Metacognitive Therapy for PTSD Treatment

Introduction to PTSD and Metacognitive Therapy

Posttraumatic stress disorder (PTSD) is considered an anxiety disorder by the American Psychiatric Association, and occurs when an individual experiences a highly stressful or emotional event. During such an event, one might think that their life or the lives of others are in danger. A person might feel afraid or believe that they have no control over what is happening. Such traumatic events include but are not limited to warfare, sexual assault, serious injury, or threats of imminent death (American Psychiatric Association, 2013). Trauma is not rare; in fact, nearly 6 out of every 10 men (or 60%) and 5 out of every 10 women (or 50%) "experience at least one trauma in their lives" (Gradus, 2009).

Effective treatments for PTSD are available, such as behavioral and psychoanalytic approaches and cognitive behavioral therapy. However, this paper will focus primarily on a relatively new approach known as Metacognitive Therapy (MCT). MCT offers a distinct framework for understanding and treating PTSD by targeting the mechanisms underlying persistent distress rather than the trauma memories themselves.

In the early 1990s, two leading experts on MCT, Dr. Adrian Wells of the University of Manchester and Dr. Gerald Matthews of the University of Cincinnati, developed MCT's underlying theory. Initially intended for patients with generalized anxiety disorder, MCT has since been adapted for use in treating a variety of mental health problems such as panic attacks, social anxiety disorder, PTSD, worry and rumination, obsessive-compulsive disorder, and depression (Wells, 2008). The core of MCT is not a specific thought, but the person's reaction to that thought. This is contradictory to cognitive behavioral therapy, which is commonly utilized to treat PTSD wherein a patient is repeatedly exposed to a traumatic memory, which is increasingly refined in the level of detail at which it was experienced (Wells & Colbear, 2012).

History and Theoretical Foundation of MCT

Essentially, think of MCT as a type of therapy that "involves changing how people think rather than what they are thinking about," whereas cognitive behavioral therapy "focuses more on the content of people's thoughts" (Miller, n.d.). It may help to remember that metacognition "refers to your knowledge and control of your cognitive processes" (Matlin, 2013, p. 188). For the most part, people tend to have some direct conscious experience of metacognition periodically throughout their daily lives. For example, think of when you are unable to remember an individual's name but know that it is stored somewhere in your memory. This metacognitive state is known as the "tip-of-the-tongue effect," wherein your memory is trying to inform you that the name is somewhere in your memory even though you are unable to currently remember it.

Likewise, certain psychological disorders can create difficulty and bias in our thinking pattern, which can worsen and result in emotional suffering (Wells, n.d.). This harmful pattern, commonly referred to as the Cognitive-Attentional Syndrome, stems from threat and coping strategies that have paradoxical effects and make up chains of verbal thoughts in the form of worry and rumination (Wells, n.d.). Metacognitions govern the Cognitive-Attentional Syndrome; the goal of a therapist through MCT is to help the patient remove the Cognitive-Attentional Syndrome by developing new ways of controlling a patient's attention that relate to negative thoughts and beliefs, and to modify their metacognitive beliefs that give rise to unsupportive thinking patterns (Wells, n.d.).

More specifically, MCT helps treat PTSD by focusing on and unlocking or removing the barriers to natural adaptation, and equips the individual with general skills that protect them from the risk of any future re-traumatization. Furthermore, MCT does not require "exposure to memories or detailed discussion of the trauma itself," and is based on "identifying the factors that impede normal emotional recovery following trauma" (Wells & Sembi, 2004). This treatment is deemed highly effective and is supported by data from several published studies.

The empirical research reviewed here focuses on the combined works of Dr. Adrian Wells and Dr. Judith S. Colbear, as well as Yaghoob Vakili and Dr. Ladan Fata. The first empirical review focuses on Dr. Wells and Dr. Colbear's controlled trial of treating PTSD with MCT, wherein "twenty participants aged 18 to 65 years old with chronic PTSD were randomly allocated to either a total of 8 sessions of MCT or a delayed treatment control" (Wells & Colbear, 2012). Specific measures from patients relating to PTSD, emotional symptoms, and underlying metacognitive variables were obtained during pre-treatment and post-treatment, and were followed up at 3 and 6 months post-intervention (Wells & Colbear, 2012).

