Ed Watkins - BABCP Conference and Workshops

Report
Targeting rumination by
changing processing
style: Experiential and
Imagery exercises
Edward Watkins, PhD
University of Exeter
[email protected]
BABCP 2011
© ERW 2011
Acknowledgements - Funders
© ERW 2010
Acknowledgements
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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
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Therapy development & trial
Dr Katharine Rimes
Dr Anna Lavender
Dr Janet Wingrove
Dr Neil Bathurst
Rachel Eastman
Professor Jan Scott
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
Rumination = recurrent dwelling on feelings, problems,
upsetting events, negative
aspects of self
Why can’t I
What does
this mean
about me?
What am I
doing to
deserve
this?
handle
things
better?
Why did this
happen to me?
What will
others think
of me?
Why do I feel
so bad?
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
© ERW 2009
(problem-solving) and unhelpful
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 countercondition 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
OR
constructive resolution,
Problem-solving, working
through
gets stuck in a distressing
loop that goes nowhere?
Watkins (2008)– Positive consequences of RT
What can I
do next?
What is
important
to me now?
What are
the
positive
benefits of
this?
How did
this
happen?
What can I
learn from
this?
How can I fix
this?
Reduces negative mood &
improves planning &
problem-solving in
experiments
Predicts recovery from
upsetting and traumatic events
and from depression in some
prospective studies
© ERW 2009
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, actionoriented).
 Use experiential exercises and imagery to induce
this processing style, as counter to rumination,
and as means to develop constructive habit
PILOT RCT
Acute
ADM
treatment
GP/CMHT
referral to the
study
Residual
Depression
Screening
assessment Informed consent?
(n = 42)
Yes: Conduct full intake
assessment
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
No: Return to
treatment-as-usual
Randomise (n=42)
Treatment as usual
(antidepressants)
May include CBT
Individual RFCBT + TAU
Up to 12 sessions
Watkins et al., in press British Journal
of Psychiatry
Post-intervention assessment – blind at 16-20 weeks (n = 40)
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
ns
Length current
episode mths
7.57 (6.13)
9.14 (6.3)
.67
ns
Previous
episodes
4.84 (3.02)
5.43 (2.93)
.45
ns
HRSD
12.19 (2.80)
13.29 (3.32)
1.33
ns
BDI
28.29 (7.63)
30.76 (8.17)
1.03
ns
RSQ
57.88 (8.52)
56.40 (11.92)
.21
ns
Axis I
diagnoses
1.86 (1.24)
2.05 (0.92)
.32
ns
© ERW 2009
Change in BDI by treatment arm
30
BDI score
25
20
15
TAU (ADM)
10
5
0
pre-intervention
post-intervention
time
© ERW 2009
Change in BDI by treatment arm
35
BDI score
30
25
20
TAU (ADM)
TAU+RFCBT
15
10
5
0
pre-intervention
post-intervention
time
Condition X Time, F (1, 38) = 10.26, p < .005. 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
35
RFCBT 12 sessions; CBT 20 sessions
BDI score
30
25
TAU (ADM)
TAU+RFCBT
TAU+CBT
TAU-PAYKEL
20
15
10
5
0
pre-intervention
post-intervention
time
Condition X Time, F (1, 38) = 10.26, p < .005. Between-treatments
effect size for  BDI,
Cohen’s d = 1.06
© ERW 2009
Change in HRSD by treatment arm
14
HRSD score
12
10
8
TAU (ADM)
TAU + RFCBT
6
4
2
0
pre-intervention
post-intervention
time
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
© ERW 2009
Factors maintaining rumination
1. 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 behaviour experiment
HOW?
Probably found easier, more natural
WHY?
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 processfocused style…
1. Compare effective vs
ineffective thinking in
functional analysis
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2. Use
imagery,
experiential
exercises
Shifting processing style
 Coach experiential exercises/ build up
activities to shift out of abstractevaluative rumination style
 Focus on recreating experiences of
being in a concrete process-focused
style (counter to rumination)
 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, nonjudgemental
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, presentmoment
 Clear goals, rules & immediate feedback
Key elements of “flow”
(Csikszentmihalyi, 2002)
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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 selfpotential
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?
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
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?
