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Lise Poulsen Floris jumped at the opportunity to undergo three sessions of metacognitive therapy.

Explainer | How to stop worrying: metacognitive therapy helps this writer learn to leave her anxious thoughts on the ‘sushi conveyor belt’

  • Overthinking is a habit we develop for dealing with worrisome thoughts. Psychologist Adrian Wells developed MCT to help patients break the habit
  • It’s not the thoughts themselves that are the problem, but the time spent engaging in them, ruminating and worrying, that weighs us down, expert says

Overthinking has been part of my life for the last year and a half, since the world started feeling the impact of the coronavirus.

I have tried to find answers to existential questions like “Why am I a pleaser?” or “Am I making the most of my life?” and spent most of my waking hours worrying about the impact the pandemic has had on our lives, or simply whether I might have said something to someone to offend them.

Research shows that symptoms of stress, depression and anxiety are often caused by bad reflexes such as overthinking. So I jumped at the opportunity when Sisi Gu Starlit, a psychology student in Kuala Lumpur, Malaysia, offered to give me three sessions of metacognitive therapy (MCT) with her.

Starlit is training with an acclaimed MCT expert, Danish psychologist and author Pia Callesen, whose bestselling book Live More, Think Less has been translated into seven languages, with a Chinese version coming out in October.

The cover of Pia Callesen’s bestselling book.

Callesen trained under Adrian Wells, the clinical psychologist at the University of Manchester in the UK who founded MCT. His research suggests that overthinking – that is, worrying and rumination – is a learned strategy that we choose, consciously or unconsciously, as a way to deal with our difficult thoughts and feelings.

It’s not a fixed trait, but a habit that we fall into and we can learn to change it if we want.

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I did a bit of homework before my first session with Starlit, and learned that MCT targets the psychological processes that are involved in the control of thinking, enabling patients to free themselves from rumination and worry.

This definition appeared in an important study carried out by Callesen and three other experts, including Wells. In the study, 174 adults suffering from depression, some from severe depression, were randomly divided into two groups: 89 patients received 24 sessions of cognitive behavioural therapy (CBT) – in which the focus is on challenging the content of thoughts, and the other 85 received 24 sessions of MCT.

Fifty-two per cent of the people who received CBT recovered from their depression, versus 74 per cent of those who received MCT.

Sisi Gu Starlit is a psychology student in Kuala Lumpur, Malaysia.
Callesen hopes that the results will lead health authorities to further recommend MCT, and Hong Kong-based MCT therapist Kino Lam shares that hope. Lam, an occupational therapist who has worked on psychiatric rehabilitation for several years, trained at the MCT Institute in Manchester and says he is disappointed that many have not even heard about this “new wave of psychotherapy”.

“I find that the development of psychotherapy and related professional training in Hong Kong is far behind compared to Western countries,” says Lam.

Cultural differences might be to blame. Lam says there is perhaps a tendency in Asian cultures to see worrying as a problem-solving strategy. According to Callesen, worry and rumination is exactly what keeps sadness and meaninglessness alive.

On the day of our first session, Starlit gave me an evaluation form, the Cognitive-attentional Syndrome (CAS) Questionnaire, to figure out how much time I spend ruminating and worrying – and whether I think that worrying actually helps me. The assessment showed that I spend close to “all of the time” every week ruminating and that it was near impossible for me to control my thoughts.

Callesen is an acclaimed MCT expert, Danish psychologist and author.
Next, we identified my “trigger thoughts”, the thoughts that attract my attention. At the time, a lot of my worry was concentrated around my life as an accompanying spouse. Am I useful to anyone? Can I inspire anyone? And how can I possibly justify lying by the pool on a normal Tuesday afternoon when everyone else is at work?

We then identified my current strategy to deal with trigger thoughts: to ruminate. We also understood that the consequence of my overthinking is a lowered quality of life. The outlook was dim.

After only one session of MCT, though, I started to believe that I might have “some” control over my thoughts. It was especially Starlit’s use of metaphors that helped me see the big picture through everyday-life examples, such as the sushi conveyor belt.

Positive thinking: how it can improve your life and well-being

Try to imagine that your trigger thoughts are pieces of sushi at a “running sushi” restaurant, she suggested. You can consciously choose to take the pieces – or let them roll on. The same pieces may roll past again and again – but you can continue to choose to ignore them.

In a chat with Callesen, I asked for more metaphorical tips to help stop my overthinking. She suggested that we think of our trigger thoughts as mosquito bites. “If we just let them be and stop scratching them, they will go away,” she said.

Another way to limit rumination is to set aside a certain time every day to ruminate. According to Callesen: “It’s not the trigger thought in itself that causes unpleasant symptoms, nor is it the amount of trigger thoughts. It’s the time spent engaging in these thoughts, ruminating and worrying, that weighs us down.”

Hong Kong-based MCT therapist Kino Lam is disappointed that many have not even heard about this “new wave of psychotherapy”.

Callesen often recommends that her clients allocate a period of time for worry and rumination every day, say between 5pm and 6pm. The benefits of this method are twofold: “You’re more likely to feel in control and prevent yourself becoming overwhelmed, and you will often find that trigger thoughts have disappeared by themselves and you won’t even need the time to ruminate,” she says.

During the final evaluation at the end of my third session with Starlit, it became clear that MCT had worked for me. For the statement, “I cannot control my thoughts”, I now scored zero out of 100 – meaning that I did not agree at all that I had no control over them – whereas I scored 90 before the first session.

Before my first session, I had “completely agreed” that analysing my problems would help me find answers, whereas now I “completely disagreed”.

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It turned out that daily “rumination time” was not the solution for me but that my thoughts tend to self-regulate. It happens that I do slip now and again and ruminate – but as Callesen says: “Sometimes we can’t help but to scratch the mosquito bite.”

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