Fernando, K., Carter, J. (2007). I just can’t stop thinking about it! Rumination, avoidance and depression. New Zealand Clinical Psychologist, 17(2), 8-13.

I just can’t stop thinking about it! Rumination, avoidance and depression Kumari Fernando, Department of Psychological Medicine, University of Otago (Christchurch) Janet Carter, Department of Psychology, University of Canterbury

Introduction that engaging in this passive coping Rumination or “overthinking” (e.g., strategy makes it more likely that people Nolen-Hoeksema, 1987) is a passive focus will not engage in more active ways to on feelings, symptoms and thoughts cope with their depressed mood (e.g., which appears to maintain and exacerbate seeking positive reinforcement from the depressed mood. Although originally situation or leaving the negative situation). conceptualised to have specific deleterious Also, negative mood is more likely to effects on depression, there is growing make the person encounter other negative evidence to suggest that rumination may memories through semantic connections also be associated with worry, avoidance in memory (e.g., Bower, 1981). Finally, behaviours, impaired problem solving and Nolen-Hoeksema (1987) suggests that interpersonal problems. rumination may amplify depressed mood by making the ruminating person more In this article, we review research on likely to generate helpless explanations for rumination and consider the association their situation and thus perpetuate their between rumination and depression. We belief that they are depressed. highlight recent research that indicates an interesting association between The empirical support for the relationship rumination and avoidance and outline between rumination and depression has treatments that implicitly or explicitly come from experimental, community and target rumination. We also summarise clinical studies. The tendency to engage in strategies for reducing rumination. rumination has typically been assessed with a scale developed by Nolen- Nolen-Hoeksema (1987) suggests three Hoeksema and Morrow (1991), the ways that a ruminative style of coping can Response Style Questionnaire, a self- exacerbate and perpetuate negative mood report measure (see Table 1 for sample and contribute to depression. It may be items).

Table 1. Sample items from the Response Style Questionnaire. I think about my feelings of fatigue and achiness I think about how passive and unmotivated I feel I think “I won’t be able to do my job/work because I feel so badly” I think about how I don’t feel up to doing anything I think about how hard it is to concentrate I think about how alone I feel Note: Questions are answered with “never”, “sometimes”, “often” or “always”

Fernando, K., Carter, J. (2007). I just can’t stop thinking about it! Rumination, avoidance and depression. New Zealand Clinical Psychologist, 17(2), 8-13. There is evidence that depressed experience more frequent and more individuals can reliably assess their own severe depressive episodes than men (e.g., responses to depressive symptoms, Nolen-Hoeksema & Morrow, 1991; regardless of severity (Kuehner & Weber, Nolen-Hoeksema, Morrow, & 1999; Nolen-Hoeksema & Morrow, 1993; Fredrickson, 1993). However, although Nolen-Hoeksema, Parker, & Larson, gender differences in depression are 1994) and that this self-report is correlated evident in clinical samples, gender with actual behaviour (Just & Alloy, 1997). differences in rumination have only been The tendency to ruminate appears to be reported in community samples, not in stable over time, and this stability remains clinical samples (Bagby et al., 1999; evident even when symptom status Kuehner & Weber, 1999). changes (Just & Alloy, 1997; Kuehner & Weber, 1999; Nolen-Hoeksema, Morrow, Rumination also seems to impair & Fredrickson, 1993; Nolen-Hoeksema, problem-solving abilities. Lyubomirsky Parker, & Larson, 1994), including when and Nolen-Hoeksema (1993) found that depression has remitted (Roberts, Gilboa, individuals chose to ruminate (and refused & Gotlib, 1998). to engage in distracting activities) because they felt that this strategy allowed them to Clinical implications of rumination gain more insight into their problems and Most studies find that a ruminative to generate better solutions to their response to low mood and other problems even when they thought they depressive symptoms is associated with would enjoy the distracting activities. In increased severity and duration of addition to poorer problem solving, depression (Butler & Nolen-Hoeksema, ruminators rate their problems as more 1994; Morrow & Nolen-Hoeksema, 1990; severe, have more negative thoughts, Nolen-Hoeksema & Morrow, 1991; Trask more critical thoughts and blame & Sigmon, 1999). In individuals with themselves more for their problems, than depression, rumination has been non-ruminators (Lyubormisky, Tucker, associated with a poorer outcome, Caldwell and Berg (1999). Rumination has irrespective of initial depression severity also been linked to negative interpersonal (Ezquiaga et al., 2004; Hoffman, Baldwin, effects. Individuals who ruminate have & Cerbone, 2003; Kuehner & Weber, been found to be more likely to need and 1999) and with higher levels of seek social support, but view the hopelessness and interpersonal distress interpersonal support they receive as (Lam, Schuck, Smith, Farmer, & inadequate and unsatisfying (Nolen- Checkley, 2003). In addition, Nolen- Hoeksema & Davis, 1999; Nolen- Hoeksema, Parker and Larson (1994) have Hoeksema, Parker & Larson, 1994). shown that people who engaged in more rumination following the loss of a loved Rumination is not (always) unhelpful one were more depressed six months Although initially conceptualised as being following the loss. unitary, Treynor, Gonzalez and Nolen- Hoeksema (2003) demonstrated that Nolen-Hoeksema and others have also rumination has two components: a reported that women are more likely than reflective, analytic component and a men to ruminate (Butler & Nolen- brooding component. Brooding (but not Hoeksema, 1994). Rumination may self-reflection) is associated with negative provide an explanation for why women emotions. Similarly, Watkins (2004) has

