Speaker A
Today, we're going to talk about rumination.
This video explores how rumination hinders mental health progress and therapy effectiveness, offering insights on managing repetitive negative thinking.
Key Takeaways
- Rumination significantly reduces the effectiveness of psychotherapy for depression and anxiety.
- It predicts the onset and relapse of various mental health disorders including PTSD and substance abuse.
- Therapy that does not address rumination may fail or even worsen symptoms.
- Mindfulness, meditation, and physiological regulation can help manage rumination.
- Early identification and targeted intervention for rumination improve treatment outcomes.
Summary
- Rumination involves repetitive negative thinking that traps the mind in harmful thought loops.
- Patients with mood, anxiety, and PTSD disorders often struggle with rumination, which impedes emotional processing.
- Traditional psychotherapy may be less effective for ruminators, as rumination predicts poorer treatment outcomes.
- Rumination increases the risk of developing depression, substance abuse, eating disorders, and PTSD after trauma.
- Elevated rumination at treatment start predicts longer time to remission and higher relapse rates in depression.
- Rumination acts as an emotional magnifier, prolonging and intensifying negative emotions like sadness and anger.
- It can cause individuals to remain stuck on past negative events for years, preventing emotional recovery.
- Targeting rumination specifically is crucial to improving therapy effectiveness and mental health outcomes.
- Incorporating techniques from yoga and meditation can help control the mind and reduce rumination.
- Understanding and managing rumination is key to preventing symptom worsening and relapse in mental health conditions.
Full Transcript — Download SRT & Markdown
Speaker A
When I was a third-year psychiatry resident, I had a group of patients that came into my office with a couple of different diagnoses: one person had a mood disorder, one person had an anxiety disorder, and one person had PTSD.
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And so, as I started working with them, I started doing psychotherapy because that's what a third-year resident is supposed to do; I had a wonderful supervisor, so I started therapizing them, right?
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So we worked a lot on their emotions, emotional processing, things like journaling, doing things like thought logs that look at the relationship between their thoughts, their actions, and their behaviors.
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But despite doing all of this emotional work, they didn't seem to be getting better, and when I was sitting in the room with them, it just sort of felt to me like their minds were out of their control.
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No matter how much we talk about how hurt they feel, their mind would start spiraling in some kind of direction.
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So I started doing something a little bit unorthodox; I sort of looked at this and I sort of said, okay, like this mind is going way off track.
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They get stuck in these cycles of repetitive thinking.
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Let's just learn how to shut off the mind.
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So I started teaching them more stuff from like yoga and meditative traditions, and then something kind of funny happened.
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So then I got called into my program director's office one day.
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And she asked me like, so how are things going with this set of patients?
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How are things going with the supervisor?
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And I said, honestly, like things seem a little bit hard, you know, I'm trying to do psychotherapy with them.
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It doesn't seem very effective.
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I'm teaching them some like yoga and meditation techniques, those seem to be working like, okay, I'm not quite sure.
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And that's when she informs me that the supervisor that I'm working with is essentially firing me.
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She says that this supervisor that you're working with feels like she can't work with you anymore.
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And I was like really shocked and I was like, did I do something wrong?
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Like, you know, why?
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Like I was a bit confused.
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And she said, well, like, you know, the supervisor says that you're sitting with these patients and you're doing something, but it's not psychotherapy.
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And she's a psychotherapy supervisor, so she can't like guide you in something unless you're willing to like do that thing.
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So thankfully, it turned out to be totally fine.
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I don't think the supervisor made a mistake or anything.
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In fact, I think it was a really, really pro move on her part.
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She recognized that I was doing something that has value.
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And that I probably needed a different kind of guidance to learn psychotherapy and sort of blend these two things.
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And that was awesome.
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It worked out great.
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A lot of the stuff that I ended up doing with my patients was actually pretty effective.
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And a lot of that stuff is like when we think about something like rumination or depression or anxiety, we don't really think about how can I control the mind itself?
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Or how can I put my mind in a or how can I put my brain in a physiologic state where we are less likely to ruminate?
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So if you guys want info like that, check out Dr. K's guide.
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We have a ton of great techniques in there about sort of shaping your brain, shaping your body, and shaping your mind.
