In a previous blog I noted that rumination and worry– repeated dwelling on feelings, problems, and difficulties – is an important process causing and maintaining depression. Many people with depression report that they brood repetitively on their symptoms of depression (e.g., “Why can’t I get better?”), on their perceived inadequacies (e.g., “Why can’t I do this?” “Why do I always get things wrong?”), and on past upsetting events and losses. We know from long-term follow-ups and from experimental studies that rumination exacerbates negative mood and predicts increases in depression.
Despite these negative consequences of rumination, many people report that they find it very hard to stop ruminating. Patients with depression often describe rumination as compulsive and habitual, that it occurs without conscious intent, that it often starts before they are even aware that they are doing it, and that it is very difficult to control. Furthermore, rumination often occurs again and again in the same situations or circumstances, for example, when experiencing sad or anxious mood, or at a particular place and time such as going to bed, or when meeting certain people. These qualities of worry and rumination mean that people can often become very stuck.
Interestingly, all of these characteristics of worry and rumination match recent psychological accounts of habits. In an influential paper, Wendy Wood and David Neal of Duke University reviewed our state-of-the-art knowledge of the formation and change of habits. Based on the existing evidence, they proposed that “habits are learned dispositions to repeat past responses, triggered by features of the context that have covaried frequently with past performance, including performance locations, preceding actions in a sequence, and particular people” (Wood and Neal, 2007, p. 843). This account of habit formation emphasises that repeated performance of any behavior (including thinking in a particular way such as rumination) in a consistent set of circumstances causes the behavioral response (e.g., rumination) to become associated in procedural memory with those aspects of the circumstances that are consistently paired with the response across multiple occasions (e.g., prior behavior, particular setting, internal state such as sad mood or tiredness). In other words, a process of associative learning (classical conditioning) results in aspects of the internal and/or external environment becoming conditioned to the behavioral response, such that provision of the environmental cue can trigger the behavioral response. This habitual learning works through similar processes as when repeated pairing of a ringing bell with the provision of food led dogs to salivate to the bell in Pavlov’s famous experiments.
This conditioning and associative learning account of habit formation has a number of important implications. It suggests that often a habit will develop because initially a behavior is performed deliberately as an individual intentionally pursues his or her goals. For example, at first an individual may choose to dwell on their difficulties and problems in an effortful attempt to understand their situation and think through solutions. The rumination is thus voluntary and driven by the person’s goals. However, if such rumination regularly and consistently occurs in the same place, such as lying in bed at night, then over time, this location can become an automatic cue to trigger the rumination, whether or not the person is choosing to ruminate or not. Once a response becomes habitual, the context activates the response directly, without any involvement of goals. Hence rumination could be triggered automatically and involuntarily, whether or not it is consistent with the individual’s goals. Indeed, because the habit is based on the strong associative representation, it will continue to be enacted even when it is at odds with what the person wants to do. Because the context-response pairing is acquired slowly with experience over time, it is highly resistant to change and does not alter easily to changes in related goals or beliefs or occasional deliberate attempts to act counter to the habitual response.
This model of how habits are formed explains why they are hard to control or change. Because it also applies to pathological worry and rumination, it also explains why people with anxiety and depression find it so hard to stop, even when they recognise that it is unhelpful and intend to reduce it, that is, when it is acting at odds with their personal goals.
Fortunately, there is a well-developed evidence base for how to change habits, which indicates that it is possible to change habits. Applying this knowledge suggests a number of valuable lessons and tips that can help to get on top of worry and rumination. This includes indicating how common approaches to tackle worry and rumination may not be helpful.
Tip 1: Changing your goals, beliefs, attitudes, and intentions and obtaining new information is unlikely to be effective at changing habitual behaviour.
As explained above, habits are resistant to change, and simply deciding that you don’t want to think this way anymore, or persuading yourself that this is not a helpful approach is unlikely to change the behavior. Providing heavy smokers with new information about the health risks of smoking may persuade them that it is a bad idea, but on its own does not tend to change how often they smoke. Exhorting yourself to stop a habit or challenging your beliefs or thoughts does not change the learnt association that is driving the habit. It is therefore important to not blame yourself for the rumination or for finding it hard to stop – this is the nature of a habit. Similarly, you should not consider difficulties to reduce rumination as a failure of will-power or your desire to change.
