Please note that Rumination-Focused ERP is a new and evolving approach to ERP. Neither this exercise nor the rest of the treatment has been researched, and therefore neither is evidence-based. Please also note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship.
This article describes the exercise I use to teach people how to stop ruminating. The exercise starts with the following instructions:
Identify a problem that you usually ruminate about.
Your job is to not try to solve that problem.
Don’t try to push it out of your mind or forget about it.
Don’t actively try to keep it in mind either.
It can be there or not be there; it doesn’t matter. Your job is to not try to solve it.
How do you know if it worked?
In the past, I would just ask people if they were able to stop, and if they said yes, I would take their word for it. But I learned that sometimes people thought they’d stopped ruminating when they actually hadn’t fully, especially if they had a definition of rumination that was narrower than mine. I now use two questions to make sure a person has completely stopped ruminating. The first question is:
What is your anxiety level, from 0-10?
As discussed here, I believe that anxiety is a product of rumination.* Therefore, if a person has fully stopped ruminating, their anxiety level will be close to 0. While it might not be 0.0, it shouldn’t be much higher. If it’s significantly higher than 0, they are still engaging in some way, and we need to help them figure out what they’re doing so they can stop. Fortunately, this is a multiple choice test. Here’s what they might be doing:
- Trying to figure something out (‘rumination proper’)
- Directing attention/monitoring
- Keeping their guard up
- Pushing away thoughts, trying not to let thoughts enter awareness
- Using mindfulness or ‘bad distraction’
- Engaging in self-talk
Notably, a person might be doing a combination of several of these, and it may therefore be necessary to repeat this exercise several times, identifying issues one by one until the person’s anxiety level comes down to about 0.
But even if their anxiety is close to 0, it’s important to ask one more question:
Did that feel totally easy? How much of an effort were you making, from 0 to 10?
Remember that ruminating is doing something, and not ruminating is not doing it. If someone says they’re not ruminating but it requires effort, that tells us that they are doing something, which indicates a flaw in their approach. Not ruminating needs to feel like getting off of a treadmill, not getting onto one. The experience of not ruminating should feel as effortless as lying on your sofa.
But please note that when I say that not ruminating should feel easy and not require effort, I only mean that the experience of not ruminating should feel effortless. I don’t mean that, for example, making the decision to stop ruminating is always easy, or that figuring out what’s wrong with your approach is always easy. There are many parts of this process that do require effort. All I mean is that when you’re not ruminating, it shouldn’t feel like you’re making an effort.
So if someone says their anxiety level is about 0 but their effort level is higher, we need to go back to the same multiple choice test and figure out what it is they’re doing, or what it is they’re doing that requires effort. Again, it may be necessary to repeat this several times until not ruminating feels totally easy.
Thus, this exercise entails asking someone to stop ruminating, and then identifying any problems with their approach until their anxiety is about 0 and it feels effortless.
If a patient is having trouble, it’s a great idea to provide them with the multiple choice options and enlist their help in figuring out what’s going on. (It could even make sense to do this before giving the initial instructions. I personally prefer to initially provide just the instructions, and then identify issues as they come up. This is purely stylistic.)
A Closer Look at the Multiple Choice Options
Now let’s take a closer look at each of the multiple choice answers, keeping in mind that there is overlap among them.
1. Trying to figure something out (‘rumination proper’)
This is pretty self-explanatory. Just keep in mind that this includes not only trying to solve the original problem, but also trying to solve another problem; trying to figure out if you’re doing it right; trying to figure out if you’ll be able to do it outside of the session; etc.
Analytical thinking of all kinds is controllable. Just like you can stop solving a math problem or planning a party, you can stop ruminating.
2. Directing attention/monitoring
This includes someone who is directing attention towards the problem even if they aren’t really analyzing it; someone who is directing attention towards their thoughts to see if they’re ruminating or to see what thoughts are coming up*; and someone who is directing attention towards an emotion or a feeling in their body.
People often think that in order to stop directing attention towards one thing, they have to direct it towards something else. These people need to be told: Directing attention is like mentally holding onto something. You don’t need to grab onto something else, just to let go.
3. Keeping your guard up
Keeping your guard up is like bracing yourself mentally; it’s sort of like directing attention towards the general possibility of threat, or like a mental radar. Once someone realizes they’re doing this, they can typically stop.
Sometimes a person is bracing themselves against rumination. Such a person needs to understand that rumination isn’t something that happens to them, it’s something they do. And as long as they don’t do it, it won’t happen. Metaphorically, they are leaning up against a locked door.
When addressing this latter issue, I might say something like: It sounds like you’re imagining that if you don’t keep yourself braced against rumination, it’s going to come flooding in. But that’s not how this works: Rumination isn’t something that happens to you; it’s something you do. The most that can happen against your will is a thought occurring to you, but as long as you don’t engage with it, nothing more can happen. Right now, it’s like you’re leaning up against a locked door. You can let go.
