Dean Watkins | Cognitive Behaviour Therapy for treatment of Anxiety and..
Dean Watkins have developed a particular interest in working with anxiety problems and stress, and draw upon a number of treatment models and approaches within cognitive and behaviour therapies to help empower the individual to more effectively handle their anxiety and take back control in how they live their life.
Following on from my posts about attention and distraction, a useful metaphor that illustrates what can happen when we try to avoid difficult thoughts and feelings is called The Shrinking Room Metaphor. This metaphor is taken from the book ACT in Practice by Bach and Moran (2008). Typically when using this metaphor I will be in a therapy office so will illustrate it from this perspective.
If you imagine that the room you are in right now is your world, and there is plenty of space in this room to move about in and to get on with living your life. However within the world there are some things that you are not willing to have, that you don’t want. In order to avoid coming into contact with these things you have to make a number of adjustments in how you live your life to make sure you don’t encounter them. Suppose the filing cabinet over there represents one of your worries, for example “I’ll make a fool of myself!” And you’re not willing to have this worry so you want to completely avoid it. So in order to avoid it then you have to avoid going over to that part of the room, and you need to turn you back on that part of the room so that you can’t see it. That can feel okay, because it is only a small part of the room, you still have a large part of the room to live in and can get on with your life, and you can be free from “I’ll make a fool of myself!”
However, the problem is that there is other stuff in the room that you don’t like and are not willing to have. The desk represents “difficult memories” and you definitely don’t want to have these difficult memories, so you do the logical thing and turn your back on the desk as well; you focus on living your life in the area where you can’t see the desk or the filing cabinet. But what about the lamp which represents the fear that “I’ll make a mistake!” Before long you are have to avoid a lot of things in your world, and the problem with this approach is that there are constant reminders of what is happening and there are things in the room that will relate to the things you’re trying to avoid. The carpet you standing on also has the lamp, desk and filing cabinet on it, this reminds you of their presence. So maybe you should stand on the chair to get away from the carpet!
The fact that you are now living in a very small part of the room is a reminder as to why - in order to avoid the experiences that you are not willing to have. The more your are trying to distract yourself from and avoid experiences, the more aware you become of the experiences you are trying to avoid and your world gets smaller. The problem is that there could be good and meaningful things that you could be doing in the areas of the room that you are avoiding. What if in order to avoid one area of the room it meant you had to avoid relationships, or you had to give up on progressing or changing your career? The cost of this avoidance can be huge, and this can then impact on your mood, it can become depressing, boring and frustrating living in a small area of the room when you know there are other things you could be doing.
So the question becomes, are you willing to have the room as it is with the things that you like and don’t like, in order to be able to live your life more fully and meaningfully? This means that difficult feelings will be a part of your life, but at the same time they are not controlling what you can and can’t do or where you can go in your life.
In CBT and ACT the focus is on developing effective ways of responding to the difficult thoughts and feelings so that they do not restrict your activities, and so that you are able to focus on and engage in the things that matter to you in life.
(This post reflects my views on the use of distraction as a coping strategy. It is informed by my reading of the research, training, and clinical experience, but others would have a different view on whether distraction is a useful strategy or not).
This post follows on from my previous one on the role of attention in maintaining anxiety problems. If it is the case that "what you focus on you amplify" then this would suggest it would be useful to pay less attention to your anxiety and worries, and instead, to shift the focus of your attention onto other things that are happening in the moment that could be more beneficial to focus on. The ability to shift and refocus your attention is an important skill to develop and it would therefore seem reasonable to assume that distraction would be a sensible strategy. For example, you could distract yourself from your anxiety and worries by shifting your attention onto playing a game on your phone. This may be a useful strategy at times, and if used occasionally, but it may not be so helpful if used more frequently to cope with anxiety.
What is Distraction
To distract can be defined as the act of diverting attention from something. The Oxford dictionaries define to distract oneself as:
"Divert one's attention from something unpleasant by doing something different or more pleasurable."
