a metacognitive model and therapy for generalized anxiety disorder

A Metacognitive Model and Therapyfor Generalized Anxiety Disorder

Adrian Wells*Department of Clinical Psychology, University of Manchester, Manchester, UK

In this paper a cognitive model of Generalized Anxiety Disorder(GAD) is described. Evidence for the model is briefly reviewed and thespecific form of cognitive therapy (metacognitive therapy) derivedfrom the model is outlined. The model accounts for the disappointingeffects of existing cognitive-behavioural treatments of GAD in terms ofa failure to focus on key beliefs concerning worry itself. The modelasserts that pathological worry in GAD is maintained by positive andnegative metacognitive beliefs concerning the advantages and thedangers of worrying. Individuals with GAD tend to use internalinformation such as a felt sense that they will be able to cope as asignal to terminate worrying. Although worrying is used as a means ofcoping with anticipated threats, it becomes the object of negativebeliefs and appraisals. Several feedback cycles maintain the problem.When worrying is appraised as dangerous anxiety increases and it isdifficult for the individual to obtain an internal state signalling that itis safe to stop worrying. Unhelpful behavioural strategies such asavoidance of situations that trigger worry, thought control strategiescharacterized by a lack of attempts to interrupt ongoing worrysequences, and attempts to suppress thoughts that trigger worryingmaintain maladaptive metacognitions and anxiety. Specific strategiesfor conceptualizing GAD cases, and for modifying key metacognitionsare presented. Copyright # 1999 John Wiley & Sons, Ltd.

INTRODUCTION

The experience of excessive, generalized, andsubjectively out of control worry is a key featureof Generalized Anxiety Disorder (GAD). Whilstcognitive behavioural treatments of GAD areeffective, the overall rate and degree of improve-ment is only modest, with approximately 50% ofpatients showing high endstate functioning. It hasbeen suggested that improvement in treatmenteffectiveness would be gained from the develop-ment of a specific cognitive model of GAD, focusingon chronic worry mechanisms (Wells, 1995).

It is only relatively recently in clinical psychologythat worry has become a legitimate topic for theory

and research (Borkovec et al., 1983; Davey et al.,1992; Davey and Tallis, 1994). The survival of theconstruct in clinical psychology owes much to thepioneering work of Borkovec and colleagues whohave provided analyses of the phenomenology ofworry and the consequences of worrying (e.g.Borkovec et al., 1983; Borkovec and Inz, 1990;Borkovec et al., 1991). Borkovec et al. (1983) defineworry as `a chain of thoughts and images nega-tively affect-laden and relatively uncontrollable'.Worry is viewed as a predominantly verbal ratherthan an imaginal process, which is aimed atproblem solving under conditions of uncertainty(Borkovec et al., 1983; Davey, 1994). Differencesbetween worry and other types of intrusive mentalexperience, namely obsessional thoughts, have beenexplored. In a naturalistic study, Wells and Morri-son (1994) demonstrated that normal worries weremore verbal, less involuntary, and more realistic

CCC 1063±3995/99/020086±10$17.50Copyright # 1999 John Wiley & Sons, Ltd.

Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 6, 86±95 (1999)

*Correspondence to: Dr A. Wells, University of Manchester,Department of Clinical Psychology, Rawnsley Building,Manchester Royal Infirmary, Oxford Road, ManchesterM13 9WL, UK. E-mail: [email protected]

than normal obsessions, and were associated with agreater compulsion to act. Using retrospectiveratings of normal worry and obsessions, Clarkand Claybourn (1997) showed that worry was ratedas focused more on the consequences of negativeevents; was rated as more distressing, and causedmore worry about feeling distressed. Worry wasrated as more likely to lead to effective solutions,was more likely to be associated with checking, andcaused more interference with everyday life. Inother work Purdon and Clark (1993) suggest thatego-dystonicity should be emphasized in differ-entiating obsessional thoughts and worry.