When someone says their anxiety is about 0 but it doesn’t feel easy, it’s likely they have their guard up.
4. Pushing away thoughts, trying not to let thoughts enter awareness
Thought-suppression plays a far smaller role in OCD than people think it does, but sometimes it does make an appearance, and that’s what we’re talking about here.
It’s crucial to distinguish between something being in awareness, and directing attention towards it. The former is not controllable, and trying to control it will backfire because in the process of trying to keep something out of awareness, you are directing attention towards it, which keeps it in awareness. The latter is controllable, as per 2 above. Again, for a full discussion of the difference between awareness and attention, see here, and for an experiential exercise, see here. (Although I have said this elsewhere, it bears restating that it is not always possible to thread the needle between attention and awareness, and it is therefore important to hold this distinction lightly and allow the line to be blurry sometimes.)
Even if a problem remains in awareness, if a person completely lets go of trying to solve it and of directing attention towards it, their anxiety will still come down to about 0.
The language I use most frequently in these cases is: It’s there; don’t engage.
5. Using mindfulness or ‘bad distraction’
These issues are related to 2 and 4 above, but warrant individual attention.
Many people who struggle with rumination have tried to use mindfulness or ‘bad distraction’ to solve this problem. Evidently these strategies haven’t worked or they wouldn’t be seeking help. Nonetheless, they may default to these strategies when we ask them to stop ruminating. When this happens, we just need to point this out, and guide them not to use these strategies.
Distraction is ‘bad’ if it is (1) an attempt to push something out of awareness, and/or (2) an attempt to stop paying attention to one thing by paying attention to something else. Let’s look at each of these:
- As discussed above, you can’t force something out of awareness. Trying to force something out of awareness will actually keep it in awareness, because in the process of trying to force it out you are directing attention towards it. For further discussion see here.
- You don’t need to direct your attention towards one thing to stop directing it towards another thing. As mentioned above, directing attention is like mentally holding onto something: You can let go without grabbing onto something else.
If a person is having either of these problems, it’s important to use the opportunity to provide the relevant information above.
As discussed here, there are multiple reasons that mindfulness is a problematic intervention for compulsive rumination. The ones most relevant in this context are: that it can involve directing attention towards the problem or towards one’s thoughts; that it can be used as ‘bad distraction’; that it involves doing something. When someone uses mindfulness during this exercise, it’s important not only to ask them not to, but to also be specific about what they were doing in the process that was problematic.
For example, if someone says they were trying to be mindful of their thoughts, they’re talking about directing attention. So in addition to letting them know that we are not asking them to use mindfulness, we would also highlight that they are directing attention towards the problem, and guide them to stop doing so.
If someone says they were watching their breath or trying to notice different things in the room, they’re probably talking about ‘bad distraction.’ So in addition to letting them know that we are not asking them to use mindfulness, we would also highlight that they are trying to use ‘bad distraction’ and provide the relevant information above.
But even if a person says they’re watching their breath because it helps them, and they are neither directing attention towards the problem nor using ‘bad distraction,’ we would still ask them to stop, because we want them to learn that not ruminating doesn’t require doing anything.
6. Engaging in self-talk
Whether you talk to yourself out loud or just in your head, everyone engages in self-talk sometimes, and sometimes it’s helpful. But in the context of not ruminating, the problem with self-talk is twofold: first of all, it keeps you engaged with the problem; second, it is doing something and we want people to understand that not ruminating is about not doing something.
Fortunately, not talking in your head is as easy as not talking out loud, so once a person identifies this issue, they are usually able to resolve it easily.
That’s literally it.
The above is everything you need to teach someone how to stop ruminating. Again, you just help them identify and solve these problems with their approach one by one until their anxiety is about zero and it feels effortless.
No worries if you need to go, but if you have time, I’d be happy to do some practice together. Below are some things people commonly say during this exercise. I invite you to read each one, take a look back at our multiple choice options, and see if you can formulate what problem the person is having and what you would tell them. Then we can compare notes.
“I keep trying to think about other things but it’s still there.”
The main problem here is that the person doesn’t seem to understand that it’s okay for it to be there, as long as they don’t direct attention towards it or try to figure it out. It also sounds like this person is trying to use ‘bad distraction;’ they might also be trying to push the problem out of awareness.
So I might say something like:
Your job isn’t to make it go away. Your job is to let it be there without directing attention towards it or trying to solve it. You also don’t need to actively try to distract yourself by thinking about other things. Just let it be there, and don’t engage.
“I keep trying to stay present/mindful but my mind keeps wandering.”
There’s no evidence here of ‘bad distraction’ or directing attention towards the thought, so as far as we know, the only problem is just that they think they need to do something.
So I might say something like:
You don’t need to be mindful or present. You can think about whatever you want, or let your mind wander. Your only job is not to solve that problem or direct your attention towards it.
