Rumination in Obsessive-Compulsive Disorder: An Overview of My Skills Class at EABCT 2024
Dr. Jean-Philippe Gagné
* Disclaimer *: Please note that this article is meant to be an informational overview and is not intended to be used as a clinical guide. Please see below for resources if you are interested in learning more about this topic.
It was an absolute honour to present my skills class, Rumination in Obsessive-Compulsive Disorder: Catching the Sneakiest of Compulsions, at the 54th Annual Congress of the European Association for Behavioural and Cognitive Therapies (EABCT 2024) in Belgrade, Serbia. Sharing insights on such an important, yet often overlooked, aspect of obsessive-compulsive disorder (OCD) with clinicians dedicated to advancing cognitive-behavioural therapy (CBT) was a privilege. The conversations and feedback from this wonderful community have left me feeling energized and inspired.
The Sneaky Nature of Rumination in OCD
Rumination is one of the sneakiest compulsions in OCD. Unlike more obvious compulsions, such as handwashing or checking, rumination happens entirely within the mind. People with OCD may engage in rumination as they try to solve the “puzzle” of their intrusive thoughts: they dwell on the meaning, causes, and consequences of their intrusive thoughts. This mental behaviour often feels productive at first, but it traps the person in an endless cycle of distress and doubt, reinforcing the overimportance of unwanted intrusive thoughts and thus maintaining the OCD system. Due to the never-ending nature of rumination, patients often report increasing feelings of hopelessness and depression.
Although rumination can come up across OCD subtypes, it is common in those suffering from repugnant obsessions. For example, these individuals may have unwanted intrusive doubts about their identity and may repeatedly attempt to uncover “evidence” that they are not dangerous or immoral. This can lead to short-lived bouts of reassurance but also to more doubt and uncertainty.
During the skills class, I emphasized that while rumination has historically been viewed as part of the obsessional domain, it is better conceptualized as a covert compulsion—a mental behaviour aimed at neutralizing distress and/or reassuring oneself. Understanding this shift is key to treating OCD effectively. The class was designed to help clinicians recognize rumination in their patients, assess its impact, integrate it into case formulation, and encourage its discontinuation—like any other compulsions.
Rumination as a Mental Habit
A central theme was how rumination functions as a mental habit. Just like any other habit, it is automatic and context driven. In the case of OCD, it is often triggered by anxiety or intrusive thoughts. Once a patient starts ruminating, they often feel stuck, unsure how to stop. By conceptualizing rumination as a compulsion, clinicians can focus on helping patients break this habit.
Practical Interventions for Targeting Rumination
The session provided a detailed roadmap for clinicians to address rumination using a variety of CBT strategies. These included:
Psychoeducation: Helping patients understand that rumination, though well-intended, keeps them stuck. It is essential for clinicians to explain that ruminating on intrusive thoughts will not provide the long-term certainty or reassurance patients are seeking.
Awareness Building: Since rumination is often automatic, patients need help catching themselves in the act. Adding a “rumination” column to monitoring forms or pointing it out in session helps patients develop awareness of when they are ruminating. Discussing the warning signs (e.g., cognitive, emotional, physiological, behavioural) that it is happening or about to occur can also be helpful.
Behavioural Experiments: We also explored using behavioural experiments to target positive beliefs about rumination, such as the idea that “thinking it through” will lead to certainty. Often, these experiments help patients collect data supporting that tolerating uncertainty is far more beneficial than engaging in endless mental loops.
Encouraging Competing Responses
Given that rumination is a deeply ingrained habit, habit reversal strategies can be powerful. Patients are encouraged to replace the act of ruminating with an alternative behaviour, such as using grounding exercises, engaging in distracting activities, or using alternative statements like, “I can tolerate not knowing for sure.” These alternative behaviours, paired with behavioural activation, give patients tools to break free from rumination and regain control of their daily structure.
Preventing Relapse
Relapse prevention was another key focus. Even when patients successfully reduce rumination, it is important to prepare them for its potential return. We discussed strategies for identifying early warning signs and reinforcing the tools learned in therapy to ensure lasting change.
Wrapping Up
In closing, this session emphasized that tackling rumination requires patience, skill, and persistence. By treating rumination as a covert compulsion and incorporating these targeted CBT strategies, clinicians can help their patients reduce its impact and make significant strides in their OCD treatment.
I’m grateful for the opportunity to share these insights at EABCT 2024 and for the meaningful discussions that followed. Let’s continue to shine a light on this sneaky compulsion, empowering patients to break free from its grip and embrace uncertainty with confidence.
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Bream, V., Challacombe, F., Palmer, A., & Salkovskis, P. (2017). Cognitive behaviour therapy for obsessive-compulsive disorder (1st ed.). Oxford University Press.
Clark, D. A. (2019). Cognitive-behavioral therapy for OCD and its subtypes (2nd ed.). Guilford Press.
Heinzel, C. V., Lieb, R., Kollárik, M., Kordon, A., & Wahl, K. (2020). Development and preliminary psychometric properties of the Rumination on Obsessions and Compulsions Scale (ROCS). Journal of Obsessive-Compulsive and Related Disorders, 27, 100554. https://doi.org/10.1016/j.jocrd.2020.100554
Wahl, K., van den Hout, M., Heinzel, C. V., Kollárik, M., Meyer, A., Benoy, C., … & Lieb, R. (2021). Rumination about obsessive symptoms and mood maintains obsessive-compulsive symptoms and depressed mood: An experimental study. Journal of Abnormal Psychology, 130, 435-446. https://doi.org/10.1037/abn0000693
