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Cognitive and Behavioral Practice 15 (2008) 85–92www.elsevier.com/locate/cabp

Chronic PTSD Treated With Metacognitive Therapy: An Open Trial

Adrian Wells, University of ManchesterMary Welford, Janelle Fraser, Paul King, Elizabeth Mendel, Julie Wisely, Alice Knight, and David Rees

North Manchester General Hospital

1077© 20Publ

This paper reports on an open trial of metacognitive therapy (MCT) for chronic PTSD. MCT does not require imaginal reliving, prolongedexposure, or challenging of thoughts about trauma. It is based on an information-processing model of factors that impede normal and in-builtrecovery processes. It is targeted at modifying maladaptive styles of worry/rumination and attention so that emotional processing can proceedspontaneously. Eleven out of 13 patients with amean duration of PTSD of 19.5months completed treatment. Therapists followed the treatmentmanual by Wells and Sembi (2004b). Self-report measures of PTSD symptoms, anxiety and depression, and assessor ratings of PTSD wereadministered at pre- and posttreatment, and at 3- and 6-month follow-up. Treatment appeared to result in large and significant improvementson all measures of PTSD and general measures of anxiety and depression. Statistically significant treatment gains were maintained at 3- and6-month follow-up. Jacobson's criteria for recovery showed that 90% of patients were recovered at posttreatment. At 6-month follow-upapproximately 89% were recovered or reliably improved. Results suggest that MCT could be highly effective and extend evidence of itsapplicability to more treatment-resistant chronic PTSD cases. Comparisons against other active interventions are now clearly indicated.

METACOGNITIVE THERAPY (MCT) offers a new and briefform of treatment for psychological disorders. Its

application to posttraumatic stress disorder (PTSD) isguided by a disorder-specific model (Wells, 2000; Wells &Sembi, 2004b). The model proposes that individuals havea self-righting process involved in adaptation and recoveryfrom the psychological and emotional effects of trauma.However, a person's style of thinking and coping re-sponses following trauma can interfere with this self-righting process, leading to the persistence of symptomsand to PTSD.

The self-righting process is called the Reflexive Adapta-tion Process (RAP). The goal of the RAP is production of aset of plans or internal programs that can be rapidly calledto control cognition and action in future encounters withthreat. It consists of the tuning and biasing of cognition andaction by intrusions from lower-level processing. Forexample, intrusive thoughts about trauma prompt theindividual to run simulations of dealing with threat, therebylaying the foundations for behavioral control programs.Startle reactions repeatedly bias attention and thusstrengthen attentional control plans.

The RAP normally progresses unhindered over time;however, PTSD symptoms persist when the person's

-7229/08/085–092$1.00/008 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

processing and coping strategies interfere with the RAP. Aparticular style of thinking, called the Cognitive-AttentionalSyndrome (CAS), consisting of worry/rumination, sus-tained attentional monitoring for threat, thought suppres-sion, and avoidance, impairs the RAP and leads to apersistence of symptoms. This style is problematic because itmaintains the person's sense of vulnerability and danger,anddoes not allow lower-level automatic cognitive processesresponsible for intrusive symptoms to decay. For example,worrying about future threats and focusing attention onsources of danger maintains anxiety and biases activity inlow-level (i.e., subcortical) processing networks responsiblefor processing danger and producing intrusions.

The CAS arises out of the individual's metacognitivebeliefs stored in long-termmemory. These include strategicbeliefs such as the following: “I must worry in order to avoidthreats in the future”; “If I remain alert to danger I will beprepared”; “I must remember everything in order to avoidit happening again.” It also includes negativemetacognitivebeliefs about the consequences and meaning of thoughts(e.g., “If I keep thinking about the trauma I'll go crazy”;“Intrusive thoughts are a sign I wanted it to happen”).

Treatment based on this model does not requireimaginal exposure, reliving, or restructuring of thoughtsand beliefs about the trauma. Instead, the focus is onremoving maladaptive thinking styles (the CAS) so thatthe RAP is facilitated. How is this achieved? Initially,patients are trained to respond to intrusive thoughts with

86 Wells et al.

detached mindfulness and worry/rumination postpone-ment. Detached mindfulness (Wells & Matthews, 1994,1996) refers to being aware of thoughts and choosingnot to influence or engage with them, for example, byanalyzing them, trying to push them away, or activelychanging their content. A range of techniques have beendeveloped to facilitate this state (e.g., Wells, 2006).

