process and suspend further analysing, rather than
engage in reality-testing the individual negative thoughts. This
appears to be a more time-ef®cient approach to treatment; for
example, MCT for depression consists of six±eight one-hour
sessions (e.g. Wells et al., in press) compared to the typical 12±
16 sessions in traditional CBT (e.g. Dimidjian et al., 2006).
Similarly, when treating patients with obsessive-compulsive
disorder (OCD), the MCT therapist focuses on the components
of the CAS and metacognitive beliefs about thoughts and
rituals, but does not focus on beliefs in other domains (e.g.
in¯ated responsibility). Some minor overlap exists between the
metacognitive approach and recent developments in cognitive
therapy for OCD. An international working group, the
Obsessive-Compulsive Cognitions Working Group (OCCWG,
1997, 2001), began by developing a consensus on the most
important belief domains in OCD. These domains are the over-
importance of thoughts, the importance of controlling one's
thoughts, perfectionism, in¯ated responsibility, overestimation
of threat and intolerance of uncertainty. The ®rst two belief
domains are metacognitive in nature, whereas the rest are
61
cognitive and would not be assessed for, or considered relevant

in MCT. However, in the metacognitive model the metacog-
nitive beliefs concern speci®c ``fusion-related'' themes (Wells,
1997) that are not identi®ed by the OCCWG. Moreover, the
metacognitive approach gives importance to beliefs about
rituals that are not a feature of any other approach.
Wilhelm and Steketee (2006) developed a cognitive therapy
(CT) treatment manual based on the six belief groupings
identi®ed by the OCCWG and suggest that therapy should
proceed by identifying which belief domain or domains are most
important for each patient and modifying each one in turn in a
modular approach. To illustrate how CT might proceed in
modifying overestimation of danger, consider the patient who
experienced an intrusion in the form of an image of her son
choking on a shard of glass. A cognitive approach would advo-
cate using the downward arrow technique to uncover fears/
beliefs underpinning the patient's overestimation of the
consequences of danger. In CT, the beliefs would be `Ì will
bring glass into my house and my son will choke to death on the
shard that falls from my shoe'' and if that happened it would
mean, `Ì'm a bad mother''. To challenge this belief, the calcu-
lation of the probability of a dangerous outcome (van Oppen &
Arntz, 1994) is undertaken, where the chance versus cumulative
chance of the event is plotted. An alternative method is simply
to generate a discrepancy between the patient's subjective esti-
mate of probability and the logical probability. More simplis-
tically, the therapist could label the thinking errors, e.g. fortune
telling and catastrophizing, to reality-test the beliefs. CT might
also include work on the core belief `Ì'm a bad mother'' using
continua techniques.
In MCT, none of the above beliefs are considered central to
the maintenance of OCD and the use of the reattribution
strategies would be contra-indicated. Clinical experience indi-
cates that many patients conduct similar probability estimates
and know that the probability of harm is in®nitesimal ± so why
does the problem persist? The answer is that probabilistic
62
reasoning is a form of ruminative response and/or a ritual that

continues to give the intrusive thought meaning and signi®-
cance. Furthermore, work on the core belief `Ì'm a bad
mother'' is unnecessary in MCT, as this thought is produced by
rumination in response to the obsession. Successfully enabling
the patient to suspend obsessional rumination makes it unlikely
that the thought `Ì'm a bad mother'' would occur. MCT
focuses on modifying the metacognitive beliefs about the intru-
sion only. In this example, the metacognitive appraisal might
be, ``thinking that my son will choke to death means it's the
case''. Regardless of the nature of the obsessional thought, if
the person can acquire a metacognitive mode of processing,
then the thoughts no longer carry any threat. Data from several
studies show that metacognitive beliefs are better predictors of
obsessional symptoms than the non-metacognitive belief
domains, at least in non-clinical samples (e.g. Gwilliam et al.,
2004; Myers & Wells, 2005; Myers et al., 2008). A recent case
series examining the ef®cacy of MCT for OCD supports the
approach of speci®cally targeting metacognitive beliefs (Fisher
& Wells, 2008).
Working at the metacognitive level also requires the
therapist to identify and link maladaptive attentional strategies
to metacognitive beliefs. A common counterproductive atten-
tional strategy is for patients to monitor their mind and body
for signs of threat. For example, an OCD patient with intrusive
thoughts about harming her children described waking up each
morning and scanning her mind for intrusive thoughts. This
strategy was driven by the metacognitive beliefs, `Ì need to
monitor my mind to assess my progress in therapy'' and `Ìf I
don't ®nd the thought then I know my children are safe.'' In
this situation, the MCT therapist modi®es the belief by high-
lighting the counterproductive nature of the strategy, i.e. that it
increases the frequency and saliency of intrusive thoughts. In
addition, the MCT therapist demonstrates that this attentional
strategy is a manifestation of metacognitive beliefs about the
importance and signi®cance of intrusive thoughts. In this case,
63
the patient is helped to shift to a metacognitive mode of pro-

cessing and to be able to evaluate the thought objectively. This
allows the patient to view the intrusive thought about hurting
her children as simply a mental event that is not signi®cant
and requires no further conceptual processing. The patient was
then instructed to ban these maladaptive threat monitoring
strategies.
Unhelpful overt and covert coping behaviours are also
components of the CAS and are driven by metacognitive beliefs
about the utility of such behaviours. Typical behaviours include
thought control strategies, and the way the MCT therapist
works with them can be readily illustrated with reference to
generalized anxiety disorder (GAD). The GAD patient often
attempts to suppress thoughts that typically trigger episodes of
worry. These control attempts are mostly unsuccessful and
therefore contribute to the negative metacognitive belief that
worrying is uncontrollable. Similarly, GAD patients often
engage in avoidance behaviours that deprive them of oppor-
tunities to discover that worrying is under their control. The
task of the MCT therapist is to increase the patient's awareness
of the role that these coping behaviours play in fuelling negative
metacognitive beliefs about uncontrollability. Subsequently, the
MCT therapist assists the patient in giving up dysfunctional
coping behaviours, with the goal of modifying negative meta-
cognitive beliefs about the uncontrollable nature of worry.
Although treatment techniques within the range of CBT
approaches are likely to achieve changes in metacognition, this
is not the explicit goal and therapy is not conducted at the
metacognitive level. For example, the logical disputation of
NATs will probably increase metacognitive awareness in terms
of how the person responds to her thoughts, i.e. the person
begins to be aware of thoughts as mental events and not as
``readouts'' of reality. Indeed, Ingram and Hollon (1986) high-
lighted the importance of developing metacognitive awareness
during cognitive therapy to enable the person to interact with
their thoughts in a ``decentred'' manner. Although the potential
64
importance of metacognitive change was acknowledged theor-

etically, treatment techniques were not explicitly developed to
modify metacognitive beliefs or processes. Furthermore, meta-
cognition was conceptualized in terms of awareness rather than
as a multi-component factor in which beliefs, strategies and
thinking style are important.
65
17
Assessment of metacognition
A primary purpose of the assessment process is to gather

information that enables the clinician to develop an idiosyn-
cratic case formulation based on a theory or model of the
particular disorder. As such, assessment is theoretically driven
and the CBT therapist is interested in ascertaining the content
of thinking, cognitive distortions, core beliefs and behaviours
that contribute to the maintenance and exacerbation of the
disorder. For example, in depressive disorders, the goal is to
identify core beliefs and negative automatic thoughts that fall
within the negative cognitive triad, such as `Ì'm a failure'',
`èverything always goes badly'' and ``nothing will ever
change''. In relation to these cognitions, the CBT therapist
looks for behaviours that prevent the individual from modi-
fying the content of these cognitions, e.g. the belief `Ì'm a
failure'' might be maintained by avoidance and other forms of
safety behaviour.
Assessment based on the metacognitive theory of psycho-
pathology is distinctive in both its focus and methods. MCT
does not ignore the behaviours and cognitions described above,
but instead seeks to elicit and understand the mechanisms that
generate and extend these types of thoughts and behaviours.
Speci®cally, the MCT therapist focuses on metacognitive beliefs
and processes that maintain the cognitive attentional syndrome
(CAS).
Assessment in MCT will proceed in a similar fashion to
other forms of therapy and typically begins from a diagnostic
perspective. Once the clinician has identi®ed the speci®c dis-
order, assessment focuses on quantifying metacognitive beliefs
and processes responsible for the maintenance of the disorder.
67
There are three forms of assessment that are speci®c to MCT

and each of these will now be described.
The AMC analysis

As discussed in Point 6, the ABC analysis, common to all forms
of CBT, can be reconceptualized in metacognitive terms and
provides a useful starting point in the assessment process. In
MCT, the `À'' is normally a thought or belief, but can be an
emotion. This is followed by ``M'', activation of a metacog-
nitive plan, which consists of explicit metacognitive beliefs and
proceduralized plans and is manifest as the CAS. In turn this
leads to ``C'', the emotional consequences. An example of the
therapist±patient dialogue in the assessment of OCD using the
AMC analysis is presented below:
Therapist: When was the last time you had a doubt about
leaving the door unlocked?
Patient: When I left my house this morning and was
getting into my car.
Therapist: What exactly was the thought?
Patient: Did the lock click?
Therapist: How did you feel?
Patient: A little anxious and angry that the thought had
happened again.
Therapist: What did you do in response to the thought?
Patient: I tried to remember the sound of the lock
clicking and went through all the steps I take
when locking my door.
Therapist: When you had the doubt about leaving the door
unlocked, did that mean anything to you?
Patient: Well, if I've had the doubt, there must be a
reason for it; these thoughts can't just come into
your head for no reason.
Therapist: Other than going over your memory, did you do
anything else?
68
Patient: I eventually went back and checked, as I

couldn't be sure it was locked.
Therapist: What would have happened if you'd decided not
to do anything and just driven off without going
back to check?
Patient: The doubt would have stayed with me for a long
time and when that happens, I can't concentrate
and I get more wound up.
In this brief example, the antecedent is the intrusive thought

about leaving the door unlocked, in the form ``Did the lock
click?'' The metacognitive plan consists of: (1) evaluating the
doubt as signi®cant and meaningful, (2) making a metacogni-
tive judgement about the importance of thoughts intruding into
consciousness, and (3) searching one's memory. The conse-
quences included feeling anxious, angry, and ultimately check-
ing that the door was locked.
This AMC analysis contrasts dramatically with a typical
ABC analysis. In the above example, an ABC analysis would
take the following form if the in¯ated responsibility model of
OCD had been used. The antecedent or the trigger would be
similar: ``Have I left the door unlocked?'' However, the ``B'', or
the thought, might be: `Ì must check as it is my responsibility
to ensure nothing bad happens.'' Therefore the consequences
are similar in that the person goes back to check and feels
anxious. However, note that the treatment target would be
radically different. In the AMC analysis, we need to modify the
metacognitive plan and beliefs but, in the ABC analysis,
therapy would focus on modifying responsibility-related beliefs
in the context of a schema model of psychopathology.
Metacognitive profiling
Another assessment method that dovetails neatly with the
AMC analysis is metacognitive pro®ling (Wells, 2000; Wells &
Matthews, 1994). The main goal of metacognitive pro®ling is to
69
elicit the nature of the processing routines and metacognitive

beliefs that are activated when an individual has to deal with a
stressful situation, e.g. entering a social situation for the patient
with social phobia or experiencing an intrusive memory in
PTSD.
Metacognitive pro®ling might start by asking the patient to
describe a recent episode in detail and conducting the pro®ling
as described below. Often, a more clinically useful approach is
to expose the person to their feared stimulus, as is done in a
Behavioural Avoidance Test (BAT), and assess for the meta-
cognitive processes that are activated under such conditions.
From this point on, the assessment questions differ consider-
ably from those of CBT and focus on: (1) metacognitive beliefs
about thoughts, (2) metacognitive beliefs about thought control
processes, and (3) the nature of the person's goals and cognitive
processes in response to a stressor. These three domains are
usefully subdivided into six different, but overlapping, categ-
ories, which are outlined below. Example questions are included
but the interested reader should refer to Wells (2000) for a
detailed discussion of metacognitive pro®ling.
Metacognitive beliefs and appraisals

