Decreasing Angry Rumination
Judith S. Beck, PhD
Janet was a 59-year-old female who entered treatment with me for dysthymia. She had been experiencing low-level depression and intermittent anger for many years. She was quite skeptical about treatment, explaining that she had spent four years with an “insight” therapist which she had found “completely unhelpful.” I asked some questions about the treatment and then described what I thought our work together would look like. She grudgingly admitted that it sounded different, but she wasn’t sure that it would help. I told her I couldn’t guarantee it would work but that there was nothing about her that made me think it wouldn’t. She was hesitant to commit herself, so I suggested that we give it a try for three or four sessions and then re-evaluate, though she was free to stop sooner, if she wanted.
Initially, it was somewhat difficult to get her to engage in behavioral activation. Her beliefs that “Nothing can help,” “I can’t affect my mood,” and “Anything I do will be a drop in the bucket,” decreased her motivation to change. But she did make progress as we focused on increasing positive emotion in each session and drew adaptive conclusions about her ability to impact her emotions.
When she entered my office for our sixth session, I could see that she was very upset. Before she even sat down, she burst out saying, “I have to talk to you about my job. I didn’t get a promotion. Someone else did. It’s so completely unfair.” As it turned out, she had gotten caught up in an unhelpful cycle of thinking. For almost six days, she had experienced near-constant angry thoughts about being passed over for the promotion. Even when she was trying to focus on doing her work, talking on the phone to her adult children, taking a nature walk, and engaging in other activities, her attention kept getting high-jacked as angry automatic thoughts popped into her head.
Her focus on unfairness led to a great deal of anger and frustration. Without her conscious awareness, Janet was simultaneously devaluing other important parts of her life: her children, her friends, her physical well-being, her spirituality, her volunteer work. We labeled Janet’s angry rumination as an “unfairness thinking cycle.”
During the mood check, I assessed that Janet’s level of anger was higher, although her depression and anxiety were actually a little lower than in our previous sessions. But her sense of well-being was also significantly reduced.
During the update, I tried to get Janet to recall experiences she had had during the week that were positive. I hypothesized that this strategy might move Janet from the “angry mode” toward a more neutral mode. But she reacted angrily. “I don’t want to focus on positive experiences. I’m too upset.” I acknowledged and positively reinforced her for this feedback. “It’s good you told me that. Would the goal for this session be to help you feel less upset?” When she replied yes, I collected some data to see whether problem solving might be in order. “Is there anything you can do? Would it be a good idea to talk to your boss?” It quickly became clear the evidence showed that Janet had no recourse.
Next, I hypothesized that it might help if we looked at the advantages and disadvantages of continuing to engage in angry rumination versus accepting what had happened and turning her mind to other things, especially things that were important to her. She agreed. Two important disadvantages to shifting her thinking emerged from our discussion. The first was that if she accepted the fait accompli, she would feel depressed, instead of angry. The second disadvantage of accepting what had happened was that she would be letting her boss and the co-worker he had promoted “win.”
We then reviewed her values, what was most important to her in life, and whether not getting the promotion would directly affect her ability to live in line with her values. She concluded it would not; she could still do everything she had done before. But, as she pointed out, there seemed to be a “cloud” over her activities and her predominant mood was still one of frustration.
After Socratic questioning, she recognized that continuing to ruminate over what had happened was not only irrelevant but also at odds with her sense of well-being, clouding her valued action. After some additional discussion, she concluded that there was no point in continuing to feel angry and that planning potentially rewarding activities could help her feel better. “But what if I keep thinking these [unfairness] thoughts?” she asked.
I told her that I thought mindfulness could help. At first she was skeptical but she agreed to give it a try. I asked her to deliberately and continuously think for two to three minutes about how unfair it was that she didn’t get a promotion. I wanted to duplicate the kind of experience she had been having so we could see whether a mindfulness exercise could affect her thinking. Then I asked her to record my voice on her cell phone as I led her through a five-minute mindfulness of the breath practice. I instructed her to focus on how her breath felt as she slowly inhaled and exhaled. I asked her to monitor her thinking and whenever she returned to focusing on unfairness, she was to non-judgmentally and gently bring her attention back to the breath. After five minutes, she stopped the recording and I asked her what she had noticed. She had found that she was able to interrupt her “unfairness thinking cycle” by shifting her attention to her breath.
I explained that mindfulness was designed to help her mind to be more flexible so she could focus her thoughts on what she wanted to be thinking about. She agreed to practice the mindfulness of the breath exercise every morning, listening to the recording. She also agreed to monitor her angry rumination throughout the day (using negative mood as a cue), and to redirect her thinking to her present experience or activity. When she had difficulty doing that, she could deliberately do the mindfulness of the breath exercise, with or without the recording. I also stressed the importance of giving herself credit for taking control of her rumination and negative mood.
By the end of the session, Janet felt better. While she was still upset about the promotion, she understood that focusing on it made her feel worse—and that shifting her thinking, especially using mindfulness, could help her feel better.