Volume 20 • Issue 2 • Summer 2020 IJCP

Research Article

(CAS) – and not as a result of the The Effectiveness of content of the situational appraisal itself (Fisher & Wells, 2009). The Cognitive Behavioural CAS comprises prolonged repetitive thinking like and worry, fixed attention on threat, and Therapy versus unhelpful coping behaviours (Fisher & Wells, 2009). Newer research Metacognitive Therapy evidence encourages us to have a fresh look at the underlying model on the Treatment of of . Cognitive (CBT) Anxiety for Anxiety Treatment Cognitive Behaviour Therapy (CBT) By Dr Marion Mensing regards thoughts, emotions, and behaviours as interconnected and focuses on changing them in order to improve the client’s psychological difficulties (Wills & Sanders, 2013). Aaron Beck developed the original model of CBT in the 1970s, which “contained a theory of how people develop emotional problems; a model of how they could heal disturbance; and a model of how further problems might be prevented” (Wills, 2013, p. 4). CBT has also strong roots in the work of Albert Ellis and his Rational Emotive Behaviour Therapy (REBT) especially with respect to the challenging of negative thoughts (Wills, 2013). Ellis developed REBT and the ABC assessment in the 1960s (Ellis & Dryden, 1999). Ellis & Dryden (1999) present an updated version of the ABC framework, which identifies “Activating Events or Introduction overestimation of the extent of Activators (A’s)” (p.8), “Beliefs (B’s) he Cognitive Behavioural damage, (3) an underestimation – , thoughts, or ideas TTherapy (CBT) therapist of one’s own coping potential, and – about their Activating events” explains anxiety as an unpleasant (4) an underestimation of possible (p. 9), and “cognitive, emotional, emotional response to a external support (Wills & Sanders, and behavioural Consequences perception of a threat, resulting 2013). The Metacognitive Therapy (C’s)”. For Ellis & Dryden (1999) from a distorted appraisal of (MCT) therapist looks at thinking irrational beliefs or irrational a situation (Beck, Emery, & about thinking () cognitions are the cause for self- Greenberg, 2005). The distortion and sees anxiety and other destructive behaviours. Beck et al. usually is a mixture of (1) an psychological problems as a result (2005) designate those underlying overestimation of the likeliness of a certain pattern of thinking – beliefs and cognitions as “cognitive of a threatening event, (2) an the cognitive attentional syndrome schemas” (p. 55).

