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The How and Why
of Rumination and Worry
Edward Watkins, PhD
University of Exeter
[email protected];
© ERW 2010
Lessons for psychological
treatments from
experimental research into
repetitive thought
© ERW 2010
Acknowledgements - People
Research collaborators
Dr Nick Moberly
Dr Michelle Moulds
Yanni Malliaris
Sandra Kennell-Webb
Prof Colin MacLeod
Simona Baracaia
Dr Celine Baeyens
Rebecca Read
Therapy development & trial
 Dr Katharine Rimes
 Dr Anna Lavender
 Dr Janet Wingrove
 Dr Neil Bathurst
 Rachel Eastman
© ERW 2009
 Professor Jan Scott
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Mood Disorders Centre co-directors
Dr Willem Kuyken
Dr Eugene Mullan
All patients and participants
Acknowledgements - Funders
© ERW 2010
Overview
 Negative repetitive thought (RT e.g., worry &
rumination) = core process in depression & anxiety
  target RT to improve treatments for depression &
anxiety
 But RT is normal & can be helpful e.g., problemsolving, coming to terms past events
 Key questions in RT: Why?, How?, Who?, What
determines if helpful or unhelpful?
  Investigate mechanisms of RT
  Translate into treatment
 Relationship to mindfulness
Repetitive Thought (RT)
 Segerstrom et al., (2003, p.3) “process of thinking
attentively, repetitively or frequently about one’s self
and one’s world”. Includes:
 Rumination = “passively and repetitively focusing on
one’s symptoms of distress and the circumstances
surrounding these symptoms” (Nolen-Hoeksema et al., 1997).
 Worry = “a chain of thoughts and images, negatively
affect-laden and relatively uncontrollable”, “an attempt
to engage in mental problem-solving on an issue
whose outcome is uncertain but contains the
possibility of one or more negative outcomes” (Borkovec
et al., 1983, p. 9).
Repetitive Thought (RT)
 But also includes –
 Cognitive Processing = the process of actively
thinking about a stressor, the thoughts and feelings it
evokes and its implications for one's life and future
(Bower et al., 1998; Greenberg, 1995) , viewed as necessary part
of process of attempting to resolve the discrepancy
between stressful events and core beliefs and
assumptions (Horowitz, 1985).
 Problem Solving e.g., repeated mental simulation and
rehearsing of future actions and situations (Taylor et al.,
1998).
Watkins (2008)– Negative consequences of RT
What does
this mean
about me?
What if it
goes
wrong?
Exacerbates negative
mood & cognition in
experiments
© ERW 2009
Why can’t
I handle
things
better?
Imagine
catastrophic
consequences
Why did this
happen to
me?
Why do I feel
so bad?
Linked to less
effective therapy
Predicts onset, duration,
severity of depression, anxiety,
PTSD, substance abuse, eating
disorders in prospective studies

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
Lesson for Psychological Treatment 1
 RT should not be treated as always
pathological
 Useful to normalise the experience – “we all do
it”
 Patients (& therapists) would benefit from
discriminating between when helpful vs.
unhelpful (“Is it an unanswerable question? Is
this leading to a useful decision or plan?”)
 Requires awareness and “skilful” action
© ERW 2010
Q1 How does it
start?
RT
Q3 What
determines
consequences?
Q2 –Why is RT more
frequent, more
persistent in some
people?
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 (i.e., unresolved tagged
mentally to aid resolution).
 RT ceases if goal is attained or abandoned
 Consistent evidence from Zeigarnik effect (interrupted
recalled better than completed), current concerns
literature, ESM studies (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
 Letting go of goals, desires may help reduce RT
© ERW 2010
Q2. What causes people to get stuck? What
underlies individual differences in RT?
 Hypothesis 1: RT (e.g., worry, rumination) is a learnt
habitual response style (Response Styles Theory, NolenHoeksema, 1991).
– Could be learnt through modelling, failure to learn more
adaptive strategies, or because it is negatively reinforced
(removal of aversive experience) –e.g., avoid risk failure,
cognitive avoidance, control feelings, second guessing (nb.
Superstitious, partial, poor discrimination) (Ferster, 1981,
Martell et al., 2001)
– Negative RT associated self-report index of habit, capturing
whether thoughts are frequent, unintended, initiated without
awareness, difficult to control (Verplanken et al., 2007).
© ERW 2010
Lesson for Psychological Treatment 3
 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 disrupting the
environmental factors (time, place, mood) that
automatically cue habit
 And/or learning an alternative incompatible
response to cues (through repetition & training).
© ERW 2010
RT as Habit
= tendency
for
Cascade
of
Negative
thoughts
Q2. What causes people to get stuck? What
underlies individual differences in RT?
 Hypothesis 2: Vulnerability to RT results in difficulties
from disengaging from negative information (local,
data signalling discrepancy) & unattained goals (distal,
underlying).
