Cognitive Behavioural Therapy (CBT) And Depressive Ruminations

Cognitive Behavioural Therapy, or CBT, is an effective psychological treatment for a wide range of psychological and emotional problems. As a psychiatrist in Edinburgh I employ CBT techniques to help people recover from depression. A prominent feature of their symptom profile is the presence of "Depressive Ruminations".

The term "rumination" relates to a repeated cycle of activity - in the case of cows ("ruminants"), this means chewing the cud! In CBT circles, ruminations are the repeated, seemingly endless, "stuck" ways of thinking seen in certain psychological conditions. It is particularly common in depression.

There can be many "themes" to an individuals ruminations, but the most common is a search for some sort of answer to questions such as "Why am I feeling like this?" or "What could I have done to avoid this?". Another common theme is one of remorse or regret - "If only I had done (whatever) differently I wouldn't be in this position now" or "I've ruined my life". Depressive ruminations about the future are also seen - "Everything's going to go wrong". Ruminations often incorporate what a CBT therapist would call "Thinking Errors".

What does it feel like to ruminate? Well, I'm sure we've all done it at one time or another! It's like trying to solve an unsolvable riddle - you just go round and round inside your head, examining the same old "clues", time and time again. If only you'd done this, or said that, or had this, or not had that. You convince yourself that there's an answer, and that when you find it then you'll be fine. But of course there is no "answer". People can ruminate for hours in severe cases, but up to an hour is more usual.

How do you know when you're ruminating? Because you've stopped doing everything else! You haven't turned the page of your book for the past 20 minutes, or you're standing in the kitchen with a dishcloth in your hands, gazing off into space. If someone asks you what you've been thinking, you can bet it's the same old depressive thoughts that you've been carrying around for ages.

Is there a problem with ruminating? Well, yes. It differs from other forms of thought such as problem-solving, or reflecting, or remembering, in two ways. Firstly, most people find it rather unpleasant. The same old worries getting churned up again and again are bound to make us feel sad or anxious. Secondly, rumination tends to worsen (or at least maintain) depression - if you focus on how bad you feel and how hopeless (you feel) your situation is, then you will ignore opportunities for change.

CBT theory sees depressive ruminations as a major obstacle to recovery from depression, and as such it is important for clients to learn how to deal with them. There are a range of techniques, but the ones I favour as a therapist in Edinburgh are both simple and effective (and almost common sense!).

If you realise you are ruminating, then now's the time to do something energetic. It's hard to ruminate when you're out on a run, or swimming, or doing press-ups. The pain tends to get in the way! Or, if you're not the exercise type, try refocusing your attention. Focus (really focus hard!) on some aspect of your surroundings - a picture on the wall, a tree, the cat - and examine it for detail, noting each and every irregularity and shade of colour. Pretend that you're a famous artist and that you're going to paint the most brilliant, detailed, lifelike picture ever! Really focusing on things outside of you (meaning "outside of your head"!) helps to dislodge your thinking from ruminative patterns. A final tactic - one that some clients swear by and others can't get the hang of at all - is to "stand-back" ("in your head", as it were!) and let your thoughts simply churn away to themselves, whilst acknowledging them as pointless symptoms of your depression. By letting them "get on with it", and refusing to "play with them", you disarm them of their depression-causing capability - eventually they'll get bored and go away!

The above techniques are those that I've found most effective working as a therapist in Edinburgh. There are a number of other methods out there in the literature, and I don't claim that these work for everybody. A good thing about the CBT ethos is that it shies away from doctrinal doings - there's no "You have to do it this way or else!" in CBT. So the bottom line is, use whatever method you find helps you the most, and say "Goodbye!" to those unpleasant ruminations!