Free patients from the rumination trap

Thoughts are powerful, and especially when habitual they strongly affect our well-being. Certainly, this view has become well-accepted in today’s field of positive psychology. Under the banner of self-regulation, researchers are increasingly focusing on our ability to manage our moods effectively. From both clinical and experimental studies, it is now clear that this ability comprises two different—but perhaps equally important—skills necessary for everyday flourishing: minimizing negative feelings such as anger, sadness, jealousy and worry, and amplifying happiness.1

People prone to destructive habits involving alcohol or drugs typically lack proficiency in one or both of these arenas. To put it simply, they either don’t know how to avoid bad moods or how to elevate themselves into good moods. Or worse, they lack both kinds of proficiencies.

Why does this matter? Because scientific evidence is mounting that such difficulties are linked to a variety of behavioral health problems, including depression, anxiety disorders and substance abuse. This article focuses on a particularly debilitating weakness in self-regulation—namely, rumination—and its role in addictive disorders.

Brooding and rumination

That brooding is psychologically unhealthy has been known for more than a century. In Sigmund Freud’s famous “Rat Man” case in 1909, he treated a young lawyer with multiple anxieties and a fear of rats. Freud termed the man’s chief problem as “obsessional brooding” and saw his fixation on negative thoughts as a form of self-punishment caused by guilt feelings about early sexual behavior.2 In other cases, Freud saw brooding as a way that people avoided acting on mainly sexual impulses by over-focusing on their thoughts.

Today, clinical researchers use the term “rumination” to describe the repetitive replay of unhappy thoughts or memories, and have found it predictive of depression and alcohol/drug dependence. While viewing sexual issues as only one potential contributor to ruminative behavior, they share Freud’s insight that it originates during childhood and takes hold by the time we’re adults. For cognitive psychologists, rumination is a type of “self-talk” that is both negative and repetitive.3

Of course, not everyone ruminates, so what family dynamics are likely to set it in motion? The consensus is that it is induced by a parenting style that is intrusive or controlling, and cold rather than nurturing.4 Think of the “helicopter parent” as the mass media likes to call it, but one whose constant hovering also lacks warmth. Children exposed to this parenting style grow into anxious teens with meager self-efficacy (confidence in handling life’s challenges) and are prone to ruminate. As adults, they typically believe that their replay of unhappy thoughts is somehow beneficial, but it almost never is. Studies show that females generally dwell on sadness-producing memories, while males fixate more on those involving anger.5

Consider these hypothetical examples. Karla is a timid 13-year-old with no close friends. During lunchtime at school, she was ridiculed about her dress and burst into tears. Nobody defended her. Since then, Karla finds herself recalling the event throughout each day and feeling worse about her loneliness. Yet she takes no concrete action to make friends, or to view the event in a less important or different way.

Devin is a burly 15-year-old. He loves playing tennis, and was scheduled to try out for his high school team. Unfortunately, the night before, Devin sprained his hand while wrestling with his cousin, and the coach canceled the tryout without offering a makeup. “Good luck next year!” he snapped, and walked away. Several times a day, Devin angrily replays his coach’s abrupt remark, feeling both furious and helpless. The repetitive scene never gets better or goes away.

Teens such as Karla and Devin have the illusion that their rumination is somehow helpful. But as research led by the late Susan Nolen-Hoeksema, PhD, of Yale University and colleagues consistently showed, ruminators rarely problem-solve their troubling thoughts away or even distance them effectively.6 It is as though they’re wearily running on a treadmill while believing that they’re reaching a destination.

Nolen-Hoeksema’s team found that these teens are at greater risk than low-ruminating peers for developing depressive symptoms—and eventually for becoming dependent on alcohol or drugs. Indeed, the risk is so high that researchers have suggested that youthful ruminators be targeted for prevention programs.7

In this light, Tony Bevacqua, author of Rethinking Excessive Habits & Addictive Behaviors, has offered a cogent explanation for the connection between rumination and substance abuse. He comments that “self-critical people experience chronic stress, depression and anxiety because they live with the voice inside their heads repeatedly telling them they’re inadequate or worthless. At the same time, family and friends contribute to this negative mindset through criticism and judgmentalism. Further compounding this dynamic are the treatment professionals who use deficit-based, emotionally charged, and negatively connoted words—such as `alcoholic’ and `addict.’”8 In Bevacqua’s view, this tripartite system sustains excessive, destructive habits.

Treatment considerations

How can you detect rumination? Simply ask your client, “Do you often find yourself having the same, unhappy or troubling thoughts day after day? If so, about what?”

People who ruminate are certainly aware of it, and the first essential step in treatment is to convince clients that it is detrimental to their emotional well-being. They need to understand that the tendency to fixate on unpleasant memories is a trap, providing an appearance of self-help but only exacerbating depression or anxiety. Why? Because ruminators rarely emerge from their “mental box” to overcome such problems as low self-esteem, weak social skills and unhappiness.

By its very nature too, rumination is antithetical to self-compassion, an important trait in positive psychology. Research shows that people who score high on self-compassion have better coping skills, greater enthusiasm and life meaning, and less shame than their low-scoring peers.9

Once you have convinced your clients of the ruminative trap, several types of intervention are available. The most frequently used comprise training in thought stopping, systematic desensitization, mindfulness, and reattribution.10

With thought stopping, clients are taught to suppress the unpleasant thought, such as by saying “Stop!” to themselves, pinching themselves, or snapping an elastic band on their wrist. In some adaptations of this technique, clients are taught to replace the obsession with a more positive thought.

Although it initially seemed promising in the 1980s, especially in treating obsessive-compulsive disorder, thought stopping has generally proven ineffective in treating rumination. Some clients actually become more anxious in trying to suppress their repetitive negative thoughts. For many others, relief is temporary at best.

