SPENCER: Pia, welcome.

PIA: Thank you.

SPENCER: So many people in their lives will experience mental health disorders, whether it's anxiety or depression. And even if they don't experience them themselves, they're very likely to have friends or family members or other loved ones who experience them. So I think it's a really relevant, important question of how do we best treat mental health challenges. And I know that you have a particular perspective on this question that I'm really interested to dig into. In particular, I know that you're a proponent of metacognitive therapy. So why don't we start with: what is metacognitive therapy?

PIA: Metacognitive therapy is actually a new paradigm in psychology, where we understand and treat depression and anxiety in a quite new way. We're used to thinking that thoughts are very important, and you have to think positive and so on to have a happy life and to not be depressed. But really, thoughts do not matter. And what metacognitive therapy teaches us is that it's not the thoughts themselves — you can have a very pessimistic mind, you don't need to be depressed, even though you think negatively about yourself or the world — it's what you do with the negative thoughts that matters. So it's your metacognitive beliefs about, "Can I leave the thought alone if it's very negative? Do I have to work on the thought?" And if you think that, then you spend maybe ten hours a day ruminating, worrying, and so on. And it's this prolonged thinking that is the cause of mental health issues like anxiety and depression. Metacognitive therapy helps us reduce the time. So if it's ten hours, we go from ten hours to half an hour of worrying and rumination and so on. And that overcomes the depression and the anxiety — well, not our economy or the real problems in the world — but the mental health issues.

SPENCER: Let me make sure I understand that. So you could have two people — let's call them Alice and Bob — and Alice and Bob could both have a whole bunch of negative thoughts. But Alice might have a certain view on her own negative thoughts that makes it much worse for herself, where Bob maybe has a different perspective on the negative thought. Could you elaborate a bit on what is the different perspective that they might have?

PIA: Well, the one person would think, "It's normal to have negative thoughts. I don't need to do anything with them." And he also believes that he can actually leave them alone. We call it the uncontrollability belief: Is it possible to have a negative thought, or many negative thoughts, and not chew on them? We use metaphors like fish hooks. Can you have ten fish hooks and you don't need to chew on the fish hooks? Can you not jump on the train at the train station, even though it's there? The negative thought is like the train at the train station. You don't need to jump on it. And so one person, Bob, might believe he can leave the thought alone, whereas the other person with the same thought doesn't believe it's possible to leave this thought alone. And he might also believe you need to work on this thought, it's a real problem: I have a very bad boss, or I don't have a good economy, or my girlfriend is unfaithful, or whatever, so I need to spend ten hours working out what to do. So he has his positive beliefs that, "Worrying and rumination will help me solve my problems." Whereas Bob thinks, "No, it won't, I don't think ten hours of rumination will solve my problem. And I don't need to spend ten hours working on my problem, I can leave them alone." So it's the uncontrollability belief and the usefulness belief, the positive belief, about the usefulness of this chewing process that is the difference. So Bob will get depressed because he's chewing ten hours a day on his thoughts, whereas the other person doesn't get depressed because he can leave the thought alone, even though they have the same negative thoughts, and they have the same problems in life.

SPENCER: You talk about these two beliefs: one is this uncontrollability belief that you can't control your thoughts, and then this other belief about the thoughts being useful, like rumination or worry being useful. From your perspective, is it sufficient to just sort of lose those beliefs? Like if someone stops believing in uncontrollability and they stop believing those thoughts are useful, then will they just worry a lot less automatically? Or are there other things that have to happen in that process?

PIA: Well, no, that's the main part. That's really what we spend time on when they come to therapy. We keep the dialogue on the meta level. We don't actually go into the content level of, "Is your interpretation right or wrong? Or could you think more positively?" We don't go into the content level. We stay on this meta level: how much time do you spend? Is it possible to not spend so much time? It will take five to 12 sessions to overcome depression because we don't problem solve or go into the content and that really is just what we need to work on. And then people will go from ten hours to half an hour. Then if you have generalized anxiety, then you also have the worry about the worry. So we also work on type two worry, as we call it. You have the normal worry and, if you have generalized anxiety disorder, you don't believe it's controllable. But you also worry about your worry, because you think the worry is causing you maybe cancer or heart attack, or it's dangerous to worry a lot because it stresses your body and so on. You also have this danger belief about worrying being dangerous. So we also work on that belief. We have the uncontrollability belief, the danger belief about worry, and also the usefulness belief. But these are basically the only beliefs we work on in metacognitive therapy and that overcomes 80-90% of mental health issues.

