Table Of Contentebook
THE GUILFORD PRESS
Rumination-Focused
cognitive-BehavioRal theRapy
FoR depRession
Also by Edward R. Watkins
Handbook of Cognition and Emotion
Edited by Michael D. Robinson,
Edward R. Watkins, and Eddie Harmon-Jones
Rumination-Focused
Cognitive-Behavioral
Therapy
for Depression
Edward r. watkins
The Guilford Press
New York London
Copyright © 2016 The Guilford Press
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Library of Congress Cataloging-in-Publication Data
Names: Watkins, Edward R., author.
Title: Rumination-focused cognitive-behavioral therapy for depression /
Edward R. Watkins.
Description: New York : The Guilford Press, [2016] | Includes bibliographical
references and index.
Identifiers: LCCN 2016000631 | ISBN 9781462525102 (hardback : acid-free paper)
Subjects: LCSH: Depression, Mental—Treatment. | Emotions and cognition. |
BISAC: PSYCHOLOGY / Psychopathology / Depression. | MEDICAL / Psychiatry /
General. | SOCIAL SCIENCE / Social Work.
Classification: LCC RC537 .W28 2016 | DDC 616.85/27—dc23
LC record available at http://lccn.loc.gov/2016000631
about the author
Edward R. Watkins, PhD, CPsychol, is Professor of Experimental and
Applied Clinical Psychology at the University of Exeter, United Kingdom,
and Director of the Mood Disorders Centre and the Study of Maladaptive
to Adaptive Repetitive Thought (SMART) Lab. Dr. Watkins has practiced
as a cognitive-behavioral therapist for 20 years, specializing in depression.
His research focuses on the experimental understanding of psychopathol-
ogy in depression—with a particular focus on repetitive negative thoughts
and rumination—and the development and evaluation of new psychological
interventions for mood disorders, including randomized controlled trials of
treatments targeting rumination in depression. Dr. Watkins is a recipient of
the British Psychological Society’s May Davidson Award for outstanding
contributions to the development of clinical psychology within the first 10
years of his career.
v
preface
t
his is a book written for clinicians who want to find better ways to
grapple with the thorny problems of rumination and worry in their patients.
It is intended to be relevant for practicing clinicians at every level, from
trainee to cognitive therapy supervisor.
Over the last 20 years, rumination and repetitive negative thought have
increasingly been identified as among the most important cognitive mecha-
nisms in the onset and maintenance of depression and anxiety. Despite this,
to date there have been only limited and often sketchy descriptions of how
to tackle rumination. I wrote this book to fill this important gap by provid-
ing a detailed and comprehensive how-to guide for therapists. The goal of
this book is thus to present the state-of-the-art principles and strategies that
I have found to be effective in reducing rumination in patients.
The book is based on the original treatment manual I wrote for a
rumination-focused cognitive-behavioral therapy (RFCBT) research trial,
and it is thus an evidence-based manual, utilizing a treatment proven to be
effective. This book evolved from and built on that manual so that it incor-
porates the clinical lessons and experience learned over the last 15 years of
developing and implementing RFCBT. While my treatment research origi-
nally focused only on rumination in the context of residual depression, the
ideas and techniques in this book are not limited to this use alone. In the
2011 trial, rumination was targeted as the only focus of therapy to provide
a strong test of whether reducing rumination would reduce residual depres-
sion. However, excitingly, a recently completed trial has confirmed the addi-
tional benefits of RFCBT for depression relative to existing treatments: the
RFCBT group significantly outperformed the standard cognitive-behavioral
therapy (CBT) group in reducing symptoms of depression in 131 adult
patients with major depression recruited in a psychiatric outpatient service
vii
viii Preface
(Hvenegaard, Watkins, Gondan, Grafton, & Moeller, 2015). Other work
has indicated the efficacy of RFCBT in preventing depression and anxiety
in young adults, and in reducing rumination and depression in adolescents
with remitted histories of depression. Further, there are good theoretical
and empirical reasons to support applying this treatment more broadly.
The approaches and techniques outlined in this manual could be used
as a stand-alone treatment for depression, incorporated as a module focused
on rumination or worry within a course of CBT for depression or other dis-
orders, or used as an adjunct to other interventions. For example, if you are
working with a patient who is struggling to make progress because of severe
rumination or worry, then the interventions in this book may help to break
this impasse, regardless of his or her diagnosis. I believe that this manual
will help therapists to treat worry and rumination in all disorders in which
these pernicious symptoms present.
The genesis of this book came over 20 years ago when I was working
as a cognitive-behavioral therapist in the specialist Affective Disorders Unit
at the Institute of Psychiatry and Maudsley Hospital, London. In this role,
I was regularly engaged in CBT with patients with depression, who were
referred to this tertiary service because they experienced the most persistent
and severe depression. Although we obtained good outcomes using Aaron
Beck’s classic CBT for depression, there was still a substantial proportion of
patients who showed little or no improvement. As I began to more closely
observe and engage with these patients, it become apparent that nearly all
of them reported rumination as a major problem, but that it had not been
previously asked about or addressed. From these observations, I began to
try to better understand the phenomenology of rumination and to experi-
ment with better ways to treat it.
Running parallel to my research, the research literature on rumination
was also rapidly expanding, with more and more evidence of its importance
as a vulnerability factor emerging, principally from the laboratory of Susan
Nolen-Hoeksema. Her research focused primarily on the consequences of
rumination, and my own experimental research, building on some fortu-
itous observations emerging from my PhD work, began to investigate the
mechanisms underpinning rumination. This research is described in Chapter
2, which illustrates the links between clinical research and clinical prac-
tice and provides further details for researchers and clinicians interested in
developing research.
RFCBT has since emerged as the integration of many years of clinical
observation and piloting of treatment approaches with the translation of
experimental findings into clinical techniques. This book is a summary and
culmination of all that clinical and research work, with the intention of
widely disseminating these ideas to the therapy community.
The treatment described in this manual emerges from the classical CBT
