By Marilee Feldman, LCPC, CADC
If you struggle with depression, I have a question for you. Would you say that you are in your head a lot, thinking a lot about your problems, reviewing bad events, and trying to figure out what they mean?
This process, incredibly common with depression, is called depressive rumination, and interestingly it really contributes to both the onset and maintenance of a depressive episode. While we may think we’re doing something useful with all this mental activity, in reality we’re doing something that makes depression worse. Therapists who know this and focus on the behavior (yes, it’s a behavior that you actively engage in) have a strategy up their sleeve—rumination focused cognitive behavioral therapy (RF-CBT)—that is shown by research to be incredibly effective. Having said that, many therapists don’t target rumination in treating depression, leaving their clients with only partially resolved symptoms and difficulty knowing how to prevent further episodes.
So what, exactly, is depressive rumination?
Depressive rumination is thinking that is characterized by a strong, steady stream of thoughts that are often focused on abstract ideas, such as examining the meaning of negative events. The thoughts are highly evaluative in nature and focus on unresolvable goals, and they seem never to bring a sense of peace or resolution. Engaging in rumination is a habit…fortunately, one that can be unlearned.
It’s important to understand that rumination is incredibly common; in fact, we all do it, particularly after something bad happens. Here are some scenarios that for many of us, would provoke a tendency to ruminate, or think quite a bit about what is happening:
- You made an embarrassing mistake in front of other people
- An important relationship came to an end
- Someone you loved died
- You have an upcoming medical procedure
- You have to confront someone
These scenarios and many others will cause many of us to engage in rumination. But what’s critical is that it’s a matter of degree…some people have a harder time than others in disengaging from rumination. And those who find themselves excessively stuck in rumination tend to experience more anxiety and depression. In fact, rumination is known as a transdiagnostic symptom, because it’s common in a number of mental health disorders, including OCD, anxiety disorders, depression, and eating disorders. And yet while it’s a highly prevalent and key component of these mental health issues, it’s incredibly overlooked in treating them.
It’s well known that our thoughts influence how we feel. In conventional cognitive behavioral therapy (CBT)—the previous gold standard for the treatment of depression—the therapist helps you learn to examine your thoughts to see if they can be modified in a helpful way. If it is determined, for example, that you think in black and white terms, the therapist might help you see shades of gray. If you see only the negative in everything, you might learn to focus on the positives.
But more recently we’ve learned that the torrent of thoughts in depression is so massive that it’s not helpful to target individual thoughts. Doing so leads only to more thoughts, setting up a vicious cycle of repetitive thinking…more rumination. What needs to happen instead is to target the overall torrent of thought, our engagement with thinking overall.
A form of therapy for depression that is now proving to be highly effective for treatment of depression is rumination-focused cognitive behavioral therapy (RF-CBT). In RF-CBT, the therapist and client work together to determine
- When the rumination occurs (time of day, setting, etc)
- Triggering events that set off rumination
- The purpose of the rumination
- The consequences of the behavior
It’s imperative that the client learn to detect when they’re ruminating, be convinced that it’s not helpful, and learn strategies for disengaging. Some of these strategies might include:
- Learning to break out of behaviors that are associated with rumination
- Learning to act in accordance with core values
- Recognizing that the goals of the thinking are unattainable, that the questions being asked are unanswerable
- Recognizing what is being avoided (eg, upsetting feelings) through rumination and learning to stop avoidant behavior
If you’re struggling with depression—or in fact a number of other mental health issues, including anxiety—learning about how rumination is playing a role, and getting rumination-focused therapy, would likely be highly effective in helping you feel better.