– Koster et al., (2011) argue RT results from impaired
attentional disengagement from negative self-relevant
information
– Donaldson & Lam, 2006 evidence that trait rumination
associated attention bias towards negative material
© ERW 2010
Trait Rumination associated longer gaze
Fixation on sad image relative to other stimuli in
eye tracker (Watkins, pilot study)
© ERW 2010
Lesson for Psychological Treatment 4
 Improving attentional control may be a means
to reduce RT
 Training attention to focus on positive
information or to move away from negative may
reduce RT (Cognitive Bias Modification).
© ERW 2010
Q3. What makes RT helpful or unhelpful?
a. Unsurprising, less interesting answer = VALENCE of thought content (Watkins, 2008)
RT
(Finding benefit = focus on positive content)
Q3. But what makes RT about negative
content/event helpful or unhelpful?
RT
Answer: Processing Mode
RT
A process approach
 Both worry and rumination share similar mental process of
abstract thinking (if different content): (i) conceptual thinking
about implications (threat vs. self- identity); (ii) thinking that is
distanced from grounding in here-and-now concrete perceptual
experience (future vs. past)
 e.g., Rumination involves repeatedly asking “why me?”,
evaluating self, thinking about the self
 Teasdale (1999) hypothesized that different modes of
processing (“conceptualizing” vs. “direct experiencing”) would
differentially influence rumination
 In parallel, proposal that pathological worry involves
conceptual-abstract style & reduced concreteness (Borkovec et
al., 1998; Stober, 1998; Stober & Borkovec, 2002; Stober,
Tepperwien, & Staak, 2000).
“Think about the causes, meanings
problem solving effectiveness 1-7
and consequences of…..” symptoms versus
& feelings (evaluative-abstract)
“Focus your attention on your
experience of……” symptoms &
feelings (experiential –
concrete)
4.5
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
Watkins & Moulds (2005) Emotion
Watkins & Baracaia (2002): Style of processing influences
problem-solving
N u m b e r o f m e a n s te p s
16
14
12
10
8
no question
why question
how question
6
4
2
0
never depressed
recovered
depressed
currentlydepressed
Depression status
Watkins (2004)– Processing style influences
recovery from upsetting event
depressed mood 1-7
4
p < .05
3.5
3
2.5
low rum - concrete "how"
2
low rum - abstract/"why"
high rum - concrete/ "how"
1.5
high rum - abstract/"why"
1
baseline
postfailure
essay1
time
essay2
essay3
Refinement of goal attainment account
 Martin & Tesser (1996) account within control theory (e.g.,
Carver & Scheier, 1982, 1990; Powers, 1973; Vallacher & Wegner, 1987),
which predicts:
 (a) Goals & actions organized hierarchically: abstract levels
(represent ends “why” a subordinate goal/action is performed,
e.g., implications for self-concept) feed down to concrete levels
(represent means of “how” the superordinate goal/action is
enacted, e.g., programmes & sequences of actions).
 (b) At any moment, attention can be focused at any particular
level, with result that goals, actions, events represented more
abstractly or more concretely (mode of processing)
 (c) Processing difficult stressful situations at abstract level may
be problematic since (i) concern more personally important thus
more emotional impact & harder to abandon; (ii) provide less
specification
of alternatives & steps to proceed
© ERW 2009
Training thinking style
 Inspired by Mathews & Mackintosh (2000),
MacLeod et al., (2002), MacLeod & Rutherford,
(2004), etc, we asked if individuals can be
trained in/out different styles?
 Focus on cognitive intervention for rumination
 Idea of training participants to adopt abstract
vs. concrete mindsets prior to a stressor
 Tests causal role of abstract style/bias on
emotional reactivity
Watkins, Moberly & Moulds, 2008 (Emotion)
- participants
imagine 30 emotional scenarios (e.g., argument
with best friend) in one style as training before a
stressful anagram test
Abstract: I would like
you to think about
why it happened,
and to analyse the
causes, meanings
and implications of
this event.’
Concrete: I would like
you to focus on how it
happened, and to
imagine in your mind
as vividly and as
concretely as possible
a “movie” of how this
event unfolded.’
Training mode causally influences
despondency after failure
Condition x Time, p < .05
45
Despondency VAS
40
35
30
Condition x Time, ns
25
Why Mode
20
How Mode
15
10
5
0
baseline
post-training
post-failure
Processing Mode
RT
Lesson for Psychological Treatment 4
 Targeting processing style may be able to shift
from maladaptive to adaptive RT
 Training individuals to be more concrete (asking
How?) is more adaptive when responding to
negative situations than being abstract (asking
Why?).
 → treatment developments
© ERW 2010
Rumination-focused CBT (RFCBT) 1
 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) → target habit
– a focus on directly shifting processing style via
imagery & experiential approaches & FA → shift
from unhelpful to helpful forms of RT
– i.e., Both approaches focused on changing
process of thinking, not content
© ERW 2010
Functional analysis
FA focuses on variability & context of rumination (when
helpful/unhelpful, when less/more; Antecedents –
Behaviour – Consequences). Used to:
 (a) recognise warning signs for rumination –
increase awareness of habit
 (b) develop alternative strategies and contingency
plans (e.g., relaxation, assertiveness) & repeatedly
practise to generate new habit
 (c) alter environmental and behavioural
contingencies maintaining rumination (remove
environmental cues to habit).
