Question 1

What is rumination-focused cognitive-behavioural therapy and how does it differ from standard CBT?

Edward Watkins · Accepted Answer

Rumination-focused CBT is a variant of CBT that explicitly targets rumination, so it has a lot in common with respect to structure, use of guided discovery and Socratic questioning, scheduling plans, homework, and collaboration. RFCBT is informed by theory and evidence indicating that pathological rumination may be a learnt habit and therefore that it may benefit from behavioural approaches to targeting habits, as well as evidence that thinking style can influence whether rumination is helpful or not. It thus differs from standard CBT in a greater emphasis on understanding the context and function of rumination, using functional analysis paralleling those in behavioural activation approaches to depression, and a focus on changing the process of thinking. As such, there is a reduced emphasis on challenging the accuracy and veridicality of individual negative automatic thoughts, but instead on looking at how sequences of thoughts unfold, their effects and which thoughts and behaviours are useful in which contexts. The formulation is also different – instead of formulation based on underlying patterns of beliefs, the formulation is focused on the context and function of rumination.

For detailed information see - 
https://www.guilford.com/books/Rumination-Focused-Cognitive-Behavioral-Therapy-for-Depression/Edward-Watkins/9781462536047

Question 2

What does RFCBT teach people to do with rumination?

Edward Watkins · Accepted Answer

In brief, RFCBT teaches people to spot when they are ruminating and to shift into more helpful ways of focusing on the area of concern. RFCBT recognises that rumination is often an attempt to make sense of, understand or resolve a personally important difficulty and thus it is not helpful to try and get people to stop thinking about things that bother them. Rather, RFCBT tries to help people to focus on the things that bother them in a more helpful way, for example, shifting from unhelpful brooding to problem-solving. The therapy aims to help patients to discriminate between when their thinking about problems is helpful and when it is unhelpful and then to move systematically to the more helpful thinking.

Question 3

Do people ruminate to avoid feeling and accepting emotion?

Edward Watkins · Accepted Answer

Rumination has different functions for different people, although most commonly there is some form of avoidance involved, which negatively reinforces the rumination by minimising short-term distress, even if it has long-term negative consequences. In some cases, the rumination can act to reduce or control unwanted emotions. For example, if someone is very scared of losing control of their temper, when they become irritated they may ruminate about how they are over-reacting and being oversensitive, which will shift their mood from being angry to feeling down. So rumination can act to control emotions. Rumination is often also set off by emotional experiences or the recall of emotional memories. Such rumination typically involves abstract “thinking about” these experiences as an attempt to understand the emotional event (asking “Why? What does it mean?”). However, such abstract thinking takes the individual away from being in the direct sensory experience and away from the specific context of the event.  As such, it can reduce the intense emotions associated with experiencing a difficult experience and thus become negative reinforced – this usually happens inadvertently at first, but then makes rumination more frequent, and in the long run, it is unhelpful because it prevents any chance for the client to work through and habituate to the event. For example, one client had very upsetting intrusive memories of arguments and confrontations with her ex-husband from the time of their divorce, but whenever a memory popped into her mind, she would start to analyse it, which took her away from the detail and intensity of the memory and prevented her from coming to terms emotionally with what happened. Staying with the memories and replaying the events slowly was helpful in breaking this link with rumination and helping her to move on.

Question 4

What is your top 'un-hooking' tip or technique?

Edward Watkins · Accepted Answer

There is no single top technique as what works is so individual and idiosyncratic. The core techniques that we find useful in most people are:

1. Identifying rumination as a habit and looking out for the cues or triggers that come before it. This greater awareness of the pattern can help patients to step out of it.

2. Exploring bouts of rumination in extensive moment-by-moment detail to understand the causes, consequences, and functions of the rumination.

3. Reviewing if the rumination is helpful – is it working for the person to achieve the goals? When and where does it work or doesn’t it work? This can help clients to discriminate between problem-solving and brooding, and reflect on the pros and cons of the behaviour.

4. Finding an alternative but more helpful behaviour to use as a functional equivalent and replacement to the rumination – for example, if rumination has the function of controlling anger, then learning other more adaptive ways to manage anger such as relaxation and assertiveness. Where possible, we want to build these alternatives from the client’s existing repertoire, for example, times when they were exposed to triggers for rumination but acted differently.