Irish Association for Counselling and 13 IJCP Volume 20 • Issue 2 • Summer 2020

CBT for anxiety treatment strategies in CBT for anxiety are draws on the cognitive model BT is directive, very simplification, being specific, of anxiety, which depicts how Cstructured, and uses focussing on the present, helping to the immediate thoughts about standardised procedures accept certain situations, learning a triggering situation or the way to reassure the often to stop worrying, encouraging the client perceives the situation insecure anxious client the client to take certain risks, affect emotions, behaviours and by providing some order; becoming more comfortable with physiological responses (Beck anxiety symptoms (Beck et al., et al., 2005). This model implies a clear agenda with a 2005; Greenberger & Padesky, that irrational beliefs often lead focus on specific targets 2016; Newman & Borkovec, 2002). to dysfunctional perceptions and underlies each session Examples for tactics are creating “perseverative, involuntary intrusion a fear ladder, image exposure, of automatic thoughts” (p. 31) (Beck et al., 2005) assignments to approach feared which result in anxiety (Beck et al., situations, relaxation methods, 2005). Clients may already find client’s ability to monitor his or her exercises to deal with shame, it helpful to learn about anxiety own thinking (Beck et al., 2005). reverse role play, and use of logic being the outcome of “exaggerated, In CBT, the therapist leads the and evidence to attack the irrational automatic thinking” (Beck et al., client mainly by asking questions. (Beck et al., 2005; Greenberger 2005, p. 168) and may then be Beck et al. (2005) call this & Padesky, 2016; Newman & open to reframe their thinking (Beck approach “the Socratic method” Borkovec, 2002). et al., 2005). The typical duration (p. 177). Zinbarg, Craske, & Barlow (2006) of anxiety treatment using CBT lies structure their CBT approach somewhere between five and twenty Often a patient reports that for anxiety treatment into four sessions (Beck et al., 2005). when confronted by a new modules: The first module is The first step in CBT for anxiety anxiety-producing situation he about the correction of the client’s treatment – after ruling out any will start by asking himself the distorted thoughts and concepts general medical reasons for the same questions he heard from with respect to anxiety and symptoms – is normalising the the therapist: “Where is the worry, and about supporting the symptoms, helping the client to evidence?” “Where is the logic?” recognition and the replacement of understand the bodily responses “What do I have to lose?” “What these thoughts; the second module to perceived threats (Beck et al., do I have to gain?” “What would contains relaxation techniques; the 2005). The therapist will explain be the worst thing that could third module is about the exposure the two types of fear: fear of the happen?” “What can I learn from to images which give rise to worry, threat itself, and fear of the anxiety this experience?” (Beck et al., and the fourth module is about the symptoms (Beck et al., 2005). 2005, p. 178) exposure to real situations which Information about the role of the used to evoke worry. adrenal system, the fight-or-flight CBT is directive, very structured, Tubridy (2007) bases her response, and the nervous system and uses standardised procedures method of controlling panic on when facing the threat, will change to reassure the often insecure Barlow’s CBT approach, and the client’s perspective and begin to anxious client by providing some also highlights the influence of help to overcome the second type order; a clear agenda with a focus catastrophising on the adrenaline of fear, the fear of the symptoms on specific targets underlies each levels: “your anxiety level will themselves (Tubridy, 2007). Beck et session (Beck et al., 2005). The follow your adjectives” (p. 175). al. (2005) propose a role-play with four steps of problem-solving – Tubridy (2007) recommends three the client, in which the therapist according to Beck et al. (2005) ways of invalidating catastrophic represents the client’s frightening – are: (1) Conceptualisation, (2) thinking: (1) use of positive coping thoughts about the symptoms and Strategy, (3) Tactic, (4) Assessment. affirmations, (2) challenge the the client has the task to respond The CBT therapist conceptualises possibility of a feared outcome in a more rational way. The CBT the problem by detecting what or question the severity of the therapist will also explain the it means for the client and what feared outcome, and (3) stop cognitive model to the client and actually triggers anxiety (Beck et the catastrophic appraisal with emphasise the outcome of therapy al., 2005; Newman & Borkovec, something like a “mental slap” being particularly dependent on the 2002;). Examples of common (p. 178) and turn to something

