434 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Cognitive Restructuring of Metacognitive Beliefs
Another important therapeutic component of cognitive therapy for GAD is the identifica-
tion and modification of positive and negative metacognitive beliefs about worry. Wells
(1997, 2006, 2009) has discussed how cognitive restructuring and behavioral experiments
can be used to challenge the GAD client’s core beliefs about the dangers and uncontrol-
lability of worry as well as any misconceived beliefs about the potential benefits of worry.
The therapist is able to identify the individual’s main metacognitive worry beliefs from
the worry induction exercise and from cognitive restructuring of biased threat interpreta-
tions. Moreover, the Worry about Worry Self- Monitoring Form (Appendix 10.3) can be
used to collect additional information on the client’s core metacognitive beliefs.
Wells (2006) notes that cognitive restructuring of negative metacognitive beliefs
involves questioning the evidence that worry is harmful, questioning how worry could
be dangerous, reviewing counterevidence, and learning new information. For example,
individuals with GAD often believe that worry is stressful and so could cause physical
harm such as a heart attack. Wells (2006) suggests that the client can be provided infor-
mation that worry is not stressful but instead a coping strategy in response to stress.
The client could be assigned a homework task of finding information that worry can
directly cause heart attacks. A list of individuals the client knows could be generated
with one list for all chronic worriers and the other list of all individuals who suffered a
heart attack. How many people appear on both lists? Students who are chronic worri-
ers are often convinced that the worry will cause a significant decline in their academic
performance. Again a survey could be conducted to determine how many engaged ver-
sus disengaged students are worriers. An alternative explanation is that many factors
determine a student’s level of academic performance and worry can play a small, even
insignificant, part of it. Beliefs about the uncontrollability of worry can be challenged
by having clients participate in worry induction exercises, paradoxically increase their
level of worry during stressful times, or try to lose complete control of worry (Wells,
2006). The point of these behavioral experiments is to provide evidence that in fact
worry is a controlled (i.e., strategic) maladaptive coping strategy and the dangers of los-
ing complete control of worry are more imaginal than real.
Cognitive restructuring of the positive beliefs about worry would follow the same
format as described for the negative beliefs. For example, the belief that worries lead to
problem solving can be tested by examining how often the individual’s excessive worry
led to problem resolution. Wells (2006) suggests a mismatch intervention in which the
client is asked to compare his catastrophic worry script against a reality-based script.
How can worry be adaptive if it is a mismatch with reality? Another behavioral experi-
ment for the individual who believes worry improves his work performance is to ask the
client to purposely increase his level of worry prior to leaving for work on certain days
and then to monitor the level of improvement in work productivity.
Clinician Guideline 10.23
Cognitive restructuring and behavioral experiments that focus directly on the modification
of core positive and negative metacognitive beliefs about worry are an important ingredient
of treatment for GAD that is introduced midway through a course of therapy.