metacognitive therapy for ptsd: a core treatment manual

Metacognitive Therapy for PTSD 365

treatment of PTSD in Viemam War veterans.Journal of Clinical Psy- chology, 53, 917-923.

Weathers, E W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

Yalom, I. (1995). The theory and practice of group psychotherapy (4th ed.). NewYork: Basic Books.

The author wishes to thank the female therapists involved in conducting treatment: Stephanie Fallon, Evelyn Sandeen, Ella Nye, Maureen McGlynn, Annette Brooks, Andrea Blmnenthal, and Sharon Sprague; thanks to Celia Michael for encouraging this work; and thanks to Jan Wallner for her support.

Address correspondence to Diane T. CastiUo, Psychology Service (l16B), New Mexico VA Health Care System, 1501 San Pedro S.E., Albuquerque, NM; e-maih [email protected].

Metacognitive Therapy for PTSD: A Core Treatment Manual

A d r i a n Wells , University o f Manches t e r S u n d e e p S e m b i , Universi ty o f L iverpool

This article describes a new brief treatment for PTSD based on a metacognitive model (Wells, 2000). The treatment derived from this approach can be divided into core and supplementary treatment components. The core treatment manual is presented hoe. The core treatment does not require imaginal reliving of trauma or cognitive challenging of thoughts and beliefs about trauma. It enables patients to develop a metacognitive perspective and disengage unhelpful thinking styles such as worry/rumination and attentional monitoring that block the natural propensity for cognitive-emotional adaptation following trauma. The content, techniques, and sequence of the basic program are described in detail to support practical application of the new treatment by therapists.

p , SYCHOLOGICAL TREATMENTS for PTSD have consisted o f various methods and the study of t r ea tment effi-

cacy is still at an early stage. Treatments compr i sed of exposure me thods and cognitive therapy focused on modi- fying negative appraisals have been shown to be effective in cont ro l led trials. In comparat ive studies, exposure therapy a lone and cognitive res t ructur ing without exposure have been shown to be equally effective (e.g. Rich- ards, Lovell & Marks, 1994; Tarrier et al., 1999). However, a p ropo r t i on of pat ients do no t r e spond o r fail to com- plete t reatment (Sherman, 1998; van Etten & Taylor, 1998). P ro longed imaginal reliving of t r auma is distressing and is poor ly to lera ted by many clients (Scott & Stradling, 1997). Exposure and cognitive therapy approaches are relatively br ie f intervent ions involving abou t 10 sessions. hnp l emen ta t i on of these t rea tments requires a high degree of therapis t skill. We believe that for t r ea tment to be more widely accessible, in tervent ions that are brief, less demand ing , and less potent ial ly distressing are needed. Ideally, such approaches should be g r o u n d e d in empir i- cally testable theories of the psychological mechanisms under lying normal and abnormal pos t t raumat ic processing.

Cognitive and Behavioral Practice 11 ,365-377 , 2004 107%7229/04/365-37751.00/0 Copyright © 2004 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

In this article we presen t a new cognitive therapy for PTSD. We descr ibe the theoret ical background , briefly review evidence for a central tenet of the model , and then provide a detai led guide to the treatment. The mode l on which the t r ea tment is based was first advanced by Wells (2000) and is g r o u n d e d in an informat ion-process ing theory of psychological d isorder (Wells & Matthews, 1994, 1996).

A Cogni t ive M o d e l o f PTSD

The start ing po in t for the new mode l is the assump- t ion that following t r auma an in terna l goal of process ing is the deve lopmen t of a b luepr in t or p lan for gu id ing th inking and act ion in potent ia l future encounte rs with threa t . Jus t as individuals can be conceptua l ized as having a p lan or script that guides th inking and behavior when ea t ing in a restaurant , peop le have plans that guide cognitive and behavioral activities dur ing encounte rs with threat . The goal o f emot iona l processing, which normal ly proceeds u n i m p e d e d and spontaneously, is the strength- en ing of such a plan. We have t e rmed the process by which emot iona l processing takes place and plans are deve loped the Reflexive Adap ta t ion Process (RAP), a te rm in t ended to capture the idea that this is in i t ia ted auto- matically in response to intrusive thoughts. Whe t he r or no t adap ta t ion occurs depends on the style of th inking and coping a dop t e d by the person. In terna l beliefs and

366 Wells & Sembi

environmental factors lead to a style o f thinking and coping behaviors that block the development of adaptive plans and prevent the return of cognition to a "normal" state o f processing. Beliefs of a metacognitive nature (i,e., about thinking itself) are o f central importance because they guide activities of the individual's cognitive system and can lead to styles of thinking that facilitate or impede emotional processing. Such metacognitive beliefs can be represented verbally but are linked to implicit plans that guide thinking. For example, much of the knowledge used to guide thinking and behavior is no t verbally ex- pressible. In verbal form, examples of such beliefs in- elude the following: I must worry in order to be prepared; I must try to remember all of the details of the trauma so that I can understand why me; I should be alert to all sources of danger; I f I pay close attention to all possible threat I won't be taken by sur- prise; I must not think about what happened or I'll not cape. These metaeognitions (and plans they represent) give rise to perseveration, which is persistent and recurrent thinking about trauma, threat, and one's reaction to it. Perseveration consists of worry/ruminat ion, threat monitoring, and maladaptive thought-control strategies. It is maladaptive because it strengthens and maintains perceptions of threat and it blocks the processes necessary for the RAP. The model is novel in its emphasis on styles of thinking (e.g., worry, attentional monitoring for threat, mental control) rather than on content, and for its focus on metaeognitions, which are the beliefs and strategies used to appraise and regulate thinking itself. Like other models, the approach sees coping through avoidance, use of alcohol, and so on as further examples of unhelpful coping. In the present model alcohol is a problem because it alters the conscious experience of intrusions so that mental simulation is disturbed, whilst avoidance pre- vents the person discovering that the environment is no t still dangerous. In each case cognition cannot return to a "normal" state of functioning.

A diagrammatic outline of the model is presented in Figure 1. In the model symptoms such as intrusive thoughts and hyperarousal are normal in-built responses following trauma. They act as biasing agents on cognition and lead to the selection and revision of metacognitions for guiding thinking and coping. Normally, symptoms such as intrusive recollections (flashbacks) coupled with attentional orienting responses provide an impetus for run- ning mental simulations of dealing with trauma. Such mental simulations are a rudimentary mechanism for lay- ing the foundations of a metacognitive plan for coping and subsequent action (the RAP). The flexible use of imagery is a typical and potentially useful medium of pre- liminary plan compilation. It is useful because it repre- sents the dynamics of action and cognition over time and relates multiple modes of responding (thinking, behav- ing, feeling) in concer t in a way that can be controlled by

Trauma (arousal/threat level)

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1-'1 !

Adaptive situational processing

Low ruminative activity

Flexible attention control

Mental simulation (planning)

Acceptance of symptoms

g Exit i cognitive re-tuning

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Threat monitoring

Negative appraisal of coping/ symptoms

Avoidance/thought control

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i |

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Figure 1. A schematic representation of the metacognitive model of PTSD.

the individual. In PTSD, the resources needed for mental simulation are drained by, and ending the threat cycle in- compatible with, compet ing processing activities. In par- tieular, if the person believes that the way to cope is to engage in repeated conceptual (i.e., verbal) analysis of past events a n d / o r to worry about the future, this can interfere with more adaptive imaginal simulations. Furthermore, the person may not be flexible enough in their use of thinking strategies such that there is an overuse of recyclic thinking (e.g., trying to remember all of the details, trying to work out blame) that constitutes chronic analyt- ical dwelling on trauma-related information. If the person believes that the best way to cope is to avoid situations, avoid thoughts of trauma, a n d / o r execute hypervigilant threat-monitoring strategies, this interferes with mental simulation and maintains perceptions of danger so that the anxiety program persists. The anxiety program is also maintained by negative interpretation of traumatic symptoms such as interpreting intrusive thoughts and hyperarousal as a sign of mental breakdown. As a consequence

Metacogni t ive Therapy for PTSD 367

of these factors, the t raumat ized individual is unable to exit the emot iona l process ing (RAP) cycle because mental s imulat ion is incomple te and/orcognition does no t re- tune to the normal threat-free envi ronment .

