Profile: Professor Ed Watkins Discusses Rumination
Ed Watkins is a Professor in Experimental and Applied Clinical Psychology at the University of Exeter, where he is also the Co-founder and Director of the Mood Disorders Centre. He was awarded the British Psychological Society’s May Davidson Award in 2004 and is currently serving as an expert member of the NICE Guideline Group for Depression in Adults. Psychology Tools spoke to Ed about his model of rumination, the importance of detail, and his perspective on interventions in the future.
The path to unhelpful thinking
What attracted you to clinical Psychology initially?
I wanted to put into practice what I had learnt about psychology and scientific method in a way that could help people. I was probably influenced by having David Clark as one of my tutors at university, so at undergraduate level I was exposed to the links between science and practice and became interested in clinical psychology.
Why did you focus on mood disorders and unhelpful thinking, and what for you is most interesting about this area?
Like many things in life, it was about luck and timing, and not directly planned. I was doing CBT training at the Institute of Psychiatry in London, and there was a post available in the depression centre – I guess I discovered an aptitude for working in that domain. My PhD research and clinical work started to converge, which made this more interesting.
Mood disorders and unhelpful thinking are fascinating in a few ways. At a personal and emotional level there is often a sense of ‘there but for the grace of God’, because many people experiencing depression have gone through significant loss and difficulty, so it is more about circumstances than individuals. At an intellectual and scientific level, it is about how powerful our thinking can be and how it can have such an influence on how people feel.
Most fascinating for me, is how people often have both unhelpful and helpful patterns of thinking, and understanding how they switch between these, or sometimes get stuck in one or the other.
Can you give me the 2-minute version of your model of rumination?
Repeated dwelling on self, emotions or problems is a normal process that we all do. It is a natural function of trying to achieve unfulfilled goals and make sense of situations, and often occurs after significant losses or surprises.
However, in some people, typically because of earlier learning experiences and/or modelling from close others, it can become a habit. It becomes more frequent, triggered by emotions or other contexts, harder to control and longer-lived.
One key part of rumination and becoming stuck in an unhelpful habit is when it involves more abstract thinking about causes, consequences and meanings, such as asking ‘Why me?’. This tends to move focus away from the particular situation or problem and thinking becomes decontextualized, which exaggerates emotional responses. This can lead to negative overgeneralizations and then becomes harder to resolve. Such abstract thinking makes the unhelpful habit more likely.
Why should clinicians know about it?
Rumination is a very common transdiagnostic problem that contributes to many difficulties and disorders, and so we need to explicitly target it to make headway on many disorders.
It is also a maintaining factor in anxiety and depression – and can also block therapeutic efforts. Many approaches to tackling rumination don’t necessarily work because they don’t reflect this dual nature of unresolved goals and habit. So, distraction and occasional thought challenging don’t address these drivers.
What is helpful about it clinically and how can practitioners translate this knowledge into working more effectively with clients?
The model is helpful clinically because it is proven to be effective, unlike many other approaches. It is flexible because it is based on exploring the idiosyncratic presentation of each client, and it is engaging because it is focused on empowering clients and building from their experience.
The focus on talking about habits is a useful destigmatizing way into exploring rumination. We use functional analysis to tackle the habitual quality, by exploring the triggers, sequence and consequences of episodes of rumination. By exploring variability in rumination, we can hypothesize its function for an individual. We can identify when it is likely to be triggered, remove or alter potential triggers, whether internal or external, and practice alternative helpful responses to those triggers to learn a new habit.
When working with clients, a key general approach is modelling, shaping and asking for specific, concrete, experiential detail (eg., a detailed second-by-second exploration of events) to initiate more concrete helpful thinking. This is further developed by identifying shifts from unhelpful to helpful thinking in the functional analysis. We then practice these shifts experientially, learning to shift from “Why?” to “How?”
Over the time that you have been focused in this area, what about your approach has changed the most?
I’ve become more and more focused on two things. Firstly, the importance of repeated practice and consolidating skills – “less is more” in the sense of going over the same exercises and linking them to the key triggers for that client’s rumination rather than introducing more and more exercises. Secondly, becoming more and more aware of the nuances of language: the importance of keeping language direct and simple, as well as how phrasing itself can shift to abstract or concrete thinking.
You were right there at the start of transdiagnostic thinking with the book you published in 2004. What excites you about this area? How has this affected your approach clinically?
I am excited about the potential ability to tackle complexity and multiple co-morbidity, such as anxiety and depression, as this is the most common presentation. The ability to focus on mechanisms that cut across disorders has great potential to improve interventions. Clinically, I have moved more to focusing on individualistic formulations that are based around the key processes and functions for an individual, rather than specific diagnosis.
What’s your take on progress in diagnosis-specific interventions vs transdiagnostic interventions? What should we be concentrating on teaching trainees? Is it a case of ‘both-and’?
Both have value. There is currently stronger evidence for diagnosis-specific interventions, in part because this is how trials have been set up, and it is clear that this approach has produced big dividends, such as improving the treatment of anxiety disorders.
