Cognitive Interventions for Anxiety 221
Metacognitive Control
An important part of intervention at the metacognitive level is a consideration of the
actual thought control strategies used to deal with unwanted cognition. It is well known
that certain control responses such as the intentional suppression of unwanted thoughts,
rumination, self- critical or punishment responses, neutralization, reassurance seeking,
and thought stopping are ineffective at best and counterproductive at worst (for review
see D. A. Clark, 2004; Wells, 2000, 2009). The cognitive therapist should target any
ineffective control responses used by the client. Cognitive restructuring and empirical
hypothesis- testing exercises may be necessary in order to highlight the deleterious effect
of cherished mental control responses. More adaptive approaches to mental control such
as thought replacement, behavioral distraction, attentional training, or passive accep-
tance of the thought (e.g., mindfulness) can be introduced in a pragmatic fashion in
order to empirically determine for the client the most effective mental control strategy
to cope with unwanted anxious thoughts.
At this point we have no empirical data to indicate that cognitive therapy that
incorporates a metacognitive perspective is more or less effective than a more standard
cognitive therapy that focuses only on automatic anxious thoughts and beliefs. As will
be seen in a later chapter, the CBT approach to OCD has a strong focus at the metacog-
nitive level and a number of clinical trials have demonstrated its efficacy for OCD. Clini-
cal experience would suggest that evidence of faulty metacognitive appraisals, beliefs,
and control strategies in the persistence of a client’s anxiety disorder would warrant a
greater focus on these processes in therapy.
Imaginal Reprocessing and Expressive Writing
Although memories of past traumatic experiences are a prominent diagnostic feature of
PTSD (DSM-IV-TR; American Psychiatric Association [APA], 2000), recollections of
highly anxious experiences can play a key role in the persistence of any anxiety disorder.
In fact threatening visual images of past experiences or anticipated possibilities in the
future are common in all the anxiety disorders (Beck et al., 1985, 2005). These anxious
fantasies or past recollections are often a biased and distorted representation of real-
ity that can fuel an anxious state. For example, in panic disorder an individual might
imagine a horrible death via suffocation, a person with social anxiety might remember
a past experience of trying to speak up in a group of unfamiliar people, someone with
OCD might recall a vivid memory of touching something quite disgusting and feeling
a profound sense of contamination, or the individual with GAD might imagine her life
after experiencing a financial disaster. In each of these cases the therapist should include
imagery or memory modification as a therapeutic goal for treatment.
Modification of anxious memories or imagery begins with clients providing a full
and detailed account of their memory or anxious fantasy. The therapist should elicit
all relevant automatic thoughts, beliefs, and appraisals that constitute the biased threat
interpretation of the memory or anticipated event. Descriptions of reliving approaches
to traumatic memories in CBT for PTSD suggest a number of methods for enhancing
clients’ exposure to traumatic memories or anxious images and dealing with elevated
anxiety levels (e.g., Foa & Rothbaum, 1998; Ehlers & Clark, 2000; Shipherd, Street,
& Resick, 2006; Taylor, 2006). Extensive discussion and therapeutic questioning is an