This can seem like a good idea. Given that the more we focus on, engage or struggle with anxious thoughts and feelings, the worse they tend to get, then distracting your attention away from these thoughts and feelings should break this feedback loop. However, there are different views as to whether distraction is a useful skill to train. It is included in the writing of some leading therapists work, e.g., in the self-help book - "Overcoming Anxiety" by Helen Kennerley.
Kennerley promotes distraction as a potentially helpful strategy; stating that as you can only concentrate on one thing at a time, if you turn our attention to something neutral or pleasant then you will distract yourself from worrying thoughts and images. This then breaks the cycle of worrying and prevents anxiety increasing. She goes on to describe three types of distraction - physical exercise, refocusing and mental exercise. Physical exercise means to keep active when stressed which in theory reduces the likelihood you will dwell on things. Refocusing is where you pay great attention to other things around you, and mental exercise is where you engage in some mental activity, e.g., mental arithmetic, reciting poetry.
Sage et al., (2008) in their book "CBT for Chronic illness and palliative care", recommend mental distraction in order to shift attention away from a cycle of unhelpful thoughts and memories or persistent physical distress.
I was recently attending a CBT for chronic pain workshop in which distraction was one of the strategies recommended. The presenter described an example of using distraction in this way; suggesting that "if someone is struggling with their pain then they could see or call a friend to distract them self from it."
Problems with distraction
In training in the use of Acceptance and Commitment Therapy (ACT) and in using behavioural principles, I have learnt that rather than just looking at what the person is doing (form of behaviour), it is important to understand what the intention or purpose (function of behaviour) of the behaviour is. Looking at things in a functional way means that the same behaviour could be used in different ways with different purposes. For example, someone could have a drink of alcohol in order to feel less anxious and more confident, or they could have a drink as part of enjoying a social occasion. In the first case the drinking is primarily driven by reducing anxiety, whereas in the second case it is focused on enjoying the experience. Another way of thinking about it, is you could take the behaviour of running, and whilst running is running, the experience of running to get away from something that is threatening is a very different experience compared to running to meet a loved one.
This difference can be described in different ways, for example, as the difference between approach or avoidance behaviour, moving towards or away from something. A classic metaphor is the idea of the carrot and stick; working for the carrot is different to working to avoid getting hit by a stick!
When you look at the use of distraction in a functional way, therefore looking at the intention of the action, you can see potential problems with it as a coping strategy. Distraction is motivated by trying to get away from something, and it is this motivation that makes it problematic. If I am doing something to get away from anxiety and worry, then the action is driven by or all about the anxiety and worry I am trying to get away from. The problem with trying to get away from something is that your mind has to keep checking in to see if it is working or not, this checking will keep refocusing your attention back on to the things (anxiety and worry) you are trying to distract from! Distraction can operate like a form of suppression, and there is a lot of evidence showing that suppression - e.g., trying to block out unwanted thoughts and feelings - can actually have the opposite or a paradoxical effect. Suppression can result in you getting more of the very thing you are trying to have less of. For example, if there is a ticking clock in your room, I challenge you to distract yourself from the sound of the ticking clock. Make sure that you cannot hear the ticking at all by focusing your attention onto something else, e.g., these words you are reading pr checking your e-mails. Just make sure you are distracting yourself from the sound of the clock.
How did that go? It is quite possible that you were not even aware of or paying much attention to the clock before trying the exercise. If you weren't aware of the clock prior to the exercise it was not because you were distracting yourself from it, instead you were probably just focusing your attention on to, and prioritising other things. However, as soon as you try to distract your attention from the clock, you probably found that you became more aware of it and kept tuning in to it in order to try to distract yourself!
Whilst you may be able to use distraction effectively at times, the problem is distraction risks having the opposite effect and putting your attention back on the thing you're trying to escape. In addition you may not be able to focus on the thing that you are using as a distraction because you are too busy trying to distract yourself from the anxiety. Another problem is that the activities you use as distraction can become increasingly associated with the anxiety you are trying to distract from, so can unintentionally become a trigger for your anxiety and worries.
