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

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Presentation on theme: "© ERW 2011 Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter"— Presentation transcript:

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

2 © ERW 2010 Acknowledgements - Funders

3 Acknowledgements  Research collaboratorsMood Disorders Centre co-directors  Dr Celine Baeyens  Dr Nick MoberlyProfessor Willem Kuyken  Dr Michelle MouldsDr 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

4 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

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

6 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

7 © ERW 2009 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

8 Rumination-focused CBT (RFCBT) 3  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

9 But dwelling on difficult events is common, normal & often adaptive What determines whether dwelling on a problem/upset leads to either gets stuck in a distressing loop that goes nowhere? constructive resolution, Problem-solving, working through OR

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

11 Rumination-focused CBT (RFCBT) 4  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

12 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) PILOT RCT Residual Depression 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 Watkins et al., in press British Journal of Psychiatry

13 © ERW 2009 Baseline scores TAU (n = 21)RFCBT+ TAU (n =21) Fp age45.24 (9.33)43.05 (11.09).48ns F:M10:1114:7  2 =.87 ns Length current episode mths 7.57 (6.13)9.14 (6.3).67ns Previous episodes 4.84 (3.02)5.43 (2.93).45ns HRSD12.19 (2.80)13.29 (3.32)1.33ns BDI28.29 (7.63)30.76 (8.17)1.03ns RSQ57.88 (8.52)56.40 (11.92).21ns Axis I diagnoses 1.86 (1.24)2.05 (0.92).32ns

14 © ERW 2009 Change in BDI by treatment arm

15 © ERW 2009 Change in BDI by treatment arm Condition X Time, F (1, 38) = 10.26, p <.005. Between-treatments effect size for  BDI, Cohen’s d = 1.06

16 © ERW 2009 Change in BDI by treatment arm –Watkins et al, in press, BJP Condition X Time, F (1, 38) = 10.26, p <.005. Between-treatments effect size for  BDI, Cohen’s d = 1.06 RFCBT 12 sessions; CBT 20 sessions

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

18 © 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

19 Factors maintaining rumination 1.AVOIDANCE (not addressed today)

20 Factors maintaining rumination 2. Thinking Style

21 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

22 The HOW-WHY behaviour experiment

23 HOW? Probably found easier, more natural

24 WHY?

25 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)

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

27 Switching thinking style Shifting from evaluative.. to a more process- focused style… 1. Compare effective vs ineffective thinking in functional analysis 2. Use imagery, experiential exercises 

28 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)

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

30  Compassion experiences - Recreating feeling compassionate, tolerant, caring, nurturing, non- judgemental

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

32 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

33 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

34 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?

35 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

36 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?

37 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

38 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

39 © ERW 2009  Thank you  Please feel free to contact me at with any questions, thoughts, plans about research, for handouts etc

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

41 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

42 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)

43 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

44 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

45 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.

46 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.

47 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

48 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

49 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

50 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 ).

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

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

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

54 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?

55 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

56 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

57 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

58 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

59 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

60 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 Loss of positive reinforcement (reward) Negatively reinforced

61 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

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

63 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)

64 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

65 Deprivation (high FR responses before reward) –ve reinforced (removal distress),  freq Loss of discrimination to contingency Learn passivity (not learn behaviour  +ve reinforcement) Narrowing repertoires Ferster 1981 – learning history & depression Reduced contact +ve reinforcers Escape & Avoidance Respond to history of deprivation rather actual environment DEPRESSION

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

67 Divorce, “coming out”, loss of job, loss of social contact Less contact with +ve reinforcers, increased contact punishers DEPRESSION Irritability, sadness, guilt Irritable & confrontational with partner, avoids career opportunities ONSET MAINTENANCE

68 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

69 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).

70 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”

71

72 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

73 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

74 Watkins & Moulds, 2005, Emotion Group x Condition X Time F (1,75) = 8.37, p <.005: “ Think about the causes, meanings and consequences of…..” symptoms & feelings (evaluative-abstract) versus “ Focus your attention on your experience of……” symptoms & feelings (concrete-process- focused)

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

76 Behavioural Activation (BA) – Martell et al., 2001  Increasing approach – reducing avoidance  Focus on context/function

77 For high-severity depression cases, Dimidjian et al., 2006, JCCP

78 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

79 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

80 Trigger – Response Avoidance Pattern Trigger Response Alternative Coping (Approach) TRAP & TRAC guides “What is the TRAP here?" "So what could get you back on TRAC?"

81 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

82 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.

83 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.

84 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)


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