As discussed in Chapter 2 Abramson and his colleagues (Abramson, Alloy, Hankin, Haeffel, MacCoon, & Gibb, 2002) have examined the relationship between cognitive vulnerability and Beck’s theory of depression. Within the context of their cognitive vulnerability-stress model of depression, they studied the role of rumination. They found cognitive vulnerability to underlie the tendency to ruminate negatively, and they posited that cognitively vulnerable individuals are at high risk of engaging in rumination. Depressive rumination involves the perpetual recycling of negative thoughts (Wenzlaff, 2004). There is evidence that negative rumination leads to (a) negative affect, (b) depressive symptoms, (c) negatively biased thinking, (d) poor problem-solving, (e) impaired motivation and inhibition of instrumental behavior, (f) impaired concentration and cognition, and (g) increased stress and problems (for review, see Lyubomirsky & Tkach, 2004). Depressive ruminators are caught in a vicious cycle. Due to their rumination they become keenly aware of the problems in their lives, but at the same time they are unable to generate good solutions to those problems. Therefore, they feel hopeless about being able to change their lives (Nolen-Hoeksema, 2004).

Various approaches for treating rumination are described in the literature. They include thought stopping, in vivo and imaginal exposure, systematic desensitization and relaxation training, CBT, metacognitive therapy, mindfulness meditation, distraction therapy, and attention training therapy (Purdon, 2004). With depressive rumination, distraction therapy, CBT, and attention training therapy have been effective to some extent. Purdon (2004, pp. 221-222), from her review of the effectiveness of distraction therapy with depression concludes: “Suppression of depression-related thoughts appears to be somewhat successful in the short term, but these efforts may be highly vulnerable to disruption and therefore rather inefficient as a long-term strategy for managing depressive rumination.” The lack of enduring effectiveness of distraction therapy can be attributed to two main causes: (a) the research on thought suppression shows that distraction or suppression leads to a rebound of thought occurrences once control efforts have ceased (e.g., Wegner, Schneider, Carter, & White, 1987); and (b) because negative ruminations are influenced by negative core beliefs (cognitive vulnerability), if these core beliefs are not corrected, the surface ruminations are likely to remain refractory (e.g., Rachman, 1997). Instead of thought suppression, a more positive, constructive method is to distract from the thoughts mindfully; that is, the mind is gently moved on to alternative, positive thoughts or images, seeing any intrusive
thoughts as clouds across the field of vision or other imagery. This procedure is akin to detached mindfulness (see 15).

The effectiveness of CBT with depressive rumination has been modest. Although CBT is well established as the most effective psychological treatment for overcoming depression, its focus is on the cognitive triad, not on depressive rumination, because ruminative styles of thinking have not been given prominence in either the CBT model of depression or in the treatment of depression. In therapy, the focus of CBT has largely been on modifying the content of negative automatic thinking related to the cognitive triad, rather than focusing on the process of negative thinking. This bias in therapy may partially account for the large proportion of depressed patients who do not respond to CBT or who relapse following treatment. In other words, traditional CBT challenges the content or output of thoughts. Many clinicians (e.g., Wells and Papageorgiou, 2004) believe CBT would be more effective if it were to address processes or metacognitive beliefs, that is, how people arrive at what they “know.” The concept of metacognition includes an analysis of how an individual’s thinking about his thinking plays a key role in the development of psychological problems. For example, the patient who is depressed about everything has numerous negative, depressive thoughts. What is of interest is not simply the content and meaning of specific thoughts, but the meaning of thinking in this particular way.

Papageorgiou and Wells (2001) distinguish depressive rumination from negative automatic thoughts. They regard rumination as a coping strategy that exacerbates depression in the same way that anxious rumination (worry) serves to maintain anxiety. They interviewed depressed individuals about their rumination and found depressed people to hold positive views of their rumination. Depressed patients believe that their ruminations are helpful for solving problems, gaining insight, identifying potential triggers and causes, preventing future mistakes, and prioritizing important tasks. Unfortunately, because these ruminations are negative and unconstructive, they play a major role in the development, persistence, and relapse of depression. These findings highlight the necessity for restructuring these underlying beliefs or metacognitions. Understanding and correction of these metacognitive beliefs about the ruminations will likely decrease the erroneous use of rumination for problem solving, which will lead to a reduction of depressive symptoms. The reasoning and attention switching procedure for treating depressive rumination described in this chapter is based on these theoretical rationales and empirical findings.

Few treatments or techniques have been directly targeted at treating rumination in depression. The most structured and systematic treatment for depressive rumination, attention training therapy (ATT), has been developed by Wells (Wells, 1990; Wells & Papageorgiou, 2004). Single case studies have shown that ATT is helpful for a number of problems including health anxiety and major depression (see Wells & Papageorgiou, 2004). Similarly, I (Alladin, 1994,Alladin, 2006), as part of my cognitive hypnotherapy package, have developed thought stopping and attention switching for dealing with depressive rumination. Because the focus of this technique has been on distraction, in the light of the recent
findings that thought suppression leads to an increase in rumination, the technique has been revised and labeled reasoning and attention switching (RAAS).