Edward Watkins

Edward R Watkins Ph.D.

Mood for Thought

Depression

How to Reduce Worry and Rumination 1: Become More Specific

Evidence for a simple approach to reduce depression, anxiety, and rumination

Posted Jul 21, 2013

In my previous blog I discussed how depressive rumination is characterised by repeated dwelling on problems, difficulties, and symptoms in an abstract processing style, characterised by asking “Why?” and thinking about causes, meanings, and implications. Experimental studies have indicated that this abstract processing might be one mechanism that contributes to the negative effects of rumination by impairing problem solving and exacerbating the emotional response to negative events.

This leads to the hypothesis that training people with depression or who have the tendency to get stuck in rumination to become more specific when faced with difficulties or problems will help to reduce depression and rumination.

As a proof-of-principle test of this idea (see this paper), we looked at the possible benefits of training people with elevated symptoms of depression to be more concrete over 1 week. Volunteers with elevated symptoms of depression were allocated at random to a concreteness training condition versus a bogus training condition, versus no training. The concreteness training involved participants practising thinking about the specific details of recent mild negative events – how the event happened, where it happened, who was there, what they did – and trying to get as vivid a mental picture of the event and its circumstances, and focusing on the sequence of how the event happened. This practice was facilitated by having these mental exercises on audio-recordings which the participants listened to and practised every day for a week. The bogus training condition had the same rationale as the active condition, but did not involve active practice at being concrete.

Our assumption was that practise at thinking about negative events in a concrete way would help to keep difficulties in perspective, make plans and problem solve, and reduce the emotional response to these difficulties. Because we found this effect in the short-term for a single session of practice, we figured that repeated practice might lead to more long-term effects: if being more concrete helps to not get so upset to a mistake or to bad news, then if this occurred on multiple occasions, it might help to reduce depression.

This is what we found. Across the week of practice, levels of depression symptoms halved in participants practising being more concrete, whereas they hardly changed in the no training condition. The bogus training group improved a bit but not as much as the actual training, suggesting that the benefit of the concreteness training was not just simply due to positive expectancy and placebo effects. We also found that the concrete training reduced rumination.

However, this study was not in patients diagnosed with clinical depression. Moreover, we only looked at the effects of being concrete over a week, rather than longer term outcomes. Thus, there will still doubts as to whether this approach would generalize to clinical depression.

To test this, our next study was a randomised controlled trial funded by the UK Medical Research Council, in which we investigated concreteness training in patients diagnosed with major depression recruited from primary care (see paper). We adapted the concreteness training into a guided self-help treatment, in which patients first met with a therapist to practice the skills and then used a booklet and recorded audiofiles to practise the skills over 6 weeks, with several brief telephone sessions to support and motivate continued practice.

Volunteers for the study were randomly allocated to the concreteness training or to a control training condition or to treatment-as-usual from their family doctor. The control training condition was matched for amount of therapy contact, the use of audio-recorded exercises, structure, and the explanations given to patients but differed in using progressive muscle relaxation as the active element rather than practising being concrete. I will need another blog to provide a detailed discussion of control conditions in psychological treatments. We followed patients up for 6 months after treatment.

We found that adding the concreteness training to treatment-as-usual significantly improved outcomes, reducing rumination and symptoms of depression and anxiety , and this benefit lasted over 6 months. This suggests that learning to be more concrete for negative events was helpful as an intervention for depression.

Interestingly, we found that the relaxation training condition was also good at reducing depression and worked as well as the concreteness training. Because both treatments encouraged participants to spot when they might be about to ruminate or worry, and then to practice doing something different (either being concrete or a relaxation exercise), this suggests that finding any positive activity to use as a counter to rumination might be helpful in reducing depression.

How can you become more concrete and specific?

Here is a summary of the techniques that we taught patients in the trial when faced with a negative event or when remembering and imagining a negative event.

First, focus on your sensory experience (Ask yourself: “What can I see? What can I hear?”). Notice what is specific and distinctive.

Ask yourself: “What is happening? How? Where? When? With whom? How is this event different and unique from other events?”

Second, notice the process by which events and behaviours unfold. As best you can, be aware of the sequence of events, what comes before, and what follows after each action and event. Notice the series of steps, of actions and events that lead up to an event.

Ask yourself: “How did this come about? How did this event unfold? What are warning signs? What might change the outcome?”

Third, focus on how you can move forwards. Ask yourself how you can break things down into discrete, manageable steps which you can take to move forward into helpful action. Take the first step in the chain of actions (whether mental or physical) that you can do to deal with a given difficulty and then follow the sequence, step by step, dealing with new difficulties as they arise and acknowledging your own progress when things go well!

Ask yourself: “How can I move forwards? How can I break this down into smaller steps? What is the first step I can take?”

We have found this focus on asking “How?” instead of asking “Why?” questions is quite helpful in shifting people away from depression. Patients found this particularly helpful as a form of “Emotional First Aid” that they apply when they first notice that they are getting stressed or upset.

The key trick to this working is repeated practice at thinking in a more concrete way. If you practise this every day at a set time or place and then as best you can try to use it when a difficulty comes up, after a while it becomes more automatic, and you can find yourself coping better with stress.