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And what I didn't realize at the time is that these were patients who were ruminators.
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These are patients who repetitively think about something over and over and over again.
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It's almost as if their mind is turned against them.
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And the really shocking thing about rumination is we may think, okay, like if your mind gets caught in thought loops or spirals, like you should go see a therapist.
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But actually, it turns out that if you are someone who ruminates, therapy is less likely to be effective for you.
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So this was first demonstrated in large-scale longitudinal studies in which rumination prospectively predicted the onset of major depressive episodes and depressive symptoms in non-depressed and currently depressed individuals across follow-up periods ranging from six weeks to five years.
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So what this means is that if you were, if you were a ruminator.
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The degree of rumination predicts the onset of depression.
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But it's not just depression.
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Large-scale prospective longitudinal studies found that rumination predicted subsequent substance abuse, eating disorders, alcohol abuse, and PTSD symptoms following trauma, even after controlling for initial symptoms.
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So this is kind of shocking.
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Because what this, what these studies show is that if you have a traumatic event, if you are someone who ruminates.
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The likelihood for that traumatic event to turn into PTSD is correlated with your rumination.
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So not only does rumination increase your risk for all kinds of mental disorders.
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But it actually interferes with treatment.
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So it turns out that as a PGY3, what I didn't realize is.
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It's not that I was doing psychotherapy incorrectly.
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It's that if you're someone who ruminates, there's a good chance that psychotherapy won't be as effective for you.
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Indeed, there is growing evidence that elevated rumination at the start of treatment predicts poorer outcomes to cognitive-behavioral therapy (CBT) for depression, such as increased time to remission and reduced likelihood of achieving remission.
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Rumination at the end of mindfulness-based CBT treatment predicts depressive relapse.
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So that means that when you complete a course of treatment.
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If you are a ruminator.
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If you're ruminator, that increases the risk that your depression will actually relapse and you'll get depressed again.
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For patients receiving brief CBT in a partial hospitalization program, baseline rumination predicted subsequent anxiety and depression, and examination of symptom trajectories indicated that when rumination did not improve, symptoms of depression and anxiety did not improve and were likely to worsen over time.
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So this is crazy, right?
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This means that if you are someone who ruminates and you go to treatment, and you do not target the rumination specifically.
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There's this will reduce the efficacy of treatment and in some studies may even predict worsening depression and anxiety despite the fact that you did the treatment.
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So how is it that rumination interferes with treatment of psychotherapy?
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And why is it that rumination predicts the the propensity for depressive relapse, symptoms of anxiety, for a trauma to turn into PTSD?
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How does this actually happen?
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So the first problem with rumination is that it is an emotional magnifier.
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The first negative effect of rumination found in experimental studies is that it exacerbates and prolongs existing emotional states such as sadness, anger, anxiety, and depression.
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And in parallel, it elaborates and further polarizes any thought content focused on during the rumination.
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So these are two really important things to understand, okay?
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The first thing that it does is it magnifies and prolongs whatever we think about.
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And usually negative states.
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So sadness, anger, whatever.
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So here's practically what happens.
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So if I do something stupid today, generally speaking, tomorrow is a new day.
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And I don't have to linger with the effects of my stupidity.
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If you are someone who ruminates, the problem is that if you make a mistake today, it causes you hurt for the next year.
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For the next two years, maybe even a lifetime.
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I've worked with ruminators that had problems in high school, like they got dumped by their significant other.
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And they just like feel trapped by that particular injury, and this is like 20 years later.
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You may have seen sort of examples of this, right, people who get like sort of frozen in time.
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And can't move past something.
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That is literally what rumination does.
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So rumination takes a single instance of damage and turns it into dot damage until you are done ruminating with it.
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Which oftentimes is sort of never, right?
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Because you can keep on replaying these thoughts over and over and over again.
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So not only does it increase the duration of emotional injury, it also increases the intensity.
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Now, how does this happen?
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This is something that's really important to understand.
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And it kind of leads to black and white thinking.
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So, this is something that's really wild.
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Have you all ever been like at the grocery store and tried to figure out what to buy?
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So you're sitting there at a grocery store, there's lots of different options.
