Editor’s Note: We often come across patients who seem stuck in a repetitive, negative style of thinking that we call rumination. Rumination is often associated with depression or anxiety, and when severe, it can seem akin to psychosis. The symptoms are common to many disorders but diagnostic of none. Patients call it stewing, over-analyzing, or “stinkin’ thinking.” There’s no specific medication for rumination, though treating the underlying condition can help. Psychotherapy looks more promising, and Dr. Watkins has developed a new form of CBT that targets rumination. Many of his ideas involve straightforward behavioral strategies, and I’ve found they translate well into the brief therapy sessions that often accompany a medication visit.

 

TCPR: Why is it important to address rumination in patients with depression?

Dr. Watkins: Treating rumination is likely to achieve fuller and more lasting remission from depression. People who ruminate are more likely to get stuck in depression, less likely to benefit from treatments, and more likely to ­experience future episodes of depression (Watkins ER et al, Br J Psychiatry 2011;199(4):317–322).

 

TCPR: So, when we say “rumination,” are we talking about “worry,” or are they different?

Dr. Watkins: Worry and rumination are very similar. Both involve repetitive thinking about negative events in an abstract and passive way, but they differ in content. Worry has a focus on future threats, while the focus of rumination is on the past, loss, and meanings for the self. Worry takes the form of “what if” questions, where people imagine negative consequences in their future. Meanwhile, rumination is characterized by questions such as, “Why did this happen? Why me? Why am I so depressed? Why does this always happen to me? Why can’t I get better?”

 

TCPR: Can you give us a specific example of a patient who is having ruminative thoughts?

Dr. Watkins: Sure. Take a patient who has recently gone through a breakup. This patient, if ruminating, will likely focus on trying to understand why the relationship ended, instead of focusing on the detailed sequence of events leading up to the end of the relationship. The patient asks questions such as, “Why did my partner treat me like this? Why did I mess it up? Why can’t I make relationships work? Why does this keep happening to me?”

 

TCPR: How do you explain rumination to a patient?

Dr. Watkins: I explain that it’s a habit of overthinking and over-analyzing negative experiences. I’ll also normalize it as something we all do. It’s natural to think through problems until they make sense, especially when faced with losses, unresolved goals, or unexpected events. Indeed, in some situations rumination can be helpful—for example, thinking problems through can at times lead to useful problem solving.

 

TCPR: Can you further explain how rumination can also be beneficial for some people?

Dr. Watkins: Repetitive thinking about negative experiences can be productive and functional. It can lead to problem solving, learning, and coming to terms with upsetting experiences. However, rumination really refers to unhelpful negative thinking. So, to avoid confusion, I’ve introduced the idea of constructive versus unconstructive repetitive thought (Watkins ER, Psychol Bull 2008;134:163–206). But many ruminators do view their rumination as helpful. They see it as an attempt to understand, gain certainty, or problem solve after an upsetting experience. But that can be a double-edged sword: When patients view rumination as helpful, it can be harder to break out of the habit. Sometimes patients cannot differentiate between when they are brooding with rumination versus constructively solving a problem.

 

TCPR: Psychiatrists probably see a lot of ruminating patients. What are some ways they could guide patients to break that pattern in a brief therapy visit?

Dr. Watkins: Often this is something that hasn’t been discussed with patients, but you can in a short session help them recognize that they are ruminating. The two key steps are first, to spot the warning signs for rumination, and second, to make a plan for an alternative, more helpful behavior in response to this trigger. Common warning signs for rumination are physical signs of anxiety (such as tension, feeling hot, or a sinking feeling in the stomach), attention narrowing, and self-doubt or self-criticism.

 

TCPR: What comes next?

Dr. Watkins: A simple and effective approach is to ask patients to write out an “if-then plan.” For example, “If I notice that I am starting to get tense in my shoulders, then I will practice my relaxation exercises.” The if part of the plan is the warning sign for rumination, and the then part is a constructive alternative. Writing out plans in this way helps patients remember to enact the new behavior when stressed. These plans—called implementation intentions—are proven to help with habit change. A wide range of behaviors can be useful alternatives, including relaxation, behavioral activation, explicit problem-solving, and compassion. It is best to choose a behavior that the patient can already do and has already found helpful at stopping rumination.

 

TCPR: What are some examples of a behavior we can choose?

Dr. Watkins: Activities that engage people directly in an experience, where patients are immersed in the moment, can be quite powerful. They are not evaluating what they are doing but are absorbed in it, and in this “absorbed” state, they are no longer ruminating. These activities vary greatly from individual to individual. For some, it involves engaging with nature. For others, it could be dance, socializing, exercise, or being creative: drawing, music, painting, cooking, or gardening.

 

TCPR: You’ve developed a therapy that helps patients here. Can you tell us more about rumination focused cognitive behavioral therapy (RF-CBT) and how it works?