 (d) shift towards more helpful thinking &
discriminating
between helpful vs. unhelpful thinking
© ERW
2010
Shifting processing style 1
 Coach experiential exercises/
build up activities to shift out of
abstract-evaluative rumination
mode
A) Focus on recreating
experiences of being in a
process-focused mode –
absorbed, caught up in the task,
“flow”, “in the zone”, peak
experiences
© ERW 2010
Shifting processing style 2
B) Compassionate, tolerant,
caring, nurturing, nonjudgemental mode
Both involve focus on holistic
experiential shift: thoughts,
feelings, posture, sensory
experience, bodily sensations,
attitude, motivation, facial
expression, action feelings
© ERW 2010
PILOT RCT
Acute
ADM
treatment
Residual
Depression
GP/CMHT
referral to
the study
Screening
assessment Informed consent?
(n = 40)
Yes: Conduct full intake
assessment
Randomise (n=42)
Treatment as usual
(antidepressants)
May include CBT
Individual RFCBT + TAU
Up to 12 sessions
Post-intervention assessment – blind at 16-20 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
No: Return to
treatment-as-usual
Change in HRSD by treatment arm
14
HRS D sco re
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. Betweentreatments effect size for HRSD,
Cohen’s d = 0.895
© ERW 2009
Change in HRSD by treatment arm
14
HRSD score
12
10
TAU (ADM)
TAU+RFCBT
TAU+CBT
TAU-PAYKEL
8
6
4
2
0
pre-intervention
post-intervention
time
Condition X Time, F (1, 38) = 7.38, p < .01 Betweentreatments
Cohen’s d = 0.895
© ERW 2009 effect size for  HRSD,
Change in RSQ (rumination) by
treatment arm
62
57
RSQ score
52
47
TAU
RFCBT
42
37
32
27
22
pre-intervention
post-intervention
time
Condition by Time, F(1, 37)= 4.01, p < .05
Between-treatments effect size for RSQ, Cohen’s d = 0.645
Concreteness training
 Watkins, Baeyens, Read (2009)
 59 stable dysphoric participants (29 current MDE,45
past MDE).
 Randomized to
– Active concreteness training (concrete
exercises from Watkins et al. (2008) adapted
and recorded on CD), practised daily 1 week
– Bogus training (=placebo control, matched
contact time & rationale)
– Waiting list control
Concreteness Training
 Key elements via direct instructions, guiding
questions:
– (a) focusing on details in the moment (e.g.,
questions asking participants to focus on and
describe what they could see, hear, feel);
– (b) noticing what is specific and distinctive about the
context of the event;
– (c) noticing the process of how events and
behaviors unfold (e.g., “imagine a movie of how
events unfolded”);
– (d) generating detailed step-by-step plans of how to
proceed from here.
© ERW 2010
Watkins et al., 2009
Waitinglist Concreteness-active CD
Bogus training
N = 59
35
30
B D I-II
25
20
15
10
Time p < .001, f = 1.36
Time
24x Cond p = .03, f = .37
18.1
11.7
5
0
Assessment 1 Pre-training Post-training
Condition x Time, F (2, 56) = 8.4, p < .001
MRC Cognitive Training Guided Self-help Trial
 121 patients MDE recruited in primary care
 Guided self-help: 1 face-to-face session (90 mins), 3 x
30-min phone sessions over 6 weeks, CD exercises
 Random allocation to
– Concreteness Training (CT) + Treatment-as-usual
(TAU)
– Relaxation Training (RT) treatment control,
matched for rationale, duration, therapist contact) +
TAU
– TAU (as provided by GP, 50% antidepressants)
 Blind assessment (SCID, HRSD, BDI) pre-treatment,
post-treatment, 3 & 6 month follow-up
 Stratification by a) severity of depression; b)
antidepressant use
Lesson for Psychological Treatment 5
 Targeting processing style has treatment value
 Clinical work can inform experimental research
 Experimental research can inform and develop
treatments. There is value in:
– Treatment targeted on core identified process
– Developing interventions informed by basic
research into mechanisms of core process
© ERW 2010
Lessons to treat RT
 Patients (& therapists) would benefit from
discriminating between when RT helpful vs. unhelpful
= awareness & skilful action
 Letting go of goals, desires
 Learning an alternative incompatible response to RT
cues (through repetition & training).
Mindfulness
 Improving attentional control
 Training to be more concrete (Focus on immediate
context )
 Increase self-compassion
= potential
mechanism
© ERW 2010
Rumination and mindfulness
 Thus, mindfulness = antithetical state to
rumination
 Evidence that mindfulness reduces rumination:
– Experimental studies e.g., Feldman et al., 2010
– RCTs – Chambers et al., 2008, non-clinical group,
mindfulness retreat vs. WL; Jain et al., 2007,
students elevated distress, mindfulness vs.
relaxation; Ramel et al., 2004, lifetime mood
disorders, MBSR vs. WL [BUT not found in recent
MBCT vs ADM trial in recurrent depression, Kuyken
et al., 2007).
© ERW 2010
 Thank you
 Please feel free to contact
me at
[email protected]
© ERW 2010