Cognitive Interventions for Anxiety 219
(i.e., self- conscious) and how bad she feels, she is instructed to shift her focus of atten-
tion and observe the appearance and facial expressions of other people in the situation.
Note whether these people really are looking at you (Wells, 2000). Although empirical
support for the efficacy of ATT or SAR is still preliminary, findings from a series of
single-case studies are promising (Papageorgiou & Wells, 1998; Wells & Papageorgiou,
1998b; Wells, White, & Carter, 1997).
Metacognitive Intervention
The ability to monitor and regulate our information- processing apparatus is a critical
executive function that is important to human adaptation and survival. We not only
evaluate external stimuli that impinge on our senses, but we also evaluate our own
thoughts and beliefs. Flavell (1979) referred to this capacity to evaluate and regulate
our thinking processes as metacognition, or “thinking about thinking.” Metacognition
is evident as a dynamic cognitive process in which we appraise the thoughts, images,
and impulses that enter the stream of consciousness as well as more enduring beliefs or
knowledge about cognition and its control. Wells (2000) defined metacognition as “any
knowledge or cognitive process that is involved in the appraisal, monitoring or control
of cognition” (p. 6).
An important function of metacognitive processes is the instigation of cognitive
control strategies that could lead to the intensification or shift in internal monitoring
(i.e., conscious awareness) toward or away from a particular thought (Wells, 2000). As
evident from the review in Chapter 3, emotion has a significant biasing effect on informa-
tion processing. It is conceivable that during anxious states, metacognitive beliefs about
threat are activated and internal monitoring processes become biased toward detection
and elaboration of threat- related thinking. Examples of threat- relevant metacognitive
beliefs include “The more one thinks anxious thoughts, the more likely the feared out-
come will happen,” “I’ll become completely overwhelmed with anxiety if I don’t stop
thinking this way,” “If I think it is dangerous, the situation must be dangerous.” In turn
these beliefs could lead to activation of compensatory metacognitive control strategies,
such as efforts to intentionally suppress anxious thoughts, which paradoxically cause
an increase in the salience of the unwanted thoughts and persistence of the negative
emotional state (Wells, 2000, 2009; Wells & Matthews, 2006).
The relevance of a metacognitive conceptualization is clearly evident in OCD and
GAD where individuals engage in obvious appraisals of their unwanted distressing
thoughts (i.e., obsessions, worry) and wage desperate attempts to control the mental
intrusions (see D. A. Clark, 2004; Wells, 2000, 2009, for further discussion). However,
metacognitive beliefs, appraisals, and control strategies are evident in most of the anxi-
ety disorders and so it can be important to intervene at this level when offering cognitive
therapy for anxiety. There are three aspects to cognitive therapy at the metacognitive
level that must be considered.
Metacognitive Assessment
As a first step it is important to identify the primary metacognitive appraisals, beliefs,
and control strategies that characterize the anxious state. Once the main automatic anx-