I use the series of exercises in this article to help patients practice eliminating compulsive rumination. Since Exposure is About Learning, Not Habituation, the goal of these exercises is not to make patients anxious. Rather, the goal is for them to learn that they can control rumination, even when they encounter a trigger.
Some notes to therapists:
- Doing these exercises in session also provides an opportunity to identify and address any problems the patient is having when trying not to ruminate. A list of such problems can be found here and here.
- Be sure not to move to the next exercise until the patient can do the previous one easily — and I do mean easily. If they feel like they’re working hard at not ruminating in session, there’s something wrong with their approach.
- Although I have suggested homework to accompany each exercise, this does not mean you can do only one exercise in a session. I often do several or all of them within a session if the patient progresses quickly.
A couple of notes to patients doing these exercises:
- Be careful not to turn these exercises into an excuse to ruminate or check. In order to avoid this, I recommend (1) scheduling these exercises in advance, and (2) planning the number of times you will do the exercise in advance.
- Remember that the goal of these exercises is just to show you that you can stop ruminating all the time. Doing these exercises will not make your symptoms better or make you ruminate less. That’s your job. These exercises just show you that you have the ability to do your job.
Exercise 1: Response Prevention
First you have to learn How to Stop Ruminating. This exercise is described fully here.
Homework
- Stop ruminating all the time.
- Monitor any times when you feel like you can’t stop.
- Address any of the problems discussed here and here that are getting in the way.
Exercise 2: Practicing Response Prevention
Now that you know how to stop ruminating, let’s practice turning it on and off.
“Let’s ruminate for 30 seconds, and then stop and not ruminate for a minute.”
Repeat this a few times until any problems have been addressed and it is easy to turn rumination off and keep it off.
Note:
The exact times don’t matter. I recommend about 30 seconds of rumination because that’s enough time to get into it, and a minute of not ruminating because that’s enough time to see that you can sustain not ruminating.
Homework:
Same as before:
- Stop ruminating all the time.
- Monitor any times when you feel like you can’t stop.
- Address any of the problems discussed here and here that are getting in the way.
Warning:
If you’re doing this on your own, you must pick the times, as well as the number of rounds you will do, in advance, and you must use a clock or timer.
Exercise 3: Exposure and Response Prevention
“Now that you know you can turn rumination off even when you’re anxious, let’s practice doing it even when you encounter a trigger.
“Let’s do/read/look at something triggering for a moment (as little time as it takes to do/read/look at it) and then refrain from ruminating.”
Notes:
You can repeat a trigger every minute, but again the times don’t really matter.
Another way to do this exercise is for the therapist to periodically say triggering things, while the patient refrains from ruminating.
As discussed above, the goal is not to get anxious, the goal is to learn.
Homework:
- At a scheduled time (whether once or multiple times a day), do/read/look at something triggering for a moment — as little time as it takes to do/read/look at it — and then move on without ruminating.
- Another way to do this is to set reminders throughout the day to bring the obsession to mind.
- As always, address any of the problems discussed here and here that are getting in the way.
Warning:
Again, it is extremely important that this homework be done on a predetermined schedule.
Exercise 4: Exposure and Response Prevention with an Ongoing Trigger
“Now that you know that you can refrain from rumination even when you encounter a trigger, let’s practice refraining from rumination even when you encounter an ongoing trigger.
“Let’s do/read/look at something triggering, and refrain from ruminating while we are doing so.”
For example, let’s:
- Hold a knife
- Read an article about schizophrenia
- Look at pictures of children
Without trying to figure out:
- Whether we want to stab someone/ourselves
- Whether we’re in touch with reality
- Whether we’re a pedophile
Notably, many exposure exercises should not be assigned until a person can successfully engage with an ongoing trigger without ruminating. Otherwise they’re just ruminating while doing the exposure, which might show them that they can do something despite feeling very anxious, but doesn’t show them that they can do it without feeling very anxious.
Homework
Engage with ongoing triggers (e.g., watching or reading something, going somewhere, being around someone) while refraining from ruminating, both during and after.
I hope the above exercises are helpful to both therapists and patients. To reiterate what was said above, please remember that the goal of these exercises is just to show you that you can stop ruminating all the time. Doing these exercises will not make your symptoms better or make you ruminate less. That’s your job. These exercises just show you that you have the ability to do your job.