By Andrea Hellenthal, Ph.D.
July 7, 2022

U.S. Army photo by Sgt. Henry Villarama

As a German exchange scholar, when I thought of a theme for Mental Health Awareness month, before I suggested it, I had to first look up the English word: rumination.

That is, the procedure by which cattle move already partially digested food from the stomach back into the mouth and chew it again. What an apt image for a process in which we humans also chew on the same thoughts over and over again! But what helps cows with digestion can become a major burden for us. In psychology, we define rumination as repetitive, prolonged, and recurrent negative thinking about one's self, feelings, personal concerns and upsetting experiences¹.

The reality is, chewing on our problems over and over again does not make them easier to swallow. Ruminating is not helpful and can become a major burden – especially for military personnel. Rumination is difficult to control and is an extremely unproductive experience. It takes up a lot of mental capacity; in fact, you can't concentrate on anything else. Typical ruminations are of one's own weaknesses and failures, wrong decisions, unfulfilled tasks and conflicts in relationships. The thoughts are related to the own person – they are self-critical and deprecating. In the process, one negative thought produces other negative thoughts. Like a magnet, the bad thought attracts other bad memories. And since our thoughts influence our feelings, ruminating worsens our mood. The negative effects exacerbate and prolong existing emotional states such as sadness, anger, anxiety and depression².

Why rumination can become a major burden, especially for military personnel

Rumination has been shown to be a key contributing factor in the onset, severity and maintenance of multiple disorders like major depressive episodes, anxiety disorders, substance and alcohol abuse and posttraumatic stress disorder (PTSD).² It is one variable that may explain why negative and traumatic experiences of service members may exacerbate their mental health problems. Military personnel are at particularly high risk for exposure to traumatic events and the development of trauma-related sequelae⁵. In the context of trauma, rumination is a form repetitive negative thinking that focuses on the causes of the traumatic event and its consequences of one's life. It is characterized by the unproductive questions of "why?" (Why did this happen to me?) and "what if?" (What if I have done something to prevent this from happening?). Researchers proposed trauma-related rumination as a form of an avoidance strategy, because reflecting on causes, consequences and moods associated with the experience in a cycle of negative thoughts keeps one from engaging in active problem solving⁶. In a study with treatment-seeking female veterans, trauma-related rumination was not only very common with more than 80% of patients reporting active engagement, it furthermore was significantly associated with several PTSD symptoms. Additionally the severity of trauma related rumination was associated with overall PTSD symptom severity⁷.

Please keep in mind, if ruminating causes great distress or disrupts daily activities and relationships, a mental healthcare provider should be consulted. You can schedule an appointment with the mental health clinic or speak to your primary care provider. The inTransition program can assist you to find mental health care.

Rumination easily becomes a habit. Certain context variables make it more likely: we ruminate mostly in the morning and in the evening, and mostly alone and not when we are in the company of others². We can take advantage of this with techniques to manage rumination.

Managing Rumination

Rumination management techniques are relatively simple, small strategies. The difficulty is not that you have to understand how to use these techniques, but that you use them until the strategies themselves become habitual.

And how do you create new habits? First, by quickly identifying that you're ruminating and realize that it isn’t helpful. The two-minute rule helps here³:

Just keep doing what you're doing for two minutes – thinking or ruminating. After that, you should ask yourself the following three questions:

In the last two minutes......

...have I made any progress in solving a problem?

...do I understand anything that was not clear to me before?

...have I been less self-critical or downbeat?

If you can't answer "yes" to at least one of the questions, then you are most likely ruminating. That means you should definitely break the cycle now.