The technique of detached mindfulness may promotesimilar effects to those achieved with mindfulness medita-tion (e.g., Kabat-Zin, 1990). However, it differs frommindfulness meditation in several respects. First, itspecifically involves awareness of cognition rather thanthe broader context of attention to present-momentexperiences. In so doing it is directly aimed at enhancingmetacognitive awareness rather than awareness of thepresent moment. Second, it facilitates flexible executivecontrol through immediately relinquishing maladaptivestreams of cognition and action. Detached mindfulnessrequires immediate suspension of any type of cognitive orbehavioral response to thoughts, thereby increasingmetacognitive control and disconnecting any influenceof beliefs on thinking. In contrast, mindfulness meditationprogresses through stages of using responses to thoughts,such as focusing on the breath and bringing attention backto the present moment. Third, detached mindfulnessincludes “detachment,” which is not commonly part ofmindfulness. This refers to occupying a meta-level ofexperience in which thoughts and internal events are notfused with the sense of self and external reality but can beseen as separate from both the sense of “me” and theexternal world. As we have stated in earlier work (Wells &Matthews, 1994), the participant learns how to “reside” ata new level in which internal experiences such as beliefs,thoughts, or memories are separate from the self, whilethe true self becomes the perceiver of these inner events.

Detached mindfulness is a relatively small componentof the treatment, but it contributes to establishing anappropriate mode of processing, improving executivecontrol, and removing cognitive perseveration in the formof worry/rumination. However, further strategies areimportant. Positive metacognitive beliefs about the needto ruminate and worry in order to cope are challenged.The therapist helps the patient see how brooding in thisway leads to negative emotions and how it has not yet ledto solutions. The patient is specifically asked to interruptworry/rumination in response to intrusive thoughts andfeelings, and to postpone the activity until a brief “worrytime” each day. The use of this worry time is notmandatory. Careful monitoring to ensure that the patientis removing all forms of worry and rumination is under-taken as treatment progresses.

Negative metacognitive beliefs about the meaning ofsymptoms are also challenged using verbal and behavioralreattribution methods. For instance, if a patient believes

that intrusive thoughts are a sign of imminent loss ofmental control, an experiment can be conducted inwhich the patient is invited to try and lose control byhaving more intrusive thoughts.

Later in treatment the focus shifts to removing unhelp-ful threat-monitoring strategies. This is achieved bychallenging positive metacognitive beliefs about the useful-ness of threat monitoring: helping patients notice them-selves threat-monitoring, applying detachedmindfulness totheir focus of attention, and then redirecting attention ontononthreatening aspects of the external environment. Foran illustration of the nature of this treatment, the reader isreferred to the case example at the end of this report.

The metacognitive model is supported by results ofrecent empirical studies. For example, thinking style charac-teristic of the CAS—namely, worry—is associated with anescalation of intrusive thoughts following stress (Butler,Wells & Dewick, 1995; Wells & Papageorgiou, 1995), andthought control strategies typified by worry predict the laterdevelopment of PTSD (Holeva, Tarrier, & Wells, 2001) anddistinguish individuals with acute stress from those without(Warda & Bryant, 1998). Metacognitive beliefs are positivelyassociated with trauma symptoms, with specific associationsmediated by thinking style as predicted by the model(Roussis & Wells, 2006). Finally, brief periods of attentionalmonitoring for threat following exposure to stress have beenfound to lead to increased levels of subsequent intrusivethoughts (Turl & Wells, submitted for publication).

An earlier study of the effects of MCT suggested thatthe treatment was associated with substantial reductionsin symptoms, but it involved a small number of cases witha mean symptom duration of 7 months (Wells & Sembi,2004a). However, chronic cases of PTSD prove moreresistant to treatment, and it is important to establishbroader treatment effects before moving to a randomizedcontrolled trial. The aim of the present study was toexplore if MCT is associated with recovery or symptomimprovements when applied to a further set of patients,specifically those cases that are more chronic.

Method

Participants

All patients were recruited from a clinical psychologywaiting list of referrals made by doctors or psychiatrists.First, the waiting list was screened for patients referred foremotional problems following trauma. In order to identifypotential chronic cases, only those patients for whom thetrauma had occurred at least 3 months earlier wereconsidered appropriate. Twenty-three patients wereidentified as potential chronic cases and were offeredassessments, from which 19 attended for an initialinterview. Following administration of the PTSD sectionof the Structured Clinical Interview for DSM-IV (First,Spitzer, Gibbon, & Williams, 1997), 13 patients met

87Treating Chronic PTSD

criteria for PTSD and were suitable for the trial. Theremaining patients were excluded for the followingreasons: 1 patient could not speak English, 2 patientshad current ongoing exposure to trauma (e.g., threats tolife), 2 patients expressed strong suicidal wishes, and 1patient had current alcohol abuse. Of the 13 patientsentering treatment, 2 (1 male and 1 female) dropped outand did not respond to efforts to contact them.