As dep ic ted in Figure 1, maladapt ive and adaptive strategies arise from metacogni t ions as r ep resen ted by the arrow lead ing f rom metacogni t ions to strategy. The strategies i m p l e m e n t e d in turn have an effect on metacognit ions as dep ic ted by the re tu rn arrow. For example , strategies such as trying no t to th ink certain thoughts activate metacognit ive thought -moni to r ing strategies in which the person moni tors for the occur rence of target thoughts. This can have the effect of t r igger ing the unwanted thought itself. The resulting failure to avoid thoughts can s t rengthen negative metacogni t ive beliefs abou t the uncontrol labi l i ty of thoughts about t rauma. To take an- o the r example o f the effect of strategies on metacogni- dons, the use o f worry and hypervigi lance s t rengthens metacogni t ive plans for these activities, so in essence the person becomes an increasingly skilled "threat detector." Moreover, the nonoccu r rence of threat can be taken as evidence that worrying and hypervigi lance are working. Such an effect s t rengthens positive beliefs about the usefulness of these strategies. Adaptive strategies, on the o ther hand, allow reflexive adap ta t ion to occur so the person spontaneously develops plans for coping in the future ra ther than be ing stuck in a t t empt ing to cope with non- existent threat in the present .

Symptoms subside when a satisfactory p lan for coping has been establ ished and the person is able to exit the RAP. Exit ing requires metacogni t ive mon i to r ing and control processes, and the RAP cont inues unti l discrepancies between the cur ren t status of the self (e.g., feel ing vulner- able) and a des i red or a normat ive in ternal goal state is e l iminated. This process of checking for discrepancies consists of in-built metacognit ive mon i to r ing and control processes that are par t of the RAP. However, discrepancies persist when metacognit ive beliefs mainta in the focus of processing on danger.

We have seen how metacogni t ive beliefs about the value of w o r r y / r u m i n a t i o n under l i e perseverative processing in the form of negative conceptua l activity. Othe r factors also lead to a genera l repe t i t ion of processing. For example , an individual may be dissatisfied with the way in which she or he coped dur ing the trauma. This will lead to r epea ted activation of the RAP leading to intrusions about the t rauma so that the individual can p lan more satisfactory responses. Such dissatisfaction may no t occur immedia te ly after the t r auma but can be in i t ia ted by la ter negative social factors such as criticism or blame, which is one potent ia l pathway to delayed-onset PTSD. Stresses that are difficult to br ing u n d e r personal control also contr ibute to perseverat ion because the individual is in a state o f pers is tent menta l s imulat ion and planning.

The Model in Action A "walk th rough" of the mode l for a par t icu lar case

will he lp to clarify how the mode l works. A case conceptualization based on the mode l is p re sen ted in Figure 2.

In this example the RAP is repea ted ly t r iggered by intrusive images and reexper ienc ing of pain. The occur- rence o f these and re la ted symptoms leads to the activa- t ion of metacogni t ions to guide in format ion process ing requ i red for the RAP. In this case the metacogni t ions are ma ladap t ive a n d l ead the ind iv idua l to act ivate w o r r y / ruminat ive strategies of self-regulation, hypervigi lance for danger, bodi ly checking, avoidance, and though t control. Metacognit ive beliefs also lead the individual to fear symptoms themselves, th ink ing that this could lead to "losing it." As a result of these strategies, no rma l activities o f the RAP are b locked and so intrusions automatical ly pers is t as a m e a n s of k ick-s tar t ing the adapt ive RAP process. The maladapt ive strategies used also keep anxiety and a sense of threa t going, thereby fuel ing anxious symptoms. Some strategies such as bodily checking in com- b ina t ion with anxiety cont r ibu te to feel ing d e a d / u n r e a l .

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Adaptive situational processing

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Worry about danger Look out for danger

Avoid traffic Avoid TV programmes/

reminders Try to control thoughts

Check pulse

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Figure 2. A case conceptualization based on the metacognitive model.

368 Wells & Sembi

Thus, intrusive thoughts and anxious symptoms persist, cu lmina t ing in a state of PTSD.

Predictions and Clinical Implications The model assumes that posttraumatic s)maptomatol-

o g y - - t h a t is, intrusions (memories and flashbacks), nightmares, he igh t ened arousal, and hype rv ig i l ance - - a r e normal in the immedia te af termath o f a t raumatic event. They are indicators that the individual 's cognitive system is c o m m e n c i n g the RAP process. Difficulties arise, however, when the individual uses inappropr i a t e coping strategies a n d / o r in terprets the symptoms in a th rea ten ing way. These factors dis turb the compi la t ion of an appro- pr ia te plan for deal ing with threat and subsequent fading of the RAP. A basic impl ica t ion is that t r ea tment that re- moves the barr iers to no rma l adaptive processing should be effective in rel ieving PTSD.

The m o d e l makes several testable predic t ions . O n e of the most p r o m i n e n t is that specific in ternal aspects of processing in ter fere with the RAP under ly ing emot iona l processing. Worry and rumina t ion dra in resources necessary for processing images and runn ing simulations. They also focus the individual on negative outcomes, thereby fuel ing the anxiety p rog ram and dra in ing the resources n e e d e d for const ruct ing a coping conf igurat ion (plan). A fur ther p red ic t ion is that some coping strategies (e.g., avoidance and dissociation) will in ter fere with emot iona l processing. Excessive efforts to control or avoid thoughts of t rauma will in ter fere with no rma l s imulat ion processes. Finally, since the intr insic goal of processing is to develop a p lan for coping, factors that cont r ibute to per- cept ions of the self as ineffective at coping with the threat will cont r ibute to perseverat ion of the RAP and symptoms of failed emot iona l processing. Candidates of inter- est are negative self-appraisals resulting from beliefs about the self or aspects of the t rauma, and psychosocial factors such as negative social support .

It is appa ren t f rom these predic t ions that responses to symptoms of stress, such as intrusive thoughts, startle responses, and hypervigilance, should be m a n a g e d in a par- t icular way that blocks worry / rumina t ion , threat monitoring, and avoidant coping. Adjustment processes should be allowed to run their own course without inflexible or maladapt ive upper-level involvement.

In the following section we descr ibe briefly how the mode l accounts for impor tan t PTSD-related phenomena .

Explanation of Imaginal Exposure Effects While the mode l predicts that p r o l o n g e d imaginal re-

living of t r auma is no t necessary for effective t reatment , the efficacy of the t echn ique can be exp la ined within the context of the model . The technique will be effective when it allows the individual to run menta l simulations of exper ience that facilitate the RAP and lead to p lan forma-

tion. Moreover, imaginal reliving will p romo te habi tuation, which will weaken reflexive influences on processing and increase the flexible control of a t tent ion and coping so that adaptive strategies may be implemented . Imaginal exposure will also be beneficial in cases where pat ients fear anxious symptoms, and when the evocation of symptoms dur ing exposure provides evidence that chal lenges symptom-rela ted worries.