Wells (1994, 1995) suggests that worry can be aform of coping, and Wells and Matthews (1994)assert that at least two varieties of worry should bedistinguished, an adaptive and a maladaptivevariety. The adaptive variety is oriented at problemsolving and leads to problem-focused behaviour.However, the maladaptive variety generates arepetitive range of negative outcomes in which theindividual attempts to generate coping solutionsuntil some internal goal is achieved. Furtherdistinctions between worry subtypes have beensuggested. Wells (1994, 1995) suggests that it isuseful to distinguish between two broad types ofworry in conceptualizing pathological worry pro-cesses, and this distinction is a feature of his modelof GAD. The distinction is based on differences inthe content and form that worry takes and the twoworry types have been termed Type 1 and Type 2worry. Type 1 worry refers to worry about externalevents and internal non-cognitive events such asphysical symptoms, thus worrying about financesor about one's physical health are examples of Type1 worry. In contrast, Type 2 worry consists of worryabout one's own cognitive events and processes.This is essentially worry about worry, also knownas meta-worry since it involves metacognitive pro-cesses of monitoring and appraising one's ownthoughts. Examples of meta-worry themes includeappraisals of loss of control of thinking, and ofharm resulting from negative thoughts and worries.According to Wells's (1995, 1997) model, Type 2worries are a central feature of pathological worrystates like that found in generalized anxietydisorder. In view of advances in the conceptualcomplexity surrounding the analysis of worry, arevised definition of worry is suggested that mayprove to be useful in future theoretical andempirical work:

Worry is a chain of catastrophizing thoughts that arepredominantly verbal. It consists of the contemplation

of potentially dangerous situations and of personalcoping strategies. It is intrusive and controllablealthough it is often experienced as uncontrollable.Worrying is associated with a motivation to prevent oravoid potential danger. Worry may itself be viewed asa coping strategy but can become the focus of anindividual's concern.

A COGNITIVE MODEL OF GAD

A model of generalized anxiety disorder (GAD)should attempt to account for the maintenance ofexcessive, generalized and uncontrollable worry asthe central distressing characteristic of this disorder.Wells (1995, 1997) has advanced a metacognitivefocused cognitive model of GAD. Metacognition inthe form of beliefs and appraisals about thinkingand the processes of monitoring and controllingthoughts are central concepts in this model. Themodel differs from other cognitive conceptualiza-tions of GAD by emphasizing the role of meta-cognitive beliefs and appraisals rather thanmaladaptive beliefs about the world as a dangerousplace. An implicit feature of this approach is thatworry in GAD is not merely a symptomaticconsequence of anxiety, but it is an active andmotivated style of appraisal and coping driven bythe individual's beliefs. The individual with GADuses worry in order to cope with anticipateddangers or threats. The model is depicted dia-grammatically in Figure 1.

The onset of a worry sequence is often triggeredby an intrusive thought which typically occurs inthe form of a `what if' question, e.g. `what if I amunable to complete this assignment'. This initialdanger appraisal activates positive metacognitivebeliefs about the usefulness of worrying as a copingstrategy. Examples of positive beliefs held by GADpatients included, `my worrying helps me cope','worrying keeps me safe', and `If I worry I'll beprepared'. The person with GAD thus executesworry sequences in which a range of `what if'danger-oriented questions are contemplated andpotential strategies for dealing with these scenariosare generated. This process is referred to as Type 1worrying since the content of the individual'sworries tends to focus on external events and non-cognitive internal events, e.g. physical symptoms orsocial concerns. Type 1 worrying is associated withemotional responses as depicted by the bi-direc-tional dotted line in Figure 1. The contemplation ofdangerous scenarios leads to the activation of aninherent anxiety programme and thus cognitive and

Copyright # 1999 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 6, 86±95 (1999)

Cognitive Therapy of GAD 87

somatic anxiety symptoms result. However, therelationship between Type 1 worrying andemotional responses is complicated by the factthat Type 1 worrying can lead to a reduction inanxious affect and accompanying symptoms. Whenthe Type 1 worry process meets its goal ofgenerating acceptable coping responses, anxietydiminishes. It follows that the duration of ananxiety response linked to Type 1 worry isassociated with the length of time taken to meetgoals for coping. The person with GAD continueswith worry until he/she assesses that he/she willbe able to effectively cope with anticipated danger.This assessment is often based on internal cues suchas: a `felt sense' that he/she will be able to cope; thebelief that all important outcomes have beenconsidered; and a superstitious reasoning processsupported by appraisals such asÐ`I've done myworrying therefore it should turn out OK'. Worry-ing stops when these internal goals are met.However, worrying may also stop when competinggoals, which have processing priority, are activated.

