JP: Welcome, I'm Jackie Persons. I'm Director of the Cognitive Behavior Therapy and Science Center, which is a small group private practice in Oakland California. I'm also clinical professor in the psychology department at UC Berkeley. I'm here today with Professor Ed Watkins. Professor Watkins is Professor of Experimental and Applied Clinical Psychology at the University of Exeter. And I think the fact that he's professor of both applied and clinical psychology is very much tied to why we've invited him to do this interview with us. He does both basic research and clinical applied research and he's a clinician. So the work he's doing is very directly relevant to clinicians and that's one of the key reasons we're talking to him today. In addition to his research on rumination, he also studies diet and behavioral change to prevent depression and obesity, the use of e-therapies to prevent depression and anxiety, and the use of innovative trial designs to disentangle the active ingredients of internet-delivered CBT. He has been funded by the Wellcome Trust, the UK Medical Research Council. He received a European Commission FP7 Award and a NARSAD Young Investigators Award. He won the British Psychological Society’s May Davidson award in 2004 for Outstanding Career Contributions to the Development of Clinical Psychology and he's a member of the UK Nice Guidelines Review Board for Adult Depression. Thank you so much, Dr. Watkins, for giving us your time here today.
DW: Thank you, Jackie, it's a pleasure to talk to you.
JP: So I'm here with Dr. Watkins as part of the series entitled Translating Science into Practice that is hosted by and developed by the Society for a Science of Clinical Psychology. The goal of our series is to help clinicians access and use findings from the scientific literature to guide their clinical work. We're here today to talk about Dr. Watkins' work on rumination in depression. I will tell you from my own clinical experience that in the last year or two learning about rumination and learning strategies to target it in clinical work has made a huge difference in my clinical work. So I want to thank you because I know you are a huge contributor to the research and clinical development in this field. I'm reading your book now. It's titled Rumination-Focused Cognitive-Behavioral Therapy for Depression and it was published earlier this year by Guilford. I'm finding it extremely helpful. Before I begin my discussion with Dr. Watkins I want to ask listeners to, after you listen to this interview, if you would be willing to complete a very brief survey located on the same page as this interview that would be helpful to us as we develop this series for clinicians.
So, Ed, I want to focus today our discussion on your article published in the Journal of Abnormal Psychology in 2014 titled A Habit Goal Framework for Depressive Rumination co-authored by the late Susan Nolen-Hoeksema and we will be posting some kind of access to this article to our listeners on the SSCP website. So could I ask you to start by giving us a brief summary of the habit goal framework that is described in your article?
DW: Certainly. I want to start also by acknowledging Susan’s role in that paper. It's quite an important paper, both for the theory, but also because it ended up being the last piece of work that we did together before her final demise. So it bears an honor for Susan as much as anything else. The essence of what we were trying to do with that paper was reconcile two different views that there are in the literature about what happens in rumination. So there's Susan's original view that, in depression, it's a habitual response style that people do automatically that can make them feel worse. But there's also a very strong literature and evidence in the more cognitive psychology framework that rumination is something that is a naturally occurring process when people's goals aren't met. It’s an idea that it’s a normal process to ruminate, to dwell on things when they don't go your way, when you have something unexpectedly go wrong, and it's a loss. It’s a normal process, this state of rumination, that everyone has, but for some people there seems to be a more problematic, depressive rumination where you get stuck. And what we’re really trying to do is -- because both seem equally valid approaches from both the phenomenology and also the science space -- Is there a way that we can actually link the two?
And so I guess the key idea we came up with was that... while it's normally enough because of cognitive mechanisms that if you've got that hasn't gone right--you’ve got a goal you'd like to make progress on but you haven't perhaps because of a loss like you might find in depression.... one would keep thinking about that issue until it is in some way resolved. It may also be that if that process happened again and again and again in a consistent context, you might then start to develop the conditions in which you could have stimulus-response associative learning whereby that context becomes enough to trigger the response of thinking about it over and over again. So it can go from something that is happening from a goal driven process ---which is normal and it might happen for everybody under the right circumstances --to something that becomes a more habitual process that is less controlled and more automatic, as we see in depression. And in particular that might happen if that tendency to respond in a ruminative way happens, a sad mood over and over again and in particular we made the distinction about how that could move away from problem solving if people are thinking about the situation in a more abstract and more passive way.