Dose-Response Phenomena The mode l explains the dose-response re la t ionship in

PTSD in which repea ted stressors or events of greater magni tude (or causing greater arousal) lead to more severe PTSD. This effect is a t t r ibuted to the dynamic inter- play between lower- and upper-level processing. Repeated and intense events lead to the formation of strong associa- tive links between lower-level processors, producing sensiti- zation to threat and more readily activated RAP responses. As a result, threat- re la ted mater ia l is more likely to in- t rude into consciousness and diminish higher-level flexible cont ro l over processing, n e e d e d for the imp lemen ta t ion of adaptive processing and subsequent fading of the RAP.

Delayed-Onset PTSD Delayed-onset PTSD is exp la ined by the mode l in the

following way. Initially following trauma, individuals may fulfill the goals of the RAP. However, at some po in t there is a shift to maladapt ive r e spond ing before comple te consol idat ion of the plan. This shift can be t r iggered by envi- ronmen ta l and social events that lead to negative reappraisal of the self, a r eoccur rence of threa t appraisals, a n d / o r won T . Compet ing processing priori t ies can also temporar i ly block the RAP as the capture o f a t ten t ion by stress symptoms is avoided. For instance, dea l ing with on- going cu r ren t personal issues may suppress stress symptoms unti l compe t ing self-regulatory demands are re- moved, at which po in t PTSD symptoms emerge.

PTSD Symptom Clusters The model explains the three PTSD symptom c lus te rs - -

in t rus ions / reexper iencing, hyperarousal, and avoidance / d i s soc ia t ion - -a s follows. I n t ru s ions / r eexpe r i enc ing and hyperarousal are seen as normal consequences of stress that are par t of the RAP process. They indicate activity of reflexive processing that serves to bias conscious processing and retrieval of in format ion f rom long-term memory by repeatedly in t roduc ing mater ia l into consciousness as the basis of forming a cogni t ion-act ion plan. Symptoms of avoidance /d issoc ia t ion are seen as coping strategies that are maladapt ive if used in the long te rm because they disrupt the RAP.

Treatment Implications An impl icat ion of the mode l as dep ic ted in Figure 1 is

that it can be t ranslated into an individual case conceptu-


al izat ion, which is used to socialize to t r e a t m e n t and as a f ramework suppor t ing individual techniques. Patients can readi ly identify the maladapt ive strategies that form a vicious cycle of PTSD symptoms and the adaptive responses that are to be deve loped in t rea tment . The goal of treat- m e n t is to free up the t raumat ized pat ient ' s na tura l ca- pacity for self-regulation a n d adapta t ion following trauma. This consists of enabl ing a shift to a metacogui t ive mode of processing in which w o r r y / r u m i n a t i o n strategies and threa t mon i to r ing are d i scont inued and a strategy of "detached mindfulness" (cf. Wells & Matthews, 1994, 1996) is establ ished in dea l ing with symptoms. This offers a means of improving flexible r e spond ing and a t tenua t ing excessive active involvement with intrusions, symptoms, and memories . The suspension of maladapt ive strategies unlocks the barr iers to in-built adaptive emot iona l processing. These techniques are the rud imenta ry basis o r "core" o f t rea tment , which is descr ibed in this manual . However, addi t ional strategies are par t of the b roa de r metacognitive t rea tment approach, namely, runn ing mental s imulat ions of coping with the t r auma and direct chal- l enging of metacogni t ive beliefs abou t symptoms. The core t r ea tment is descr ibed la ter in this article. Before doing so, in the next section we review the empirical status of one of the central and novel predict ions of the m o d e l - - that maladapt ive strategies of wor ry / rumina t ion and thought control cont r ibu te to the deve lopmen t of PTSD.

A Brief Rev iew o f Research on Worry a n d Thought Control

A central p red ic t ion of the mode l is that wor ry / rumi - na t ion should be associated with the presence or devel- o p m e n t o f PTSD symptoms. In particular, worry should b lock the RAP and therefore lead to a persis tence or increase in intrusive images as the person 's cognitive system at tempts menta l simulations and adapta t ion .

Several studies have tested for a re la t ionship between worry and t rauma reactions, and two exper imenta l studies have examined the effects of worry on intrusive images fol lowing stress. Butler, Wells, and Dewick (1995) asked nonpa t i en t par t ic ipants to watch a gruesome and stressful film about a workshop accident , and then to engage in one of the following postfi lm men ta t ion strategies for a pe r iod of 4 minutes: worry in verbal form abou t the film, image the negative aspects of the film, or settle down (control condi t ion) . The individuals who worr ied experi- enced the highest f requency o f intrusive images about the film over the next 3 days. In a larger study, Wells and Papageorg iou (1995) used a similar film-stressor method- ology, only this study c o m p a r e d the effects of five differ- en t postfi lm menta t ion condit ions. These strategies were: (a) worry about the film, (b) worry about usual concerns, (c) image the negative aspects of the film, (d) dis tract ion

by speeded letter-cancellation, o r (e) settle down. These condi t ions were selected because they were cons idered to differ in the extent to which they caused b locked emo- t ional processing of images and "tagging." Tagging refers to the activating of memor ies of the stressor and engaging in processing that sets up a wide range of associations so that an increasing n u m b e r of concepts become retrieval cues for stress-related material . The results showed that the two worry condi t ions were associated with the highest f requency o f intrusive images about the t r auma over the 3 days following exposure to the film. Moreover, there was a l inear i nc remen t in f requency o f intrusions across different condi t ions that was consistent with predictions concern ing a cozjoint incubat ion mechan i sm involving blocked emot ional processing and tagging. The results o f these analogue studies o f t rauma-re la ted stimu- lat ion suppor t the hypothesis that worry following stress can lead to an increase in poststress symptoms of intrusive images.

The mode l also suggests that par t icular metacogni t ive coping strategies should be l inked to PTSD and negative outcomes following stress. Several studies, bo th cross- sectional and longi tudinal , have examined the relat ionship between though t cont ro l strategies and pos t t r auma stress symptoms. Individual differences in strategies used to control distressing, intrusive thoughts can be measured with the Though t Control Ques t ionnai re (TCQ: Wells & Davies, 1994). The T C Q assesses five factorially der ived domains of strategy: distraction; social control; worry; punishment ; reappraisal . The scale appears to have a similar factor s tructure in pa t ien t and nonpa t i en t samples (Reynolds & Wells, 1999). The use o f worry and punish- m e n t to cont ro l thoughts is positively associated with stress vulnerabil i ty and appears to be elevated in some clinical syndromes. Holeva, Tarrier, and Wells (2001) conduc ted a longi tud ina l study of the predic tors of PTSD following serious motor-vehicle accidents in which victims requ i red hospital t rea tment . Measures of though t control (TCQ) and social suppor t admin i s te red within 4 weeks o f the acc iden t were used as p r ed i c to r s o f PTSD 4 to 6 months after the accident . The presence of stress symptoms (acute stress disorder) at Time 1 was controlled. The use of worry to control thoughts at Time 1, a change in perceived social support , and an in terac t ion between perceived social suppor t and the use of social t hough t control strategies significantly predic ted subsequent PTSD. In cross-sectional analyses o f symptoms, thought -cont ro l strategies were predict ive of acute stress d i sorder (ASD) at Time 1 and o f PTSD at Time 2. Both dis t ract ion and social control T C Q subscales were negatively cor re la ted with ASD and PTSD caseness, suggesting a possible positive benefi t of these metacognitive control strategies. How- ever, worry and pun i shmen t bo th emerged as positive predictors o f ASD and PTSD. These f indings for worry and

370 Wells & Sembi

p u n i s h m e n t cont ro l strategies are e c h o e d in a study by Warda and Bryant (1998). They f o u n d that individuals with ASD used m o r e worry and p u n i s h m e n t thought - control strategies than non-ASD patients. Reynolds and Wells (1999) showed that part icular T C Q strategies distin- guished recovered and nonrecovered patients with major depress ion a n d / o r PTSD, and that change in T C Q strategies was associated with recovery. The recovered group was more likely to use distract ion and reappraisal and less likely to use worry and punishment .