Of the 11 patients entering and completing the trial,there were 5 men and 6 women (mean age=38.9 years;range=19 to 58). The time elapsed since the index traumaranged from 6 to 39 months, with a mean duration of19.5months. Most of the sample (72.7%) had suffered withPTSD for longer than 12 months. None of the patients hadundergone psychological treatment for PTSD since theindex event. Participants reported a range of traumas: roadtraffic accidents (n=5), victims of violent physical assault(n=2), victims of armed robbery (n=2), threatened andheld at gunpoint (n=1), witnesseddeath by stabbing (n=1).

Six patients had additional Axis I diagnoses. In twocases there weremore than two diagnoses assigned overall.Four patients had a depressive disorder (major depressivedisorder, or depression NOS), which, in each case, devel-oped after the traumatic event. Other additional diag-noses included specific phobias (n=2), social phobia(n=1), agoraphobia (n=1), and generalized anxiety dis-order (n=1). The two patients with multiple additionaldiagnoses were identified as having specific phobia, socialphobia, and depression NOS in one case, and majordepressive disorder and agoraphobia in the other.

Five patients were taking psychotropic medication. Onepatient was taking a beta-blocker and four patients weretaking tricyclic antidepressants, prescribed, in each case, bytheir doctors following the trauma. All patients takingmedicationhadbeenon a stable dose for aminimumperiodof approximately 5 months, and they agreed to maintaintheir medication throughout treatment and follow-up.

Two patients had experienced a previous acute trauma.Ten patients were of Caucasian-British background and 1was of Asian non-British background. Four patients werecurrently in paid employment, and 1 patient was astudent. Of the 5 who were not in employment, 4 wereunemployed (2 of these had given up work after the indextrauma), and 1 patient was on long-term absence due to illhealth. In 2 cases there was an ongoing compensationclaim and/or unresolved legal issues.

Measures and Procedure

All outcome measures were administered at pretreat-ment, posttreatment, and at 3-and 6-month follow-up. Acombination of specific symptom measures, general mea-sures of emotion, and self-report and assessor ratingswere used. Diagnosis was made by the assessor, who hadexperience administering the SCID-I/P. The initial diag-

nosis was reviewed by the group at a regular assessmentmeeting.

Self-Report Measures

PTSD symptoms were assessed by means of the Impactof Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979),and the Penn Inventory (PI; Hammarberg, 1992). The IESassesses symptoms of intrusive thoughts and avoidance onseparate subscales. Alpha coefficients for the subscales arereported as .78 and .82, respectively, and test-retest reli-ability for the total score and subscales ranges from .89to .79. Despite the fact that the IES is not a diagnosticmeasure, this is an advantage because diagnostic criteriachange over time—however, the IES has been used as aconsistent standard measure over 20 years (Joseph, 2000).Moreover, normative data are available on the IES, whichfacilitates analysis of clinical significance of change.

The PI is a 26-itemmeasure of the severity of PTSD andhas an overall alpha coefficient of .94. Test-retest reli-ability for all subjects is reported as .96 and .89 for those intreatment (Hammarberg, 1992).

Two more general measures were also used. Thesewere the Beck Anxiety Inventory (BAI; Beck, Epstein,Brown & Steer, 1988) and the Beck Depression Inventory(BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961).The BAI has high internal consistency, with an alpha of.92 (Beck, Epstein, Brown & Steer, 1988), and a test-retestreliability of .75 (Fydrich, Dowdall, & Chambless, 1992).The BDI has an alpha of.86 and test-retest reliability of.48to.86 (Beck, Steer, & Garbin, 1988).

Assessor Ratings

Patients were assessed independently of the therapistat pretreatment, posttreatment, and follow-up. Twoassessor rating scales (0 to 8) were used for this purpose.The first scale asked: “How distressing are this patient'sPTSD symptoms at present (i.e., in the past week)?” Thesecond asked: “How disabling is this patient's PTSD atpresent (i.e., lifestyle, relationships, work, etc.)?” Theresponse options were labeled at three points on thescales: 0 (not at all), 4 (moderately), 8 (severely). Eachtherapist acted as a separate assessor for other therapists.