JP: Ok. Ok. So let me see, I'm going to summarize this briefly just to see if I've got it. So there’s this one literature that rumination is a normal process in response to when your goals don't get met and it's a kind of a state process. And then there's Susan Nolen-Hoeksema's literature suggesting that rumination is a habit and it's a response to, often triggered by negative mood. Is that right? And so what you're trying to do is to reconcile and tie these two literatures together. And so then we get the idea that in depression we often have a normal process that's gone awry where rumination may have become habitual and cued by certain stimulus conditions in the environment.
EW: Ya. Ya. And the other thing would be... that we all are going to ruminate some of the time, and that's going to be a normal process when things go wrong, or when we have unexpected events in our lives and we see that. Sometimes in depressed people we get both, sometimes we get rumination because something's happened to them. They are also ruminating about more everyday things that other people aren't ruminating about. So there's a mixture of ruminating to a loss, an unresolved goal and this more habitual process. The argument that we've made is that if the goal driven rumination kept happening and it was contingent to the same stimuli, in this case feeling sad, then that becomes, through associative learning, that can become a trigger for it. And that would be particularly the case under certain circumstances and of note they happen to be the same circumstances that you often see for people at risk for depression, which is where you would have lots of unresolved goals and you're experiencing difficulties, adverse events, trauma... because the more that happens, the more likely you are to get that pairing of sad mood and repetitive thinking and that's combined with a reduced repertoire of coping skills... whether that’s through learning experience, or modeling from parents, or other factors. So you're then more likely to not only have sad mood followed by repetitive thinking, but that repetitive thinking tends to be more abstract, more general 'why did this happen to me' type rather than problem solving. And under those circumstances, the habit of depressive rumination will develop. And indeed that's what *** seems to suggest ... *** abuse or neglect are much more likely to be ruminators.
JP: Very interesting. You just said about five things I want to follow up on, but before I do that, let me ask you if you were going to think about the three main take-home messages that you would see as important for clinicians to take away from your article, what would you suggest they are?
EW: So I think that there are three key interlinked messages. The first message would be what we just talked about. Rumination can be both a normal response to goals, so that we need to normalize it in that context. But it can also become a mental habit.
JP: A problematic habit.
EW: Ya. So that's the first message. The second message follows from the idea of it being a mental habit. So there's a number of things that come from a process being a habit: it’s cued, it's automatic, it doesn't take effort or at least it's hard to control, it's hard to change, it doesn't respond to just telling yourself it's not a good idea. And linked to that, there are two possible ways to change the habit in a more effective way. And they are… that would be the third message.
EW: You can change a habit through stimulus control. You can take away the cues to the habit. Or you can effectively try and learn a new habit on top of the old habit and replace the habit. And of course that requires certain things in terms of identifying the trigger and then repeated practice of the alternative. And that also has huge implications for what one might do clinically.
JP: Yes. So three main messages. One is that rumination can be both normal so that we might want to normalize it with our patients and it can be a problematic habit. The key idea, second, that rumination can be viewed as a habit which means that it’s cued, it's automatic, no effort, and it's not so easy to change either. We could say more about that. And then you're saying the key point ...the two key ways to change rumination or the habit might be through stimulus control to remove or change the cues or to train a new habit. So could you just say more about both of those? Both the stimulus control piece to change the habit and the counter conditioning, I believe is another word you're using, to train a new habit...Help the clinicians do that.
EW: I think in essence the approach that's particularly helpful for trying to work towards both of those is something that is already well-established in cognitive-behavioral interventions with different degrees of emphasis, and that's really to do a functional analysis. So you sit down with an individual client and you look at when they ruminate, where they ruminate, and under what context and then you can start to see when it does happen and when it doesn't happen and you can start to map what might be the antecedents or the triggers. And then gives you the option to think about stimulus control if those antecedent or triggers are amenable to environmental control. I'll give you some examples. After people report ruminating in particular places or particular times of the day or particular part of the daily routine. Two obvious examples of that is lying in bed in the morning before getting up and lying in bed before getting to sleep and in fact impairing getting to sleep. And so identifying that and then making a change in someone's routine, what to do at that point, it could be one way to interrupt that.
JP: So with the person who is lying in the bed ruminating in the morning we might suggest that they get up instead of doing in that. What about lying in bed at night they could listen to a relaxation or some other kind of audio recording in order to give a different mental.... what do you think?