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And then you're like, I don't know what to buy.
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And you sit there and you think about it for a little bit.
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And as you think about it for a little bit, you make a decision.
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So I want you all to understand this is really wild.
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But the more that your mind thinks about something, the more polarized you become.
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This is just a feature of the mind, okay?
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If that sounds kind of crazy, just hear me out.
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So when I'm like, if I don't know if I should take this job or not take this job, what do I do?
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I think about it.
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So at the beginning, I may be like, let's say here, here is take job and here is pass on job.
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And at the beginning of my thinking process, I'm somewhere in this middle area.
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Right, but despite the fact that I'm in in the middle area, as I think about it more and more and more, I start to drift this way.
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And drift this way, and drift this way, and then eventually, I make up my mind.
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So I want you all to think about how crazy it is to make up your mind.
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I want you all to think about how impossible it is for a computer, if a computer makes a calculation and ends up with a question mark.
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I don't know about generative AI because they just hallucinate all kinds of crap.
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Right, once you have a certain amount of inputs, like if I have a mathematical equation and I don't have enough information to solve the equation.
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And I put it into a computer, the computer is going to say at the first iteration or the tenth iteration.
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We don't have enough info to solve the problem.
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That is not how the human mind works.
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The more that we chew over things in our mind, the more polarized we become, naturally.
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I wasn't sure if I was going to break up with you, I thought about it a lot, and now I know I'm going to break up with you.
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What new information do I have?
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None.
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So, the more that we turn things over in our mind, the more abstract we become, right?
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So as I think about things, more and more and more, I will start to deduce abstract principles.
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So like, let's take the example of someone who is ruminating.
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Let's say here, here's high school.
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And I never had a girlfriend.
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Let's say the reason I never had a girlfriend is because my parents were poor, right?
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So like I couldn't hang out with people, everyone wanted to have the fancy shoes, and I didn't have the fancy shoes.
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So I considered myself unattractive, and that's why I don't have a girlfriend.
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Then I go to uni.
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And then what happens is I struggled to adjust to uni.
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I ended up getting depression in my freshman year.
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Really, really common occurrence.
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And since I got depression in my freshman year, I didn't form, when everybody was making friends, I didn't make friends.
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So I kind of got left out of all of the forming friend circles.
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So now I got kind of left behind.
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And then that's the reason that I don't have a girlfriend.
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And then now I started my job.
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But since I didn't have a girlfriend in high school or college, I don't know how to talk to girls.
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And since I am behind now, I have no girlfriend.
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So if we look at this situation.
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There are strong contextual reasons why I've been single my whole life.
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This problem happened over here, this problem happened over here.
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But then what happens with the mind does is I chew on this over and over and over again.
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I start to come up with an abstract conclusion.
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Which is that I am a loser.
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So the the brain, what the brain does, what the mind does is it looks at this problem.
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And it collects all of this data.
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And then it tries to draw an abstract conclusion.
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Now, here's the problem with an abstract conclusion.
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The more intelligent you are, by the way, the more likely this is to happen.
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This is not actionable.
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So what we find with rumination is actually shocking, even though ruminators report that it increases perceived insight into problems.
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Experimental studies demonstrate that rumination interferes with effective problem-solving both by making individuals more pessimistic, and also more abstract and less able to access specific details of how to resolve a difficulty.
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Okay, and this includes dysphoric mothers with infants under 12 months.
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So this is wild.
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So what this means is like, this is something that is in your brain.
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And like, forget about all these like complicated, you know, histories.
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And no high school this happened.
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And college this happened.
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Like we can study the effects of rumination and how much it causes problems with like mothers and infants who are like 12 months.
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So this effect can be observed over there.
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So it's it's really like a neurological effect.
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It happens in the brain.
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And so what happens when we ruminate a lot is we develop this abstract thing.
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And if I ask someone who feels like a loser, how well do you understand your problem?
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They will say, I understand it incredibly well.
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The reason that I'm an incel is because of X, Y, Z, I'm not trying to bash on incels.
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Because of this and this and this and this and this and this.
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I understand everything.
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The black pill is real, I've read so much research.
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It's so true of so many people's experiences.
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My understanding is great.
