Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk BABCP 2011 © ERW 2011 Acknowledgements - Funders © ERW 2010 Acknowledgements 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 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 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) 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 e.r.watkins@exeter.ac.uk with any questions, thoughts, plans about research, for handouts etc © ERW 2009 Additional slides from full workshop follow 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)