Therapists

Each of the authors treated at least one patient. All ofthe therapists were clinical psychologists with varyinglengths of post-qualification experience.

Treatment

Treatment followed the manual by Wells and Sembi(2004b). Each therapist received supervision from AWon apilot case treatedwithMCTbefore participating in the trial.Supervision of individual cases then occurred throughouttreatment every 2 to 3 weeks to ensure adherence to the

88 Wells et al.

treatment manual. Treatment sessions were offeredweekly. Each session was 30 to 60 minutes in durationand the intervention could be terminated when patientshad implemented each of its components.

Initially, therapists constructed a personal case for-mulation with patients based on the metacognitive model.Each patient was socialized by means of presentation ofthe model, discussion of the effects of idiosyncratic copingstrategies in maintaining symptoms, and a thoughtsuppression experiment.

This was followedby introducing the concept of detachedmindfulness and worry/rumination postponement as a re-sponse to intrusions. To prepare the ground for this andweaken metacognitive beliefs supporting maladaptive stra-tegies, an advantages/disadvantages analysis of worry/rumination was undertakenwith the view of helping patientsto see that worry/rumination served no purpose andimpeded recovery. In-session practice of detached mind-fulness was undertaken and a clear distinction was madebetween worry postponement and the maladaptive strategyof trying to suppress thoughts about the trauma. Severalanalogies and exercises specifically designed to facilitatedetachedmindfulness were used. Early in treatment patientswere asked to practice detached mindfulness and worry/rumination postponement for homework in response tothoughts about their trauma. Later, worry postponementwas applied to all classes of current worry/ruminative-basedprocessing, not just trauma-related thoughts.

The next stage of treatment involved dealing withchanges in the pattern of attention, particularly the oc-currence of threat monitoring. Again, an advantages/disadvantages analysis of threat monitoring was implemen-ted and the advantages were challenged. For example,therapists helped patients to discover that threat monitor-ing maintained an inflated sense of danger. Patients werethen asked tobecome aware of threatmonitoring and applydetached mindfulness. This process was facilitated bypractice of attending to neutral material in the environ-ment as part of the session; for homework, the patientpracticed redirecting attention to nonthreatening featuresof the external environment in day-to-day situations,including those that were reminders of the trauma. Inthis latter context patients were encouraged to return tousual pretrauma routines, if necessary.

Results

Of the 13 patients initially entering treatment, 11completed treatment and 2 dropped out (i.e., failed toattend two subsequent sessions), with no reason given.Among the 11 completers, a range of 3 to 15 sessions weredelivered (mean: 8.5). Two of the completers wereretraumatized during follow-up. These traumas con-sisted of being physically attacked by intruders at home,and being threatened with a weapon during a robbery.

Another completer was retraumatized at the beginningof treatment following a road accident. During treat-ment or follow-up none of the patients received addi-tional treatment.

Scores on the outcome measures at pre-and post-treatment and at follow-up are presented in Table 1.Repeated-measures t tests showed statistically significantimprovements in all self-report and assessor ratings at post-treatment, and the gains were maintained across 3- and6-month follow-up. A Bonferroni correction for multiplecomparisons yields a critical p value of 0.003. Using thislevel, all gains remained significant, apart from those for theBDI at follow-up. Posttreatment effect sizes (Cohen's d;1988), computed as M1–M2/SD M1, were very large andas follows: IES=2.9, PI=2.6, BAI=2.1, BDI=1.5. At 3- and6-month follow-up the effect sizes were as follows: IES=2.7,2.5; PI=2.2, 2.1; BAI=1.6, 1.2; BDI=1.0, 1.1. Effect sizes forthe assessor ratings of distress were 6.9 at posttreatment andat 3- and 6-month followup. For assessor ratings of disability,effect sizes were 10.0 at posttreatment and 6-month follow-up, and 9.8 at 3-month follow-up.

While these data address the magnitude and statisticalsignificance of change, they do not address its clinicalsignificance. In order to determine the proportion ofpatients who made clinically reliable improvement andthe proportion who met formal criteria for recovery, themethods of Jacobson, Follette, andRevenstorf (1984) wereused.