SPENCER: It's really interesting to me to contrast this with other systems. Maybe you could tell the listeners a little bit about cognitive behavioral therapy, which is one of the most common paradigms in treating anxiety and depression, and then contrast it with your approach.

PIA: Well, it's a huge difference. It's actually like day and night. And I know this because I did cognitive behavior therapy for the first ten years of my career as a psychologist, so I've done a lot of CBT. There are hardly any similarities. The theory is completely different. In CBT, thoughts are important and what you think about yourself in the world will actually cause depression, from a CBT view. So if you have negative beliefs about being a failure, then you will more likely become depressed. In CBT, it's your negative thinking that's the problem. And also you need to expose yourself; if you're anxious about something, you need to habituate to what you're anxious for. It's a lot of work because you need to restructure your thoughts and spend a lot of time on your thoughts, restructuring them and so on, and expose yourself to anxiety-provoking things. It's quite hard work. Whereas in metacognitive therapy, the thoughts don't matter, the content doesn't matter. You can believe you are a failure. If you don't do anything with that thought, if you leave the thought alone, it will self-regulate. So one day, you'll think you're a failure; if you leave it alone, the next day, you'll think, "I'm a perfect person, I'm a good person." It'll self-regulate. Your view about yourself and your negative thoughts will become positive if you leave them alone, like a weather system, nearly. One day, it's sunny, and the next day, it's rainy. And that's the same with your mind and your thoughts and feelings. But if you ruminate ten hours a day, this self-regulation will not be possible, and you will prolong the state of mind. A bad day will be prolonged to depression If you chew on the thoughts ten hours a day. If you dwell on them, then the bad day will eventually become a depression. It's like putting gasoline on a fire; it will never go out. it can become chronic if you keep on ruminating ten hours a day on your negative thoughts and feelings.

SPENCER: In CBT or cognitive behavioral therapy, there is the idea of negative core beliefs, which is essentially these beliefs that people might have about themselves or the world that can promote or sustain mental illness. For example, someone believes that they're worthless, or someone believes that everybody hates them or things like this. I wonder if you agree with this, but it seems to me like in metacognitive therapy, you could maybe view it as focused on certain negative core beliefs and claiming that certain negative core beliefs are the ones that actually matter, which are beliefs about belief. I'm wondering, do you accept that framing?

PIA: What you think about yourself doesn't really matter, because that changes from day to day. So if you don't worry or ruminate so much and have internal focus, your view of yourself will change by itself. We actually did a study when I did my PhD, and the most interesting finding to me was actually that the core beliefs, the schemas, were more changed in metacognitive therapy than in CBT. That really surprised me. Just very shortly, my PhD was a randomized trial, half the people got CBT, and half the people got MCT (metacognitive therapy), and then we evaluated the effect on different assessment forms, like core beliefs about yourself, cognitive forms, but also metacognitive thought forms about the metacognitive beliefs. But the most interesting finding was that, if you change the metacognitive beliefs, your core view on yourself changes more than when you actually work on the core beliefs like you do in CBT. That really surprised me. The most interesting finding in my PhD was actually that the core belief, beliefs about yourself, changed more when you worked on the meta level and your metacognitive beliefs. So when you change the metacognitive beliefs about uncontrollability and usefulness, then your core beliefs about yourself change more in the positive direction than when you got CBT. And that was really interesting, because CBT actually focuses on your core beliefs. And that didn't change as much as just working on the metacognitive level. That really surprised me and, of course, also my supervisor.

SPENCER: Yeah, that's really interesting. What did you expect to find in the study? Did you expect to find that they would be equally good? What was your anticipation?

PIA: Well, my hypothesis was equally good because that's the null hypothesis, but there were some single case trials for chronically depressed patients who got really much better in metacognitive therapy. We had some very promising pilot data, but none of us knew how good the metacognitive therapy was compared to CBT and cognitive therapy. So 50% recovered in cognitive therapy, but it was 74% in metacognitive therapy, which is the highest level of recovery when it comes to depression ever reported in any trial, really. There were 70, 80 people in each group, so it was very, very well-powered. It's really good.

SPENCER: Can you tell us about the protocols? Suppose that I were to go do metacognitive therapy. What are the different steps that the therapist is taking me through?