14 Irish Association for Counselling and Psychotherapy Volume 20 • Issue 2 • Summer 2020 IJCP else. Also Tubridy (2007) an observer of thought or belief” recommends gradually increasing uring the course (p. 79). To enhance the efficacy exposure to the threat once the D of therapy, further of these exercises the therapist client has developed some trust in exercises follow to asks the client to combine them the relaxation techniques and in the change the client’s with the exercise of postponing thought replacement. beliefs about the danger worry/rumination for a few hours Borkovec, Newman, & Castonguay of worry/rumination, – as a homework (Wells, 2009). (2003) work out some evidence Wells (2009) also suggests to that worrying in Generalised Anxiety and later also the beliefs make use of certain techniques Disorder (GAD) can also be a about the usefulness of “to strengthen metacognitions that strategy to avoid the processing worry/rumination regulate thinking, remove unhelpful of deeper feelings and they see thinking styles that impede normal here a limitation of traditional CBT (Wells, 2009) emotional processing, or modify for GAD clients who might prefer beliefs” (p. 67); these techniques discussing to exploring (2) the worry/rumination that are “attention training technique their emotions. followed, (3) the feelings and (ATT)” (p. 67) and “situational As Wells (2012) puts it: “CBT is a symptoms caused by the worry/ attention refocusing (SAR)” (p. 67). ‘shape shifter’ and it continuously rumination, (4) any thoughts about ATT involves “selective attention” incorporates concepts from other a bad outcome caused by the (p. 68) to a specific sound in a theories and techniques” (para. 2), worry/rumination, feelings, and room with many different sounds but “the combining of CBT and MCT symptoms, (5) beliefs about the coming from various directions, treatment techniques is likely to be danger of worry/rumination, (6) “rapid attention switching” (p. problematic as they are based on beliefs about the uncontrollability 68) between different sounds in conflicting messages” (para. 2). of worry/rumination, (7) lack of different locations, and “divided confidence in memory/cognition, attention” (p. 68) with an attempt Metacognitive Therapy (MCT) for (8) beliefs about the usefulness to focus on different sounds in Anxiety Treatment of worry/rumination, and (9) different locations simultaneously. Metacognitive Therapy (MCT) uses the coping strategies the client Wells (2009) emphasises the experiential practices to target the deploys (Wells, 2009). Wells rationale for ATT to be not about Cognitive Attentional Syndrome (2009) proposes to let the client blocking out unwanted thoughts (CAS) and to build up more control experience that, attempts to and feelings but about regarding about thinking processes and more suppress thoughts are ineffective them as “additional noise” (p. 69). flexibility in reactions to thoughts, e.g. by asking him or her not “SAR is intended to explicitly emotions and threats; these to “think of a blue rabbit in any enhance the processing of practices aim to modify attention, shape or form” (Wells, 2009, information that is incompatible awareness, and the relationship p. 108). The MCT therapist then with the patient’s dysfunctional with thoughts (Fisher & Wells, uses “detached beliefs” (Wells, 2009, p. 77). For 2009). MCT draws on the theory (DM)” (Wells, 2009, p. 79) with example, Nordahl & Wells (2018) that it is the way a person responds a recent triggering thought for refer to an SAR experiment in to negative, automatic thoughts the client to experience that it treating which leads to anxiety or other is indeed possible to control to challenge the client’s belief psychological problems, rather than worry/rumination (Wells, 2009). of having poor cognition: The the negative, automatic thoughts Mindfulness, according to Wells therapist went for a 10-minute themselves (Fisher & Wells, 2009). (2009), generally refers to an walk with the client, who got MCT usually requires between awareness of “inner cognitive the instruction to be really self- five and ten sessions and starts events, namely, thoughts, beliefs, conscious in the first 5 minutes with the case conceptualisation memories, and feelings of and focus on the surroundings as (Wells, 2009). For the case knowing” (p. 79), whereas DM much as possible in the second conceptualisation in anxiety has additional qualities of firstly 5 minutes. The client was then treatment the MCT therapist and refraining from any attempts to asked to recall what he had the client explore a recent episode engage, evaluate, or cope, and noticed in the first 5 minutes of worry/rumination and identify secondly becoming aware of in comparison to the second 5 (1) the first triggering thought, “the perspective of the self as minutes. The client’s cognitive

