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Metacognitive therapy for generalized anxiety disorders in group: A case study
Abstract
Objectives
In Metacognitive therapy (MCT), homework is used, for example, to increase awareness of thoughts and thought processes, to challenge metacognitive beliefs in real‐life situations, and to practice new ways of processing thoughts, feelings, and symptoms. All MCT treatment manuals include homework assignments to be given between each session.
Method
The following study provides a detailed description of the implementation of homework in a group‐based MCT treatment for generalized anxiety disorder (GAD) at an outpatient clinic in Norway. The treatment described in this case consisted of 10 weekly group sessions (7 patients) lasting two hours.
Results
This case study demonstrates that group‐based MCT can be used to treat GAD and describes how the use of homework can facilitate therapeutic change.
Conclusion
Overall, the effectiveness of MCT was found to be high. Homework gives patients the opportunity to take charge of their therapy and develop a sense of responsibility for their own progress, both during and after treatment.
... Third, Hammersmark et al. (2023) presented a case of group metacognitive therapy (MCT) for seven clients with generalized anxiety disorder (GAD). The case illustrates how so-called third-wave cognitive behavioral treatment (CBT) deviate from the traditional focus on thought-content in CBT (e.g., examination of negative automatic beliefs), and rather emphasizes perseverative thinking styles (e.g., worry, rumination), threat-focused attentional processes, and maladaptive coping strategies as maintaining factors in GAD. ...
... The case study on group MCT (Hammersmark et al., 2023) illustrate some important considerations in the use of BSH when shifting from individual-to group therapy. Although GAD typically involves worry that involves different domains (e.g., health, work, fear of making mistakes, etc.), the focus on thinking styles and attentional processes (rather than thought content) facilitates the development of a shared case formulation that promotes group cohesion and a collective understanding of maintaining factors and relevant BSH (e.g., metacognitive beliefs). ...
... Several authors commented on potential barriers and obstacles to client engagement with BSH. For example, lack of engagement could be due to limited socialization to the treatment model and frustration, especially in the early phase of treatment (e.g., Hammersmark et al., 2023;Murphy et al., 2023), which highlight the need to have a continuous emphasis on the rationale for the treatment and BSH specifically (Callan et al., 2019). Emotional barriers, such as worry and distress (Hammersmark et al., 2023;Magistrale et al., 2023;Warwar, 2023), or difficulties with identifying emotions and anxiety levels (Church et al., 2023) were other potential barriers. ...
... A particularly effective metacognitive technique is referred to as 'detached mindfulness' (Wells, 2005). This technique focuses on developing one's perception of the momentary changes of affective states, shown to significantly reduce feelings of distress, emotional reactivity, and to improve overall cognitive functioning (Hammersmark et al., 2024). ...
... This perceptual illusion has been explained as the result of poor metacognitive sensitivity that obscures the detection of affective fluctuation (Brown & Ryan, 2003;Grossman et al., 2010). To address this metacognitive deficiency, detached mindfulness has emerged as a uniquely effective therapeutic technique (Wells & Matthews, 1994;Hammersmark et al., 2024). This involves participants learning to observe moment-to-moment changes in mental states, including subtle emotional fluctuations, and allowing these states to occur without engaging with or reacting to them. ...
This paper investigates the computational mechanisms underlying a type of metacognitive monitoring known as detached mindfulness, a particularly effective therapeutic technique within cognitive psychology. While research strongly supports the capacity of detached mindfulness to reduce depression and anxiety, its cognitive and computational underpinnings remain largely unexplained. We employ a computational model of metacognitive skill to articulate the mechanisms through which a detached perception of affect reduces emotional reactivity.
... A particularly effective metacognitive technique is referred to as 'detached mindfulness' (Wells, 2005). This technique focuses on developing one's perception of the momentary changes of affective states, shown to significantly reduce feelings of distress, emotional reactivity, and to improve overall cognitive functioning (Hammersmark et al., 2024). ...
