Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk.

Targeting rumination by changing processing style: Experiential and Imagery exercises
Edward Watkins, PhD University of Exeter BABCP 2011 © ERW 2011

Acknowledgements - Funders
© ERW 2010

Acknowledgements Research collaborators Mood Disorders Centre co-directors Dr Celine Baeyens Dr Nick Moberly Professor Willem Kuyken Dr Michelle Moulds Dr Eugene Mullan Rebecca Read Sandra Kennell-Webb All patients and participants Simona Baracaia Therapy development & trial Dr Katharine Rimes Dr Anna Lavender Dr Janet Wingrove Dr Neil Bathurst Rachel Eastman Professor Jan Scott Last but not least in the year following his retirement I want to Acknowledge my huge debt of gratitude to John Teasdale – without his wisdom, encouragement & guidance, none of this research possible. John provided expert teaching mentorship in linking clinical application and experimental design – and he helped kickstart the whole chain of studies… was involved in first studies that set off this whole chain of work.

Plan of Skills class Thinking Style and avoidance as key elements driving pathological rumination A functional-contextual approach – Functional analysis ***Shifting processing mode – Experiential exercises Video This workshop will be more practical than theoretical. There is an extensive research literature relevant to these issues – summarise another time. Shift relevant research slides to end. Will use discussion, experiential exercises, role-play, video to work through these ideas. Flexible re time spent on each Designed to be interactive – please ask questions at any point Will present some case material/video – these patients have given special written consent for their information/sessions to be used for training purposes However, clearly request respect their confidentiality – only discuss in this setting. PLEASE ASK QUESTIONS AS WE GO ON TWO KEY MESSAGES – Applying functional analysis to rumination/worry -Idea of directly switching mode GENERATE DETAILS RE INDIVIDUALS BACKGROUND, EXPERIENCES, KEY QUESTIONS

Key process in onset and maintenance of depression & anxiety
Rumination = recurrent dwelling on feelings, problems, upsetting events, negative aspects of self Why can’t I handle things better? What will others think of me? What does this mean about me? Why did this happen to me? What am I doing to deserve this? Why do I feel so bad? Rumination as common Key process in onset and maintenance of depression & anxiety

Rumination-focused CBT (RFCBT)
RFCBT focuses on increasing effective behaviour – i.e., not stopping rumination but making it functional RFBCT grounded within the core principles and techniques of CBT for depression (Beck, Rush, Shaw, & Emery, 1979) with two adaptations: a functional-analytical perspective using Behavioural Activation (BA) approaches (Addis & Martell, 2004; Martell et al., 2001; Watkins, 2009; Watkins et al., 2007; Watkins et al., in press) An explicit focus on shifting processing style via imagery and experiential approaches

Rumination-focused CBT (RFCBT) 2
Within BA terms, rumination conceptualized as avoidance (cognitive & actual) that is negatively reinforced (e.g., avoid risk of failure; pre-empt criticism; reduce intensity) Rumination becomes a learned habitual behaviour May be reinforced superstitiously, partial reinforcement, poor discrimination helpful thinking (problem-solving) and unhelpful © ERW 2009

Cues trigger ruminative response automatically [mood, stress, contexts) Information-giving, thought challenging unlikely to change a habit Hence treatment only effective if counter-condition alternative responses to warning signs Hence focus on identification of warning signs and then repeated practice of an alternative response under mood/stress challenge to develop more functional habit

But dwelling on difficult events is common, normal & often adaptive
What determines whether dwelling on a problem/upset leads to either We all ruminate – dwell on problems and upsets For most people in most circumstances this is relatively brief and adaptive – i.e., resolving problem, working through/processing event This has been the question driving my research programme What differentiates depressive rumination from problem solving? What differentiates depressive rumination from emotional processing? OR constructive resolution, Problem-solving, working through gets stuck in a distressing loop that goes nowhere?

Watkins (2008)– Positive consequences of RT
What are the positive benefits of this? How did this happen? What can I do next? What can I learn from this? What is important to me now? How can I fix this? Reduces negative mood & improves planning & problem-solving in experiments Rumination as common N-H 2000, 2007 Predicts recovery from upsetting and traumatic events and from depression in some prospective studies © ERW 2009

The way that people think during stress and problems may be part of the learnt habit Either an unhelpful unconstructive processing style (conceptual, evaluative, existential, abstract, judgemental, passive) Or a helpful processing style (non-judgemental, non-evaluative, constructive, concrete, action-oriented). Use experiential exercises and imagery to induce this processing style, as counter to rumination, and as means to develop constructive habit

PILOT RCT Residual Depression GP/CMHT referral to the study
Screening assessment -Informed consent? (n = 42) No: Return to treatment-as-usual Yes: Conduct full intake assessment Acute ADM treatment Randomise (n=42) Treatment as usual (antidepressants) May include CBT Individual RFCBT + TAU Up to 12 sessions Post-intervention assessment – blind at weeks (n = 40) Inclusion: a. DSM-IV criteria for MDD last 18 mths, not last 2 mths; b. residual symptoms ≥ 8 on 17-item HRSD & ≥ 14 on BDI-II; c. ADM for ≥ 8 weeks Exclusion: History of bipolar disorder, psychotic disorder, current substance dependence PILOT RCT Residual Depression One unable to contact – gone to Iraq, one significant worse change – hospitalized, alcohol abuse both TAU Watkins et al., in press British Journal of Psychiatry

Baseline scores TAU (n = 21) RFCBT+ TAU (n =21) F p age 45.24 (9.33)
43.05 (11.09) .48 ns F:M 10:11 14:7 2 =.87 Length current episode mths 7.57 (6.13) 9.14 (6.3) .67 Previous episodes 4.84 (3.02) 5.43 (2.93) .45 HRSD 12.19 (2.80) 13.29 (3.32) 1.33 BDI 28.29 (7.63) 30.76 (8.17) 1.03 RSQ 57.88 (8.52) 56.40 (11.92) .21 Axis I diagnoses 1.86 (1.24) 2.05 (0.92) .32 © ERW 2009