Three Ways to Break the Rumination Cycle

These three strategies have shown evidence of effectiveness to get out of the cycle of negative thoughts:

1. Distraction

Distraction does not solve problems, but neither does rumination! Distraction can be helpful for emotion regulation, to calm down briefly⁴. Ruminating takes a lot of mental capacity, so instead you could do activities that really tie up your attention and not those where you can keep ruminating. Helpful activities include walking, jogging, cooking, calling someone, watching a documentary, cleaning or going shopping. Those who tend to brood in bed in the morning might get up immediately and make a change of scenery. If ruminating keeps you from sleeping in the evening, it's just as important to get up first and do something else. For example, brew some non-caffeinated tea or read a newspaper. Even if it seems unpleasant at first, distraction is also helpful to make it easier to sleep afterwards.

2.  Mindful distancing

It is important to realize that thoughts are not facts. Thoughts are thoughts, no more and no less. Therefore, we can choose not to believe everything we think.

The simplest strategy for dealing with repetitive, cyclical thoughts is: do nothing!

You don't have to get rid of the thoughts, break them off, or engage in discussions. You just watch the thoughts come and go and realize that they are just thoughts, temporary mental constructs.

When you have negative thoughts, consciously say to yourself:

"Aha! That's what I'm thinking right now. I'm not my thought, I'm having a thought."

3. Try practicing this technique with the "Leaves on the Stream" exercise. Focus attention on the present moment

By ruminating about certain things, you give them attention. This makes those issues seem bigger, more important, and more frequent than they actually are. Rumination can be stopped by taking attention away from the cyclical thoughts and focusing it on something else. The easiest way to do this is to focus on the sensations of the moment: seeing, hearing and feeling.

Military Meditation Coach Podcast offers a selection of guided exercises to train you to focus your attention on the present moment. Try a body scan first, as it is an exercise in which you learn to be mindful of your body. You practice to keep your attention completely on yourself and to feel your body step-by-step from the feet to the head. In doing so, you encounter your thoughts, sensations and feelings with a benevolent, accepting attitude.

References

1. Watkins, E.R. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134(2), 163-206.
2. Watkins, E.R., Roberts, H. (2020). Reflecting on rumination: Consequences, causes, mechanisms and treatment of rumination. Behaviour Research and Therapy, 127.
3. Hvenegaard, M., Moeller, S. B., Poulsen, S., Gondan, M., Grafton, B., Austin, S. F., Kistrup, M., Rosenberg, N., Howard, H., & Watkins, E. R. (2020). Group rumination-focused cognitive-behavioural therapy (CBT) v. group CBT for depression: phase II trial. Psychological medicine, 50(1), 11–19.
4. Andreotti, E., Congard, A., Le Vigouroux, S., Dauvier, B., Illy, J., Poinsot, R., & Antoine, P. (2018). Rumination and Mindlessness Processes: Trajectories of Change in a 42-Day Mindfulness-Based Intervention. Journal of cognitive psychotherapy, 32(2), 127–139.
5. Reger, G. M., Bourassa, K. J., Smolenski, D., Buck, B., & Norr, A. M. (2019). Lifetime trauma exposure among those with combat-related PTSD: Psychiatric risk among U.S. military personnel. Psychiatry Research, 278, 309–314
6. Bravo, A. J., Kelley, M. L., Mason, R., Ehlke, S., Vinci, C., & Redman Ret, L. (2020). Rumination as a Mediator of the Associations Between Moral Injury and Mental Health Problems in Combat-Wounded Veterans. Traumatology, 26(1), 52–60.
7. Arditte Hall, K.A., Davison, E.H., Galovski, T.E., Vasterling, J., & Pineles, S.L. (2019). Associations Between Trauma-Related Rumination and Symptoms of Posttraumatic Stress and Depression in Treatment-Seeking Female Veterans. Journal of traumatic stress, 32 2, 260-268

Andrea Hellenthal, Ph.D. is a psychologist specializing in clinical psychology. She works for the German Armed Forces and is employed there at the University. Additionally, she treats patients in her own practice. She is currently participating in a scientific exchange program with the U.S. Armed Forces and works for the Psychological Health Center of Excellence.