EW: We could do that. We'd probably start...as part of stimulus control we might be doing some sleep hygiene work. So the whole idea that they may already have a buildup in association of getting into bed and their thoughts getting activated. I think one of the reasons why some of the simple stimulus control mechanisms for sleep might work quite well.... for insomnia might work quite well... if someone's lying in bed****get up and go somewhere else and do something until they feel sleepy again, and then go back to bed and repeat until they fall asleep quickly, that's working on the same principle of interrupting the link between lying in bed and being awake, and being in bed and ruminating. That's a simple thing they can do, but we may also build in alternative strategies for that person like relaxation or focusing your attention on something else as well.
JP: Yes. Can you say more about repetitions and the need to get in a lot of repetitions in order to learn a new habit and help us implement that clinically?
EW: Ya. One of the key ideas that comes up from the habit change is to... you need three things really. You need to have repeated performance of the alternative behavior that you want to replace, so instead of ruminating, doing something incompatible to rumination that’s helpful and doing that again and again. You also need to make sure that’s contingent to the same stimulus cues…. so it's not just that I practice being active or problem solving, but that I’m doing that to whatever may be the idiosyncratic triggers or cues, which could be mental, could be certain thoughts happening, or could be physical, feeling tense or alert or thoughts that feel unfocused, or whatever for that individual. And then we need it to be reinforcing, so we need the new behavior to have some functional benefit, either it's functioning by replacing the original rumination, so it's getting some pay off or it's helpful to making them feel better. That cue routine and reinforcement are the key things to build a new habit.
JP: So to build a new habit we have to pay attention to training the new habit so you will do active problem solving or you're going to do focus on your breath or you're going to do listen to music ...one of my patients does this while she's jogging so instead of ruminating now she listens to music. So you're saying one of the things that's important, which I hadn't fully grasped, is that it's important to train the new habit in the same stimulus situation as the one that prompts the rumination because we're trying to train it up so that the stimulus situation now prompts the new habit, not the old rumination.
EW: Yes. In that sense it’s counterconditioning the new response to the original stimuli with the view that that then becomes the habit. So, after a while, when they're in that situation, that difficulty comes up again, or that stimulus, or they start feeling stressed or whatever, the alternative response is more likely to happen automatically than the rumination. There’s a new habit there. That requires quite a lot of repetition, particularly if the rumination is well entrenched as a habit. You have to do it again and again. We emphasize that when we talk about habit. There are some benefits in talking to clients around the construct of habit in itself because everyone understands it, what a habit is. It seems a less stigmatizing thing to talk about, and also implicitly and more explicitly, it's not going to change overnight. We're working on a habit…. people get that we're going to have to work at this. So what do…. we would typically identify the trigger and then practice doing something different there and we practice that in the session so we do a real live practice so people have a sense how to do it. For example, if the trigger ...it's quite common that it’s physiological arousal, early signs of anxiety, often quite good triggers-- heart rate going up, feeling tense, that kind of thing... we might do something in the session to induce that feeling, for example recalling a previously stressful situation and when someone has that feeling, we would then practice doing the alternative thing rather than ruminating which could be working through a structured kind of problem solving or switch attention outward on to something more constructive. It could be relaxation. It could be a range of things. We would probably choose something that's already in the person's repertoire so we know they can do it, and it’s more reinforcing for that person. So they get some sense of control from doing it. And then we practice it in the session and typically we would record it on audio so we could give that audio to the person and say practice this, schedule that to practice. Schedule a practice to make the link between the stimuli and the response. We’d also make what we would call an If-Then plan, which is similar to the track track idea in behavioral activation whereby you explicitly make a plan where you say if I notice this certain stimulus happening, I notice I'm getting tense out in the world, then I will do this and I will use the plan. That would be another form of the work. We’re effectively trying to get people to do scheduled practice to make the link, but also to practice as it emerges in the day to day today world, as a way of strengthening the ecological validity and generalizability of the learning. And if you get people doing that for a couple of weeks, if there quite common ruminators, they're probably going to have multiple examples a day, so over a few weeks you get potentially quite a lot of practicing if someone’s positive about trying to do it.
JP: Let me ask you this because I'm not quite clear. So when the person is practicing, they're not just practicing the new behavior like the relaxation strategy or the focus on the present and the environment and do something productive. They are practicing actually experiencing the cue and then practice.