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My understanding level is 100.
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What are you going to do about it?
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Nothing can be done.
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I don't know what to do about it.
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I can't think of any solution because I am a loser.
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This is the problem with rumination.
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Because when we make an abstract conclusion from these highly specific actionable scenarios.
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We end up with a conclusion that is not actionable.
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So it keeps us stuck.
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It also makes us pessimistic.
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Which is a big problem because not only does it enhance our negative emotional circuitry.
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But here in my nucleus accumbens and my frontal lobes, anytime my brain thinks about doing an action.
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Should I go to the gym?
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Then what my brain does is it calculates the probability of success of that action.
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So should I go to the gym?
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And what does the the the black pillar do?
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The black pillar says, there's no point in going to the gym because going to the gym doesn't make me not a loser.
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It doesn't correct for all my social skills.
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It doesn't like correct for all of the things that I've missed.
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It doesn't correct for the fact that I have an avoided attachment style.
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So any point of progress is insufficient at solving this big abstract thing.
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This is the this is the effect of pessimism on on your mind.
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So when you have negative emotional stuff that's being amplified, and you have a pessimistic thinking.
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It decreases the value of action.
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And once the value of action goes down, then your motivational circuitry basically says it isn't worth it.
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And if you all pay attention to people who are red pillars or black pillars or whatever on the internet.
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You will notice a couple of very, very simple things.
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The first is look at how abstractly they're thinking.
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Are they thinking concretely or are they thinking in big sweeping generalizations?
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The second thing is look at the value of progress in their mind.
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Do they say, okay, like if I have this problem, does moving forward in it help at all?
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Let's say it won't help at all.
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It doesn't matter.
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So progress becomes useless.
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And when progress becomes useless, that's how you get stuck in time for years.
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The next thing to consider is that rumination increases self-focus and amplifies the vicious repetitive cycle between negative mood and negative cognition.
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Wherein each increases the likelihood of the other.
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And focuses attention on the discrepancy between one's desired state and the actual situation, making this discrepancy more salient.
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In vulnerable individuals, this pattern of mutual amplification between negative thinking (including rumination itself) and negative mood produces an emotional cascade.
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In which rumination can lead to very intense levels of negative affect.
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Vicious cycles of rumination and intense negative affect may thus in turn trigger further dysregulated responses in an attempt to escape these aversive states, such as distracting or compensatory impulsive behaviors, including non-suicidal self-injury (NSSI), reassurance-seeking, or bingeing on food, alcohol or drugs.
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Okay.
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So what does this mean?
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So when we ruminate, what this does is it focuses on where we are, where we want to go.
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And it highlights this gap.
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And the more, so so I I don't know if this kind of makes sense.
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Like making progress in your life involves moving from here to here, and then here to here, and then here to here.
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But that's not how rumination functions.
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It doesn't think like that.
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That's the whole problem.
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What it does is it looks at the gigantic gap between where you are and where you want to go.
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And it just highlights all of your shortcomings.
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This is the way that it becomes an emotional magnifier.
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And this is one of the mechanisms through which it interferes with problem-solving.
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Because we're not thinking about the next step.
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Our mind is literally focused on all the things that I'm doing wrong and all how far I have to go.
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So here's the problem.
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Here's my actual state.
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Here's my desired state.
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And what ruminators will do is instead of moving towards happiness or progress.
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What they tend to do is this feels bad.
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And what they try to do is move away from feeling bad.
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They don't try to actually move towards their goal.
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They simply try to move away from this state.
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I'm not going to grind to improve my life.
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I just want to stop feeling this way.
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There's one last really damaging thing about rumination.
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Which is that it makes you less sensitive to contextual changes.
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So let's take a quick look.
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So rumination has been hypothesized to make ruminators less sensitive and responsive to contextual cues and events in the world around them, including signals of potential reward, changing contingencies, or interpersonal reactions.
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Such abstract and internal preoccupation could prevent ruminators from adaptively responding to changes in the environment or from benefiting from corrective learning that disconfirms negative beliefs.
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This, I think, is arguably the most damaging thing about rumination.
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Is that if you make some conclusion about your life, I am a loser.
