Today we're going to talk about

rumination. When I was a third-year

psychiatry resident, I had a group of

patients that came into my office with a

couple of different diagnoses. One

person had a mood disorder, one person

had an anxiety disorder, and one person

had PTSD. And so, as I started working

with them, I started doing psychotherapy

because that's what a third-year

resident is supposed to do. I had a

wonderful supervisor. So, I started

therapizing them, right? So we we worked

a lot on their emotions, emotional

processing, things like journaling,

doing things like thought logs that look

at the relationship between their

thoughts, their actions, and their

behaviors. But despite doing all of this

emotional work, they didn't seem to be

getting better. And when I was sitting

in the room with them, it just just sort

of felt to me like their minds were out

of their control. No matter how much we

talk about how hurt they feel, their

mind would start spiraling in some kind

of direction. So I started doing

something a little bit unorthodox. I

sort of looked at that this and I sort

of said, "Okay, like this mind is going

way off track. They get stuck in these

cycles of repetitive thinking. Let's

just learn how to shut off the mind." So

I started teaching them more stuff from

like yoga and meditative traditions and

then something kind of funny happened.

So then I got called into my program

director's office one day and she asked

me like, "So how are things going with

this set of patients? How are things

going with the supervisor?" And I said,

"Honestly, like things seem a little bit

hard. You know, I'm I'm trying to do

psychotherapy with them. It doesn't seem

very effective. I'm teaching them some

like yoga and meditation techniques.

Those seem to be working like okay, I'm

not quite sure. And that's when she

informs me that the supervisor that I'm

working with is essentially firing me.

She says that this supervisor that

you're working with feels like she can't

work with you anymore. And I was like

really shocked and I was like, did I do

something wrong? Like you know why? Like

I was a bit confused. And she said well

like you know the supervisor says that

you're sitting with these patients and

you're doing something but it's not

psychotherapy. and she's a psychotherapy

supervisor, so she can't like guide you

in something unless you're willing to

like do that thing. So, thankfully, it

turned out to be totally fine. I don't

think the supervisor made a mistake or

anything. In fact, I think it was a

really really pro move on her part. She

recognized that I was doing something

that has value and that I probably

needed a different kind of guidance to

learn psychotherapy and sort of blend

these two things and that was awesome.

It worked out great. A lot of the stuff

that I ended up doing with my patients

was actually pretty effective. And a lot

of that stuff is like when we think

about something like rumination or

depression or anxiety, we don't really

think about how can I control the mind

itself or how can I put my mind in a

phys or how can I put my brain in a

physiologic state where we are less

likely to ruminate. So if you guys want

info like that, check out Dr. K's guide.

We have a ton of great techniques in

there about sort of shaping your brain,

shaping your body, and shaping your

mind. And what I didn't realize at the

time is that these were patients who

were ruminators. These are patients who

repetitively think about something over

and over and over again. It's almost as

if their mind is turned against them.

And the really shocking thing about

rumination is we may think okay like if

your mind gets caught in thought loops

or spirals like you should go see a

therapist. But actually it turns out

that if you are someone who ruminates,

therapy is less likely to be effective

for you. So this was first demonstrated

in a large-scale longitudinal studies in

which rumination prospectively predicted

the onset of major depressive episodes

and depressive symptoms in non-depressed

and currently depressed individuals

across follow-up periods ranging from

six to 6 weeks to 5 years. So what this

means is that if you were if you're a

ruminator the degree of rumination

predicts the onset of depression but

it's not just depression. large-scale

prospective longitudinal studies, that

means that studying things ahead um

prospectively, right? So, we're not

doing like a retrospective data

analysis, found that rumination

predicted subsequent substance use,

eating disorders, alcohol abuse, and

PTSD symptoms following trauma even

after controlling for initial symptoms.

So this is kind of shocking because what

this what these studies show is that if

you have a traumatic event, if you were

someone who ruminates, the likelihood

for that traumatic event to turn into

PTSD is correlated with your rumination.

