Second, through the psychological processes that characterised and maintained distress states, such as feeling overwhelmed, guilt, avoidance and distancing.
Structural equation modelling found evidence consistent with the central predictions of the metacognitive model that these beliefs cause and maintain distress directly, but also indirectly by driving worry.
Structural equation modeling was consistent with cross-sectional hypotheses derived from the theory that metacognitive beliefs cause and maintain distress both directly and indirectly by driving worry.
It is based on the premise that negative illness appraisal (i.e. negative thoughts about cancer and its consequences) instigates and maintains distress.
In summary, the findings support predictions from the S-REF model that negative metacognitive beliefs cause and maintain distress by activating the CAS.
According to this model, negative thoughts about cancer may activate metacognitive beliefs and worry, or may be a product of worry, but do not directly cause or maintain distress.
21 The metacognitive model would suggest that treatment effectiveness may be improved by shifting the focus away from reappraisal of the content of thoughts to focusing on modifying unhelpful metacognitive processes understood to maintain distress.
Nevertheless, pre-existing experiences and those occurring after birth may be significant in increasing women's vulnerability to distress and maintaining the distress [ 32] and we cannot be certain that women's responses were not influenced by prior events or those occurring at the time of survey completion.
However in order to provide more compelling evidence of a causal role for metacognitive beliefs in maintaining emotional distress after cancer, prospective research is needed to demonstrate a temporal relationship.
According to this model, negative content of thoughts about cancer may trigger metacognitive beliefs and activate the CAS or may be a product of worry and rumination, but have no direct causal role in maintaining emotional distress.
Specifically, positive metacognitive beliefs will cause emotional distress by activating worry, but will have no direct effect, whereas negative metacognitive beliefs will maintain emotional distress both by triggering a direct emotional response and through exacerbating worry, including worry about worrying (metaworry).
