Metacognitive Therapy for PTSD 365

treatment of PTSD in Viemam War veterans.Journal of ClinicalPsy-
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 wishesto thank the female therapists involvedin 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 diane.castillo@med.va.gov.

Metacognitive Therapy for PTSD: A Core Treatment Manual

A d r i a n Wells, University o f M a n c h e s t e r
S u n d e e p S e m b i , University o f Liverpool

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 pa-
tients 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 , SYCHOLOGICALTREATMENTS for PTSD have consisted

o f various m e t h o d s a n d the study o f t r e a t m e n t effi-
cacy is still at an early stage. Treatments c o m p r i s e d o f ex-
p o s u r e m e t h o d s a n d cognitive t h e r a p y focused on modi-
fying negative appraisals have b e e n shown to b e effective
in c o n t r o l l e d trials. In comparative studies, e x p o s u r e
t h e r a p y alone a n d cognitive restructuring without expo-
sure have b e e n shown to be equally effective (e.g. Rich-
ards, Lovell & Marks, 1994; Tarrier et al., 1999). However,
a p r o p o r t i o n o f patients d o n o t r e s p o n d o r fail to com-
plete treatment (Sherman, 1998; van Etten & Taylor, 1998).
P r o l o n g e d imaginal reliving o f t r a u m a is distressing a n d
is p o o r l y tolerated by m a n y clients (Scott & Stradling,
1997). Exposure a n d cognitive t h e r a p y a p p r o a c h e s are
relatively b r i e f interventions involving a b o u t 10 sessions.
h n p l e m e n t a t i o n of these treatments requires a high de-
gree of therapist skill. We believe that for t r e a t m e n t to be
m o r e widely accessible, interventions that are brief, less
d e m a n d i n g , a n d less potentially distressing are needed.
Ideally, such a p p r o a c h e s should be g r o u n d e d in empiri-
cally testable theories of the psychological mechanisms un-
derlying n o r m a l a n d a b n o r m a l posttraumatic processing.
Cognitive and Behavioral Practice 1 1 , 3 6 5 - 3 7 7 , 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 p r e s e n t a new cognitive t h e r a p y for
PTSD. We describe the theoretical b a c k g r o u n d , briefly
review evidence for a central tenet of the model, a n d then
provide a detailed guide to the treatment. T h e m o d e l o n
which the t r e a t m e n t is b a s e d was first advanced by Wells
(2000) a n d is g r o u n d e d in an information-processing
theory o f psychological disorder (Wells & Matthews, 1994,
1996).
A C o g n i t i v e M o d e l o f PTSD
T h e starting p o i n t for the new m o d e l is the assump-
tion that following t r a u m a an i n t e r n a l goal o f processing
is the d e v e l o p m e n t o f a b l u e p r i n t or p l a n for g u i d i n g
t h i n k i n g a n d action in potential future e n c o u n t e r s with
t h r e a t . J u s t as individuals can be c o n c e p t u a l i z e d as having
a p l a n or script that guides t h i n k i n g a n d behavior w h e n
e a t i n g in a restaurant, p e o p l e have plans that guide cog-
nitive a n d behavioral activities d u r i n g e n c o u n t e r s with
threat. T h e goal o f e m o t i o n a l processing, which n o r m a l l y
p r o c e e d s u n i m p e d e d a n d spontaneously, is the strength-
e n i n g o f such a plan. We have t e r m e d the process by
which e m o t i o n a l processing takes place a n d plans are de-
v e l o p e d the Reflexive A d a p t a t i o n Process (RAP), a t e r m
i n t e n d e d to c a p t u r e the idea that this is initiated auto-
matically in response to intrusive thoughts. W h e t h e r o r
n o t a d a p t a t i o n occurs d e p e n d s on the style o f thinking
a n d c o p i n g a d o p t e d by the person. I n t e r n a l beliefs a n d
366 Wells & Sembi

environmental factors lead to a style o f thinking and cop-

ing behaviors that block the development of adaptive Trauma
plans and prevent the return of cognition to a "normal" (arousal/threatlevel)
state o f processing. Beliefs of a metacognitive nature (i,e.,
about thinking itself) are o f central importance because JL
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

1-'1
represented verbally but are linked to implicit plans that
guide thinking. For example, m u c h o f the knowledge
used to guide thinking and behavior is n o t verbally ex- !
Maladaptive situational
pressible. In verbal form, examples of such beliefs in- processing
elude the following: I must worry in order to be prepared; I Worry/rumination
must try to remember all of the details of the trauma so that I can
Threat monitoring
understand why me; I should be alert to all sources of danger; I f
Negative appraisal of coping/
I pay close attention to all possible threat I won't be taken by sur- symptoms
prise; I must not think about what happened or I'll not cape. Adaptive situational
processing Avoidance/thought control
These metaeognitions (and plans they represent) give
Dissociation
rise to perseveration, which is persistent and recurrent Low ruminative activity
thinking about trauma, threat, and one's reaction to it.
Perseveration consists of worry/rumination, threat moni-
Flexible attention control El
i!
Mental simulation (planning)
toring, and maladaptive thought-control strategies. It is
i|
maladaptive because it strengthens and maintains per- Acceptance of symptoms

ceptions of threat and it blocks the processes necessary

;" Psych0s0cial "-
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
g ~', Stressors ,}

used to appraise and regulate thinking itself. Like other Exitre-tuning i

models, the approach sees coping t h r o u g h avoidance,
use of alcohol, and so on as further examples of unhelp-
ful coping. In the present model alcohol is a problem be-
cause it alters the conscious experience of intrusions so
that mental simulation is disturbed, whilst avoidance pre-
vents the person discovering that the environment is n o t
still dangerous. In each case cognition c a n n o t 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 guid-
ing thinking and coping. Normally, symptoms such as
intrusive recollections (flashbacks) coupled with atten-
tional 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 im-
agery is a typical and potentially useful m e d i u m o f 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 concert in a way that can be controlled by
cognitive
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, competing processing activities. In par-
tieular, if the person believes that the way to cope is to en-
gage 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 e n o u g h in their use of
thinking strategies such that there is an overuse of re-
cyclic thinking (e.g., trying to r e m e m b e r all of the details,
trying to work out blame) that constitutes chronic analyt-
ical dwelling on trauma-related information. If the per-
son 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 symp-
toms such as interpreting intrusive thoughts and hyper-
arousal as a sign of mental breakdown. As a consequence
 Metacognitive Therapy for PTSD 367

o f these factors, the traumatized individual is u n a b l e to The Model in Action

exit the e m o t i o n a l processing (RAP) cycle because m e n -
tal simulation is i n c o m p l e t e and/orcognition
t u n e to the n o r m a l threat-free e n v i r o n m e n t .
does n o t re-
A "walk t h r o u g h " o f the m o d e l for a p a r t i c u l a r case
will h e l p to clarify how the m o d e l works. A case c o n c e p t u -
alization based on the m o d e l is p r e s e n t e d in Figure 2.
As d e p i c t e d in Figure 1, maladaptive a n d adaptive In this e x a m p l e the RAP is r e p e a t e d l y t r i g g e r e d by in-
strategies arise from m e t a c o g n i t i o n s as r e p r e s e n t e d by trusive images a n d r e e x p e r i e n c i n g o f pain. T h e occur-
the arrow l e a d i n g f r o m m e t a c o g n i t i o n s to strategy. T h e r e n c e o f these a n d r e l a t e d symptoms leads to the activa-
strategies i m p l e m e n t e d in turn have an effect on meta- tion o f metacognitions to guide i n f o r m a t i o n processing
cognitions as d e p i c t e d by the r e t u r n arrow. F o r example, r e q u i r e d for the RAP. I n this case the m e t a c o g n i t i o n s are
strategies such as trying n o t to think certain thoughts m a l a d a p t i v e a n d l e a d the i n d i v i d u a l to activate w o r r y /
activate metacognitive t h o u g h t - m o n i t o r i n g strategies in ruminative strategies o f self-regulation, hypervigilance
which the p e r s o n m o n i t o r s for the o c c u r r e n c e o f target for danger, bodily checking, avoidance, a n d t h o u g h t con-
thoughts. This can have the effect o f triggering the un- trol. Metacognitive beliefs also l e a d the individual to fear
wanted thought itself. The resulting failure to avoid thoughts symptoms themselves, t h i n k i n g that this c o u l d l e a d to
can s t r e n g t h e n negative metacognitive beliefs a b o u t the "losing it." As a result o f these strategies, n o r m a l activities
uncontrollability o f thoughts a b o u t trauma. To take an- o f the RAP are b l o c k e d a n d so intrusions automatically
o t h e r e x a m p l e o f the effect o f strategies on metacogni- persist as a m e a n s o f kick-starting t h e a d a p t i v e RAP
dons, the use o f worry a n d hypervigilance strengthens process. T h e maladaptive strategies used also k e e p anxi-
metacognitive plans for these activities, so in essence the ety a n d a sense o f t h r e a t going, t h e r e b y fueling anxious
p e r s o n b e c o m e s an increasingly skilled "threat detector." symptoms. Some strategies such as bodily checking in com-
Moreover, the n o n o c c u r r e n c e o f threat can be taken as b i n a t i o n with anxiety c o n t r i b u t e to feeling d e a d / u n r e a l .
evidence that worrying a n d hypervigilance are working.