So not only does rumination increase

your risk for all kinds of mental

disorders, but it actually interferes

with treatment. So it turns out that as

a PGY3, what I didn't realize is it's

not that I was doing psychotherapy

incorrectly. It's that if you're someone

who ruminates, there's a good chance

that psychotherapy won't be as effective

for you. Indeed, there is growing

evidence that elevated rumination at the

start of treatment predicts poorer

outcomes to cognitive behavioral therapy

for depression, such as increased time

to remission and reduced likelihood of

achieving remission. Rumination at the

end of mindfulness CBT treatment

predicts a depressive relapse. So that

means that when you complete a course of

treatment, if you are a ruminator, if

you're a ruminator, that increases the

risk that your depression will actually

relapse and you'll get depressed again.

For patients receiving brief CBT in a

partial hospitalization program, so

these are people who have intensive uh

care, right? They're receiving intensive

care. Baseline rumination predicted

subsequent anxiety and depression. And

the examination of symptom trajectories

indicated that when rumination did not

improve, symptoms of depression and

anxiety did not improve and were likely

to worsen over time. So this is crazy,

right? This means that if you are

someone who ruminates and you go to

treatment and you do not target the

rumination specifically that there's

this will reduce the efficacy of

treatment and in some studies may even

predict worsening depression and anxiety

despite the fact that you did the

treatment. So how is it that rumination

interferes with treatment of

psychotherapy? And why is it that

rumination predicts the the propensity

for depressive relapse, symptoms of

anxiety, for a trauma to turn into PTSD?

How does this actually happen? So the

first problem with rumination is that it

is an emotional magnifier. The first

negative effect of rumination found in

experimental studies is that it

exacerbates and prolongs existing

emotional states such as sadness, anger,

anxiety, and depression. Okay. And in

parallel it uh it elaborates and further

polarizes any thought content focused on

during the rumination. So these are two

really important things to understand.

Okay. The first thing that it does is it

magnifies and prolongs whatever we think

about and usually negative states. So

sadness, anger, whatever. So here's

practically what happens. So if I do

something stupid today, generally

speaking, tomorrow is a new day and I

don't have to linger with the effects of

my stupidity. If you are someone who

ruminates, the problem is that if you

make a mistake today, it causes you hurt

for the next year, for the next two

years, maybe even a lifetime. I've

worked with ruminators that had problems

in high school, like they got dumped by

their significant other and they just

like feel trapped by that particular

injury and this is like 20 years later.

You may have seen sort of examples of

this, right? People who get like sort of

frozen in time and can't move past

something. That is literally what

rumination does. So rumination takes a

single instance of damage and turns it

into dot damage until you are done

ruminating with it, which often times is

sort of never, right? Because you can

keep on replaying these thoughts over

and over and over again. So not only

does it increase the duration of

emotional injury, it also increases the

intensity. Now how does this happen?

This is something that's really

important to understand and it kind of

leads to black and white thinking. So,

this is something that's really wild.

Have you all ever been like at the

grocery store and tried to figure out

what to buy? So, you're sitting there at

a grocery store, there's lots of

different options, and then you're like,

I don't know what to buy. And you sit

there and you think about it for a

little bit. And as you think about it

for a little bit, you make a decision.

So, I want y'all to understand this is

really wild, but the more that your mind

thinks about something, the more

polarized you become. This is just a

feature of the mind. Okay, if that

sounds kind of crazy, just hear me out.