Systematic desensitization also has been used for a long time. While holding the debilitating thought in their mind, clients are taught to reduce anxiety via body relaxation. This method is based on the behavioral principle that the undesirable response can be eliminated by evoking another, mutually incompatible response. In systematic desensitization, scenes related to the anxiety are presented to clients in a graded sequence while they’re in a physically relaxed state. The goal is that eventually, the troubling thought or memory ceases to arouse any anxiety. This intervention has generally proven effective, especially when involving rumination marked by worrying.

Associated with positive psychology today are mindfulness training and reattribution. Based on Far Eastern meditation, mindfulness was first popularized by psychological innovators such as Jon Kabat-Zinn at the University of Massachusetts Medical Center. Mainstream healthcare professionals were initially skeptical, but it has become well-accepted. Meditative practices associated with Buddhism and other spiritual traditions are taught as distinct from rituals and theological beliefs. In this way, medical journals such as Hypertension, Pain Medicine, and Sleep regularly publish articles on mindfulness training for a variety of ailments, including anxiety and rumination.

Underlying mindfulness training is the basic idea that to fight or focus on negative thoughts serves only to strengthen them. Thus, as Wiveka Ramel, PhD, of San Diego State University and colleagues reported in Cognitive Therapy and Research, individuals “are instructed to notice the thoughts and feelings that arise without becoming absorbed in their content.”11 In a structured course typically lasting six or eight weeks, clients learn to dissociate their feelings from their negative thoughts: to serenely watch them pass like clouds meandering across the sky. In recent years, studies have shown that mindfulness is effective in reducing rumination and depressive symptoms, as well as enhancing overall well-being.12

Reattribution is associated with research on explanatory style, pioneered by Martin Seligman, PhD, of the University of Pennsylvania and colleagues. It is based on the view that how we interpret negative events in our life has huge consequences for our emotional health. Studies have shown that explanatory style comprises three distinct aspects:

• Permanence. Does one believe that the distressing situation will always exist or will be only temporary?.

• Pervasiveness. Does one view the unpleasant situation as all-encompassing or specific in nature?

• Personalization. Does one blame oneself entirely for a bad event, or spread the blame to others?13

Research shows that people prone to rumination generally have an explanatory style that views upsetting events as permanent, all-encompassing and self-caused. Thus, the goal of reattribution training is to reverse that mindset, by teaching clients to see distressing events as temporary, specific and caused by others.

Typically, clients are first introduced to this concept and shown how attributions can influence mood. For example, they might be given hypothetical examples such as failing a math exam, being ignored on the street by a passing friend, or not receiving a reply to an important e-mail, and asked how explanatory style would affect a person’s mood. Over time, clients are guided in examining their own explanatory style, and adopting a more positive way of interpreting past events. With this strategy, they learn to change their habitual pattern of thinking, and rumination is minimized.

Though reattribution makes sense in theory, research shows that especially with high ruminators, it’s generally effective only when combined with other methods, such as mindfulness training.14

Edward Hoffman, PhD, is an adjunct associate psychology professor at Yeshiva University and co-author of Positive Psychology: The Science of Happiness and Flourishing, published by Cengage.

References

1. Compton WC, Hoffman E. Positive Psychology: The Science of Happiness and Flourishing. Belmont, Calif.: Cengage; 2013.

2. Thurschwell P. Sigmund Freud (2nd ed.). New York City: Routledge; 2009.

3. Lyubomirsky S, Nolen-Hoeksema S. Effects of self-focused rumination on negative thinking and interpersonal problem-solving. J Pers Soc Psychol 1995;69:176-90.

4. Spasojevic J, Alloy LB, Abramson LY, et al. Reactive rumination: outcomes, mechanisms, and developmental antecedents. In Papageorgiou C and Wells A (eds). Depressive Rumination: Nature, Theory and Treatment. West Sussex, England: Wiley; 2004.

5. Rusting CL, Nolen-Hoeksema S. Regulating responses to anger: effects of rumination and distraction on angry mood. J Pers Soc Psychol 1998;74:790-803.

6. Nolen-Hoeksema S, Wisco BE, Lyubormirsky S. Rethinking rumination. Persp Psychol Sci 2008;3:400-24.

7. Nolen-Hoeksema S, Stice E, Wade E, et al. Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. J Abnorm Psychol 2007;116:198-207.

8. Bevacqua T. Words: the most powerful drug. Elephant 2015. Retrieved from www.elephantjournal,com/2015/08/words-the-most-powerful-drug.

9. Phillips WJ, Ferguson SJ. Self-compassion: a resource for positive aging. J Gerontol B Psychol Sci Soc Sci 2013;68:529-39.

10. Purdon C. Psychological treatment of rumination. In Papageorgiou C and Wells A (eds). Depressive Rumination: Nature, Theory and Treatment. West Sussex, England: Wiley; 2004.

11. Ramel W, Goldin PR, Carmona P, et al. The effects of mindfulness meditation on cognitive processes and affect and in patients with past depression. Cog Ther Res 2004;28:433-55.

12. Deyo M, Wilson K, Ong J, et al. Mindfulness and rumination: does mindfulness training lead to reductions in the ruminative thinking associated with depression? Explore (NY) 2009;5:265-71.

13. Seligman MEP. Learned Optimism: How to Change Your Mind and Your Life. New York City: Vintage; 2006.

14. Wells A, Papageorgiou C. Metacognitive therapy for depressive rumination. In Papageorgiou C and Wells A (eds). Depressive Rumination: Nature, Theory and Treatment. West Sussex, England: Wiley; 2004.