Change in BDI by treatment arm
© ERW 2009

Change in BDI by treatment arm
Condition X Time, F (1, 38) = 10.26, p < Between-treatments effect size for  BDI, Cohen’s d = 1.06 © ERW 2009

Change in BDI by treatment arm –Watkins et al, in press, BJP
RFCBT 12 sessions; CBT 20 sessions Condition X Time, F (1, 38) = 10.26, p < Between-treatments effect size for  BDI, Cohen’s d = 1.06 © ERW 2009

Change in HRSD by treatment arm
One more hrsd available Condition X Time, F (1, 38) = 7.38, p < .01. Between-treatments effect size for HRSD, Cohen’s d = 0.895 © ERW 2009

Recovery, Remission & Relapse
Recovery (50% reduction in HRSD): TAU 26% vs. TAU + RFCBT 81%, 2 = 9.92, p < .001 Full Remission (BDI-II < 14, HRSD < 8): TAU 21% vs. TAU+RFCBT 62%, 2 = 5.24, p < .05. [CBT in Paykel et al., 1999 study 25%] Relapse between pre & post assmts (5 mths) TAU 53% vs. TAU+RFCBT 9.5%, 2 = 6.89, p < .01 Note two missing values – both from TAU – one for sure showed no improvement-worsened ended in hospital after return to alcohol abuse – not included in these analyses © ERW 2009

Factors maintaining rumination
AVOIDANCE (not addressed today)

Factors maintaining rumination
2. Thinking Style

A behaviour experiment
A behavioural experiment used with patients The broken down car exercise – recall/imagine time when needed to get somewhere important soon and car would not start . Get as vivid an image of this situation as possible. Imagine that you are in a real hurry The HOW-WHY EXPERIMENT Imagine yourself in this situation. Important meeting – for personal/professional reasons e.g. job interview, collecting child. Picture it as vividly as possible. Start by imagining the car – detailed picture. Vivid as possible. Imagine sitting in car looking out front window, trying to start nothing happening, hurry to get to important meeting. Notice what feeling. Make sure that you capture that feeling that this is a really important meeting. Notice any emotions feelings, physical sensations – note how intense they are. Now staying in that situation, continuing to imagine yourself in that place start to ask yourself questions. Notice your thoughts and feelings as you ask each question – Why did this happen to me? Why me? Why did this happen to me today of all days? Why can’t I get the car started? What will this mean? What are the consequences of this? What will happen if I am late? How will the others thing of me? What does it mean about me? What have I done to deserve this? Why does this keep happening to me? Notice what thoughts you have now. Note what feelings you have – how intense are they. Note down any physical sensations. Ok now lets return to the original situation. ONCE AGAIN IMAGINE that you are sitting in the car and it won’t start. Turn the key nothing happens. Picture the view of looking out of your windscreen. Imagine that as vividly as possible. Notice and note down what you are feeling – emotionally and physically. As you continue to imagine that situation, ask yourselves questions like How did this happen? How did the car break down? What did I notice? What are the sequence of events leading to this point? How can I understand this? How can I fix it? What is the first step I can take to solve this problem? How can I decide what to do next? Again spend a few moments on this and note what you are feeling and thinking. Compare your responses between the two conditions – any differences. Group discussion. COACH approach – What did you notice? What learnt? Common observations: 1st time more negative feelings, sadness, panic, tension, anger, irritability b. 1st time less action, less constructive thinking, fewer plans, more repetitive, acting out c. Many people report that found much easier and natural to do 2nd version than 1st version

The HOW-WHY behaviour experiment
The HOW-WHY EXPERIMENT Imagine yourself in this situation. Important meeting – for personal/professional reasons e.g. job interview, collecting child. Picture it as vividly as possible. Start by imagining the car – detailed picture. Vivid as possible. Imagine sitting in car looking out front window, trying to start nothing happening, hurry to get to important meeting. Notice what feeling. Make sure that you capture that feeling that this is a really important meeting. Notice any emotions feelings, physical sensations – note how intense they are. Now staying in that situation, continuing to imagine yourself in that place start to ask yourself questions. Notice your thoughts and feelings as you ask each question – Why did this happen to me? Why me? Why did this happen to me today of all days? Why can’t I get the car started? What will this mean? What are the consequences of this? What will happen if I am late? How will the others thing of me? What does it mean about me? What have I done to deserve this? Why does this keep happening to me? Notice what thoughts you have now. Note what feelings you have – how intense are they. Note down any physical sensations. Ok now lets return to the original situation. ONCE AGAIN IMAGINE that you are sitting in the car and it won’t start. Turn the key nothing happens. Picture the view of looking out of your windscreen. Imagine that as vividly as possible. Notice and note down what you are feeling – emotionally and physically. As you continue to imagine that situation, ask yourselves questions like How did this happen? How did the car break down? What did I notice? What are the sequence of events leading to this point? How can I understand this? How can I fix it? What is the first step I can take to solve this problem? How can I decide what to do next? Again spend a few moments on this and note what you are feeling and thinking. Compare your responses between the two conditions – any differences. Group discussion. COACH approach – What did you notice? What learnt? Common observations: 1st time more negative feelings, sadness, panic, tension, anger, irritability b. 1st time less action, less constructive thinking, fewer plans, more repetitive, acting out c. Many people report that found much easier and natural to do 2nd version than 1st version The HOW-WHY behaviour experiment

HOW? Probably found easier, more natural

WHY? A number of you noted that the why type question could lead to irritability and anger. If more self-critical could perhaps have been more critical. Here is an example from a short drive from Exeter……

