Rumination: what it is, why it is so hard to stop and how therapy treats it

Javier is 34 and works at an accountancy firm. For a few weeks now he has been waking at 6:10, fifty minutes before his alarm, and he can't get back to sleep. He sits on the edge of the bed, with his partner still asleep, and goes back over Friday's meeting, when his manager corrected him in front of the whole team. Why didn't I say anything? What will they think of me now? Why do I always freeze when there are people watching? By the time the alarm goes off he has been turning it over for almost an hour, he has reached no conclusion and he feels more tired and lower than he did the night before. What he is doing has a name, rumination, and it can be worked on in therapy.

This guide is written for psychologists and therapists who come across rumination in their practice, almost always inside another complaint (a depression, a break-up, a problem at work, insomnia that won't shift), and also for patients and families looking for reliable information. It covers what rumination is, why it is so hard to stop, how it differs from worry and from obsessions, how to assess it and which treatments have evidence behind them.

What rumination is

Rumination means going over your own distress, again and again, along with its possible causes and consequences, without moving on to do anything to change the situation. The definition most used in research comes from the response styles theory that Susan Nolen-Hoeksema put forward in 1991. In the review she published in 2008 with Blair Wisco and Sonja Lyubomirsky, "Rethinking Rumination", they describe it as a way of responding to distress that involves focusing repetitively and passively on the symptoms and on what caused them or what they will lead to. The person stays fixed on the problem and on how they feel about it, but doesn't act.

The authors stress one point: rumination is defined by the process, by thinking perseveratively about one's own feelings and problems, and not by the particular content of the thoughts. You can ruminate about an argument, a mistake at work, a break-up or your own sadness. The depression guideline from the UK's National Institute for Health and Care Excellence (NICE) gives two examples that you hear a lot in practice: "Why did this happen to me?" and "Why can I not get better?".

Not every look back is rumination. Thinking about what went wrong so you can learn something from it is useful, and almost everyone does it. The difference is in the outcome: when reflection works, it ends in a decision or a new way of seeing things; rumination comes back to where it started and leaves the person feeling worse than before.

Why it is so hard to stop ruminating

If rumination only did harm, it would be easy to let go of. The trouble is that, from the inside, it feels useful. Understanding that is half the work in therapy.

What the person thinks they get out of it

When they ruminate, people say they are trying to understand what their feelings mean, to find the links between their problems and to work out why things happen to them. Many hold strong beliefs about the value of going over things: "if I think it through, I'll understand it", "if I stop thinking about it, it'll happen again". Edward Watkins, at the University of Exeter, also describes more specific functions that come up again and again in his patients: anticipating criticism so it doesn't catch them off guard, avoiding the risk of failure or humiliation, controlling feelings they don't want to have, keeping themselves on their toes so they don't become lazy or arrogant, or having an excuse not to do something.

Rumination as a way of avoiding

From the behavioural activation point of view, rumination is an avoidance behaviour: while the person is going over Friday's meeting, they are not making the phone call they have been putting off or leaving the house. Nolen-Hoeksema and her colleagues go a step further and suggest that rumination builds a case for hopelessness: if everything is this serious and this uncontrollable, there is nothing to be done, and that frees the person from the responsibility to act. That is why a patient who ruminates for hours often says, rightly, that they are exhausted even though they haven't done anything.

The problem with asking "why"

Watkins' experimental research separates two ways of dwelling on a problem. The helpful one is concrete, specific and focused on the process: how exactly did it happen, what step can I take now. The harmful one is abstract and evaluative: what does this say about me, what does it mean. When Javier asks himself what freezing says about him, he ends up at "I never get anything right", a jump to the general that drags his mood down and gets in the way of problem solving. If he asks how it happened, minute by minute, and what he could say next time his manager corrects him, the thinking leads somewhere. People prone to unhelpful rumination tend towards the abstract style.

Rumination, worry and obsessions: how they differ

All three are forms of repetitive thinking, they overlap in many patients and it pays to tell them apart, because they are not treated the same way. Rumination and worry are closely related and share a lot: both are repetitive, self-focused and abstract in style, and both make anxiety and depression worse. Even so, when they are measured together they come out as two distinct processes.

Nolen-Hoeksema's review proposes an underlying difference: the theme of worry is threat and the theme of rumination is loss, whether through bad luck, one's own failure or others not living up to expectations. If the main complaint is anticipating the future, the article on generalised anxiety disorder covers how to work with worry. If what you see are intrusive ideas that the person experiences as alien and neutralises with rituals, check the criteria for obsessive-compulsive disorder before treating it as rumination.

What rumination does to mood and to daily life

The 2008 review sets out the effects with the most support. Rumination makes depression worse, makes thinking more negative, gets in the way of problem solving, interferes with the actions that could improve the situation and wears down social support, because the people around the person tire of hearing the same thing. It also predicts the onset of depressive episodes, more consistently than it predicts how long they last.

It is not limited to depression. Rumination has been linked to anxiety, binge eating, binge drinking and self-harm. With binge eating and drinking, the review points to a mechanism you will recognise in practice: the person tries to escape the loop with something that distracts them, even if it harms them.