When you felt [e.g. anxious, scared, low, angry], did you have
any thoughts about your mental state? What were they?
Do you think worry/rumination can be dangerous or harmful
in any way?
Coping strategies and goals

When you felt [insert emotion], what did you do to cope with
the situation/emotion?
Did you do anything to control your thoughts/emotions?
What was your goal is using these coping strategies?
What told you that your coping strategies were successful?
70
Attentional processes
What were you paying most attention to in the situation?
Were you focusing on feelings/thoughts/the situation?
Were you self-conscious? What were you most conscious of?
Memory
Did you notice any memories when in that situation?
Did you use your memory to work out what was happening or
to deal with the situation?
Judgements
How did you form your judgements in the situation?
How con®dent were you about your thoughts, feelings,
judgements and memories?
Mode of processing
Did you accept your thoughts/judgements as facts, based in
reality?
Could you see your thoughts as unrepresentative of what was
happening in the situation?
Were you able to keep your distance from the negative thoughts
and feelings when they occurred?
Metacognitive questionnaire assessment

Self-report questionnaires are used across all forms of cognitive
and behavioural therapies and are important in assessing the
severity of symptoms and monitoring change during and
following therapy. Questionnaires are also designed to assess
the putative psychological mechanisms responsible for problem
maintenance. In MCT, self-report questionnaires help to deter-
mine the components of the cognitive attentional syndrome.
71
Administration of selected questionnaires on a session-by-

session basis guides the clinician as to which metacognitive
beliefs and processes should be targeted in treatment. A range
of measures have been developed and used that are speci®c
to MCT.
One of the most useful generic metacognitive questionnaires
is the Metacognitions Questionnaire-30 (MCQ-30; Wells &
Cartwright-Hatton, 2004), which assesses positive beliefs about
worry, negative metacognitive beliefs about uncontrollability
and danger of thoughts, beliefs about cognitive con®dence, and
cognitive self-consciousness (the tendency to monitor one's
mind). There are a large number of disorder-speci®c question-
naires. For example, in depression, questionnaires have been
designed to measure positive and negative metacognitive beliefs
about rumination, as these categories of belief are pivotal
in maintaining rumination and consequently depression. The
speci®c measures are the Positive Beliefs about Rumination
Scale (PBRS; Papageorgiou & Wells, 2001), which taps beliefs
such as ``ruminating will help me ®nd answers to my depres-
sion''. The ¯ip-side of the coin is that negative beliefs about
rumination need to be assessed with the Negative Beliefs about
Rumination Scale (NBRS; Papageorgiou et al., in preparation),
which measures beliefs about the uncontrollability and harmful
nature of rumination, as well as beliefs about the social and
interpersonal consequences of ruminating.
The use of metacognitively focused questionnaires, reformu-
lated ABC analysis and metacognitive pro®ling provides the
MCT therapist with a solid platform on which to build an
idiosyncratic formulation based on disorder-speci®c metacogni-
tive models. The focus of assessment and the resultant formu-
lation is very different from that seen in CBT and in the ``new-
wave'' cognitive-behavioural therapies.
72
18
Case formulation in MCT
Case formulation plays an integral role in the delivery of

empirically supported cognitive-behavioural approaches to
common mental health problems. There are strong theoretical
and clinical reasons for employing a case formulation approach,
and MCT is no different from CBT in this regard. Case formu-
lation provides the link between assessment and treatment and
speci®es the psychological constructs that need to be identi®ed
and modi®ed over the course of therapy. The nature and
construction of the case formulation is distinct in MCT, which
will be illustrated here with reference to depression. The case
formulation is based on the metacognitive model of depression
described in Point 14. There are ®ve main components that need
to be derived for the case formulation: the trigger, the nature of
rumination, positive beliefs which determine whether rumina-
tion is sustained as a response to the trigger, negative metacog-
nitive beliefs and unhelpful coping responses. A brief example
of the therapeutic dialogue is illustrated below.
Step 1. Identifying the trigger
Therapist: Can you think of a recent time when you became

more aware of feeling low? What was the ®rst
thing you noticed: a thought, a feeling or a
particular situation?
Patient: It was when I was watching TV and there was a
®lm in which the man was lonely, and I thought,
he's just like me, all alone.
73
Step 2. Determining the nature of rumination

Therapist: When you had the thought, `Ì'm all alone'',
what did you then go on to think about? [The
therapist is exploring the nature of rumination.]
Patient: Well, I started to think that it's the same old
situation. I'm sitting in here on my own watch-
ing TV, and I started to think about why I was
in this situation. I ended up thinking that my life
is always going to be dreadful.
Therapist: How long did you spend thinking about being
alone and that nothing was going to change?
Patient: I'm not sure; quite a while. I couldn't concen-
trate on the rest of the programme; it could have
been half an hour or maybe more.
Step 3. Linking rumination to depression

Therapist: It might sound like a silly question, but when
you were thinking like that, what happened to
your mood?
Patient: Obviously it got worse. I started to feel frus-
trated with myself as well as feeling down.
Step 4. Eliciting the negative metacognitive beliefs

Therapist: When you were feeling low and frustrated, did
you have any thoughts about the way you were
feeling?
Patient: That it was inescapable and I should be able to
pull myself together.
Therapist: It sounds as if you spent quite a long period of
time dwelling on your situation and how you
were feeling. What would have happened if you
hadn't spent so long thinking about your
situation?
74
Patient: I don't really know.

Therapist: Well, it sounds as if your mood became worse
the more you thought about yourself and your
situation. It seems that as you think about
your life not changing, everything seems worse.
Do you think it would be helpful to stop
ruminating?
Patient: I really wish I could. When I start thinking
about my life, I can't stop thinking about how
dreadful everything is.
Therapist: It sounds as if you know that ruminating about
these issues is unhelpful, but that it's impossible
to stop thinking about it so much.
Patient: But my life is bad.
Step 5. Discovering the positive metacognitive

beliefs
Therapist: Do you think ruminating in the way we just
talked about will help you in any way?
Patient: Not really, but sometimes I think that a way out
will pop into my head if I keep thinking about it
and I can work out why I'm like this.
Therapist: Would there be any disadvantages or problems if
you stopped dwelling on your situation?
Patient: I'd probably feel better, but if I didn't think
about these things I wouldn't be able to work
out ways of preventing becoming depressed
again.
The above information would be used to create an idiosyncratic

case formulation, as shown in Figure 4. The metacognitive
model of depression (Wells, 2009) has very little overlap with
the cognitive theory of depression (Beck et al., 1979). In devel-
oping an MCT case formulation and in the process of MCT,
minimal attention is paid to the three fundamental components
75
Figure 4 Metacognitive case formulation of depression
of Beck's cognitive model. There is no detailed assessment of

core beliefs (schemas), negative automatic thoughts or cognitive
distortions. The MCT therapist does not completely ignore
these factors, but views them as markers for the metacognitive
beliefs and processes that maintain the cognitive attentional
76
syndrome. For example, the occurrence of an NAT represents a

trigger for a metacognitive plan containing positive and nega-
tive metacognitive beliefs about rumination. It is these beliefs
and the ruminative process that would be addressed in MCT,
not reality-testing of the NAT.
We have chosen to highlight the distinctive nature of the
metacognitive case formulation for depression, but it should be
noted that the case formulation for all disorders is based on the
S-REF model of psychopathology and is therefore distinct from
behavioural or other cognitive models of emotional disorders.
Further illustrations of this can be seen in the brief overviews of
the case formulation approaches for OCD and PTSD below.
In OCD, the case formulation is concerned with eliciting
metacognitive beliefs about obsessions, e.g. ``thinking that the
house will burn down means it is the case'' or ``thinking I could
be a paedophile makes it so''. A central focus on metacognitive
beliefs without drifting into cognitive appraisals is unique to
MCT. In addition to these beliefs, the MCT therapist must
include beliefs about rituals in the formulation. These can be
either positive, ``rituals give me peace of mind'', or negative,
``my rituals are out of control''. No other approach explicitly
formulates positive and negative beliefs about rituals, although
such beliefs may be modi®ed fortuitously during cognitive and
behavioural interventions.
As is the case with the other disorders, the case formulation in
PTSD is concerned with conveying how the cognitive attentional
syndrome maintains PTSD symptoms, described in detail in
Points 14 and 30. In summary, the MCT therapist highlights the
fact that metacognitive beliefs about worry, rumination, threat
monitoring and other coping strategies keep these processes in
place, e.g. ``the belief that worry keeps me safe will drive me to
continue to use worry''. Negative metacognitive beliefs focus on
the signi®cance of symptoms such as the belief that they are
themselves a source of danger (e.g. `Ìf I continue to think about
the event I will lose my mind''). Other cognitive approaches do
not emphasize the role of metacognitive beliefs in maintaining
77
counterproductive behaviours and thinking styles and are

more concerned with problems in autobiographical memory
processes.
78
19
Meta-level socialization procedures
Successfully socializing patients to the nature of therapy and

the theoretical model used is crucial for effective and ef®cient
treatment. Whatever the treatment approach, poor socialization
often leads to problems in therapy because the patient is
unaware of the aims of therapy and does not have a shared
understanding with the therapist. MCT differs from other CBT
approaches in that, regardless of the disorder being treated, the
patient is socialized to the role that the cognitive attentional
syndrome (see Point 3) and metacognitive beliefs play in
problem maintenance.
A number of explicit socialization methods are available to
the MCT therapist, but before these are described, it is
important to realize that implicit socialization to the meta-
cognitive model begins during the assessment phase. Self-report
questionnaires, as described in Point 17, that assess metacog-
nitive beliefs and processes are routinely administered to
patients.
In addition to the useful clinical information derived from
the questionnaires, it is also likely that completion of ques-
tionnaires helps to increase metacognitive awareness and
attunes the patient to the goals of therapy. For example,
patients often report that they hadn't thought about how much
time they spent worrying or that they hadn't given considera-
tion to the number of times they try to control thinking. The
completion of speci®c metacognitive questionnaires helps the
patient acquire an appropriate mental framework and begins
the process of switching from object to metacognitive mode.
The keystone of the socialization process is the case formu-
lation, which is the mechanism through which patients are
79
provided with a coherent and theoretically valid framework for

understanding the metacognitive processes that underpin the
emotional disorder. Once the case formulation has been
constructed (see Point 18 for a metacognitive formulation of
depression), the task of the therapist is to illustrate carefully
how each component of the formulation contributes to the
maintenance of the disorder. Examples of questions the ther-
apist should use to illustrate the effects of rumination are:
· When you ruminate, does it lead you to feeling better?