5. Shifting processing style from an unhelpful abstract style (e.g., asking “Why me?”) to a helpful concrete style (e.g., asking “How did this happen? How can I do something to help myself?)
6. Using self-compassion exercises to step out of the self-critical, negative evaluation common to rumination.

For more information see: https://www.guilford.com/books/Rumination-Focused-Cognitive-Behavioral-Therapy-for-Depression/Edward-Watkins/9781462536047

Question 5

What is rumination? Can we view it as a mental habit and what role does a person's relationship with their emotions play? Also, is it a part of mental health problems other than depression? I'm particularly interested if it is involved in insomnia? Thanks!

Edward Watkins · Accepted Answer

Rumination is repetitive thinking about the self, negative emotions, difficult events, and problems. It is important to recognise that rumination is a normal process, which can sometimes be helpful, and which we all do. Everyone ruminates when something important to them doesn’t work out or they lose something meaningful, especially if it is unexpected. This reflects theory and evidence that repeated thinking is often triggered by unresolved personally important goals, and such thinking can sometimes help to resolve the goal. This is normal rumination. However, for some people, often as a result of earlier learning experiences, rumination can become a mental habit that is triggered by stress, low mood, or anxiety, such that rumination becomes tied to relatively minor day-to-day events. The pathological rumination we find in patients with mental health problems is typically this more habitual form, which is harder to control, more frequent and more intrusive.

There is evidence for rumination (repetitive negative thinking) playing a role in nearly all mental health problems – as well as depression, there is evidence for repetitive negative thinking playing a role in the onset and maintenance of generalized anxiety disorder, social anxiety, post-traumatic stress disorder, insomnia, alcohol difficulties and psychosis. Dwelling on negative emotions in a passive, abstract way tends to exacerbate and prolong negative emotions and reduce effective problem-solving, thereby contributing to worsening symptoms.

Question 6

I'm interested in the concept of co-rumination and can people get locked into relationship dynamics that revolve around this?

Edward Watkins · Accepted Answer

Yes, there does seem to be some evidence that some people can get into the pattern of ruminating aloud together (i.e., co-rumination) and whilst this seems to produce a sense of a closer bond in the relationship, it can also drive increased depression and other mental health issues.

Question 7

What would the recommended strategy be for helping a client whose rumination is on their partner's past sexual history (i.e. retroactive jealousy)?

Edward Watkins · Accepted Answer

First, we would explore several recent examples of jealous rumination to identify what sets off the rumination and to understand the triggers. Second, in reviewing these examples, we would also examine the content and consequences of the rumination, to try and understand what the purpose of the rumination is for the client. There could be many different functions for dwelling on the partner’s past sexual history. For example, it could reflect an insecurity about the partner leaving or losing interest and an attempt to understand and prevent this or it could be about reassurance-seeking. Ideally, we want to tackle this function for the rumination and find a more helpful alternative. Third, we would look for examples of times that the client is exposed to possible triggers for jealous rumination and does not ruminate but rather carries on without dwelling on it. We would examine these closely to see what the client is doing differently here and then look to get the client to practice this alternative response more systematically to the triggers to break out of the ruminative habit.

Question 8

I've a patient who went through significant trauma in January 2021. They can't seem to stop ruminating, and I'm genuinely trying to help with CBT techniques and they're appreciative of the efforts. How might this be helpful for my patient?

Edward Watkins · Accepted Answer

Rumination is a common response after traumatic events.  There is growing evidence that rumination can be unhelpful and contribute to the maintenance of PTSD, especially when it is passive and abstract. Breaking out of rumination can be very helpful for recovering from trauma. An important step can be to help the patient to stay with traumatic events in the form of imaginal re-exposure, habituation and cognitive restructuring, without shifting into ruminative “thinking about” the event, which seems to block such habituation (also see answer to question above].

Question 9

Loved your book on RFCBT for depression. Have you any intention of creating a course on here or a different platform?

Edward Watkins · Accepted Answer

Thank you for the positive feedback. We are in the process of developing and piloting an online training programme for therapists, which we will run from the University of Exeter – for details and updates see our website - https://psychology.exeter.ac.uk/staff/profile/index.php?web_id=ed_watkins

Rumination-Focused CBT

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