In depression its weight is especially large. The NICE guideline on depression in adults lists rumination, alongside avoidance, among the coping styles that increase the risk of relapse, and asks that cognitive behavioural therapy for chronic depressive symptoms covers rumination as one of the processes that keep them going. The article on depression treatment covers the full approach to the condition.

How to assess rumination in practice

You can't see rumination: you have to ask about it. Many patients don't mention it because they experience it as their normal way of thinking, or because they believe it is exactly what they should be doing to get out of the problem.

The interview questions

It helps to cover five things. When and where rumination starts (what time, what place, doing what). How long an episode lasts, in minutes, because "all day" is no use for measuring change. What it revolves around and how it begins. What the person believes they get from going over it. And what they stop doing meanwhile. Javier, for example, said he ruminated mostly in bed, on waking and at bedtime, that each episode lasted between half an hour and an hour, and that he believed that if he didn't go over what he had done wrong properly, it would happen again.

In the interview you also need to look at the content. If the thoughts are about death, not wanting to go on or being a burden to others, this is no longer just rumination and suicide risk has to be assessed in that same session.

Scales for measuring rumination

The most widely used is the Ruminative Responses Scale (RRS), which grew out of response styles theory. It has 22 items about what the person does when they feel sad or down. Later work split it into two subscales, brooding and reflection, and the Spanish adaptation by Gonzalo Hervás (2008) found the same two factors. Brooding, a passive comparison between how things are and how they should be, is the subscale most closely tied to depression.

If the patient also ruminates about the future, or about topics that have nothing to do with mood, the Perseverative Thinking Questionnaire (PTQ) measures repetitive negative thinking regardless of content. Giving the same scale at the start and every few weeks gives you a figure to compare against.

The rumination log

For two weeks the patient notes every episode they spot: day and time, where they were and what they were doing, what set it off, what they were going over, how many minutes it lasted, their mood before and after (0 to 10) and what they did when it ended. Watkins describes the contexts that come up most often: first thing in the morning, late at night, being alone, feeling tired or bored, physical pain or tension, sitting doing nothing (a coffee, a cigarette), feeling disorganised or rushed, and withdrawing to the bedroom when upset. Javier's log confirmed two windows, on waking and at bedtime, and a third he hadn't mentioned: the car, on the drive home from work. The article on therapy homework assignments has ideas to stop the log being dropped after three days.

How to stop ruminating: the psychological treatment of rumination

No treatment is about "not thinking". Trying to suppress negative thoughts tends to backfire: they come back stronger. What works is changing the person's relationship with the thought, changing its style, or changing what they do when they start to ruminate. These are the options with the most support.

Rumination-focused cognitive behavioural therapy

Watkins and his team in Exeter developed it for patients whose depression wasn't fully lifting. It starts from a functional analysis: rather than arguing with the content of the thoughts, you look at the contexts in which rumination appears, the function it serves and its consequences. From there, three things are worked on:

• Spotting the warning signs and triggers, so the patient notices early that they are ruminating.
• Shifting the thinking style, from the abstract "why?" to the concrete "how?", with imagery exercises in which the person recalls times they were completely absorbed in something and practises that way of paying attention.
• Finding an alternative that serves the same function. In one of his cases, a patient ruminated about her failings so as not to become lazy and arrogant; treatment replaced that rumination with compassion exercises, first towards others and then towards herself.

In an early case series, 14 patients with residual depression that hadn't responded to medication had 12 weekly 60-minute sessions. Half reached full remission, and rumination fell to levels similar to those of people who had never been depressed. A randomised controlled trial with 42 people in the same situation then compared treatment as usual with treatment as usual plus up to 12 sessions of this therapy: adding it improved symptoms and remission rates, and the effect ran through the change in rumination. The authors point out that there was no control group receiving the same amount of attention, so the specific ingredients of the therapy can't be fully separated out. Watkins himself notes that some studies have found standard cognitive behavioural therapy works less well for people who ruminate the most, which is a good reason to target rumination directly when it is intense.

Behavioural activation: getting out of the trap

If rumination is a way of avoiding, treatment means getting back to doing things. Behavioural activation teaches the patient to recognise the sequence (something upsets them, they feel bad and they withdraw to go over it) and to replace the withdrawal with a concrete action. Nolen-Hoeksema cites dozens of experimental studies in which a few minutes of pleasant or neutral distraction (going for a run, meeting someone) improved mood and also the quality of thinking and problem solving. The nuance matters: distraction is a first step. Once mood lifts a little, the person needs to go back to the problem and deal with it, because if they only run from it, it returns.

Metacognitive therapy

Adrian Wells' metacognitive therapy doesn't argue with what the person thinks, but with what they believe about the way they think. It works on positive beliefs ("ruminating helps me understand") and negative ones ("I can't control it, I'll go mad"), which are what keep the process running. Its best-known techniques are postponement (when rumination appears, the person sets it aside for a fixed, short slot later on, and often by then it is no longer needed), attention training and what is called detached mindfulness: letting the thought be there without answering it or following it.