PIA: When you come to therapy with me, I would first ask about a critical situation in your life where you have a negative thought or a catastrophe thought. So whenever you have a negative thought, what would be the first one? We call it the trigger thought. It could be anything from, "Oh, my God, what if I get cancer?" or "Oh, I'm not good enough," or whatever. And then the most important question would be, what do you do with that thought? Do you leave it alone? Or do you work on the thought somehow? That would be the most important question. What do you do with the thought? I could ask you, what do you normally do if you have a negative thought?

SPENCER: Yeah, so maybe let's just do a real example, if you don't mind. For my own life, one thing I tend to worry about is work projects. Throughout the day, I might have a thought about a work project pop into my mind and I might say, "Oh, no, what if we don't get that thing done on time?" or "What if the implementation of that part doesn't go well?" or something like that.

PIA: Yeah. Do you just leave that 'what if' alone, or do you kind of plan what to do if that 'what if' happens? So do you go into planning mode: I will do that and what if that happens, then I will do that.

SPENCER: I think I do tend to go into a kind of planning mode, thinking more about that project, thinking about what would happen if it didn't go well, and stuff like that.

PIA: So that would be the thinking — we call it the cognitive attentional syndrome — which, if you do that too much, then you'll have symptoms: stress, anxiety, bad sleep, insomnia and so on. So I would ask, "So how much time do you spend? Is it just two minutes or would you spend the whole evening, the whole day doing this 'what if' planning?" That would be the next question.

SPENCER: In my particular case, I think what happens is, I might spend a couple of minutes thinking it through, but then I'll be on to the next thing, I'll go back to work or whatever. But that might happen many, many times a day. So there may be many instances.

PIA: That in itself is not a problem. Worrying, we all do that. But then you have the metacognitive beliefs, and they are important. So that would be the next question. Do you believe it's possible to control? Could you do it more, do it less? Is it possible one day to do it for ten hours and the next day, just to not do it at all? Is it under your control, how much time you spend doing this process? If you wanted to, could you leave this alone? If I gave you $100,000 or $100, could you then leave it alone if you wanted to, for one day?

SPENCER: Yeah, it's really interesting, because I feel like I can't control the thought popping into my head, like, what if this thing goes wrong? But I feel like I could learn to notice, "Okay, I just had that thought," and then not stick with it.

PIA: Exactly. Very, very good observation. Yes, that's a really good point. Because no one can control the popping up, the trigger thought is uncontrollable, that's completely right. But what you can learn — and that's what we actually focus on in this therapy — is your reaction, your answer to the trigger thought, not the trigger thought itself, but the answering part. Actually, not many people know this but that is controllable, if you answer it or not, if you leave it alone. That's the uncontrollability: can you leave this thought alone? And then we will work on getting to a point where independent of what happens, you have a choice, you can leave it alone if you want to. Then I would ask you about usefulness. Do you think it's useful to spend ten hours worrying and planning? Or do you think you'd get the same success level if you spend less time, maybe only five minutes?

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SPENCER: I'm curious about the idea of worry being helpful or unhelpful. I wonder if you agree with this or not, but it seems to me that some worry is helpful. If there really is something that could go horribly wrong and you realize it, spending some time thinking about that thing can be beneficial, but that people who have mental health challenges often go way overboard. They do way more worrying than is actually productive. I'm curious to hear how you think about the distinction between useful worrying and unuseful worrying?

PIA: Well, it's very interesting because I don't think worrying is actually useful at all because how do you know — I raise my favorite question —- how do you know that you worry about the right things? How do you know you spend time on the right worries? Can you know that?

SPENCER: I don't think you can know for sure that you're worrying about the right thing. But surely, some of the things people worry about, there's actually something that they can do to help reduce the chance of something bad happening. Let's suppose you get in a fight with your partner and then, the next day, you're thinking about it and you realize that my partner seemed really upset at me. Maybe there is something to think about there to figure out what you could have done differently, or what you could do now to make it up to your partner, and it doesn't seem to me like not thinking about it at all is the right answer. Maybe what you would say is that worrying is still not helpful, but maybe some other kind of thinking about it that is helpful? I'm not sure. What's your perspective?

PIA: Well, I'm not sure about this prolonged thinking in any way because, when I was young, I thought long-term regret would help me become better and make fewer mistakes and so on. But long-term regret won't help you. It's about timing, of course, so maybe two minutes is okay to kind of reflect: What did I do? What did she say? But more than that won't really get you closer to solutions. And that's what people also say. They just spin around in their heads, and they don't get closer to solutions by overthinking. We have this concept called worry time, illumination time, where you have like 15 minutes a day where you can do these things and then you can leave it alone the rest of the time.