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And then you're at work, and then someone at work is like, hey, you want to hang out sometime?
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You get some kind of signal that you're not a loser.
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You get some kind of signal that, oh, actually there's an opportunity right now.
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There's actually contrary information to your belief that you're a loser.
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You're not stuck in this situation forever.
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The nature of rumination makes it so that you are unable, or it is more difficult for you to change to to to detect changes in your context.
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So if you induce rumination, so induced rumination interferes with contextual sensitivity.
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Reduced responsiveness to infant vocalizations in mothers with generalized anxiety disorder or major depressive disorder.
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Reduced sensitivity to infants in mother-child interactions for both dysphoric and non-dysphoric mothers.
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So this is important.
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So we may think, okay, like what, like this is because everybody's depressed, right?
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That's why they're not responding to changes in the context.
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And the changes in the world around them that afford them new opportunities.
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No, so these studies actually show that if you take a mother who has an infant, and the mother is non-dysphoric.
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So the mother is actually totally doing fine.
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And you induce rumination in the mother, she will become less sensitive and responsive to the vocalizations of her infant.
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This is how deep this stuff actually runs.
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So the most devastating thing about rumination is even if your circumstances change and you can make progress.
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Which happens in just about every patient that I've worked with who ruminates.
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The rumination interferes with your ability to see those kinds of changes.
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So then you feel like you're stuck forever.
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So now let's try to recap and understand where this picture puts us.
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So if I'm someone who's a ruminator.
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I have one negative event.
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And then I sort of play that over and I multiply the damage times 10.
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So this turns into dot damage.
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Instead of a single instance of damage.
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Then what happens is I may have a second negative event, and then I may have a third negative event.
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And then I sort of end up making an abstract conclusion.
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Now that I'm a loser.
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I have negative emotion.
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I can't see any concrete action.
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I become pessimistic.
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So it's not worth trying.
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And then this becomes a self-fulfilling prophecy.
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Because if I add these three things, then what happens?
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Oh, yeah, I am a loser.
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Look at all this evidence.
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Look at all this evidence.
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Look at all this evidence.
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But in the same way that we, if we induce rumination in non-dysphoric mothers.
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And they start to have problems with their infant.
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Something very cool happens.
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If we can stop rumination, a lot of these problems will start to get better on their own.
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Because the rumination in and of itself is what is creating the problems.
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And this is something I want you all to really understand because this is kind of a mind-blowing moment.
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At least it was for me.
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See, when you ruminate, you think about your problems, so you think the problem is out here.
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You think the problem is what you see in the outside world.
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That's not the problem.
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The problem is in here.
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The problem is the way that you are viewing things.
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The rumination literally impairs problem-solving.
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Literally magnifies negative emotion.
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So there's one additional problem that is super scary about rumination.
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Which is when we get stuck in this cycle, ruminators tend to be more avoidant.
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So if we disable the rumination, a lot of things will start to get better.
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Then the question very naturally becomes, how do we do that?
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So the first is that rumination is triggered by negative emotion.
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So this is what's really weird, in your brain, when your amygdala activates.
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When you start to experience negative emotion.
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It triggers in a habitual way the ruminative thought process.
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So if you start to have a bad day, then the rumination triggers.
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Now, here's what we need to do.
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We need to separate ruminative thinking from problem-solving.
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Right, so all rumination is going to do is make us think more and more abstractly.
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It's going to polarize our thoughts and it's going to interfere with problem-solving.
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So this sounds so weird.
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But like when we ruminate, we think we're trying to figure out a problem.
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Like we're we're trying to find a solution.
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It actually is very bad at doing that.
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So here's what we need to do.
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When we ruminate, usually it's triggered by a negative emotion.
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This negative emotion needs to be dealt with separately.
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So if you're ruminating, you're not going to solve your problem.
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So we got to start solving our problem outside of rumination.
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Separate these two things.
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Instead, what we need to do is is some kind of focused emotional regulation technique.
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So you can do Nadi Shuddhi Pranayama, we teach a lot of stuff about, you know, emotional regulation.
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Check out Dr. K's guide, it'll really help with all this kind of stuff, okay?
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Deal with that negative emotion.