Irish Association for Counselling and Psychotherapy 15 IJCP Volume 20 • Issue 2 • Summer 2020 performance significantly improved mainly on physical and emotional while giving his attention to his n MCT much of symptoms; in MCT, the therapists surrounding (Nordahl & Wells, I the work is about used methods to change the 2018). accepting thoughts metacognitive beliefs about worry, During the course of therapy, without reactive and focused on metacognitive further exercises follow to change engaging, detaching the detachment from a thought the client’s beliefs about the self from the thought, (Nordahl et al, 2018). To measure danger of worry/rumination, and the outcome of therapy, Nordahl et later also the beliefs about the attention training al. (2018) used the “Penn State usefulness of worry/rumination practices to develop Worry Questionnaire (PSWQ)” (Wells, 2009). The therapist control of attention, (p. 395) with the result that “65% combines those exercises redirecting attention of patients were recovered after with verbal challenging of the in anxiety-triggering MCT compared with 38% after maladaptive metacognitions, situations, and CBT” (p. 398). such as unhelpful beliefs about Regarding social anxiety the uncontrollability and danger challenging unhelpful disorder, Nordahl & Wells of worry/rumination, and a lack meta-cognitions (2017) engaged further in the of confidence in memory and question, which of the conflicting cognition (Wells, 2009). assumptions in CBT versus MCT treatment effects than CBT provides the better fit to reality, Effectiveness of CBT Versus MCT (Normann et al., 2014). As there i.e. which is the better model for for Anxiety Treatment are more variations in CBT than in understanding social anxiety? Normann, van Emmerik, & Morina MCT and because of the relatively The CBT model emphasises (2014) analysed the results small sample, these results “social self-beliefs (schemas) of 16 research studies on the demand further investigation as the core underlying factor effectiveness of MCT for anxiety (Normann et al., 2014). for maladaptive self-processing and on a total of 384 Nordahl et al. (2018) carried out and social anxiety symptoms” participants with diagnoses of a study on recovery rates for 81 (Nordahl & Wells, 2017, p. 1) anxiety or depression. Collectively, clients with Generalised Anxiety whereas the MCT model regards the researchers of the 16 studies Disorder (GAD). They designed this beliefs/thoughts about thinking had allocated 234 participants study with the particular aim to (meta-cognitions) as the decisive to MCT, 112 to CBT and 73 compare the effectiveness of CBT factor. Nordahl & Wells (2017) to a waiting list (Normann et with MCT (Nordahl et al., 2018). collected a vast amount of data al., 2014). Comorbidity rates Six therapists, trained in both in online surveys about social were high (Normann et al., modalities, were treating 28 clients anxiety at two different time 2014). MCT showed large and with CBT and 32 clients with MCT points and tested the fitting of the sustainable gains in treatment (Nordahl et al., 2018). Nordahl CBT model and the fitting of the of anxiety and depression et al. (2018) used a “crossover MCT model to the respective data in comparison to clients on design of therapists to control sets, with the result that the MCT the waiting list (Normann et the therapist factor” (p. 393), model showed the better fit and al., 2014). In addition, MCT which means every therapist had therefore provides the better lens presented large effect sizes to use CBT as well as MCT with for understanding social anxiety. with respect to the sustainable different clients. They allocated 21 Compared to CBT, MCT also change of metacognitions, which clients to a waiting list for control has certain advantages as an brings some assurance of the purposes (Nordahl et al., 2018). intervention for patients in cardiac change of metacognition having “Patients not willing to withdraw rehabilitation who are suffering a therapeutic effect (Normann psychotropic medication for a from depression and anxiety: et al., 2014). Only five studies period of three weeks before entry the model and the strategies are of the 16 were controlled trials to the trial were not included” transdiagnostic and there is no with relatively small samples (Nordahl et al., 2018, p. 393). In need to challenge the content of comparing MCT with CBT CBT, the therapists used relaxation negative thoughts which in this (Normann et al., 2014). Here, techniques, cognitive therapy, and case can be quite realistic (Wells MCT showed significantly larger image exposure, and focussed et al., 2018).

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Conclusion therefore relevantly from CBT, in CBT is a well-established a way that the two can hardly be Marion Mensing psychotherapeutic approach for combined. The MCT model regards the treatment of anxiety and has a certain style of thinking and Marion Mensing graduated with a its roots in Albert Ellis’s Rational unhelpful coping behaviours as PhD in Natural Sciences (Dr. rer. nat.) Emotive Behaviour Therapy the core feature of psychological from the University of Muenster in from the 1960s and Aaron Germany in 1990 with Statistical disorders. In MCT much of the Beck’s Cognitive Therapy from Research as main area and work is about accepting thoughts the 1970s. It focusses on the worked for more than two decades triangle of thoughts, emotions, without reactive engaging, in different roles in the financial and behaviours which influence detaching the self from the services industry in Germany, each other. The model is based thought, attention training Luxembourg and Ireland. Recovering on the assumption that negative practices to develop control of from a severe life crisis, she automatic thoughts and their attention, redirecting attention changed her direction. She studied underlying irrational beliefs in anxiety-triggering situations, Counselling and Psychotherapy at or schemas affect emotions, and challenging unhelpful meta- PCI College in Cork, qualifying with behaviours and physiological cognitions. an IACP accredited Diploma in June responses. The communication of Recent studies about the 2020. She will enrol for an additional this model, and of the importance effectiveness of MCT and CBT year, leading to a BSc (Hons) in of thought monitoring is itself an on the treatment of anxiety show Counselling & Psychotherapy in important first element of CBT. a promising potential for MCT conjunction with Middlesex University, With respect to anxiety and panic, London. Pluralistic Counselling is her compared to CBT, especially modern CBT approaches include main therapeutic orientation. She is in the treatment of General the correction of the client’s a student member of IACP. irrational negative thoughts and Anxiety Disorder. The results of a concepts, relaxation techniques, longitudinal online survey about Contact details: and gradually increasing exposure social anxiety further challenges Dr. Marion Mensing, 2 Castle to threat. the underlying assumption in CBT Street, Dunmanway, Co. Cork MCT denies the importance of that irrational beliefs are the root [email protected] thoughts themselves and differs of the problem. 083-8090294.