Processing mode hypothesis
Theory and experiments  hypothesis that there are distinct styles of rumination, with distinct functional consequences Adaptive, constructive ruminative self-focus = concrete, process-focused, specific thinking, focused on the concrete & specific experience & process of how things happen moment-by-moment Maladaptive, unconstructive ruminative self-focus = abstract, general, evaluative thinking, thinking about why an outcome occurred (Moberly & Watkins, 2006; Rimes & Watkins, 2005; Watkins, 2004; Watkins & Baracaia, 2002; Watkins & Moulds, 2005; Watkins & Teasdale, 2001, 2004, Watkins, 2008, Psych Bull; Watkins, Moberly & Moulds, 2008)

Targeting avoidance & rumination
Treatment approach 2 – mode of processing Intervention – Shifting processing mode

Switching thinking style
Shifting from evaluative..   to a more process-focused style… A number of distinct phrases, labels and metaphors can be used to help illustrate the difference between the two types of thinking style. Best to use the language understood and used by the patient: Useful vs less useful; thought-thought vs thought-action, How vs Why, straight line-direct vs detour, squiggly; reflective vs ruminative, sergeant-major versus coach Thinking style is built up in steps – follows on from work on effectiveness and then we build it up through relaxation, practise at imagery etc 2. Use imagery, experiential exercises 1. Compare effective vs ineffective thinking in functional analysis

Shifting processing style
Coach experiential exercises/ build up activities to shift out of abstract-evaluative rumination style Focus on recreating experiences of being in a concrete process-focused style (counter to rumination) Video of visualisation exercise : 2554 stepping out of rumination by looking at how you can do things – another way to step out of it by focusing on opposite experience, times when doing something really focused on, really absorbed, for minutes and hours Completely focused, absorbed, caught up in it, completely at one with it, not bothered by thoughts, Can you think of examples of activities when you have been doing that? Yesterday, packing books in boxes 2600 Trying to do way of packer foreman, re heights and widths. Thinking about interplay shapes and sizes of books and words on books [very open, creative, sensory-perceptual type thinking] packing and thinking 2622 useful to recreate as vividly as can that situation, see what can see in that situation, looking out from your eyes doing that activity, notice where you are, see colours, shapes, getting strong picture whats immediately in front of you? A square a box, trying to find a structural harmony but also playing with the words, how they are arranged as well. What actions, movements making seeing those feeling those Notice any sensations in body or muscles Notice any feelings /emotions as totally focused and absorbed Notice where putting attention? Putting attention on aspects of words and shapes – patterns 2704 imagine a few seconds worth – whats in front of me, what do with it, what pattern I can see, smell of books, words and numbers as more and more vivid, reexperience thoughts and feelings, notice what mind looking at coherence of words as look down cross-section feeling – absorbed, interested, exploring, and useful emotions – what feeling I can do this, this is interesting, lots of things could come out of this what mood like? – positive self-= more confident, imagination in good way 2797 take a step out of situation – did it change how feeling right here right now feel more capable, kind of renewed vigour for arts and sciences How was that sitn different from when ruminating and dwelling? Physically doing, not about me, about design and theories, more creative An important element. What was most important thing as doing it? Not so much to get it right as to see what came out of it – wanted to carry on it doing Sounds like an interesting difference – not so much about right, outcome, more exploring, playing ideas Does it happen much? Does it feel different rumination? Could pull it up quickly. Felt like back in it. 2922 – other situations like that – further back in the past. 1. finals 2. more day to day things get absorbed – gardening [next step to look at building in more of these activities – building up] focus opposite from what doing in rumination – using different bits of psyche different in inwards vs outwards, also up vs down (optimism vs pessimism), circle description, going out in lots of different directions 3077 Anything different in what you were doing? Focus on sensory details of what doing rather than how feeling 3112 rumination is all about getting it right –focused on outcome, this is focused on the process on details, outwards, see what happens next impact just now [if time would then go and use as an exercise against an episode of rumination] How to build it up: try new things and recording Practising reliving these things//when notice mindfog (Early warning sign of rumination] What do you think would happen? [could run as experiment]. Counter to rumination. About getting mind back into that groove. 3206 compare episode when caught up and when ruminating and see what different. See common elements – use that to plan to build more of it in. What can I do that really helps me get into this state of mind? Would shift it forwards. 3256 follow-on from there end of session 3270 summarise – what do you think has come out of what talking about it today? I have moved on, most interesting, about using my brain more. Definitely lifted my mood just now today. Video of EW – Compassionate exercise

Absorption experiences - recreate being caught up in the task, “flow”, “in the zone”, peak experiences (connected world direct way)

Compassion experiences - Recreating feeling compassionate, tolerant, caring, nurturing, non-judgemental Video of visualisation exercise : 2554 stepping out of rumination by looking at how you can do things – another way to step out of it by focusing on opposite experience, times when doing something really focused on, really absorbed, for minutes and hours Completely focused, absorbed, caught up in it, completely at one with it, not bothered by thoughts, Can you think of examples of activities when you have been doing that? Yesterday, packing books in boxes 2600 Trying to do way of packer foreman, re heights and widths. Thinking about interplay shapes and sizes of books and words on books [very open, creative, sensory-perceptual type thinking] packing and thinking 2622 useful to recreate as vividly as can that situation, see what can see in that situation, looking out from your eyes doing that activity, notice where you are, see colours, shapes, getting strong picture whats immediately in front of you? A square a box, trying to find a structural harmony but also playing with the words, how they are arranged as well. What actions, movements making seeing those feeling those Notice any sensations in body or muscles Notice any feelings /emotions as totally focused and absorbed Notice where putting attention? Putting attention on aspects of words and shapes – patterns 2704 imagine a few seconds worth – whats in front of me, what do with it, what pattern I can see, smell of books, words and numbers as more and more vivid, reexperience thoughts and feelings, notice what mind looking at coherence of words as look down cross-section feeling – absorbed, interested, exploring, and useful emotions – what feeling I can do this, this is interesting, lots of things could come out of this what mood like? – positive self-= more confident, imagination in good way 2797 take a step out of situation – did it change how feeling right here right now feel more capable, kind of renewed vigour for arts and sciences How was that sitn different from when ruminating and dwelling? Physically doing, not about me, about design and theories, more creative An important element. What was most important thing as doing it? Not so much to get it right as to see what came out of it – wanted to carry on it doing Sounds like an interesting difference – not so much about right, outcome, more exploring, playing ideas Does it happen much? Does it feel different rumination? Could pull it up quickly. Felt like back in it. 2922 – other situations like that – further back in the past. 1. finals 2. more day to day things get absorbed – gardening [next step to look at building in more of these activities – building up] focus opposite from what doing in rumination – using different bits of psyche different in inwards vs outwards, also up vs down (optimism vs pessimism), circle description, going out in lots of different directions 3077 Anything different in what you were doing? Focus on sensory details of what doing rather than how feeling 3112 rumination is all about getting it right –focused on outcome, this is focused on the process on details, outwards, see what happens next impact just now [if time would then go and use as an exercise against an episode of rumination] How to build it up: try new things and recording Practising reliving these things//when notice mindfog (Early warning sign of rumination] What do you think would happen? [could run as experiment]. Counter to rumination. About getting mind back into that groove. 3206 compare episode when caught up and when ruminating and see what different. See common elements – use that to plan to build more of it in. What can I do that really helps me get into this state of mind? Would shift it forwards. 3256 follow-on from there end of session 3270 summarise – what do you think has come out of what talking about it today? I have moved on, most interesting, about using my brain more. Definitely lifted my mood just now today. Video of EW – Compassionate exercise

