A good assessment requires psychotherapists to listen carefully to their patients. Although they need to be open to the unique problems and symptom presentations of their patients, they can expect to find some common patterns among suicidal patients, including a tendency toward ruminations, which are often perceived as uncontrollable.
Effective interventions for suicide often involve helping patients to learn to regulate their thoughts and emotions, and to reconsider the maladaptive thinking patterns, such as ruminations, that cause significant emotional pain and fuel thoughts of suicide.
Consider this example:
Ever since his wife left him, John had intrusive thoughts about suicide that he could not get out of his mind. He would think, “I am no good. I might as well kill myself,” or “Other people would be better off if I were dead,” or “I might as well kill myself because there is no other way to end my misery.” These unwanted and apparently uncontrollable thoughts kept him up at night and clouded his thinking during the day.
Dr. Nakasone, John’s psychotherapist, identified John’s ruminations as an important component of his overall treatment. However, first she had to understand John’s thinking style and what these intrusive thoughts meant to him. Then, she will need to focus on rumination as one part of her overall treatment plan for John.
Basics of Ruminations
Rumination is a style of thinking characterized by prolonged and repetitive negative thinking about one’s problems or one’s emotional reactions to problems. Instead of leading to effective problem-solving strategies, ruminations only increase distress. Ruminative flooding is an intense form of rumination characterized by accompanying head pain and pressure (Galynker, 2017; Rogers, 2022). Ruminations are transdiagnostic and can be found in many different mental disorders.
Suicidal patients often present with a complex emotional soup, involving a mixture of many emotions that can wax and wane over time, and a cognitive web where feelings and thinking patterns appear to exacerbate, feed off of, or mitigate each other at different times. Ruminations are a common component of this emotional soup and cognitive web. Ruminations often co-occur with feelings of overarousal (e.g., agitation and nightmares; Faccini et al., 2022) and negative urgency (a strong desire to escape a situation perceived as unbearable; Valderrama et al., 2022).
Ruminations can either be brooding (dwelling on negative feelings or distress) or reflective (attempting to understand the reasons for distress). Of the two, brooding is most closely associated with suicide attempts (Horwitz et al., 2018).
Worry and rumination are similar in that both involve repetitive and difficult-to-control thoughts. Nonetheless, they are separate, albeit overlapping, constructs: worry concerns future events, and rumination concerns past events (Stade & Ruscio, 2023). Although Dr. Nakasone has identified John’s ruminations, she will still be alert for signs of worry.
Ruminations are intrusive, and ruminators have difficulty disengaging from them (Forkmann et al., 2023). For example, a rumination scale includes items such as “I cannot escape these thoughts,” or “I am unable to stop thinking about suicide” (Rogers et al., 2022, p. 1781). People may attempt to control ruminations through thought suppression (“just stop thinking about it”), although this is usually an ineffective strategy for regulating emotions and thoughts. The failure to regulate one’s emotions may lead to a cycle of rumination, hopelessness, and thoughts of suicide. Negative affect or overarousal can increase the risk of, or the intensity of, ruminations. Ruminations consume mental energy that could be better spent on problem-solving. Although ruminations involve thinking about one’s problems, they actually lead to a loss of control over one’s thinking processes. They do not lead to solutions; instead, they can exacerbate the impact of negative events.
Role of Ruminations in Suicide
Ruminations may come in different forms, such as anger, grief, depressive, or suicide-specific ruminations, which are “rumination about one’s suicidal thoughts, intentions, and plans” (Rogers & Joiner, 2018, p. 428). Suicide-specific ruminations may occur along any step of the suicide continuum, from thoughts to plans to preparations. Perseverating on suicidal thoughts may increase the short-term risk of a suicidal attempt (Rogers et al., 2022) even when other risk factors are controlled (Rogers & Joiner, 2018).
Among research participants with suicide ideation, those with suicide-specific ruminations were more likely to attempt suicide (Hensel et al., 2024). Suicide-specific ruminations may cause people to withdraw or to view themselves as a burden on others. They could involve mental rehearsals wherein people habituate themselves to the thoughts of their own deaths.
In the long term, ruminations could be seen as one of the factors that predispose people to suicidal thoughts. According to O’Connor’s integrated motivational-volitional (IMV) model of suicide, certain conditions may lead people to develop dysfunctional styles of thinking or acting, which could make them vulnerable to developing suicidal thoughts. Ruminations would be one of the dysfunctional thinking styles, along with others, such as deficits in social problem-solving or memory biases that facilitate the development of suicidal ideation (O’Connor, 2021).
In the short term, suicide-specific ruminations may occur in suicide crisis states or periods of high emotional arousal that occur immediately before a suicide attempt. Galynker (2017) noted that the more people ruminate about their life problems, the less able they are to develop helpful solutions. It is a vortex that is difficult to escape.
Treatments for Ruminations
Given the link between ruminations and suicide, reducing ruminations may help suicidal patients reduce feelings of distress and the likelihood that they will develop a suicidal crisis state.