Going back to the example of distraction from the chronic pain workshop, the problem I have with this is that seeing or talking to a friend as a way of distracting from pain does not seem like the best reason to see a friend. If the friend knew this was the motives for seeing them they may not be too impressed and even feel used. Instead, why not see the friend because investing in the friendship is important and meaningful. Do it more as a towards behaviour rather than an away behaviour. In the process of seeing the friend, the person may get very engaged and absorbed in what they are doing that they become less aware of the pain; but this is a nice consequence for them, rather than the reason for seeing the friend.
Relating this back to anxiety, rather than do something to distract from your anxiety, can you identify reasons why you would choose to do the activity that are about the activity rather than anxiety reduction, for example go for a run in the service of your health and fitness rather than to try to distract yourself.
In my view, distraction is typically an unnecessary strategy that can potentially backfire. By letting go of trying to distract, you can actually free your attention to focus on things or activities that can produce more desirable consequences.
In Cognitive Behaviour Therapy (CBT) we are trying to identify factors or processes that are playing a role in maintaining the problems and keeping things stuck. Recognising and increasing awareness of problematic or ineffective patterns of thinking and behaviour is essential in order to be able to break and change these patterns. In looking for maintaining factors we can:
identify key thoughts, beliefs and fears that influence and guide the emotional reactions and behavioural responses; identifying the strategies (responses) that are being used to try to cope with the anxious thoughts and feelings that get triggered, and assess the consequences of these strategies - how they are working, looking at both the short-term and long-term effect.
Another factor that is very important to pay attention to and address is the role of attention - looking at what the person is paying attention to or focusing on when struggling with anxiety? For example if you struggle with performance anxiety then you will probably focus your attention onto how anxious you are feeling, how you perceive yourself as coming across, and you may find yourself scanning the audience for signs of being judged of negatively - e.g., do they appear bored, distracted, critical.
Given that attention is a limited resource, then in addition to noticing what you are paying attention to, it can be equally important to notice what you are not paying attention to that could be very useful or important to focus on. So when someone with performance anxiety is focusing on their anxious thoughts, feelings and sensations, and is focusing on trying to manage and reduce them, they have severely limited their ability to focus on the actual presentation, engaging with the audience, or on why presenting this information may be important to them.
You can think of focusing your attention onto something as being analogous to pointing a
spotlight onto a stage. What you focus the light onto becomes illuminated and easier to see but then other areas of the stage become darker. We are able to focus our attention in very narrow ways, focusing on specific things or details, or we can broaden our attention and take in more things or the bigger picture. With the spotlight you might focus in closely on one character of part of the stage, or you can make the focus more broad to light up more areas of the stage. There are times when a very narrow and focused attention is helpful and necessary, and times when it is not helpful. A skill is being able to determine when which is going to be more effective, and often we will be frequently switching from broad to narrow to broad again.
When anxiety becomes a problem there will be increased attention and thinking oriented
towards perceived threat. This shift of focus onto the perceived threat is a normal and natural reaction. If you imagine that you are in a dangerous situation, e.g., for some reason you
find yourself in the presence of a lion, from a survival perspective the only thing that it is important to pay attention to is the lion and your point or place of safety. In this scenario, nothing else is important to focus on, for example, the beautiful scenery, because if you don't get safe from the lion, you will not be around to enjoy the scenery in the future. In the presence of actual danger, giving the danger your full attention can save your life. The priority is get safe first, enjoy the scenery another time.
The challenge with being human and having the ability to think is that we can now encounter lions in our minds. We can picture lions, imagine them, remember past experiences with them and be fearful of these lions also. To make things more challenging, given the way that language operates, anything can now be experienced as a lion, therefore viewed as dangerous, for example the thought of embarrassing yourself, the memory of a shameful experience, a racing heart can now be seen as a heart attack. The brain has one way of responding to lions and that is to activate the threat system - fight/flight/freeze response, and ideally to activate to escape from the lion. The problem is that when the lion is a verbal or virtual one, then this fight/flight/freeze response doesn't work so well, and can actually make things worse. Trying to fight against or run from your own thoughts, feelings and sensations does not tend to work as well as when this response is applied to external dangers.