EW: Whether that's deliberately making the link in the context of behavioral activation where we give them a mood challenge and then do the practice like we would in session and then they go off and repeat that from audio. Or whether it's making that link in their day to day responses so we explicitly make a plan: If I notice X, then I do this.
JP: Then I’ll do it. So that's the taking use of spontaneous cue presentation to practice the new skill so they get linked up together. In addition to doing that, we might have the person do exactly what you just did in the session which is we're going to explicitly elicit the cue, we're going to present the cue. We're going to think about something from the past that's going to make us tighten up and feel anxious. That's the cue, we're going to explicitly elicit that, and then we're going to practice the new skill so they get linked together. That's what happens in the explicit practice. Is that right?
EW: Yes, absolutely. It’s very much taking on board this idea that we're not just trying to train a new responses, we’re trying to train a particular response to a particular context. And we need to very explicitly do that. And that makes a lot of sense when it comes to conditioning theories and so forth. That sometimes happens when people are doing cognitive behavioral therapy, but we're maybe being a bit more explicit about it. When we're trying to get people to do that in their practice here. All with the view that this is actually going to help change the habit and make it more likely that over time the habit itself will change.
JP: Right, so we have this habit idea, so that means a lot of practice is needed. How many times of practice, how many repetitions are you thinking are needed to give the person some chance of having this habit be changed?
EW: It's hard to say for sure because I think there's quite a lot of individual difference here, and it's quite hard to quantify exactly how much practice people have done when we’ve done face-to-face therapy. The literature on habit change in other areas suggests that it's 60-100 repetitions is where you see the automaticity of the new habit reach mass asymptote…so you can't get any better it. And whether that's enough to get a habit that's workable -- because that's where it balances off-- but maybe you need less to get a habit that's workable. And if we've got quite say into examples, like the memory of ‘Oh I felt sad and then I did this different thing and I've got an explicit rule with an implementation intention if I'm anxious I'll do something else.....then it might be that we can get to that effect with fewer practices. But at this point that's kind of an empirical question. And we probably need to do more research on actually investigating that. We started to collect more data in some of the studies we’re doing onon how automatic and how habitual these responses are, so when we go back in to that data and mine it a little bit, we can see if we can get some sense of how many repetitions you'll need. But the sense is that when people start telling us that it's changed as a habit because they start saying it's becoming more automatic that I'm doing these different things, that really does start to feel like we're making progress.
JP: Yes, yes. Now one of the interesting things about the new learning that you talk about in your article is the degree to which its highly context-dependent. Is that accurate?
EW: That would be the argument from the general habit literature and the general associative learning literature. We haven't tested it so much with the rumination literature.
JP: I see. But you’d be expecting that based on the other literature.
EW: And the other literature would say that if you've learned to do a new response to a particular context... if the context changes to some degree, that may change. I think it may not be as bad as that, partly because a lot of what we are training people to respond to when we’re training a new response as a habit to rumination is typically ….what we’ve ended up doing, the stimulus is an internal one. So it's a physical feeling, it’s a state of anxiety, it's a physiological sensation, it's a thought. And because that’s internal, my sense is that may help it to generalize across situations because you're walking around with it, with you, all the time. And that may mean that what's going on externally, contextually, may be slightly filtered through the fact that this part of what you experience. That's a hunch but we need to test it. I think a lot of work in habit change is focused on things that are environmental cues, and of course environmental cues can affect other environmental cues.
JP: I see, so that is very interesting thank you. I’m realizing I moved quickly to habit change and so on, but I think I would like to focus a little more on the stimulus control piece of identifying the cues themselves because I'm assuming that's a very important, a key piece of the clinical work. Can you say more about that?
EW: Yes, it's critical to identify the cues. That's another place where simple things we would do, a functional analysis. So the idea of doing an ABC: antecedent, behavior, consequence. Take rumination as the behavior and then you're trying to track what comes before that. And often there's something happening in the world, so it's a situation, and then there will be some other people around them, and then there will be some internal response: thoughts or a feeling or sensation. What we will be looking for is which of those come before the rumination, as part of this sequence, as part of the process. A really good analogy that would be familiar to people who do cognitive behavioral therapy is that if you think about the model the thing that you would do if you were investigating someone who is having panic attacks, you would do a very fine tune detailed analysis of what led up to the point where they were having the panic, what happened with the feeling, what happened with the behavior, a second-by-second, very detailed analysis of content to see the process of how it builds up. And we would do the same thing, we would ask people about their most recent example of rumination, and we go through them second by second, as much detail as we can, what happened then and then what happened after that and then what did you notice and what did you feel and what did you think until we can map out that sequence. And we do it for a couple of examples and then see if there are any commonalities in terms of what was happening. That would be one way we would try to spot those triggers. The other thing of course is have people do self monitoring. So having diary records, completed between sessions, they would themselves note down when they ruminated and what was happening just before, and that could be doubly useful, both as something to discuss in the session as a way of identifying, but also as we know with lots of habits, becoming quite aware of them is quite an important step and actually having people filling records and doing some self monitoring is often quite powerful in that.