Effective transdiagnostic treatments could also revolutionize treatment, however these haven’t really been assessed rigorously, as we are still working out the best methodology for this and studies have tended to be diagnostic driven so this remains an empirical question. Therefore, at this point I would suggest that both be taught.
The recent Michelle Moulds / Richard Bryant review of rumination in PTSD specifically flagged your work as a promising area for improving PTSD interventions. Are there other areas where you think rumination focused approaches are likely to be especially promising?
Probably lots of areas, given rumination contributes to exacerbation and impaired recovery. Several likely areas include increased work in prevention; emotion dysregulation, anger, and suicide and self-injury. The overlap between physical and mental health through multiple morbidity, for example with depression and cardiac disease, also looks promising. Rumination may contribute to both via biological processes like inflammation but also via influencing behavior.
Sadly, the majority of clinical psychologists never publish. What motivates you to carry out and publish research – what is different about you, what drives you? Why do you value research as well as clinical practice?
I have always been interested in both helping people and understanding how things work, so combining research and therapy is a great way to do both.
I have a lot of curiosity about trying to understand things more and to dig a bit deeper, and learning new things and finding ways to improve clinical practice is very motivating. I was also lucky in that my early mentors, John Teasdale and David Clark, modelled this interaction between the clinic and research and publication, and embodied this approach.
What’s your balance of clinical work, training and research, and what’s valuable about this balance?
Sadly, as a senior academic, I very rarely directly provide treatment myself anymore as it has been superseded by management. My clinical skills are kept up through supervision – particularly via detailed feedback on videos of rumination therapy for trial therapists. I probably have 50% of my time for research and the rest is a mixture of teaching and training.
What are you working on now that makes you most excited? Can you tell us a little bit about it?
We are developing and testing a digital app to target rumination and other processes as a means to prevent depression and anxiety, and to improve mental health in young people.
Accumulating knowledge and experience
If you could go back in time and give some advice to your younger self training as a clinician, what would it be? What do you wish you had known then that you know now?
That’s hard to answer because so much of clinical skill and nous is simply the accumulation of experience and getting better at spotting patterns and being fluent at responding. One thing that has developed with time is keeping things simple – saying less, being more to the point, direct, straightforward, and honing in to the key issues quicker.
Is there a paper or book that you keep going back to, or which has provided particular insights for you?
The Barnard and Teasdale (1993) Affect, Cognition and Change: Re-Modelling Depressive Thought book, which introduced the Interacting Cognitive Subsystems model. I still think the ideas and depth of thinking in this book are underappreciated. It is well ahead of its time in trying to develop a dynamic model of cognition that informs a complex and sympathetic understanding of depression. Inspiring.
When you’re supervising trainees or other clinicians working with this client group, what are some of the most common challenges that they face?
The thing we focus on most often is helping therapists to get more detailed and specific with patients who ruminate. Often descriptions of events are still rushed and a bit abstract and lacking contextual and sensory detail. Helping therapists to slow things down and really dig into the detailed experience is a common challenge.
If you could make trainees read one thing at the moment, what would it be?
I still think that too few trainees really get a good grasp of functional analysis, and what a powerful and flexible approach it can be to apply to a wide range of problems. So, I would recommend books that really target that; Christopher Martell and colleagues’ Behavioral Activation book, and the Functional Analytic Psychotherapy book (Kohlenberg & Tsai) is another excellent but little-referred to book. If I may, my book on rumination-focused CBT which provides a specific more recent example of how to apply functional analysis.
If you could do it all over and go through training now, what do you think you would focus on?
I think I would still focus on the same core elements in clinical training – CBT, adult mental health. I would be interested in learning more on the physical/mental interface too. On a research training front, more data science, machine learning, big data and physiology training would be good.
Looking forward – a perspective on the future
What developments in psychological treatment interventions or techniques do you think look really promising?
From a research perspective I think two areas that will have a significant impact – not perhaps immediately, but once properly developed. Firstly, unpacking the active mechanisms of treatment: we know that CBT for depression can work but we don’t know what components of the therapy are key. If we can determine this, we can further enhance therapy.
Secondly, personalization of therapy – so, which treatment to give to which patient. Currently this is based on clinician and patient preference, treatment availability or trial-and-error. There is emerging evidence that we can do this better using machine learning and data from trials, using potential predictors of treatment response, and I think this could have a huge impact.
How do you think psychologists might be treating worry and rumination differently in twenty years’ time?
I suspect we will have refined and honed down some of the things we have started doing in the last 5-10 years; improved ways of changing habits and shifting processing styles through a combination of functional analysis (with this becoming more precise and attuned), and experiential/behavioral work. This is currently only being used by a minority of psychologists and we are constantly improving our approach with experience, so it will probably become more mainstream.
In addition, we will be using technology more. Apps could be used as in-the-hand ways to support habit change, especially if they provide just-in-time ecological momentary interventions to help support learning a new habit just as a trigger occurs. We may have also improved our cognitive psychology derived training – a really efficient cognitive bias modification, that effectively targets worry and rumination.