Targeting perseveration to reduce distress

Whether you call it negative self-referential processing, perseverative negative thought, or repetitive thought, the tendency to ruminate in a self-critical manner is common in anxiety and depression. “Our field is full of terms for this, but I tend to just think of it as a ‘chronically busy mind,’” says clinical psychology researcher Douglas Mennin, PhD, a professor and director of the clinical psychology PhD program at Teachers College, Columbia University, where he directs the Regulation of Emotion in Anxiety and Depression Lab. “Perseverative negative thought is an attempt to self-regulate, but it’s an illusion of control, and it ends up causing more problems than it solves.”

To help patients step out of those harmful patterns, Mennin and his collaborator David Fresco, PhD, of the University of Michigan, began developing their Emotion Regulation Therapy (ERT) more than 15 years ago. The manualized treatment for treating chronic distress integrates components of cognitive-behavioral, acceptance, dialectical, mindfulness-based, and experiential, emotion-focused treatments into an affective science framework to help patients identify emotions, manage them adaptively, and use emotional information to guide their decisions and behaviors. We asked Mennin to walk us through the approach and share what clinicians most need to know.

We have efficacious treatments for anxiety and depression, but there are certain individuals who are not as responsive to treatment. They tend to be the people who get caught in their minds and have a lot of repetitive distress. This can often happen in someone who’s chronically anxious or depressed, and also people experiencing difficult scenarios in their lives, such as having or caring for someone with an unpredictable health condition.

Consider cognitive behavioral therapy, for example, which is often effective for social anxiety. But there’s a subset of individuals where, you get them to go to the party and meet people, and then you ask them, “Wasn’t it great that you conversed with all these people?” But they’ll get very self-critical about the experience and say, “No, everything I said sounded stupid, I’m an idiot.” We can recognize that the ways they’re talking to themselves and the ways that they’re processing their emotions have become problematic.

Cognitive treatments certainly talk about worry or rumination or self-criticism. But not a lot of the empirically based treatments directly target that process. There’s been some evidence to show, for example, that when processes like rumination aren’t directly targeted in depression treatments, patients don’t do as well, and when they are targeted, they do better.

Therapies like cognitive therapy try to have patients approach things that are in their mind, but a lot of treatments don’t really break down that emotional process well. When individuals are worrying or ruminating, those processes are motorized by the need to have predictability, the need to feel safe. It’s important to get into the experience of how people process emotional information in different moments, and how they end up getting caught in their minds this way.

The key is to get people to be more aware of the cascades of their emotional experience while they’re in distress. One metaphor that we use a lot is a snowball at the top of a hill. At the top, the snowball is fluffy and soft. Those are our emotions, our generative wants and fears. But as the snowball rolls down the hill, it picks up sticks and rocks and ice and dirt—all these ways we talk to ourselves. When our patients come into therapy, their snowball has been rolling for days and is very muddy, and that often makes it harder to know how to take effective action. In treatment, we’re trying to help people catch the snowball closer to the top of the hill—what we often refer to as gaining clarity for action.

We introduce mindful regulation skills, which draw from mindfulness and emotion regulation, to create better clarity in the moment rather than just distress relief. Instead of helping patients dispute emotional thoughts, as in cognitive behavioral therapy, we translate the complexity of emotions into motivational language to help them make choices about where they want their thoughts and actions to go.

We originally developed the treatment for generalized anxiety disorder and depression, particularly for those with ruminative depression and anxiety. We’ve expanded it to anyone who has a DSM disorder and endorses worry, rumination, or self-criticism. We’re also testing it in people experiencing difficult health experiences, regardless of a psychiatric diagnosis, including people who have a loved one with cancer and people who are losing their eyesight.

Treatment generally has two phases. First, we focus on teaching these mindful regulation skills. People learn that when they’re in these distressing moments, they can gain that clarity for action—something we call “being counteractive.” Next, it’s about using skills to make choices toward directions that are important to them. That part is called “being proactive.” It’s about building a sense of agency so people feel like they can take action despite those internal conflicts.

We’ve done several trials, including mechanism studies, and we see efficacy in a variety of contexts. (See, for example, Journal of Consulting and Clinical Psychology, Vol. 86, No. 3, 2018opens in new window, and Behaviour Research and Therapy, Vol. 170, 2023opens in new window).

Our neural studies show ERT is hitting areas of the brain that have to do with attention and metacognition. After treatment, we see greater connectivity between the default mode network—which tends to be very active when people are stuck in negative self-referential processing—and the executive control network. And that greater connectivity is associated with mindful regulation skills and improvements in anxiety and depression as well.

Worry and rumination are understandably experienced as aversive. It may be hard for people to realize that they are purposeful, and the mind is calling them up to create more of a sense of control from threat and feelings of loss. Understanding this two-step process—first feeling, and then perseveration to control the feeling—is essential for individuals to make change without falling back into that pattern. By identifying the emotion and becoming clearer about its message, individuals can make other action-based choices around these feelings rather than getting caught in loop worrying about a threat or ruminating on a loss (or potential loss).

As clinicians, I don’t think we focus on specific moments often enough with patients. We know from the research that when people talk about events beyond two weeks ago, they shift from episodic memory to semantic memory. That means that instead of talking about the event, they talk about their beliefs about themselves and others. If you ask them, “How often do you worry?” they think about who they are and say, “I’m a worrier, so I worry all the time.” But if you ask them, “How much did you worry in the past two weeks,” it may be a lot less than they think.

In therapy, the more we can get into patient’s lives to talk about a specific example, and an actual situation occurring now or recently, the more we’ll get into actual bodily activation. We can bring patients into those hard moments, offer a better understanding of their emotions, help them gain clarity, and then offer tools for self-regulation. One way to do that is to review an event in the present tense, as though it’s happening now.

It’s a subtle shift, and there’s an art to it. Patients often want to move it back to the averages. But by making an effort to stay present in a specific moment or event, patients start seeing what’s going on in their minds as it’s happening. It’s not trying to psychoeducate the patient about how the mind works, nor is it just letting them talk about their experiences. It’s taking the functional analysis and drawing it into parts of the mind, so patients get more comfortable with seeing where their mind is going before that snowball starts rolling down the hill.