JP: So self monitoring as a strategy for increasing awareness of the cues. So let me shift a little bit if that's okay and ask you about cognitive restructuring. So your model suggests that cognitive restructuring is unlikely to be very helpful. Would you go so far as to say that it’s contraindicated to treat rumination?
EW: No, I wouldn't go that far. I think the argument would be that it's harder for cognitive restructuring to reduce rumination. It can do so, but it can only do so under certain conditions. And that partly reflects the theoretical model and it partly reflects our clinical experience. So I did a lot of work at the beginning with people who are ruminating a lot where I was taking a very traditional Beckian CBT approach, and it would help to some degree. But what we’d find is often that you could change one specific thought, and do that well together, and you could see that change. But then another thought would just come up. So there was something about…. it was only just one thought in this whole process that people who ruminate a lot have. So just taking it one thought at a time. It didn't seem particularly...
JP: I had a patient once... she described it as mental ping pong. One thought comes up and we respond to it, then another one comes up and we respond. But then it just seems to go on and on. It doesn't really...
EW: And sometimes it's worse than that because you get some patients … this is partly an interaction between a patient and possibly someone doing therapy less well...but you sometimes get the effect of... 'Oh I've challenged that negative thought' and then the patient goes 'Well that's really obvious, why didn't I think of that before?' and then they start getting into a ruminative train about beating themselves up ….that they should have been able to spot and change the negative thoughts. You’ve got those two issues. There are two metaphors. There's a metaphor where your thoughts are a chain, and if you just break one link in the chain you're okay. One good challenge might do that. But if you see the thoughts of rumination as kind of a flow of water, like a river or a waterfall, changing one thought at a time is like stopping a drop of water. What we're trying to do is...can we shift the flow? That doesn't mean we don't do thought challenging or Socratic questioning. It's not cognitive restructuring in the sense of we’re looking at the accuracy, but you'll be asking questions about the function or the helpfulness… so you move to that process level rather than that content level.
JP: And would you say you might be asking questions... what helps me clinically, but tell me if I'm on track, is to ask questions about not just the function of any particular thought, but perhaps the function of the whole process, the rumination as a thing itself as opposed to looking at each thought.
EW: Absolutely. That was the sense, that we could get stuck in thoughts. And it also reflects the fact that some people who ruminate really do want to focus on every little thing that's happening, and so we want to move away from the meaning and the content and say ‘Look, there's this process happening here. Let's look at the overall process.’ And that's where we would track it. We would ask quite detailed questions in the same way that you would often do if you were doing thought challenging. But rather than detailed questions being there so that we can then go ‘Okay now let's see if this is an accurate representation. So can we see how the process unfolds…” and then look at what the effects of that are and where they could maybe do something different.
JP: Right, so what the effects are might help us start to identify what might be the function of this whole process.
EW: Yes. I don't think it's particularly productive to ask a patient what's the function of that thought, is moreso... you do an antecedent behavior consequence kind of track a sequence of rumination, you'll see the trigger here, I was starting to feel a bit irritable and then I started having all these thoughts about how I'm being over-sensitive and I'm overreacting. And the consequence of that is that I feel down but I don't feel irritable anymore. If you get a few examples of that, you can conceptualize it together 'Well I wonder whether one of the things that might be happening here is that your rumination is something about controlling anger even though it makes you feel terrible.' If that makes sense to the patient and there are a few examples of that, then we can start to say ‘Okay the trigger is the sense of being irritable, how about we find an alternative behavior you can do that helps you feel in control of anger that doesn't have all the downside of beating yourself up about being over-sensitive.’
JP: So then to begin to look at other strategies to reduce irritability, strategies other than rumination.