· If you described the content of your rumination, would it
be positive or negative?
· Has your rumination led to a way of resolving your
dif®cult situation?
· Does rumination ever result in action or does it lead to
inaction?
· Does rumination help you to overcome and cope with your
low mood?
The overarching goal in MCT is to socialize the patient to the

role that the CAS plays in maintaining their current dif®culties;
speci®cally, that perseveration in the form of worry or rumina-
tion exacerbates and deepens the distress as well as prevents
self-knowledge from being updated. Socialization also stresses
that attentional strategies and particular coping responses
prevent modi®cation of metacognitive beliefs and contribute to
a perception of threat that maintains disorder.
In relation to GAD, socialization in MCT focuses on con-
veying the fact that worrying is a ubiquitous phenomenon, but
has become a problem for the individual because of speci®c
positive and negative beliefs about worry and because of
particular coping attempts that are counterproductive. The
person is helped to see that the strategies used to try and cope
with worry are unsuccessful and fuel uncontrollability beliefs.
The MCT therapist highlights the con¯icting nature of positive
and negative beliefs about worry and enables the person to
80
recognize that holding both types of belief leads to the

maintenance of worry. To illustrate that uncontrollability and
danger-related metacognitions are the central problem, a useful
socialization question is: ``How much of a problem would you
have if you no longer believed worry was uncontrollable and
dangerous?'' Patients readily acknowledge that there would no
longer be a problem.
In MCT for GAD (Wells, 1995, 1997), negative metacog-
nitive beliefs about uncontrollability are the most important;
these do not feature in other generic or speci®c models of GAD.
For example, in Beck's model (Beck et al., 1985), patients are
socialized to a schema model of GAD in which core beliefs
about the world being a dangerous place and the self as being
unable to cope are pivotal. Such beliefs drive behaviours which
prevent discovery of alternative or more realistic beliefs, e.g. `Ì
am able to cope effectively most of the time''. A more speci®c
schema theory is the intolerance of uncertainty (IOU) model
(Dugas et al., 1998). In this model, patients are socialized to the
idea that their perception and beliefs about the need for
certainty play a fundamental role in worry and anxiety. The
goal of treatment is not to eliminate uncertainty from everyday
life, as this would be impossible, but to ameliorate anxiety and
worry by helping the patient become more able to deal with and
accept uncertain situations. The IOU model also socializes
patients to the maintaining role of positive beliefs about worry
but does not focus on negative beliefs about worry; instead, it
focuses on problem solving and cognitive exposure.
In Point 18 on case formulation, we emphasized that MCT
for OCD explicitly focuses on metacognitive beliefs about
intrusions and rituals and therefore patients are socialized to
the maintaining role of these beliefs. A number of cognitive
models of OCD have been developed and there are some shared
features. Clark (2004) argues that the similarities between
cognitive approaches outweigh the differences and that all can
be classi®ed as appraisal models. It is also true that the meta-
cognitive model is an appraisal theory in that interpretations of
81
intrusions are important. However, the distinctive feature is

that MCT remains focused on and socializes patients only to
metacognitive processes, whereas other approaches focus on
several cognitive domains, e.g. in¯ated responsibility, overesti-
mation of danger and the need for certainty.
Behavioural experiments are typically used to socialize the
patient to the metacognitive model. In traditional CBT
approaches, thought suppression experiments are used to illus-
trate that this particular strategy tends to back®re and increase
the frequency of unwanted thoughts. In MCT, thought sup-
pression experiments are also used to demonstrate the counter-
productive nature of thought suppression, but are also used in
line with the metacognitive approach. For example, in GAD
thought suppression experiments can serve multiple functions.
First, they illustrate that the individual's attempt to control
thoughts has fuelled the uncontrollability belief. Modi®cations
of the thought suppression experiment are used to facilitate
detached mindfulness (see Point 25). They can also be used to
demonstrate that the person is consciously selecting a particular
strategy in response to intrusive thoughts and therefore is able
to make a different decision and choice when an intrusive
thought is detected.
82
20
Shifting to a metacognitive mode of
processing
In MCT, an essential treatment goal is to help the patient
change modes of processing. A fundamental feature is that the
therapist needs to work at the metacognitive level explicitly and
not as a byproduct as in CT. Working at the metacognitive
level (see Point 16) should enable the patient to increase aware-
ness of dysfunctional thinking styles and processes and to
change their mental model of cognition and ways of experi-
encing thoughts.
Developing the metacognitive mode of processing consists of
developing new types of awareness about mental events and
processes. Patients are helped to see that the problem is not the
occurrence of worrying thoughts, but that the dif®culty lies in
the way in which the individual relates to her internal experi-
ences. This process begins with socialization (see Point 19) and
continues with speci®c strategies such as detached mindfulness
and modi®cation of metacognitive beliefs.
For example, the OCD patient is in object mode and appar-
ently has a fear of contamination by germs and dirt. However,
the goal of treatment is to help the patient shift to a meta-
cognitive mode of processing in which they see the problem as
placing too much importance on their thoughts about dirt and
germs. On one level, the entirety of MCT can be seen as helping
the patient to acquire and shift to a metacognitive mode of
experiencing.
83
21
Modifying negative metacognitive beliefs
MCT is the only approach that explicitly focuses on modifying
negative metacognitive beliefs. Negative metacognitive beliefs
about thoughts or perseverative thinking can be subdivided into
beliefs about worry/rumination being uncontrollable and beliefs
about the danger of this thinking style. Typical uncontroll-
ability beliefs are that worrying/ruminating is beyond control,
whereas examples of danger-related beliefs include, ``worrying
could make me go crazy'' and ``people will reject me if they
knew how much time I spent dwelling on my situation''. During
episodes of perseverative thinking, these negative beliefs are
activated, leading to extended thinking and negative appraisals
of worrying or ruminating, which exacerbate anxiety, depres-
sive affect and other distressing emotions.
Modifying uncontrollability beliefs
In MCT for depression and GAD, the ®rst treatment target is

the modi®cation of beliefs concerning the uncontrollability of
worry or rumination. Following the case formulation, this is
accomplished by discussing the evidence for and against uncon-
trollability. The conundrum is put to patients that: `Ìf worry
is completely uncontrollable, how does it ever stop?'' Some
patients report that the worrying is never-ending, but careful
questioning elicits the fact that there are signi®cant periods
when the person is not engaged in worrying or ruminating, for
example when fully engaged in an absorbing task or when they
are distracted from their worry. At this point, the worry/
rumination postponement experiment is introduced. Patients
85
are asked to notice a trigger for the worry/rumination such as

an intrusive thought and then to simply postpone the worry/
rumination until later that day. The patient is instructed that 15
minutes can be devoted to ruminating/worrying, but that this is
not compulsory. This is one of the most effective strategies for
challenging uncontrollability beliefs and is described in detail in
Point 23. It quickly demonstrates that worry can readily and
easily be brought under the individual's control.
However, worry/rumination postponement is only one way
of modifying uncontrollability beliefs. The MCT therapist
could utilize loss of control experiments, in which the patient is
speci®cally requested to try and lose control of their worrying.
This can be done in session or as a homework task. There is a
paradoxical effect when patients conduct this experiment, as
patients view their worrying as more controllable, thus demon-
strating that loss of control is not possible.
In OCD, patients believe they will lose control of their
thoughts or will not have peace of mind if they do not remove
an obsessional doubt. In this case, the individual is asked to
postpone their usual ritual (e.g. checking) to see if they lose
control. This is followed by experiments such as ``doubting
more'', to see if it is possible to lose control and in order to
begin to establish an alternative relationship with intrusions.
Modifying danger metacognitions
In MCT for GAD, individuals hold negative metacognitive

beliefs about the dangers of worrying that fall into three
domains: physical, social and psychological. Typical beliefs
include: ``worrying is harmful for my body and could lead to a
heart attack'', ``my partner would leave me if I told her all my
worries'' and ``worrying could make me lose my mind''. Each
type of belief is modi®ed through verbal and behavioural
reattribution methods. A number of verbal reattribution
methods are at the MCT therapist's disposal, including:
86
1 Questioning the mechanism.

2 Examining the evidence that worry is harmful.
3 Reviewing counter-evidence.
4 Education and normalizing the occurrence of worry.
These verbal reattribution methods are followed up with beha-

vioural experiments to consolidate changes in metacognitive
beliefs. Speci®c experiments have been developed as part of
MCT for GAD and include the ``loss of control'' experiment
(Wells, 1997). For example, patients might be concerned about
loss of control of their mind or behaviour. The patient is asked
to try and make the feared event come true by worrying as
much as possible during the allotted worry period and/or
during the treatment session. This is reinforced by asking the
patient to push their worries in the same way when they next
notice a worry trigger in a real-life context. These experiments
often serve the dual purpose of modifying both danger and
uncontrollability beliefs. Similar strategies can be used across
the emotional disorders, albeit with minor alterations. For
example, the OCD patient might believe that obsessional
rumination is uncontrollable; the worry postponement experi-
ment can be applied in this case and can also be extended to
uncontrollability beliefs about rituals.
Explicitly targeting negative metacognitive beliefs about the
uncontrollability and danger of perseverative thinking is a
feature unique to MCT. In GAD, no other form of cognitive or
behaviour therapy directly attempts to modify negative meta-
cognitive beliefs about the uncontrollability of worrying or
danger-related metacognitions. The same is true for other dis-
orders: in depression, CBT does not focus on negative meta-
cognitive beliefs about the uncontrollability of rumination or
the social and interpersonal consequences of engaging in rumi-
nation. Recent therapeutic developments such as behavioural
activation incorporate sessions on reducing levels of rumination,
but do not view the modi®cation of negative metacognitions as
the vehicle to achieve that change.
87
22
Modifying positive metacognitive beliefs
The modi®cation of positive metacognitive beliefs plays an

integral role in MCT for all emotional disorders, as these beliefs
lead the person to maintain an unhelpful coping strategy in
response to unwanted thoughts and/or feelings. This can be
exempli®ed in the case of GAD. An intrusive thought occurs,
often in the form of a ``what if'' question (such as, ``What if I
fail my test?''). At this point, a person usually has a wide array
of responses that can be implemented in response to this
intrusion, including: (1) worrying about failing the test and the
implications of failure, (2) trying to suppress the intrusive
thought, (3) mental distraction, e.g. thinking about something
else instead or counting backwards, (4) physical distraction, or
(5) detached mindfulness, as will be seen in Point 25. However,
in GAD worry is most commonly sustained as a strategy
because positive metacognitive beliefs are activated about the
need to worry in order to cope effectively.
Positive metacognitive beliefs are not limited to the perse-
verative thinking component of the CAS, as patients hold
positive beliefs about attentional strategies and particular
coping behaviours. For example, in PTSD and OCD, patients
often hold positive beliefs about threat monitoring, e.g. ``scan-
ning the environment for signs of danger keeps me safe''.
Threat monitoring is not limited to external stimuli and patients
often monitor for signs of anxiety, because emotion itself is
often appraised as dangerous.
Modifying positive metacognitive beliefs begins with verbal
reattribution. Depressed patients typically generate a broad
range of positive beliefs about the function of rumination, but
they typically fall into two broad domains: (1) rumination will
89
help uncover the cause of the depression, and (2) rumination

will produce an answer to how to overcome depression.
Unfortunately, these erroneous positive beliefs lead the person
into increasing bouts of rumination that maintain depression
and solutions do not miraculously appear.
The MCT therapist conducts an advantages±disadvantages
analysis and points out that there are more disadvantages than
advantages to worry and rumination. The next step is to
critically evaluate and challenge the advantages generated by
patients, followed by exploration of whether there are better
methods of achieving the advantages than via rumination. In
CBT, the therapist also uses the technique of the advantages±
disadvantages analysis, but this is not directed at modifying
metacognitive beliefs but ordinary beliefs (e.g. ``What are the
disadvantages in believing you must do a perfect job?'').
At times, the MCT therapist needs to ask very direct ques-
tions in order to challenge positive beliefs, e.g. `Ìf rumination is
helpful, why do you continue to have dif®culties with low
mood? What does this tell you about the usefulness of rumina-
tion?'' This type of question can be followed up by paradoxical
suggestions. For instance, the MCT therapist could state: ``You
might be right that rumination is helpful; maybe the problem is
that you haven't spent enough time ruminating about your
problems.'' Patients readily acknowledge that this would not be
a helpful way forward. In this way, patients come to
understand that rumination is not bene®cial.
Other verbal reattribution strategies to modify rumination
include questioning the mechanism through which rumination
works and emphasizing that it generates more problems and
negative mood states and rarely if ever presents solutions.
Continuing on a similar theme, the MCT therapist explores the
patient's goals of rumination and questions its effectiveness in
achieving these goals. The task in this instance is to generate
more effective alternatives for achieving goals. Another method
involves the therapist exploring whether patients are employing
inappropriate criteria to signal when to cease rumination, e.g.
90
being emotionally stable. An alternative can then be reinforced,