Mindfulness and mindfulness-based cognitive therapy

Mindfulness-based cognitive therapy (MBCT) teaches people, in a group over eight weeks, to observe thoughts and sensations without getting caught up in them. In two controlled trials with people who had had three or more episodes of depression and were well at the time, it reduced the risk of relapse over one year compared with usual treatment. In those who had had two episodes or fewer the effect wasn't seen, so it is not a recommendation for everyone. The article on mindfulness in therapy covers the protocols and the one on acceptance and commitment therapy covers defusion, another way of stepping back from thoughts.

Night-time and early-morning rumination

Many patients ruminate in bed, and rumination and insomnia feed each other. Watkins suggests changing the routine: if the thoughts start the moment the person wakes, get up and do something instead of lying there. Javier agreed that if he was awake at 6:10 he would get up, shower and go for a twenty-minute walk before breakfast; the first weeks were hard, and his log showed the morning episodes dropping from an hour to under fifteen minutes. At night, stimulus control helps (getting out of bed if sleep doesn't come after a while), as does saving the thinking for a fixed time well away from bedtime. The article on cognitive behavioural therapy for insomnia has the full protocol.

What the patient can do between sessions

These tips don't replace treatment, but they are the ones that come up most in practice and they can be handed over in writing:

1. Name it. Saying "I'm ruminating" the moment you notice it already puts a little distance between you and the thought.
2. Ask a check-in question. "Am I closer to a solution than I was five minutes ago?" If the answer is no, it is time to switch activity, not to keep thinking.
3. Swap "why" for "how". Instead of "why does this always happen to me?", ask "what concrete step can I take this week?" and write it down.
4. Move and do something absorbing. A walk, cooking, a conversation, a game with the children. Attention on something concrete leaves less room for rumination.
5. Postpone. Set aside fifteen minutes at a fixed time to think about the problem, with paper in front of you, and not just before bed.
6. Watch the triggers. Rereading old messages, scrolling social media at midnight or lying in bed awake all feed the loop.
7. Talk, but not in circles. Telling someone helps; going over it for hours with a friend without reaching any decision (what research calls co-rumination) tends to do the opposite.

When rumination is a warning sign

Rumination has been linked to self-harm and, according to Nolen-Hoeksema's hypothesis, it gradually builds hopelessness. If the patient keeps returning to the idea of dying, of not waking up or of others being better off without them, assess suicide risk directly and in that same session. Asking about it does not increase the risk. The article on the suicide risk protocol for psychology practices sets out the steps. In Spain, the 024 line offers free support at any hour to people with suicidal thoughts and to their families, and in an emergency you should call 112. Elsewhere, use your local crisis line or emergency number.

How to document progress with rumination

A patient who ruminates tends to judge their progress by the worst day of the week. That is why it helps to keep figures in writing to compare against:

• The RRS (or PTQ) score at the start and at each review, with its date.
• Minutes of rumination per day and the windows in which it appears, taken from the log.
• The list of warning signs and, next to each one, the agreed alternative ("if I wake before the alarm, I get up and go for a walk").
• Functional goals, such as having breakfast with the family again or finishing work reports without leaving them until the end of the day.
• The plan for when rumination comes back. For relapse prevention, the NICE guideline suggests identifying the warning signs that came before things got worse, rumination among them, and preparing detailed plans for each one. The article on relapse prevention covers how to put that plan together.

Reviewing these figures with the patient every few weeks shows them an improvement they can't see from inside the loop.

Rumination in your practice with My Psico Agenda

My Psico Agenda doesn't assess or treat anyone: that is your job. What it does is keep everything around a treatment like this in order:

• Notes for every session. In each appointment's "Details / Notes" you record the scale score, the warning signs you worked on and what was agreed for the week, and the patient's "Clinical History" holds the case summary.
• Your own fields in the record. Under "Additional data" you add the fields you need, such as "Baseline RRS", "Rumination windows" or "Warning signs". If you work in a centre, the centre can also add its own "Centre fields", shared across all its therapists' records.
• The log in the patient's hands. You upload the template to "Patient files". It goes up as "Hidden"; when you switch it to "Visible", the patient finds it in their space under the "Documents" tab, and in the record you see "Seen" with the date they opened it.
• The details, before the first session. With "Send form to the patient" you send them a link so they can fill in their details on their phone and, if you turn it on, sign the consent on that same page.
• A fixed slot every week. With "Recurring therapy" you book their slot, and they get a WhatsApp reminder 24 hours before with buttons to confirm or cancel.
• Consistency, in numbers. In each patient's statistics you see "Total sessions", "Attendance" and "Cadence", useful when you start spacing out sessions towards the end of treatment.
• Who has stopped coming. "See inactive patients" shows the people who have gone two months without a session and have nothing booked, with a "Contact on WhatsApp" button. With patients who ruminate, dropping out without a word is sometimes part of the problem.

There are plans for therapists from €4.99/month + VAT and for centres from €99.99/month + VAT, and you can try it free for 1 month, no card needed and no lock-in. Our software for psychologists page has everything that's included.