So, when I'm like, if I don't know if I

should take this job or not take this

job, what do I do? I think about it. So,

at the beginning, I may be like, let's

say here here is take job and here is

pass on job. And at the beginning of my

thinking process, I'm somewhere in this

middle area, right? But despite the fact

that I'm in in the middle area, as I

think about it more and more and more, I

start to drift this way and drift this

way and drift this way and this and then

eventually I make up my mind. So I want

y'all to think about how crazy it is to

make up your mind. I want you all to

think about how impossible it is for a

computer if a computer makes a

calculation and ends up with a question

mark. I don't know about generative AI

because they just hallucinate all kinds

of crap, right? Once you have a certain

amount of inputs, like if I have a

mathematical equation and I don't have

enough information to solve the equation

and I put it into a computer, the

computer is going to say at the first

iteration or the 10th iteration, we

don't have enough info to solve the

problem. That is not how the human mind

works. The more that we chew over things

in our mind, the more polarized we

become naturally. I wasn't sure if I was

going to break up with you. I thought

about it a lot and now I know I'm going

to break up with you. What new

information do I have? None. So the more

that we turn things over in our mind,

the more abstract we become. Right? So

as I think about things more and more

and more, I will start to deduce

abstract principles. So like let's take

the example of someone who is

ruminating. Let's say here's high school

and I never had a girlfriend. Let's say

the reason I never had a girlfriend is

because my parents were poor, right? So

like I couldn't hang out with people.

Everyone wanted to have the fancy shoes

and I didn't have the fancy shoes. So, I

considered myself unattractive and

that's why I don't have a girlfriend.

Then I go to uni and then what happens

is I struggled to adjust to uni. I ended

up getting depression in my freshman

year. Really, really common occurrence.

And since I got depression in my

freshman year, I didn't form when

everybody was making friends, I didn't

make friends. So, I kind of got left out

of all of the forming friend circles.

So, now I got kind of left behind. And

then that's the reason that I don't have

a girlfriend. And then now I started my

job but since I didn't have a girlfriend

uh in high school or college I don't

know how to talk to girls and since I am

behind now I have no girlfriend. So if

we look at this situation there are

strong contextual reasons why I've been

single my whole life. This problem

happened over here. This problem

happened over here. But then what

happens what the mind does is I chew on

this over and over and over again. I

start to come up with an abstract

conclusion which is that I am a loser.

So the the brain what the brain does

what the mind does is it looks at this

problem and it collects all of this data

and then it tries to draw an abstract

conclusion. Now here's the problem with

an abstract conclusion. The more

intelligent you are by the way the more

likely this is to happen. This is not

actionable. So what we find with

rumination is actually shocking. Even

though ruminators report that it

increases perceived insight into

problems, experimental studies

demonstrate that rumination interferes

with effective problem solving, both by

making individuals more pessimistic and

also more abstract and less able to

access specific details of how to

resolve a difficulty. Okay? And this

includes dysphoric mothers with infants

under 12 months. So this is wild. So

what this means is like this is

something that is in your brain and like

forget about all these like complicated

you know histories and know high school

this happened and college this happened

like we can study the effects of

rumination and how much it causes

problems with like mothers and infants

who are like 12 months. So this effect

can be observed over there. So it's it's

really like a neurological effect. It

happens in the brain. And so what

happens when we ruminate a lot is we

develop this abstract thing. And if I

ask someone who feels like a loser, how

well do you understand your problem?

They will say, I understand it

incredibly well. The reason that I'm an

incel is because of XYZ. I'm not trying

to bash on insults because of this and

this and this and this and this and this

and this. I understand everything. The

black pill is real. I've read so much

research. It's so true of so many

people's experiences. My understanding

is great. My understanding level is 100.

What are you going to do about it?

Nothing can be done. I don't know what

to do about it. I can't think of any

solution because I am a loser. This is

the problem with rumination because when

we make an abstract

conclusion from these highly specific

actionable scenarios, we end up with a

conclusion that is not actionable. So it

keeps us stuck. It also makes us

pessimistic which is a big problem

because not only does it enhance our

negative emotional circuitry but here in

my nucleus cumbent in my frontal loes

anytime my brain thinks about doing an

action. Should I go to the gym? Then

what my brain does is it calculates the

probability of success of that action.