such as the idea that an absence of rumination would more
effectively achieve this goal.
Often verbal reattribution strategies go a long way to modi-
fying positive beliefs about rumination, but it is sometimes
necessary to conduct behavioural experiments to modify these
beliefs. A common belief is that rumination helps to solve
problems, and in order to test this belief, the patient is asked to
ruminate one day, followed by minimal or no rumination the
next day, and to note whether more problems were solved on
the rumination day. These types of experiment are called worry/
rumination modulation experiments (Wells, 2000).
Positive metacognitive beliefs about the function of worry
can be modi®ed through ``mismatch strategies'' (Wells, 1997).
This strategy requires the patient to write down all the worries
encapsulated in a speci®c worry episode and to compare these
worries with an actual event. This can be done retrospectively
as a verbal reattribution strategy or done prospectively as a
behavioural experiment. In the latter case, the patient is asked
to worry about a forthcoming event and a note is made of all
the worries. The patient is then exposed to the feared situation
and a comparison is made between the actual events and the
negative predictions.
91
23
Worry/rumination postponement
Worry and rumination occur in all emotional disorders and
therefore a main therapeutic goal should be to eliminate or, at
the very least, substantially reduce the amount of time an
individual spends in these maladaptive thinking styles.
The worry/rumination postponement experiment is a strategy
used in MCT that helps strengthen metacognitive control but
principally is used to challenge metacognitive beliefs about the
uncontrollability of these mental processes. It can also reduce
danger-related negative metacognitive beliefs, although beliefs
in this domain must also be addressed explicitly over the course
of therapy.
Worry/rumination postponement begins with verbal reat-
tribution strategies instantly recognizable to the CBT therapist.
However, the target beliefs are metacognitive beliefs concerning
uncontrollability, e.g. `Ì can't control my worrying thoughts'',
and not beliefs at the cognitive level, e.g. ``What if I lose my
job?'' The MCT therapist reviews with the patient the evidence
for and against the uncontrollable nature of worry and rumina-
tion to demonstrate that perseverative thinking can be con-
trolled (see Point 21 for more details on verbal reattribution of
negative metacognitive beliefs). Following verbal reattribution,
the worry/rumination postponement is introduced with an
appropriate rationale, as illustrated below:
We have discussed the important role that your belief that

worry is uncontrollable plays in keeping your worry and
anxiety in place. One of the reasons you believe worry is
uncontrollable is because you have had so few experiences of
successfully interrupting your worrying. Unfortunately,
93
when you have tried to stop worrying, the strategies you've

used, such as attempting not to think about a speci®c topic,
have not worked very well. Using this type of strategy has
actually fuelled your belief that worrying is uncontrollable.
So I would like you to try a different way of responding to
your worries when they occur.
Patients are then given the following explicit instructions:
When you notice a worry pop into your mind, I'd like you to
say to yourself, ``Stop; this is only a thought, I'm not going to
engage with it now, I'll leave it alone and worry about it
later.'' Allocate a time later in the day, when you will allow
yourself 15 minutes to worry. When that time arrives, you can
engage in your postponed worry, and worry as much as you
want to. However, you don't have to use this worry period
and most people choose not to use it as they have either
forgotten about the worry or prefer not to do it. However, if
you do decide to use the worry period, please make a note of
why you decided to use it. This is an experiment to ®nd out
how much control you really have over your worry.
One very important feature of this experiment is that the

therapist must make a clear distinction between worry post-
ponement and thought suppression. Patients are not being
asked to rid themselves of the content of unwanted thoughts;
instead, they are being asked to suspend any further processing
of the initial thought. The therapist should monitor changes in
degree of conviction that worry is uncontrollable.
Although the worry/rumination postponement experiment
increases awareness of the pervasive nature of worry or
rumination, the MCT therapist undertakes a detailed review of
the breadth of application to ensure that the patient is applying
the strategy to the majority of instances of perseverative think-
ing. At times, patients are resistant to postponing rumination or
worry due to strongly held positive beliefs about the usefulness
94
of worry/rumination. In such instances, the therapist's task is to

use verbal and behavioural reattribution methods to modify
such positive metacognitive beliefs (see Point 22).
In MCT, worry postponement is used to challenge uncon-
trollability and limit the CAS. Controlled worry periods have
been used in other treatment approaches for GAD (e.g.
Borkovec et al., 1983). However, the MCT approach differs
from such stimulus control applications. Stimulus control is
based on the assumption that patients have lost discriminative
control over the worry process; postponed worry periods are
designed to enable patients to regain control over worry. In
MCT, it is not assumed that there is any actual loss of control;
instead, beliefs about control are erroneous.
Borkovec and colleagues ask individuals to utilize postponed
worry periods during which they ``problem solve'' their worries.
This is not a feature of MCT, since problem solving of indi-
vidual concerns is contra-indicated as another example of
extended reasoning about thought content. As described above,
in MCT the use of the postponed worry period is optional and
used later in treatment. Then, the patient actually tries to lose
control of their worry in order to further modify uncontroll-
ability beliefs and beliefs about the dangerous nature of worry.
95
24
Attention training technique
A primary goal of MCT is to reduce self-focused processing

and enhance metacognitive control, which can be achieved
through a speci®c strategy called the Attention Training Tech-
nique (ATT; Wells, 1990). ATT comprises three externally
focused auditory attentional tasks: selective attention, attention
switching and divided attention tasks. These are conducted
sequentially during a 10±15-minute ATT session. Selective
attention is practised for approximately ®ve minutes before the
next step of rapid attention switching for ®ve minutes. The ®nal
step of ATT is a two-minute divided attention component.
The term attention training is often referred to in the new
generation of cognitive-behavioural approaches and should not
be confused with ATT. For example, Acceptance and Commit-
ment Therapy (ACT; Hayes et al., 1999) incorporates training in
self-directed attention, with the goal of sustained exposure to
emotions thereby leading to desensitization of the conditioned
response and the reversal of avoidance behaviour. The purpose
of ATT is not to sustain exposure to unwanted emotions but to
develop greater executive control. In Mindfulness Based
Cognitive Therapy (MBCT; Segal et al., 2002), reference is also
made to attention training. But in this instance it refers to the
redeployment of attention as a component of meditation.
Speci®cally, patients are asked, if they notice an unwanted
thought during meditative practice, to reallocate their focus to
their breathing. In this way, patients treated with MBCT remain
self-focused, whereas ATT is designed to counteract excessive
self-focus and utilizes only external focusing. ATT is not applied
in response to thoughts or emotions. It is not a coping technique
but a training exercise that is intended to build the necessary
97
framework and procedures for improving metacognitive control

over processing.
A summary description of ATT, as outlined by Wells (2000,
2009), is presented below.
Step 1: Introducing ATT

ATT begins by providing the patient with a credible and
understandable rationale for the treatment technique. The
unifying theme across disorders is that excessive self-focus leads
to an increase in the saliency and severity of symptoms, but the
rationale is tailored to the speci®c presenting problem. Self-
focus here is used as a short-hand label for the CAS. In panic
disorder and health anxiety, the therapist stresses that focusing
on bodily symptoms plays a crucial maintaining factor, whereas
in depression, patients are helped to see that the tendency to be
attentive to thoughts and feelings is associated with rumination,
thereby exacerbating and maintaining low mood. Socialization
experiments are used to highlight how excessive self-focus and
rumination maintain and exacerbate the patient's presenting
problem. The case formulation is used to highlight the
association between excessive self-focused attention and the
presenting problem.
Once the patient has a good understanding of the main-
taining role of excessive self-focus, the therapist introduces
ATT. Credibility of the technique should be assessed and, if
there is low credibility, then further work is undertaken to
socialize the patient to the role that maladaptive attentional
strategies play in problem maintenance.
Step 2: Self-focus ratings

Before implementing ATT, the patient's current level of self-
focus versus external focus is assessed using a simple Likert
scale. This rating is repeated after implementing ATT. The scale
98
provides an index of change following the ATT procedure; a

two-point change in level of self-focus is normally required and,
if the change is less than this, the reasons are explored and ATT
potentially re-administered.
Step 3: Implementation of ATT

Before ATT starts, the therapist emphasizes that the task is to
practise focusing attention as guided. A crucial instruction is
that, should intrusive thoughts or feelings occur, the task is
simply to treat these thoughts or feelings as background noise
and not attempt to suppress or remove them.
ATT begins with the auditory selective task. The therapist
instructs the patient throughout the procedure and guides the
patient to attend to at least three sounds in the room, such as
the therapist's voice, the ticking of a clock or the hum of a
computer. Next, the patient is instructed to attend sequentially
to three other sounds or spatial locations outside the consulting
room. Once six to eight sounds have been identi®ed and
selectively attended to, the therapist instructs the patient to
switch their attention rapidly between the different sounds.
These stages are each conducted for ®ve to six minutes. The
®nal stage is to instruct the patient in a divided attention task,
which requires them to attempt to listen to all the sounds
simultaneously; this is practised for two to three minutes.
Throughout the task, the MCT therapist ensures that the
patient ®nds the task relatively dif®cult, i.e. attention demands
are high.
Step 4: Review ATT and set homework

After practising ATT the theorist reviews the procedure with
the patient and plans how it will be implemented for home-
work. Patients are asked to complete ATT at least once per day
for 15 minutes, but are reminded that it should not be used as a
99
coping strategy, e.g. to distract themselves from unwanted

thoughts and feelings.
ATT has been shown to be associated with symptom
improvements and changes in worry and beliefs in a range of
disorders, including panic disorder (Wells, 1990; Wells et al.,
1997), major depressive disorder (Papageorgiou & Wells, 2000)
and health anxiety (Cavanagh & Franklin, 2001; Papageorgiou
& Wells, 1998). In addition, the ®rst case study of ATT for
auditory hallucinations was recently completed (Valmaggia et
al., 2007). See Wells (2007) for a review of the effects of ATT.
100
25
Implementing detached mindfulness
MCT aims to promote ``detached mindfulness'' (DM; Wells &
Matthews, 1994), which counteracts the cognitive attentional
syndrome. Detached mindfulness refers to how individuals
respond to mental events (e.g. worries, intrusive images, nega-
tive thoughts, and memories). As described in Point 7, detached
mindfulness involves discontinuation of any further cognitive
or coping response to thoughts, which typically involves the
suspension of perseverative thinking and speci®c coping stra-
tegies such as focusing, avoidance or transforming thoughts.
The second feature of detachment consists of an individual
directly experiencing self as an observer separate from the
occurrence of the thought itself.
Application of detached mindfulness in MCT

The overall treatment goal of MCT is to promote detached
mindfulness and therefore most treatment strategies available
to the MCT therapist contribute to the development of this
state. However, several speci®c techniques have been developed
that facilitate detached mindfulness (Wells, 2005). Described
below are two of these techniques.
Free association task