Individuals with GAD not only have positivebeliefs about worrying, they also hold negativemetacognitive beliefs about the worry process andthe consequences of worrying. Examples of nega-tive beliefs include: `Worrying could make me gocrazy; I must control my worry or I will cease tofunction; worry is uncontrollable'. During worryepisodes negative beliefs become activated and thisleads to negative appraisal of the worry process.This negative appraisal or Type 2 worry, also

influences emotional responses. Type 2 worryintensifies anxiety, and if worrying is interpretedas imminently dangerous, rapid escalations ofanxiety in the form of panic can result. Therelationship between Type 2 worry and emotionconstitutes a vicious cycle (as depicted in Figure 1)in which cognitive and somatic symptoms associ-ated with anxiety can be interpreted as evidence ofloss of control and/or the harmful nature ofworrying. Anxious responses may also be inter-preted as a sign of a likely failure to cope thatcontributes to a need for continued Type 1 worry-ing. Two other mechanisms associated with Type 2worry are also involved in problem maintenance:Behavioural Responses, and Thought Control. Theseare now considered in turn.

To prevent the feared consequences of worrying,the person with GAD engages in a number ofbehaviours. Whilst gross forms of avoidance are nota particular hallmark of GAD, more subtle forms ofavoidance are relevant in some cases. For example,individuals seek reassurance in order to terminateworry sequences or in order to avoid the need toworry in the first instance. In addition, somepatients avoid triggers for worry such as situations,people or information. Since positive and negativebeliefs about worrying co-exist and the individual ismotivated to worry in response to initial `what if'threat appraisals, individuals with GAD rarelyattempt to actively interrupt worry sequences.They are likely to avoid situations that trigger threatappraisals and thus the need to worry in the firstinstance. These behavioural strategies are problem-atic in several respects. The individual who avoidsworry triggers is unable to practise alternativestrategies for appraisal and coping. Avoidance orreassurance-seeking removes an opportunity todevelop beliefs that worry is subject to cognitiveself-control. In addition, avoidance, reassurance-seeking, or similar behaviours such as checking orinformation search, prevent the person with GADdiscovering that worrying is harmless. Thesebehavioural strategies prevent exposure to discon-firmatory evidence that proves that worrying isneither uncontrollable nor harmful. Thus Type 2worries and negative beliefs are maintained.

The second process involved in problem main-tenance is thought control. As the person with GADbelieves that worrying is beneficial, few attemptsare made to interrupt worry sequences before thegoal of worrying is achieved. Therefore, theindividual has few experiences of successfullyinterrupting or controlling the worry process,and negative appraisals of uncontrollability and

Figure 1. A Metacognitive model of generalized anxietydisorder (Reproduced from: Wells, 1997, p. 204)


88 A. Wells

associated negative beliefs remain unchallenged.Rather than interrupting the worry process, whichis a motivated coping activity, the person withGAD is more likely to try not to think aboutparticular topics that trigger worry in the first place.For example, a person currently worrying aboutpersonal competency at work may attempt not tothink about work when away from that environ-ment. The problem with thought suppressionattempts is twofold. First, it is rarely entirelysuccessful and this may be taken as evidencesupporting the uncontrollability of thought. Second,it may produce a paradoxical enhancement ofintrusions which is taken as further evidence offailed mental control thus strengthening Type 2worries and negative metacognitive beliefs.

In summary, excessive, generalized and un-controllable worry results from an interactionbetween the effects of positive and negative beliefsabout worrying. Individuals with GAD have atendency to execute worrying as a means of copingwith anticipated danger. This may increase anxietyresponses in the short term but is associated with areduction in anxiety as the goals of worrying aremet. This reduction in anxiety strengthens thesubsequent usage of worry as a coping strategy.However, when negative beliefs about worryingbecome activated, and worrying itself is negativelyappraised as dangerous, anxiety is intensified andthe potential for meeting goal-states that terminateworrying is diminished. At this point, the indi-vidual is likely to experience a greater sense ofvulnerability since a predominant mode of coping(worrying) develops its own problems and worry-ing itself is appraised as uncontrollable anddangerous.

EMPIRICAL EVIDENCE FOR THE MODEL

Research on patients with GAD and on worry-prone individuals has provided support for severalcentral components of the GAD model. In the nextsection a brief summary of existing research ispresented together with new finding from ourresearch programme.

Relationships Between Positive and NegativeMeta-beliefs and Pathological Worrying

The cognitive model proposes that problematicworrying is linked to both positive and negativebeliefs about worrying. Thus, positive and negativebeliefs should correlate positively with worryproneness. In addition, since negative beliefs are

the predominant marker for GAD worry, indi-viduals with GAD should endorse greater negativebeliefs than other anxious patients.

In two studies investigating the reasons given forworrying by students, Borkovec and Roemer (1995)showed that subjects rated motivation, preparationand avoidance as the most characteristic reasons fortheir worry. Individuals meeting criteria for GAD,based on scores on the Generalized AnxietyDisorder Questionnaire, rated using worry for`distraction from more upsetting things' signifi-cantly more than non-anxious subjects. In a secondstudy, GAD subjects gave significantly higherratings than non-worried anxious or non-anxioussubjects for distraction from more emotional topics.GAD subjects also gave significantly higher ratingsfor superstitions and problem solving than non-anxious subjects did.