Studies of rumina t ion show that the tendency to ruminate, def ined as recyclic negative thinking about the causes and symptoms of depress ion, is associated with negative outcomes following stressful life events. Ruminat ion has been found to be very similar to worry in bo th form and funct ion (Papageorgiou & Wells, 1999, 2003). In prospective studies ruminat ion has been shown to be positively associated with depressive symptoms following significant negat ive life events involving an e a r t h q u a k e (Nolen- H o e k s e m a & Morrow, 1991) and following be reavement (Nolen-Hoeksema, Parker, & Larson, 1994).

The results of these studies suppor t a central supposi- t ion of the presen t mode l that th inking stTles and metacognitive coping strategies can adversely affect outcomes following stress and that perseverative styles of th inking involving w o r r y / r u m i n a t i o n and choice of par t icular thought-contro l strategies are unhelpfu l for adapta t ion.

T h e C o r e T r e a t m e n t M a n u a l

In the r e m a i n d e r of this article we presen t the core metacogni t ive t r ea tment based on the model . We have p resen ted this in the format of e ight t r ea tment sessions, a l though longer is requ i red in some cases, d e p e n d i n g on the rate of pa t ien t progress.

Structure and Duration o f Treatment Trea tment sessions are he ld on a weekly basis. The ini-

tial sessions last 45 to 60 minutes. Once patients are en- gaged and able to effectively imp lemen t control over worry and detached mindfulness, the dura t ion of sessions is r educed to 30 minutes. Effective mastery is indica ted by the presence of each of the following: (a) the individual reports having successfully disengaged worry / rumina t ion f rom the occur rence of intrusions, arousal, and or ien t ing responses; (b) the individual accepts symptoms as a normal par t of adap ta t ion that do not require active avoidance or suppression; (c) the individual reports allowing in t rus ions /memor ie s / though t s related to the t rauma to occupy their own "mental space" while watching the spontaneous behavior of them as a passive observer. In our pre l iminary evaluat ion of the effectiveness of core t rea tment , 8 to 11 sessions were requ i red in o rde r to achieve PTSD-free outcomes. The rate of progress through

the different t r ea tment phases influences the n u m b e r of sessions required.

Session h Case Conceptualization and Socialization The first step is elicitation and consol idat ion of knowl-

edge concern ing the na ture and base rates of specific PTSD symptoms (intrusions, flashbacks, nightmares, and arousal symptoms). Following this, an individual case conceptual izat ion is const ructed based on the metacognitive mode l dep ic ted in Figure 1.

The task of conceptual iza t ion is s implif ied by direct- ing the course of quest ions to explor ing a series of specific and recent episodes in which the pa t ien t was trou- b led by symptoms associated with the trauma, or in which there was an exacerbat ion of anxious affect. The aim is to elicit examples of each of the e lements in the model . Much of the discussion focuses on explor ing the presence and extent of (a) worry / rumina t ion about the tFauma, (b) at tentional moni tor ing strategies, (c) strategies for coping with symptoms/distress (e.g., avoidance, thought control, distraction, alcohol), (d) beliefs about symptoms, worry, and at tent ional strategies. An effective sequence for ob- ta ining this mater ia l is to begin by asking about symptoms and then explor ing the strategies used to manage or avoid symptoms. The therapis t next asks directly about at- tent ional moni to r ing for threat , and wor ry / rumina t ion . Questions are then targeted at eliciting beliefs about symptoms, worry / ruminat ion , and threat monitoring. This sequence is i l lustrated in the following dia logue which was the g round ing for the conceptual iza t ion presen ted in Figure 2.

ELICITATION OF SYMPTOMS

T: I ' d like to begin by asking about the symptoms you have been exper ienc ing in the past month . Can you descr ibe them to me?

P: I feel as if I ' m dead. Like I d o n ' t exist anymore. T: Is it like being de tached from things a round you? P: Yes, it 's unreal . I have to check my pulse and hear t

to make sure I ' m still alive. T: What about o the r symptoms such as distressing

thoughts or memories? P: I keep seeing myself on the f loor and I can feel

pain in my legs and the b lood flowing f rom my head. I can actually feel the pain again.

T: What about feel ing anxious or f r ightened? P: I feel scared all the t ime when I go ou t now, I ' m

cons tan t ly th ink ing s o m e t h i n g bad will h a p p e n .

STRATEGIES (ATTENTION AND COPING)

T: Do you do anything to try and reduce or avoid these symptoms?

P: I avoid things. T: What are you avoiding?

Metacognitive Therapy for PTSD 371

P: Walking in streets where there is a lot of traffic, holes in the street, crossing the road.

T: Do you avoid things that r e m i n d you of what happened?

P: I avoid watching hospital scenes on the television. T: Do you avoid the scene of the accident? P: If possible. But I have to go there. I look away

when driving past, bu t somet imes I force myself to look at the whole scene to see if it was my fault. I only look at the whole scene when I feel I can cope, bu t it 's only for a few seconds.

T: What do you do when you are looking? P: I try to look at all of the possibilities to analyze what

happened. But when I see myself on the floor with the pain and blood, I look away, and try not to th ink about it.

T: You men t ioned something I 'd like to ask you more about. You said you try no t to th ink about it. Do you try to control your thoughts at other times too?

P: Yes, I try no t to th ink about what happened. If I get a thought I try to push it out of my m i n d or think about something else.

T: Have you found that what you pay at tent ion to has changed since the event?

P: Yes, I pay more a t tent ion to things that are not safe. I 'm constantly looking around for traffic and listen- ing for sounds of lorries. It can be anything, I've been watching a ceiling fan at work because it's wobbling.

W O R R Y / R U M I N A T I O N

T: You men t ioned paying more at tent ion to danger, and it sounds like you are spending time worrying and dwelling on what happened.

P: Yes, everyday I 'm worrying, and so I end up avoiding things.

T: How much of the day are you worrying about bad things that could happen?

P: It's usually in the background and when I have to go out I get really worried.

T: How much of the day are you dwelling and rumina t ing about what happened?

P: I have periods when I think about it a lot, usually when I feel depressed. But I try not to get into that state.

T: What are you trying to achieve by worrying about things?

P: I 'm trying to be cautious and avoid accidents. T: What are you trying to achieve by repeatedly think-

ing about what happened? P: I 'm trying to work out if it was my fault.

M E T A C O G N I T I V E BELIEFS A B O U T WORRY/ /

R U M I N A T I O N AND A T T E N T I O N

T: Do you think worrying is helpful in any way? P: It makes me more aware of the potential risks

T: How does that work? P: It makes me think of what could happen so that I

act more cautiously. But it also means I don ' t do so many things now.

T: Is be ing cautious something you do? P: Yes, I make an effort to be cautious. T: How do you do that? P: I keep a lookout for danger. T: So it sounds as if you believe that worrying and

keeping a lookout for danger keep you safe.