Focus on holistic experiential shift via memories, images: thoughts, feelings, posture, sensory experience, bodily sensations, attitude, motivation, facial expression, action feelings

Key elements of “flow” (Csikszentmihalyi, 2002)
Deep & effortless involvement in activity Merging of action & awareness Balanced ratio between challenge (opportunities) & skills Focused attention on the task at hand Narrow temporal focus – immediate, present-moment Clear goals, rules & immediate feedback Make clear that this is a way to make the experiences induced valuable, meaningful to clients – to increase immersion, enthusiasm etc – induce any of these elements includes likelihood of getting full-state – and associated experience of joy, pleasure, creativity, meaningfulness, value Deep & effortless involvement in activity Merging of action & awareness Balanced ratio between challenge (opportunities) & skills (challenging but controllable, requires skill) Focused attention on the task at hand – sensory detail, external or internal, process (rather than rumination, evaluation) Narrow temporal focus – immediate, present-moment Structured demands - Clear goals, rules & immediate feedback Loss of self-consciousness Changed perception of time Connection with environment – self-guiding Sense of possibility of control Activity intrinsically rewarding – valued as an end in itself (autotelic) Focus on discovery, learning, growth – build complexity and potential of self

Key elements of “flow” (Csikszentmihalyi, 2002)
Loss of self-consciousness Changed perception of time Connection with environment – self-guiding Sense of possibility of control Activity intrinsically rewarding – valued as an end in itself (autotelic) Focus on discovery, learning, growth – build self-potential Make clear that this is a way to make the experiences induced valuable, meaningful to clients – to increase immersion, enthusiasm etc – induce any of these elements includes likelihood of getting full-state – and associated experience of joy, pleasure, creativity, meaningfulness, value Deep & effortless involvement in activity Merging of action & awareness Balanced ratio between challenge (opportunities) & skills (challenging but controllable, requires skill) Focused attention on the task at hand – sensory detail, external or internal, process (rather than rumination, evaluation) Narrow temporal focus – immediate, present-moment Structured demands - Clear goals, rules & immediate feedback Loss of self-consciousness Changed perception of time Connection with environment – self-guiding Sense of possibility of control Activity intrinsically rewarding – valued as an end in itself (autotelic) Focus on discovery, learning, growth – build complexity and potential of self

Key elements in shifting style
Requires preparation & socialisation into model, use of relaxation & imagery work as groundwork Find vivid memories and imagery of being in process-focused absorbed state – used to a. kick start mode b. Develop habit c. as example for functional analysis to make future plans Review memory to build up details Recreate mental state using guiding questions to direct imagination to details – present tense, field perspective: Sensory experience – As vividly as you can see what you are looking at. Describe what you can see Motivation & Attitude Posture – As you become more absorbed, notice your posture of relaxation Physical sensations – Notice the sensations in your body Feelings – Experience and hold onto your feelings, letting them deepen Facial expressions – Urges to actions Attention – What do you notice? Where are you focusing your attention? Importance of having a balance of activities – need sufficient process-focused absorbed activities versus validation, maintenance activities – valuable for recharging batteries Interactive exercise – getting into style of thinking for feeling absorbed and less absorbed. Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on. For experiential exercise – do negative first then positive. Make clear that negative state is what depressed ruminators are like, whilst positive experience is the new style that we train people into “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” With patients only focus on training positive experience – but to give you a sense of change – start with time finding it hard to concentrate “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Take a note of how you are feeling, energy, what you are thinking and feeling. Compare what doing, experience of each mode Shift into period when more absorbed – notice feelings, posture

Experiential Exercise
Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Compare what doing, experience of each mode Make clear that in treatment that the absorbed work only comes with some preparation and lead in – much preparation time and work Emphasise need for socialisation into model, grounding in previous FA, build up with contingency plans looking at different styles of thinking, use of relaxation and straightforward imagery – such that by the time get to experiential exercises patients already got a handle for this -when inducing working on making it as concrete as possible – building up from aspects of sensory experience, posture, expression, attitude, attention, thoughts, feelings – all feed into each other. May need more preparation, more direction for less imaginative, more groundwork If not get images then work around it making more concrete Differs from MBCT – FOCUS ON ACTING ON For most clients even most macho, concrete it is possible to find relevant examples to draw upon times that absorbed in – sport, extreme activities, working with hands Importance of getting to action – emphasise idea that act to change feeling rather reverse Interactive exercise – getting into style of thinking for feeling absorbed and less absorbed. Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on. For experiential exercise – do negative first then positive. Make clear that negative state is what depressed ruminators are like, whilst positive experience is the new style that we train people into “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” With patients only focus on training positive experience – but to give you a sense of change – start with time finding it hard to concentrate “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Take a note of how you are feeling, energy, what you are thinking and feeling. Compare what doing, experience of each mode Shift into period when more absorbed – notice feelings, posture