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Once the negative emotion is gone, then what we want to do, or we're not feeling that negative emotion very actively right now.
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Stop the rumination.
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What we want to do is then we want to engage in problem-solving.
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So problem-solving should only be done when you are happy.
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Only be done when you're happy.
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There's a second aspect of problem-solving, which is remember that the reason that our problems feel unsolvable is because we're overly abstract.
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What can I do today to become no longer a loser?
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That's not something I can do.
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Maybe I can work out, maybe I do whatever.
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There's all kinds of practical things I can do, right?
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But it doesn't feel like it works.
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Instead, what we need to do is really focus on concrete thinking.
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And watch out for the pessimistic angle.
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So we need to start doing is acting.
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We need to start thinking in a very, very concrete way.
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And this is where the solution that I want you all to do is the solution that will be insufficient.
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Watch out for that pessimistic thinking.
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Don't stop, don't quit something just because it isn't going to work.
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If it is moving you in the right direction, then you should just do it.
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That's it.
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It's as simple as that.
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So watch out for that negative kind of thinking.
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The third thing that we need to do is look at our context.
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And improve context.
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So even if you feel like a loser today, chances are your situation is different than the way that it used to be.
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Chances are that for each situation that you think makes you a loser.
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There was some context that was contributing to that.
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And now you may say, oh, but I've like fallen so far behind, there's no way I can recover.
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The context doesn't matter.
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That's the ruminative thinking.
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That's the pessimistic thinking.
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That is the thinking of insufficiency.
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So what I want you all to do is really look at, be on the lookout for any opportunity for change.
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Look at, okay, does this one person, is this person like inspiring me a little bit?
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Could this person be like one of my writing buddies?
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I could review their writing, they could review my writing.
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Is this person maybe like this person asked me if I wanted to hang out sometime?
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And then the pessimistic thinking is like, oh, they're not going to want to be date me or whatever.
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Which is totally fine.
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But I'm going to hang out with them anyway.
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So so be very, very sensitive to changes in context.
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And here's the other critical, critical, critical thing.
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So when I work with people who ruminate, one really good way to tie this all together is to try to improve your context.
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Don't worry about solving your problem.
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Because nothing is going to work to solve your problem, right?
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What can you do to increase your context?
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Let's say you're alone.
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And you don't have any girlfriends or whatever, boyfriends, whatever.
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What can you do to increase your con improve your context?
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What can you do to put yourself in a situation where a girlfriend or a boyfriend is more likely to arise?
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Can you make platonic friendships with people of the opposite gender?
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And then ask you to hook hook you up with someone?
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Maybe set you up on a blind date.
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If you're struggling in the professional side, can you start to do a little bit more networking?
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Talk to your boss a little bit.
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Focus on the context.
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Even if you are a loser, look at the environment around you.
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And how can you improve your environment just a little bit?
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If you all do these things, then there's a good chance that your rumination will improve.
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Because we're targeting the rumination directly.
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The last thing that I'm going to leave you all with is a meditation.
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So this is where when we get stuck in the cycle of rumination, there's one meditation that I I found really helps my patients a fair amount.
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Which is the meditation of what's the next thought?
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So anytime you have a thought, anytime you start to ruminate.
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One thought leads to another, leads to another, leads to another, but you're trapped inside those thoughts.
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Oh my God, then this is going to happen, this is going to happen, this is going to happen.
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Take a step back.
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Because this is what I ended up doing with my patients that ended up getting the supervisor uncomfortable with me.
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Is I started teaching them things like this.
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I started teaching them what's the next thought?
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Go meta for a moment and observe the process of rumination.
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Just ask yourself, okay, brain.
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What thought is next?
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Okay, brain.
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What thought is next?
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Okay, brain.
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What thought is next?
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We don't dwell on the thought.
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We don't wallow in the negativity.
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Okay, now you're upset about this.
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Okay, fine.
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What are you upset about next?
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What's the next thought?
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What's the next thought?
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What's the next thought?
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And if you use this exercise, you may find that it calms you down a little bit.
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And then you can engage in the contextual problem-solving.
Topics:ruminationoverthinkingmental healthdepressionanxietyPTSDpsychotherapycognitive behavioral therapymindfulnessmeditation