M E T A C O G N I T I V E BELIEFS A B O U T SYMPTOMS

T: Do you worry about your symptoms? P: Yes, I think it's not normal to be like this and I 'm

concerned it means I 'm losing it. T: What do you mean by losing it? P: That I can ' t cope anymore. Maybe there's some-

thing wrong with my mind. T: What's the worst that could be wrong? P: Well, I 'm afraid this problem means that I can ' t

cope as well as other people. T: Do you ever believe that you are going crazy? P: Not crazy.Just that I 'm mentally weak some way. T: Do you do anything to stop yoursefffrom losing it? P: I try to control my thoughts. T: Do you think anything bad could happen if you

d idn ' t do that? P: I suppose I could lose it. T: So it sounds as if you believe that if you don ' t con-

trol your thoughts that could happen? P: Yes.

Following case conceptualization the therapist moves onto socialization. This consists of present ing the formu- lation in which the therapist stresses that PTSD symptoms are a normal part of adapt ing to traumatic expe r i ences - - that, u n d e r normal circumstances, the symptoms subside over time as necessary informat ion about the traumatic event and how to deal with it is learned. However, this process of adaptat ion can be disrupted when individuals engage in specific types of th inking and behavior. Several factors can block adaptation, and these include:

* worrying or rumina t ing about the t rauma or one's responses

• paying too much a t tent ion to threat and danger after the event

* trying to avoid or excessively control thoughts about the t rauma

* negative beliefs about the me a n i ng or consequences of symptoms

The na ture and pervasiveness of wor ry / rumina t ion is then highlighted by asking patients about the thoughts they have had dur ing the day about their traumatic exper ience or react ion to it. This typically results in the

372 Wells & Sembi

descr ip t ion of many negative thoughts and beliefs and the r epo r t of circular th inking based on: "what if . . . . if only . . . . why . . . . and why me?" type questions. It is no t a pr incip le focus of t r eaunen t to chal lenge the conten t of these ruminat ive thoughts, bu t to enable patients to dis- cont inue this verbal iterative style of negative thinking. Thus, a l though these "automatic thoughts" are elicited, this is done only to h ighl ight the extent of the pat ient 's ruminat ion . The thoughts are no t c h a l l e n g e d / b a l a n c e d in the t radi t ional cognit ive-behavioral sense.

Patients are in t roduced to the idea that their intrusive thoughts, flashbacks, nightmares , startle responses, and arousal symptoms are no rma l and necessary following trauma. The symptoms are a sign that their cognitive system is a t t empt ing to process the t rauma and recal ibrate or adjust to the event that has taken place. However, their responses and coping strategies have the effect of prevent ing this processing f rom taking place. The therapis t emphasizes that it is impor tant not to avoid these symptoms because they are par t of an automat ic adapta t ion process.

The next step is to provide an overview of the nature and goals of t reatment . The case formula t ion provides a vehicle for do ing this. Notice that in Figure 2 the "adaptive processing" box is empty. The therapis t describes to the pa t ien t how t rea tment will consist of emptying the "maladaptive" box in the formula t ion and put t ing new strategies that the pa t ien t will learn in t rea tment into the adaptive box in o rde r to exit the PTSD cycle. The pa t ien t is given a copy of the conceptual iza t ion to take home and think about before the next session.

Sessions 2 to 3: Worry Postponement and Detached Mindfulness

The aim of the next session(s) is to re inforce awareness of the p rob lemat i c na tu re of persevera t ion and to faci l i ta te a l te rna t ive r e s p o n d i n g to symptoms. T h e r e are three basic componen t s to this: (1) the advantages / disadvantages analysis, (2) pract ice of de t ached mindfulness, (3) worry pos tponement .

Advantages~disadvantages analysis. The first step is to help clients see that engaging in worry / rumina t ion serves no purpose and contributes to "locking" them into merely replaying negative aspects of the t r auma or their dissatisfaction with thei r own coping responses. The therapis t guides the pa t ien t th rough an advantages /d isadvantages analysis of wor ry / rumina t i on as a means of socialization and motivat ing clients to abandon preservative styles of thinking. The therapis t inquires as to whether there are any advantages to rumina t ion and a list of advantages is drawn up. This is followed by drawing up a list of disadvantages. The disadvantages are p r o m p t e d by questions such as the following: What happens to your anxiety when you worry? Does worrying help you move on from the trauma? Is worrying realistic or just negative? Does worrying help you feel

better about yourself?. Does worrying create problems ? Does worrying help you see the situation more clearly ?

The next step is to weaken beliefs about the advantages of perseverat ion. Frequently, an advantage to ruminat ion that pat ients r epor t is that it may he lp them to f ind answers. This bel ief can be weakened by asking the pa t ien t why this has no t h a p p e n e d yet given that they ap- pear to have spent a considerable a m o u n t of t ime thinking about what has happened . Patients quickly come to accept that perhaps there are no answers and this therefore becomes a reason to abandon ruminative thinking. In some instances, as in the case i l lustrated in Figure 2, pat ients express the be l ie f that worrying acts as a safety strategy by enhanc ing p reparedness or cautiousness. A two-pronged approach is used here. The disadvantages of worry are contras ted with the advantages with the aim of showing how the disadvantages outweigh the advantages. The therapis t then questions whether p reparedness and cautiousness can be achieved without worrying (How can you be cautious without worrying?). The aim here is to show how worrying and cautiousness are no t synonymous and therefore one can decide to reduce worry without sacri- ficing safety.

An advantages /d isadvantages analysis is also under- taken in examining the motivations for o the r unhelpfu l coping behaviors inc luded in the conceptual iza t ion such as a lcohol use, trying to suppress thoughts, and so on. When thought suppression is a feature of the formula- tion, a within-session suppression expe r imen t is used to show how at tempts to avoid and control thoughts can be disadvantageous. Here the therapis t asks the pa t ien t to try not to th ink a target thought (e.g., "Try no t to th ink about a blue tiger") for a pe r iod of two minutes. Typically pat ients r epor t that they exper ience the thought and this is used as an illustration of how trying to suppress thoughts is no t part icular ly effective.

Detached mindfulness. Individuals with PTSD repeatedly engage with intrusive thoughts and symptoms in counter- product ive ways involving wor ry / rumina t ion , overcon- trol, a t tent ional moni to r ing for threat , and negative appraisals. Some of these responses exaggerate the cu r ren t sense of danger, and each of them can interfere with the processes involved in normal adapta t ion . A goal of treat- m e n t is to d rop these unhelpfu l inf luences on adapta t ion so that normal adap ta t ion processes may resume. An ini- tial step in achieving this consists of t ra ining in "de tached mindfulness" (Wells & Matthews, 1994), which increases awareness of unhelpfu l th inking styles, disrupts them, and facilitates flexible control over responding.

Detached mindfulness refers to taking a perspective on one 's own thought processes in which they are ob- served in a de t ached way, wi thout in terpre t ing , analyzing, con t ro l l ing , or r eac t ing to t h e m in any way. Pat ients are i n s t ruc t ed to r e s p o n d in a pa r t i cu l a r way when they


exper ience intrusive thoughts, flashbacks, and nightmares as follows:

"When you have an intrusive thought , flashback, or have had a n ightmare , it is impor t an t that you do the following. Acknowledge to yourself that these symptoms are occurr ing, and r emind yourself that engaging with these symptoms is unhelpful . Some peop le f ind it he lpful to say to themselves: This is

jus t a symptom, I don't need to do anything with it. I am

jus t going to leave it alone. I am not going to try to avoid

it or equally ruminate on it. R e m e m b e r that engagemen t with these symptoms includes quest ioning the mean ing o f the symptom, trying to work out what has h a p p e n e d to you, rumina t ing about why it should have happened , asking What i f . . . , Why . . . .

