Targeting rumination by changing processing style: Experiential and Imagery exercises

1. Targeting rumination by changing processing style: Experiential and Imagery exercises Edward Watkins, PhD University of Exeter e.r.watkins@exeter.ac.uk BABCP 2011

2. Acknowledgements - Funders

3. Acknowledgements • Research collaboratorsMood Disorders Centre co-directors • Dr Celine Baeyens • Dr Nick Moberly Professor Willem Kuyken • Dr Michelle Moulds Dr Eugene Mullan • Rebecca Read • Sandra Kennell-Webb All patients and participants • Simona Baracaia Therapy development & trial • Dr Katharine Rimes • Dr Anna Lavender • Dr Janet Wingrove • Dr Neil Bathurst • Rachel Eastman • Professor Jan Scott

4. Plan of Skills class • Thinking Style and avoidance as key elements driving pathological rumination • A functional-contextual approach – Functional analysis • ***Shifting processing mode – Experiential exercises • Video

5. Rumination = recurrent dwelling on feelings, problems, upsetting events, negative aspects of self Why can’t I handle things better? What will others think of me? What does this mean about me? Why did this happen to me? What am I doing to deserve this? Why do I feel so bad? Key process in onset and maintenance of depression & anxiety

6. Rumination-focused CBT (RFCBT) • RFCBT focuses on increasing effective behaviour – i.e., not stopping rumination but making it functional • RFBCT grounded within the core principles and techniques of CBT for depression (Beck, Rush, Shaw, & Emery, 1979) with two adaptations: • a functional-analytical perspective using Behavioural Activation (BA) approaches (Addis & Martell, 2004; Martell et al., 2001; Watkins, 2009; Watkins et al., 2007; Watkins et al., in press) • An explicit focus on shifting processing style via imagery and experiential approaches

7. Rumination-focused CBT (RFCBT) 2 • Within BA terms, ruminationconceptualized as avoidance (cognitive & actual) that is negatively reinforced (e.g., avoid risk of failure; pre-empt criticism; reduce intensity) • Rumination becomes a learned habitual behaviour • May be reinforced superstitiously, partial reinforcement, poor discrimination helpful thinking (problem-solving) and unhelpful

8. Rumination-focused CBT (RFCBT) 3 • Cues trigger ruminative response automatically [mood, stress, contexts) • Information-giving, thought challenging unlikely to change a habit • Hence treatment only effective if counter-condition alternative responses to warning signs • Hence focus on identification of warning signs and then repeated practice of an alternative response under mood/stress challenge to develop more functional habit

9. But dwelling on difficult events is common, normal & often adaptive What determines whether dwelling on a problem/upset leads to either OR constructive resolution, Problem-solving, working through gets stuck in a distressing loop that goes nowhere?

10. Watkins (2008)– Positive consequences of RT What are the positive benefits of this? How did this happen? What can I do next? What can I learn from this? What is important to me now? How can I fix this? Reduces negative mood & improves planning & problem-solving in experiments Predicts recovery from upsetting and traumatic events and from depression in some prospective studies

11. Rumination-focused CBT (RFCBT) 4 • The way that people think during stress and problems may be part of the learnt habit • Either an unhelpful unconstructive processing style (conceptual, evaluative, existential, abstract, judgemental, passive) • Or a helpful processing style (non-judgemental, non-evaluative, constructive, concrete, action-oriented). • Use experiential exercises and imagery to induce this processing style, as counter to rumination, and as means to develop constructive habit

12. Inclusion:a. DSM-IV criteria for MDD last 18 mths, not last 2 mths; b. residual symptoms ≥ 8 on 17-item HRSD & ≥ 14 on BDI-II; c. ADM for ≥ 8 weeks Exclusion: History of bipolar disorder, psychotic disorder, current substance dependence Acute ADM treatment GP/CMHT referral to the study Screening assessment -Informed consent? (n = 42) Yes: Conduct full intake assessment No: Return to treatment-as-usual Randomise (n=42) Treatment as usual (antidepressants) May include CBT Individual RFCBT + TAU Up to 12 sessions Post-intervention assessment – blind at 16-20 weeks (n = 40) PILOT RCT Residual Depression Watkins et al., in press British Journal of Psychiatry

13. Baseline scores

14. Change in BDI by treatment arm

15. Change in BDI by treatment arm Condition X Time, F (1, 38) = 10.26, p < .005. Between-treatments effect size for  BDI, Cohen’s d = 1.06

16. Change in BDI by treatment arm –Watkins et al, in press, BJP RFCBT 12 sessions; CBT 20 sessions Condition X Time, F (1, 38) = 10.26, p < .005. Between-treatments effect size for  BDI, Cohen’s d = 1.06

17. Change in HRSD by treatment arm Condition X Time,F (1, 38) = 7.38, p < .01. Between-treatments effect size for HRSD, Cohen’s d = 0.895