This task has multiple goals, including developing meta-
awareness, low levels of conceptual processing and detachment.
The task can be presented following a discussion of the natural
¯ow and decay of emotionally neutral thoughts over the course
of a typical day facilitated by simple questions, such as ``What
101
happens to the majority of your everyday thoughts? Where do

these thoughts go?'' Patients quickly come to realize that for the
vast majority of their thoughts, ``detached mindfulness'' is the
natural processing state; it is only the intrusive thoughts that
are volitionally allocated attention and sustained processing
that become problematic. The next step is to convey that
intrusive thoughts are no different from other thoughts and
therefore it is entirely possible to choose not to engage with
intrusive thoughts. The task itself is then introduced as a means
of developing experiential (procedural) knowledge to support
the state:
In a moment I am going to say a list of common words and I

would like you to let your mind roam freely in response to
the words. It's important that you do not attempt to control
your mind or your response to the words; I just want you to
passively notice what happens in your mind. For some
people, not much happens, other people ®nd that pictures or
images come into their mind and some people also report
feelings or sensations. I'm now going to say the list of
common words: orange, pen, table, tiger, trees, glasses,
breeze, statue. What happened when you just watched your
mind?
Patients typically report that as each word is spoken, an image

of that word occurs. Often these are discrete images, each
replacing the previous one, but sometimes images merge
together or no thought occurs. The natural ebb and ¯ow
of thoughts is pointed out by asking what happened to the ®rst
thought as the task proceeded. Patients come to see that
thoughts decay without the need to attempt to remove them or
process them in an extended way. Repeating the procedure and
asking the patient to become aware of the self as a separate
observer of the thoughts enhance detachment.
Detached mindfulness in response to intrusions and other
classes of unwanted thought can be further facilitated by
102
including emotionally salient words in this task. The central

idea is that patients can simply notice thoughts and not get
caught up in further processing of them. Patients are asked to
apply the strategy of passively noticing their negative thoughts,
worries, intrusions and feelings for homework.
Tiger task
This task provides patients with the experience of DM, by
bringing an image of a tiger to mind and simply watching the
image without attempting to in¯uence the image. The therapist
assists this process with the following instructions:
In order to get a feel for using detached mindfulness, I'd like

you to begin by bringing an image of a tiger to mind. I don't
want you to try and in¯uence the image, so don't try to
change the tiger's behaviour or change anything about it.
The image might be in black and white or colour; it doesn't
matter, just notice the tiger. The tiger might move, but don't
make it move; just watch how the image develops over time,
but do not try to in¯uence it; simply watch the image of the
tiger in a passive way.
These tasks are practised in session, but can also be used as

homework tasks to promote detached mindfulness. The
ultimate goal for patients is to ``do nothing'' upon noticing
an intrusive thought, whether it occurs in the form of a worry, a
negative automatic thought, an obsession, an aversive memory
or an image. In MCT, detached mindfulness is used in con-
junction with worry/rumination postponement to facilitate low
levels of perseverative thinking, to modify maladaptive
attentional strategies and remove dysfunctional coping beha-
viours. In other words, the implementation of detached mind-
fulness limits the cognitive attentional syndrome and reduces
psychopathology.
103
Recent innovations in cognitive approaches to treating

emotional disorders, such as Mindfulness Based Cognitive
Therapy (MBCT; Segal et al., 2002) and Acceptance and
Commitment Therapy (ACT; Hayes et al., 1999), use the term
``mindfulness'' in describing their theories and treatment stra-
tegies. However, ``mindfulness'' is distinct from ``detached
mindfulness'' as speci®ed in MCT. The use of similar terms has
caused confusion in clinicians' minds, with the two constructs
often viewed synonymously, but parallels should not be drawn
simply on the basis of terminological similarities.
Mindfulness is de®ned as ``paying attention in a particular
way; on purpose, in the present moment and non judgmentally''
(Kabat-Zinn, 1994: 4). Over the past two decades, interest in
the concept of mindfulness has burgeoned and has been incor-
porated into a range of clinical approaches. Mindfulness was
®rst utilized by Kabat-Zinn (1982), in his Mindfulness Based
Stress Reduction (MBSR) programme, as a treatment package
for patients with chronic pain, but has subsequently been used
for a range of behavioural and emotional dif®culties (Kabat-
Zinn, 1998). In this context, the state of mindfulness is achieved
through various Buddhist meditation exercises (Hanh, 1976).
MBCT combines cognitive therapy with mindfulness medita-
tion practice, whereas ACT develops mindfulness through
many different treatment components, including acceptance,
cognitive defusion, willingness, focusing on the present moment
and attentional training (Masuda et al., 2004).
A brief foray into the application of mindfulness as used in
ACT and MBCT illuminates the differences from detached
mindfulness. Roemer and Orsillo (2002) suggest that the inte-
gration of mindfulness and acceptance practices would enhance
the ef®cacy of CBT for GAD and have included elements of
mindfulness in their approach (Roemer & Orsillo, 2007).
Mindful practices in ACT include imagining leaves ¯oating
down a stream and attempting to place thoughts, feelings and
experiences on the leaves and watch them ¯oat away. This
strategy is not the same as DM because it entails further
104
processing in the form of doing something with the thoughts. In

MCT, this could be used as a metaphor to explain that
thoughts are ¯eeting events that do not require attention, but
not as a speci®c exercise as it is essentially a thought control
strategy. Progressive muscle relaxation is conceptualized as a
method of promoting mindfulness, rather than a method of
controlling anxiety in Roemer and Orsillo's acceptance-based
behaviour therapy for GAD. This treatment strategy is not
applied in MCT.
Another treatment component of ACT designed to promote
mindfulness is termed ``cognitive defusion''. ACT utilizes many
different strategies under this umbrella term. One speci®c
method, called deliteralization, refers to removing the literal
content of the thought, thereby enabling the client to take a
non-judgemental stance on their thoughts with greater will-
ingness and acceptance. Physicalizing is an example of a
deliteralization strategy, in which the patient ascribes colours or
shapes to the intrusive thought. This stands in stark contrast to
detached mindfulness, in which the central component is the
absence of further processing in the form of transformation in
response to thoughts. Also, the clinical target of the above
strategy is the thought that intrudes into consciousness, not the
beliefs (or plans) that drive conceptual processing, as in MCT.
Furthermore, detached mindfulness in MCT is used as a com-
ponent of behavioural experiments to modify uncontrollability
beliefs, which is not a speci®c goal of other mindfulness
techniques.
As previously mentioned, MBCT is an integration of cog-
nitive therapy strategies and mindfulness meditation. A range
of meditative exercises is included in each treatment session and
given for homework. Exercises include mindful eating, during
which the therapist and patient slowly eat raisins, focusing their
attention on aspects of eating as well as on their thoughts and
emotions. A body scan is introduced where the patient is
instructed to focus his attention on different parts of his body
and is encouraged to view any sensations in a non-judgemental
105
manner. If unwanted thoughts occur, the patient is asked to

return his attention to his body. Other forms of meditative
exercises included are mindful stretching, mindful walking and
sitting meditation, where awareness is focused on breathing and
patients are asked to refocus their attention on their breathing
should it be captured by thoughts, feelings or experiences. A
generalization strategy is also included, which is the use of a
brief three-minute breathing space to cultivate mindfulness
during the day. This strategy can also be used in response to
symptoms of anxiety or other unwanted feelings or thoughts.
This requires the patient to allocate attention away from
triggering stimuli and to refocus on their breath. MCT does not
employ any of these strategies; indeed, responding to intrusive
thoughts or feelings by redirecting attention away from the
aversive experiences runs contrary to the aims of MCT, as
doing so may maintain erroneous metacognitive beliefs about
the need to respond to thoughts and feelings.
Clearly, mindfulness meditative practices call upon meta-
cognitive processes and beliefs because they involve the allo-
cation of attention and control of cognition. However, these
procedures have not been developed in the context of a model
of metacognition and psychopathology. The goals of the
techniques, unlike the goal of DM, are not operationalized in
metacognitive terms and they impact potentially on a wide
range of factors, all of which may not be bene®cial. For
instance, it is noteworthy that mindfulness meditation uses
strategies that increase body focus as a means of moving
attention away from thoughts.
106
26
Situational attentional refocusing
Situational attentional refocusing (SAR; Wells, 2000; Wells &

Papageorgiou, 1998) is a treatment strategy designed to reverse
the current maladaptive attentional strategies a person adopts
in a stressful context. Although the types of attentional strategy
may vary between patients and across disorders, maladaptive
attentional strategies prevent the person from modifying their
knowledge. Typical dysfunctional attentional strategies include
both excessive self-focus seen in social phobia and inappro-
priate threat monitoring that so often characterizes PTSD
or OCD.
In social phobia, the individual engages in self-focused
processing when exposed to a feared social situation, which is
guided by positive metacognitive beliefs concerning the utility
of self-focus. In addition to focusing on signs and symptoms of
anxiety, individuals allocate attention to a self-generated image
of how they believe they appear to other people, i.e. from an
observer's perspective. In this constructed image, the signs of
anxiety are viewed as extremely conspicuous and exaggerated.
For example, the social phobic may blush, which in reality is
barely noticeable; in the image of the mind's eye, however, the
person views herself as ``burning up'' and being the colour of
beetroot. This self-focus interferes with the processing of exter-
nal features of the social environment, so the person fails to
learn that they are not really conspicuous and the centre of
everyone's attention. Self-focus also increases awareness and
severity of anxiety, and reduces performance in social
situations.
SAR strategies allow the MCT therapist to reduce excessive
self-focus and allow new information to be incorporated in
107
processing routines. In the case of social phobia, this means

enabling the person to shift to focusing their attention exter-
nally rather than remaining self-focused. For example, patients
with social phobia often express the concern that people stare at
them in social situations. A patient commented that when she
entered a bar, everyone turned and looked at her. The therapist
asked how she knew this to be true as she typically avoided eye
contact in social situations. Instead, she would focus her
attention on how she was feeling and the negative image in her
mind. Behavioural experiments involving directing attention
externally rather than internally allowed the person to
incorporate new knowledge. Therefore, in the above example,
the behavioural experiment simply consisted of focusing
attention externally on other people in the environment in
order to facilitate belief change.
Similar dysfunctional attentional strategies are evident in
PTSD and are also guided by positive metacognitive beliefs
about the helpful nature of such strategies. For example,
patients are frequently hypervigilant for threat, driven by the
belief that ``checking for danger keeps me safe''. The therapist
helps reorient the person's attention on to neutral stimuli and
safety signals in the environment. In this way, the ``danger and
threat programme'' is taken off-line and cognition is allowed to
tune back to a pre-trauma routine.
108
27
Targeting meta-emotions
Meta-emotion is emotion about emotion or emotion applied to

regulating emotion or used as a reference point for coping.
Patients often use emotions as a source of metacognitive infor-
mation that contributes to the maintenance of the psychological
disorder. In the S-REF model (see Point 2), the information
derived from positive and negative emotional states contributes
to appraisals of thoughts and of self-knowledge and is used to
indicate whether continued coping efforts are required. For
example, in GAD, when an intrusive thought in the form of a
``what if'' question occurs, self-focused attention increases, the
worry process begins and the person uses their emotional state,
i.e. reduction in anxiety, as a cue to when to cease worrying.
Meta-emotions clearly overlap with the construct of emo-
tional reasoning, in which beliefs such as `Ì feel worthless
therefore I am worthless'' or `Ì feel hopeless therefore the
future is hopeless'' operate and are addressed in cognitive
therapy. A closely related construct is ex-consequentia reason-
ing (Arntz et al., 1995), in which emotions are perceived as
indicators of threat, in the form of: `Ìf I feel anxious, then there
must be danger.'' However, Wells (2000) argues that the con-
cept of meta-emotions extends beyond these forms of system-
atic errors or biased thinking and instead represents internal
information that regulates cognition and coping strategies.
The MCT therapist pays careful attention to meta-emotional
states. In depression, patients are often hypersensitive to poten-
tial signs of depression and/or recurrence of the problem and
will interpret any symptoms in a negative way as indicating
relapse. This style of responding can reactivate the CAS in
patients, i.e. the patient will then engage in rumination, increase
109
the level of self-monitoring and resort to avoidance. For