Why me . . . . or I f only . . . type questions, worrying about symptoms, trying to control or avoid thoughts o r symptoms. It is impor t an t to let your thoughts or symptoms occupy their own space and time without engaging with them."

To facilitate comprehens ion , several analogies are used in sessions to demonst ra te the way that intrusive symptoms should be treated.

Analogy 1. The Recalcitrant Child. Patients are asked to t reat their intrusions in the same way that they migh t dea l with an annoy ing chi ld tha t they had to look after (i.e., they could not avoid). They need to acknowledge that the child was there bu t paying too much a t tent ion to the child (engaging with it) would merely serve to re inforce its bad behavior, and a t tempt ing to punish the child (suppress it) would upse t the child even further. Thus, the best thing to do is to jus t leave the child a lone and let it settle of its own accord.

Analogy 2. Pushing Clouds. Intrusive symptoms can be t rea ted as if they were clouds in the sky. That is, they are someth ing that is passing by and someth ing we can do no th ing about. They are par t of a natura l self-regulating weather system and a t tempt ing to stop or push them away is no t necessary and no t possible. Even if we could, this would disturb the balance necessary for rainfall and nature . There- fore, the th ing to do is let them occupy their own space and passively watch their behavior over time.

A critical t r ea tment c o m p o n e n t at this stage is ensur ing that pat ients unde r s t and the difference between nonengagement in a de t ached mindful mode , and avoidance of thoughts. A v o i d a n c e - - f o r instance, tu rn ing a t tent ion to o the r distract ing act ivi t ies-- is a form of active engagemen t with thoughts in the sense that a t tempts are be ing made to exclude the thoughts f rom consciousness.

Practical illustrations. Use o f the d e t a c h e d mind fu l m o d e and the consequences o f engagemen t with symptoms is then i l lustrated in the therapy session. In one ex- p e r i m e n t pat ients are asked to first create a menta l image of a green tiger, and then to engage with the image by trying to exclude all thoughts of tigers f rom consciousness. This is then contras ted with forming an image of a g reen t iger and observing the image without do ing anything with it. Pat ients typically r e p o r t difficulty exc lud ing thoughts of tigers, but f ind that if they assume d e t a c h e d mindful observation, that thoughts of tigers take on the i r own life and become less salient. In ano the r exper iment , patients can be asked to sit quietly and observe in a detached way a bodi ly sensation. For instance, pat ients are asked to passively observe the sensations in their m o u t h without moving thei r mouth-par ts or swallowing for a pe- r iod o f 3 to 4 minutes.

A useful strategy for facil i tating de t ached mindfulness is for the therapis t to ask the pa t ien t to sit quietly and let his or he r thoughts roam freely dur ing a free-association exercise while observing these in ternal events. The in- structions for this task are as follows:

"One way to exper ience the sense of de t ached mindfulness that will allow you to apply it to your distressing thoughts is to pract ice first with more genera l thoughts and feelings. In a m o m e n t I will say a series of words and what I would like you to do is sit and passively watch the movemen t of thoughts in your mind and feelings in your body as I say different words. For example , I might say the word blue and your task is to watch what happens in your mind and body as a result. Do no t try to del iber- ately form any thoughts o r activate any feelings o r m e m o r i e s - - s o m e t i m e s noth ing re la ted to the word may happen , that doesn ' t matter, you jus t need to watch your spontaneous thoughts and feelings without influencing them. [Pause.] Let's start: apple [pause for 10 secs], ocean [pause] , tree [pause] , chocolate

[pause], home [pause], birthday [pause], orange juice."

Worry postponement. Once the pa t ien t unders t ands the idea o f de t ached mindfulness and in-session pract ice has been comple ted , the therapis t moves on to reduc ing wor ry / rumina t ion . For this purpose the therapis t intro- duces the wor ry-pos tponement strategy. The instruct ion is given that whenever intrusive symptoms occur, the pa- t ient should acknowledge that the t h o u g h t / f l a s h b a c k / n igh tmare has occurred, and tell him- or herse l f no t to worry or rumina te abou t the t r auma or symptoms now, jus t let the symptom fade in its own time, and actively th ink about it later.

Patients are asked to allocate 15 minutes each evening as a des ignated worry or analysis time. The worry t ime should take place at least 2 hours before they go to bed,

374 Wel l s & S e m b i

and they should review the whole day. If pat ients h a p p e n to r e m e m b e r what had been worrying them, they can decide to engage in as much wor ry / rumina t i on as they feel they need to over the 15-minute per iod. However, it is emphasized that this is not compulsory and many patients dec ide no t to worry. At the end o f this pe r iod patients are asked to stop worrying and to deal with any fur ther worry as they had in the day, by applying de t ached mindfulness, and carrying any thoughts over to the next day's worry pe r iod if necessary.

Application of detached mindfulness and worry postponement. Clients are ins t ructed to apply de t ached mindfulness for homework in response to intrusive thoughts, flashbacks, and n igh tmares , a n d are asked to d i scon t inue daily wor ry / rumina t ion -based th inking by using the pos tpone- men t strategy. Careful therapis t mon i to r ing is r equ i red to ensure that patients are applying the m e t h o d consistently to the full range of intrnsive thoughts and wor ry / rumination exper ienced .

S e s s i o n s 4 to 5 In the next two sessions the therapist monitors progress

with de t ached mindfulness homework and worry post- p o n e m e n t and facilitates con t inued pract ice and generalization of the techniques.

The first issue concerns whether bo th techniques are be ing used consistently and frequently. The use of de- t ached mindfulness is assessed by asking pat ients to esti- mate the percen tage of t ime that they have been able to apply de t ached mindfulness to intrusive thoughts. It is impor t an t that the therapis t and pa t ien t do no t confuse this as a ra t ing of the a m o u n t of distress. The next ques- t ion asked by the therapis t assesses if there has been any decrease in usage of the technique over time, and if so, what the cause of this is. In some cases this is due to a reduct ion in distress associated with intrusions. The therapist should emphasize that the main aim of the technique is not to change distress but to "unlock barriers to natural processing," and therefore it is necessary to apply the tech- n ique to most instances of intrusions. The th i rd quest ion the therapis t asks concerns the b read th of appl ica t ion of de t ached mindfulness. It is impor t an t that the pa t ien t ap- plies it to all types of distressing intrusions re la ted to the t rauma and its consequences. In particular, some patients r epor t a specific recur r ing int rus ion that p redomina tes , and having app l ied de t ached mindfulness to this intru- sion they notice that o the r intrusions take precedence , bu t they do no t apply de t ached mindfulness to these new events as they should.

To assess consistency of usage of con t ro l led worry periods, the therapis t asks about the amoun t of t ime spent w o r r y i n g / r n m i n a t i n g pe r day, and how often the pa t ien t has succeeded in pos tpon ing wor ry / rumina t ion . Any d ropof f of usage of the technique should be explored.

Reduct ion in the f requency o f p o s t p o n e m e n t strategies are to be expec ted if there has been a r educed f requency of worry.

Generalization. The therapis t then proceeds to intro- duce the idea that wor ry / rumina t i on p o s t p o n e m e n t can be appl ied to all types of worry and persis tent negative thinking. At this stage it helps to list a range of cur ren t concerns that the pa t ien t has had in the past week in o rde r to raise awareness of the pervasiveness of perseverative thinking, All types of dwelling and worry are then targeted for subsequent homework practice of pos tponed worry periods.