Key elements in shifting style
Requires preparation & socialisation into model, use of relaxation & imagery work as groundwork Find vivid memories and imagery of being compassionate to self or others – used to a. kick start mode b. Develop habit c. as example for functional analysis to make future plans Review memory to build up details Recreate mental state using guiding questions to direct imagination to details – present tense, field perspective: Sensory experience – As vividly as you can see what you are looking at. Describe what you can see Motivation & Attitude Posture – As you become more absorbed, notice your posture of relaxation Physical sensations – Notice the sensations in your body Feelings – Experience and hold onto your feelings, letting them deepen Facial expressions – Urges to actions Attention – What do you notice? Where are you focusing your attention? Importance of having a balance of activities – need sufficient process-focused absorbed activities versus validation, maintenance activities – valuable for recharging batteries Interactive exercise – getting into style of thinking for feeling absorbed and less absorbed. Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on. For experiential exercise – do negative first then positive. Make clear that negative state is what depressed ruminators are like, whilst positive experience is the new style that we train people into “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” With patients only focus on training positive experience – but to give you a sense of change – start with time finding it hard to concentrate “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Take a note of how you are feeling, energy, what you are thinking and feeling. Compare what doing, experience of each mode Shift into period when more absorbed – notice feelings, posture

Compassion Work Can use imagery building past experience (compassion to others close, etc) or compassionate imagery (Gilbert) Need to stay with experience and repeat re learning habit Need to allow time to work through it Work up hierarchy from easier points of compassion to more difficult (e.g., other to self) Avoid conceptual analysis and comparative thinking Break down and adapt to overcome barriers experientially Repeated practice in session and outside of session Use functionally

Summary Avoidance & rumination play major role in maintenance of depression Both can be normal & adaptive behaviours Value of adopting contextual, functional approach – FUNCTIONAL ANALYSIS Function of rumination moderated by processing style – Value of interventions to SHIFT style

Please feel free to contact me at e.r.watkins@exeter.ac.uk
Thank you Please feel free to contact me at with any questions, thoughts, plans about research, for handouts etc © ERW 2009

Additional slides from full workshop follow
Group approaches More information on avoidance More information on experimental work More information on functional analysis © ERW 2009

Initial sessions during RFCBT
Standard CBT assessment interview to determine symptoms and problems Establish that rumination is a major problem – i.e. patients report extensive unproductive dwelling on negative material Examine consequences of rumination Identify rumination as the target of therapy – a treatment goal Explain what rumination is, using examples from patients own experience If possible have some audio/video of this stage of therapy – video of rationale and early assessment section Ask to actively observe and look out to notice key steps and key messages. Talk through the handouts on rumination – consider their content Illustrate by using patients own language Focus on area that complain about

Rationale – key points 1. Recurrent negative thinking and avoidance maintain depression (the central engine driving depression) 2. Both of these responses are quite normal and functional in limited amounts under the right circumstances – i.e. “it is not surprising that you use them - everyone else uses them too.” 3. However, when used excessively or when they are out of balance, they become problematic. 4. Excessive use occurs because of past learning – either copying others or previous occasions when you learnt that rumination was a useful strategy – i.e. it has perceived benefit. 5. Because it was learnt, it can be replaced/overlearnt with a new more adaptive strategy. 6. Therapy will coach you in learning a new more adaptive approach based on your own experience (lead into functional analysis) Emphasise that therapy about coaching, providing skills, tools Go at pace matched to client

Group RFCBT Two variants
(1) In Exeter, using BA variant explicitly uses BA terms with some RFCBT elements, avoidance key focus. Used open trial, moderate improvements (BDI reduce pts). 90 min sessions Session 1: Introduction, Mood-avoidance links, self-monitoring Session 2: Examine avoidance, TRAPs, idea of alternative response. Record TRAPS

Group RFCBT Session 3: take ACTION, plan alternatives, visualise putting into action Session 4: Breaking down challenges – smaller steps Session 5: Rumination – form of TRAP, generate consequences and functions of rumination, Alternatives to rumination –How vs Why?. Session 6: Connecting with the Present – absorption exercise, use memory of absorption to interrupt rumination. Plan absorbing activities

Group RFCBT Session 7: Self-compassion – interactive experiential exercise, Plan to be more compassionate Session 8: Learning from experience – become more aware of triggers. Discriminating context. Notice when each tool works best Session 9: Values – acting in line values Session 10: Resilience – review skills, plan for ongoing activity, relapse prevention plans, review experience of group.

Group RFCBT (2) Revised group plan emerged consideration BA groups plus development of rumination-focused prevention groups. 90 min sessions (?still in pilot). Main focus from beginning is Rumination. Session 1: Introduction, Handling stress, introduce worry/rumination, examples generated group, rumination as habit, generate consequences, self-monitoring. Session 2: Noticing warning signs, stepping out of habit – introduce if-then plans, changing circumstances.

