Sometimes when Ernst Koster, associate professor of clinical psychology at the University of Ghent, is treating someone for depression, he’ll ask them to do math. A computer program plays audio recordings of numbers at a certain pace—3, 6, 9 and so on. He asks the patient to add the last two digits they hear. If they get it right, the task goes a bit faster; if they get it wrong, it goes slower. It’s about juggling separate bits of information at once: the digits you’re hearing, the calculations you’re making and the anxiety that may or may not be starting to buzz around in your head. “In order to perform well, you need to ignore the distress and maintain focusing on the task,” Koster tells Thrive Global. “The moment you think, ‘why am I doing this, it will go to waste.”
While this might seem like a simple enough challenge, the research suggests that mental exercises like these can treat depression by targeting its building blocks. Doing this therapy through the internet reduces symptoms of depression, Koster’s recent work finds, and earlier research found that this same auditory task, done repeatedly over the course of ten weeks, helped people who ruminate a lot spend less time brooding. They also reacted less when experimenters gave them an intentionally stressful task in the lab.
“What you need to do is ignore the stress created by the task and keep focusing on the problem at hand,” Koster explains. This develops a crucial skill in navigating one’s emotions: being aware of stress or an another difficult feeling without getting drawn into it. It’s about setting better boundaries with your own cognitive processes—which is precisely the kind of thing needed to address what might be the world’s most urgent mental health issue.
The World Health Organization reports that depression has become the leading cause of disability worldwide. An estimated 322 million people—4.4 percent of the human race, and a number just shy of the entire U.S. population—are living with depression. And while antidepressants are more prevalent than ever and will constitute a $16 billion global market by 2020, new research indicates that these medications don’t address the mental patterns that underpin, provoke and keep the condition going. That’s where a new class of treatments based on training people in cognitive skills comes in.
The way depression is usually described, you’d think it was some sort of metaphysical entity; Andrew Solomon’s authoritative book on the topic is called The Noonday Demon, after all. Mental health professionals used to think that problems with memory, attention and concentration were side effects to mood disorders, but now, psychologists and brain scientists are appreciating how much they’re a part of them. In the tradition of cognitive behavioral therapy and mindfulness alike, the more clearly you can identify the mechanical patterns that perpetuate depression, the better you can target and readjust them.
That’s key when facing rumination, the thinking about thinking about thinking that's been found again and again to be a strong mediator for anxiety and a huge risk factor for depression. People who ruminate frequently are less forgiving of themselves, abuse alcohol more, take more risks driving and are at greater risk of suicidal ideation.
Coming from the Latin for “chewing cud,” rumination is the repeated picking at the causes and symptoms of one’s distress; it’s a problem-solving strategy that never actually arrives at a solution. In its most toxic forms, rumination is a runaway train of thought—thinking about what you think about what you think about, without much control available for getting your mind to settle somewhere else. “At some point they might say to themselves, ‘I should stop ruminating,” Koster says. “But they don’t—they’re unable to interrupt this process.” But with the right interventions, you can learn to regain control.
In clinical psychology, it’s thought that depressives have “negative schemata,” or ways of filtering or interpreting the events of life and mind in an uncharitable light. Depressive hindsight bias—where past negative events are seen as more foreseeable and inevitable than positive ones—is an example. When you have depression, negative things are taken in more easily. If you already think everything is terrible, then you’re going to be more receptive to terrible events than benign or pleasant ones—in the same way that a Chicago Cubs fan, before last season, would find it more believable that their team would miss the playoffs than win the World Series. These patterns are symptoms of—and risk factors for—depression.
Treating this can get quite finely grained: in a 2016 paper in Emotion, Koster and his team used eye-tracking technology to monitor whether or not a healthy participant’s gaze was drawn to more negative or positive words in emotionally loaded, scrambled sentences (e.g., “winner” and “loser” in “am winner born loser a I”). A red or green square would appear to frame the negative or positive word when the eye-tracker could detect the eye was lingering there—providing real-time feedback to help participants quickly disengage from negative information and instead focus on positive stuff. After that, participants were presented with emotionally challenging imagery, and then asked to revise their interpretation of it. And getting guided by those red boxes lead to greater reinterpretation of those images, similar to the reappraisal that's a core principle of cognitive behavioral therapy.