Direct evidence of a relationship between meta-cognitive beliefs and worrying comes from work byCartwright-Hatton and Wells (1997). They devel-oped the Meta-Cognitions Questionnaire (MCQ) toassess dimensions of positive and negative beliefsabout worry and individual differences in meta-cognitive processes. This questionnaire has fivesubscales that show good psychometric properties.The subscales are: (1) Positive beliefs (e.g. worryinghelps me cope); (2) Beliefs about uncontrollabilityand dangers of worrying (e.g. when I startworrying I cannot stop; worrying is dangerous forme); (3) Cognitive confidence (e.g. I have a poormemory); (4) General negative beliefs includingthemes of punishment, superstition and respons-ibility (e.g. not being able to control my thoughts is asign of weakness); (5) Cognitive self-consciousness(e.g. I pay close attention to the way my mindworks).

Alpha reliabilities for the subscales range from0.72 to 0.89 (n � 306: Cartwright-Hatton and Wells,1997). Cartwright-Hatton and Wells (1997) demon-strated that all MCQ subscales were significantlyand positively correlated with worry proneness andwith trait-anxiety. Multiple regression analysesshowed that worry proneness remained positivelyassociated with trait-anxiety, positive worry beliefs,negative beliefs about uncontrollability and danger,and lack of cognitive confidence when trait-anxietyand all of the MCQ subscales were entered in theequation. In a further study, the MCQ scores ofGAD patients, obsessive-compulsives, patients withother anxiety or depressive disorders, and non-patient controls were examined. No significantdifferences emerged in the endorsement of positiveworry beliefs, however, GAD patients and the



obsessive-compulsive patients endorsed signifi-cantly greater negative beliefs concerning uncon-trollability and danger than the other groups. GADand OCD patients also showed significantly higherscores than normal controls on negative beliefs ingeneral, concerning themes of superstition, punish-ment and responsibility.

In a later study, Wells and Papageorgiou (1998)tested the metacognitive predictors of pathologicalworry and obsessive-compulsive symptoms whilstcontrolling for the statistical interpendency of thesevariables. Pathological worry was assessed with thePenn State Worry Questionnaire (PSWQ: Meyeret al., 1990), a non-content based measure of worrycharacteristic of GAD. Pathological worry andobsessive-compulsive symptoms were significantlypositively correlated with MCQ subscales in thenon-patient sample tested (n � 120). Pearson corre-lations for each of the MCQ subscales with thePSWQ were as follows: (1) Positive beliefs, 0.45(p5 0.001); (2) Danger/uncontrollability, 0.59(p5 0.001); (3) Cognitive confidence, 0.22(p5 0.03); (4) Superstition, punishment andresponsibility, 0.34 (p5 0.001); (5) Cognitive self-consciousness, 0.26 � p5 0.03). The results ofmultiple regression analysis in which the overlapbetween pathological worry and obsessive-compulsive symptoms was controlled, demon-strated that only MCQ positive belief, and beliefsabout danger and uncontrollability associated withthoughts, predicted pathological worry. Of thesetwo significant predictors, negative meta-beliefsconcerning danger and uncontrollability made thegreatest contribution to the equation.

Evidence for the Role of Type 2 Worry

The content of GAD worries appears to be verysimilar to the content of normal worries. Craske et al.(1989), showed that GAD patients reported asignificantly greater proportion of worries aboutillness, health and injury than control subjects.However, the controls reported a significantlyhigher proportion of financial worries than GADsubjects did. Worries in both groups did not differin terms of the maximum anxiety or maximumaversiveness associated with them, the degree towhich the content was likely, or the level of anxietyaroused by attempting to resist worrying. In aregression analysis with grouping; GAD versuscontrol, as the dependent variable, only perceivedcontrol was a significant predictor. Similar findingsof limited differences in worry content (at the Type1 level) between high and low worriers have been

found by Vasey and Borkovec (1992). The finding offew differences between GADs and non-patients inworry content at the Type 1 level, but theemergence of controllability as a predictor of GADgrouping is consistent with the idea that differencesshould be more pronounced at the Type 2 level asopposed to the Type 1 level. Previous studies maybe conceptualized as concentrating on Type 1 worrythemes and have not directly elicited Type 2 worrycontent.