So should I go to the gym? And what does

the the the black pillar do? The black

pillar says there's no point in going to

the gym because going to the gym doesn't

make me not a loser. It doesn't correct

for all my social skills. It doesn't

like correct for all of the things that

I've missed. It doesn't correct for the

fact that I have an avoidant attachment

style. So any point of progress is

insufficient at solving this big

abstract thing. This is the this is the

effect of pessimism on on your mind. So

when you have negative emotional stuff

that's being amplified and you have a

pessimistic thinking, it decreases the

value of action. And once the value of

action goes down, then your motivational

circuitry basically says it isn't worth

it. And if y'all pay attention to people

who are red pillars or black pillars or

whatever on the internet, you will

notice a couple of very very simple

things. The first is look at how

abstractly they're thinking. Are they

thinking concretely or are they thinking

in big sweeping generalizations? The

second thing is look at the the value of

progress in their mind. Do they say okay

like if I have this problem does moving

forward in it help at all? And they say

won't it help at all? It doesn't matter.

So progress becomes useless. And when

progress becomes useless that's how you

get stuck in time for years. The next

thing to consider is that rumination

increases self-focus and amplifies the

vicious repetitive cycle between

negative mood and cognition wherein each

increases the likelihood of the other.

The focus uh and focuses attention on

the discrepancy between one's desired

state and the actual situation making

this discrepancy more salient. Okay. In

vulnerable individuals, this pattern of

mutual amplification between negative

thinking and negative mood produces an

emotional cas cascade in which

rumination can lead to very intense

levels of negative affect. Okay. So what

does this mean? So when we ruminate what

this does is it focuses on where we are,

where we want to go and it highlights

this gap. And the more so, so I I don't

know if this kind of makes sense. Like

making progress in your life involves

moving from here to here and then here

to here and then here to here and then

here to here. But that's not how

rumination functions. It doesn't think

like that. That's the whole problem.

What it does is it looks at the gigantic

gap between where you are and where you

want to go and it just highlights all of

your shortcomings. This is the way that

it becomes an emotional magnifier. And

this is one of the mechanisms through

which it interferes with problem solving

because we're not thinking about the

next step. Our mind is literally focused

on all the things that I'm doing wrong

and all how far I have to go. So here's

the problem. Here's my actual state.

Here's my desired state. And what

ruminators will do is instead of moving

towards happiness

or progress, what they tend to do is

this feels bad

and what they try to do is move away

from feeling bad. They don't try to

actually move towards their goal. They

simply try to move away from this state.

I'm not going to grind to improve my

life. I just want to stop feeling this

way. There's one last really damaging

thing about rumination, which is that it

makes you less sensitive to contextual

changes. Okay, so let's take a quick

look. So rumination has been

hypothesized to make ruminators less

sensitive and responsive to contextual

cues and events in the world around

them, including signals of potential

reward, changing contingencies, or

interpersonal reactions. Such abstract

and internal preoccupation could prevent

ruminators from adaptively responding to

changes in the environment or from

benefiting from corrective learning that

disisconfirms negative beliefs. This I

think is arguably the most damaging

thing about rumination is that if you

make some conclusion about your life, I

am a loser and then you're at work and

then someone at work is like, hey, you

want to hang out sometime? You get some

kind of signal that you're not a loser.