SPENCER: So then the idea would be, if you notice yourself having worries that are not during your devoted worry time, you think, "Okay, this is not worry time. I'll push this till tomorrow," or "I'm not supposed to do it now." Is that the idea?

PIA: Exactly, exactly. But of course, it's important that you feel the control to actually do that. This would be a behavioral experiment. Would it be possible for you to wait until eight o'clock? And then people try it out and they realize, "I could wait until eight." So it's like an uncontrollability experiment. And then they believe more and more that this worry process is under their control. And that's what metacognitive therapy is about.

SPENCER: My suspicion is that there are different things that we do that we might call worry, and some of them are useful and some not so useful. For example, let's go back to the example where, say you have a fight with your partner, and it kind of went badly, and the next day you're thinking about it. It seems to me that there might be a useful exercise to do around that. It may take more than two minutes — maybe it'll take ten minutes, maybe it'll take 15 minutes — where you're analyzing carefully like, "Okay, what was my contribution to the problem? What could I have done better? What was their contribution? What could they have done better?" and making a plan for what you want to do going forward. That kind of procedure seems useful to me, but that might differ from what most people are doing.

PIA: Well, not really. I think that the main difference between you and the people who become depressed or anxious is the metacognitive beliefs. So even if you are a happy worrier — we call them happy worriers, and I think you sound like a happy worrier (that's someone who only has the usefulness belief) — if you only have positive beliefs about the usefulness, you won't get a mental illness. It needs the negative beliefs. You need the uncontrollability belief and the danger belief if you really want to become depressed or anxious. It's all about the negative metacognitive beliefs. So if you are a happy worrier who only has the positive beliefs, like it sounds like you have, it's useful, to some extent it's good, then you won't become depressed because you only have the positive metacognitive beliefs. It takes the negative metacognitive beliefs, the uncontrollability and worry is dangerous, it's gonna make me stressed and give me a heart attack. That's why you don't get anxious, because you still worry, you still analyze, you still ruminate, but you only have the positive metacognitive beliefs about the process.

SPENCER: Just to clarify, I do feel like I stress myself out needlessly. I don't want to say I'm not excessively worrying. I do think I'm a worrier type personality and I think I worry more than I ideally would, and it causes stress for myself. I just want to clarify that. [laughs] I think on the margin, I would be better worrying less, yeah.

PIA: Okay. Okay. So could you easily do that if you wanted to? Could you make that choice and say, "Well, I'll do it less."

SPENCER: I think for me, the challenge is catching it when it's happening. So if a worried thought comes up and I notice, "Oh, wait, I'm having a worried thought now," I feel like it's pretty easy to just let that thought go. It's like I don't get too stuck in it. But the problem is, that's happening to me many times a day and you're just getting so many things thrown at you that it's hard to notice, "Oh, wait, I'm worrying now." So I'm curious, do you have exercises you use to help increase that awareness of like, "Oh, wait, I'm starting to worry now," and catch themselves in that moment.

PIA: Worry is useful. That's two different main processes. The worry is more future-oriented where what if, what if, what if, and that's usually not unconscious. You notice straight away because you get symptoms like heartbeat and so on, so you're aware of it straight away usually. It's more the rumination that is slowly moving into you and you can maybe ruminate for four hours before you actually realize, "Uh, I've been ruminating for four hours." The past-oriented, the dwelling, the why did I do that? The 'why did this happen? Why am I feeling like this?' is not very conscious. We have some exercises like attention training and so on, that will increase your awareness. But the worry process, the 'what if' process, you're usually not unaware of that because it gives you physical symptoms, and you know you're doing it when you're doing it usually.

SPENCER: Just to clarify, is the distinction you're drawing between rumination and worry just that rumination is about the past and worry is about the future or are there other differences there?

PIA: Yeah, the difference is, for rumination, the function is finding solutions: why is this happening? Why do I feel this way? Why do I feel so depressed? So it's more like, why or what should I do? How should I solve this problem? Whereas for the worry process, the function is more to be prepared and to prepare yourself for different future scenarios. There's different functions and goals in the two processes. The difference is also how aware you are. The rumination, usually you're not very aware of it. So if I have a depressed person, they don't say, "I'm a ruminator." They never say that. If I ask them, what's your problem? They say, "I feel low, I feel low mood," and so on. And if I ask them, how much time do you spend ruminating, they'll usually say, "I don't spend any time, I just feel low." And they have very low awareness about the rumination; they just don't notice they're doing it. They would never say, "I'm a ruminator." Whereas the anxious people, the people with anxiety, they will usually say, "I worry too much. I am a worrier. I worry all the time." So they have much more awareness of this worry process than depressed people have. That's just to differentiate a bit.