Dr. Nakasone can reduce ruminations by teaching her patient more effective strategies for regulating emotions and reducing overarousal. She may teach him to use distraction (drawing one’s attention to engaging activities that keep people from rumination), reappraisals (thinking about things in a new way or thinking through things rationally), or social control (talking to others about one’s problems or getting reassurance from others; Hallard et al., 2021), and mindfulness training, which may reduce ruminations by decentering a person by having them focus their non-judgmental attention on the present moment. If necessary, Dr. Nakasone could also consider teaching her patient relaxation skills or referring him for medications, which may help reduce the overarousal, which increases the frequency and intensity of ruminations.
Recommendations for Practitioners
Ruminations represent a transdiagnostic and maladaptive thinking style that focuses on intrusive thoughts on past challenges or perceived errors and may involve suicide-specific thoughts. They increase negative affect, may lead to overarousal, and increase the risk of a suicide attempt.
Psychotherapists, such as Dr. Nakasone in the case example, can help their patients by
- Evaluating them for the presence of ruminations, specifically looking for brooding, suicide specific ruminations, or controllability.
- Helping them identify and appreciate the link between ruminations, poor mental health, and suicidal urges. They can help their patient review the context, antecedents, and triggers of their ruminations (Sirota et al., 2020).
- Helping them to reduce their overall stress or overarousal level, which will help break the negative affect/rumination cycle. For example, anxiety, insomnia, and nightmares tend to make ruminations worse (Faccini et al, 2022); thus, interventions to address those issues, such as relaxation exercises, sleep hygiene instructions, or cognitive-behavior therapy for insomnia, may be indicated (Bryan & Rudd, 2018).
Teaching them mindfulness or other cognitive control techniques. Mindfulness can help patients identify when the ruminative patterns are beginning, and cognitive therapy can help them address maladaptive beliefs or feelings, especially shame and harsh self-criticism, which are common among suicidal patients (Bryan & Rudd, 2018; Sirota et al., 2020).
References
Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. Guilford.
Faccini, J., Joshi, V., Graziani, P., & Del Monte, J. (2022). Non-constructive ruminations, insomnia and nightmares: Trio of vulnerabilities to suicide risk. Nature and Science of Sleep, 14. https://doi.org/10.2147.NSS.S339567
Forkmann, T., Knorr, A., Gerdes, C., Vüst, B., Hamacher, D., & Teismann, T. (2023). Metacognitions about suicidal thoughts. Journal of Psychiatric Research, 161, 199-205.
https://doi.org/10.1016/j.jpsychires.2023.03.018
Galynker, I. (2018). The suicidal crisis. Oxford. https://doi.org/10.1093/MED/97801902.60859.003.007
Hallard. R. I., Wells, A., Aadahl, V., Emsley, R., & Pratt, D. (2021). Metacognition, rumination and suicidal ideation: An experience sampling test of the self-regulatory executive function model. Psychiatry Research, 303. https://doi.org/10.1016/j.psychres.2021.114083
Hensel, L. M., Forkmann, T., & Teismann, T. (2024). Suicide-specific rumination as a predictor of suicide planning and intent. Behaviour Research and Therapy, 180. https://doi.org/10.1016/j.brat.2024.104597
Horowitz, A. G., Czyz, E. K., Berona, J., & King, C. A. (2018). Rumination, brooding, and reflection: Prospective associations with suicide ideation and suicide attempts. Suicide and Life-Threatening Behavior, 49(4), 1085–1093. https://doi.org/10.1111/stlb.12507
O’Connor, R. (2021). When it is darkest. Vermillion.
Rogers, M. L., & Joiner, T. E. (2018). Lifetime acute suicidal affective disturbance symptoms account for the link between suicide-specific rumination and lifetime past suicide attempts. Journal of Affective Disorders, 235, 428–433. https://doi.org/10.1016/j.jad.2018.04.023
Rogers, M. L., Law, K. C., Houtsma, C., Tucker, R. P., Anestis, M. D., & Joiner, T. E. (2022). Development and initial validation of a scale assessing suicide-specific rumination: The Suicide Rumination Scale. Assessment, 29(8), 1717-1794. https://doi.org.10.1177/10731911211033897
Sirota, N. A., Moskovchenko, D. V., Yaltonsky, V. M., Makarova, I. A., & Yaltonskaya, A. V. (2020). Cognitive therapy of depressive ruminations. Neuroscience and Behavioral Physiology, 50(1), 51–56. https://doi.org/10.1007/s11055-019-00868-z
Stade, E. C., & Ruscio, A. M. (2023). A meta-analysis of the relationship between worry and rumination. Clinical Psychological Science, 11(3), 552–573. https://doi.org/10.1177/21677026221131309
Valderrama, J., Macrynikola, N., & Miranda, R. (2022). Early life trauma, suicidal ideation, and suicide attempts: The role of rumination and impulsivity. Archives of Suicide Research 26(2), 731–747. https://doi.org/10.1080/13811118.2020.1828208
Samuel Knapp, EdD, ABPP
Board Certified in Counseling Psychology
Correspondence: Samuelknapp52@yahoo.com