Such an effect strengthens positive beliefs a b o u t the use-
fulness of these strategies. Adaptive strategies, on the o t h e r
h a n d , allow reflexive a d a p t a t i o n to occur so the p e r s o n
spontaneously develops plans for c o p i n g in the future
I (aroUsal/threat
Traumalevel) II
r a t h e r than b e i n g stuck in a t t e m p t i n g to c o p e with non-
existent threat in the present.
Symptoms subside when a satisfactory p l a n for c o p i n g
JL
has b e e n established a n d the p e r s o n is able to exit the
RAP. Exiting requires metacognitive m o n i t o r i n g a n d con-
.In~r~~iii~uilain
f
trol processes, a n d the RAP continues until discrepancies +
between the c u r r e n t status o f the self (e.g., feeling vulner-
able) a n d a d e s i r e d o r a normative internal goal state is ~l Worrying eepame I I Maladaptivesituational
processing
eliminated. This process o f c h e c k i n g for discrepancies
consists of in-built metacognitive m o n i t o r i n g a n d control Worryaboutdanger
Lookout for danger
processes that are part o f the RAP. However, discrepan- Avoidtraffic
cies persist when metacognitive beliefs m a i n t a i n the focus Avoid TVprogrammes/
o f processing o n danger. reminders
Tryto controlthoughts
We have seen how metacognitive beliefs a b o u t the Checkpulse
value o f w o r r y / r u m i n a t i o n u n d e r l i e perseverative pro-
cessing in the form of negative c o n c e p t u a l activity. O t h e r Adaptivesituational
processing
factors also lead to a general r e p e t i t i o n o f processing. F o r
example, an individual may be dissatisfied with the way in
which she o r he c o p e d d u r i n g the trauma. This will lead
to r e p e a t e d activation o f the RAP leading to intrusions
.s
iF
(' Psychosocial '~
,,
about the trauma so that the individual can p l a n m o r e sat-
isfactory responses. Such dissatisfaction may n o t occur
',, Stressors ,,'
i m m e d i a t e l y after the t r a u m a b u t can be initiated by later
negative social factors such as criticism o r blame, which is
o n e potential pathway to delayed-onset PTSD. Stresses
Exit
cognitivere-tuning
I
that are difficult to b r i n g u n d e r p e r s o n a l control also
contribute to perseveration because the individual is in a Figure 2. A case conceptualization based on the metacognitive
state o f persistent m e n t a l simulation a n d planning. model.
368 Wells & Sembi
Thus, intrusive thoughts a n d anxious symptoms persist,
c u l m i n a t i n g in a state o f PTSD.
Predictions and Clinical Implications
The m o d e l assumes that posttraumatic s)maptomatol-
o g y - - t h a t is, intrusions (memories a n d flashbacks), night-
mares, h e i g h t e n e d arousal, a n d h y p e r v i g i l a n c e - - a r e nor-
mal in the i m m e d i a t e aftermath o f a traumatic 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, how-
ever, when the individual uses i n a p p r o p r i a t e c o p i n g strat-
egies a n d / o r interprets the symptoms in a t h r e a t e n i n g
way. These factors disturb the c o m p i l a t i o n o f an appro-
priate plan for dealing with threat a n d subsequent fading
o f the RAP. A basic implication is that t r e a t m e n t that re-
moves the barriers to n o r m a l adaptive processing should
be effective in relieving PTSD.
T h e m o d e l makes several testable predictions. O n e
o f the most p r o m i n e n t is that specific internal aspects o f
processing interfere with the RAP u n d e r l y i n g e m o t i o n a l
processing. Worry a n d r u m i n a t i o n d r a i n resources neces-
sary for processing images a n d r u n n i n g simulations. They
also focus the individual on negative outcomes, thereby
fueling the anxiety p r o g r a m a n d d r a i n i n g the resources
n e e d e d for constructing a c o p i n g configuration (plan). A
f u r t h e r p r e d i c t i o n is that some c o p i n g strategies (e.g.,
avoidance a n d dissociation) will interfere with e m o t i o n a l
processing. Excessive efforts to control or avoid thoughts
o f t r a u m a will interfere with n o r m a l simulation pro-
cesses. Finally, since the intrinsic goal o f processing is to
develop a p l a n for coping, factors that c o n t r i b u t e to per-
ceptions o f the self as ineffective at c o p i n g with the threat
will c o n t r i b u t e to perseveration o f the RAP a n d symp-
toms of failed e m o t i o n a l processing. Candidates of inter-
est are negative self-appraisals resulting from beliefs a b o u t
the self or aspects of the trauma, a n d psychosocial factors
such as negative social support.
It is a p p a r e n t f r o m these p r e d i c t i o n s that responses to
symptoms o f stress, such as intrusive thoughts, startle re-
sponses, a n d hypervigilance, should be m a n a g e d in a par-
ticular way that blocks w o r r y / r u m i n a t i o n , threat monitor-
ing, a n d avoidant coping. Adjustment processes should be
allowed to r u n their own course without inflexible o r
maladaptive upper-level involvement.
In the following section we describe briefly how the
m o d e l accounts for i m p o r t a n t PTSD-related p h e n o m e n a .
Explanation of Imaginal Exposure Effects
While the m o d e l predicts that p r o l o n g e d imaginal re-
living of t r a u m a is n o t necessary for effective treatment,
the efficacy o f the t e c h n i q u e can be e x p l a i n e d within the
c o n t e x t o f the model. T h e t e c h n i q u e will be effective
w h e n it allows the individual to r u n m e n t a l simulations of
e x p e r i e n c e that facilitate the RAP a n d lead to p l a n forma-
tion. Moreover, imaginal reliving will p r o m o t e habitua-
tion, which will weaken reflexive influences on process-
ing a n d increase the flexible control of attention and
c o p i n g so that adaptive strategies may be i m p l e m e n t e d .
Imaginal e x p o s u r e will also be beneficial in cases where
patients fear anxious symptoms, a n d when the evocation
o f symptoms d u r i n g e x p o s u r e provides evidence that
challenges symptom-related worries.
Dose-Response Phenomena
T h e m o d e l explains the dose-response relationship in
PTSD in which r e p e a t e d stressors o r events o f greater
m a g n i t u d e (or causing greater arousal) l e a d to m o r e se-
vere PTSD. This effect is attributed to the dynamic inter-
play between lower- a n d upper-level processing. Repeated
a n d intense events lead to the formation of strong associa-
tive links between lower-level processors, p r o d u c i n g sensiti-
zation to threat and m o r e readily activated RAP responses.
As a result, threat-related material is m o r e likely to in-
trude into consciousness a n d diminish higher-level flexible
c o n t r o l over processing, n e e d e d for the i m p l e m e n t a t i o n
o f adaptive processing a n d s u b s e q u e n t fading o f the RAP.
Delayed-Onset PTSD
Delayed-onset PTSD is e x p l a i n e d by the m o d e l in the
following way. Initially following trauma, individuals may
fulfill the goals o f the RAP. However, at some p o i n t t h e r e
is a shift to maladaptive r e s p o n d i n g before c o m p l e t e con-
solidation o f the plan. This shift can be t r i g g e r e d by envi-
r o n m e n t a l a n d social events that lead to negative reap-
praisal o f the self, a r e o c c u r r e n c e o f t h r e a t appraisals,
a n d / o r w o n T . C o m p e t i n g processing priorities can also
t e m p o r a r i l y block the RAP as the capture o f a t t e n t i o n by
stress symptoms is avoided. For instance, d e a l i n g with on-
going c u r r e n t personal issues may suppress stress symp-
toms until c o m p e t i n g self-regulatory d e m a n d s are re-
moved, at which p o i n t PTSD symptoms emerge.