SPENCER: I see. Yeah, that's really interesting. Maybe we should talk about some specific problems people suffer from and how metacognitive therapy addresses them. Maybe let's talk about low self- esteem. How does that come up in metacognitive therapy and how would you work with someone who has that?

PIA: Yeah, that's very interesting, because that's the core beliefs we started off talking about, and we see them as not as stable as we do in cognitive therapy. In CBT, you see them as stable, internal beliefs about yourself, the world and so on. But we don't see them as stable in metacognitive therapy. They are self-regulatory so they will change throughout your life or even from day to day. So your self- esteem one day will be good, "I feel good about myself." But then the next day, you'll feel bad about yourself. And if you don't do anything with that feeling, it will self-regulate. So you'll have unstable self- esteem and that's the normal self-esteem, where one day I feel good about myself, and the next day, I don't. But if you ruminate a lot and work a lot on your self-esteem, that's a paradox. if you work on solving your self-esteem, you will actually prolong the low self-esteem. And that's the paradox. I have a lot of people who have chronic low self-esteem and have been doing loads of things to feel better about themselves. They would do diaries, where they put positive events in the diary, or try to talk to themselves, you know, "You're good enough, you're good enough, you're good enough," and so on, and spend many, many hours a day trying to change the low self-esteem. And it hasn't worked. They come to metacognitive therapy and say, "Well, I still feel bad about myself and all this working on it and trying to think positive and so on, it just makes me really tired and exhausted and hasn't changed my self-esteem." So then we start saying, "Well, would you be willing, for the next six weeks, to do something else and see what happens?" And most people are willing because they've tried everything else. We then invite them to leave it alone — the lazy approach, the detached mindfulness — which is the opposite of working on the thought. Detached mindfulness is not being thoughtless or emotionless; it's just about not working on the thoughts and emotions. So like the fishhook or the train metaphor, you have the fish hooks, you have the train, but you don't do anything with it. And then they usually say, "Well, I'll try it out," and then, whenever they feel bad about themselves, they practice leaving it alone or postpone ruminating about it. And then they realize, well, it was changing by itself. So if they don't work on the self-esteem, they will naturally feel good about themselves some of the days and have a normal self-esteem. That's the metacognitive way.

SPENCER: The way you describe this reminds me a little bit of acceptance and commitment therapy, also known as ACT, where you take the thoughts that you're having, and as far as I understand it, in ACT, you view them from an outside perspective. One metaphor is, you treat your thoughts like they're just leaves floating by on a stream. It's like, "Oh, I had the thought that I'm a shitty person. And I had the thought that I have cancer," and you just observe the thoughts, let them float away, a very mindfulness- based approach. I'm wondering how that relates to the metacognitive therapy approach.

PIA: Well, some of the metaphors you use to describe it gives people the idea that it will float away, it'll move on. And we don't actually have this. In metacognitive therapy, the goal is not for thoughts to move on. We leave them alone; so they might stay or they might not float on. The clouds might not move on; the clouds might stay there. We don't give people any promises of thoughts or feelings disappearing, necessarily. But they might do and that's the secondary bonus if they do. But the metaphors in metacognitive therapy are more like, well, can you leave it (like the fishhooks, for example) alone? Or can you have a chewing gum in your mouth and not chew on it? So the thoughts are still there. They're not floating on. They're not moving on, necessarily. Can you still leave them alone, even if they're not moving on? I think they call it defusion in acceptance and commitment; we call it detached mindfulness to leave something alone, to leave thoughts alone.

SPENCER: I see. I'm curious: even though the goal is not to have people have fewer thoughts per se, do you find that, when people go through these exercises and they change their beliefs about worry, that they start having fewer worried thoughts? Or do you think that they tend to have the same number, but they just engage with them very differently?

PIA: It's a little bit different, I would say. Not many people say, "I actually have few of them. I'm more clear in my head. If I don't ruminate so much, worry so much, my head becomes clearer, and I have fewer trigger thoughts." Some people say that, but not all. But we don't really go for that goal. The most important goal is the metacognitive beliefs that change, that independent of whether my brain is very active and I have a lot of thoughts or if I don't have, no matter what the day is like, or if it's night or day, I can choose to leave it alone. That's what we do. That's the main goal.