You get some kind of signal that oh

actually there's an opportunity right

now. There's actually contrary

information to your belief that you're a

loser. You're not stuck in this

situation forever. The nature of

rumination makes it so that you are

unable or it is more difficult for you

to change to to detect changes in your

context. So if you induce rumination, so

induced rumination interferes with

contextual sensitivity, reduced

responsiveness to infant vocalizations

in mothers with generalized anxiety

disorder or major depressive disorder,

and reduced sensitivity to infants in

mother child interactions for both

dysphoric and non-disphoric mothers. So

this is important. So we may think,

okay, like what like this is because

everybody's depressed, right? That's why

they're not responding to changes in the

context and in changes in the world

around them that afford them new

opportunities. No. So these studies

actually show that if you take a mother

who has an infant and the mother is

non-disphoric, so the mother is actually

totally doing fine and you induce

rumination in the mother, she will

become less sensitive and responsive to

the vocalizations of her infant. This is

how deep this stuff actually runs. So

the most devastating thing about

rumination is even if your circumstances

change and you can make progress, which

happens in just about every patient that

I've worked with who ruminates, the

rumination interferes with your ability

to see those kinds of changes. So then

you feel like you're stuck forever. So

now let's try to recap and understand

where this picture puts us. So if I'm

someone who's a ruminator, I have one

negative event and then I sort of play

that over and I multiply the damage

times 10. So this turns into dot damage

instead of a single instance of damage.

Then what happens is I may have a second

negative event and then I may have a

third negative event and then I sort of

end up making an abstract conclusion.

Now that I'm a loser, I have negative

emotion. I can't see any concrete

action. I become pessimistic. So it's

not worth trying. Right? And then this

becomes a self-fulfilling prophecy

because if I add these three things then

what happens? Oh yeah, I am a loser.

Look at all this evidence. Look at all

this evidence. Look at all this

evidence. But in the same way that we if

we induce rumination in non-disphoric

mothers and they start to have problems

with their infant, something very cool

happens. If we can stop rumination, a

lot of these problems will start to get

better on their own. Because the

rumination in and of itself is what is

creating the problems. And this is

something I want you all to really

understand because this is kind of a

mind-blowing moment. At least it was for

me. See, when you ruminate, you think

about your problem. So you think the

problem is out here. You think the

problem is what you see in the outside

world. That's not the problem. The

problem is in here. The problem is the

way that you are viewing things. The

rumination literally impairs problem

solving. Literally magnifies negative

emotion. So there's one additional

problem that is super scary about

rumination, which is when we get stuck

in this cycle, ruminators tend to be

more avoidant. So goal pursuit that is

focused on avoiding an undesirable state

rather than approaching a desired state

may make it hard to make sufficient

progress towards the goals as it

provides little concrete guidance

regarding necessary steps and may be

hard to definitively resolve. High trait

ruminators are more likely to have

avoidance goals than low trait

ruminators. So if we disable the

rumination a lot of things will start to

get better. So then the question very

naturally becomes how do we do that? So

the first is that rumination is

triggered by negative emotions. So this

is what's really weird in your brain.

When your amygdala activates, when you

start to experience negative emotion, it

triggers in a habitual way the

ruminative thought process. So if you

start to have a bad day, then the

rumination triggers. Now here's what we

need to do. We need to separate

ruminative from problem solving. Right?

So all rumination is going to do is make

us think more and more abstractly. Is

going to polarize our thoughts and is

going to interfere with problem solving.

So, this sounds so weird, but like when

we ruminate, we think we're trying to

figure out a problem. Like, we're trying

to we're trying to find a solution. It

actually is very bad at doing that. So,

here's what we need to do. When we

ruminate, usually it's triggered by a

negative emotion. This negative emotion

needs to be dealt with separately. So,

if you're ruminating, you're not going

to solve your problem. So, we got to

start solving our problem outside of

rumination. Separate these two things.

Instead, what we need to do is some kind

of focused emotional regulation

technique. So, you can do nadish

pranayam. We teach a lot of stuff about,

you know, emotional regulation. Check

out Dr. K's guide. It'll really help

with all this kind of stuff. Okay. Deal

with that negative emotion. Once the

negative emotion is gone, then what we

want to do or we're not feeling that

negative emotion very actively right

now. Stop the rumination. What we want

to do is then we want to engage in

problem solving. So problem solving

should only be done when you are happy.

Only be done when you're happy. There's

a second aspect of problem solving,

which is remember that the reason that

our problems feel unsolvable is because

we're overly abstract. What can I do

today to become no longer a loser?

That's not something I can do. Maybe I

can work out. Maybe I whatever. There's

all kinds of practical things I can do,

right? But it doesn't feel like it

works. So instead, what we need to do is

really focus on concrete thinking and

watch out for the pessimistic angle. So

what we need to start doing is acting.