18. Recovery, Remission & Relapse • Recovery (50% reduction in HRSD): • TAU 26% vs. TAU + RFCBT 81%,2 = 9.92, p < .001 • Full Remission (BDI-II < 14, HRSD < 8): • TAU 21% vs. TAU+RFCBT 62%,2 = 5.24, p < .05. [CBT in Paykel et al., 1999 study 25%] • Relapse between pre & post assmts (5 mths) • TAU 53% vs. TAU+RFCBT 9.5%, 2 = 6.89, p < .01

19. Factors maintaining rumination • AVOIDANCE • (not addressed today)

20. Factors maintaining rumination 2. Thinking Style

21. A behaviour experiment • A behavioural experiment used with patients • The broken down car exercise – recall/imagine time when needed to get somewhere important soon and car would not start . Get as vivid an image of this situation as possible. Imagine that you are in a real hurry

22. The HOW-WHY behaviour experiment

23. HOW? Probably found easier, more natural

24. WHY?

25. Processing mode hypothesis • Theory and experiments  hypothesis that there are distinct styles of rumination, with distinct functional consequences • Adaptive, constructive ruminative self-focus = concrete, process-focused, specific thinking, focused on the concrete & specific experience & process of how things happen moment-by-moment • Maladaptive, unconstructive ruminative self-focus = abstract, general, evaluative thinking, thinking about why an outcome occurred(Moberly & Watkins, 2006; Rimes & Watkins, 2005; Watkins, 2004; Watkins & Baracaia, 2002; Watkins & Moulds, 2005; Watkins & Teasdale, 2001, 2004, Watkins, 2008, Psych Bull; Watkins, Moberly & Moulds, 2008)

26. Targeting avoidance & rumination • Treatment approach 2 – mode of processing • Intervention – Shifting processing mode

27. Switching thinking style Shifting from evaluative..   to a more process-focused style… 2. Use imagery, experiential exercises 1. Compare effective vs ineffective thinking in functional analysis

28. Shifting processing style • Coach experiential exercises/ build up activities to shift out of abstract-evaluative rumination style • Focus on recreating experiences of being in a concrete process-focused style (counter to rumination)

29. Absorption experiences - recreate being caught up in the task, “flow”, “in the zone”, peak experiences (connected world direct way)

30. Compassion experiences - Recreating feeling compassionate, tolerant, caring, nurturing, non-judgemental

31. Focus on holistic experiential shift via memories, images: thoughts, feelings, posture, sensory experience, bodily sensations, attitude, motivation, facial expression, action feelings

32. Key elements of “flow” (Csikszentmihalyi, 2002) • Deep & effortless involvement in activity • Merging of action & awareness • Balanced ratio between challenge (opportunities) & skills • Focused attention on the task at hand • Narrow temporal focus – immediate, present-moment • Clear goals, rules & immediate feedback

33. Key elements of “flow” (Csikszentmihalyi, 2002) • Loss of self-consciousness • Changed perception of time • Connection with environment – self-guiding • Sense of possibility of control • Activity intrinsically rewarding – valued as an end in itself (autotelic) • Focus on discovery, learning, growth – build self-potential

34. Key elements in shifting style • Requires preparation & socialisation into model, use of relaxation & imagery work as groundwork • Find vivid memories and imagery of being in process-focused absorbed state – used to a. kick start mode b. Develop habit c. as example for functional analysis to make future plans • Review memory to build up details • Recreate mental state using guiding questions to direct imagination to details – present tense, field perspective: • Sensory experience – As vividly as you can see what you are looking at. Describe what you can see • Motivation & Attitude • Posture – As you become more absorbed, notice your posture of relaxation • Physical sensations – Notice the sensations in your body • Feelings – Experience and hold onto your feelings, letting them deepen • Facial expressions – • Urges to actions • Attention – What do you notice? Where are you focusing your attention?

35. Experiential Exercise • Experiential exercise – process-focused versus evaluative experiment • Think of an activity that you do fairly often – that you can be totally absorbed in AND at other times find difficult to focus on • “Reflecting on past experience, can you think of times when you were immersed in an activity/ dwelling on something else & finding it hard to concentrate?” • “As best you can, relive and re-experience that situation. Recall and vividly imagine the setting – look out in that situation. See what you were looking at during that time, recreate how you were thinking, notice what you were attending to. Experience your feelings, and physical sensations. Notice how you feel.. Explore those feelings – what is your posture, facial expression. As best you can, recapture and hold onto that feeling of being absorbed in the process of …. Focus on what you can see in this situation. Notice what you are paying attention to. What is important to you in that situation?” • Compare what doing, experience of each mode

36. Key elements in shifting style • Requires preparation & socialisation into model, use of relaxation & imagery work as groundwork • Find vivid memories and imagery of being compassionate to self or others – used to a. kick start mode b. Develop habit c. as example for functional analysis to make future plans • Review memory to build up details • Recreate mental state using guiding questions to direct imagination to details – present tense, field perspective: • Sensory experience – As vividly as you can see what you are looking at. Describe what you can see • Motivation & Attitude • Posture – As you become more absorbed, notice your posture of relaxation • Physical sensations – Notice the sensations in your body • Feelings – Experience and hold onto your feelings, letting them deepen • Facial expressions – • Urges to actions • Attention – What do you notice? Where are you focusing your attention?