example, a depressed patient described having a very good
week, but then questioned this mood state and began to
ruminate on how long ``the good mood'' would last, with the
resultant effect of a rapid deterioration in mood. In addition,
the same patient had anxiety about positive emotional states
(meta-emotion), as these were regarded as transitory and
meant that, when her mood dipped, the decreases would be so
dramatic as to make the subsequent depressive episodes
unbearable. Indeed, this patient expressed her preference for
maintaining a relatively ¯at affect (meta-emotion), as this would
avoid large ¯uctuations in mood. This is a metacognitive
process in which the patient selected a particular emotional state
volitionally. In this instance, the therapist modi®es the
metacognitive beliefs driving the strategy and normalizes
mood ¯uctuations. Patients can be asked what happens to the
emotions, e.g. ``Do they continue for ever or do they ¯uctuate?''
or ``Have you ever experienced an emotion that has lasted for
ever?'' Clearly, the answer is no, and by not engaging with the
emotion, the patient would learn that emotions rapidly fade and
are replaced by other emotional states.
The premise that an individual is volitionally selecting a
particular mood state or is fearful of emotion can be readily
understood in the context of a metacognitive framework, but is
not readily conceptualized in other forms of therapy. However,
recent work on emotional schemas (e.g. Leahy, 2007) that has
been stimulated by the S-REF model has begun to explore the
idea that beliefs about emotions may be important in CBT.
110
28
Delivering metacognitively focused
exposure
Exposure is a fundamental feature of all cognitive and beha-
vioural interventions, including MCT. However, exposure in
behaviour therapy, cognitive therapy and MCT is based on
distinct theoretical constructs that translate into different forms
and applications of exposure in therapy. The use of exposure is
important in both assessment (see Point 17) and treatment.
In MCT, exposure is used primarily in the form of a brief
behavioural experiment, which is presented with a speci®c
theoretical rationale designed to test and change metacognitive
beliefs and processes. As MCT treats disorders through modi®-
cation of the cognitive attentional syndrome, it is not predi-
cated on a behavioural model of anxiety. This means that MCT
does not rely on extensive exposure, as is the case in exposure
and response prevention for OCD, or imaginal or in-vivo
exposure to traumatic images/memories in PTSD.
Exposure is used in MCT in a number of ways, but this
discussion will focus on just two: (1) the modi®cation of meta-
cognitive beliefs, and (2) the facilitation of adaptive processing
in trauma.
Modi®cation of metacognitive beliefs requires the therapist
to identify and test positive and negative metacognitive beliefs
about thinking, as illustrated by the following therapist±patient
dialogue in a case of OCD:
Therapist: What do you think will happen when you have

thoughts about hurting your son?
Patient: That I might end up acting on those thoughts
and hurt my son and he'll be taken into care.
111
Therapist: Do you try to control these thoughts in any

way?
Patient: I try not to have them by avoiding contact with
my son when my husband isn't here. When I'm
alone with my son, I almost always get the
thoughts. I also change the image I have of
hurting my son into one where I'm playing with
him.
Therapist: What do you think would happen if you no
longer avoided being alone with your son and
didn't change the intrusive thought into a
positive image?
Patient: I'd hurt my son, if I didn't get rid of the thought.
Therapist: It sounds like you believe these thoughts are
really important. Do you think having thoughts
about hurting your son will lead you to doing so?
Patient: Yes, I really don't want to have them.
Therapist: How much do you believe that having the image
of hurting your son could make you do it?
Patient: Quite a lot when I have the image and I'm alone
with my son; I guess about 70 per cent.
Therapist: So it seems that you are giving these thoughts
considerable importance. What we need to do is
help you recognize that these thoughts are
insigni®cant and meaningless.
This patient was asked to interact with her son and postpone
her thought control strategies and coping behaviours to test the
metacognitive belief: ``Thinking that I will hurt my son will
make me do it.'' She was asked to do this under two
conditions: ®rst, to respond when the intrusions spontaneously
occurred and, second, to deliberately invoke the obsession and
keep it in mind for two to three minutes whilst playing with her
son, and then to continue to postpone her neutralizing
strategies. This approach is different from that taken from the
behavioural perspective, which focuses predominantly on
112
enabling the person to habituate to the anxiety and would

require substantially greater periods of time (several hours)
than the two to three minutes used in the above metacogni-
tively focused behavioural experiment. The behavioural
approach might expose the patient to a recording of her
thought. Speci®cally, that she repeatedly listens to the thought
whilst not engaging in any neutralizing behaviours. Prolonged
and repeated exposure of this kind would not be a feature of
MCT. The aim of CBT is to promote habituation to the
intrusion, but the aim in MCT is to challenge the metacognitive
belief about the intrusion and allow the patient to relate to it in
new ways. Therefore, therapy should be conducted solely at the
metacognitive rather than the cognitive or behavioural level.
Fisher and Wells (2005) demonstrated that brief exposure and
response prevention (ERP) presented with a metacognitive
rationale was more effective than ERP presented with a
behavioural (habituation) rationale in OCD patients.
A second use of exposure in MCT is in the treatment of
PTSD, in which metacognitively delivered exposure aims to
reduce and replace dysfunctional processing and coping beha-
viours. Instead of responding to intrusive thoughts and
memories with perseverative thinking and counterproductive
coping strategies, patients are instructed to respond to these
cognitive events using detached mindfulness. The rationale
given to patients is that unhelpful strategies such as worry,
rumination, avoidance and hypervigilance are preventing
normal adaptive processing of symptoms resulting from a
traumatic experience. MCT for PTSD is discussed in detail in
Points 14 and 30. The distinctive nature of this treatment
approach is that it does not require repeated and prolonged
exposure to trauma memories; therefore, patients are never
asked to write or narrate detailed accounts of their traumas.
Instead, patients are instructed merely to notice the intrusions
and desist from further conceptual processing, i.e. abandon
thought control and perseverative thinking. In-vivo exposure
can be a component of treatment but only to the extent that
113
patients are asked to return to their usual pre-trauma routine if

appropriate and to abandon maladaptive strategies of threat
monitoring in these situations (e.g. Wells & Sembi, 2004a).
114
29
Developing new plans for processing
The metacognitive model proposes that the CAS is linked to the

priming of dysfunctional processing plans, in response to
unwanted thoughts, feelings or events. For example, in depres-
sion, the metacognitive plan and associated metacognitive
beliefs might be: `Ì need to ruminate in order to ®nd a way out
of depression'', ``My sadness is uncontrollable'' and ``Negative
thoughts are important and must be attended to''. Therefore
each time a negative thought or mood deviation intrudes into
consciousness, the person effectively ``downloads'' a plan from
long-term memory, resulting in prolonged and sustained
rumination. A goal of the MCT therapist is to modify this
plan. Each aspect of MCT is designed to enable the patient to
develop and select an appropriate alternative plan that limits
the CAS, thereby ameliorating psychopathology.
In general, developing a new plan for processing is an
explicit focus of the latter stages of MCT. This functions as a
relapse prevention strategy designed to reduce vulnerability to
future episodes of prolonged emotional disturbance. Construc-
tion of the new plan begins with a detailed account of the
patient's old plan. The new or replacement plan consists of
selecting the opposite attentional strategies and coping beha-
viours and an absence of perseverative thinking. Outlined in
Figure 5 is an example of an old plan and the new plan for an
OCD patient with contamination fears about toxic materials.
The MCT therapist enables the patient to practise the new
plan frequently in a range of situations. For the OCD patient
illustrated in Figure 5, this included brief exposures (®ve
minutes) to feared situations and implementation of the new
plan. As described in Point 28, the goal is not habituation, as in
115
Plan A (old plan) Plan B (new plan)
1 Pay attention to intrusions 1 Apply detached mindfulness to

intrusions
2 Give meaning and signi®cance 2 Tolerate initial anxiety/distress
to intrusions when intrusions occur
3 Scan environment for signs of 3 Ban scanning the environment
dirt and broken glass
4 Avoid the cleaning zones of 4 Do not avoid any situations
supermarket
5 Tell self not to be stupid in 5 Don't engage in thought control
response to doubts strategies
6 Try to mentally distract self 6 Desist from analytical reasoning
from thoughts
7 Try to remove intrusions from 7 If wash hands in response to
consciousness intrusion, keep intrusion in mind
8 Calculate probability of harm rather than attempting to
coming to children banish the intrusion
9 Monitor mind for intrusions
10 Wash hands without having
the intrusion
Figure 5 Example of an old plan and new plan for an OCD

patient with contamination fears
behaviour therapy, but modi®cation of repeated dysfunctional

processing guided by metacognitive beliefs. Practising the new
plan is not limited to homework tasks; it should be imple-
mented in therapy each time the therapist notices activation of
the maladaptive plan, e.g. occurrences of perseverative thinking
or inappropriate threat monitoring. In other words, the MCT
therapist is working at the metacognitive level and not the
cognitive level when developing and helping patients to imple-
ment new processing.
Development of the new plan includes a discussion of fears
of recurrence and anticipated problems in the future. The fear
of recurrence often involves a particular plan for processing
that is problematic. A common maladaptive response strategy
used by patients with OCD is to continue to monitor the stream
116
of consciousness in order to check for an absence of negative

thoughts. This constitutes a maladaptive plan, which should be
highlighted and modi®ed. In a similar fashion, discussion
regarding future possible stressful situations and how the
patient imagines dealing with these situations also elicits
counterproductive processing plans and erroneous metacogni-
tive beliefs. Practice and rehearsal help to reduce vulnerability
by consolidating alternative plans for processing.
117
30
Integrating MCT techniques: a case study
In this ®nal section, a case study of MCT for PTSD is pre-

sented. This case study illustrates how MCT combines the
distinctive practical and theoretical features into a coherent and
novel treatment. The treatment described is based on two
treatment manuals (Wells, 2009; Wells & Sembi, 2004a).
Sadie arrived home one evening and was attacked by three
young men as she got out of her car. She tried to prevent the
theft of her car, but as she struggled with one of her attackers,
she became entangled in the seat belt and was dragged down
the road as the car was driven off. Consequently, she suffered a
number of leg injuries and substantial lacerations to her upper
body and face. After this traumatic incident, Sadie developed
PTSD and had been experiencing symptoms for approximately
two years. The main PTSD symptoms were repeated intrusive
memories of the incident and a strong sense of re-experiencing
the event in which she would feel disconnected from reality and
could hear the sound of the car's roaring engine and feel the
burning pain in her legs as if the event were happening again.
Up to three hours per day were spent worrying and rumi-
nating. Worry primarily focused on the possibility of a similar
event happening again in the future, whereas the rumination
centred on her inability to prevent the theft. As a direct
consequence of the PTSD symptoms, Sadie felt that her life
had been taken away. Her once thriving small business was on
the point of collapse because she often avoided leaving her
home. Not surprisingly, there were marked levels of depression
and anxiety.
In the ®rst treatment session, the nature and rationale of
MCT for PTSD was presented to Sadie. The therapist explained
119
that it is ``normal'' to experience such symptoms in the after-

math of a traumatic event and, in fact, these symptoms are a
necessary part of an adaptation process. However, trauma-
related symptoms normally fade over time, but unfortunately
the symptoms can inadvertently be maintained when people use
particular coping strategies. Fortunately, it is relatively straight-
forward to identify these unhelpful coping strategies and replace
them with helpful behaviours and responses to the unwanted
thoughts and memories.
The therapist carefully conducted a focused assessment in
order to identify the metacognitive beliefs, processes and coping
strategies and construct an idiosyncratic case formulation based
on the metacognitive model of PTSD (see Point 14). As pre-
viously noted, Sadie was spending a great deal of time rumi-
nating and worrying. There had also been a substantial change
in her attentional processes; she was aware of being very
vigilant for signs of threat whenever she left the house and also
frequently checked her body for signs of anxiety.
To uncover the metacognitive beliefs underpinning perse-
verative thinking, the therapist explored why Sadie believed
that worrying about a similar event occurring was helping and
what advantages were gained by repeatedly examining the event
from many different angles. Sadie was also asked about the
advantages of looking out for signs of threat in her environ-
ment and her body.
The main positive metacognitive belief elicited about worry
was: ``Worrying about the event happening again means I can
take action to avoid it and ensure that I am safe at all times.''
In terms of rumination, the belief was: `Èxamining what
happened from all angles means I can work out why it
happened and then I can stop thinking about it and be happy
again.'' Her negative metacognitive beliefs about worry and
rumination were: ``When I start thinking about the event, I
can't stop'' and `Ìf I can't stop going over the event, I'll go
mad.'' Her metacognitive beliefs about threat monitoring were:
`Ìf I look around me for threat then I can make sure I'll be
120
safe'' and ``Noticing that I'm anxious makes me alert for