PTSD Symptom Clusters
The m o d e l explains the three PTSD symptom c l u s t e r s - -
intrusions/reexperiencing, hyperarousal, a n d a v o i d a n c e /
d i s s o c i a t i o n - - a s follows. I n t r u s i o n s / r e e x p e r i e n c i n g and
hyperarousal are seen as n o r m a l c o n s e q u e n c e s o f stress
that are p a r t of the RAP process. T h e y indicate activity o f
reflexive processing that serves to bias conscious process-
ing a n d retrieval o f i n f o r m a t i o n from long-term m e m o r y
by r e p e a t e d l y i n t r o d u c i n g material into consciousness as
the basis o f f o r m i n g a cognition-action plan. Symptoms
of a v o i d a n c e / d i s s o c i a t i o n are seen as c o p i n g strategies
that are maladaptive if used in the long t e r m because
they disrupt the RAP.
Treatment Implications
An implication o f the m o d e l as d e p i c t e d in Figure 1 is
that it can be translated into an individual case conceptu-
 Metacognitive Therapy for PTSD
alization, which is u s e d to socialize to t r e a t m e n t a n d as
a framework s u p p o r t i n g individual techniques. Patients
can readily identify the maladaptive strategies that form a
vicious cycle of PTSD symptoms a n d the adaptive responses
that are to be d e v e l o p e d in treatment. T h e goal o f treat-
m e n t is to free u p the t r a u m a t i z e d patient's natural ca-
pacity for self-regulation a n d adaptation following trauma.
This consists o f e n a b l i n g a shift to a metacoguitive m o d e
o f processing in which w o r r y / r u m i n a t i o n strategies a n d
t h r e a t m o n i t o r i n g are d i s c o n t i n u e d a n d a strategy o f "de-
t a c h e d mindfulness" (cf. Wells & Matthews, 1994, 1996)
is established in d e a l i n g with symptoms. This offers a
m e a n s o f i m p r o v i n g flexible r e s p o n d i n g a n d a t t e n u a t i n g
excessive active involvement with intrusions, symptoms,
a n d memories. T h e suspension o f maladaptive strategies
unlocks the barriers to in-built adaptive e m o t i o n a l pro-
cessing. These techniques are the r u d i m e n t a r y basis o r
"core" o f treatment, which is d e s c r i b e d in this manual.
However, a d d i t i o n a l strategies are p a r t o f the b r o a d e r
metacognitive t r e a t m e n t approach, namely, r u n n i n g men-
tal simulations o f c o p i n g with the t r a u m a a n d direct chal-
l e n g i n g of metacognitive beliefs a b o u t symptoms. T h e
core t r e a t m e n t is d e s c r i b e d later in this article. Before
d o i n g so, in the next section we review the empirical status
o f one of the central a n d novel predictions of the m o d e l - -
that maladaptive strategies o f w o r r y / r u m i n a t i o n a n d
t h o u g h t control c o n t r i b u t e to the d e v e l o p m e n t o f PTSD.
A Brief R e v i e w o f R e s e a r c h o n Worry
a n d T h o u g h t Control
A central p r e d i c t i o n o f the m o d e l is that w o r r y / r u m i -
n a t i o n should be associated with the p r e s e n c e or devel-
o p m e n t o f PTSD symptoms. In particular, worry should
b l o c k the RAP a n d t h e r e f o r e lead to a persistence o r in-
crease in intrusive images as the person's cognitive system
attempts m e n t a l simulations a n d adaptation.
Several studies have tested for a relationship between
worry a n d t r a u m a reactions, a n d two experimental studies
have e x a m i n e d the effects o f worry on intrusive images
following stress. Butler, Wells, a n d Dewick (1995) asked
n o n p a t i e n t participants to watch a g r u e s o m e a n d stress-
ful film a b o u t a workshop accident, a n d then to engage
in o n e o f the following postfilm m e n t a t i o n strategies for a
p e r i o d o f 4 minutes: worry in verbal form a b o u t the film,
image the negative aspects o f the film, o r settle down
(control c o n d i t i o n ) . T h e individuals who worried experi-
e n c e d the highest f r e q u e n c y o f intrusive images a b o u t
the film over the n e x t 3 days. In a larger study, Wells a n d
P a p a g e o r g i o u (1995) used a similar film-stressor m e t h o d -
ology, only this study c o m p a r e d the effects of five differ-
e n t postfilm m e n t a t i o n conditions. These strategies were:
(a) worry about the film, (b) worry a b o u t usual concerns,
(c) image the negative aspects o f the film, (d) distraction
369
by s p e e d e d letter-cancellation, o r (e) settle down. These
conditions were selected because they were c o n s i d e r e d to
differ in the e x t e n t to which they caused b l o c k e d emo-
tional processing o f images a n d "tagging." Tagging refers
to the activating of m e m o r i e s o f the stressor a n d engag-
ing in processing that sets u p a wide r a n g e o f associations
so that an increasing n u m b e r of concepts b e c o m e re-
trieval cues for stress-related material. T h e results showed
that the two worry conditions were associated with the
highest frequency o f intrusive images a b o u t the t r a u m a
over the 3 days following e x p o s u r e to the film. Moreover,
t h e r e was a l i n e a r i n c r e m e n t in frequency o f intrusions
across different conditions that was consistent with pre-
dictions c o n c e r n i n g a cozjoint incubation m e c h a n i s m in-
volving blocked emotional processing a n d tagging. T h e
results o f these a n a l o g u e studies o f trauma-related stimu-
lation s u p p o r t the hypothesis that worry following stress
can l e a d to an increase in poststress symptoms o f intru-
sive images.
T h e m o d e l also suggests that particular metacognitive
c o p i n g strategies s h o u l d b e linked to PTSD a n d negative
o u t c o m e s following stress. Several studies, b o t h cross-
sectional a n d longitudinal, have e x a m i n e d the relation-
ship between t h o u g h t c o n t r o l strategies a n d p o s t t r a u m a
stress symptoms. Individual differences in strategies used
to control distressing, intrusive thoughts can be m e a s u r e d
with the T h o u g h t Control Q u e s t i o n n a i r e (TCQ: Wells &
Davies, 1994). T h e T C Q assesses five factorially derived
d o m a i n s o f strategy: distraction; social control; worry;
p u n i s h m e n t ; reappraisal. T h e scale a p p e a r s to have a sim-
ilar factor structure in p a t i e n t a n d n o n p a t i e n t samples
(Reynolds & Wells, 1999). T h e use o f worry a n d punish-
m e n t to c o n t r o l thoughts is positively associated with
stress vulnerability a n d appears to be elevated in some
clinical syndromes. Holeva, Tarrier, a n d Wells (2001)
c o n d u c t e d a l o n g i t u d i n a l study o f the p r e d i c t o r s of PTSD
following serious motor-vehicle accidents in which vic-
tims r e q u i r e d hospital treatment. Measures o f t h o u g h t
control (TCQ) a n d social s u p p o r t a d m i n i s t e r e d within 4
weeks o f t h e a c c i d e n t were u s e d as p r e d i c t o r s o f PTSD
4 to 6 m o n t h s after the accident. T h e p r e s e n c e of stress
symptoms (acute stress disorder) at Time 1 was controlled.
The use o f worry to control thoughts at Time 1, a c h a n g e
in perceived social support, a n d an interaction between
perceived social s u p p o r t a n d the use o f social t h o u g h t
control strategies significantly predicted subsequent PTSD.
In cross-sectional analyses o f symptoms, t h o u g h t - c o n t r o l
strategies were predictive o f acute stress d i s o r d e r (ASD)
at Time 1 a n d o f PTSD at Time 2. Both distraction a n d
social control T C Q subscales were negatively c o r r e l a t e d
with ASD a n d PTSD caseness, suggesting a possible posi-
tive benefit o f these metacognitive control strategies. How-
ever, worry a n d p u n i s h m e n t b o t h e m e r g e d as positive pre-
dictors o f ASD a n d PTSD. These findings for worry a n d
370
p u n i s h m e n t c o n t r o l strategies are e c h o e d in a study by
W a r d a a n d Bryant (1998). T h e y f o u n d that individuals
with ASD u s e d m o r e worry a n d p u n i s h m e n t t h o u g h t -
control strategies than non-ASD patients. Reynolds and
Wells (1999) showed that particular T C Q strategies distin-
guished recovered a n d n o n r e c o v e r e d patients with m a j o r
depression a n d / o r PTSD, a n d that c h a n g e in T C Q strat-
egies was associated with recovery. T h e recovered g r o u p
was m o r e likely to use distraction a n d reappraisal a n d less
likely to use worry a n d p u n i s h m e n t .