EW: So we can *** into the habit change because we can link it to the stimulus, in this case irritability, and it's naturally reinforcing to the person because it’s functionally equivalent to the rumination without the downside. So in that case you might be teaching a combination of relaxation to deal with the physical effects of anxiety and possibly assertiveness because then you can actually deal with the situation that's causing the irritability. So, in a sense, we're very flexible. We can use the full range of cognitive behavioral techniques but the selection of them is based on how they fit into that model of what's going to be most effective to replace the ruminative habit with a more functional alternative.
JP: Yes. Yes. Thank you. Could you say something about the difference between productive ruminative thought and unproductive ruminative thought. This particular example might help with that, but we'd like to hear more about that piece.
EW: This comes back to the idea that it's normal to think about something that hasn't gone your way or something unexpected or when you're hoping to make progress on a goal and you haven't. And of course these are the kinds of events that happen to everybody, so not getting a promotion or the end of a relationship, all sorts of things that might trigger rumination and trying to make sense of what happened and review what happened. The idea is that’s normal and sometimes it seems to be helpful and sometimes it doesn't. What we've been looking at is what might make that distinction. One of the key things that seems to be important is the way that people are thinking about the situation that's happened to them and the end result goal. So if what you're thinking in a very concrete and specific way, so you're paying attention to detail of the situation, how it happened, the context, the sensory details, who it was with, where it was, what was going on, and how it unfolded over time.... that seems to be much more helpful both in emotional response but also active problem solving than if you're thinking about the same situation in a much more generalized or abstract way. The classic example of that is something bad happens and the person thinks "Why did this happen? What does it mean about me? Why did this happen to me? Why does this keep happening to me?" A clinical example would be... one of our clients, a few clients we’ve had, someone who is depressed, a mother of a young girl, teenage children where they sometimes get into disagreements or arguments with the kids. So a trigger to a bout of rumination might be a kid misbehaves or not being able to discipline the kids. And then that person will start thinking "Why is this so difficult? Why can't I get control? Why am I such a bad mother?" and that will go on and on and on. They move away from the discrete detail of the particular interaction. "What does it mean about me?" and they'll think about other situations that have gone wrong, or other situations in which it's not worked. So if in that same situation, the person thinks about how did this happen?" and replays the details of the interaction. "They said this, I said this, this happened...." And they also think "How can I do something about it? What can I do next?" you will often get a much more constructive sense of the situation. It stays a bit more in perspective. And that's what we've seen both clinically and through a number of experimental studies that shifting from this "Why" question versus these "How" questions or "What" questions. It makes a big difference.
JP: OK. So the less productive rumination would be Why/abstract type of questions and the more productive rumination would tend to be what are the details of what happened and how did it happen and that kind of thinking would tend to lead to more productive thinking and problem solving.
EW: Yes. That's right. And what happens with those why questions is they move away from the detail of the situation and they de-contextualize it, so that feeds into the generalizing that we see in depression. Whereas the How questions tend to ground it more in the context, which helps keep it in perspective, but also generates potential options for doing something different. Because it brings about behavior... what could I do differently? Rather than something wrong with me, or something wrong with the world, or....
JP: Right. So now part of the interventions you've been doing in your therapy involve concreteness training. How do you do that exactly with your patient? I assume it's pretty close to what we've just talked about, but is there anything else involved in concreteness training?
EW: Yes. It's similar to that. We'd be emphasizing all of those elements like paying attention to the detail of the situation, the context, sensory, perceptual, and sequence of what happened, and you can proceed. Usually it goes through a couple of phases. What we often do is try to get some experience that illustrates experientially to people that there's a difference in these styles of thinking. Often we'll do a behavioral experiment while having talked through a couple of situations where someone ruminates, I'll note it down with the kind of questions they're asking themselves, the Why questions or the Meaning questions. We'll get them to imagine the situation again and prompt them with those questions and see how they feel, and whether they make active plans or not. And then as a second part of the experiment, get them to imagine that same situation again, but this time I prompt them with more of those How questions like how did it happen and how can you do something about this?... Often even just doing that in the session, they get a session “Oh ya, I’m being a bit more positive here, or I’m able to be a bit more active here.” So we’re giving a very quick indication in the experiment that there may be a shift in their thinking. And that gives them motivation for them to go practice and do a more formal version of that where we spell out the elements. And again we often try to link that to the warning signs or cues to rumination or to difficult situations. We practice in the session. We get them to recall a recent event that was a bit upsetting-- not too upsetting because it's easiest to practice it on a milder event to start with. And then practice going through and focusing on the details and thinking through the sequence and thinking how they might do it. And there's a standardized set of prompts. Get them to practice that in the session, and then they would have a recording of that that they would go off and practice.