Group RFCBT Session 3: Different Styles of thinking, experiential alternative to rumination-e.g., relaxation, How vs Why? Experiential exercise, link into if-then plan, practice with “hot” warning sign Session 4: Alternatives to rumination that serve function; useful rules of thumb (unanswerable questions, 30 min rule, lead to action?), absorption Session 5: Self-compassion, experiential exercise, acting in a more caring way towards self Session 6: Interpersonal Effectiveness, comparing effective vs ineffective, resilience

Key aspects of environment during functional analysis
The richness of the environment – The time of the day – Solitude – Rituals and routine – disruption Mood triggers – News signals – Evaluating self, plans and outcomes – Lack of structure Lack of absorbing/valued activities Anniversaries/reminders Discuss how we think these may influence rumination The richness of the environment – a rather uninteresting environment lacking much in the way of diverting sensory stimuli may be associated with more rumination. The time of the day – rumination is often associated with getting up in the morning and going to bed at night. Solitude – rumination is often associated with being alone Rituals and routine – increased rumination may occur during particular regular habits and become associated with those habits e.g. sitting down to have a coffee after getting back from work. - - look out for changes in routine, and secondary problem behaviours that can increase the disruption in routine -e.g. sleeping late in day, missing meals, withdrawal Mood triggers –rumination is often associated with events that can change mood, e.g. criticism, losses, threats. It can also be set off by other events that influence mood over which patients may have more voluntarily control e.g. listening to sad music. News signals – events that herald the possibility of new information, which patients tend to expect to be negative, are often triggers of rumination and have associated avoidance – e.g. the telephone ringing, arrival of the post. Evaluating self, plans and outcomes – rumination is often triggered when people consider what they need to do, what they have just been doing, or make comparisons between themselves and other people. Thus, planning and review times can be triggers for rumination, as can impending situations that are perceived to involve some measure of self-ability or social comparison. Lack of structure Lack of absorbing/valued activities – key that any increased activities are meaningful to the client and valued – not just putting in any other experience for the sake of it Anniversaries/reminders

Dealing low motivation
Encourage change from the "outside-in" by changing behaviour without waiting for any internal change (“inside-out”) act according to goals rather than feelings divorce action from mood dependence - act while acknowledging that they didn't feel like acting at that moment Set up as experiment – small step Implementation intentions

FA & rumination In group setting (RFCBT group pages 16-21):
A) Emphasize spotting warning signs – by situation, environment, physical response, actions, thoughts B) Introduce idea of (i) changing the situation (pacing, prioritizing, environmental control, change routine) [facilitate change context to help break habit] (ii) React differently If I notice this warning sign, then I can do this ....alternative. Generate warning signs & trigger in group Generate alternatives in group Generate functions (p ). e.g., coach vs sergeant major, again discrimination between short-term vs long-term effects

A CASE EXAMPLE Bills arrive in post
Why do people put up with me? I’m a failure as a person because I’m not working What’s wrong with me? Why am I useless? How am I going to pay my bills? What does this mean about me? Bills arrive in post Starts with constructive thought then hijacked by abstract-evaluative Warning Signs: heart rate , tense, attention closing in Patient with residual depression, comorbid GAD, OCD, social phobia, PTSD.

A CASE EXAMPLE Bills arrive in post
Why do people put up with me? I’m a failure as a person because I’m not working What’s wrong with me? Why am I useless? How am I going to pay my bills? What does this mean about me? Bills arrive in post Starts with constructive thought then hijacked by abstract-evaluative Anxious, Depressed, Exhausted, Tearful, Poor Concentration, Goes back to Bed, ruminates over 3 hours Warning Signs: heart rate , tense, attention closing in

A CASE EXAMPLE What is the best way to get positive result? What can I do differently? What would someone else do to cope? Why is this so difficult? I’ll probably make wrong decision How can I handle this? Starts with constructive thought then hijacked by abstract-evaluative Tension reduced, Makes plan, Gets on with day, ruminates only 25 minutes Warning Signs: heart rate , tense, attention closing in Felt dismissed by partner when discussing decision

Key elements in switching mode
Requires preparation – i.e. socialisation into model, use of functional analysis and contingency plans to start shift, use of relaxation and imagery work as groundwork Find vivid memories and imagery of being in process-focused absorbed state – used to a. kickstart mode b. as coping strategy c. as example for functional analysis to make future plans – redress balance in life Review memory to build up details Recreate mental state using guiding questions to direct imagination to details – present tense, field perspective: Sensory experience – As vividly as you can see what you are looking at. Describe what you can see Motivation & Attitude Posture – As you become more absorbed, notice your posture of relaxation Physical sensations – Notice the sensations in your body Feelings – Experience and hold onto your feelings, letting them deepen Facial expressions – Urges to actions Attention – What do you notice? Where are you focusing your attention? Importance of having a balance of activities – need sufficient process-focused absorbed activities versus validation, maintenance activities – valuable for recharging batteries Interactive exercise – getting into style of thinking for feeling absorbed and less absorbed. Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on. For experiential exercise – do negative first then positive. Make clear that negative state is what depressed ruminators are like, whilst positive experience is the new style that we train people into “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” With patients only focus on training positive experience – but to give you a sense of change – start with time finding it hard to concentrate “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Take a note of how you are feeling, energy, what you are thinking and feeling. Compare what doing, experience of each mode Shift into period when more absorbed – notice feelings, posture

Switching style Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Compare what doing, experience of each mode Make clear that in treatment that the absorbed work only comes with some preparation and lead in – much preparation time and work Emphasise need for socialisation into model, grounding in previous FA, build up with contingency plans looking at different styles of thinking, use of relaxation and straightforward imagery – such that by the time get to experiential exercises patients already got a handle for this -when inducing working on making it as concrete as possible – building up from aspects of sensory experience, posture, expression, attitude, attention, thoughts, feelings – all feed into each other. May need more preparation, more direction for less imaginative, more groundwork If not get images then work around it making more concrete Differs from MBCT – FOCUS ON ACTING ON For most clients even most macho, concrete it is possible to find relevant examples to draw upon times that absorbed in – sport, extreme activities, working with hands Importance of getting to action – emphasise idea that act to change feeling rather reverse Interactive exercise – getting into style of thinking for feeling absorbed and less absorbed. Experiential exercise – process-focused versus evaluative experiment Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on. For experiential exercise – do negative first then positive. Make clear that negative state is what depressed ruminators are like, whilst positive experience is the new style that we train people into “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” With patients only focus on training positive experience – but to give you a sense of change – start with time finding it hard to concentrate “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” Take a note of how you are feeling, energy, what you are thinking and feeling. Compare what doing, experience of each mode Shift into period when more absorbed – notice feelings, posture