Because the IES has been widely used and its normativedata are available, this measure was chosen for analysis ofclinical significance and reliability of change. First, a cutoffscore on the IES was calculated. For this purpose cutoffpoint c was used since representative normative data existon a no-trauma sample (Briere & Elliott, 1998). Thisyielded a cutoff score of 28.5. Next, the reliable changeindex was computed and yielded a 13-point changeneeded to ensure reliable change. These criteria wereapplied to the pre-to post-IES data on 10 out of the 11 casesfor which there were complete data at both Time 1 andTime 2 (one patient returned an incomplete IES atpretreatment). The analysis revealed that 90% of patientsmet criteria for recovery, and 10% were reliably improvedat posttreatment. Thus, all patients demonstrated aclinically significant response. At 3-month and 6-monthfollow-up 1 patient refused to complete further ques-tionnaires—this patient reported to the assessor that hehad recovered and the assessor ratings were completed.Recovery rates on the IES at follow-up are thereforecomputed without this case. At 3-month follow-up, 66.6%were recovered and 33.3% were reliably improved. At6-month follow-up, 55.6% were recovered, 33.3% werereliably improved, and 1 patient (11.1%) was unchanged.Thus, at 6-month follow-up approximately 89% of patientsshowed recovery or reliable improvement.

Table 1Means, standard deviations, and paired differences on each outcome measure across treatment and follow-up

Variable Pre Post 3m 6m Pre / Post Pre / 3m Pre / 6m

M SD M SD M SD M SD t (df) p t (df) p t (df) p

1. IES 49.9 12.9 12.6 11.7 15.0 14.8 18.0 14.7 6.8 (9) b .0005 6.9 (8) b .0005 4.7 (8) .0022. PI 44.3 8.7 21.6 6.7 25.0 11.0 26.2 10.4 5.7 (8) b .0005 5.6 (9) b .0005 4.9 (9) .0013. Assessor 1 6.1 0.8 0.6 1.0 0.6 1.0 0.5 0.8 13.4 (10) b .0005 16.0 (10) b .0005 16.7 (10) b .00054. Assessor 2 6.6 0.8 0.6 1.1 0.7 1.3 0.6 0.8 14.3 (10) b .0005 22.1 (10) b.0005 15.7 (10) b .00055. BAI 26.7 10.0 6.1 5.6 11.0 6.8 14.4 9.9 7.1 (8) b .0005 4.4 (8) .002 8.2 (8) b .00056. BDI 24.1 10.4 8.9 5.8 13.5 9.1 12.9 9.8 4.6 (10) .001 3.0 (9) .014 2.9 (9) .016

Note. IES=Impact of Event Scale; PI=Penn Inventory; Assessor 1=Assessor rating severity; Assessor 2=Assessor rating disability;BAI=Beck Anxiety Inventory; BDI=Beck Depression Inventory.

89Treating Chronic PTSD

Four patients did not meet the criteria for recovery at6-month follow-up. One patient was unchanged, and threemet criteria for reliable improvement but did not cross thecutoff. Two patients who improved but were not recoveredwere among three individuals who were retraumatized.One was retraumatized after treatment but before the3-month follow-up, while the other was retraumatized at thebeginning of treatment. These traumas consisted of beingattacked andbeing victimof a robbery. Therewereno otherremarkable or consistent differences between the unrecov-ered and recovered patients. It should be noted that a thirdpatient was also retraumatized during treatment but metcriteria for recovery at posttreatment and at follow-up.

Discussion

The present open trial was intended as a preliminaryinvestigation of whether MCT is associated with recoveryor improvement in symptoms when applied in thetreatment of chronic PTSD. Patients treated had experi-enced consistent symptoms for 6 to 39 months (mean:19.5) before commencing treatment.

Posttreatment and follow-up scores on all self-reportand assessor ratings showed statistically significantimprovements in specific PTSD symptoms and in moregeneral measures of anxiety and depression. Treatmentgains appeared to be maintained over 3-and 6-monthfollow-up. The effect sizes at posttreatment and follow-upfor self-report measures were very large, albeit slightlylower than those obtained in an earlier study of MCT inless chronic cases of PTSD. Effect sizes for assessor ratingswere unprecedented and may well reflect the sensitivity ofthis measure to change. However, we cannot rule out biason the part of the assessors; therefore, caution should betaken in interpreting these ratings.

