In this article, John takes a fresh look at the nature of rumination , suggesting we should see it as natural part of human behaviour, even though in grief, it is usually unhelpful.

Recently I was asked to explain my position on the perils of rumination for people who are bereaved. What is it about grief that makes rumination so hazardous, that I feel bound to make public warnings on social media? It’s a fair question, and for a moment I was filled with self-doubt. People who know me professionally will have heard me say that I don’t do opinion, I do evidence. Where then, does my position on grief rumination originate? Where’s the evidence?

Rumination in general can be a harmless, even relaxing pastime. It’s derived from the extra stomach cows and other ruminants have. Tucked safely away inside their bulk is their rumen. Rumination is analogous with chewing the cud. Anyone who has even sat in a meadow on a sunny day watching shapes in the clouds and softly musing on life, the universe, and everything, will understand the joys of rumination, thinking things through, making sense of the world, chewing over ideas to see where it leads. Meditation can be a form of rumination too. 

Ruminating in grief is, however, fraught with danger insomuch that it can complicate grief (van der Houwen et al., 2010) My own professional evidence is admittedly anecdotal. When therapists are reporting anecdotes, they rename it “lived experience” to make it respectable. Joking apart, in 25 years and hundreds of clients, I have met harmful rumination many times. I have learnt to watch for it and detect when it becomes potentially harmful. I even know how to head it off at the pass. I have even learnt to capitalise on it and steer it towards a positive outcome. When, through many observations, you witness the same phenomenon repeatedly, and with many clients, the probability that the concept is valid and reliable increases with each new situation. It turns out however, that I am not alone in observing the pitfalls of ruminative thinking. A literature search of the keywords, ‘rumination and ‘grief’ revealed the extend of the research, and with some relief, I find my own position vindicated. The top hits in a Google Scholar search are all from the Stroebe and Schut stable, with their colleague Marten Eisma being the prolific lead publisher. Their work has tended to focus on grief rumination as repetitive negative thinking, in particular, as a consequence of depression and worry. Eisma and colleagues concluded that clients ruminate as a means of avoiding going too deep into the reality of the loss (Eisma et al., 2013). In a later paper Eisma and colleagues suggests exposing the colleague to their grief, thus overcoming grief avoidance and hence harmful rumination (Eisma et al., 2020). Andrews and colleagues (2021) explored whether grief-related rumination has an evolutionary function. They concluded that very possibly it does They also observed that the incidence and intensity of such rumination varies both by personality and circumstances of the death. 

One doesn’t have to read many papers on grief rumination to notice the strong emphasis on rumination as a disorder which can be treated. It does not, in my view, need to be seen in this light. When defined more widely, rumination in grief is not always harmful, and with effective counselling, can be harnessed. In a longitudinal study, Marten Eisma and colleagues (2015) departed from their generally symptomological  definitions and were able to distinguish between adaptive and maladaptive rumination (Eisma et al., 2015). 

What if we look again at the nature of rumination? What if we view as a natural human attempt to construct meaning, and make sense of our world? Those who work with grief understand that the ability to make sense and find meaning in loss is one of the most important aspects of a successfully navigating a grief journey (Neimeyer, 2001, 2006, 2009) UnfortunateLy it has this potential to take our thoughts down a dark rabbit hole of maladaptive rumination,  but it doesn’t have to be that way. I have examples from my own research to make this case. 

In my doctoral research (Wilson, 2017) I worked with two clients in long-term therapy. Both made positive use of repetitive thinking, but as fadaptive rather than maladaptive rumination. ‘Tony’, at age 40 was caught up in a delayed grief reaction following the death of his brother some thirty years previously. In every session I supported him as he ruminated on the link between his depressive moods and behaviour in an ultimately successful attempt to relate his way of being with his unexpressed grief.  ‘Sophie’, another participant in my doctoral research, had a shallow recovery trajectory, due to losing her spouse in traumatic circumstances (Wilson et al., 2021). However, she ruminated effectively and positively in practically every session. During two years of counselling, I provided the safe space but needed to make few interventions.

So what makes the difference? I like to visualise the repetitive thinking that characterises rumination, as a circle around which the client moves. If a trip around the circle is negative and nothing is gained, this journey has been depressing If subsequent trips are even more depressing, the circle becomes a helix, with the client moving downwards. If, on the other hand, an increment of positive understanding is acquired each time, the client can move upwards through the helix, which is exactly what Tony and Sophie did. The trick for the counsellor is to listen really closely to each round of reoccurring thought, as expressed by the client. If it becomes overwhelmingly negative, with nothing changing, there will be an inevitable downward path. If however, even the slightest positive thought enters the journey, there is room for optimism and an opportunity for the counsellor to offer reinforcement and encouragement. 