JP: And the recording would be of the prompts themselves, to remind yourself to ask yourself…
EW: Imagine the situation and then working through the prompts.
JP: Imagine the situation... So in the session you might have the person imagine a situation like: Oh I just had a disagreement with my teenage daughter. Now I'm going to walk through this particular set of prompts that Dr. Watkins just gave me. One is let me just focus on what happens, let me focus on the details in time, what happened first, and then what happened second, and then what happened next, and I'm going to walk through all those, and then I'm going to ask myself "Is there anything I could do?" Would those be the kind of prompts?
EW: Yes, noticing the detail of what was happening. And how did this happen? And how can I do something about it? How could I get started? Those kind of prompts. Typically the first time we do it, we get the person to describe the situation so then the therapist can prompt not just generically, but more specifically. If you know the situation was an argument with a teenage daughter, then you'd want to know what did you say and how did you say it and what was your tone of voice and where did you say it? So you could prompt them the first couple of times with a bit more detail so they get a sense of what they're trying to get to. And then the other thing you'd do in therapy is that you'd keep coming back to that. So when they're describing the situation, you introduce the distinction between being more concrete and being more abstract. "You describe the situation but you're still talking about it in quite an abstract way. Can we try to get more detail with that?" So we encourage therapists to drill down to more detail. The rule of thumb is can you get a mental picture of what the person...?
JP: Ah. Yes. You talk about imagine it as if it were a movie. And so if your patient is talking to you about a situation where you cannot get any visual image or movie of what happened then that's a cue to you and the patient that it's too abstract. Is that accurate?
EW: Ya. Something like that. Also, can you get down to the exact behavior? Often people use terms that are already quite abstract. They'll say this person insulted me. Well I have no idea what actually happened. Something like a gesture... that's the kind of a cue to say just tell me what actually happened. I want to see the person's behavior and other people's behaviors.
JP: Ah. What are the behaviors. And it's true I wouldn't be able to have a movie in my mind if the person said he insulted me. We would need to know the actual behaviors. Let me ask you one final question which is about assessment and measures. Would you recommend that clinicians use measures or scales to assess rumination and would you recommend doing that as the therapy proceeds?
EW: If you think that the rumination might be an issue-- and often that's worth doing with patients that have depression or anxiety-- it's probably a good idea to assess it. How much you use a score in a formal way is personal preference. What can be quite useful is Susan Nolen-Hoeksema's Response Style Questionnaire which asks lots of things like ‘What do you do when you feel sad, down, or depressed? Like thinking things over…’ That can be quite useful as a jumping off point for a discussion with somebody. If they're scoring quite high on that, it's like saying ‘Oh this looks like something that's happening a lot.’ And that can be a useful entry point for thinking about rumination as something that person might do. And it's been my experience when you introduce the idea of rumination with patients with depression and anxiety, it makes a lot of sense to lots of them. And sometimes it's not something they've discussed before. There is actually something they can grab hold of. ‘Ya, that does describe me. I think it would be useful to focus in on that.’ So it can be useful in that kind of context, in an assessment, as a frame for what you do. It's not really been designed as a clinical measure, a change measure.
JP: And here you're talking about Susan Nolen-Hoeksema's Response Styles Questionnaire?
EW: Technically the ruminative subscale of the Response Styles Questionnaire. Ya, it does change with symptoms, it does change with treatment. We've shown that in a couple of studies. But I'm not sure it's the best clinical measure. What we've actually found that's been quite useful is a more ad-hoc measure where you just get patients to report on a scale or on a line the frequency of their rumination, the duration-- sometimes they can have shorter or longer... what's the average duration, how much control they have over it, and how much it interrupts other activities. Because those seem to be-- clinically-- are more sensitive to intervention, to pick up on those other changes.
JP: I see. So you might then just develop an ad-hoc scale where you're asking about frequency. So you'd just be asking for an average count per day, or something like that?
EW: Or over the week.
JP: How often did you ruminate? Duration, what was the average or maximum duration?
EW: We typically would ask average and also the longest of the week.
JP: Average duration of rumination over the week and what was the longest time you spent ruminating...I wrote C. What was that third thing? Oh! Control.