Studies that have used the Anxious ThoughtsInventory (AnTI: Wells, 1994) have providedpreliminary data on the relationship between Type1 and Type 2 worry and pathological worry. TheAnTI is a multidimensional measure of worryproneness. Factor analyses of scale items haveyielded a replicable three-factor instrument. Thefirst two factors measure social (alpha � 0.84) andhealth (alpha � 0.81) worry whilst the third factormeasures metacognitive appraisals and processesincluding Type 2 worry or meta-worry(alpha � 0.75), e.g. `I worry that I can't controlmy thoughts as well as I would like to'.

The AnTI has been used to test a centralprediction of Wells's model. The model predictsthat Type 2 worry and associated metacognitionsshould be positively correlated with pathologicalworrying irrespective of the frequency of Type 1worries. In a test of this hypothesis, Wells andCarter (1999) asked 140 non-patient subjects tocomplete a questionnaire battery consisting of theAnTI, PSWQ, Speilberger Trait Anxiety Subscale,individual ratings of how much worry was aproblem for the individual, and a rating of thecontrollability of worry. For purposes of this study,the Penn State Worry Questionnaire (PSWQ, Meyeret al., 1990) and the rating of `how much is worry aproblem for you', served as separate dependentvariables. All three AnTI subscales were signifi-cantly positively correlated with PSWQ and withproblem level. The correlation between meta-worryand PSWQ was 0.69, and between meta-worry andproblem level was 0.63. Correlations of health andsocial worries with these pathological worrymeasures ranged from 0.33 to 0.60. The results ofregression analyses controlling for the interdepen-dency of trait-anxiety, AnTI subscales and patho-logical worry measures, showed that only trait-anxiety and AnTI meta-worry significantly pre-dicted PSWQ when trait-anxiety and the other AnTIsubscales were in the equation. Thus, consistentwith predictions based on Wells's model, Type 2worry but not Type 1 worry was significantlyassociated with pathological worry measured by


90 A. Wells

PSWQ. A similar pattern emerged when problemlevel associated with worrying was treated as thedependent variable. Once again, Type 2 worry andtrait-anxiety significantly predicted problem levelbut social and health worries did not. In subsequentanalyses, which additionally controlled for theuncontrollability of worrying, trait-anxiety andType 2 worry remained significant predictors ofPSWQ. Type 2 worry also remained significantlypositively associated with problem level even whenuncontrollability of worry and PSWQ were enteredas predictors. These data suggest that irrespective ofthe content of Type 1 worries and of the uncontroll-ability of worry, Type 2 worry is significantlyassociated with pathological worry measures.

Cognitive Consequences of Worrying

The GAD model suggests that use of worrying as aprocessing strategy may create its own problemsthat contribute to intrusive mental experience andthe development of negative beliefs and Type 2worry. Two lines of research are relevant toevaluating this proposition. The first has examinedthe effect of worrying on subsequent thinking, andthe second has explored the effects of worrying onintrusive images following exposure to stress.

Borkovec et al. (1983) asked high and low worrysubjects to engage in 30, 15 or 0 min of worry andthen asked these individuals to focus on theirbreathing for a further 5 min. During the breathingtask, thought content reports were obtained everyminute. Compared to non-worriers, the worriersreported more anxiety and depression, less task-focused attention, and more negative thoughtsduring the breathing task. When the worrier andnon-worrier data was combined, the data revealedthat for the 15-min worry period, negative thoughtdistractions increased, whilst for the 0- and 30-minworry groups, distractions decreased. In a sub-sequent study, York et al. (1987) showed thatsubjects had more negative thought intrusionsafter the induction of worry than after a neutralcondition. These results suggested that brief periodsof worrying can increase subsequent negativethinking. It has been suggested that worry is similarto fear processes in that brief exposure can increasefear, whilst longer exposure leads to fear extinction.

In theoretical work, Borkovec and Inz (1990)suggest that worrying may distract from emotion-ally distressing thoughts in the form of images. As aconsequence, worrying may be associated with areduction in distress, which could lead to negativereinforcement of the worrying process such that