Fur the r practice of de t ached mindfulness can be im- p l e m e n t e d in these sessions if necessary, The therapis t then moves on to in t roducing the applicat ion of de tached mindfulness to the after-effects of nightmares. Some patients repor t that after t rauma-related d reams /n igh tmares they are t roub led by thoughts or feelings el ici ted by them. The therapis t instructs pat ients to apply the technique of de t ached mindfulness to such after-effects when they occur.

Eliminating other maladaptive strategies. At this po in t in t rea tment , the therapis t under takes a review of the pa- t ient 's use of o the r coping strategies that are counterpro- ductive for adapta t ion. These strategies include use of alcohol or o the r substances to avoid thoughts and feelings, thought suppression strategies, avoidance of stimuli such as television news, and so on. The therapis t helps the pa- t ient to see how these strategies are a p rob lem. For example, many o f these strategies can be seen as a form of avoidance of thoughts and memor ies of t rauma, and this leads to a discussion of the p rob lems caused by cognitive avoidance. Once the pa t ien t identifies the unhelpfu l con- , sequences of these strategies, the therapis t asks the pa- t ient to ban them for homework.

S e s s i o n s 6 to 7: A t t e n t i o n a l M o d i f i c a t i o n

The a t tent ional phase of core t r ea tment is i n t roduced when patients have in the past week: (a) mas te red the use of de t ached mindfulness and r epor t ed success in using the strategy in response to at least 75% of intrusive symptoms, and (b) successfully a b a n d o n e d wor ry / rnmina t i on and all forms of dwelling on past, present, and future events such that no episodes last longer than approximate ly 2 to 3 minutes.

In this phase, t r ea tment focuses on hypervigilance, an a t tent ional coping strategy that maintains the pe rcep t ion of dange r and anxiety. Two types of a t tent ional monitoring strategies are problematic: at tention to internal sources of threat (i.e., sensations and feelings) and external at- tent ion to threat in the form of scanning the environ- men t for danger.

Systematic manipula t ions of a t tent ion are an impor- tant c o m p o n e n t o f the core t r e a tmen t as they shift


patients out of threat-modes of processing that repeatedly generate information concern ing danger. Rather than persist ing in a loop of r epea ted processing of danger, patients should be moving on to developing a p lan for dealing with danger, and for contro l l ing cogni t ion that allows threat- re la ted processing to decay. The search for threat is not synonymous with having a plan for dealing with threat once detected, perceiving the self as an effective agent of coping, and allowing cogni t ion to re-rune to the no rma l (non threa ten ing) envi ronment .

Stage I. Explanation and rationale. The fo l lowing out- l ine is used as a basis for therapists to descr ibe the role that a t tent ion plays in the ma in tenance o f PTSD:

'3(ou have seen how worry / rnmina t ion and at tempts to control symptoms can mainta in your p rob lem, and you have been successful in reduc ing those responses. We should now cons ider ano the r impor- tant aspect of the p rob l em that can keep your sense of danger and anxiety going. This is the role played by your focus of at tent ion. Following trauma, it is quite natural for peop le to become overly aware of people or objects a r o u n d them that are reminders of the trauma. This is one type of a t tent ion that can maintain a sense of danger and stop you from return- ing to a ba lanced view of the world. For some people, there is a tendency to focus too much on internal thoughts about the t rauma or anxiety symptoms. For instance, when in a si tuation similar to that in which the t rauma occurred, the person focuses on a memory or pic ture of what happened . This is often an image f ragment of a par t icular momen t , which may be the worst moment . Focusing in this way increases the sense of threat and anxiety, and takes a t tent ion away from focusing on cur ren t events that could provide a be t te r sense of safety and control."

The rat ionale is i l lustrated by asking questions concern- ing the consequences of idiosyncratic threa t -moni tor ing strategies. For instance, the therapis t asks: Do you think there are any problems with constantly scanning the environment

for signs of threat? Is scanning for threat likely to increase or de- c, ease your anxiety ? Does paying attention to threat give you a balanced picture of how safe a situation is? Does paying attention to threat mean you will cope better?This process is under- taken for external a t tent ional mon i to r ing for threat and also for in ternal moni tor ing. The therapis t therefore moves toward a conceptual iza t ion of hypervigi lance as be ing ano the r form of unhelpfu l p reoccupa t ion similar to wor ry / rumina t ion .

Before the pa t ien t is willing to give up threa t monitoring, it is often necessary to weaken the positive beliefs suppor t ing its usage. The therapis t does this by question- ing whether hypervigilance would have actually averted

the t raumatic event, how the person would know exactly what to be hypervigi lant for, and by examin ing counter- evidence concern ing the potent ia l unhelpfu l role of hypervigilance. The following t ranscr ipt illustrates a typical l ine of ques t ioning used to raise awareness o f the role of a t tent ion and to weaken beliefs about its usefulness:

T: Have you not iced that what you pay a t ten t ion to has changed since you were attacked?

P: I 'm not sure. T: For instance, do you f ind that you not ice cer ta in

things more than you d id before? P: I 've no t iced how much cr ime there is, it always

seems to be in the news. T: Do you th ink that is because crime has suddenly

increased since your assault, or has someth ing else changed?

P: Well it 's obviously in my mind, it's the way I ' m th inking abou t things.

T: Yes, that 's an impor t an t observation. Someth ing has changed in what you pay a t ten t ion to. Has your a t tent ion changed in any o the r way? For example , what do you pay a t tent ion to when you go out now?

P: I ' m on the lookout for groups of youths, and when I see them I walk the o ther way.

T: Any o ther changes to what you look for? P: I ' m always looking to see if I can see anyone look-

ing suspicious. T: Do you th ink there are any p rob lems with using

your a t tent ion in this way? P: Well, it makes me feel safe, and if I ' d done this

before maybe I would have been safe. T: Tha t sounds like an advantage. I f you had been like

this, would that have p reven ted the attack? P: No, p r o b a b l y not , as they were n o t ac t ing

suspiciously. T: So it may no t have helped. Can you see any dis-

advantages of do ing this? For example , does it he lp you to feel calm when you are out?

P: No, it does the opposi te , because I see dange r everywhere.

T: So the quest ion is, is there really danger everywhere or is your strategy keeping your anxiety and stress going?

P: I ' m keep ing it going. T: So we need to take a look at do ing someth ing

about your at tent ion.

Stage 2: Awareness and abandonment. Once the p rob lem with threa t mon i to r ing is unders tood , the therapis t asks the pa t ien t to consciously acknowledge the d i rec t ion o f their a t tent ion the next t ime they feel anxious in a situa- t ion and to stop threa t moni tor ing. In o rde r to apply this technique pat ients are encouraged to re tu rn to their normal rout ine of daily life. In most cases this does mean

376 Wells & Sembi

re tu rn ing to the si tuation in which the t r auma occurred, or in similar situations. This is the only po in t in the core t r ea tment where a degree of in-vivo exposure may take place. However, it is no t habi tua t ion bu t the facili tation of awareness of and d is rupt ion of threa t mon i to r ing that is the goal of this p rocedure .

