Wednesday, 13 February 2013

10 things I learnt from Ed Watkins workshop on CBT to Treat Depressive and Anxious Rumination

Yesterday I attended an extremely  useful workshop given by Professor Ed Watkins from the University of Exeter yesterday about how  Rumination-Focussed Cognitive Behavioural Therapy (RFCBT) can help clients with both depression and anxiety-related disorders.

In this post I will present 10 things I learnt about RFCBT

1) Worry and Rumination are quite similar - the main difference is that worry tends to be future-oriented and rumination past-oriented. "Repetitive thinking" (RT) can be used to cover both processes; clinically you should use whatever term makes sense to the client.  Clients may talk about "dwelling on", "brooding", "going over things again and again", "stewing on things", "chewing things over", "procrastinating" - notice what term they use and stick with it.

2) Repetitive thinking is often a key pathological process.  It can maintain both anxiety and depression. Consequently identifying it, labelling it, and changing it can be a key step in shifting depression and anxiety

3) Rumination and worry can be thought of as part of avoidance which is known to be part of both depression and anxiety. Rumination and worry tend to involve withdrawal from others, reduced activity and taking less risk - all characteristics of major depression. Worrying can be an alternative to confronting the thing one is worried about.

4) Rumination and worry are quite normal - we all do it - and need not always be unhelpful. Whereas Adrian Wells's Metacognitive Therapy (MCT) tends to view all rumination and worry as pathological, Watkins' RFCBT appears more attuned to the possibility that there is some purpose to it, and sometimes it may actually be helpful. Even if it is not helpful, its useful to identify its aim  (Padesky's there's a good reason for what you are trying to do idea) and substitute more helpful ways of achieving this goal.

5) Functional analysis is a key technique in determining the purpose and nature of rumination and worry for an individual client. Functional analysis involves identifying the antecedents, behaviours and consequences (ABC) of the problem (in this case repetitive thinking).
Antecedents -  "tell me about a recent time when you found yourself chewing things over. What kicked it off? what did you notice first? what was going on in your body? where were you? what was going through your mind? who were you with?" These are all good questions to elicit the antecedents.
Behaviour - "what happened next? how  long did it last? what ended it? were you thinking about the past a lot? were you trying to figure out the meaning of things? (rumination) were there a lot of what-ifs? (worrying)
Consequences "Did it help? In what ways was it useful? In what ways was it not useful? What was it trying to achieve? What happened as a result? Did you feel different? What were the long-term consequences? What would you like to happen? I this way both the positive and negative consequences of repetitive thinking can be identified.
Functional analysis begins in the assessment session and may be augmented by asking the client to keep a diary. The diary would focus on the problem behaviour. Notice that rumination and worry are treated as behaviours.

6) Functional analysis will draw out the range of repetitive thinking which the client is currently doing. It will also clarify for both client and therapist the ways in which it is helpful or unhelpful. Most often the helpful parts which actually be problem-solving, planning or decision-making. It may be that sometimes it may be useful to come to terms with a loss, or be part of a grieving process.  In this way RFCBT can be seen as being a guided discovery towards something like Butler and Hope's Worry Decision Tree. A logical follow-up will be further worked aimed at
1) distinguishing between unhelpful and helpful repetitive thinking
2) reducing the unhelpful processes (unhelpful repetitive thinking)
3) coaching in planning, problem-solving and decision-making

7) Repetitive thinking is best explained as a bad or unhelpful habit.
Framing RT as a habit is very often a useful way of socialising clients into RFCBT. We all have bad habits and we all know that they can be difficult to change, but they can be changed.  This way of thinking about RT gives the right message.
 Rumination and worry are generally unhelpful, and you can change them, and we will need to work to change them, and it may require quite a lot of practice.
 An alternative message given in more mindfulness-based approaches would be that of a skill - that learning to ruminate or worry less is like learning a new skill).

8) RFCBT proposes a number of ways to reduce unhelpful repetitive thinking.
These include
i) Becoming more aware of the triggers
This follows from the "A" part of  functional analysis. For example, a client may notice that a trigger to rumination is being on their own on their walk to work.
ii)Altering environmental contingencies
For example, the above client may be encouraged to try out listening to cheerful music on their way to work..
iii) Changing processing style
Repetitive thinking involves abstract and very often uncompassionate thinking. can be countered by exploring flow experiences (point 8) and learning to be more compassionate (point 9)

9) Modelling and scheduling experiences of deep absorption and engagement (flow) can provide an effective contrast to repetitive thinking.  Ask the client to recall an experience of deep absorption - it may be doing a sport, a hobby or at work. You can then either schedule more activities like that (flow activities scheduling) or help the client get back in touch with those feelings using imagery.
a) Ask the client to notice  the triggers of rumination or worry
b ) Get back in touch with their  flow experience -
c) Return to the task that was interrupted by the rumination or worry.
In this way recreating the flow experience in imagination is not just a distraction  - it is teaching the client to get back in touch with a very concrete, focussed processing style which they can use to be more effective.

10) Compassionate Mind  training is another way to change thinking style in a helpful way. Many ruminators and worriers are self-critical. If they can learn to be kinder to themselves, this will change their style of thinking. Paul Gilbert and Deborah Lee have done a lot of work  on compassionate mind training, for example involving developing an image of the "perfect nurturer" and bringing it to mind when you need it. RFCBT's approach is slightly different in that it involves real experiences of compassion - for example when they had been compassionate to some else. Through imagery work the client is invited to get in touch with the feelings and thoughts of compassion. They can then practice this through homework and work through a hierarchy of more difficult times to bring compassion. Often it will be hardest to be self-compassionate in which case this will be at the top of the hierarchy.

To sum up:-
 RFCBT is an evidence- based, short-term trans-diagnostic approach which can help with depression and anxiety. It can almost certainly also be useful in dealing with other problems such as PTSD and anger-management.  Many of its techniques (functional analysis, guided discovery, behavioural experiments, imagery, homework setting, exposure hierarchy will be familiar to the CBT practitioner. It also has similarities but also differences with Wells's Megacognitive Approach, Gilbert's Compassion-Focussed therapy, Butler and Hopes Worry Tree and Positive Psychotherapy approaches enhancing flow and engagement.

You can find out more about Ed Watkin's Rumination Focussed CBT by following these links
Ed Watkins Powerpoint Presentation of RFCBT (pdf)
Ed Watkins paper of depressive rumination
Psychology tools resources on rumination