And if I thought it was relevant I might add:
Ruminating is like trying to solve a math problem. If I asked you to stop solving a math problem, you wouldn’t need to do mindfulness; you would just stop. Do the same thing here.
“I don’t know what to do instead.”
This person is like the last one: They think they’re supposed to do something.
I might say something like this:
You can do literally anything; it doesn’t matter. I’m asking you to get off of the treadmill, and you’re asking me what to do instead. My answer is: Do anything you want, as long as you stay off the treadmill.
“It keeps popping into my mind.”
It sounds like this person might be trying to keep the thought out of awareness. It also sounds like they might be paying attention to what thoughts enter their mind.
With regard to the first issue, I might say something like:
Popping in? You must be trying to push it out. Your job isn’t to get rid of it, it’s to stop directing attention towards it. Just let it be there and don’t engage.
With regard to the latter issue, I might add:
It sounds like you’re watching the door to see who comes in. Try to let go of doing that.
“I keep thinking about whether I’m going to be able to keep this up” or ”I keep worrying that I’m not doing this right.”
This one is straightforward. This person is ruminating about ruminating, which is ‘rumination proper.’
I might say:
Trying to figure that out is also rumination. If the thought occurs to you that you might not be able to keep this up, or that you might be doing it wrong, treat that the same as the original problem: Don’t engage with it. Don’t try to figure it out and don’t direct attention towards it.
“Now I’m just worrying about something else.”
Again, ‘rumination proper.’ I might say:
The point of this exercise is that you can choose what you think about. Thoughts occur to you, but you decide if you want to engage with them or not. The same way that you’re choosing not to engage with the original problem, you can choose not to engage with these other ones.
“I’m really not trying to figure it out but I’m still anxious about it.”
This person is most likely directing attention. I might say:
It sounds like even though you’re not trying to solve it, you might still be directing your attention towards it. Just like trying to figure something out is controllable, directing attention is also controllable. Try to let it be there and just not engage.
“I’m not trying to figure it out exactly, but I can’t stop seeing disturbing images or scenes.”
Visuals haven’t been discussed in this article, but the problem here is: ‘rumination proper.’ This person may think they’re not trying to figure anything out, but they most likely are.
Except in very unusual circumstances, visualizing anything vivid or ongoing requires effort. The most you might visualize without effort is a vague, peripheral image. So if the image is vivid or ongoing, the person is probably visualizing it on purpose in an effort to figure something out (e.g., by checking their response to the image).
So I would say all of that:
Except in very unusual circumstances, you can’t visualize something vivid or ongoing unless you’re making an effort to do so. The most you might visualize without effort is a vague, peripheral image. So if the image is vivid or ongoing, you’re probably visualizing it on purpose in an effort to figure something out. Do you know what you might be trying to figure out?
“I feel sad (or any other emotion)”
Feeling emotional doesn’t indicate rumination, but this person seems to be thinking about, or at least paying attention to, how they are feeling. We would want to convey that the feeling itself is not a problem, but directing attention towards it and ruminating about it are.
I might say:
That’s okay, I’m not asking you to control your feelings, just your thoughts. You can feel whatever comes up. Just make sure you’re not directing attention towards the feeling or trying to figure anything out about it. Let yourself feel whatever you feel, but don’t engage with it mentally.
But what if they say they feel anxious or uneasy? Is that different since we don’t want them to feel anxious?
Even though our goal is for the person not to feel anxious, we want that to happen as a consequence of not ruminating. We do not want people to ruminate about why they’re feeling anxious or to direct attention towards the feeling. Therefore we would treat anxiety like any other feeling, and ask the person not to direct attention towards it or ruminate about it.
In Rumination-Focused ERP, the immediate next step after teaching someone how to stop ruminating, is to work on doing this even when confronting triggers. ERP Exercises for Compulsive Rumination provides a series of exercises for working on this.
Once a person has mastered these exercises, the next step is to work on eliminating rumination (as well as compulsive research and reassurance-seeking) consistently. This may require:
- Addressing justifications for rumination
- Addressing other common issues with consistency
- Refraining from rumination even when caught off guard by a major triggers
- Working on gently distinguishing between awareness and attention
Once a person has eliminated rumination consistently, they are ready to do exposures, in the context of not ruminating. This specific approach to exposure is discussed here, and a guide and worksheet for designing an exposure protocol can be found here.
(I believe it is also important to address the emotional and relational dynamics that drive rumination and other OCD symptoms, and I hope to post resources about this topic in the coming months.**)
I believe that knowing how to stop ruminating is not only foundational to the treatment of OCD and other anxiety disorders, but also a basic life skill that every person should be taught. We humans don’t realize how much control we have over certain parts of what goes in our minds, or where the line is between what we can and can’t control. Finding out can be life-changing.
*As I have noted elsewhere, I am talking about anxiety specifically, not fear.
** Anyone eager to explore this topic is encouraged to read Individual Psychotherapy and the Science of Psychodynamics, by Dr. David Malan. See specifically chapters 10 and 11.