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
 Thank you
 Please feel free to contact me at
[email protected]
with any questions, thoughts, plans about research,
for handouts etc
© ERW 2009
Additional slides from full workshop follow
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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
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)
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 10-15 pts). 90 min sessions
 Session 1: Introduction, Mood-avoidance links, selfmonitoring
 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, selfmonitoring.
 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
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
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. 35-37).
A CASE EXAMPLE
What’s
wrong with
me?
What does
this mean
about me?
Why do
people put
up with
me?
Why am I
useless?
I’m a failure
as a person
because I’m
not working
How am I
going to pay
my bills?
Bills arrive in post
Warning Signs: heart rate , tense,
attention closing in
Patient with residual depression, comorbid
GAD, OCD, social phobia, PTSD.
A CASE EXAMPLE
What’s
wrong with
me?
Why do
people put
up with
me?
Why am I
useless?
I’m a failure
as a person
because I’m
not working
How am I
going to pay
my bills?
What does
this mean
about me?
Bills arrive in post
Warning Signs: heart
rate , tense, attention
closing in
Anxious, Depressed,
Exhausted, Tearful,
Poor Concentration,
Goes back to Bed,
ruminates over 3 hours
A CASE EXAMPLE
What can I
do
differently?
What is the
best way to
get positive
result?
What would
someone else
do to cope?
I’ll probably
make wrong
decision
How can I
handle this?
Felt dismissed
by partner when
discussing
decision
Why is this
so difficult?
Warning Signs: heart
rate , tense, attention
closing in
Tension reduced,
Makes plan, Gets on
with day, ruminates only
25 minutes
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?
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
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 shortlived
 RT will reoccur until goal discrepancy resolved
© ERW 2010
Major depression is often characterised
by:
-Co-morbid anxiety
-Hopelessness – “black cloud”
Problems unresolved, get
-Guilt, shame
worse
-Poor problem-solving
- Unassertive
- Avoidance
-Withdrawal from others
-Reduced activities
Loss of positive
reinforcement (reward)
- No new or “risky” actions
Negatively reinforced
- Concern obligations & responsibilities
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
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
Loss of
rather actual
discrimination to
environment
contingency
Deprivation (high
FR responses
before reward)
Escape &
Avoidance
Learn passivity
(not learn
behaviour 
+ve
reinforcement)
–ve reinforced
(removal
distress), freq
Narrowing
repertoires
Reduced
contact +ve
reinforcers
DEPRESSION
BA model of depression: categorises rumination as
avoidance
ONSET
Negative Events
MAINTENANCE
low levels of +ve
Sadness,
reinforcement,
loss of
narrowing
energy,
behavioural
symptoms,
repertoires
etc
DEPRESSION
Secondary
problems/Avoidance
: withdrawal, staying
bed, rumination
ONSET
Divorce, “coming
out”, loss of job,
loss of social
contact
MAINTENANCE
Less contact
Irritability,
with +ve
sadness, guilt
reinforcers,
increased
contact
punishers
DEPRESSION
Irritable &
confrontational with
partner, avoids
career opportunities
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…..” versus
(evaluative-abstract)
“Focus your attention on
your experience of……”
(concrete-processfocused)
“…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)
Categoric memory (proportion)
“Think about the causes,
meanings and consequences
of…..” symptoms & feelings
(evaluative-abstract)
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
baseline
“Focus your attention on
versus your experience of……”
symptoms & feelings
(concrete-process-focused)
Evaluative
Concrete
post-rumination
Watkins & Moulds, 2005, Emotion
“Think about the causes, meanings and versus
problem solving effectiveness 1-7
consequences of…..” symptoms &
feelings (evaluative-abstract)
4.5
“Focus your attention on your
experience of……” symptoms &
feelings (concrete-processfocused)
4
3.5
depressed-evaluative
depressed-concrete
control-evaluative
control-concrete
3
2.5
2
1.5
Group x Condition X Time F (1,75) = 8.37, p < .005:
1
pre-manipulation
post-manipulation
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
HRSD Response and Remission
Rates (%)
Remission
100
90
80
70
60
50
40
30
20
10
0
Response Only
60
56
56
40
36
23
ADM
CT
BA
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 longerterm 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
Response
Alternative
Coping
(Approach)
“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 nonvalued 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)

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