SPENCER: Another thing that I think confused me a little bit about your approach is that some problems arise from things in the world. Take, for example, someone who's in an abusive relationship. And they come into your office, and they're worrying all the time. But let's say their partner is really treating them horribly and beating them up and all those kinds of things. I would imagine in such a case, that problem solving would be the first thing to try. It'd be like, "Okay, how do we help this person get to a safe situation?" Whereas working at the level of their beliefs about their worry, or beliefs about their thoughts, may not be as effective. I'm curious to hear your reaction to that kind of situation.

PIA: Well, I would say the opposite. In the old days, when I was a CBT therapist, I actually would work on that level, the problem-solving level. It's very interesting, I actually had a case like that recently in metacognitive therapy. If she would have come into my clinic 15 years ago, I would have problem-solved. But it was so interesting what happened when I removed her ten hours of ruminating. Just very, very quickly, she had an abusive relationship, she was beaten up a lot and so on. But apart from that, she also ruminated and worried a lot, so she would have a lot of dilemma rumination: What should I do? Should I stay? Should I go? Why is he doing this? Could I do something to prevent it? And he promised and blah, blah, blah. She was maybe hit two times a day but all the thinking actually lasted ten hours a day. But I did metacognitive therapy with her and started with, "Would you leave the thoughts alone and go from ten hours a day thinking to maybe half an hour a day?" And I was amazed what happened to her because, when she did that, she got much more energy, her self-esteem came back, and her mind actually became clearer so she could actually find out what she wanted to do. She could feel, "I want this," and she could actually have the energy to go on the internet and find an apartment and move away from this abusive partner and so on. She could actually problem solve her life herself when we removed all this overthinking she was also doing. That's really amazed me how people become much more powerful when they don't have this backpack of thinking on them as well. So I would never go back to problem-solving. I would always remove the cast, as we call it — the cognitive behavioral syndrome, all this overthinking — remove that and then see what's left. It's so rare that you need to work on anything else, really. I'm really surprised. And I also had a couple actually the other day. When I removed all this overthinking and they only argued from 8:00 to 8:30 every night (because they used to argue for ten hours a day), I thought after that, we would need to work on their communication, because they had really, really poor communication. I thought that's going to be the next step. But we didn't get there because, when they left the thoughts alone, and they only argued from 8:00 to 8: 30, they could talk to each other really well. Their communication was really good when they didn't talk about their thoughts in the heat of the moment.

SPENCER: I can certainly see how spending a ton of time ruminating or worrying can sap people's energy and it can give them lack of clarity. But it seems like at least sometimes people actually just genuinely don't know what to do, and they don't know how to solve a problem in their world. It seems like you think that you should never help someone problem-solve, pretty much. Is that right?

PIA: I would like to. I always say to myself, "Okay, let's remove the cast, and then I will go to problem solving." But amazingly, it's very rare that people want that. Because when we remove this overthinking, people have no depression, no anxiety, they have more energy. It's so rare. I can't think of the last time that we ended up problem-solving, because actually, they got a different job, they just changed the environment themselves when they weren't bound by all this thinking. I can't think of the last time I ended up problem-solving afterwards. But of course, one time has to be the first so it might happen one day and I would be open to that. But maybe people don't lack problem-solving skills. Maybe it's the overthinking that is inhibiting them from accessing this problem-solving ability that they maybe have already.

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SPENCER: Let's talk about the belief side of this, too. An example I've seen in my own life is where someone seems to genuinely believe that they're worthless. And if someone believes they're worthless, it's very natural to see why they might feel unhappy all the time. But it sounds like, from your point of view, somehow, their rumination is actually keeping this belief in place. So maybe you could just unpack a little bit more, how is it that stopping the rumination frees up this belief to change? Because that connection doesn't seem totally obvious to me.