Ed Watkins, a professor of experimental and applied clinical psychology at the University of Exeter in the U.K., has had lots of success in training his patients in “concreteness,” or sticking to the details of events rather than rushing into interpretations. In a 2008 study that helped give birth to this line of research, Watkins and his colleagues found that when people are primed to think abstractly, they’re more emotionally reactive than if they’re primed to think concretely. (That people with depression tend to “over-generalize,” or take a single event to be indicative of universal principles, is a longstanding finding in the field. Like "I did poorly on an algebra test, so I’m bad at math," for instance.)
Watkins' experiments had a degree of devilishness in their design: to get participants to think abstractly in one experiment, the researchers asked them to imagine experiencing a fictional scenario, like an argument with a best friend, a successful job interview. They then asked them to either think about why it happened, and analyze its causes, meanings, or implications, or to focus on how the event went down, and imagine as vividly and concretely as possible a mental “movie” of what unfolded. In another, the participants were told to imagine they bumped into an old friend at a railway station, had a grand time catching up, and as they departed, they shook hands and felt one of two things: the strength of their grip (in the concrete condition) or the strength of their loyalty (in the abstract.) After being primed to think in these ways, the participants were given a “stressor task” in the form of exceedingly difficult—or literally impossible to finish—word puzzles. Afterward, the abstract groups had worse moods than the concrete.
Following that, Watkins has used concreteness training as an intervention in clinical populations, too. In a 2009 paper in the Journal of Abnormal Psychology, his team found that concreteness training not only helped people with depression describe problems more concretely, but it also significantly reduced their rumination and self-criticism. Similarly, in a randomized control trial, targeting rumination reduced both depressive symptoms and the risk of another depressive episode after treatment.
Humans naturally want to know why things happen, Watkins says, but scratching around your brain for causes can become unhealthy, especially when you start pointing the finger of blame toward yourself. “Some bad stuff happened, and I’m trying to make sense of it—I want to make sense of it,” he says. “What happens is often the questioning turns in on itself: why did it happen to me? Why does this keep happening to me? Why can’t I do this as well as I used to? It ends up taking the person out of the details of the situation, which makes it that much harder to solve it. It also tends to make them more self critical.” And the more abstract you get, the more the negative filters—the depressive schemata— can take over. “You can see how it just escalates,” Watkins says. “‘I happened to do badly on this one thing. Well, that brings up this memory of another thing I've done badly one. Why do I keep doing badly on everything?’ Before you know it, everything's been massively exaggerated and escalated and generalized.”
Watkins sees this a lot in his clinical practice, where many of his patients are parents. They’ll have challenges with their kids, and Watkins coaches them to evaluate things more concretely. They might have an argument with their teenage son or daughter over homework, and it can quickly spiral into abstract, self-aggressive thoughts—Why I can't do this? Why am I having difficulties? Why are we having arguments? Why am I not a good mother? He’ll coach them to rewind and evaluate the details of what happened: when your daughter came in, you were already a bit stressed, and when you told them “do your homework” they ignored you, and you got angry. Taking things beat-by-beat like that allows for more agency and greater insight: maybe if the conflict was handled with a different, perhaps gentler style, there could have been better results. “That's grounding it in the context,” Watkins says. “If I changed a bit of my behavior, then it wouldn’t have got so heated. That would move it away from the sense of ‘I’m just a bad mom’—really grounding it in the particular instance that happened.”
Rather than getting tangled up in abstraction, it’s better to adjust your thinking toward action. Or so Watkins’ research indicates thus far: “It's more helpful to ask, ‘How did it happen and how can I do something about it?’ than to ask, ‘Why did happen and what does it mean about it?,’” he says. It’s like becoming your own detective, Watkins wrote in a chapter on treating rumination: you profile your own mental habits, see where they get you into trouble and learn to readjust them.