danger and I won't be caught out.''
The metacognitive model of PTSD also speci®es a number of
additional unhelpful coping strategies that prevent the person
escaping from unhelpful conceptual processing. Accordingly,
the therapist assessed for such strategies and found that Sadie
was checking the doors and windows repeatedly in an attempt
to control her anxiety. She also avoided being out of her own
house after dark, and tried to control her thoughts by trans-
forming the aversive memories. Instead of becoming injured, in
her memory she tried to imagine capturing the assailants and
gaining retribution. This strategy was driven by the metacog-
nitive belief: `Ìf I don't get rid of the images, I'll go mad.''
These strategies were included in the case formulation, as
illustrated in Figure 6.
The case formulation was shared with Sadie as the ®rst step
in socialization (Point 19) to the metacognitive approach. Sadie
was helped to understand that the strategies listed above were
maintaining and exacerbating her trauma symptoms, as well as
increasing her levels of anxiety and depression. In order to
accomplish this goal and to give Sadie an appropriate mental
framework for understanding the aims of MCT, the therapist
used the ``healing metaphor'':
Your body has an inbuilt method of repairing itself; for

example, if you cut your hand the body heals itself, you
don't have to do anything to heal the cut. Your mind is no
different; it too has an inbuilt mechanism for healing itself.
Let's imagine you have a wound. Leaving it alone and doing
nothing to it is the best thing you can do; if you keep
interfering with the wound it will slow down the healing
process. Your intrusive memories and other symptoms are
like a wound and it's best to leave them to their own devices.
Worrying or ruminating about your intrusive thoughts and
memories, trying to control thoughts and control your
attention is like interfering with the wound. You must allow
121
Figure 6 Metacognitive case formulation of PTSD
the healing process to take care of itself and you'll ®nd that
the emotional wound will fade.
The socialization process was completed by asking Sadie a

series of questions to help her understand the problems inherent
in using worry and other unhelpful coping strategies in response
to her intrusive thoughts. For example, ``Does worrying lead to
you feeling safe?'' and ``Does focusing attention on signs of
danger help you to have an accurate view of how dangerous
situations actually are?'' The therapist then used a behavioural
experiment to illustrate the rebound effect of thought
122
suppression, followed by training in detached mindfulness using

a free association task (Points 7 and 25). The detached mind-
fulness state was contrasted with the effects of thought control,
before implementing the worry/rumination postponement
exercise as homework.
Sadie reported a reasonably high degree of success in
implementing detached mindfulness to the negative thoughts,
intrusive memories and images. The postponed worry/rumina-
tion period was never used, as Sadie felt it unnecessary. How-
ever, she had engaged with approximately 40 per cent of her
intrusive thoughts, which she labelled as the ``worst images''.
Using metacognitive pro®ling (see Point 17), it was determined
that her goal was to remove these thoughts from memory and
she was searching for methods to achieve this. In other words,
the occurrence of the most distressing thoughts activated the
metacognitive belief: `Ì need to ruminate in order to ®nd a way
of getting rid of these images.'' The MCT therapist discussed
this strategy in reference to the case formulation and reiterated
the counterproductive nature of this strategy. Sadie was asked
to bring the worst image to mind and to practise detached
mindfulness. To her surprise, Sadie experienced only a brief
period of anxiety in response to this exercise and found that the
thought faded rapidly. She was encouraged to continue with
detached mindfulness for homework and to apply the worry/
rumination postponement to all forms of unwanted thought.
Therapy moved on to modifying the attentional strategies
contributing to problem maintenance. Sadie was asked how she
worked out what she needed to pay attention to in order to be
safe. She stated that she needed to scan the environment and
repeatedly ask herself `Ìs it safe?'', followed by ``What if it isn't
safe?'', and then generate reasons for and against. The therapist
identi®ed that this was another example of worrying and should
be banned. Through further questioning, Sadie realized that she
wasn't paying attention to signs of safety in the environment.
This was illustrated starkly over the course of the following
week, when she had been instructed to focus her attention in a
123
balanced way. Whilst driving, she was stationary at a set of

traf®c lights and noticed three young men wearing similar
clothing to that of her attackers. Previously, this would have
acted as a trigger for worry and intrusive memories and a series
of maladaptive attentional strategies. Instead, she scanned her
environment more fully and noticed that there was a police car
behind her. This slightly fortuitous event provided a clear
illustration of how simply focusing on signs of potential threat
overestimated the level of danger.
The ®nal sessions of MCT focused on modifying residual
positive and negative metacognitive beliefs. Sadie expressed a
common concern about relapsing, but had developed a plan
that she was at times implementing. Every other day, she would
check her mind for intrusive thoughts in order to ensure that
the thoughts had vanished. The counterproductive nature of
this strategy was discussed with Sadie and re-conceptualized as
a metacognitive belief driving another form of threat moni-
toring, i.e. ``Checking my mind for intrusive thoughts keeps me
safe.'' Modi®cation of this belief was achieved through illus-
trating that the strategy increased the frequency of thoughts
and was a self-initiated trigger for worry. It also played a
maintaining role in keeping the sense of threat alive.
A therapy blueprint was developed with Sadie, which com-
prised a written and diagrammatic representation of the case
formulation and an account of how to apply detached mind-
fulness to intrusive thoughts. Sadie was encouraged to continue
to implement the treatment strategies after the end of treatment
in order to strengthen her new metacognitive plan with the goal
of maintaining and extending the improvement she had made
over the course of MCT.
The treatment approach illustrated in this case example has
been evaluated in several studies. Wells and Sembi (2004b)
treated eight cases in a single case series and Wells et al.
(2008) ran an open trial of chronic PTSD cases. In each case,
treatment was associated with very large and signi®cant reduc-
tions in symptoms, and the majority of patients recovered.
124
Colbear (2006) reported the results of a randomized controlled

trial demonstrating that eight sessions of MCT were highly
effective compared to a no-treatment waiting period. In an
intention to treat analysis, 80 per cent of the MCT group had
recovered (on the Impact of Event Scale) at post-treatment
compared with none of the patients in the waiting list con-
dition. In a recent randomized controlled trial, MCT was
superior to exposure therapy for PTSD (Proctor, 2008).
125
Conclusion
In this book, we have described the theoretical and practical

features of MCT and contrasted this approach with other forms
of CBT. MCT is based on a speci®c theory of the control of
thinking that leads to persistence and strengthening of psycho-
logical disturbance. It provides a distinctive theoretical and
clinical approach to understanding and treating psychological
disorders, with an emphasis on speci®c styles of thinking, mental
regulation and experiential awareness. The theory is supported
by over twenty years of empirical research. Individual treatment
techniques and full treatment packages are gaining increasing
empirical support (for a review, see Wells, 2009) as effective and
ef®cient interventions.
127
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133
Index
ABC analysis 23, 24, 69 attentional bias vii, 7, 8, 33

Acceptance and Commitment attentional control 7, 31±2, 39,
Therapy (ACT) 32, 97, 104±5 43±4
activity scheduling 49 attentional modi®cation 34±5,
advantages-disadvantages 39±40, 49, 123±4
analysis 90
AMC analysis 23±5, 68±9 BAT see Behavioural Avoidance
amygdala 10, 31, 32 Test
anxiety: Attention Training Beck, A. T.: ABC analysis 23;
Technique 31; intolerance of cognitive distortions 3, 34;
uncertainty 81; meta-emotions depression 18, 75±6;
109; post-traumatic stress generalized anxiety disorder
disorder 50, 52, 119, 120, 121; 81; schema theory 5, 18, 33
relapse prevention 37; social Behavioural Avoidance Test
phobia 107; see also (BAT) 70
generalized anxiety disorder; behavioural experiments 49, 108,
worry 122±3; detached mindfulness
appraisal models 81±2 105; exposure 111, 113;
assessment 67±72, 79 metacognitive beliefs 87, 91;
ATT see Attention Training socialization 82
Technique beliefs 3, 4, 8±9, 15±20, 39; ABC
attention switching 97, 99 analysis 23, 69; AMC analysis
Attention Training Technique 23, 24, 25, 68, 69; assessment
(ATT) 31±2, 34, 97±100 67, 70, 72; case formulation
135
INDEX
74±5, 76±8; change in cognitive distortions 3, 16, 34, 39,

experience of 43; declarative 59, 76
37; depression 45, 46, 48±9, cognitive therapy (CT) 62, 64
74±5, 76±7; generalized cognitive-behaviour therapy
anxiety disorder 45, 80±1; (CBT) 3, 4±5, 8±9, 13; ABC
modi®cation of 60, 85±7, analysis 23; advantages-
89±91, 111±13, 124; object/ disadvantages analysis 90;
metacognitive modes 21; assessment 67, 72; attentional
obsessive-compulsive disorder strategies 34±5; beliefs 15,
45, 61±2, 63, 77, 81; positive 18±19, 39; depression 49±50;
18, 48±9, 52, 72, 75, 89±91, emotions 110; knowledge 37;
94±5, 108; post-traumatic limitations of 55; mindfulness
stress disorder 45±6, 51±2, 28; post-traumatic stress
120, 123; Situational disorder 17; rumination 60±1;
Attentional Refocusing 32; targets of change 59; thought
socialization procedures 80±1 objecti®cation 22; thought
Borkovec, T. D. 95 suppression experiments 82
Colbear, J. 125
CAS see cognitive attentional contamination fears 13, 21
syndrome coping behaviours 13, 48, 59, 64,
case examples 48±9, 119±24 115; depression 17; detached
case formulation 49, 73±8, 79±80, mindfulness 103; post-
98, 120, 121, 124 traumatic stress disorder 120,
CBT see cognitive-behaviour 121; socialization procedures
therapy 80; see also strategies
change 43±4 CT see cognitive therapy
Clark, D. A. 81
cognition 3, 4, 8, 21, 33, 43±4 danger: modifying beliefs 85,
cognitive attentional syndrome 86±7; post-traumatic stress
(CAS) 7, 10, 11±13, 15, 111; disorder 50, 51±2, 108;
attentional modi®cation 35; questionnaires 72; worry/
depression 49, 50, 76±7; rumination postponement
detached mindfulness 27, 28±9, experiment 93
103; dysfunctional processing deliteralization 105
plans 115; emotional depression 17±18, 45, 46±50;
processing 34; post-traumatic assessment 67; Attention
stress disorder 17, 50, 51±2; Training Technique 31±2, 100;
self-focus 41, 98; socialization case formulation 73±7;
procedures 80; threat cognitive model 75±6;
monitoring 39; universal dysfunctional processing plans
treatment 55 115; meta-emotions 109±10;
cognitive bias 34 Mindfulness-Based Cognitive
cognitive defusion 105 Therapy 28; modifying
136
INDEX
negative beliefs 85, 87; number 109; mindfulness 104, 105;

of MCT sessions 61; positive modifying negative beliefs 85,
metacognitive beliefs 89±90; 86±7; positive metacognitive
post-traumatic stress disorder beliefs 89; socialization
119; questionnaires 72; relapse procedures 80±1; thought
prevention 37; self-focus 98 suppression experiments 82;
detached mindfulness (DM) see also anxiety
27±9, 43, 49, 52, 89, 101±6; goals 70, 90±1
case study 123, 124; exposure
treatment 113; free association "healing metaphor" 121±2
task 101±3; mindfulness health anxiety 13, 98, 100
distinction 104±5; processing Hollon, S. D. 64
plan 116; thought suppression homework 99±100, 123
experiments 82; tiger task hypochondriasis 23, 31
103
distraction 34±5, 85, 89, information processing 7±10,
99±100 33±4
divided attention 97, 99 Ingram, R. E. 64
DM see detached mindfulness intolerance of uncertainty (IOU)
downward arrow 61, 62 81
intrusive thoughts 20, 81±2, 89,
Ellis, A. 23 99; detached mindfulness
emotions: ABC/AMC analysis 102±3; exposure 113;
23; cognitive processing generalized anxiety disorder
networks 33, 34; extended 109; maladaptive attentional
thinking 7; meta-emotions strategies 63±4; obsessive-
109±10 compulsive disorder 16; post-
ERP see exposure and response traumatic stress disorder 17,
prevention 50, 51, 121, 123, 124;
executive control 31±2, 44, 50 probabilistic reasoning 62±3;
exposure 32, 111±14, 115, 125 processing plan 116
exposure and response prevention IOU see intolerance of
(ERP) 111, 113 uncertainty
extended thinking 7
judgements 71
Fisher, P. L. 113
¯exibility 10, 19, 21±2, 31 Kabat-Zinn, J. 104
free association task 101±3, 123 knowledge 20, 33, 35, 37±8
generalized anxiety disorder loss of control 86, 87, 95

