درمان فراشناختی برای اختلال اضطراب فراگیر: طبیعت، شواهد و تصویر سازی مورد فردی

Metacognitive therapy (MCT) is based on over 25 years of research focusing on the processes that contribute to the development and maintenance of psychological disorders. The approach identifies a common set of processes in psychopathology, and MCT shows promising results in effectively treating a range of disorders. This paper presents the central theoretical tenets of MCT and uses a clinical vignette to illustrate the structure and techniques of treatment based on Wells's (2009) manual as they relate to a specific case of generalized anxiety disorder.

This paper provides a general introduction to the theory of metacognitive therapy (MCT) and a more specific outline of how to use MCT for generalized anxiety disorder (GAD), illustrated with the clinical case of William. In the final part of the paper the scientific evidence for MCT in GAD is presented. MCT was developed to address the control of cognition and the strategies and knowledge that govern thinking. It contrasts significantly with the theory and focus of standard CBT. Metacognition refers to cognition applied to cognition and may be defined as any knowledge or cognitive processes involved in the appraisal, control, and monitoring of thinking (Flavell, 1979). In short, metacognition is thinking about thinking. Metacognitive theory has distinguished between metacognitive knowledge, which is information that individuals have about their own thinking and about strategies that affect it, and metacognitive regulation, which are the strategies used to change the nature of processing. In the metacognitive theory of psychological disorder (Wells, 2009 and Wells and Matthews, 1994), metacognition is central in determining the maintenance and control of negative and biased thinking styles. According to Wells, most people have negative thoughts and beliefs and in most cases these thoughts and beliefs are transitory mental experiences. The negative thoughts become a problem because of the way an individual responds to them. Thus, an important tenet of metacognitive therapy, and one of the features distinguishing it from traditional CBT, is that neither the content nor the subjective validity of thoughts and beliefs are the central source of disorder. In basic terms, according to metacognitive theory, an individual's metacognitions monitor and control their responses to thoughts, which cause persistence or perseveration of ideas and maintain psychological and interpersonal problems. This supposition can be clearly illustrated in the situation of GAD, where the content of worry shifts around. The content of worry in GAD is not dissimilar from everyday worries experienced by most people. However, people with GAD experience their worry as uncontrollable and excessive, and it is associated with marked distress. The metacognitive model provides an explanation of this in terms of differences in the way individuals relate to, appraise, and control their worry The theoretical grounding of MCT is the Self-Regulatory Executive Function Model (S-REF), which emphasizes the similarities in maladaptive cognitive processing across all psychological disorders (Wells, 2000, Wells, 2009, Wells and Matthews, 1994 and Wells and Matthews, 1996). The S-REF model postulates a thinking style called the cognitive attentional syndrome (CAS). In MCT the CAS is a universal feature of psychiatric disorders and is responsible for prolonging and intensifying distressing emotions. The CAS is a thinking pattern of inflexible self-focused attention (the focus is on self-observation and monitoring of thought processes), perseverative thinking (in the form of worry and rumination), threat monitoring, and coping behaviors that backfire and interfere with effective mental control and adaptive learning. The CAS is considered to be a problem for psychological well-being because it maintains threat-focused processing and fails to provide information that can modify the individual's maladaptive appraisals and beliefs. In addition to this, the CAS uses attentional resources that might otherwise be directed toward more adaptive responses, and biases perception and automatic processing in a negative way. There is a large evidence base supporting the presence and effects of the CAS in emotional disorders (see Wells, 2009, for a review). The CAS is driven by metacognitive beliefs and metacognitive knowledge stored in long-term memory, and MCT implies that all disorders are linked to this higher level of metacognitive beliefs about thinking. These beliefs fall into either positive or negative domains. Positive meta-beliefs concern the advantages of worrying, ruminating, threat monitoring, and controlling cognition (e.g., “Worrying about the future helps me be prepared”). Having positive meta-beliefs alone is not in itself pathogenic but increases the tendency to worry as a coping strategy, which does not provide the most effective way of managing negative affect and thoughts. According to MCT, psychopathology develops when negative meta-beliefs about loss of control and danger are activated. These beliefs concern the uncontrollability of worries and rumination and beliefs about the dangerousness or importance of thoughts. An example of a negative metacognition is: “Worrying is out of control and will make me lose my mind.” The patient with GAD can hold both positive and negative beliefs about worrying, which cause conflicting motivations to sustain or try to avoid negative thoughts. However, the negative beliefs are most important and lead to worry about worry resulting in elevated and persistent distress. The negative beliefs about the uncontrollability of the process contribute to the use of unhelpful forms of control or no control at all. Metacognitive Model of GAD

In this paper we have described Wells's metacognitive model and treatment of GAD, illustrated in the case of William (Robichaud, 2013-this issue). The model is based on the principle that worry is not effectively regulated in GAD, because of the effects of metacognition on mental control and extended thinking. In particular, metacognitive beliefs have a crucial role that intensifies the aversive experience of worry and its threat value. GAD patients use paradoxical or incompatible metacognitive control strategies that reduce their exposure to experiences of self-control and/or contribute to instances of impaired control. The patient does not have a deficit or absence of control; rather, beliefs about control are unhelpful and strategies used to cope with worries and negative thoughts are counterproductive. It should be noted that MCT is not simply a matter of gaining “better” control, because the model emphasizes the importance of using experiences in therapy to challenge beliefs about the uncontrollability of worry and beliefs that worry is dangerous. The metacognitive therapist is cautious not to convey the idea that worry must be controlled; instead, the aim is to show that thoughts are insignificant for further processing, and the individual has a choice about how to respond to his thinking. This approach contrasts with other approaches that focus on reality testing the content of worry, involve problem solving of concerns, or distinguish between types of worry that should be analyzed and responded to or not. In each of these other approaches the therapist may in some cases be seen to be dealing with the problem of excessive thinking with more thinking. MCT suggests instead that treatment should focus on reacting to negative ideas by reducing the reliance on worrying and thinking and by ultimately doing little or nothing in response to negative thoughts. This contrasts with meditation or relaxation strategies, which countenance responding to thoughts with changes in attention, breathing exercises, and with CBT, which focuses on worry exposure or challenging schemas concerning uncertainty.