Studies o f r u m i n a t i o n show that the t e n d e n c y to rumi-
nate, defined as recyclic negative thinking about the causes
a n d symptoms o f depression, is associated with negative
o u t c o m e s following stressful life events. R u m i n a t i o n has
b e e n f o u n d to be very similar to worry in b o t h form a n d
function ( P a p a g e o r g i o u & Wells, 1999, 2003). In prospec-
tive studies r u m i n a t i o n has b e e n shown to be positively as-
sociated with depressive symptoms following significant
negative 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) a n d following b e r e a v e m e n t
(Nolen-Hoeksema, Parker, & Larson, 1994).
T h e results o f these studies s u p p o r t a central supposi-
tion o f the p r e s e n t m o d e l that thinking stTles a n d meta-
cognitive c o p i n g strategies can adversely affect outcomes
following stress a n d that perseverative styles o f thinking
involving w o r r y / r u m i n a t i o n a n d choice o f particular
thought-control strategies are u n h e l p f u l for adaptation.
The Core Treatment Manual
In the r e m a i n d e r o f this article we p r e s e n t the core
metacognitive t r e a t m e n t based on the model. We have
p r e s e n t e d this in the f o r m a t o f eight t r e a t m e n t sessions,
although l o n g e r is r e q u i r e d in some cases, d e p e n d i n g on
the rate of p a t i e n t progress.
Structure and Duration o f Treatment
T r e a t m e n t sessions are h e l d on a weekly basis. T h e ini-
tial sessions last 45 to 60 minutes. O n c e patients are en-
g a g e d a n d able to effectively i m p l e m e n t control over
worry a n d detached mindfulness, the d u r a t i o n of sessions is
r e d u c e d to 30 minutes. Effective mastery is i n d i c a t e d by
the p r e s e n c e of each o f the following: (a) the individual
reports having successfully disengaged w o r r y / r u m i n a t i o n
from the o c c u r r e n c e o f intrusions, arousal, a n d o r i e n t i n g
responses; (b) the individual accepts symptoms as a nor-
mal p a r t o f a d a p t a t i o n that do n o t require active avoid-
ance or suppression; (c) the individual reports allowing
i n t r u s i o n s / m e m o r i e s / t h o u g h t s related to the t r a u m a to
occupy their own "mental space" while watching the
s p o n t a n e o u s behavior o f t h e m as a passive observer. In
o u r p r e l i m i n a r y evaluation o f the effectiveness o f core
treatment, 8 to 11 sessions were r e q u i r e d in o r d e r to
achieve PTSD-free outcomes. The rate of progress through
Wells & Sembi
the different t r e a t m e n t phases influences the n u m b e r o f
sessions required.
Session h Case Conceptualization and Socialization
T h e first step is elicitation a n d consolidation o f knowl-
edge c o n c e r n i n g the n a t u r e a n d base rates o f specific
PTSD symptoms (intrusions, flashbacks, nightmares, a n d
arousal symptoms). Following this, an individual case
conceptualization is constructed based o n the metacog-
nitive m o d e l d e p i c t e d in Figure 1.
T h e task o f conceptualization is simplified by direct-
ing the course o f questions to e x p l o r i n g a series o f spe-
cific a n d r e c e n t episodes in which the p a t i e n t was trou-
b l e d by symptoms associated with the trauma, o r in which
t h e r e was an e x a c e r b a t i o n o f anxious affect. T h e aim is to
elicit examples of each o f the e l e m e n t s in the model.
Much of the discussion focuses on e x p l o r i n g the presence
and extent of (a) w o r r y / r u m i n a t i o n about the tFauma, (b)
attentional m o n i t o r i n g strategies, (c) strategies for coping
with symptoms/distress (e.g., avoidance, thought control,
distraction, alcohol), (d) beliefs a b o u t symptoms, worry,
a n d attentional strategies. An effective sequence for ob-
taining this material is to b e g i n by asking a b o u t symptoms
a n d t h e n e x p l o r i n g the strategies used to m a n a g e or
avoid symptoms. T h e therapist n e x t asks directly a b o u t at-
tentional m o n i t o r i n g for threat, a n d w o r r y / r u m i n a t i o n .
Questions are then targeted at eliciting beliefs a b o u t symp-
toms, w o r r y / r u m i n a t i o n , and threat monitoring. This se-
q u e n c e is illustrated in the following dialogue which was
the g r o u n d i n g for the conceptualization p r e s e n t e d in
Figure 2.
ELICITATION OF SYMPTOMS
T: I ' d like to begin by asking a b o u t the symptoms you
have b e e n e x p e r i e n c i n g in the past m o n t h . Can
you describe t h e m to me?
P: I feel as if I ' m dead. Like I d o n ' t exist anymore.
T: Is it like being d e t a c h e d from things a r o u n d you?
P: Yes, it's unreal. I have to check my pulse a n d h e a r t
to make sure I ' m still alive.
T: W h a t a b o u t o t h e r symptoms such as distressing
thoughts o r memories?
P: I keep seeing myself on the floor a n d I can feel
pain in my legs a n d the b l o o d flowing from my
head. I can actually feel the pain again.
T: W h a t a b o u t feeling anxious or frightened?
P: I feel s c a r e d all the time w h e n I go o u t now, I ' m
c o n s t a n t l y t h i n k i n g s o m e t h i n g b a d will h a p p e n .
STRATEGIES (ATTENTION AND COPING)
T: Do you do anything to try a n d r e d u c e o r avoid
these symptoms?
P: I avoid things.
T: W h a t are you avoiding?
 Metacognitive Therapy for PTSD
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 o n the television.
T: Do you avoid the scene of the accident?
P: If possible. But I have to go there. I look away
w h e n driving past, b u t s o m e t i m e s I force myself
to look at the whole scene to see if it was my fault.
I only look at the whole scene w h e n I feel I can
cope, b u 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
h a p p e n e d . But when I see myself on the floor with
the pain a n d blood, I look away, a n d try n o t to
t h i n k a b o u t it.
T: You m e n t i o n e d s o m e t h i n g I ' d like to ask you m o r e
about. You said you try n o t to t h i n k about it. Do you
try to control your thoughts at other times too?
P: Yes, I try n o t to t h i n k a b o u t what h a p p e n e d . If I get
a t h o u g h t I try to push it out of my m i n d or think
a b o u t s o m e t h i n g else.
T: Have you f o u n d that what you pay attention to has
c h a n g e d since the event?
P: Yes, I pay m o r e a t t e n t i o n to things that are n o t safe.
I ' m constantly looking a r o u n d for traffic and listen-
ing for sounds of lorries. It can be anything, I've b e e n
watching a ceiling fan at work because it's wobbling.
WORRY/RUMINATION
T: You m e n t i o n e d paying more attention to danger,
a n d it sounds like you are s p e n d i n g time worrying
a n d dwelling o n what h a p p e n e d .
P: Yes, everyday I ' m worrying, a n d so I e n d u p avoid-
ing things.
T: How m u c h of the day are you worrying a b o u t bad
things that could h a p p e n ?
P: It's usually in the b a c k g r o u n d a n d when I have to
go out I get really worried.
T: How m u c h of the day are you dwelling a n d rumi-
n a t i n g a b o u t what h a p p e n e d ?
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 a b o u t
things?
P: I ' m trying to be cautious a n d avoid accidents.
T: What are you trying to achieve by repeatedly think-
ing a b o u t what h a p p e n e d ?
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 W O R R Y / /
RUMINATION AND ATTENTION
T: Do you t h i n k worrying is helpful in any way?
P: It makes m e m o r e aware of the potential risks
371
T: How does that work?
P: It makes me think of what could h a p p e n so that I
act more cautiously. But it also m e a n s I d o n ' t do so
m a n y things now.
T: Is b e i n g cautious something you do?
P: Yes, I make a n 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 a n d
keeping a lookout for d a n g e r keep you safe.
M E T A C O G N I T I V E BELIEFS A B O U T S Y M P T O M S
T: Do you worry a b o u t your symptoms?
P: Yes, I think it's n o t n o r m a l to be like this a n d I ' m
c o n c e r n e d it m e a n s I ' m losing it.
T: What do you m e a n by losing it?