Q1. What initiates RT? Theory: Martin & Tesser (1996), Watkins (2008) – RT triggered by a discrepancy between actual & desired/expected state = unresolved goal, loss, trauma Discrepancy increases attention to & accessibility of information related to goal – with instrumental function of focusing on goal resolution (cf Zeigarnik effect, e.g., coming to terms, making sense), i.e., attempt at problem solving. RT ceases if goal is attained or abandoned © ERW 2010

Q1. What initiates RT? Evidence: recall of interrupted tasks better than of completed tasks (Zeigarnik, 1938) current concerns appear in thought if action regarding concern met with unexpected difficulties, if little time remained for action toward the goal (Klinger, Barta, & Maxeiner, 1980) rumination about person left behind on coming to university predicted by extent to which activities shared with this person not resumed at university (Millar, Tesser, & Millar, 1988) ESM study found that momentary ruminative self-focus associated with lack of progress on important goals (Moberly & Watkins, 2009) © ERW 2010

Implications of problematic goal attainment account
Explains RT as a normal cognitive process, with potential instrumental effects Adaptive or maladaptive depends upon whether increased focus on discrepancy helps to problem solve or not Problem if goal unattainable & unable to let go of goal – e.g., perfectionism, goal linked self-concept, unanswerable question → Perseveration of RT results from ineffective processing that prevents problem-solving & coming to terms (See Q3) © ERW 2010

Lesson for Psychological Treatment 2
Telling people to stop worry & rumination won’t work Thought-stopping & Distraction can only be short-lived RT will reoccur until goal discrepancy resolved © ERW 2010

Major depression is often characterised by: Co-morbid anxiety
Hopelessness – “black cloud” Guilt, shame Poor problem-solving Unassertive Avoidance Withdrawal from others Reduced activities No new or “risky” actions Concern obligations & responsibilities Problems unresolved, get worse e.g. common presentation as the one who does everything for other people – not get it back in return Generate examples of avoidance in depression – look at what people /clients tend to do – try and characterize different types/forms of rumination Loss of positive reinforcement (reward) Negatively reinforced

AVOIDANCE Procrastination – putting things off, going round and round things in your head without making a decision Trying to avoid thinking about upsetting or emotional events Suppressing feelings Not trying new challenges and not taking risks Withdrawal from other people and hiding away Giving up activities that used to enjoy or be good at Not being assertive or expressing feelings to other people Preferring to think about things rather than doing things Numbing oneself with drugs or alcohol Likely to be linked with rumination Can be common to both anxiety and depression

Avoidance can be functional or dysfunctional
a normal response to threats and difficulties - useful for acute, short-lived problems

Dysfunctional Consequences of Avoidance
Avoidance leads to not coming into direct contact with an ongoing problem – no chance to fix it Avoidance closes life down. Avoidance tends to generalise, leading to a closed, not very fulfilled life Avoidance prevents exposure to new information that may disconfirm concerns or provide opportunity for learning All common to rumination (being “stuck” in head rather than in the world)

Avoidance in Anxiety and Depression
A learnt & reinforced behaviour May provide temporary relief from misery But hypothesized to contribute to long-term maintenance of anxiety in CBT models Also hypothesized to contribute to maintenance of depression – Garland & Scott (2007) “Use of avoidant coping strategies leads to the recurrence of negative situations & events”. Ferster (1981) - Escape and avoidance become motivating goals in depression - escaping from an aversive environment is negatively reinforced  narrowing repertoires

Ferster 1981 – learning history & depression
Respond to history of deprivation rather actual environment Loss of discrimination to contingency Learn passivity (not learn behaviour  +ve reinforcement) Narrowing repertoires Deprivation (high FR responses before reward) Reduced contact +ve reinforcers Depressed people = learning history on Fixed Ratio schedule with high number of responses before reward (i.e., deprivation) Behaviours maintained by negative reinforcement (alleviation/removal of unpleasant state)  learn passive approach to life (i.e., not learn that certain behaviours led to positive reinforcement). Lose discrimination  Patients may respond more to level of deprivation (e.g. long periods without love) than to external, environmental contingencies 2) Such learning  narrowing repertoires = reduced activities  reduced contact with positive reinforcers- more vulnerable to depression. 3) Escape and avoidance become motivating goals in depression - escaping from an aversive environment or avoiding aversive conditions is negatively reinforced, increases in frequency  narrowing repertoires (e.g. complaining, pacing, ruminating to avoid silence, inactivity or risky activities). –ve reinforced (removal distress), freq Escape & Avoidance DEPRESSION

BA model of depression: categorises rumination as avoidance
ONSET MAINTENANCE low levels of +ve reinforcement, narrowing behavioural repertoires Sadness, loss of energy, symptoms, etc Negative Events DEPRESSION Secondary problems/Avoidance: withdrawal, staying bed, rumination

Less contact with +ve reinforcers, increased contact punishers
ONSET MAINTENANCE Less contact with +ve reinforcers, increased contact punishers Irritability, sadness, guilt Divorce, “coming out”, loss of job, loss of social contact Used to explain the model to clients -- Irritable & confrontational with partner, avoids career opportunities DEPRESSION

Rumination as escape & avoidance
Reinforced in the past by removal of aversive experience. Superstitious reinforcement/Partial reinforcement/Poor discrimination Functions of rumination may include: Avoid challenges of job or tedium of daily grind. Avoid risk of failure or humiliation Cognitive avoidance (worry) –preparation, planning Pre-empting other’s criticism / Anticipating potential negative responses/criticism to avoid actual criticism (second guessing – mind-reading) Control of feelings Making excuses Motivation – spurring oneself on

Rumination as a learnt habit
Rumination may be become more frequent and extensive if it is a learnt behaviour with perceived positive consequences i.e. rumination may be a response that someone has learned in the course of their life to particular environments This is the view taken by contextual-functional approaches to depression e.g. behavioural activation (Martell, Addis & Jacobson, 2001).