worrying proliferates. Two studies have exploredthe relationship between worrying and intrusiveimages following exposure to stressful stimuli. Ifworrying diverts attention from distressing images,as suggested by Borkovec and Inz, then worryingcould block emotional processing of images. Asymptom of failed emotional processing wouldthen be an increase in the frequency of intrusiveimages. In a preliminary study, Butler et al. (1995),asked three groups of subjects to watch a gruesomefilm about a workshop accident. Subjects were thenasked to do one of the following for a 5-min period:(1) settle down; (2) image the events in the film;(3) worry in verbal form about the events in thefilm. Subjects who were asked to worry about thefilm, reported significantly more intrusive imagesrelated to the film over the next 3 days than subjectswho had imaged or settled down. In a subsequentstudy, Wells and Papageorgiou (1995), replicatedand extended these findings by testing for possiblemechanisms underlying the incubation effects ofworry on intrusive images. They used four post-stress manipulations that theoretically varied in theextent to which they blocked emotional processingand produced `tagging'. Tagging refers to theaccessing of information concerning the stressorand engaging in elaborative processing such that awider range of material serves as a retrieval cue forstress-related intrusions. The study showed thatworrying about the film resulted in the highestfrequency of intrusions over a subsequent 3-dayperiod. Moreover, there was an incremental patternof frequency of intrusive images across manipula-tion conditions that were consistent with a co-jointtagging and blocked emotional processing mechan-ism.

In summary, there is direct support for the ideathat using worry as a processing strategy isassociated with an increase in intrusive thoughts.Thus, under some circumstances, individuals whoworry as a predominant means of coping, may wellbe engaged in an activity that contributes to aproliferation of intrusive thoughts. It is likely thatsuch effects would reinforce appraisals of dimin-ished control, and over longer time periods con-tribute to negative meta-beliefs and appraisalsconcerning the consequences of worrying.

IMPLICATIONS FOR TREATMENT

The model outlined above has several implicationsfor the treatment of generalized anxiety disorder.Since the model emphasizes a particular interactionbetween cognitive and metacognitive processes in



maintaining GAD, a specialized form of cognitivetherapy (Metacognitive Therapy) has been devel-oped (Wells, 1995, 1997). Existing cognitive beha-vioural treatments of GAD appear to produce onlymodest effects (e.g. Butler et al., 1987, 1991;Borkovec et al., 1987; Borkovec and Costello, 1993;Durham et al., 1994). The present model helps toexplain the modest response rate for CBT interven-tions. In particular, previous approaches have notbeen based on a specific model of the processesinvolved in the maintenance of GAD. The use ofgeneral cognitive therapy methods, predominantlythose of Beck et al. (1985), leads to a therapeuticfocus on challenging and restructuring Type 1worries and corresponding non-metacognitivebeliefs. This approach will be of limited use becauseit fails to substantially change patients' negativeappraisals and negative beliefs about worrying, andrigid positive beliefs that lead to the repeatedselection of worrying as a means of dealing withthreat. The effectiveness of cognitive therapy ofGAD could be improved by formulating cases interms of the metacognitions and maintenanceprocesses outlined in the model.

A detailed account of this new treatment andhow to implement metacognitive change strategiesis presented in Wells (1997). Some of the key issuesand strategies in metacognitive-focused cognitivetherapy of GAD are considered briefly below.

Sequencing of Metacognitive Modification

Typically, cognitive modification is practised in aparticular sequence for optimum effectiveness.First, negative appraisals and beliefs about theuncontrollability of worry should be elicited andmodified, and second meta-worries and negativebeliefs about the dangers of worrying should betargeted. Once these belief/meta-appraisals havebeen effectively modified, the therapist should thenformulate and challenge positive beliefs aboutworry, and finally introduce alternative strategiesfor appraising threat.

There are particular reasons for adopting thissequence. When patients believe that worrying isuncontrollable, it is highly threatening to engage inbehavioural experiments consisting of attempts tolose control. The initial modification of uncontroll-ability beliefs increases compliance with subsequentexperiments. Negative metacognitions should betargeted in therapy before positive beliefs sincethese are often most closely linked to acute anxiety(e.g. panic attacks) associated with worrying. Thepractise of alternative strategies for processing

threat, should be introduced after metacognitivebelief change so that alternative strategies do notbecome behaviours that prevent the disconfirmationof dysfunctional beliefs about worrying. However,the clinician should remain flexible in deciding onthe intervention sequence. In a recent case of GAD,a patient initially requested that therapy result inher being able to worry without having distressingsomatic symptoms. In this case positive worrybeliefs were targeted earlier in treatment in parallelwith modifying negative symptom appraisals(Type 2 worry).

Eliciting Metacognitions

A prerequisite to case formulation is elicitation ofrelevant metacognitions. Two general categories ofType 2 worry and negative beliefs are relevant:(1) uncontrollability/loss of control of worry;(2) dangers of worrying. Relevant metacognitionscan be elicited with self-report measures, such asthe Anxious Thoughts Inventory (Wells, 1994), theMeta-Cognitions Questionnaire (Cartwright-Hattonand Wells, 1997), and the GAD scale (GADS: Wells,1997). The GADS is a particularly useful clinicaltool as it measures a range of variables central tocase conceptualization, and facilitates the monitor-ing of changes in key negative and positive beliefsand behaviours during the course of treatment.