(GAD) 15±16, 45; controlled
worry periods 95; coping maladaptive attentional strategies
behaviours 64; meta-emotions 59, 63±4, 103, 107, 114, 116±17
137
INDEX
Matthews, G. 4, 27 self-awareness 41±2;

MBCT see Mindfulness-Based Situational Attentional
Cognitive Therapy Refocusing 32, 107±8;
MBSR see Mindfulness-Based socialization procedures
Stress Reduction 79±82; thinking styles 3±4, 5,
MCQ-30 see Metacognitions 13; universal treatment 55;
Questionnaire-30 worry/rumination
MCT see metacognitive therapy postponement experiment
meditation 28, 104, 105±6 85±6, 87, 93±5
memory: long-term 8, 9; meta-emotions 109±10
metacognition 3; metacognitive mindfulness 104±6; see also
pro®ling 71; post-traumatic detached mindfulness
stress disorder 52 Mindfulness Based Cognitive
meta-awareness 47 Therapy (MBCT) 28, 97, 104,
metacognition: assessment of 105±6
67±72; focus on 3±5; Mindfulness Based Stress
metacognitive awareness 64±5 Reduction (MBSR) 104
Metacognitions Questionnaire-30 mismatch strategies 91
(MCQ-30) 72 modes 9, 21±2, 27, 43, 83
metacognitive mode 21±2, 27, modulation experiments 91
83 morality 17
metacognitive pro®ling 69±71,
123 negative automatic thoughts
metacognitive therapy (MCT) vii, (NATs) 9, 13, 23, 59±60, 64;
127; AMC analysis 23±5, assessment 67; content of 39;
68±9; Attention Training depression 49, 76, 77; schema
Technique 31±2, 34, 97±100; distinction 8
attentional modi®cation 34±5, Negative Beliefs about
39±40; beliefs 15±20, 85±7, Rumination Scale (NBRS) 72
89±91; case formulation 73±8;
case study 119±24; cognitive object mode 21±2, 27, 83
bias 4±5; cognitive processes obsessive-compulsive disorder
33±4, 39±40, 43, 59; depression (OCD) 16±17, 41, 45, 61±3;
46±50; detached mindfulness AMC analysis 68±9; case
27±9, 101±6; exposure 111±14; formulation 77; exposure and
information processing model response prevention 111±13;
7±10; knowledge 37±8; levels loss of control experiments 86;
of control 33±5; metacognitive mode of processing 83; positive
level 59±65; meta-emotions metacognitive beliefs 89;
109±10; modes 9, 21±2, 27, 83; processing plan 115±17;
perseverative processes 39; socialization procedures 81±2;
plans 115±17; post-traumatic threat monitoring 12±13, 107;
stress disorder 50±3, 119±25; uncontrollability 87
138
INDEX
on-line processing 8, 9, 34 Re¯exive Adaptation Process

Orsillo, S. M. 104, 105 (RAP) 50, 52
relapse prevention 37, 38, 115
panic-disorder 18, 31, 98, 100 rituals 16, 77, 87
PBRS see Positive Beliefs about Roemer, L. 104, 105
Rumination Scale rumination vii, 5, 13, 19, 43; case
perseverative thinking 17±18, 39, formulation 74, 77; CBT/MCT
59, 115; detached mindfulness comparison 60±1; cognitive
101, 103; negative attentional syndrome 11±12;
metacognitive beliefs 85, 87; depression 17±18, 46±8, 49, 74,
post-traumatic stress disorder 77, 89±90, 109±10; modulation
113; processing plan 116; experiments 91; negative
socialization 80; worry/ automatic thoughts 60;
rumination postponement positive metacognitive beliefs
experiment 93 89±91; postponement
plans 19±20, 37, 38, 115±17 experiment 52, 85±6, 87, 93±5,
positive beliefs 18, 48±9, 52, 72, 123; post-traumatic stress
75, 89±91, 94±5, 108 disorder 12, 50, 52, 119, 120,
Positive Beliefs about 121±2, 123; questionnaires 72;
Rumination Scale (PBRS) 72 self-focus 98; socialization
post-traumatic stress disorder procedures 80;
(PTSD) 12, 17, 50±3, 124±5; uncontrollability 85±6, 87
beliefs 45±6; case formulation
77; case study 119±24; Salkovskis, P. M. 16
emotional processing 34; SAR see Situational Attentional
exposure 111, 113±14, 125; Refocusing
positive metacognitive beliefs schemas 5, 8, 15, 18±19, 33;
89, 108; threat monitoring 41, depression 18, 49, 76;
107, 108 emotional 110; generalized
probability 17, 62±3 anxiety disorder 81; processes
pro®ling 69±71, 123 40
PTSD see post-traumatic stress selective attention 97, 99
disorder self-awareness 41±2
self-focused attention vii, 28, 41;
questionnaires 71±2, 79 Attention Training Technique
97, 98±9; generalized anxiety
Rachman, S. 16±17 disorder 109; Situational
RAP see Re¯exive Adaptation Attentional Refocusing
Process 107±8
rational emotive-behaviour self-regulation 7, 11, 15
therapy (REBT) 3, 4±5, 13; Self-Regulatory Executive
ABC analysis 23; beliefs 15, 19; Function (S-REF) model viii,
knowledge 37 7±10; case formulation 77;
139
INDEX
emotional schemas 110; levels threat monitoring 12±13, 19,

of control 33; meta-emotions 34, 39, 41, 43; attentional
109; self-awareness 41 bias vii; executive control 31;
self-report questionnaires 71±2, maladaptive attentional
79 strategies 63±4; positive
Sembi, S. 124 metacognitive beliefs 89;
Situational Attentional post-traumatic stress
Refocusing (SAR) 32, 34, disorder 50, 52±3, 107, 108,
107±8 114, 124; processing plan
social phobia 13, 18, 32, 116; social phobia 32;
107±8 socialization 80
socialization 79±82, 98, 121, tiger task 103
122 TOF see thought-object-fusion
S-REF see Self-Regulatory trauma 17, 20, 32, 119±20,
Executive Function model 122
Steketee, G. 62 triggers 13, 60, 85±6; ABC/AMC
stimulus control 95 analysis 23, 24, 25, 69; case
strategies: maladaptive 59, 63±4, formulation 73±4; depression
103, 107, 114, 116±17; 47, 48
processing 8; socialization
procedures 80; see also coping uncertainty 81
behaviours uncontrollability 15, 19;
Stroop task 8, 34 depression 18, 45, 46;
generalized anxiety disorder
TAF see thought-action-fusion 16, 45, 64, 80, 81, 82;
TEF see thought-event-fusion modifying beliefs 85±6, 87;
thinking errors 39, 49±50, 62 questionnaires 72; worry/
thinking styles 3±4, 5, 7, 8±9, rumination postponement
13 experiment 93±4, 95
thought-action-fusion (TAF) universal treatment 55
16±17, 45
thought-event-fusion (TEF) 16, verbal reattribution 86±7, 89,
45 90±1, 93
thought-object-fusion (TOF) 16, vertical arrow technique see
45 downward arrow
thoughts 21, 22, 25, 85;
depression 49; free association Wells, Adrian vii, 4; AMC
task 101±3; mindfulness analysis 23; detached
practices 105±6; self-awareness mindfulness 27; exposure and
41; suppression of 15, 50±1, 64, response prevention 113; meta-
82, 94, 122±3; see also intrusive emotions 109; post-traumatic
thoughts; negative automatic stress disorder 124
thoughts Wilhelm, S. 62
140
INDEX
worry vii, 5, 13, 19, 43; postponement experiment

cognitive attentional 52, 85±6, 87, 93±5, 123;
syndrome 11±12; generalized post-traumatic stress
anxiety disorder 16, 45, disorder 12, 119, 120, 121±2,
80±1, 89, 109; intolerance of 123; socialization procedures
uncertainty 81; modulation 80±1; uncontrollability
experiments 91; 85±6; see also anxiety
141

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What are the main topics discussed in the text?

What are the main topics discussed in the text?

What challenges does the text discuss?

What challenges does the text discuss?

Metacognitive

Metacognitive therapy is based on the principle that worry and

This series provides straightforward, accessible guides to a

The CBT Distinctive Features Series will be essential reading for

Titles in the series:

For further information about this series please visit

Peter Fisher and Adrian Wells

Simultaneously published in the USA and Canada

Routledge is an imprint of the Taylor & Francis Group,

This edition published in the Taylor & Francis e-Library, 2009.

Ø 2009 Peter Fisher and Adrian Wells

All rights reserved. No part of this book may be reprinted or

This publication has been produced with paper manufactured to

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

ISBN 0-203-88147-8 Master e-book ISBN

ISBN: 978-0-415-43498-0 (hbk)

Part 1 THE DISTINCTIVE THEORETICAL FEATURES

Part 2 THE DISTINCTIVE PRACTICAL FEATURES

Metacognitive therapy (MCT) originated with Adrian Wells

The integration of laboratory ®ndings with clinical observa-

Metacognition is a term used to refer to a speci®c category of

in the form of worry and rumination. These styles can be

different. In the former two approaches it resides in the

the content of schemas but attributes them to the individual's

of thinking and metacognition that extends and repeatedly

MCT offers an answer to this conundrum. It states that it

According to S-REF theory and MCT, a particular style of

questions, whereas worry seeks answers to ``what if'' questions.

thoughts; the person with contamination fears monitors for

MCT gives prominence to metacognitive beliefs in the develop-

generalized anxiety disorder (GAD), the metacognitive model

occurs in two forms: probability and morality TAF. Probability

meaning of sadness or depression (e.g. Nolen-Hoeksema, 1991;

beliefs. REBT identi®es a speci®c set of beliefs that are primarily

for reacting to inner events triggered by problematic situations.

A distinctive theoretical feature of MCT is the idea that cog-

responses to negative ideas that can buffer against the activa-

The metacognitive model's analysis of psychological disorder is

Figure 1a ABC analysis

Figure 1b AMC analysis

The MCT question reveals metacognitive beliefs about uncon-

In the AMC analysis, metacognitions may repeatedly gener-

Because the CAS links disorder to styles of responding to

Detached mindfulness has no parallel with techniques used

CAS and with a view to enhancing metacognitive control. The

also appears to be associated with neurobiological changes

Self-Regulatory Executive Function (S-REF) metacognitive

Differentiating between levels and describing the interrela-

management treatment approaches, they concentrate on

We have already seen how the metacognitive approach differ-

As described in Point 10, the modi®cation of attention through

The S-REF model views self-awareness as a complex multi-

It is recognized that self-awareness can be bene®cial when it

As the foregoing discussion has begun to elucidate, metacog-