Clinical Report Patients report early experiences of criticism/blame and trying to work out how to avoid it. Patients report using rumination INSTEAD of confronting problems in actuality. Using rumination as an excuse not to do things. “I am doing something about it by thinking about it”

Watkins & Teasdale (2001 J.AbPsych, 2004, JAD) modified rumination paradigm (Nolen-Hoeksema & Morrow, 1993; Lyubomirsky & Nolen-Hoeksema, 1995). Depressed patients: For 8 minutes “Think about the causes, meanings and consequences of…..” (evaluative-abstract) “Focus your attention on your experience of……” (concrete-process-focused) versus “…the physical sensations in your body”, “the way you feel inside”, etc, etc – ruminative self-focus on same content

Watkins & Teasdale (2001 J.AbPsych, 2004, JAD)
“Think about the causes, meanings and consequences of…..” symptoms & feelings (evaluative-abstract) “Focus your attention on your experience of……” symptoms & feelings (concrete-process-focused) versus

Watkins & Moulds, 2005, Emotion
“Think about the causes, meanings and consequences of…..” symptoms & feelings (evaluative-abstract) “Focus your attention on your experience of……” symptoms & feelings (concrete-process-focused) versus To test if this effect generalised to recurrent focusing on symptoms and the self, Watkins and Moulds (in press) induced different styles of self-focus prior to problem solving. Depressed patients and never depressed controls were randomly allocated to abstract-evaluative self-focus (rumination) and experiential self-focus conditions. Measured MEPS before and after manipulations. Manipulations matched for self-focus and only differed in style. Prediction: if processing style is important in problem solving, then compared to conceptual-evaluative self-focus, experiential self-focus will improve problem solving in depressed patients. Group x Condition X Time F (1,75) = 8.37, p < .005:

Targeting avoidance & rumination
Treatment approach 1 – contextual & functional Intervention – Functional analysis

Behavioural Activation (BA) – Martell et al., 2001
Increasing approach – reducing avoidance Focus on context/function Looks at when and where people feel better /worse, increase actiivity, contingency, context

For high-severity depression cases, Dimidjian et al., 2006, JCCP
60 56 56 40 36 Chapter 8 –figure from Dimidjian et al., 2006 Journal of Consulting and Clinical Psychology Figure text to read as follows: Figure 8.1. Response and remission rates at posttreatment based on the Hamilton Rating Scale for Depression (HRSD) for the high-severity sub-group for antidepressant medication (ADM), cognitive therapy (CT), and behavioral activation (BA). Total bar represents response; lower bar represents remission. Adapted from Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E. et al. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, , published by American Psychological Association (APA). Reprinted [or adapted] with permission. BA – without any focus on thought content – better than CBT for sever depression 23 For high-severity depression cases, Dimidjian et al., 2006, JCCP

Key principles of contextual-functional approach (BA & RFCBT)
Viewing depression as - a set of actions in context - as understandable and predictable given a person's life history and current context e.g. avoiding short-term pain leading to longer-term negative consequences Looking at function rather than form Looking at process rather than content Looking at rumination as a learnt habit

Implications of Rumination as Habit
Habits resist informational interventions (Verplanken & Wood, 2006) Hence, focus on thought content alone (e.g., thought challenging) may be insufficient – need to change process. Successful habit change involves (i) disrupting the environmental factors (time, place, mood) that automatically cue habit (Wood & Neal, 2007); (ii) training to associate cue (warning sign) with incompatible response in conflict unwanted habit

TRAP & TRAC guides Trigger – Response Avoidance Pattern Trigger
Alternative Coping (Approach) Welcome to the Mnemonic Section!!!! Trigger can be internal or external event Response – typically some form of emotional response but it may be overt behaviour Find an experiential/active exercise for this. “What is the TRAP here?" "So what could get you back on TRAC?"

Rumination-focused CBT (RFCBT)
RFCBT focuses on increasing effective behaviour – i.e., not stopping rumination but making it functional RFBCT grounded within the core principles and techniques of CBT for depression (Beck, Rush, Shaw, & Emery, 1979) with two adaptations: a functional-analytical perspective using Behavioural Activation (BA) approaches (Addis & Martell, 2004; Martell et al., 2001) An explicit focus on shifting processing style via imagery and experiential approaches

Overview of treatment components
The key elements of the therapy are: Providing an idiosyncratic assessment tied into a clear rationale for the focus on rumination, building on the idea that rumination is learnt behaviour. It is important here to incorporate the patients’ developmental history into the rationale. Encourage practise at spotting rumination, avoidance and early warning signs of each, using formal homework. Functional analysis to examine the context and functions of rumination and avoidance. These analyses then lead onto developing contingency plans, involving more functional responses to early warning signs. The format of interventions will often involve imagery and vizualisation exercises.

Overview of treatment components
The key elements of the therapy are: The use of experiments to examine whether rumination is adaptive or not and to try out alternative strategies, e.g. the How-Why experiment. Increased activity and reduced avoidance, including building up routines and increasing non-ruminative activities. This activity needs to be made as explicit as possible, targeting behavioural changes. The use of experiential exercises and vizualisations to provide functional experience of adaptive use of attention as a counter to rumination. Used to establish alternative thinking style. A focus on the client’s values to minimise rumination about non-valued areas and to encourage activity in line with values.

Treatment rationale 1. Recurrent negative thinking and avoidance maintain depression (the central engine driving depression) 2. Both of these responses are quite normal and functional in limited amounts under the right circumstances – i.e. “it is not surprising that you use them - everyone else uses them too.” 3. However, when used excessively or when they are out of balance, they become problematic. 4. Excessive use occurs because of past learning – either copying others or previous occasions when you learnt that rumination was a useful strategy – i.e. it has perceived benefit. 5. Because it was learnt, it can be replaced/overlearnt with a new more adaptive strategy. 6. Therapy will coach you in learning a new more adaptive approach based on your own experience (lead into functional analysis) Emphasise that therapy about coaching, providing skills, tools Go at pace matched to client

Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk.

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Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk.

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Presentation on theme: "Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk."— Presentation transcript:

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