P: T h a t I c a n ' 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 p r o b l e m m e a n s 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 h a p p e n if you
d i d n ' t do that?
P: I suppose I could lose it.
T: So it sounds as if you believe that if you d o n ' t con-
trol your thoughts that could h a p p e n ?
P: Yes.
Following case conceptualization the therapist moves
onto socialization. This consists of p r e s e n t i n g the formu-
lation in which the therapist stresses that PTSD symptoms
are a n o r m a l part of a d a p t i n g to traumatic e x p e r i e n c e s - -
that, u n d e r n o r m a l circumstances, the symptoms subside
over time as necessary i n f o r m a t i o n a b o u t the traumatic
event a n d how to deal with it is learned. However, this
process of adaptation can be disrupted when individuals
engage in specific types of t h i n k i n g a n d behavior. Several
factors can block adaptation, a n d these include:
* worrying or r u m i n a t i n g a b o u t the t r a u m a or one's
responses
• paying too m u c h a t t e n t i o n to threat a n d d a n g e r
after the event
* trying to avoid or excessively control thoughts a b o u t
the t r a u m a
* negative beliefs a b o u t the m e a n i n g or consequences
of symptoms
T h e n a t u r e a n d pervasiveness of w o r r y / r u m i n a t i o n is
then highlighted by asking patients a b o u t the thoughts
they have had d u r i n g the day a b o u t their traumatic ex-
p e r i e n c e or r e a c t i o n to it. This typically results i n the
372 Wells & Sembi
d e s c r i p t i o n of m a n y negative thoughts a n d beliefs a n d
the r e p o r t of circular thinking based on: "what if . . . . if
only . . . . why . . . . a n d why me?" type questions. It is n o t a
principle focus o f t r e a u n e n t to challenge the c o n t e n t o f
these ruminative thoughts, b u t to enable patients to dis-
c o n t i n u e this verbal iterative style o f negative thinking.
Thus, a l t h o u g h these "automatic thoughts" are elicited,
this is d o n e only to h i g h l i g h t the e x t e n t o f the patient's
r u m i n a t i o n . T h e thoughts are n o t c h a l l e n g e d / b a l a n c e d
in the traditional cognitive-behavioral sense.
Patients are i n t r o d u c e d to the i d e a that their intrusive
thoughts, flashbacks, nightmares, startle responses, a n d
arousal symptoms are n o r m a l a n d necessary following
trauma. T h e symptoms are a sign that their cognitive sys-
tem is a t t e m p t i n g to process the t r a u m a a n d recalibrate
o r adjust to the event that has taken place. However, their
responses a n d c o p i n g strategies have the effect of pre-
venting this processing from taking place. T h e therapist
emphasizes that it is i m p o r t a n t n o t to avoid these symptoms
because they are p a r t o f an automatic a d a p t a t i o n process.
T h e n e x t step is to provide an overview of the nature
a n d goals of treatment. T h e case formulation provides a
vehicle for d o i n g this. Notice that in Figure 2 the "adap-
tive processing" box is empty. T h e therapist describes to
the p a t i e n t how t r e a t m e n t will consist of e m p t y i n g the
"maladaptive" b o x in the f o r m u l a t i o n a n d p u t t i n g new
strategies that the p a t i e n t will learn in t r e a t m e n t into the
adaptive b o x in o r d e r to exit the PTSD cycle. T h e p a t i e n t
is given a copy o f the conceptualization to take h o m e a n d
think a b o u t before the n e x t session.
Sessions 2 to 3: Worry Postponement and
Detached Mindfulness
T h e aim o f the n e x t session(s) is to reinforce aware-
ness o f the p r o b l e m a t i c n a t u r e o f p e r s e v e r a t i o n a n d to
facilitate a l t e r n a t i v e r e s p o n d i n g to symptoms. T h e r e
are three basic c o m p o n e n t s to this: (1) the a d v a n t a g e s /
disadvantages analysis, (2) practice o f d e t a c h e d mindful-
ness, (3) worry p o s t p o n e m e n t .
Advantages~disadvantages analysis. T h e first step is to
help clients see that engaging in w o r r y / r u m i n a t i o n serves
no p u r p o s e a n d contributes to "locking" t h e m into merely
replaying negative aspects o f the t r a u m a o r their dissatis-
faction with their own c o p i n g responses. T h e therapist
guides the p a t i e n t t h r o u g h an advantages/disadvantages
analysis o f w o r r y / r u m i n a t i o n as a means o f socialization
a n d motivating clients to a b a n d o n preservative styles of
thinking. T h e therapist inquires as to w h e t h e r there are
any advantages to r u m i n a t i o n a n d a list o f advantages is
drawn up. This is followed by drawing up a list o f disad-
vantages. T h e 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 worry-
ing help you see the situation more clearly ?
T h e next step is to weaken beliefs a b o u t the advan-
tages o f perseveration. Frequently, an advantage to rumi-
nation that patients r e p o r t is that it may h e l p t h e m to
find answers. This belief can be w e a k e n e d by asking the
p a t i e n t why this has n o t h a p p e n e d yet given that they ap-
p e a r to have spent a considerable a m o u n t o f time think-
ing a b o u t what has h a p p e n e d . Patients quickly c o m e to
accept that p e r h a p s there are no answers a n d this there-
fore b e c o m e s a reason to a b a n d o n ruminative thinking.
In some instances, as in the case illustrated in Figure 2,
patients express the b e l i e f that worrying acts as a safety
strategy by e n h a n c i n g p r e p a r e d n e s s or cautiousness. A
two-pronged a p p r o a c h is used here. T h e disadvantages o f
worry are contrasted with the advantages with the aim o f
showing how the disadvantages outweigh the advantages.
T h e therapist t h e n questions w h e t h e r p r e p a r e d n e s s a n d
cautiousness can be achieved without worrying (How can
you be cautious without worrying?). T h e aim h e r e is to show
how worrying a n d cautiousness are n o t synonymous a n d
therefore o n e can decide to r e d u c e worry without sacri-
ficing safety.
A n advantages/disadvantages analysis is also under-
taken in e x a m i n i n g the motivations for o t h e r u n h e l p f u l
c o p i n g behaviors i n c l u d e d in the conceptualization such
as alcohol use, trying to suppress thoughts, a n d so on.
W h e n t h o u g h t suppression is a feature o f the formula-
tion, a within-session suppression e x p e r i m e n t is used to
show how attempts to avoid a n d control thoughts can be
disadvantageous. H e r e the therapist asks the p a t i e n t to
try n o t to think a target t h o u g h t (e.g., "Try n o t to t h i n k
a b o u t a blue tiger") for a p e r i o d o f two minutes. Typically
patients r e p o r t that they e x p e r i e n c e the t h o u g h t a n d this
is used as an illustration of how trying to suppress thoughts
is n o t particularly effective.
Detached mindfulness. Individuals with PTSD repeatedly
engage with intrusive thoughts a n d symptoms in counter-
productive ways involving w o r r y / r u m i n a t i o n , overcon-
trol, attentional m o n i t o r i n g for threat, a n d negative ap-
praisals. Some o f these responses exaggerate the c u r r e n t
sense o f danger, a n d each o f t h e m can interfere with the
processes involved in n o r m a l adaptation. A goal o f treat-
m e n t is to d r o p these u n h e l p f u l influences on a d a p t a t i o n
so that n o r m a l a d a p t a t i o n processes may resume. A n ini-
tial step in achieving this consists o f training in " d e t a c h e d
mindfulness" (Wells & Matthews, 1994), which increases
awareness of u n h e l p f u l t h i n k i n g styles, disrupts them,
a n d facilitates flexible control over responding.
D e t a c h e d mindfulness refers to taking a perspective
on one's own t h o u g h t processes in which they are ob-
served in a d e t a c h e d way, without interpreting, analyzing,
c o n t r o l l i n g , o r r e a c t i n g to t h e m in any way. Patients
are i n s t r u c t e d to r e s p o n d in a p a r t i c u l a r way w h e n they
 Metacognitive Therapy for PTSD
experience intrusive thoughts, flashbacks, a n d nightmares
as follows:
"When you have an intrusive thought, flashback, or
have h a d a nightmare, it is i m p o r t a n t that you d o
the following. Acknowledge to yourself that these
symptoms are occurring, a n d r e m i n d yourself that
e n g a g i n g with these symptoms is unhelpful. Some
p e o p l e find it helpful to say to themselves: This is
j u s t a symptom, I don't need to do anything with it. I am
j u s 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 engage-
m e n t with these symptoms includes questioning
the m e a n i n g o f the symptom, trying to work o u t
what has h a p p e n e d to you, r u m i n a t i n g a b o u t why it
should have h a p p e n e d , asking What i f . . . , Why . . . .