37. Compassion Work • Can use imagery building past experience (compassion to others close, etc) or compassionate imagery (Gilbert) • Need to stay with experience and repeat re learning habit • Need to allow time to work through it • Work up hierarchy from easier points of compassion to more difficult (e.g., other to self) • Avoid conceptual analysis and comparative thinking • Break down and adapt to overcome barriers experientially • Repeated practice in session and outside of session • Use functionally

38. Summary • Avoidance & rumination play major role in maintenance of depression • Both can be normal & adaptive behaviours • Value of adopting contextual, functional approach – FUNCTIONAL ANALYSIS • Function of rumination moderated by processing style – Value of interventions to SHIFT style

39. Thank you • Please feel free to contact me at e.r.watkins@exeter.ac.uk with any questions, thoughts, plans about research, for handouts etc

40. Additional slides from full workshop follow • Group approaches • More information on avoidance • More information on experimental work • More information on functional analysis

41. Initial sessions during RFCBT • Standard CBT assessment interview to determine symptoms and problems • Establish that rumination is a major problem – i.e. patients report extensive unproductive dwelling on negative material • Examine consequences of rumination • Identify rumination as the target of therapy – a treatment goal • Explain what rumination is, using examples from patients own experience

42. Rationale – key points 1. Recurrent negative thinking and avoidance maintain depression (the central engine driving depression) 2. Both of these responses are quite normal and functional in limited amounts under the right circumstances – i.e. “it is not surprising that you use them - everyone else uses them too.” 3. However, when used excessively or when they are out of balance, they become problematic. 4. Excessive use occurs because of past learning – either copying others or previous occasions when you learnt that rumination was a useful strategy – i.e. it has perceived benefit. 5. Because it was learnt, it can be replaced/overlearnt with a new more adaptive strategy. 6. Therapy will coach you in learning a new more adaptive approach based on your own experience (lead into functional analysis)

43. Group RFCBT • Two variants • (1) In Exeter, using BA variant explicitly uses BA terms with some RFCBT elements, avoidance key focus. Used open trial, moderate improvements (BDI reduce 10-15 pts). 90 min sessions • Session 1: Introduction, Mood-avoidance links, self-monitoring • Session 2: Examine avoidance, TRAPs, idea of alternative response. Record TRAPS

44. Group RFCBT • Session 3: take ACTION, plan alternatives, visualise putting into action • Session 4: Breaking down challenges – smaller steps • Session 5: Rumination – form of TRAP, generate consequences and functions of rumination, Alternatives to rumination –How vs Why?. • Session 6: Connecting with the Present – absorption exercise, use memory of absorption to interrupt rumination. Plan absorbing activities

45. Group RFCBT • Session 7: Self-compassion – interactive experiential exercise, Plan to be more compassionate • Session 8: Learning from experience – become more aware of triggers. Discriminating context. Notice when each tool works best • Session 9: Values – acting in line values • Session 10: Resilience – review skills, plan for ongoing activity, relapse prevention plans, review experience of group.

46. Group RFCBT • (2) Revised group plan emerged consideration BA groups plus development of rumination-focused prevention groups. 90 min sessions (?still in pilot). Main focus from beginning is Rumination. • Session 1: Introduction, Handling stress, introduce worry/rumination, examples generated group, rumination as habit, generate consequences, self-monitoring. • Session 2: Noticing warning signs, stepping out of habit – introduce if-then plans, changing circumstances.

47. Group RFCBT • Session 3: Different Styles of thinking, experiential alternative to rumination-e.g., relaxation, How vs Why? Experiential exercise, link into if-then plan, practice with “hot” warning sign • Session 4: Alternatives to rumination that serve function; useful rules of thumb (unanswerable questions, 30 min rule, lead to action?), absorption • Session 5: Self-compassion, experiential exercise, acting in a more caring way towards self • Session 6: Interpersonal Effectiveness, comparing effective vs ineffective, resilience

48. Key aspects of environment during functional analysis • The richness of the environment – • The time of the day – • Solitude – • Rituals and routine – disruption • Mood triggers – • News signals – • Evaluating self, plans and outcomes – • Lack of structure • Lack of absorbing/valued activities • Anniversaries/reminders

49. Dealing low motivation • Encourage change from the "outside-in" by changing behaviour without waiting for any internal change (“inside-out”) • act according to goals rather than feelings • divorce action from mood dependence - act while acknowledging that they didn't feel like acting at that moment • Set up as experiment – small step

50. FA & rumination • In group setting (RFCBT group pages 16-21): • A) Emphasize spotting warning signs – by situation, environment, physical response, actions, thoughts • B) Introduce idea of (i) changing the situation (pacing, prioritizing, environmental control, change routine) [facilitate change context to help break habit] • (ii) React differently • If I notice this warning sign, then I can do this ....alternative. • Generate warning signs & trigger in group • Generate alternatives in group • Generate functions (p. 35-37).