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Worry and rumination according to CMT
By Francesco Gazzillo
Posted on 1/17/2020 5:45 PM

Worry and rumination: from adaptation to self-punishment


     It is normal and adaptive that, when something threatens our sense of safety, we muse about what has happened, why it happened, how we contributed to it, and what we could have done to prevent it. Along the same line, it is normal and adaptive that when we are afraid that something bad will happen, we start thinking about it and try to understand what we can do to prevent it. These are adaptive manifestations of our capacities for reflection. However, these capacities may be perverted and become the phenomena of rumination and worry so well-known to contemporary psychology.

     Even if rumination is more past-oriented and worry is more future-oriented, they are both repetitive, self-focused, and perseverative forms of thought characterized by cognitive inflexibility and by an attention focused mainly on negative stimuli. Both are transdiagnostic processes and risk factors for the maintenance and exacerbation of negative emotions and moods, and both are part of many emotional problems such as anxiety disorders, panic disorders, obsessive-compulsive disorders, depressive disorders, binge eating, and binge drinking.

     To my knowledge, there is no empirically supported psychodynamic model for understanding worry and rumination, while there are several cognitive models. These cognitive models stress how worry and rumination may be expressions of a specific response style developed in response to negative childhood experiences, connected to attempts to satisfy individual fundamental needs, and supported by specific metacognitive beliefs and a specific cognitive-attentional syndrome (see, for example, Nolen-Hoeksema, 1991; Martin and Tesser, 2006; Wells, 2009).

     How can we understand worry and rumination according to Control-Mastery Theory?  According to CMT, people may start ruminating or worrying when (a) they achieve a goal previously inhibited by a pathogenic belief supporting interpersonal guilt; or (b) when, in the attempt to achieve an important goal obstructed by a pathogenic belief, something happens that threatens their sense of safety. Worry and rumination are distortions of normal reflexive thinking, away from being an adaptive form of thought aimed at mastery and problem solving, to becoming a tool for self-punishment. This self-punishment is mediated by the compliance of the individual with a pathogenic belief supporting interpersonal guilt or by her/his identification with the traumatizing caregiver who contributed to the development of a pathogenic belief which supports interpersonal guilt.

     A clinical example may be of help. Robert is a 45-year-old man who, for the first 2 years of his therapy, was constantly worried about the possibility of having some physical illness. He first complained about the condition of his intestines, focused his attention on any sensation he felt from that part of his body, and spent his time developing diagnostic hypotheses about the nature of his illness and its possible cures. When the findings of medical examinations were negative, Robert changed his focus to sensations the he felt in his head and kept worrying.  He developed hypotheses about the nature of his “illness” and looked for the necessary cures. Again, when medical tests were negative, he worried about some other malady.  Over a period of time, he spent all day tracking the sensations in his body and developing hypotheses about his pathology by searching the Internet and looking for a cure. This process increased his anxiety level, as well as its physiological correlates—tachycardia, tachypnea, headache, and sleep difficulties—which in turn were thought to be further evidence of his physical illness. Due to the energy spent worrying, Robert felt weak and concluded that being weak was an additional problem, something he could not accept in himself. He looked for food supplements to address his feelings of weakness and then interpreted their inefficacy (or their supposed side effects) as further evidence of a possible illness. His deepest fear was that he had a severe illness. He became a pronounced hypochondriac, constantly worrying about his physical health.

     Robert had a tragic history. His father, an ostensible authoritarian but actually a fragile and introverted man, committed suicide when Robert was in his early adulthood. For a long time, his father treated him as a confidant with whom he talked about his depressive preoccupations. The day his father committed suicide, Robert had noticed “something strange” in the man’s attitude, but he decided to go out and spend time walking and reading the newspaper in a park. He was fed up with being his father’s confidant. When he went home, he found his father had hung himself.  Robert was devastated because he thought that he should and could have saved his father’s life. Several years later, his brother developed cancer, and Robert thought that he could redeem himself by saving his brother’s life. When his brother died, Robert thought that even this death was one of his failures.

     Robert’s pathogenic beliefs had their roots in his early relationship with his family. His father always had depressive problems, and the relationship between his parents had always been so unsatisfying that Robert thought that it was one of the causes of his father depression.  Moreover, Robert felt that his mother wanted him to help his father, and he developed the unconscious belief that, if he had not taken care of his father, he would have died (omnipotent responsibility). His brother, on the other hand, had a congenital pathology and thus was allowed to do anything he wanted.  In addition, he was regarded as the “genius” of the family. According to Robert, while his brother thought he was superior to him, he knew that he was smarter than his brother but had to hide this fact to protect his brother’s self-esteem (defending against survivor guilt). Finally, Robert’s mother appeared to be so burdened by is father’s and brother’s problems that he felt he should not burden her with his concerns (defending against burdening guilt).

     Robert’s worries about his health can be seen as a way of punishing himself for the fact that he had not been able to save his family, in particular his father (omnipotent responsibility guilt) and his brother (survivor guilt).  His punishment came in the form of an identification with his parents and brother. Given that he was unable to cure their pathologies and had survived his beloved brother, Robert now felt he should suffer as they did because of a pathology that nobody could cure. Moreover, his ruminations were also a punishment for his being fed up of his efforts not to burden other people with his needs: now he felt needy and communicated his needs to the people he loved, but punished himself for this neediness by anxiously thinking that he would have never been strong again. By trying to force himself to be strong, Robert was complying with his mother’s requests.

     In order to help our patients stop worrying and ruminating, we should help them carry out their plans (Curtis & Silberschatz, 2007; Weiss, 1998) paying particular attention to their pathogenic beliefs which support interpersonal guilt. And the core of Robert plan was to overcome the guilt toward his family and to feel to have the right to put his needs in the foreground. However, as with any other symptom and problem, CMT neither prescribes nor proscribes specific techniques, so that even techniques developed from a cognitive or metacognitive perspective may be of help if experienced as pro-plan by a patient. Paraphrasing Freud (1886-1895), our aim should be to go back from worry and rumination to normal reflection aimed at mastering past adverse experiences and preparing ourselves to solve future problems.