Why me . . . . o r I f only . . . type questions, worrying
a b o u t symptoms, trying to control o r avoid thoughts
o r symptoms. It is i m p o r t a n t to let y o u r thoughts o r
symptoms occupy their own space a n d time without
e n g a g i n g with them."
To facilitate c o m p r e h e n s i o n , several analogies are used
in sessions to demonstrate the way that intrusive symptoms
should be treated.
Analogy 1. The Recalcitrant Child. Patients are asked to
treat their intrusions in the same way that they
m i g h t d e a l with an a n n o y i n g child t h a t they h a d
to look after (i.e., they could not avoid). They n e e d to
acknowledge that the child was there b u t paying too
m u c h attention to the child (engaging with it)
would merely serve to reinforce its b a d behavior,
a n d a t t e m p t i n g to punish the child (suppress it)
would u p s e t the child even further. Thus, the best
thing to d o is to j u s t leave the child alone a n d let it
settle o f its own accord.
Analogy 2. Pushing Clouds. Intrusive symptoms can be
treated as if they were clouds in the sky. T h a t is, they
are s o m e t h i n g that is passing by a n d s o m e t h i n g we
can do n o t h i n g about. T h e y are p a r t of a natural
self-regulating w e a t h e r system a n d a t t e m p t i n g to
stop or push t h e m away is n o t necessary a n d n o t
possible. Even if we could, this would disturb the
balance necessary for rainfall a n d nature. There-
fore, the thing to d o is let t h e m occupy their own
space a n d passively watch their behavior over time.
A critical t r e a t m e n t c o m p o n e n t at this stage is
ensuring that patients u n d e r s t a n d the difference
between nonengagement in a d e t a c h e d m i n d f u l
m o d e , a n d avoidance of thoughts. A v o i d a n c e - - f o r
instance, t u r n i n g attention to o t h e r distracting
activities--is a form o f active e n g a g e m e n t with
thoughts in the sense that attempts are b e i n g m a d e
to exclude the thoughts from consciousness.
373
Practical illustrations. Use o f the d e t a c h e d m i n d f u l
m o d e a n d the consequences o f e n g a g e m e n t with symp-
toms is t h e n illustrated in the therapy session. In o n e ex-
p e r i m e n t patients are asked to first create a m e n t a l i m a g e
o f a g r e e n tiger, a n d t h e n to engage with the image by try-
ing to exclude all thoughts of tigers from consciousness.
This is t h e n contrasted with f o r m i n g an i m a g e o f a g r e e n
tiger a n d observing the image without d o i n g anything
with it. Patients typically r e p o r t difficulty e x c l u d i n g
thoughts o f tigers, b u t find that if they assume d e t a c h e d
m i n d f u l observation, that thoughts o f tigers take on t h e i r
own life a n d b e c o m e less salient. In a n o t h e r e x p e r i m e n t ,
patients can be asked to sit quietly a n d observe in a de-
t a c h e d way a bodily sensation. F o r instance, patients are
asked to passively observe the sensations in their m o u t h
without moving their mouth-parts or swallowing for a pe-
riod o f 3 to 4 minutes.
A useful strategy for facilitating d e t a c h e d mindfulness
is for the therapist to ask the p a t i e n t to sit quietly a n d let
his or h e r thoughts r o a m freely d u r i n g a free-association
exercise while observing these internal events. T h e in-
structions for this task are as follows:
"One way to e x p e r i e n c e the sense of d e t a c h e d
mindfulness that will allow you to apply it to y o u r
distressing thoughts is to practice first with m o r e
g e n e r a l thoughts a n d feelings. In a m o m e n t I will
say a series o f words a n d what I would like you to d o
is sit a n d passively watch the m o v e m e n t o f thoughts
in your m i n d a n d feelings in y o u r b o d y as I say
different words. F o r example, I m i g h t say the w o r d
blue a n d y o u r task is to watch what h a p p e n s in y o u r
m i n d a n d b o d y as a result. Do n o t try to deliber-
ately f o r m 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 n o t h i n g related to the word
may h a p p e n , that d o e s n ' t matter, you j u s t n e e d to
watch your spontaneous thoughts a n d feelings with-
out 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. O n c e the p a t i e n t u n d e r s t a n d s the
i d e a o f d e t a c h e d mindfulness a n d in-session practice has
b e e n c o m p l e t e d , the therapist moves o n to r e d u c i n g
w o r r y / r u m i n a t i o n . For this p u r p o s e the therapist intro-
duces the w o r r y - p o s t p o n e m e n t strategy. T h e instruction
is given that w h e n e v e r intrusive symptoms occur, the pa-
tient should acknowledge that the t h o u g h t / f l a s h b a c k /
n i g h t m a r e has occurred, a n d tell him- or herself n o t to
worry or r u m i n a t e a b o u t the t r a u m a o r symptoms now,
j u s t let the symptom fade in its own time, a n d actively
think a b o u t it later.
Patients are asked to allocate 15 m i n u t e s each evening
as a designated worry o r analysis time. T h e worry time
should take place at least 2 hours b e f o r e they go to bed,
374 Wells & Sembi
a n d they s h o u l d review the whole day. If patients h a p p e n
to r e m e m b e r what h a d b e e n worrying them, they can de-
cide to engage in as m u c h w o r r y / r u m i n a t i o n as they feel
they n e e d to over the 15-minute period. However, it is
emphasized that this is n o t compulsory a n d many patients
d e c i d e n o t to worry. At the e n d o f this p e r i o d patients are
asked to stop worrying a n d to deal with any f u r t h e r worry
as they h a d in the day, by applying d e t a c h e d mindfulness,
a n d carrying any thoughts over to the n e x t day's worry
p e r i o d if necessary.
Application of detached mindfulness and worrypostponement.
Clients are instructed to apply d e t a c h e d mindfulness for
h o m e w o r k in response to intrusive thoughts, flashbacks,
a n d n i g h t m a r e s , a n d are asked to d i s c o n t i n u e daily
w o r r y / r u m i n a t i o n - b a s e d t h i n k i n g by using the postpone-
m e n t strategy. Careful therapist m o n i t o r i n g is r e q u i r e d to
ensure that patients are applying the m e t h o d consistently
to the full range o f intrnsive thoughts a n d w o r r y / r u m i n a -
tion e x p e r i e n c e d .
S e s s i o n s 4 to 5
In the next two sessions the therapist monitors progress
with d e t a c h e d mindfulness h o m e w o r k a n d worry post-
p o n e m e n t a n d facilitates c o n t i n u e d practice a n d general-
ization o f the techniques.
T h e first issue c o n c e r n s w h e t h e r b o t h techniques are
b e i n g used consistently a n d frequently. T h e use o f de-
t a c h e d mindfulness is assessed by asking patients to esti-
mate the p e r c e n t a g e o f time that they have b e e n able to
apply d e t a c h e d mindfulness to intrusive thoughts. It is
i m p o r t a n t that the therapist a n d p a t i e n t do n o t confuse
this as a rating o f the a m o u n t o f distress. T h e n e x t ques-
tion asked by the therapist assesses if there has b e e n any
decrease in usage of the t e c h n i q u e over time, a n d if so,
what the cause o f this is. In some cases this is d u e to a re-
d u c t i o n in distress associated with intrusions. T h e thera-
pist s h o u l d emphasize that the m a i n aim o f the t e c h n i q u e
is n o t to c h a n g e distress b u t to "unlock barriers to natural
processing," a n d t h e r e f o r e it is necessary to apply the tech-
nique to most instances o f intrusions. T h e third question
the therapist asks concerns the b r e a d t h of application of
d e t a c h e d mindfulness. It is i m p o r t a n t that the p a t i e n t ap-
plies it to all types o f distressing intrusions related to the
t r a u m a a n d its consequences. In particular, some patients
r e p o r t a specific r e c u r r i n g intrusion that p r e d o m i n a t e s ,
a n d having a p p l i e d d e t a c h e d mindfulness to this intru-
sion they notice that o t h e r intrusions take p r e c e d e n c e ,
b u t they d o n o t apply d e t a c h e d mindfulness to these new
events as they should.
