Have you ever been stuck in a swirl of negative thoughts, rehashing things that you should or shouldn’t have said or done? Most of us will recognise this circular self-battering, a process known as rumination.
Rumination or “chewing the cud”, refers to the way that certain animals, like cows, eat, storing their partially-digested food in a special stomach called a rumen, then regurgitating it to chew it again more thoroughly.
In humans, rumination means repeatedly brooding over events from the past, such as the break up of a relationship, or a conflict with a colleague, wondering about others’ motivations or what could have been. It can go on for hours or days.
Unfortunately, while rumination helps a cow digest its food more thoroughly, it does not help us to digest our thoughts more thoroughly. And not surprisingly, rumination is linked with depression, anxiety, PTSD, substance misuse and binge eating.
Rumination often starts out positively as a way to make sense of our problems, but as some psychologists have observed, it can become habitual. This helps explain why so many of us find it so difficult to stop, but also why, it can be triggered by various contexts where we have associated our thinking with a familiar routine. This might be cleaning our teeth, or getting settled into bed. Equally, a low or anxious mood may set off the train of ruminative thoughts, negatively feeding back on our mood, and worsening it further.
What can you do to not fall into the rumination trap?
Once we start the ruminative thoughts, it is much harder to stop. Like a ball rolling down a hill – easier to catch at the start before the ball has gained momentum down the slope.
Below are some techniques that can help break rumination. Some are derived from behaviour psychology and evidence based approaches to habit change, and some through experience.
This can help in two ways. It can help you recognise your own personal rumination cues, such as time, place, situation or person. Once you are aware of these triggers, you can then try to modify or remove them. For example, if rumination is typically worse for you first thing in the morning or late at night, getting out of bed instead of lying there, may avoid a rumination episode.
The second way journaling helps is by tracking your thoughts. Organising them on paper can help relieve the burden. I find this really helpful to do when feeling overwhelmed. Problems always look much smaller on paper than in my head!
Things that you enjoy like exercise, getting outside, listening to music, doing a Sudoku or spending time with friends can distract from the cues and triggers associated with rumination and so help break the habit.
This is particularly effective if you know that there are certain moments where you are more likely to ruminate, such as the night before work. Scheduling in something fun and energising to occupy that ruminating space can really help.
3. Yoga / breathing /mindfulness / meditation
This does overlap with distraction but the breathing and focus on the present calm thoughts in a different way. Even something simple like mindfully washing your hands – being aware of the coolness of the tap against your skin, feeling the cold water tingle your hands, the smoothness of the soap and its massaging effects.
Apps like Calm and Headspace can be useful. Many find their sleep stories really effective. As a health professional you can get a 12 month free subscription to Calm with this link. https://blog.calm.com/health
4. Let go of what you can’t change and learn from mistakes
Brooding on our problems takes a lot of mental energy and prevents us from engaging fully in our task in hand. What we did or said is not something that we can change so once we can let go, we can move forward and reflect constructively on what we have learnt.
For example, I was late for an “informal” interview recently. Although the conversation went well, I didn’t get the job. This may of course have been for other reasons, but rather than beating myself up about it which I would have done in the past, I now make sure that I arrive well ahead of time so that this doesn’t happen again.
5. Challenging and stopping thoughts
Although this sounds simple, thinking or even telling ourselves ‘Stop’ or ‘ No’ when we start to ruminate can work with practice.
Once we have started ruminating, asking questions such as “What is the worst case scenario?”, “What would I say to a friend in the same situation?”, “How would others have managed this?”, “What would a friend say to me?”. This can question the validity of our thoughts by looking at them from a different perspective and so break the circular thoughts.
6. Schedule rumination or “worry time”
This can be work for children with anxiety, but can also be helpful for us. This means that setting aside 20-30 minutes (usually twice a day at the start) that you are allowed to worry or ruminate.
7. Set boundaries
Have you ever checked an email late at night and seen something there that upsets you in some way and then lost sleep over it? Or looked at something work-related just before you go on holiday and then not enjoy your well-deserved break? Setting boundaries on when we do things that can potentially cause upset is key to avoiding the rumination trap.
8. Stop linking small goals to big goals
For example, challenging the belief that a big goal such as happiness completely depends on succeeding at smaller goals such as losing weight or having certain possessions. This piles too much pressure on ourselves, exacerbating negative thoughts of worthlessness and inadequacy when we don’t achieve them.
9. Problem Solve
If we are ruminating about a particular problem, stepping back and thinking about how we might solve can help move us into a more constructive mindset. We can do this by breaking the problem down into smaller chunks and taking small steps towards solving each of these. This can help us feel less overwhelmed and more in control. In addition, this positively affects our mood, making us less likely to ruminate.
10. Reach out to others
Sharing our concerns with others can help but it is really important to make sure not to pick someone who will ruminate with us.
11. Professional help and therapy
There are various organisations supporting doctors and dentists including NHS Practitioner Health, a free and confidential service supporting doctors and dentists in England (see appendix for more information & services).
CBT (cognitive behavioural therapy) and other therapeutic modalities can be extremely effective in helping with rumination, particularly where depression and anxiety are present.
There is hope….
By using some of these tips and techniques it is possible to stop ruminating. The key is to recognise it and to learn to disrupt it before it becomes a problem. With practice, this becomes easier and more effective.
Resources for doctors
- NHS Practitioner Health – a free and confidential service supporting doctors and dentists in England www.practitionerhealth.nhs.uk E-mail: firstname.lastname@example.org. Phone 0300 0303 300
- DocHealth – psychotherapeutic support for all doctors. Call 020 7383 6533
- BMA support – A counselling & a doctor advisory service. Call 0330 123 1245 24/7.
- Sick Doctors Trust – an early intervention programme for addicted doctors. Call 0370 444 5163
- Doctors support Network a confidential peer support group for doctors & medical students with mental health concerns. www.dsn.org.uk
- Hope 4 Medics. A support group for doctors with disabilities. www.hope4medics.co.uk
- British Doctors and Dentists Group. A mutual support group for doctors and dentists recovering or wishing to recover from addiction / dependency on drugs. http://s562861170.initial-website.co.uk/
- Confidential support for surgeons – telephone line for peer to peer help from the RCS
- Psychiatrists Support Service – a confidential support and advice line for members or associates of the college.
- Coaching and mentoring services via your local deanery