... This perceptual illusion has been explained as the result of poor metacognitive sensitivity that obscures the detection of affective fluctuation (Brown & Ryan, 2003;Grossman et al., 2010). To address this metacognitive deficiency, detached mindfulness has emerged as a uniquely effective therapeutic technique (Wells & Matthews, 1994;Hammersmark et al., 2024). This involves participants learning to observe moment-to-moment changes in mental states, including subtle emotional fluctuations, and allowing these states to occur without engaging with or reacting to them. ...
Objective
Metacognitive therapy (MCT) and cognitive–behavior therapy (CBT) are effective treatments for generalized anxiety disorder. In this study, we followed-up patients who had previously participated in a randomized controlled trial of MCT compared against CBT.
Method
We collected 9-year follow-up data on 39 out of 60 original patients (i.e., 65% response rate).
Results
At 9 years, the recovery rates were 57% for MCT and 38% for CBT (completer analysis). Following MCT, 43% maintained their recovery status and a further 14% achieved recovery. Following CBT, the sustained recovery rate was 13%, while a further 25% achieved recovery. Patients in the MCT condition showed significantly more improvement with respect to symptoms of worry and anxiety. In the CBT group, 23.1% were re-diagnosed with generalized anxiety disorder (GAD) compared with 9.5% in the MCT group.
Conclusions
This follow-up study showed a continuation of gains in both treatments at long-term follow-up, but with outcomes continuing to favor MCT and strengthening its comparative superiority.
Group cohesion refers to a sense of belonging, mutual support and identification with other group members. Group cohesion has been associated with better outcomes, lower drop-out rates, more interpersonal support and better participation in psychotherapy. Nevertheless, the role of group cohesion in CBT has not yet received much attention. The rationale for delivering CBT in groups is that patients can model themselves through each other due to their similarities in symptoms. However, there has recently been a shift towards transdiagnostic CBT protocols, in which patients with varied diagnoses participate in the same groups. This shift challenges the rationale of delivering CBT in groups, and it is therefore highly important to understand if and how group cohesion develops in mixed diagnoses CBT groups. The current study used a qualitative comparative framework to investigate the patients’ experiences of group cohesion in diagnosis-specific versus transdiagnostic CBT groups. Twenty-three patients were interviewed with semi-structured interviews upon completion of the treatment. Participants had a primary diagnosis of MDD, panic disorder, agoraphobia or social anxiety disorder. A comparative thematic analysis was carried out. Three themes were found: the move from differences to similarities, the role of group cohesion in group CBT and factors helpful and hindering to group cohesion. Group cohesion developed across groups and was considered highly important in both diagnosis-specific and transdiagnostic CBT groups.
The GAD-7 is commonly used as a measure of general anxiety symptoms across various settings and populations. However, there has been disagreement regarding the factor structure of the GAD-7, and there is a need for larger studies investigating the psychometric properties of the measure. Patients undergoing treatment (N = 1201), both inpatient and outpatient patients, completed the GAD-7 at pre- and post-treatment. Measures of depression, well-being, and other anxiety measures were also completed, making it possible to investigate convergent and divergent validity. Internal consistency and convergent validity were excellent for the total sample, and there was acceptable variation related to treatment groups. We conducted an exploratory factor analysis (EFA) on a random sample (50%) of the patients at intake and then conducted a confirmatory factor analysis (CFA) to confirm the factor structure in the other part of the sample at intake. The EFA indicated a clear one-factor solution, but the one-factor solution with CFA provided a poor fit to the data. Correlating the residuals among items assessing somatic symptoms led to a good fit in a respecified CFA solution. The GAD-7 has excellent internal consistency, and the one-factor structure in a heterogeneous clinical population was supported.
Background: Individual metacognitive therapy (MCT) for generalized anxiety disorder (GAD) is well established, but only one study has investigated the effectiveness of Group MCT (g-MCT) for GAD. The aim of the current study was therefore to evaluate the feasibility and effectiveness of g-MCT for GAD within a community mental health setting whilst addressing limitations evident in the previous study.