To assess consistency of usage o f c o n t r o l l e d worry peri-
ods, the therapist asks a b o u t the a m o u n t o f time spent
w o r r y i n g / r n m i n a t i n g p e r day, a n d how often the p a t i e n t
has s u c c e e d e d in p o s t p o n i n g w o r r y / r u m i n a t i o n . Any
d r o p o f f o f usage o f the t e c h n i q u e should be explored.
R e d u c t i o n in the frequency o f p o s t p o n e m e n t strategies
are to be e x p e c t e d if there has b e e n a r e d u c e d frequency
of worry.
Generalization. T h e therapist t h e n p r o c e e d s to intro-
duce the idea that w o r r y / r u m i n a t i o n p o s t p o n e m e n t can
be a p p l i e d to all types o f worry a n d persistent negative
thinking. At this stage it helps to list a range o f c u r r e n t
concerns that the p a t i e n t has h a d in the past week in
o r d e r to raise awareness o f the pervasiveness o f persever-
ative thinking, All types o f dwelling a n d worry are t h e n
targeted for subsequent h o m e w o r k practice of p o s t p o n e d
worry periods.
F u r t h e r practice o f d e t a c h e d mindfulness can be im-
p l e m e n t e d in these sessions if necessary, T h e therapist
then moves on to introducing the application o f d e t a c h e d
mindfulness to the after-effects o f nightmares. Some pa-
tients r e p o r t that after trauma-related d r e a m s / n i g h t m a r e s
they are t r o u b l e d by thoughts o r feelings elicited by
them. T h e therapist instructs patients to apply the tech-
nique o f d e t a c h e d mindfulness to such after-effects when
they occur.
Eliminating other maladaptive strategies. At this p o i n t in
treatment, the therapist u n d e r t a k e s a review o f the pa-
tient's use o f o t h e r c o p i n g strategies that are c o u n t e r p r o -
ductive for adaptation. These strategies include use o f al-
cohol o r o t h e r substances to avoid thoughts a n d feelings,
t h o u g h t suppression strategies, avoidance o f stimuli such
as television news, a n d so on. T h e therapist helps the pa-
tient to see how these strategies are a p r o b l e m . F o r ex-
ample, m a n y o f these strategies can be seen as a form o f
avoidance o f thoughts a n d m e m o r i e s of trauma, a n d this
leads to a discussion o f the p r o b l e m s caused by cognitive
avoidance. O n c e the p a t i e n t identifies the u n h e l p f u l con-,
sequences o f these strategies, the therapist asks the pa-
tient to b a n t h e m 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
T h e attentional phase o f core t r e a t m e n t is i n t r o d u c e d
when patients have in the past week: (a) m a s t e r e d the use
of d e t a c h e d mindfulness a n d r e p o r t e d success in using
the strategy in response to at least 75% of intrusive symp-
toms, a n d (b) successfully a b a n d o n e d w o r r y / r n m i n a t i o n
and all forms of dwelling on past, present, and future events
such that no episodes last l o n g e r than a p p r o x i m a t e l y 2 to
3 minutes.
In this phase, t r e a t m e n t focuses on hypervigilance, an
attentional c o p i n g strategy that maintains the p e r c e p t i o n
o f d a n g e r a n d anxiety. Two types o f attentional monitor-
ing strategies are problematic: attention to internal sources
o f threat (i.e., sensations a n d feelings) a n d external at-
tention to threat in the form o f scanning the environ-
m e n t for danger.
Systematic m a n i p u l a t i o n s of attention are an impor-
tant c o m p o n e n t o f the core t r e a t m e n t as they shift
 Metacognitive Therapy for PTSD
patients out of threat-modes o f processing that repeatedly
generate information c o n c e r n i n g danger. Rather than
persisting in a l o o p o f r e p e a t e d processing o f danger, pa-
tients should be moving on to d e v e l o p i n g a p l a n for deal-
ing with danger, a n d for controlling cognition that allows
threat-related processing to decay. T h e search for threat
is not synonymous with having a plan for dealing with threat
once detected, perceiving the self as an effective a g e n t o f
coping, a n d allowing c o g n i t i o n to re-rune to the n o r m a l
(nonthreatening) environment.
Stage I. Explanation and rationale. T h e following out-
line is used as a basis for therapists to describe the role
that attention plays in the m a i n t e n a n c e o f PTSD:
'3(ou have seen how w o r r y / r n m i n a t i o n a n d attempts
to control symptoms can maintain your p r o b l e m ,
a n d you have b e e n successful in r e d u c i n g those
responses. We should now c o n s i d e r a n o t h e r impor-
tant aspect o f the p r o b l e m that can k e e p your sense
o f d a n g e r a n d anxiety going. This is the role played
by your focus o f attention. Following trauma, it is
quite natural for p e o p l e to b e c o m e overly aware o f
p e o p l e o r objects a r o u n d t h e m that are r e m i n d e r s
o f the trauma. This is o n e type o f attention that can
maintain a sense o f d a n g e r a n d stop you from return-
ing to a b a l a n c e d view o f the world. F o r some
people, there is a tendency to focus too m u c h on
internal thoughts about the t r a u m a o r anxiety symp-
toms. For instance, when in a situation similar to
that in which the trauma occurred, the person focuses
on a m e m o r y or picture of what h a p p e n e d . This is
often an image f r a g m e n t o f a particular m o m e n t ,
which may be the worst m o m e n t . Focusing in this
way increases the sense o f threat a n d anxiety, a n d
takes attention away from focusing on c u r r e n t
events that could provide a b e t t e r sense of safety
a n d control."
The rationale is illustrated by asking questions concern-
ing the consequences o f idiosyncratic t h r e a t - m o n i t o r i n g
strategies. F o r instance, the therapist 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 atten-
tion to threat mean you will cope better?This process is under-
taken for external attentional m o n i t o r i n g for threat a n d
also for internal monitoring. T h e therapist t h e r e f o r e
moves toward a conceptualization o f hypervigilance as
b e i n g a n o t h e r form o f u n h e l p f u l p r e o c c u p a t i o n similar
to w o r r y / r u m i n a t i o n .
Before the p a t i e n t is willing to give u p t h r e a t monitor-
ing, it is often necessary to weaken the positive beliefs
s u p p o r t i n g its usage. T h e therapist does this by question-
ing w h e t h e r hypervigilance would have actually averted
375
the traumatic event, how the p e r s o n would know exactly
what to be hypervigilant for, a n d by e x a m i n i n g counter-
evidence c o n c e r n i n g the potential u n h e l p f u l role o f hy-
pervigilance. T h e following transcript illustrates a typical
line o f questioning used to raise awareness o f the role o f
attention a n d to weaken beliefs a b o u t its usefulness:
T: Have you n o t i c e d that what you pay a t t e n t i o n to
has c h a n g e d since you were attacked?
P: I ' m n o t sure.
T: F o r instance, do you find that you notice certain
things m o r e than you d i d before?
P: I've n o t i c e d how m u c h crime there is, it always
seems to be in the news.
T: Do you t h i n k that is because crime has s u d d e n l y
increased since your assault, or has s o m e t h i n g else
changed?
P: Well it's obviously in my mind, it's the way I ' m
thinking a b o u t things.
T: Yes, that's an i m p o r t a n t observation. S o m e t h i n g
has c h a n g e d in what you pay a t t e n t i o n to. Has y o u r
attention c h a n g e d in any o t h e r way? F o r e x a m p l e ,
what d o you pay attention to w h e n you go o u t now?
P: I ' m o n the l o o k o u t for groups o f youths, a n d w h e n
I see t h e m I walk the o t h e r way.
T: Any o t h e r changes to what you look for?
P: I ' m always l o o k i n g to see if I can see a n y o n e look-
ing suspicious.
T: Do you t h i n k t h e r e are any p r o b l e m s with using
your attention in this way?
P: Well, it makes m e feel safe, a n d if I ' d d o n e this
b e f o r e maybe I would have b e e n safe.
T: T h a t sounds like an advantage. If you h a d b e e n like
this, would that have p r e v e n t e d the attack?
P: No, p r o b a b l y not, as t h e y were n o t a c t i n g
suspiciously.
T: So it may n o t have helped. Can you see any dis-
advantages o f d o i n g this? F o r example, does it h e l p
you to feel calm w h e n you are out?
P: No, it does the opposite, because I see d a n g e r
everywhere.
T: So the question is, is t h e r e really d a n g e r every-
where or is y o u r strategy k e e p i n g your anxiety a n d
stress going?
P: I ' m k e e p i n g it going.