Using Jacobson et al. (1984) criteria to take account ofvariability of measurement and normative functioning,treatment clearly led to reliable improvement or clinicalrecovery in the majority of cases. There was a recoveryrate of 90% at posttreatment, which fell to 55.5% recov-ered and a further 33.3% reliably improved at 6-month

follow-up. It appears that much of the loss of recoverystatus over follow-up can be attributed to the fact that twoof the patients were retraumatized either at the beginningof treatment or before the 3-month follow-up. Thus, thefollow-up data may underestimate typical treatmenteffects because rates of recovery have been influencedby exposure to new traumas. Despite the fact that theseretraumatized patients lost their posttreatment recoverystatus, they maintained the status of showing clinicallyreliable improvement at 6 months.

Treatment was administered in a mean of 8.5 sessions(range: 3 to 15). While the initial sessions were 45 to60 minutes in duration, later sessions typically lastedapproximately 30 minutes, suggesting that MCT may berapid and efficient in routine clinical use. By comparison,the mean number of sessions delivered in the treatmentof less chronic cases (see Wells & Sembi, 2004a) was 8.25(range: 5 to 11). Thus, it appears that chronic PTSDmightbe effectively treated with MCT without necessitating anincrease in the number of sessions over and above thoserequired for less chronic cases.

Despite the positive outcome for the patients treated,the present study results may capitalize on randomsymptom variation or spontaneous recovery, and thelack of a no-treatment control condition or assessment ofindividual baselines means that such effects cannot beestimated. However, given the chronic nature of thecurrent PTSD cases, it is unlikely that treatment coincidedwith spontaneous improvement or that nontreatmentfactors contributed significantly to the effects observed.This study is limited because of the absence of reliabilitydata on the original diagnosis. However, diagnosis wasmade by a qualified clinical psychologist experienced inusing the SCID, and each diagnosis was reviewed by thegroup. Similarly, reliability data on the assessor ratings ofsymptoms are also unavailable.

While the therapists met regularly with the lead authorto review the content of treatment sessions and checkadherence to the treatment protocol, there were no formalmeasures of adherence or treatment fidelity implemented

90 Wells et al.

in this study. Nevertheless, treatment involved little detaileddiscussion of the nature of the patient's trauma, and therewas no imaginal reliving. The only point at which someexposure was utilized was toward the end of treatment:Some patients, who were avoiding certain activities, such astraveling to certain areas of town, were asked to engage inthese activities. This differs significantly from theprolongedand/or repeated and structured exposure typically asso-ciated with cognitive-behavior therapy.

Two patients dropped out of treatment after two andthree sessions, with no reason given and no follow-upachievable. It is not possible to determine any level ofsymptomatic change in these cases because the measureswere not administered at every treatment session. Thereappeared to be nothing remarkable about these patientsthat set them apart from the completers.

Bearing in mind the limitations of an open trial of thiskind, these findings appear to support the effectiveness ofMCT in cases of chronic PTSD, and extend the findings ofan earlier treatment study (Wells & Sembi, 2004a) of lesschronic cases. Together, these studies make a strong argu-ment for the continued evaluation of MCT as a new, effi-cient, and well-tolerated treatment approach. Thisapproach should now be evaluated in multitreatmentrandomized controlled trials in order to control externalsources of symptom variation and examine the relativeeffectiveness of the new treatment against existing cogni-tive-behavioral approaches. This task is facilitated by theavailability of a published treatment manual (Wells &Sembi, 2004b).

Finally, an interesting question arising from theretraumatized cases in this study concerns the potentialfor MCT techniques to offer a prophylactic effect amongindividuals susceptible to PTSD who are exposed tofurther trauma. One case remained recovered at 6-monthfollow-up, and the other two were reliably improved,despite exposure to additional traumatic events.

Case Example

To illustrate the novel nature of treatment, a typicalcase treated in 8 sessions will be described. The patientconcerned was involved in an incident resulting insignificant head and limb injuries which requiredemergency treatment and repeated restorative surgery.Predominant PTSD symptoms were intrusive recollec-tions of the event coupled with limb pain, anxiety andnervousness when leaving home, and avoidance of someareas of the town. The patient reported a personality“change” and being unable to look to the future in anoptimistic way. There were clear depressive symptomsmarked by frequent crying and a sense of having failed.

At the first treatment session the therapist introducedthe basic rationale for metacognitive therapy. Thetherapist explained that most people experience symp-

toms after traumatic life events, that these symtoms arenormal in adapting, and usually fade with time. However,symptoms are inadvertently maintained by certain mentaland behavioral processes, and it is possible to identifythese processes and remove them. The first step, there-fore, was to identify these processes in the patient's case.