When we experience anxious thoughts, feelings and sensations, our attention is naturally drawn to these worries and fears about what might happen, we fear we won’t be able to cope so we start trying to protect ourselves. Our attention focuses in on these fears as it is this increased and narrowed focus of attention that can hopefully protect you from an actual lion. The anxious mind is doing what is should be doing to try to protect you and it becomes very skilled at looking for and finding potential threats and dangers in all kinds of situations, and then focuses on trying to get you safe from these potential or perceived threats.
Although the anxiety is focused on trying to protect you, when this way of thinking and paying attention increases, then so does the level of anxiety. The increased anxiety can occur invery specific situations such as in performance anxiety or a specific phobia, or it can be more generalised, occurring in a variety of different situations.
Michael Yapko a psychologist in the USA who specialises in the treatment of depression and in the use of hypnosis often writes or talks about the role of attention in this way:
What you focus on you amplify;
The more you focus on it then the bigger it gets.
Below are some examples of this process in action:
The more you pay attention to your thoughts about how you are coming across to others, or your worries about what they will be thinking of you, e.g., whether you appear boring or weird, how anxious you appear (internal or self-focused attention), then the more anxious you are likely to feel. Focus the spotlight on these anxious experiences and that is what you amplify. In addition, if you are focusing your attention internally on these thoughts, feelings, and sensations, then consequently you are paying less attention to the other person/people you are with and what is being said. This can result in you feeling more distant, disconnected, and can mean miss part of the conversation which can increase your anxiety.
If you fear you might have a heart attack, then to try and protect you your anxiety will pay more attention to your heart, to check in on how it seems, e.g., how fast is it beating, how strong or intense is it? By focusing on your heart the belief may be that you can make sure that nothing is wrong or catch signs of potential danger early and get help. The problem with tuning in to your body in this way is that you will then start to notice things that may be perfectly normal and happening regularly but normally you wouldn't notice. Now normal experiences are being picked up on and being viewed as concerning, which increases the need to pay attention to them. You can start to become increasingly tuned in to and sensitive to what is happening in your body or mind, noticing even the slightest change or fluctuation. The problem with this is that when you notice your heart beating faster and can see no reason for this happening, then this will trigger your anxiety and your fear of a heart attack. Things will then escalate from here as the fight/flight/freeze system is activated, and a consequence of this is an increased heart rate as the body mobilises or activates in order to be able to protect you by sending energy to the main muscle groups to help you fight or run.
This can be very similar to panic disorder, in that you may really pay attention to your body for any signs or symptoms of potential illness or health problems. You may check for lumps or bumps, marks or blemishes, signs and symptoms of a serious conditions. The problem is the more you look for things, the more you can find things. Prodding the body can make areas tender or sore, and this can then increase the fear that it is something serious. Focusing on a headache, fearing that it is a brain tumour, can increase awareness of the pain and result in more tension and tightness that can exacerbate the problem.
What are you paying attention to?
If you struggle with anxiety then it can be useful to check in and see if you find yourself spending increasing amount of times thinking or worrying about the anxiety and fears, focusing on how you feel, what is happening in your body, how you are coming across etc.,..... Also notice if you are spending less time focusing on other areas of your life that used to get more attention. The trap is that anxiety becomes more central, and everything else can recede into the background.
Whilst paying increased attention to your anxiety in ways that fuel the struggle will play an important role in maintaining the anxiety problem, it would seem like doing things that take your attention off of the anxiety could be the answer. Whilst in part this is true, there are also problems with certain strategies aimed at doing this, e.g., distraction, keeping busy. In my next post I will write about my views on why distraction is generally not a helpful strategy and can also help to maintain the anxiety.
When working with people who are struggling with anxiety, a question I will often ask, which may sound odd or even obvious, is a version of "when you felt anxious, how did you feel about the fact that you were feeling anxious in that moment?"
Typical answers to this question will be "I hate it!" "I don't want it!" or "It's horrible!" If we then explore why they feel this way about feeling anxious, the reasons will include things such as "because it feels terrible", "it stops me doing things" "I shouldn't be feeling this way, it's irrational!"
