On the last track we discussed accepting reality. You were provided with three productive techniques on how to accept reality. These three techniques were gaining distance, describing the present, and disappearing to see reality.
On this track we will discuss CBT uncertainty training in two steps. Step one is examining the costs and benefits of accepting uncertainty and step two is flooding with uncertainty. We will also examine problems associated with "thought stopping" regarding anxiety.
Intolerance of uncertainty can be a core issue for clients with anxiety. Psychologists Michel Dugas and Robert Ladouceur found that clients with anxiety cannot tolerate not knowing something for sure. In fact, one client told the researchers that he would rather know a negative for sure than be uncertain about a positive. Do your clients keep looking for a perfect solution, an answer to every possible question they can ask, and a clear prediction for every possible what-if?
In my practice, I find that the absence of this certainty may lead clients to keep worrying until they find it. Clients treated for anxiety may also avoid confronting the emotional impact of their experiences. Would you agree that this is because worriers seldom get to the point of actually facing their worst fears?
Moreover, since worriers are trying to think about how to solve all the problems, they do not use visual images, which can aid in understanding emotions. I tell my anxiety clients that feeling an emotion is one way of finding out that you can tolerate reality.
When clients are engaged in worry do you find that they are actually less anxious? Research indicates that this is because worry is abstract and linguistic, and when people rely on this abstract thinking, they do not experience visual images of bad outcomes. Since they avoid these highly emotional visual images, continuing to worry keeps them from experiencing anxiety. Thus, worry - and searching for certainty - can be a form of emotional avoidance.
Cognitive Behavior Therapy Technique: Uncertainty Training
Step 1: Examine the Costs and Benefits of Accepting Uncertainty
In order to foster a tolerance for uncertainty, let’s first discuss examining the costs and benefits of accepting uncertainty.
With Janelle, age 42, I identified unproductive worry because it involved unanswerable questions, chain reactions, unsolvable problems, things that are unknowable, demands for perfect solutions, relying on anxiety as a guide, and the demand for total control. For example, consider Janelle’s worry "It’s possible that I have a brain tumor even though the doctor says I’m healthy."
6 CBT Elements for Identifying Unproductive Worry
This worry includes a number of the elements of unproductive worry:
1. It’s an unanswerable question ("It’s possible")
2. It’s based on a chain reaction ("My health problems will go misdiagnosed and I will end up with a serious problem")
3. It’s unsolvable (you cannot eliminate possibility)
4. It’s unknowable (if it’s continually misdiagnosed, then you cannot eliminate future misdiagnosis)
5. It demands a perfect solution (absolute certainty)
6. It demands that you control the outcome ("I have to get complete reassurance" - something that is impossible)
Therefore, would you agree that Janelle’s anxiety over the possibility of a brain tumor might qualify as an unproductive worry?
Costs and Benefits
I felt that I could now examine what the costs and benefits were of Janelle accepting uncertainty for unproductive worry. For example, I asked Janelle to ask herself, "What are the costs and benefits to me of accepting that it’s possible that I have a brain tumor?" The benefits were that if she accepted it as possible - and accepted that she cannot eliminate possibility - then she didn’t have to take action on it.
I stated, "Perhaps you will worry less and give up trying to control something you cannot control. The costs are that you may be immediately a bit more anxious and think you are letting your guard down. If you experience this reaction, then ask yourself, 'Exactly what action can I take today that will really help me?' Since the worry is about an undiagnosed tumor (after having seen several doctors), the only action available is to continue seeing more doctors. This is an endless enterprise."
Think of your Janelle. How can you help your client examine the costs and benefits of accepting uncertainty?
Step 2: Flood Yourself with Uncertainty
Next, let’s look at the second step in uncertainty training. This step requires the client to flood themselves with uncertainty. Reality is clearly uncertain. I find it helpful for clients to realize they don’t know for sure what will happen tomorrow or the next day. I stated to Janelle, "You can make an educated guess, but you cannot say for sure.