T: So we n e e d to take a l o o k at d o i n g s o m e t h i n g
a b o u t your attention.
Stage 2: Awareness and abandonment. Once the p r o b l e m
with t h r e a t m o n i t o r i n g is u n d e r s t o o d , the therapist asks
the p a t i e n t to consciously acknowledge the d i r e c t i o n o f
their attention the n e x t time they feel anxious in a situa-
tion a n d to stop t h r e a t monitoring. In o r d e r to apply this
t e c h n i q u e patients are e n c o u r a g e d to r e t u r n to their nor-
mal r o u t i n e o f daily life. In most cases this does m e a n
376
r e t u r n i n g to the situation in which the t r a u m a occurred,
o r in similar situations. This is the only p o i n t in the core
t r e a t m e n t where a d e g r e e o f in-vivo e x p o s u r e may take
place. However, it is n o t h a b i t u a t i o n b u t the facilitation o f
awareness o f a n d d i s r u p t i o n o f t h r e a t m o n i t o r i n g that is
the goal of this p r o c e d u r e .
Session 8
T h e aims of the n e x t session are to review progress
with a b a n d o n m e n t o f threat m o n i t o r i n g a n d its applica-
tion d u r i n g the patient's n o r m a l daily routine. T h e first
thing assessed by the therapist is the e x t e n t to which the
patient has b e e n r e t u r n i n g to his or h e r n o r m a l p r e t r a u m a
routine. At this stage, d e p e n d i n g on the nature a n d sever-
ity o f threat, there s h o u l d be some indication o f a r e t u r n
to situations that were usually frequented. If avoidance o f
low-risk situations is an issue, t h e n patients are encour-
a g e d to go into these situations for h o m e w o r k while prac-
ticing a b a n d o n m e n t of threat monitoring.
Attention refocusing. After a b a n d o n m e n t of threat mon-
itoring, the next step is active attention refocusing, con-
sisting o f asking patients to deliberately r e d i r e c t attention
away from themselves a n d away f r o m threat, a n d o n t o
n o n t h r e a t e n i n g aspects o f the external e n v i r o n m e n t
when in situations that r e m i n d t h e m of the trauma.
(Note, however, that in o u r p r e l i m i n a r y evaluation of the
effects o f the core treatment, we d i d n o t use this addi-
tional strategy. We f o u n d that it was unnecessary as pa-
tients r e s p o n d e d well to the basic instruction to be aware
o f a n d a b a n d o n threat monitoring.) T h e therapist intro-
duces the i d e a that, "in o r d e r to allow thinking to re-tune
to the n o r m a l e n v i r o n m e n t it is helpful to practice focus-
ing attention on the e n v i r o n m e n t in a b e n i g n way. This
m e a n s l o o k i n g for signs o f safety instead o f signs o f im-
p r o b a b l e threat." This is d o n e by practicing different fo-
cusing strategies d u r i n g the t r e a t m e n t session. First, the
therapist asks the p a t i e n t to sit in the waiting r o o m a n d
focus o n aspects o f the e n v i r o n m e n t that signal that it is a
safe place. This is followed by walking in the street with
the therapist a n d practicing focusing o n safety signals. Fi-
nally, a strategy is p r a c t i c e d involving focusing o n neutral
external stimuli (i.e., u n r e l a t e d to concepts o f d a n g e r o r
safety) such as focusing on the array o f different colors
that can be seen.
Relapse Prevention
D u r i n g the final session o f t r e a t m e n t the original for-
m u l a t i o n is discussed with personalized examples from
the patient's e x p e r i e n c e o f how tackling r u m i n a t i o n via
the use o f d e t a c h e d mindfulness a n d c o n t r o l l e d worry
p e r i o d s has p l a c e d the individuals' concerns in perspec-
tive. S h o u l d patients find themselves d i s t u r b e d by m e m o -
ries of the t r a u m a in the future, they are advised to look
for signs of w o r r y / r u m i n a t i o n . O n noticing worry o r ru-
Wells & Sembi
m i n a t i o n they should once again a d o p t the techniques
they have l e a r n e d until the symptoms subside.
Summary and C o n c l u s i o n s
In this article we have p r e s e n t e d o u r core t r e a t m e n t
p r o t o c o l for metacognitive therapy o f PTSD. This treat-
m e n t is based on a m o d e l in which PTSD results from the
failure to meet an intrinsic goal following trauma. This goal
consists o f developing a metacognitive plan that serves as
a b l u e p r i n t for guiding cognition a n d action in d e a l i n g
with subsequent threats. It is assumed that p l a n compila-
tion n o r m a l l y p r o c e e d s u n h i n d e r e d over a time course
stimulated by the processing o f intrusive symptoms. Such
symptoms provide an i m p r i n t that has to be worked u p o n
by upper-level processing to establish a plan for cognition
a n d coping. T h e flexible processing o f imagery provides
o n e m e d i u m for r u n n i n g m e n t a l simulations of c o p i n g
with trauma. Several factors interfere with these n o r m a l
a d a p t a t i o n processes including: (a) w o r r y / r u m i n a t i o n
that diverts resources away from r u n n i n g simulations a n d
selectively focuses the individual on additional sources o f
threat; (b) threat m o n i t o r i n g that p e r p e t u a t e s percep-
tions o f threat a n d strengthens a danger-awareness plan
r a t h e r than c o p i n g plan; (c) avoidant types o f coping, in-
cluding t h o u g h t control, that i n t e r r u p t the n o r m a l work
of intrusions; (d) negative self-appraisals/beliefs a b o u t
symptoms a n d coping. These factors block a d a p t a t i o n
a n d p r e v e n t cognition from re-tuning to the n o r m a l
threat-free environment.
A role of w o r r y / r u m i n a t i o n a n d maladaptive metacog-
nitive control strategies in the persistence o f stress symp-
toms is s u p p o r t e d by data from e x p e r i m e n t a l a n d corre-
lational studies of patients a n d nonpatients. Moreover, a
study o f the longitudinal predictors o f PTSD following
r o a d traffic accidents provides s u p p o r t for the i d e a that
worrying as a means o f c o p i n g with u n w a n t e d thoughts is
causally related to the d e v e l o p m e n t o f PTSD even when
stress symptoms at Time 1 are controlled.
A p r e l i m i n a r y evaluation of the effectiveness o f the
metacognitive t r e a t m e n t has p r o d u c e d e n c o u r a g i n g re-
sults (Wells & Sembi, 2004). In this study, six consecutive
patients (five females, o n e mate) r e f e r r e d for t r e a t m e n t
following a variety o f traumas ( a r m e d robbery, physical
assault, rape) received the new treatment. T h e d u r a t i o n
o f PTSD r a n g e d from 3 to 7 m o n t h s across cases a n d each
p a t i e n t showed a stable baseline o f symptoms for 4 weeks
before the c o m m e n c e m e n t o f treatment. All participants
m e t DSM-IV criteria for moderate-severe PTSD a n d all
m e t criteria for m a j o r depressive d i s o r d e r d u r i n g base-
line. All participants lived in or a r o u n d a d e p r i v e d inner-
city area. A further two patients (the n e x t consecutive re-
ferrals, b o t h male victims o f physical assault) t r e a t e d were
subsequently i n c l u d e d for effect-size analysis. All patients
 M e t a c o g n i t i v e T h e r a p y for PTSD
showed marked improvement in PTSD symptoms and
general symptoms of anxiety and depression. None of the
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 a t p o s t t r e a t m e n t o r follow-
u p o n t h e P o s t t r a u m a t i c Stress D i a g n o s t i c Scale (Foa, 1995).
Pretreatment and posttreatment means on outcome mea-
sures w e r e as follows ( p r e first): I m p a c t o f E v e n t s 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
I n v e n t o r y , 4 8 . 2 - 1 4 . 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 w e r e statistically s i g n i f i c a n t , a n d post-
t r e a t m e n t e f f e c t sizes a c r o s s 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 g a i n s w e r e m a i n t a i n e d a t f o l l o w - u p (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-
tion of the treatment, and further evaluations are in
progress. Controlled studies and developments of this
n e w t r e a t m e n t a p p r o a c h a r e r e q u i r e d . It is o u r h o p e t h a t
this 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 f o r f u r t h e r
evaluations and implementations of treatment by other
clinicians working in the area of PTSD.
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Address correspondence to Adrian Wells, Ph.D., University of Man-
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Royal Infirmary, Manchester, M13 9WL UK; e-mail: adrian.wells@
man.ac.uk.