Verbal methods such as questioning the con-sequences of not controlling worries, and theadvantages/disadvantages analysis, providefurther tools for eliciting negative and positivemetacognitions. For example, a client may be askedto list the advantages of worrying, such advantagesrelate directly to positive worry beliefs, and also tolist the disadvantages or harmful effects of worry-ing. The latter directly reflect the content of Type 2worries and negative metacognitive beliefs.

Developing a Case Conceptualization

Once key metacognitions and behaviours have beenelicited, the therapist should proceed to construct acase conceptualization based on the model depictedin Figure 1. Facilitation of this process, and theprocess of socialization can be achieved by askingthe patient to recount slowly and in detail a recentintense worry episode. Data collected by this meansshould be combined with data from the GADS toproduce a more complete case conceptualization.Once an episode has been identified, the therapistshould first determine the nature of the trigger forworrying. This can be accomplished by asking:


92 A. Wells

`What was the initial event or thought that triggeredyour worrying?' The therapist should aim toidentify an initial thought that acted as the triggerfor worrying. These thoughts most often occur inthe form of `what if' questions (e.g. `What if mypartner has been involved in a car accident?').Identification of the trigger is then followed bytracking the nature of the patient's response to thetrigger (e.g. responded by worrying about the worstthat could happen and how to cope (Type 1 worry),tried to reassure self, tried not to think about it).The associated emotional response should beexplored and included in the relevant box in thecase conceptualization diagram. Once the worryingsequence has been identified, the therapist shouldproceed to identify negative thoughts about worry-ing (Type 2 worry), and the content of theseappraisals. Behaviours linked to meta-worriesshould be elicited and included in the appropriatesection of the model.

The extent to which patients with GAD articulatepositive beliefs about worrying during assessmentvaries. However, positive beliefs may be deter-mined from questionnaire measures such as theGADS. Initially, the model may be constructed withthe positive belief component missing, and a link inthe formulation is made directly between `trigger'(e.g. `What if . . .') and worrying (Type 1 worry).

Socialization

Socialization to the model consists of sharing themodel in verbal and diagrammatic form withthe patient, and eliciting feedback concerning the`goodness of fit' between the model and the natureof the patient's problem. Questions concerning thecauses of worrying should be answered withreference to the model. The central message toconvey is the idea that the patient has developedexcessive worrying because worry has itself nowbecome a source of worry, and the problem is drivenby a range of unhelpful beliefs about worrying.Therapist-directed questions offer an effective meansof socializing. For example, to introduce the idea thatappraisal of worrying is a central component of theproblem, the therapist may ask:

. If you believed that your life depended onworrying, how much of a problem wouldworrying be?

. If you believed you had control over your worry-ing, how much of a problem would you have?

. Most people worry, it is normal to do so. What isit that makes your worry such a problem.

(Therapist looks for answers such as, I have nocontrol, I'm not normal etc, and re-frames theseas metacognitions; e.g. `So the problem is thatyou believe you have no control. If you no longerbelieved that, would there be a problem?')

Modifying Type 2 Worry andMetacognitive Beliefs

In modifying negative beliefs concerning uncon-trollability, therapist and patient should explore indetail modulating influences on worry. In part-icular, the situations in which worrying was inter-rupted by competing goals should be elicited andreviewed. For example, the therapist may ask: `Wasthere a time when you were worrying, and thensomething happened to distract you from worry-ing?'. Such events can be used as evidence thatworrying can be displaced and is therefore con-trollable.

Evidence and counter-evidence concerning un-controllability should be elicited. Note that themodel predicts that there is likely to be a highdegree of ambivalence about fully controllingworry. Therefore, it is important to ask the patientif s/he has ever actually tried to give up worry onceit is initiated. Many patients report that theyattempt to reason with their worry or feel thatthey must `worry through' a topic in order to feelbetter able to cope. The fact that the patient does notunambiguously know if worry can be postponedshould be highlighted. One of the most importantmanoeuvres in challenging uncontrollabilityappraisals is the worry postponement experiment.As a homework assignment patients are asked tonotice the onset of a worry, and postpone the worrysequence until a specified time period later in theday. Once the specified time period arrives thepatient can either decide not to worry, or to worryfor a fixed time period to further test that worryingcan be controlled. The postponed worry experimentshould be repeated for homework across severalsessions as necessary. Ratings of belief in thecontrollability of worrying should be tracked acrossthe use of experiments and verbal reattributionmethods to determine effectiveness.