"When you do not tolerate uncertainty, your thoughts are something like the following: ‘It’s not certain that things will be OK; if I don’t know for sure, I should worry until I do know for sure; I’ve been worrying and I still don’t know for sure, so I should keep worrying until I am absolutely certain it will be OK.’" In contrast to worry, which is the search for certainty, in uncertainty training clients practice having the thought thousands of times that "I don’t know for sure" or "It’s always possible that something terrible could happen."
Intrusive Thoughts - I Had Her Repeat it Two Hundred Times
Janelle thought that she might have a brain tumor even though there was no real evidence that she did. Janelle experienced no symptoms common with brain tumors. But she continued having this intrusive thought, so she worried and scheduled repeated appointments with neurologists.
To further involve Janelle in uncertainty training, I had her practice repeating for twenty minutes each day, "It’s always possible that I could have a brain tumor." I told her to do nothing to neutralize this thought - not to try to reassure herself, just practice having the thought. As expected, Janelle’s anxiety went up - and then it went down as she repeated this thought hundreds of times. Whenever Janelle had the thought, "I wonder if I have a brain tumor," I had her repeat it two hundred times. Janelle began to realize that having a thought about what is possible could be tolerated. In fact, she later reported that it started to become boring.
In addition to the two steps involved in uncertainty training, let’s discuss thought stopping. You already know that thought stopping involves noticing a client noticing that he or she has an unwanted thought and then yelling "Stop!". The idea is that the client cannot stand having this thought. I find that for anxiety clients thought stopping may not work and it actually can make things worse, because the client is led to believe that the thought - "It’s possible that I have a brain tumor" - is a thought that he or she needs to fear and get rid of. In contrast to this, thought flooding about uncertainty teaches clients like Janelle that she can have thoughts about what is possible, yet do nothing to neutralize the thought.
Accepting uncertainty is a core strategy for clients dealing with anxiety. Once your client accepts that he or she can never know for sure, then that client can recognize that continuing to worry to gain certainty is a total waste of time.
Practicing flooding themselves with uncertainty thoughts - repeating them endlessly without doing anything to gain certainty - helps clients recognize that they can live with uncertainty. Perhaps you might relate it to getting on the elevator thousands of times. It is no longer feared because it has become boring. Think of your anxiety client. Could he or she benefit from these techniques?
On this track we have discussed CBT uncertainty training in two steps. Step one was examining the costs and benefits of accepting uncertainty and step two was flooding with uncertainty. We also examined problems associated with "thought stopping" regarding anxiety.
On the next track we will discuss overriding obsessive anxiety. In addition to discussing ways clients can prepare for this technique, we will focus on the two steps to overriding obsessive anxiety. The two steps are exposure and response prevention.
This material was written by Tracy Appleton, LCSW, MEd and the references listed below were used as resources:
- Nakamura, B. J. Pestle, S. L., & Chorpita, B. F. (2009). Differential Sequencing of Cognitive-Behavioral Techniques for Reducing Child and Adolescent Anxiety. Journal of Cognitive Psychotherapy, 23(2), 114-135.
- Roebers, C. M. & Fernandez, O. (2002). The Effects of Accuracy Motivation on Children's and Adults' Event Recall, Suggestibility, and Their Answers to Unanswerable Questions. Journal of Cognition & Development, 3(4), 415-443.
Peer-Reviewed Journal Article References:
Carleton, R. N., Gosselin, P., & Asmundson, G. J. G. (2010). The Intolerance of Uncertainty Index: Replication and extension with an English sample. Psychological Assessment, 22(2), 396–406.
Fergus, T. A. (2013). A comparison of three self-report measures of intolerance of uncertainty: An examination of structure and incremental explanatory power in a community sample. Psychological Assessment, 25(4), 1322–1331.
Hong, R. Y., & Lee, S. S. M. (2015). Further clarifying prospective and inhibitory intolerance of uncertainty: Factorial and construct validity of test scores from the Intolerance of Uncertainty Scale. Psychological Assessment, 27(2), 605–620.
Online Continuing Education QUESTION 5
What are two steps in CBT uncertainty training?
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