EW: Control. Out of 100, say, 0-10 or 0-100, how much control did you have over it? And we've actually found that looked like it might be one of the more sensitive things that's changing. Because sometimes the frequency and the duration don't change right away, but people say ‘Actually I can start and stop more than I could.’
JP: OK. So you might also ask for degree of control, 0-10, that you had over the week, and you notice change in that perhaps earliest. And then you might also ask for a rating, 0-10 would you do? To what degree did rumination interrupt your life?
EW: So this is how much is it causing a problem.
JP: Interfering, right. And would you rate that 0-10 also?
EW: Yes, something like that. A lot of patients will say: It’s stopping me from doing things. Or it's making me feel down, or it's impairing my sleep, or it's making it hard to concentrate at work or ...
JP: Right. Beautiful, thank you. So let me see us as coming to an end here, and let me ask you is there any final topic that is critical that we haven't talked about here that clinicians should be thinking about if they're going to start attending to rumination in their patients and start to learn from you about intervening to treat it?
EW: I think we've covered most of the key things about spotting the triggers, and the context, and practicing the habitual response, to learn a new response to that, and have a functional analysis. I guess the more general thing that might be worth thinking about-- we've talked about this in the context of depression-- that's where most of my work has been done. Theoretically, and increasingly the evidence suggests, that a lot of these ideas could be relevant in other presentations, particularly those where we get comorbidity, as we know anxiety and depression are pretty comorbid, and that's partly the reason to think that worry and rumination are pretty closely intertwined. So if you’re targeting one, you're probably targeting the other. That's one place this work might be relevant and easily adaptable to that, the approach. It may apply to other areas as well. We've seen rumination as a risk factor or a maintaining factor in other disorders, so PTSD, psychosis, eating disorders as well. So it may well be that this might be a useful adjunct to existing interventions where rumination becomes a barrier to progress. I think that's often what we find. It's such an automatic habit and it's hard to control and it is itself interfering -- because it occupies mental space, exacerbates negative emotion, and so on. I think that's one reason why it does seem to suggest that not only is rumination something that's involved in the maintenance of emotional disorders, but may also be a barrier to the therapeutic change sometimes. Where it is popping up in patients, it might be worth identifying it and then trying to target, so you can get on to the other aspects of change that you're trying to achieve. Whether that's exposure or teach them other skills or...
JP: Yes, I agree. So here we're highlighting the transdiagnostic nature of rumination and you're also suggesting at the very end that if you're a clinician who has a patient who is not making progress, it might be worthwhile to go in there and see if rumination might be a barrier and that might help this person make progress. I have found that in more than one of my depressed patients.
EW: I think it can apply in a number of ways. We've got some quite interesting examples from when we are working with depression. We’re activity scheduling. So you have people make a plan to go and re-engage in some activity, whether it's playing an instrument or seeing friends or exercise. And they come back the next week and they've done the plan .. ‘I've done the plan but I don't feel any better…’
JP: ‘I didn't get any enjoyment.’
EW: And then you'd review it and you'd see that all the way through this activity they've got a running commentary "This isn't as good as it used to be." or "I'm not doing this well" or....
JP: "What's the point?"
EW: Ya. They're ruminating as they're doing it. So it completely blocks out any of the reinforcing benefits of it. So it can be a block there. And I think the same thing can happen when you're doing exposure. If someone is in an exposure situation and all they're doing is ruminating, it blocks out any learning.
If it is happening at a high rate, it can easily prevent all the other things that might work from having their best impact. We're starting to do some work with some colleagues who look at those things. So can we target rumination to improve interventions for PTSD, for example. Because we know that rumination is one of the big predictors... both risk for PTSD after, if you ruminate about the trauma. It might one of the few things that needs to change, to help people recover from the trauma.
JP: Yes. That makes sense. Thank you, Ed, very much for your time and your obvious expertise in this area. So helpful. I'm learning a lot myself and we're looking forward to disseminating these ideas to clinicians worldwide. Those of you who are listening, I want to remind you when you finish listening, which will happen in one second, please do our survey about what you liked or didn't like about this interview. So let me again thank you, Ed. I appreciate your time, and I appreciate all the many years of work you've done to build these new ideas and help us as clinicians be more effective with our ruminators. So it's a very nice contribution and I appreciate it very much.
EW: Thank you, Jackie. It's been fun talking to you.
JP: Beautiful. Thank you. Have a nice day.
EW: Thank you.