Beliefs concerning the dangers of worrying canbe modified by similar verbal and behaviouralreattribution methods. Beliefs that worrying cancause mental or physical catastrophe such as a`mental breakdown' are amenable to modificationby behavioural experiment. In this instance theperson with GAD can be asked to deliberately tryand lose control or cause mental/physical harm by



worrying intensely during the allotted postponedworry period. This can be followed up by askingindividuals to worry more and try and lose controlnext time a worry episode occurs, rather thanpostponing the activity. Verbal reattributionmethods such as reviewing evidence that worryingis harmful, generating counter-evidence, and educa-tion about the protective effects of anxiety shouldalso be undertaken in modifying negative meta-cognitions.

Positive meta-beliefs are challenged by reviewingthe evidence and counter-evidence for them, and bythe use of `mismatch strategies'. The mismatchstrategy consists of asking a patient to write out adetailed description of the events portrayed in aworry scenario. These events are then comparedwith the events that actually transpired in aworried-about situation. This strategy can bepractised for situations that are avoided, and incombination with exposure as a behavioural exper-iment. For example, the patient is asked to worryabout and predict the negative consequences ofentering an avoided situation. The worry narrativecan be written out in detail and the patient thenenters the avoided situation whilst comparing thecontent of the worry narrative with the actualevents and features of the situation. This strategy isused to illustrate how worries distort reality, andallow the therapist to pose the question: If worriesdo not accurately depict reality how helpful canthey be? Another experimental strategy forchallenging positive beliefs about worry consistsof asking patients to engage in activities normallyassociated with worrying whilst deliberatelyincreasing or decreasing worry. This procedurecan be configured to test patient predictions thatworrying enhances coping or increases the prob-ability that events go well. If these beliefs are correctthen abandonment of worrying should lead toevidence of not coping, and of events going wrong.

Strategy Shifts and Relapse Prevention

The latter stages of treatment focus on reviewingalternative ways of thinking about threat. Sincemany patients have been worriers for most of theirlives, it is often helpful to discuss and practisealternative strategies for dealing with `What if . . .'triggers for worrying. One strategy is to encouragepatients to use positive endings for `What if'thoughts. Thus, rather than contemplating theworst consequences in response to these triggers,patients are asked to practise generating positiveoutcomes and consequences, and to use evidence

other than a `felt sense' to make predictions aboutcoping.

Relapse prevention consists of generating asummary of the patient's understanding of thenature of GAD and a description of effectivestrategies for dealing with worry. Residual positiveand negative beliefs should be assessed andchallenged, and avoidance of situations that couldtrigger worrying should be eliminated by continuedexposure combined with worry abandonment orenhancement strategies tailored to modifyingresidual metacognitions.

CONCLUSION

Advances in the understanding and treatment ofGAD are likely to result from a specific cognitiveconceptualization of the maintenance of maladap-tive worry processes. Wells's (1995, 1997) modelsuggests that excessive and generalized worry inGAD results from the repeated use of worrying as acoping strategy, and the existence of particularmetacognitions. The individual with GAD holdsrigid positive beliefs about worrying, and alsobelieves that worrying is potentially dangerousand uncontrollable. Failure to learn about thecontrollability of Type 1 worry results from a lackof experience with actually interrupting the worry-ing sequence, despite the fact that worry is oftenterminated when internal goals or a `felt sense' ofbeing able to cope is achieved. On one level thedeployment of behavioural strategies intended toavert the catastrophes of worrying or avoid theneed to worry in the first instance maintain negativebeliefs about worrying. At another level the co-occurrence of worrying, effective coping andpositive external events maintains positive beliefsabout the usefulness of worrying. The modelsuggests a number of feedback cycles involved inthe maintenance of GAD, and provides a newapproach to the treatment of the disorder. Existingevidence is consistent with the model and furtherempirical evaluations are required.

Afterword

Whilst this paper has focused on metacognitivetherapy of GAD, it should be noted that meta-cognitive theory and techniques may be relevant tothe treatment of other disorders. In particular, Wellsand Matthews (1994) suggest that attentional andmetacognitive strategies such as Attention Training(Wells, 1990) and training in `detached mindfulness'


94 A. Wells

should be developed to treat a generic `cognitive-attentional syndrome', which they associate withvulnerability to emotional disorder.

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a metacognitive model and therapy for generalized anxiety disorder

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