During the process of case formulation the therapistasked about the occurrence of thoughts about the trauma(“How much time have you spent thinking about whathappened?”). It quickly became apparent that much timewas spent going over the event and trying to work out whatcould have been done differently. When asked if thinkinghad changed in any way since the accident, the patientdescribed worrying about many other negative things thatcould happen in the future. The therapist also asked if thefocus of attention had changed since the event. It becameclear that the patient was engaged in a strategy of payingattention to threat and “anything that looks as if it couldbe unsafe.” In order to elicit metacognitive beliefs aboutthese processes, the therapist asked about the advantagesof worrying about the future, of analyzing the event, andof paying attention to unsafe things in the environment.This revealed a range of beliefs, including the following:“Paying attention to danger means I can avoid it infuture”; “If I worry about bad things, in the future I won'tbe caught out”; “If I think back over what happened, I canwork out if I'm entirely to blame.”

Apart from unhelpful strategies of worry and focusingon potential danger, the patient reported other unhelpfulcoping strategies—for example, avoiding areas of the townclose to the site of the trauma. The patient also reportedtrying to suppress a recurrent intrusive image of the event.These strategies were also entered in the formulation,their usefulness was questioned, and the patient was askedto stop them. The therapist then examined negativebeliefs about symptoms, which led to the discovery that thepatient believed “I am mentally weak” for allowing theevent to have such an emotional impact.

The next step of treatment focused on helping thepatient to see how strategies of worry, dwelling, focusingon threat, and thought suppression maintain anxiety andsymptoms. For this purpose, and to reinforce an appro-priate mental set for metacognitive therapy, the therapistintroduced the “healing metaphor”:

“Just like your body, your mind is equipped with ameans of healing itself. If you have a physical scar itis best to leave it alone and not to keep interferingwith it as this will slow down the healing process. Soit is with your mind after trauma. Your intrusivethoughts and symptoms are like a scar, and it is bestto leave them to their own devices. Do not interferewith them by worrying or ruminating in response tothem, or by avoiding and pushing thoughts away.

91Treating Chronic PTSD

You must allow the healing process to take care ofitself and gradually the scar will fade.”

The therapist then asked a series of questions tofurther facilitate understanding of the deleterious effectof worry and coping strategies: “Does worrying help you tofeel more relaxed?” and “Does paying attention to dangerenable you to experience your world in a balanced way asbefore?” Behavioral experiments were then used toillustrate the ineffectiveness of thought suppression (forexample, the patient was asked to try not to think of a blueelephant). The disadvantages of using worry were thenexplored and reinforced, and this was followed byexploring the disadvantages of suppression. This was aprerequisite for introducing an experiential exercise tofacilitate the skill of detached mindfulness.

Detached mindfulness was practiced first in the contextof a free-association task, in which the therapist slowlyarticulated words (bicycle, seaside, birthday, chocolate, orangejuice, tree, blue) after the patient had been instructed to“Watch the involuntary flow of thoughts and events in yourmind without influencing them in any way.” This wasfollowed by an exercise in which the patient was asked tocreate a mental image of the previously suppressed blueelephant. The therapist then gave the instruction: “Watchthe blue elephant in a detached way, do not influence whathappens in the image. Perhaps the elephant will move butdon'tmake itmove, perhaps it is swinging its trunk but don'tmake that happen, perhaps it is changing color but don'tchange it yourself. Just watch the image and see that it has alife of its own.” The therapist followed this exercise with aquestion to reinforce “detachment”: “When you had theimage in your mind, did you notice where you were, howyou were the perceiver of the thought? It occurred in yourmind, but you were detached from your mind.” Once the“feel” of detached mindfulness was grasped, the therapistasked the patient to practice this for homework in responseto intrusive thoughts about the trauma.

In the same session the therapist introduced the ideaof interrupting worry and rumination as an experiment todiscover if repetitive thinking about negative events wascontrollable:

“You have seen how trying to control your thoughtsdoes not work very well, and how worrying aboutthings keeps the sense of danger and anxiety going.Do you think you could stop worrying about andanalyzing what happened? Perhaps you could runan experiment to see if this is possible. Forhomework, I would like you to notice worrying orruminating and say to yourself, That's a worry, Idon't need to work this out now, I'll work it out later.Then set aside a 10-minute worry period that youcan use later in the day. So you are saving up your

worry and rumination until later. You don't actuallyhave to use your worry period—most people findthat they don't use it when the time comes.”