Fernando, K., Carter, J. (2007). I just can’t stop thinking about it! Rumination, avoidance and depression. New Zealand Clinical Psychologist, 17(2), 8-13. suggested “modes” of rumination and may have had the experience of a client demonstrated that ruminators who think who ruminates and noticed that although about problems in an abstract, evaluative, there is much intellectual discussion about overgeneral way, rather than a concrete, a problem (and perhaps emotional specific, problem-focussed way, are more reactivity), there is little emotional change likely to experience depressed mood or active problem-solving. If rumination is (Moberly & Watkins, 2006; Watkins & an avoidance strategy then an intellectual Moulds, 2005). discussion may prevent emotional processing. It is also possible that some Rumination, worry and avoidance therapies, for example traditional Jacobsen, Martell and Dimidjian (2001; cognitive behavioural approaches, increase Martell et al., 2001) suggest that rumination in some clients by asking them rumination is a form of avoidance that to focus on the content of their thoughts disallows actively being involved in one’s and the meaning of these thoughts, environment and actively engaging in potentially providing the client with problem-solving. By repetitively focussing “better tools to ruminate”. on thoughts (but not engaging in problem-solving), rumination may also Treatment and rumination prevent contact with the emotional Interventions targeting rumination are experience (Moulds, Kandris, Star, & emerging in the literature. In her book Wong, 2007; Watkins & Moulds, 2004). “Women who think too much” Susan One theory is that rumination is an Nolen-Hoeksema (2003) has outlined a emotional regulation strategy associated number of strategies individuals can use to with incomplete processing of thoughts reduce rumination or over thinking. These (Starr & Moulds, 2006). Avoidance may are summarised below. A common focus maintain this incomplete processing. of the third wave of cognitive therapies Consistent with this theory, Moulds et al. e.g. Mindfulness Therapy (Teasdale et al., (2007) found that rumination was 2000), Acceptance and Commitment associated with more behavioural and Therapy (Hayes, e.g., Hayes et al., 1999) cognitive avoidance. It may be that and Meta Cognitive Therapy (Wells, e.g., rumination with its focus on the content of 2005) is to assist the individual to material prevents processing the disengage from their ruminative thinking emotionality of events. In other words, processes. although ruminators talk and think about events that have happened, a focus on the Mindfulness Therapy is based on the verbal or more cognitive aspects of an assumption that individuals who are event might distance them from the depressed are more likely to begin a experience associated with the event. ruminative pattern triggered by feelings of Without emotional experiencing it is sadness. The aim of mindfulness therapy possible that one cannot habituate to is to help the individual become aware of these or process them (c.f. Acceptance this thinking pattern (Ma & Teasdale, Commitment Therapy - ACT e.g., Hayes, 2004). By focusing on the reduction of Strosahl, & Wilson, 1999). rumination, mindfulness training significantly reduces the chance of relapse Clinical questions (Ma & Teasdale, 2004; Teasdale et al., No studies have yet examined rumination 2000). Of note, mindfulness therapy was within the context of therapy. Therapists