Methods: The study used an open trial design, and 23 consecutively referred adults with GAD completed 10 sessions (90 min) of g-MCT, delivered by two therapists trained in MCT. Diagnoses were assessed by trained raters using the Anxiety Disorder Interview Schedule-IV. All patients but one had previous psychosocial treatment, and 17 (73.9%) had at least one comorbid axis-I disorder. Self-reported symptoms were assessed using the Penn State Worry Questionnaire, the Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9 at pre- and post-treatment as well as 3-month follow-up. Feasibility was assessed using rates of patients who declined group treatment in favor of individual treatment, patients not able to attend due to pre-scheduled dates for sessions, and drop-out rate.
Results: Of 32 eligible participants, six patients (19%) declined g-MCT in favor of individual MCT, and three (9%) were unable to attend due to scheduling conflicts. No patients dropped out during treatment, but two patients did not complete the self-report questionnaires at 3-month follow-up. g-MCT was associated with significant reductions in worry, anxiety, depression, metacognitive beliefs, and maladaptive coping. According to the standardized Jacobson criteria for recovery, 65.3% were recovered at post-treatment, whereas 30.4% were improved and 4.3% showed no change. At 3-month follow-up, the recovery rate increased to 78.3%. Moreover, recovery rates were comparable for patients with- and without comorbidity. Number of therapist hours per patient was 6.5 and the treatment has now been implemented as a standard treatment option at the clinic.
Conclusion: g-MCT for GAD is an acceptable treatment which may offer a cost-effective alternative approach to individual MCT. Recovery rates and effect sizes suggested that g-MCT could be just as efficient as individual MCT and cognitive behavioral therapy.
Cohesion is the most popular of the relationship constructs in the group therapy literature. This article reviews common definitions of cohesion, the most frequently studied measures, and a measure that may clarify group relations using two latent factors (quality and structure) to explain common variance among frequently used group relationship instruments. We present the results of a meta-analysis examining the relation between group cohesion and treatment outcome in 55 studies. Results indicate that the weighted aggregate correlation between cohesion and treatment outcome was statistically significant, r-.26, z-6.54 (p .01), reflecting a moderate effect size (d-.56). Heterogeneity of effect sizes was significant (Q-260.84, df-54, p .001) and high (I2-79.3%), supporting moderator analyses. Six moderator variables were found to significantly predict the magnitude of the cohesion-outcome association (type of outcome measure, leader interventions to increase cohesion, theoretical orientation, type of group, emphasis on group interaction, and dose or number of group sessions). Patient contributions, diversity considerations, and evidence-based therapeutic practices are highlighted.
Background: Metacognitive therapy (MCT) continues to gain increased ground as a treatment for psychological complaints. During the last years, several clinical trials on the efficacy of MCT have been published. The aim of the current study was to provide an updated meta-analytic review of the effect of MCT for psychological complaints.
Methods: We conducted a systematic search of trials on MCT for young and adult patients with psychological complaints published until January 2018, using PsycINFO, PubMed, the Cochrane Library, and Google Scholar. Trials with a minimum of 10 participants in the MCT condition were included.
Results: A total of 25 studies that examined a variety of psychological complaints met our inclusion criteria, of which 15 were randomized controlled trials. We identified only one trial that was conducted with children and adolescents. In trials with adult patients, large uncontrolled effect size estimates from pre- to post-treatment and follow-up suggest that MCT is effective at reducing symptoms of the targeted primary complaints, anxiety, depression, and dysfunctional metacognitions. The comparison with waitlist control conditions also resulted in a large effect (Hedges' g = 2.06). The comparison of MCT to cognitive and behavioral interventions at post-treatment and at follow-up showed pooled effect sizes (Hedges' g) of 0.69 and 0.37 at post-treatment (k = 8) and follow-up (k = 7), respectively.
Conclusions: Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions.
Background
Cognitive–behavioural therapy (CBT) is the treatment of choice for generalised anxiety disorder (GAD), yielding significant improvements in approximately 50% of patients. There is significant room for improvement in the outcomes of treatment, especially in recovery.