At the next session the patient reported success inapplying detached mindfulness to most instances ofintrusions, revealing some surprise that this was easierthan initially anticipated. Although the patient reportedsuccess in postponing worries, the therapist reviewed anyother worries that had occurred during theweek. It becameclear that there had been several instances that had goneundetected. For example, the patient had worried about apartner and the effect PTSD had on the relationship. Thetherapist helped the patient to see how these were furtherinstances of worry that had gone unnoticed, and that it wasimportant to apply worry-postponement to all types ofworry. The occurrence of rumination about the event wasexplored, and it was discovered that rumination was stillpresent in the form of thinking, “Why did this happen tome, what have I done to deserve this, how could I have acteddifferently to prevent it?” The therapist used this as anopportunity to increase the patient's awareness of rumina-tion to which postponement should be applied. This wasmet with some resistance as the patient believed that notthinking this way would be “careless and not finding ananswer to why it happened.” The therapist, helping thepatient to see that ruminating had occurred for 14 months,asked, “How much longer must you do this in order to becareful and find an answer?” In this way it was possible forthe patient to begin to see how ruminating about the eventhad not provided any answers, and perhaps there wasno single answer that could be found. In addition, anadvantages/disadvantages analysis of ruminating on theevent was undertaken. In this way it was possible for thepatient to discover there were few advantages but moreproblems associated with analyzing the past. For home-work, the patient continuedwith detachedmindfulness andextended the application of worry/rumination postpone-ment to all worries and ruminations.

The next session focused on identifying other instancesof worry about the future and drawing attention to the needto practice disengaging the process. The therapist identifiedsituations that were avoided and suggested that the patientreturn to pretrauma routines while applying the worry/rumination postponement. The focus of intervention thenmoved to examining the patient's use of thought suppres-sion and subtle forms of avoidance, such as avoidingmedical programs on television. The patient fearedexposure to this material as it would lead to thinkingmore about the trauma and “never getting rid of thethoughts.”This was useful as it led to a discussion of how themotivation to get rid of thoughts ran contrary to the conceptof detached mindfulness. The patient was reminded ofthe idea that natural adaptation would take care of the

92 Wells et al.

thoughts, but this needed to be allowed to happen unen-cumbered—not by trying to control spontaneous thoughtsor engaging in worry/rumination in response to them.

The next step in treatment focused on modifying thepatient's strategy of paying attention to potential danger.First, the therapist asked how the patient worked out whatwas potentially dangerous and therefore what to focusattention on in the first place. This led to the discoverythat there was an ongoing interrogation of the environ-ment: “Does it look safe? What if it isn't?” This wasconceptualized as another example of worry or “what if”–based reasoning, and a process that should be banned.Instead of looking for unsafe things, the patient was askedto experiment with refocusing attentional strategy byattending to safety signals in the environment.

At the following session the patient reported difficultywith the homework task of attending to safety signals, as itparadoxically maintained the concept that things could bedangerous. This finding is not typical, but it was used as ano-lose outcome by the therapist to illustrate howconstantly analyzing situations as safe or dangerousmaintained a sense of threat, and therefore, similar toworry, this type of “thinking too much” should be banned.As an alternative, it was suggested that, rather thanevaluating situations, the patient should allow attentionto roam freely and not be focused on any one externalevent or aimed at answering any question. This wascoupled with asking the patient to return to her normalpretrauma activities without avoiding situations.

Toward the end of treatment the therapist examinedthe patient's view of the future to determine if there wereparticular negative beliefs about recurrent symptoms orany evidence of residual worry. The patient's view of herfuture had become more positive, but it was discoveredthat there was avoidance of being “too optimistic” becausethat could lead to disappointment. This was formulated asan unhelpful metacognitive belief about the conse-quences of future-oriented positive thinking. The thera-pist challenged this belief by helping the patient to seehow pessimistic thinking produced feelings of disappoint-ment—so it was not an escape from disappointment afterall. Finally, a therapy blue-print was constructed thatcontained a copy of the case formulation, a summary ofhow to respond to intrusive thoughts and stress symptoms,and a statement reinforcing the strategy of recovery usingthe “healing metaphor.”

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Address correspondence to Adrian Wells, University of Manchester,Academic Division of Clinical Psychology, Rawnsley Building, MRI,Manchester M13 9WL; e-mail: adrian.wells@manchester.ac.uk.

Received: June 8, 2006Accepted: November 30, 2006Available online 7 February 2008