PIA: Well, usually, I will normalize the feeling. I'll say, "Well, I feel shitty sometimes, too. I also feel like I'm not good enough, I'm a failure, I'm a hopeless person. That's a normal human feeling. We all feel that once in a while." And that's a surprise to many, really a surprise, "Really?! Is that possible? Do other people have that belief once in a while?" Because we all feel like bad people once in a while, or bad parents or whatever. We all feel bad about ourselves sometimes. It's very normal. And then the next question would be, so when you have that feeling — it's a natural human feeling — what do you do with it? What have you done today with it? And then you always find this working on the thought. So people will say different things: I'll try to push the feeling away. I would try to calm myself. I would ask someone, "Am I good enough," to seek reassurance. So people do different things to this belief. And it's all this stewing, actually, all the problem-solving that is maintaining the problem somehow. So then the next question would be, have you ever tried, for a week maybe, not to problem-solve this feeling of not being a good person or being a bad person? Just be with it. It's there but you don't work on it. I use a metaphor like, "Can you look at the dirty dishes? Can you just watch the dishes without doing them? In the same way, you watch the feeling; it's there, you feel you're not good enough, you're a bad person. But for a week, you do nothing with it. You just take it around, you take it to wherever you go. You just leave it alone." They've never tried that, so that would be an experiment in itself. And then we test what happens. And then people come back, after a week maybe, and say, "Well, actually, I feel lighter, more energetic." It might not have completely changed. Maybe they're still feeling bad about themselves, but they are more present in the moment, they have more energy and so on. And some people actually also say, "Well, some days, I forgot about this feeling because I was so absorbed about other things in real life. So I nearly forgot about the feeling of being a shitty person, a bad person."

SPENCER: What about a problem like insomnia? Can you tell us how you would apply metacognitive therapy there?

PIA: Yeah, that's the same again. When people have two nights of bad sleep, which is normal, too. I have many nights — I have a little baby — so many nights of bad sleep. But even before the baby, I also had bad nights because it's a normal human condition that, some nights, you sleep like a baby, nine hours of perfect sleep, and some nights, you don't sleep, and some nights, you wake up all the time. So the normal sleep is not a perfect sleep. Normal sleep is very interchangeable. But what happens after two bad nights is that you become desperate. Because when you've had two bad nights, when you don't sleep, you think, "Oh my God, I have to sleep tonight because I'm not functioning. My mind is completely mirrored, and I can't focus. I'm a bad version of myself," and so on. So you really become desperate, and then you might Google what to do when you have bad sleep. And that's the worst you can do. Because then you get a lot of strategies and tools that you can use. When I ask people, "How much time do you spend problem-solving your sleeping?" They would start maybe at two o'clock in the afternoon and start, "Okay, now I have to think about how to get a good sleep. And I have to get the windows down. And I have to have positive thinking in my head. And I have to have my mindfulness meditation on," and they really try to optimize the sleep. And so they think that metacognitive therapy is just one more tool for the toolbox. But I have to kind of disappoint them a bit and ask, "Well, have you ever tried to throw away the toolbox and see what happens to your sleep?" In metacognitive therapy, less is more. Here, the problem-solving is actually maintaining the problem. You would get chronic insomnia if you keep on doing ten hours of problem-solving on your sleep everyday. So you throw away the toolbox in metacognitive therapy and do nothing with it. And then it will self-regulate. So you'll have good nights, bad nights, good nights, bad nights, and so on.

SPENCER: I've definitely had the experience where I'm like, "Oh, man, I have an important presentation in the morning. I really have to sleep tonight." And that makes it so much harder to sleep well. You're just like, way too aware.

PIA: The best strategy is detached mindfulness again, where you are lazy. And you might be eight hours of lazy, but you might be lucky and fall asleep. But even in the worst case, you're just eight hours of lazy, and it's better than eight hours of working on sleeping, you know what I mean? So you need to just be lazy and hope for sleep. Or worst case, it would just be eight hours of lazy, just lie there and do nothing, do as little as possible with your thoughts and feelings.

SPENCER: Let's talk about the state of the evidence for metacognitive therapy. I know that for your PhD thesis, you ran a randomized control trial. What other work has been done pitting it against a control group or pitting it against other techniques?

PIA: Well, at the moment, the large diagnoses like GAD (Generalized Anxiety Disorder), OCD, PTSD (Post-Traumatic Stress), depression and so on, have had large trials, both with control groups and CBT. And the generalized anxiety trial, where they compared CBT to MCT, they actually had a nine-year follow-up — which is really unusual. It's incredible to have a nine-year follow-up, which is amazing — and after nine years, it was still over 60% who were diagnosis-free in metacognitive therapy, and just over 30% in cognitive therapy. That's a really good recovery rate this many years after the trial.

SPENCER: Have there been any meta analyses done?

PIA: Yeah. So there's two large ones. I think the last one was in 2021 (so a couple of years ago), and there was one from 2019 or 2018. It seems promising, and it seems to be better than CBT. But of course, we need more large, powerful trials comparing Cool Kids for children with metacognitive therapy for children, and so on. There's a lot of trials that need to be done. We're just at the beginning. But for the big diagnoses like depression, generalized anxiety, OCD (obsessive thinking), PTSD and so on, there's some pretty good trials comparing both Waitlist and CBT, showing that metacognitive therapy is superior.