Rather, the habit model suggests that one way that habits can be broken is by altering or avoiding exposure to the contextual cues that automatically trigger the habitual response. In other words, it is possible to reduce worry and rumination by identifying and then removing the cues to rumination. There is good evidence that when the location associated with a habitual behavior changes, for example, when someone transfers school or moves to a new workplace, the behavior becomes less habitual. This suggests two further tips.
Tip 2: Increase your awareness of the cues to worry and rumination by monitoring your rumination and keeping a record or diary of when, where, and how you tend to ruminate.
The first step to modifying the environment to reduce rumination is to become aware of what the triggering cue(s) may be. This requires a detailed analysis of the circumstances that occur just before you start ruminating. Better monitoring itself can increase control of the habit and provides the information necessary to interrupt the rumination. The contextual cue could be time of day (many people report more rumination first thing in the morning and late in the evening), location (e.g., your bedroom or other private space where you tend to do your thinking), a preceding action or part of a routine (e.g., coming home after work and sitting down for a cigarette) or any aspect of the environment. Many people report that changes in their feelings and physical sensations can be warning signs and triggers for worry and rumination, for example, beginning to feel tense, hot, and stressed, or starting to feel down and low, with a sinking feeling in the stomach. The earlier the cue can be identified, the easier it will be to nip the rumination in the bud.
Tip 3: Where possible, change or remove the cue(s) that trigger rumination.
Once the contextual cues that trigger rumination and worry are identified, altering or removing them will reduce the likelihood of the habit being cued, and thus reduce the amount of worry and rumination. Sometimes the cues can be changed by altering behavioral routines. For example, if you find that rumination tends to start while lying in bed in the morning, then it might be helpful to change this routine, by getting up straightaway or by listening to the radio. Rumination often occurs when people are being inactive suggesting that getting up and doing something would reduce the rumination. Sometimes specific features of the environment may act as triggers. For example, listening to sad music, or looking at reminders of a past relationship may trigger rumination. Removing or replacing these cues would then reduce rumination, e.g., playing different music.
When the cue is an internal state, such as feeling tense or anxious, then taking early action to modify those feelings can reduce subsequent rumination – for example, finding ways to relax early could prevent the start of worry. The particular cue(s) will vary greatly and be idiosyncratic to each person –hence the value in spending time working out your own individual triggers.
Tip 4: Repeatedly practice an alternative more helpful response to the habitual cue.
To reduce habitual worry or rumination long term, the unhelpful response to the cueing context needs to be replaced with a more helpful response, by in effect learning a new more adaptive habit that is incompatible with worry and rumination. This requires repeated practice again and again at an alternative behavior in the same context and circumstances as triggered the rumination, so that a new context-response pairing is learnt. For example, if feeling sad triggers rumination, repeatedly practising doing something else in response to starting to feel sad, such as deliberately engaging attention on a distracting activity or talking to a friend could break the habit. It is important to remember that this will require many repetitions across time and in the same context in order to change the habit. This will not always be easy and it won’t always be possible to perform the alternative response but with persistence and effort, gradually the ruminative response will be replaced with the more helpful response. A previous blog reported how we found that daily practice at either thinking more concretely or at relaxation, both in response to warning signs for rumination, were effective at reducing depression (see article).
It seems likely that this benefit occurred because this repeated practice resulted in patients learning a new habitual response counter to rumination.
These ideas have been incorporated into our cognitive-behavioral therapy for rumination (rumination-focused Cognitive Behavior Therapy – see article) which we found successfully reduced depression and rumination when added to antidepressant medication, relative to antidepressant medication only with treatment-resistant depression, in a randomized controlled trial. So it is possible that this approach is helpful at reducing depression. However, this treatment had multiple ingredients so at this point we cannot be sure whether it was these habit-targeting elements or some other element that had the active effect. Nonetheless, these preliminary results are encouraging and suggest the value of further following up this habit change approach.