Session 8 The aims of the next session are to review progress

with a b a n d o n m e n t of threat mon i to r ing and its applica- t ion dur ing the pat ient ' s normal daily rout ine. The first thing assessed by the therapis t is the extent to which the pat ient has been re turn ing to his or her normal p re t rauma routine. At this stage, d e p e n d i n g on the nature and sever- ity of threat , there should be some indica t ion of a re turn to situations that were usually f requented . If avoidance of low-risk situations is an issue, then pat ients are encouraged to go into these situations for homework while prac- t icing a b a n d o n m e n t of threat moni tor ing.

Attention refocusing. After abandonmen t of threat monitoring, the next step is active a t tent ion refocusing, con- sisting of asking patients to del iberate ly redi rec t a t tent ion away from themselves and away f rom threat, and onto n o n t h r e a t e n i n g aspects of the external env i ronment when in si tuations that r emind them of the trauma. (Note, however, that in our pre l iminary evaluation of the effects of the core t reatment , we d id not use this addi- t ional strategy. We found that it was unnecessary as patients r e s p o n d e d well to the basic instruct ion to be aware of and abandon threat moni tor ing. ) The therapis t intro- duces the idea that, "in o rde r to allow thinking to re-tune to the no rma l env i ronmen t it is helpful to pract ice focusing a t tent ion on the env i ronment in a ben ign way. This means looking for signs of safety ins tead of signs of im- p robab le threat." This is done by pract ic ing different focusing strategies dur ing the t r ea tment session. First, the therapis t asks the pa t ien t to sit in the waiting room and focus on aspects of the env i ronmen t that signal that it is a safe place. This is fol lowed by walking in the street with the therapis t and pract ic ing focusing on safety signals. Fi- nally, a strategy is prac t iced involving focusing on neutra l external stimuli (i.e., unre la ted to concepts of danger or safety) such as focusing on the array of different colors that can be seen.

Relapse Prevention During the final session of t rea tment the original for-

mula t ion is discussed with personal ized examples f rom the pat ient ' s exper ience of how tackling rumina t ion via the use of de t ached mindfulness and cont ro l led worry per iods has p laced the individuals ' concerns in perspective. Should pat ients f ind themselves d is turbed by memories of the t r auma in the future, they are advised to look for signs of wor ry / rumina t ion . On not ic ing worry or ru-

mina t ion they should once again adop t the techniques they have l ea rned until the symptoms subside.

Summary and Conclus ions

In this article we have p resen ted our core t r ea tment p ro tocol for metacognit ive therapy of PTSD. This treat- men t is based on a mode l in which PTSD results f rom the failure to meet an intrinsic goal following trauma. This goal consists of developing a metacognit ive plan that serves as a b luepr in t for guiding cogni t ion and act ion in dea l ing with subsequent threats. I t is assumed that p lan compila- t ion normal ly proceeds u n h i n d e r e d over a t ime course s t imulated by the processing of intrusive symptoms. Such symptoms provide an impr in t that has to be worked upon by upper-level processing to establish a plan for cogni t ion and coping. The flexible processing of imagery provides one m e d i u m for runn ing menta l simulations of coping with trauma. Several factors in terfere with these normal adapta t ion processes including: (a) wor ry / rumina t i on that diverts resources away from runn ing simulat ions and selectively focuses the individual on addi t ional sources of threat; (b) threat mon i to r ing that perpe tua tes perceptions of threat and s t rengthens a danger-awareness plan ra ther than coping plan; (c) avoidant types of coping, in- c luding thought control , that in te r rup t the no rma l work of intrusions; (d) negative self-appraisals/beliefs about symptoms and coping. These factors b lock adapta t ion and prevent cogni t ion f rom re- tuning to the normal threat-free environment .

A role of wor ry / rumina t i on and maladapt ive metacognitive control strategies in the persis tence of stress symptoms is suppor t ed by data from exper imenta l and corre- lat ional studies of patients and nonpat ients . Moreover, a study of the longi tudinal predic tors of PTSD following road traffic accidents provides suppor t for the idea that worrying as a means of coping with unwanted thoughts is causally re la ted to the deve lopmen t of PTSD even when stress symptoms at Time 1 are control led.

A pre l iminary evaluation of the effectiveness of the metacognit ive t r ea tment has p r o d u c e d encourag ing results (Wells & Sembi, 2004). In this study, six consecutive patients (five females, one mate) re fe r red for t rea tment following a variety of t raumas (a rmed robbery, physical assault, rape) received the new treatment . The dura t ion of PTSD ranged f rom 3 to 7 months across cases and each pa t ien t showed a stable basel ine of symptoms for 4 weeks before the c o m m e n c e m e n t of t rea tment . All par t ic ipants met DSM-IV cri teria for moderate-severe PTSD and all met cri teria for major depressive d i sorder dur ing base- line. All par t ic ipants lived in or a round a depr ived inner- city area. A fur ther two patients (the next consecutive re- ferrals, bo th male victims of physical assault) t rea ted were subsequently inc luded for effect-size analysis. All pat ients

M e t a c o g n i t i v e T h e r a p y for PTSD 377

s h o w e d m a r k e d i m p r o v e m e n t in PTSD s y m p t o m s a n d

g e n e r a l s y m p t o m s o f anx i e t y a n d d e p r e s s i o n . N o n e o f t h e

p a t i e n t s m e t c r i t e r i a f o r P T S D at p o s t t r e a t m e n t o r follow-

u p o n the Pos t t r aumat i c Stress Diagnos t ic Scale (Foa, 1995).

P r e t r e a t m e n t a n d p o s t t r e a t m e n t m e a n s o n o u t c o m e mea-

sures were as follows (p re first): I m p a c t o f Events Scale,

5 3 . 6 - 1 0 . 3 ; D a v i d s o n T r a u m a Scale , 9 2 . 5 - 1 5 . 5 ; P e n n

Inven to ry , 48 .2-14 .8 ; BAI, 3 1 . 9 - 3 . 5 ; BDI, 2 0 . 4 - 3 . 6 . T h e

t r e a t m e n t effects we re stat is t ical ly s ign i f ican t , a n d post -

t r e a t m e n t e f fec t sizes across m e a s u r e s r a n g e d f r o m 3.0 to

5.0. T r e a t m e n t ga ins we re m a i n t a i n e d a t fo l low-up (3 a n d

6 m o n t h s , a n d 18 to 41 m o n t h s ) .

T h e s e p r e l i m i n a r y f i n d i n g s s u p p o r t c o n t i n u e d evalua-

t i o n o f t h e t r e a t m e n t , a n d f u r t h e r e v a l u a t i o n s a re in

p rogress . C o n t r o l l e d s tud ies a n d d e v e l o p m e n t s o f th i s

n e w t r e a t m e n t a p p r o a c h a re r e q u i r e d . I t is o u r h o p e t h a t

th is t r e a t m e n t m a n u a l will p r o v i d e t h e basis fo r f u r t h e r

eva lua t i ons a n d i m p l e m e n t a t i o n s o f t r e a t m e n t by o t h e r

c l in i c i ans w o r k i n g in t h e a r e a o f PTSD.

R e f e r e n c e s

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Holeva, V., Tarrier, N., & Wells, A. (2001). Prevalence and predictors of acute stress disorder and PTSD following road traffic accidents: Thought control strategies and social support. Behavior Therapy, 32, 65-84.

Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic symptoms after a natural disaster: The 1989 Loma Prieta earthquake.Journal of Personality and Social Psychology, 61, 115-121.

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Address correspondence to Adrian Wells, Ph.D., University of Man- chester, Division of Clinical Psycholog 5 Rawnsley Building, Manchester Royal Infirmary, Manchester, M13 9WL UK; e-mail: adrian.wells@ man.ac.uk.

metacognitive therapy for ptsd: a core treatment manual

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