Fernando, K., Carter, J. (2007). I just can’t stop thinking about it! Rumination, avoidance and depression. New Zealand Clinical Psychologist, 17(2), 8-13. developed as an intervention aimed at reducing relapse. Recently, Watkins et al. (in press) have developed “rumination-focussed cognitive Metacognitive Therapy (e.g. Wells, 2005) behaviour therapy” targeted at residual was initially developed for the treatment symptoms of depression. Rumination is of anxiety, but given the association of conceptualised as an avoidance strategy rumination and depression, has also been and treatment aims to reduce avoidance applied to depression. Rumination is seen while increasing other behaviours. Clients as an inflexible means of coping which is are taught to recognise when they are maintained by both positive and negative ruminating and to shift their thinking. beliefs about the impact of ruminating. Some techniques to shift thinking include The goals of metacognitive therapy are to imagery exercises (clients imagine a time socialise the client to the idea that when they were thinking in a rumination is one source of current different/more helpful way) and problems, to facilitate abandonment of behavioural experiments. Initial pilot data ruminative thinking, to enhance flexible indicates significant clinical benefits of control over cognitions and to challenge reducing rumination. metacognitive beliefs. Conclusion Although not explicitly addressing Recent years have seen a dramatic increase rumination, Acceptance Commitment in research on rumination. Research Therapy (ACT)1 aims to teach individuals indicates that rumination is an important alternative strategies for managing clinical construct which not only thoughts, other than thinking about them exacerbates depression but has a number or attempting to avoid thinking about of other negative intra- and inter- personal them. The focus is experiencing (rather consequences. Recent interventions that than avoiding) emotions in the pursuit of implicitly and explicitly address personally relevant values. Blackledge and rumination show promising results. Hayes (2001) note that it is not unpleasant emotions (or thoughts) that are distressing, but rather, it is the attempt to Key References2 avoid these emotions that causes distress. Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment They note (as other researchers have for depression: Returning to contextual done) that attempts to avoid these roots. Clinical Psychology: Science and Practice, emotions increase the frequency and 8, 255-270. severity of these emotions. ACT also Ma, S., & Teasdale, J. D. (2004). Mindfulness- focuses on the role of language in Based Cognitive Therapy for Depression: Replication and Exploration of perpetuating distress. Individuals respond Differential Relapse Prevention Effects. to words as if the words themselves are Journal of Consulting and Clinical Psychology, unpleasant stimuli (Blackledge & Hayes, 72, 31-40. 2001) and a similar avoidance occurs. Moulds, M. L., Kandris, E., Starr, S., & Wong, A. Rumination can thus be conceptualised as C. M. (2007). The relationship between a cognitive strategy for maintaining rumination, avoidance and depression in anxiety and avoidance.

2 A full list of references is available from 1 See David Mellor’s article about ACT in the Kumari Fernando: Winter 2006 volume of the Journal. [email protected]

Fernando, K., Carter, J. (2007). I just can’t stop thinking about it! Rumination, avoidance and depression. New Zealand Clinical Psychologist, 17(2), 8-13. a non-clinical sample. Behaviour Research Watkins, E., Scott, J., Wingrove, J., Rimes, K., and Therapy, 45, 251-261. Bathurst, N., Steiner, H., et al. (2007) Nolen-Hoeksema, S. (1987). Sex differences in Rumination-focused cognitive behaviour unipolar depression: Evidence and therapy for residual depression: A case theory. Psychological Bulletin, 101, 259-282. series. Behaviour Research and Therapy, Nolen-Hoeksema, S. (2003). Women who think too doi:10.1016/j.brat.2006.09.018. much. New York: Henry Holt. Watkins, E., & Moulds, M. (2005). Distinct modes Teasdale, J. D., Segal, Z. V., Williams, J., Ridgeway, of ruminative self-focus: Impact of V. A., Soulsby, J. M., & Lau, M. A. abstract versus concrete rumination on (2000). Prevention of relapse/recurrence problem solving in depression. Emotion, in major depression by mindfulness- 5, 319-328. based cognitive therapy. Journal of Wells, A. (2005). The metacognitive model of Consulting and Clinical Psychology, 68, 615- GAD: Assessment of meta-worry and 623. relationship with DSM-IV generalized Watkins, E. (2004). Appraisals and strategies anxiety disorder. Cognitive Therapy and associated with rumination and worry. Research, 29, 107-121. Personality and Individual Differences, 37, 679- 694.

Appendix A Strategies for dealing with Overthinking (Rumination) The following strategies are summarised from Nolen-Hoeksema (2003; pages 78-79; 102- 104). Please refer to this book for a more detailed description of each strategy.

Table 2. Strategies to deal with Rumination

Realise overthinking is not useful. Take a break/distract yourself from overthinking. Do physical activity to distract yourself from overthinking. Use thought stopping. Appreciate that you can control your thoughts. Use worry time scheduling – have a time set aside for overthinking. Pray/Meditate. Talk to friends/supportive others about your overthinking. Write the thoughts onto paper. Find enjoyable activities that increase positive feelings. Is there an alternative/healthier perspective on this. Accept your emotions. Find simpler explanations for negative feelings first. Are you judging yourself or comparing yourself to others? Accept responsibility for changing what you can about the situation. Brainstorm all the solutions you can to a problem. Identify your values and see how you can move towards these. Start a small action that moves you towards overcoming the problem. Examine whether your standards are realistic.