Aims
We aimed to compare metacognitive therapy (MCT) with the gold standard treatment, CBT, in patients with GAD (clinicaltrials.gov identifier: NCT00426426).
Method
A total of 246 patients with long-term GAD were assessed and 81 were randomised into three conditions: CBT ( n = 28), MCT ( n = 32) and a wait-list control ( n = 21). Assessments were made at pre-treatment, post-treatment and at 2 year follow-up.
Results
Both CBT and MCT were effective treatments, but MCT was more effective (mean difference 9.762, 95% CI 2.679–16.845, P = 0.004) and led to significantly higher recovery rates (65% v . 38%). These differences were maintained at 2 year follow-up.
Conclusions
MCT seems to produce recovery rates that exceed those of CBT. These results demonstrate that the effects of treatment cannot be attributed to non-specific therapy factors.
Declaration of interest
A.W. wrote the treatment protocol in MCT and several books on CBT and MCT, and receives royalties from these. T.D.B. wrote the protocol in CBT and has published several articles and chapters on CBT and receives royalties from these. All other authors declare no competing interests.
Few studies have compared the effects of Metacognitive therapy (MCT) and Cognitive behavioral therapy (CBT) for comorbid anxiety disorders. In the current study we compared CBT and MCT for heterogeneous anxiety disorders in a residential setting. Ninety patients with a primary diagnosis of Post Traumatic Stress Disorder, Social Phobia or Panic disorder, with and without Agoraphobia, were randomized to either CBT or MCT. Patients were assessed at pre-treatment, post-treatment and one-year follow-up. Primary outcome measures were Beck Anxiety Inventory and ADIS IV and secondary outcome measures were SCID II, Beck Depression Inventory, Penn State Worry Questionnaire, The Symptom Checklist-90 and the Inventory of Interpersonal Problems–64. Treatment fidelity was satisfactory and therapist credibility was equal in both treatments. There was a significant difference in the level of anxiety favouring MCT at post-treatment (d=0.7), but there were no differences at one-year follow-up, mainly due to a further improvement in the CBT group during the follow-up period. Both treatments were efficacious. No differences in effect on comorbid diagnoses and symptoms were found, but MCT produced larger change in personality problems. MCT seems to have a more rapid effect on anxiety symptoms, but there were no significant differences in the long term for patients with comorbid anxiety disorders.
Purpose - Because of the increased risk of long-term sickness leave for employees with a major depressive disorder (MDD), it is important for occupational health professionals to recognize depression in a timely manner. The Patient Health Questionnaire-9 (PHQ-9) has proven to be a reliable and valid instrument for screening MDD, but has not been validated in the occupational health setting. The aim of this study was to validate the PHQ-9 for MDD within a population of employees on sickness leave by using the MINI-International Neuropsychiatric Interview (MINI) as a gold standard.
Methods - Participants were recruited in collaboration with the occupational health service. The study sample consisted of 170 employees on sickness leave between 4 and 26 weeks who completed the PHQ-9 and were evaluated with the MINI by telephone. Sensitivity, specificity, positive and negative predictive value, efficiency and 95 % confidence intervals (95 % CIs) were calculated for all possible cutoff values. A receiver operator characteristics (ROC) analysis was computed for PHQ-9 score versus the MINI.
Results - The optimal cutoff value of the PHQ-9 was 10. This resulted in a sensitivity of 86.1 % [95 % CI (69.7–94.8)] and a specificity of 78.4 % [95 % CI (70.2–84.8)]. Based on the ROC analysis, the area under the curve for the PHQ-9 was 0.90 [SE = 0.02; 95 % CI (0.85–0.94)].
Conclusion - The PHQ-9 shows good sensitivity and specificity as a screener for MDD within a population of employees on sickness leave.
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.
Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity.
A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use.
A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale.
The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
Objective:
Metacognitive therapy and one of its treatment components, the attention training technique, are increasingly being delivered to improve mental health. We examined the efficacy of metacognitive therapy and/or attention training technique on mental health outcomes from single-case studies.