We need to start thinking in a very,

very concrete way. And this is where the

solution that I want y'all to do is the

solution that will be insufficient.

Watch out for that pessimistic thinking.

Don't stop. Don't quit something just

because it isn't going to work. If it is

moving you in the right direction, then

you should just do it. That's it's as

simple as that. So, watch out for that

negative kind of thinking. The third

thing that we need to do is look at our

context and improve context. So even if

you feel like a loser today, chances are

your situation is different than the way

that it used to be. Chances are that for

each situation that you think makes you

a loser, there was some context that was

contributing to that. And now you may

say, "Oh, but I've like fallen so far

behind. There's no way I can recover.

The context doesn't matter." That's the

ruminative thinking. That's the

pessimistic thinking. That is the

thinking of insufficiency. So, what I

want you all to do is really look at be

on the lookout for any opportunity for

change. Look at, okay, does this one

person is this person like inspiring me

a little bit? Could this person be like

one of my writing buddies? I could

review their writing, they could review

my writing. Is this person maybe like

this person asked me if I wanted to hang

out sometime? And then the pessimistic

thinking is like, oh, they're not going

to want to be date me or whatever, which

is totally fine, but I'm going to hang

out with them anyway. So, so be very,

very sensitive to changes in context.

And here's the other critical critical

critical thing. So when I work with

people who ruminate, one really good way

to tie this all together is to try to

improve your context. Don't worry about

solving your problem because nothing is

going to work to solve your problem,

right? What can you do to increase your

context? Let's say you're alone and you

don't have any girlfriends or whatever,

boyfriends, whatever. What can you do to

increase your improve your context? What

can you do to put yourself in a

situation where a girlfriend or a

boyfriend is more likely to arise? Can

you make platonic friendships with

people of the opposite gender and then

ask you to hook hook you up with

someone? Maybe set you up on a blind

date. If you're struggling in the

professional side, can you start to do a

little bit more networking? Talk to your

boss a little bit. Focus on the context.

Even if you were a loser, look at the

environment around you and how can you

improve your environment just a little

bit. If y'all do these things, then

there's a good chance that your

rumination will improve because we're

targeting the rumination directly. The

last thing that I'm going to leave y'all

with is a meditation. So, this is where

when we get stuck in the cycle of

rumination, there's one meditation that

I I found it really helps my patients a

fair amount, which is the meditation of

what's the next thought. So, anytime you

have a thought, anytime you start to

ruminate, one thought leads to another,

leads to another, leads to another, but

you're trapped inside those thoughts. Oh

my god, then this is going to happen.

this is going to happen. This is going

to take a step back because this is what

I ended up doing with my patients that

ended up getting the supervisor

uncomfortable with me is I started

teaching them things like this. I

started teaching them what's the next

thought. Go meta for a moment and

observe the process of rumination. Just

ask yourself, okay brain, what thought

is next? Okay, brain, what thought is

next? Okay, brain, what thought is next?

We don't dwell on the thought. We don't

wallow in the negativity. Okay, now

you're upset about this. Okay, fine.

What are you upset about next? What's

the next thought? What's the next

thought? What's the next thought? So

this is very important to understand

because when we ruminate we are inside

each thought and often times we don't

have the strength of will to control or

disrupt those thoughts. We can't stop

the chain. So we're going to do

something else. We're going to float

above it and we're just going to ask the

brain, what's the next thought? Okay,

what's next? Okay, what's next? We're

not going to get caught up in it. What's

next? What's next? And something really

cool will happen. The chain will run

through, but you won't get emotionally

amplified by it. If you are getting

emotionally amplified, that means you're

getting lost in, oh, then this is gonna

happen and this is gonna happen. No, let

it let it run. Just let it run. Okay,

borrow. What's next? What's next? What's

next? What's next? And if you use this

exercise, you may find that it calms you

down a little bit and then you can

engage in the uh contextual problem

solving.

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