Metacognitive Therapy for Generalized Anxiety Disorder: Nature, Evidence and an Individual Case Illustration Odin Hjemdal, Roger Hagen, and Hans M. Nordahl, Norwegian University of Science and Technology Adrian Wells, Norwegian University of Science and Technology and University of Manchester Metacognitive therapy (MCT) is based on over 25 years of research focusing on the processes that contribute to the development and maintenance of psychological disorders. The approach identifies a common set of processes in psychopathology, and MCT shows promising results in effectively treating a range of disorders. This paper presents the central theoretical tenets of MCT and uses a clinical vignette to illustrate the structure and techniques of treatment based on Wells's (2009) manual as they relate to a specific case of generalized anxiety disorder. What Is Metacognition and Why Is It Important? This paper provides a general introduction to the theory of metacognitive therapy (MCT) and a more specific outline of how to use MCT for generalized anxiety disorder (GAD), illustrated with the clinical case of William. In the final part of the paper the scientific evidence for MCT in GAD is presented. MCT was developed to address the control of cognition and the strategies and knowledge that govern thinking. It contrasts significantly with the theory and focus of standard CBT. Metacognition refers to cognition applied to cognition and may be defined as any knowledge or cognitive processes involved in the appraisal, control, and monitoring of thinking (Flavell, 1979). In short, metacognition is thinking about thinking. Metacognitive theory has distinguished between metacognitive knowledge, which is information that individuals have about their own thinking and about strategies that affect it, and metacognitive regulation, which are the strategies used to change the nature of processing. In the metacognitive theory of psychological disorder (Wells, 2009; Wells & Matthews, 1994), metacognition is central in determining the maintenance and control of negative and biased thinking styles. According to Wells, most people have negative thoughts and beliefs and in most cases these thoughts and beliefs are transitory mental experiences. The negative thoughts become a problem because of the way an individual responds to them. Thus, an important tenet of metacognitive therapy, and one of the features distinguish- ing it from traditional CBT, is that neither the content nor the subjective validity of thoughts and beliefs are the central source of disorder. In basic terms, according to metacogni- tive theory, an individual's metacognitions monitor and control their responses to thoughts, which cause persistence or perseveration of ideas and maintain psychological and interpersonal problems. This supposition can be clearly illustrated in the situation of GAD, where the content of worry shifts around. The content of worry in GAD is not dissimilar from everyday worries experienced by most people. However, people with GAD experience their worry as uncontrollable and excessive, and it is associated with marked distress. The metacognitive model provides an explanation of this in terms of differences in the way individuals relate to, appraise, and control their worry The theoretical grounding of MCT is the Self-Regulatory Executive Function Model (S-REF), which emphasizes the similarities in maladaptive cognitive processing across all psychological disorders (Wells, 2000, 2009; Wells & Matthews, 1994, 1996). The S-REF model postulates a thinking style called the cognitive attentional syndrome (CAS). In MCT the CAS is a universal feature of psychiatric disorders and is responsible for prolonging and intensifying distressing emotions. The CAS is a thinking pattern of inflexible self-focused attention (the focus is on self-- observation and monitoring of thought processes), persev- erative thinking (in the form of worry and rumination), threat monitoring, and coping behaviors that backfire and Keywords: metacognitive therapy; generalized anxiety disorder; anxiety; cognition; case study 1077-7229/12/301-313$1.00/0 © 2013 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. Cognitive and Behavioral Practice 20 (2013) 301–313 www.elsevier.com/locate/cabp