REFERENCES

Beck, A., Emery, G., & Greenberg, R. (2005). Kennair, L. E. O., Hjemdal, O., Solem, S., anxiety and depression. New York: The Guilford Anxiety disorders and phobias: A cognitive Hansen, B., Haseth, S., & Wells, A. (2018, Press. perspective. New York: Basic Books. September). Metacognitive therapy versus Wells, A. (2012, May). A brief interview with cognitive-behavioural therapy in adults with Borkovec, T. D., Newman, M. G., & Castonguay, Prof. Adrian Wells on the distinctive features of generalised anxiety disorder. Retrieved from: L. (2003, June). Cognitive-behavioural therapy Metacognitive Therapy (MCT). Retrieved from: https://doi.org/10.1192/bjo.2018.54 for generalized anxiety disorder with integrations https://www.stateofmind.it/2012/05/adrian- from interpersonal and experiential therapies. Nordahl, H. & Wells, A. (2017, May). Testing wells-metacognitive-therapy/ Retrieved from: https://www.researchgate.net/ the metacognitive model against the benchmark Wells, A., McNicol, K., Reeves, D., Salmon, P., publication/10742944 CBT model of social anxiety disorder: Is it time to Davies, L., Heagerty, A., Doherty, P., McPhillips, move beyond cognition? Retrieved from: https:// Ellis, A. & Dryden W. (1999). The practice of R., Anderson, R., Faija, C., Capobianco, L., REBT. London: Free association books. journals.plos.org/plosone/article?id=10.1371/ Morley, H., Gaffrey, H., Shields, G., & Fisher, journal.pone.0177109 Fisher, P. & Wells, A. (2009). Metacognitive P. (2018, April 3). Improving the effectiveness therapy: Distinctive features. East Sussex: Nordahl, H. & Wells, A. (2018, April). of psychological interventions for depression Routledge. Metacognitive therapy for social anxiety disorder: and anxiety in the cardiac rehabilitation pathway an A-B replication series across social anxiety Greenberger, D., Padesky, C. A. (2016). Mind using group-based metacognitive therapy subtypes. Retrieved from: over mood: Change how you feel by changing the (PATHWAY Group MCT): study protocol for https://doi.org/10.3389/fpsyg.2018.00540 way you think. New York: Guilford. randomised controlled trial. Retrieved from: Normann, N., van Emmerik, A. A. P., & Morina, https://doi.org/10.1186/s13063-018-2593-8 Newman, M. G. & Borkovec, T. D. (2002). N. (2014). The efficacy of Metacognitive Therapy Cognitive behavioural therapy for worry and Wills, F. & Sanders, D. (2013). Cognitive for anxiety and depression: A meta-analytic generalised anxiety disorder. In G. Simos (Ed.) behaviour therapy: Foundations for practice. review. Depression and Anxiety, 31, 402-411. Cognitive behaviour therapy: A Guide for the London: Sage. Tubridy, Á. (2007). When panic attacks. Dublin: Practising Clinician (pp. 150-172). New York: Zinbarg, R. E., Craske, M. G., & Barlow, D. H. Taylor and Francis. Gill Books. (Ed.) (2006). Mastery of Your Anxiety and Worry: Nordahl, H. M., Borcovec T. D., Hagen, R., Wells, A. (2009). Metacognitive Therapy for Therapist Guide. Oxford: University Press.

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