NJ-ACT - David A. Clark

David A. Clark’s Metacognitive Therapy

For Anxiety Disorders

By Lynn Mollick

On Sunday, April 3 a record 104 mental health professionals saw David A. Clark present NJ-ACT’s 16^th annual Master Lecture.

Dr. Clark discussed anxious thoughts, including worry, obsessions, and post-event rumination. Anxious patients exaggerate the importance of these thoughts, and seek to escape and avoid them with counterproductive cognitive strategies, such as thought suppression, and behavioral strategies, such as safety behaviors.

Patients are intolerant of the anxiety created by these thoughts, and they overestimate their ability to control them. Dr. Clark’s therapy is transdiagnostic because its interventions can be used to treat symptoms all that occur in all anxiety disorders. It is metacognitive because instead of attempting to change patients’ thoughts, it focuses on changing patients’ thoughts about their thoughts.

To Assess Patients’ Reactions to Their Anxious Thoughts Ask:

“How do you feel when you have these anxious thoughts?”

“What might these thoughts do to you?”

“What do you do to control these thoughts, and does that work?”

Dr. Clark recommended asking patients to discuss their reactions to anxious thoughts that occur spontaneously or are intentionally provoked. This can be done both during therapy sessions and between sessions.

It is also important to evaluate the importance patients give to being comfortable, and to show patients how their attempts to be comfortable by controlling their anxious thoughts increase distress.

Distinguishing Pathological from Normal Reactions to Anxious Thoughts

The goal of Clark’s metacognitive therapy is not to eliminate all anxious thoughts, but to help patients accept rather than avoid their anxious thoughts and to become comfortable with them. Dr. Clark asks patients to imaginally re-experience an anxious thought that didn’t cause distress, for example returning an item to a store, and then imaginally re-experience an anxious thought that did cause distress. This exercise demonstrates that patients accept some anxious thoughts, but cause themselves distress over other anxious thoughts

Techniques for Treating Dysfunctional Metacognitions

Emotional reasoning. Just because patients experience negative thoughts about their anxiety doesn’t mean they should act on those thoughts. If patients believe they are in danger because they notice their heart beating fast, this doesn’t mean they should act on their danger cognition by leaving where they are and going to a “safe” place. Teach patients to explore the pro’s and con’s of following their emotional cognitions in previous situations. Help patients develop guidelines for when they should and should not act on their anxious thoughts.

Intolerance of anxiety. Ask for examples of when the patient tolerated anxiety. Restructure intolerance beliefs. For example, replace “anxiety is harmful” with “anxiety is unpleasant.” Use graded imaginal symptom induction followed by graded in vivo exposure to help patients learn to be more tolerant of their anxiety.

Catastrophic metacognitions. Help patients distance from or objectify their anxious thoughts. Use Hayes’ defusion exercises -- repeat the fear over and over until it sounds like gibberish. Tell patients to use the phrase “I’m having the thought that this is dangerous,“ instead of viewing their thoughts as realistic appraisals of danger. Develop a normalized explanation about anxious thoughts such as “I’m thinking this way because I’m fatigued,” or “I’m understandably anxious about an upcoming situation.”

Behavioral and emotional avoidance. Ask patients to practice focusing their attention on their anxious thoughts and feelings. Make the symptom worse. Do exposure to external, interoceptive, and cognitive stimuli that elicit anxiety. Correct maladaptive beliefs about the efficacy of avoidance and safety behaviors.

Demonstrate the futility of maladaptive thought control strategies. The “White Bear Experiment” asks patients to not think of a white bear for two minutes. Of course they can’t do it. Then tell them to imagine they will be fined $500 every time they think of white bears. Ask patients to compare trying to control thoughts with accepting them on alternating days.

Restructure specific faulty thought control beliefs. ”My anxiety will increase.” “I will lose control.” “I am a bad person if I don’t control my thoughts.” Use CT techniques such as generating alternate explanations, empirical hypothesis testing, and evidence gathering.

Strengthen Safety Cue Processing. Help patients view situations and thoughts as safe instead of dangerous. Wean them off safety-behaviors, but encourage safety behaviors temporarily when patients need them to perform exposure exercises.

To date, there have been no randomized controlled trials comparing Clark’s transdiagnostic treatment to disorder-specific approaches. However, because it employs already-tested techniques, Clark’s transdiagnostic system should be useful, especially for patients with mixed anxiety disorders and patients who respond only partially to disorder-specific protocols.