Empirical Research and Clinical Trials

Two leading specialists in MCT are Dr. Wells and Dr. Sundeep Sembi. In 2004, they collaborated on two scholarly articles: Metacognitive Therapy for PTSD: A Core Treatment Manual and Metacognitive Therapy for PTSD: A Preliminary Investigation of a New Brief Treatment. The first article provided the world with MCT's core treatment manual, offering content, techniques, and sequences of the basic programming (Wells & Sembi, 2004a). The second article, the precursor to the first, discusses introductory treatment involving MCT. Based on the metacognitive theory of mechanisms by which natural traumatic processing is enabled or hindered by coping strategies, studies suggest that the "elimination of worry and rumination, of maladaptive attention strategies, and enhancing metacognitive flexibility, will permit natural processing and a return to normal cognition" (Wells & Sembi, 2004b).

Another article Dr. Wells collaborated on is called Treating Chronic PTSD with Metacognitive Therapy: An Open Trial, with co-authors including Mary Welford, Janelle Fraser, Paul King, Elizabeth Mendel, Julie Wisely, Alice Knight, and David Rees. This article discusses an open trial of MCT for enduring PTSD, wherein eleven out of thirteen patients (with an average duration of PTSD of 19.5 months) completed treatment provided by therapists who followed the treatment manual created by Wells and Sembi (2004a). Results indicated "significant improvements on all measures of PTSD and general measures of anxiety and depression," which were maintained at three- and six-month follow-up sessions. Furthermore, data revealed that 90% of patients were recovered after treatment and approximately 89% were recovered or reliably improved during the six-month follow-up (Wells et al., 2008).

This preliminary controlled trial aimed to test the effectiveness of MCT in the treatment of chronic PTSD and examine the effects on hypothesized underlying mechanisms. Results indicated that 70–80 percent of the patients treated for symptoms associated with PTSD, anxiety, and mood measures met the objective criteria for recovery immediately following treatment (Wells & Colbear, 2012). Treatment utilized by therapists during this study adhered to the core treatment manual created by Wells and Sembi in 2004. Additionally, each case was personally supervised by Dr. Wells to "ensure adherence to the treatment protocol" (Wells & Colbear, 2012).

Treatment led to significant changes with regard to the use of "worry" as a metacognitive coping strategy. It is now speculated that even though "treatment aims to modify metacognition and levels of worry, it may be that symptom reduction leads to less need to worry" (Wells & Colbear, 2012).

However, there were limitations within this study. For example, the absence of an objective measurement of treatment compliance—such as the rating of an audiotaped session—would have allowed for an independent assessor "to examine the level of adherence to the treatment manual" (Wells & Colbear, 2012). Additionally, the utilization of only one therapist (who was supervised by Dr. Wells) throughout the trial limits the trial's ability to properly determine how effectively a therapist can apply the treatment protocol without supervision. Moreover, the small sample size utilized limited the precise estimate of treatment effects, but it did provide credence for the need for a larger sample size. Undoubtedly, a larger sample size would represent a wider range of traumas and "would be advantageous to improve the generalizability of findings" (Wells & Colbear, 2012).

Nevertheless, this study proved that MCT is an effective treatment that produces significant results and warrants further analysis. The next phase in MCT research should evaluate and compare it with other active treatments for PTSD such as exposure, eye-movement desensitization and reprocessing (EMDR), or cognitive therapy. This would assist researchers in additional examination of changes in metacognitive theories and thought control strategies.

Effectiveness and Case Study Evidence

This empirical study sought to test the effectiveness of metacognitive therapy on an 18-year-old Iranian male diagnosed with PTSD brought on by sexual assault. The patient had previously undergone several different types of treatments, including full doses of antidepressants and benzodiazepines, but was deemed resistant to pharmacological treatment. Prior to treatment, the patient completed several psychological scales: the Impact Event Scale-Revised (IES-R), Beck Depression Inventory (BDI-II), Beck Anxiety Inventory (BAI), and Subjective Units Distress Scale (SUDS). Additionally, the patient repeated each psychological scale during 1-month, 3-month, and 6-month follow-up sessions.

Treatment procedures utilized were based on Dr. Wells and Dr. Sembi's (2004) core treatment manual. Similar to the previous study, during initial treatment, the patient was presented with an idiosyncratic formulation of his "problem" (Vakili & Fata, 2006). Follow-on treatment took an advantages-and-disadvantages analysis of the patient's worry and rumination. After which, the patient was taught "Detached Mindfulness," which assisted him in enhancing his metacognitive awareness and flexibility of control over reactions (Vakili & Fata, 2006).