Hopefully I have moved the reader away from necessarily seeing grief rumination as a disorder with my invitation to see it as a healthy attempt to make sense of a loss given the right support to do so, albeit the risks and pitfalls. Our task as practitioners is to foster each client’s meaning-making whist keeping their rumination out of danger. These are some of the ways clients and I, in collaboration, have managed this.

• Listen carefully, as described above. Identify and support new, potentially helpful thoughts, i.e. those which carry the potential to move the journey forward.
• Support your client in asking questions which give meaning. Support them in identifying the point at which no more answers are likely to be found. 

Case example: When Sophies husband David was diagnosed with a rare cancer, there was a delay in seeing a consultant due to Christmas holidays. Sophie wanted to know if David would have survived had he been seen sooner. I supported Sophie in making an appointment to ask this of the consultant. Sophie found the consultant defensive and unhelpful, and I supported her decision to let go of the question.

In my experience, repeatedly asking questions which cannot be (or unlikely to be) answered, are a common cause of negative rumination.

Case example: A bereaved daughter in danger of ruminating over her father’s hospice care was helped with an explanation from the nursing sister in charge of his care, which was kind, authoritative and perhaps most importantly, in no way defensive. In my hospice job I often found it helpful when nurses and or doctors could answer a client’s questions.

• Cognitive restructuring, or reframing. 

Case example: “I feel guilty that my dying spouse was angry with me”, reframed by suggesting that their anger was fear. The surviving spouse could understand their loved-one’s fear, which removed the guilt and ended the rumination.

• Invoke the Dual Process Model (Stroebe & Schut, 1999)

Case example, I suspended the counselling sessions of a client whom I could see was going over the same ruminative thoughts in every session. I also knew that she was socially isolated and was likely to ruminate at home too. I facilitated her joining a support/social group which enabled her to meet other widows. There she formed a friendship which moved her to the restoration-orientation of the DPM sufficiently to end the negative rumination. Then we were able to resume counselling.

Summary

Rumination in grief is nearly always harmful, to the extent that most research has concentrated on the negative aspects, often identifying rumination as a disorder. It doesn’t have to be that way. Once we view rumination as a natural adaptation to loss, we can support clients in turning it to their advantage. Client and counsellor working together can avoid harmful rumination by identifying it before it becomes a problem.

References

Andrews, P. W., Altman, M., Sevcikova, M., & Cacciatore, J. (2021). An evolutionary approach to grief-related rumination: Construction and validation of the Bereavement Analytical Rumination Questionnaire. Evolution and Human Behavior, 42(5), 441-452. 

Eisma, M. C., de Lang, T. A., & Boelen, P. A. (2020). How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement. Clinical Psychology & Psychotherapy, 27(4), 548-558. 

Eisma, M. C., Schut, H. A., Stroebe, M. S., Boelen, P. A., van den Bout, J., & Stroebe, W. (2015). Adaptive and maladaptive rumination after loss: A three‐wave longitudinal study. British Journal of Clinical Psychology, 54(2), 163-180. 

Eisma, M. C., Stroebe, M. S., Schut, H. A., Stroebe, W., Boelen, P. A., & van den Bout, J. (2013). Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss. Journal of abnormal psychology, 122(4), 961.

Neimeyer, R. A. (Ed.). (2001). Meaning Reconstruction & The Experience of Loss. American Psychological Association. 

Neimeyer, R. A. (2006). Complicated Grief and the Quest for Meaning: A Constructivist Contribution. Omega: Journal of Death & Dying, 52(1), 37-52. (In File) 

Neimeyer, R. A. (2009, 7/14/2009). Conference workshop. Researching Meaning-Making: Narratives of Grief and Loss., St Ann’s College, Oxford.

Stroebe, M. S., & Schut, H. (1999). The Dual Process Model of Coping with Bereavement: Rationale and desciption. Death Studies, 23, 197-224. (In File) 

van der Houwen, K., Stroebe, M., Schut, H., Stroebe, W., & van den Bout, J. (2010). Mediating processes in bereavement: the role of rumination, threatening grief interpretations, and deliberate grief avoidance. Soc Sci Med, 71(9), 1669-1676. https://doi.org/10.1016/j.socscimed.2010.06.047

Wilson, J. (2017). Moments of Assimilation and Accommodation in the Bereavement Counselling Process Leeds]. White Rose eTheses Online. 

Wilson, J., Gabriel, L., & Stiles, W. B. (2021). Charting the process of grief recovery in the case of Sophie. British journal of Guidance and Counselling(Living with Loss). https://doi.org/https://dx.doi.org/10.1080/03069885.2021.1983154