SPENCER: Before we wrap up, I just wanted to give the listeners an opportunity to think about how they could apply these ideas in their own life. Let's say someone wants to just do some self-experiments and explore these ideas on their own. What are some things you'd recommend they try?

PIA: One of the easy things to start off with is this rumination time, where you set up a time during the day — could be 5:00 to 5:30 — where you try to have your problem-solving, your worrying. If a worry pops up in your head, if a trigger thought pops up, let's say, in the morning, then you instruct yourself to leave it alone. And if it's still important at five o'clock, then you can work on it there. So this is kind of an experiment: can I wait? And can I wait till five o'clock? And it's not mandatory so if you don't want to worry at five o'clock, you don't need to worry, you don't have to worry. You can just wait until the next day. But then you can try out if it's possible to manipulate what you do with those trigger thoughts and maybe wait to chew on them. And that will be the first step to both increase your uncontrollability belief — you know that you think more, that you can actually leave it alone — and also you might find life goes on. You don't make more mistakes. Everything is good even though you limit the time you spend worrying and ruminating. So your usefulness belief will also be changed a bit.

SPENCER: With regard to that, when people have worries or ruminations outside of the worry time, do they write them down so that they have a list that they can review during the worry time? Or do they just say, "No, I'll just remember during the worry time."

PIA: Your brain will remember it. You don't need to do things with your thoughts. It'll still be there if it's important enough; otherwise, it wouldn't be important.

SPENCER: Okay, excellent. So that's a great, really concrete suggestion. Any other concrete things you'd suggest people try as an experiment?

PIA: Practice being together with negative thoughts and feelings without doing anything with them. That's good practice.

SPENCER: Can you elaborate a little more on what that looks like to not do anything with it? Does it mean just sort of go think about something else?

PIA: It's being lazy, so you don't have to move your attention really. You know it's there, but you don't do anything with it. It's like the fishes again. It's there, but you don't do anything with it. You feel it's there. Like a mosquito bite, you feel it's itchy and it's there, but you don't scratch it.

SPENCER: Got it. So if I had the thought, "Oh, no, what if we don't meet this deadline?" the next thing would be just to stop that process. But there's nothing in particular I need to do, just say, "Okay."

PIA: Exactly. And then you'll see, and then the day after, it will self-regulate.

SPENCER: Yeah, that's really interesting. I find it especially interesting how it contrasts with the cognitive behavioral therapy approach where cognitive behavioral therapy says, "No, you want to engage with that thought." Maybe you'd consider the evidence for that, whether that thought is true or not. Maybe you'd rewrite the thought to try to come up with a more helpful version. This is saying almost the complete opposite. It's like, "Nope, just stop right there. You don't need to engage."

PIA: It's the complete opposite of CBT. Yeah, it is. That's why it's a paradigm shift. It's the opposite approach than most other therapies, including CBT, because in other therapies, you spend time working on thoughts, changing thoughts, changing emotions. It's the opposite of most therapies.

SPENCER: Fantastic. Pia, any last things you want to say to the listeners?

PIA: I just hope that people will get interested in metacognitive therapy. There's not that many in the United States, unfortunately. But I can send a list of where. Because you need to have a properly educated metacognitive therapist. It's not enough to just listen to a podcast, and then you can do metacognitive therapy. So if you want someone who's been trained with Professor Adrian Wells, who developed the therapy, you want to find someone on the certified list, I can send you the list of these people around the world who have been trained with him.

SPENCER: Fantastic. Yeah, we can add that to the show notes. Pia, thanks so much for coming on. This was a really interesting conversation.

PIA: Thank you so much for inviting me.

[outro]

JOSH: A listener asks: "What are the most important problems psychologists should be working on?"

SPENCER: So I actually have a spreadsheet of what I think are some of the most important topics in psychology. And part of the reason I'm excited about psychology, I just think there's so many important topics that it could potentially make progress on. Everything from how do humans be happy? How do people live more filling lives? How do people get along with each other better? How do we avoid conflict or how do we even avoid, you know, extreme conflict like genocide? How do we improve our decision making? How do we reduce our biases? How do we improve mental health, right? So there's just so many of these different topics that are really, really essential to the flourishing of society and individuals that I think psychology, in theory at least, is the right field to make progress on these.