Dr. Watkins: In RF-CBT, we view rumination as a habit. We help patients spot their triggers and identify more functional and adaptive behaviors to use in place of rumination. For example, a patient who ruminates with self-critical thoughts may perceive those thoughts as motivating—imagining that they keep the patient from making mistakes or from becoming lazy and complacent. In that case, the self-critical thoughts might be triggered by situations where the patient feels tired or is falling behind on a task. After identifying the triggers, we’d help the patient learn new behaviors that can serve the same purpose of self-motivation, such as self-compassion. Instead of harsh self-criticism, compassionate thoughts are a kinder way to coach yourself along. So, the therapy is built on a close functional analysis of the patterns of rumination and repeated practice of alternative behaviors (Watkins RW, Rumination-Focused CBT for Depression. New York, NY: The Guilford Press; 2018).

 

TCPR: So, you’re helping patients change behaviors as well as thoughts, but how does RF-CBT differ from traditional CBT?

Dr. Watkins: RF-CBT focuses on changing the process of thoughts rather than challenging the content of negative thoughts. We seek to understand the whole sequence of thinking and then shift it. Key to this is understanding rumination as a common and normal attempt to address unresolved goals. When something goes wrong in our life, such as losing a job, it is natural to dwell on it, and attempts to stop those thoughts wouldn’t work in the long run. The goal in RF-CBT is not to think about those problems less often, but to think about them in a more helpful way, and that has to do with the process of thoughts.

 

TCPR: Can you tell us more about what you mean by a focus on “the process of thoughts?”

Dr. Watkins: It’s based on experimental work we’ve done, which suggests that the way that people think about negative experiences can determine whether that thinking is helpful or not (Watkins ER, Psychol Bull 2008;134:163–206). Specifically, abstract thinking tends to impair problem solving and prolong negative moods, whereas more concrete thinking tends to reduce negative moods and improve problem solving.

 

TCPR: What are some examples of the difference between abstract and concrete thinking?

Dr. Watkins: Abstract thinking focuses on the meanings, consequences, and implications of events, often in the form of “why” questions such as, “Why did this happen? Why can’t I do this? Why am I still depressed?” Concrete thinking is more down to earth. It involves paying attention to what actually happens; the senses of what one sees, hears, and feels; the context; and the sequence of events. Concrete thinking involves more useful “how” questions, such as, “How did this happen? How can I do something about it?” This form of thinking can help people solve problems, move to effective action, learn from past situations, and keep difficulties in perspective.

 

TCPR: Can you give us a case example of this?

Dr. Watkins: Sure. Consider a mother with depression, who is struggling in her relationship with her teenage daughter. When we review her rumination over the last week, she reports a prolonged bout of rumination about an argument with her daughter. Her natural tendency is to think abstractly about the causes and meanings of this argument, with abstract questions such as, “Why doesn’t she listen to me? Why am I a terrible mother?” This gets her stuck in prolonged self-criticism and self-blame. However, in the therapy session, we can help her focus on the same situation in a more concrete way and remember what led up to the argument, what exactly she said and did to her daughter, and what her daughter said and did in response, replaying it moment by moment as if in slow motion.

 

TCPR: Interesting. What happens next with the mother?

Dr. Watkins: By focusing on those concrete details, she can recognize points where she could have done something differently to prevent the argument from escalating—for example, stepping away from the conflict for a few minutes to calm down and problem-solve.

 

TCPR: Does this approach also help patients come to terms with past upsetting events?

Dr. Watkins: Yes. For example, another patient may be spending a lot of time ruminating about a painful divorce. When we look at this more closely in therapy, the trigger for her rumination about the divorce is whenever an intrusive memory of difficult encounters with her ex-husband pops into her mind. However, rather than spending time with these memories and habituating to them, the patient starts asking, “Why did this happen?” and dwelling on what the failure of the marriage says about her. This temporarily takes the patient away from staying with these upsetting memories, but it also tends to lead to self-blame and negativity. In RF-CBT, we’d encourage her to stay with the details of those memories: the sensory details and the concrete specifics. That would help her process what happened, stop blaming herself, and work through her sadness and anger about the end of the relationship.

 

TCPR: Is rumination unique to depression, or does it cross diagnostic boundaries?

Dr. Watkins: There is good evidence that rumination is transdiagnostic and plays a causal role in a range of different disorders, including depression, anxiety, eating disorders, psychosis, and substance use disorders (Nolen-Hoeksema S & Watkins ER, Perspect Psychol Sci 2011;6(6):589–609). It appears to be a final common pathway between stressful experiences and pathology (Watkins ER & Nolen-Hoeksema S, J Abnorm Psychol 2014;123(1):24–34). For example, consider a patient who experienced major stress in early childhood. That patient might try to make sense of the childhood events by thinking about them repeatedly, and that rumination drives further stress and symptoms.

 

TCPR: Have the brain circuits involved in rumination been identified?

Dr. Watkins: There is extensive study of the brain circuits linked to rumination, and a growing pattern of evidence points to increased activation of the default mode network. That network is involved in the thoughts people have when they are not focused on a particular task. Reduced inhibition from the cognitive control network has also been linked to rumination (Jacobs RH et al, PLoS One 2016;11(11):e0163952). Moreover, we have some preliminary evidence that RF-CBT can change these patterns of brain activation.

 

TCPR: Thank you for your time, Dr. Watkins.