Method:
A total of 14 studies (53 patients) were included. We used the d-statistic for multiple baseline data and the percentage change index to compute the effect sizes.
Results:
Metacognitive therapy has a large effect on depression, anxiety, other psychopathological symptoms, and all outcomes together. Effect sizes were significantly moderated by the number of sessions, the severity and duration of symptoms, and patient gender, but not by study quality or attention training technique when used as a stand-alone treatment. At the follow-up, 77.36% of the individuals were considered recovered or had maintained improvement.
Conclusion:
Metacognitive therapy and attention training technique strongly contribute to improving mental health outcomes. This study effectively informs evidence-based practice in the clinical milieu.
Background:
Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders. However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously. The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders.
Methods:
84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy. Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview. Participants made ratings of treatment expectancy after the first session. Homework compliance was assessed each session by the treating clinician.
Results:
Contrary to hypotheses, treatment expectancy and homework compliance were poorly correlated. Regression analyses revealed that homework compliance, but not treatment expectancy, predicted a significant portion of the variance in treatment outcome (10%).
Conclusions:
The present research suggests that although treatment expectation and homework compliance likely represent unique constructs of treatment engagement, homework compliance may be the more important treatment engagement variable for outcomes. The present research suggests that improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT targeting anxiety disorders.
OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Generalized anxiety disorder (GAD) is a prevalent and disabling disorder characterized by persistent worrying, anxiety symptoms, and tension. It is the most frequent anxiety disorder in primary care, being present in 22% of primary care patients who complain of anxiety problems. The high prevalence rate of GAD in primary care (8%) compared to that reported in the general population (12-month prevalence 1.9–5.1%) suggests that GAD patients are high users of primary care resources. GAD affects women more frequently than men and prevalence rates are high in midlife (prevalence in females over age 35: 10%) and older subjects but relatively low in adolescents. The natural course of GAD can be characterized as chronic with few complete remissions, a waxing and waning course of GAD symptoms, and the occurrence of substantial comorbidity particularly with depression. Patients with GAD demonstrate a considerable degree of impairment and disability, even in its pure form, uncomplicated by depression or other mental disorders. The degree of impairment is similar to that of cases with major depression. GAD comorbid with depression usually reveals considerably higher numbers of disability days in the past month than either condition in its pure form. As a result, GAD is associated with a significant economic burden owing to decreased work productivity and increased use of health care services, particularly primary health care. The appropriate use of psychological treatments and antidepressants may improve both anxiety and depression symptoms and may also play a role in preventing comorbid major depression in GAD thus reducing the burden on both the individual and society. Depression and Anxiety 16:162–171, 2002. © 2002 Wiley-Liss, Inc.
To present estimates of the lifetime prevalence of DSM-IV mental disorders with and without severe impairment, their comorbidity across broad classes of disorder, and their sociodemographic correlates.
The National Comorbidity Survey-Adolescent Supplement NCS-A is a nationally representative face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview.
Anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of participants with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2% (11.2% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for substance use disorders.
These findings provide the first prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. Approximately one in every four to five youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The likelihood that common mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment of U.S. youth to that of prevention and early intervention.
Generalized anxiety disorder (GAD) responds only modestly to existing cognitive-behavioural treatments. This study investigated a new treatment based on an empirically supported metacognitive model [Wells, (1995). Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320; Wells, (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wiley]. Ten consecutive patients fulfilling DSM-IV criteria for GAD were assessed before and after metacognitive therapy, and at 6, and 12-month follow-up. Patients were significantly improved at post-treatment, with large improvements in worry, anxiety, and depression (ESs ranging from 1.04-2.78). In all but one case these were lasting changes. Recovery rates were 87.5% at post treatment and 75% at 6 and 12 months. The treatment appears promising and controlled evaluation is clearly indicated.
The effectiveness of group metacognitive therapy for generalised anxiety disorder: A pilot study
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