Finally, the patient's attention was modified by requiring him "to remember the times he paid attention to internal and/or external sources of threat and to remember the situations in which he felt vulnerable and the situations that reminded him of the trauma" (Vakili & Fata, 2006). Results show that the patient had significant reductions in symptoms of PTSD, anxiety, depression, and distress, all the while maintaining his gains at 1-month, 3-month, and 6-month follow-up (Vakili & Fata, 2006).

Similar to the previous study, this one too had several limitations. For example, the small sample size (one patient) severely limited the precise estimate of treatment effects. More importantly, while the patient was being treated, he was still taking 40 mg of fluoxetine and 75 mg of trazodone daily (Vakili & Fata, 2006). Given the fact that only one patient was treated and was on medication throughout the procedure, it is difficult to accept without speculation that MCT was the sole basis for the patient's recovery as the article suggests.

Nevertheless, this study does allude to the possibility that MCT is an effective treatment for PTSD brought on by sexual assault. Additionally, it is significant to note that the individual treated was Iranian, which gives credence to the possibility that MCT is not limited to only Western psychology. Further analysis involving multiple ethnicities and causes of trauma is still required.

Current Limitations and Research Gaps

Surprisingly, there are currently no known "major issues" or setbacks directly associated with the utilization of MCT to treat PTSD. Unfortunately, only a limited amount of empirical data is currently available to support the assertion that MCT is an applicable treatment for PTSD. More specifically, only five published resources were found relating to the utilization of MCT as a method to treat PTSD.

It is recommended that new empirical studies be conducted in order to support previous research and possibly provide new insight into areas currently unknown, such as traumatized children and adolescents. Currently, no empirical studies have been published regarding the applicability and efficacy of MCT involving traumatized children and adolescents (Simons, 2010).

Additionally, the research conducted has primarily been conducted in Great Britain or Norway, and only one known study has been conducted in the Middle East. This suggests a lack of cultural diversity within the current data. Therefore, future researchers should broaden their cultural and geographical scopes if they hope to facilitate future research. Even though MCT is not perfect, its current contributions nevertheless far outweigh its shortcomings.

Contributions and Clinical Applications

Metacognitive therapy has provided the world with invaluable data on the understanding of human psychology, and continues to help us understand "the causes of [our] mental health problems" and provides us with a new and less intrusive way to treat certain psychological diseases (Wells, n.d.). More specifically with regard to PTSD, MCT is considered "the latest development in treatment" and "is usually brief and does not rely on exposure to memories or detailed discussion of the trauma itself" (Wells, n.d.).

MCT is still new and evolving, which makes it difficult to quantify how the study of MCT has advanced psychology in a larger sense. Nevertheless, MCT's application for changing an individual's thoughts has been deemed extremely beneficial in treating patients with PTSD. For example, in a randomized controlled study of 32 patients, 82% of the MCT group was deemed cured by Jacobson's criteria, and only 64% were considered cured as a result of exposure therapy (Simons, 2010). As previously mentioned, MCT provides us with multiple applications beyond just treating PTSD. These various applications for treating psychological disorders include but are not limited to social anxiety, depression, obsessive-compulsive disorder, panic attacks, and worry and rumination.

The applications for Metacognitive Therapy in treating PTSD are wide ranging and exciting for their abilities to improve the lives of people suffering from PTSD. A clear application of MCT is in the treatment of military members after returning from a hostile warzone. Experts in the application of MCT could train military doctors and military-affiliated physicians in the use and treatment of MCT with patients suffering from PTSD. Therapists and counselors who are familiar with MCT treatment strategies can begin with military members shortly after the PTSD event and can continue with follow-ups upon the military member's return from deployment. The military mission and the well-being of the service member can be enhanced by the effective employment of MCT.

Another place MCT can be effective in treating PTSD is in women's shelters. Although not every woman in a shelter is suffering from PTSD, the types of trauma that lead to PTSD can be wide ranging. Some women may have been in an abusive relationship, either emotionally or physically, and may have been sexually assaulted. MCT is effective in changing how people think and does not focus on what they think about, so the use of MCT can be useful in helping these women in both the recovery from a PTSD event as well as moving forward with their lives when they leave the shelter.

Conclusion

Metacognitive Therapy was developed in the early 1990s. Although originally intended as a treatment for generalized anxiety disorder, MCT has been adapted to treat a wide variety of mental health disorders. MCT focuses on changing a person's reaction to the way they think rather than what they think about. MCT emphasizes unlocking or removing the barriers to natural adaptation and equipping individuals with skills to protect against re-traumatization.