The reason for asking these questions is that they help identify the kind of relationship the person has with their anxiety. Where anxiety is a problem in a person's life, you will typically find they have a difficult or hostile relationship with their anxiety. In understanding this relationship - how someone experiences and views their anxiety - it will help make sense of their responses to it. For example, if it is viewed as wrong, bad, or threatening, it makes perfect sense to do all you can to avoid feeling anxious, to escape the feeling, to try to block it out, or ignore it.
In CBT it is important to identify the meaning attached to situations, events or experiences, as the way we view or make sense of things will affect how we feel and what we do next.
In identifying how we view anxiety, we can see whether the beliefs we hold are healthy and helpful in relation to living life in a meaningful way. If we view anxiety and the anxious thoughts and sensations it produces as wrong or threatening, then this will trigger the threat response, which results in increased levels of anxiety. Effectively we can become anxious about feeling anxious, and then get stuck in a vicious cycle.
CBT focuses on helping to normalise and make sense of our experiences, and to be able to view anxiety in a healthier rather than threatening way.
Today I'm starting a new series of posts which will look at some quotes or sayings that I sometimes use in CBT sessions, and look at how they relate to CBT and the therapy work.
In this post I'll look at the quote that is attributed to Lewis Carroll.
This points to the importance of identifying a clear focus or purpose for carrying out the therapy work. This is important with all problems, but when working with anxiety problems it is necessary to carry out some form of exposure work. Exposure work involves stepping out of your comfort zone, facing fears, and allowing the uncertainty. If you're going to engage in exposure work then it is extremely important to have good reasons for doing so, otherwise why would you choose to put yourself in challenging and scary situations.
In CBT, having a clear focus and direction for the treatment is very important. Setting clear goals to work towards helps to provide this.
There are different ways you can identify the direction you want to move in. One way is to look at how your struggle with anxiety is causing problems for you.
It can be helpful to ask:
What does your struggle with anxiety stop you from doing?
What does your anxiety make it difficult to do? What are the costs of this struggle with anxiety?
The struggle with anxiety will typically result in you avoiding anxiety provoking situations or triggers, or you will engage in safety-seeking behaviours whilst doing activities that trigger anxiety.
Examples of safety-seeking behaviours include:
You have someone with you when you go out,
You avoid eye contact,
You pay close attention to what you are saying and how you are coming across.
Safety-seeking behaviours are problematic as they maintain the belief in the feared outcome by preventing you from finding out what would happen if you were in the situation without using them. This reinforces that the situations or triggers you struggle with are threatening to you and require a threat response - anxiety. Safety-seeking behaviours also require attention, energy and effort to engage in them, so when you are focusing on managing your anxiety, you are not focusing on what you want to be doing, e.g., the social situation. This struggle with anxiety and use of safety-seeking behaviours can mean that even if you manage to cope with the situation, it can still feel more like you got through it as opposed to being able to to enjoy or embrace it.
When you have identified how the struggle with anxiety is a problem for you and recognised where it is getting in the way or holding you back from doing things, you can use this information to help identify the goals you want to work towards, and these then provide the direction for your work and therapy sessions. The following questions can be useful to think about:
If anxiety were no longer a problem for you, how would your life be different?
What would you be doing differently?
What would you do more of?
How would you behave differently in the situations that are challenging?
For example, if you find social situations challenging and you avoid them, tend to be quiet, don't express your opinion, or make limited eye contact, etc., then you may work towards being more engaged by making better eye contact, focusing on the other person/people, listening to what is being said, and saying more - asking questions, offering opinions.
This can be a way to start to identify the goals you want to work towards, and it provides reasons for doing the work of developing new skills and new ways of responding to anxiety.
When anxiety becomes a problem, then the natural response will be to want to stop it, get rid of it, or get away from the anxiety. Whilst this is an understandable goal it can be problematic as the efforts at controlling the anxiety can unintentionally keep things stuck.
It can be useful to look at the difference between behaviour that is about moving Towards something you want versus moving Away from something you don’t want, discriminating between Approach and Avoidance behaviours. Whilst we all engage in both types of behaviour, if we find ourselves engaging in increasing levels of Away behaviours then this can create problems. For example, if a large percentage of your behaviour is controlled by trying to move away from feeling anxious, or to avoid feeling anxious, then this can become very restrictive for you and will have a big impact on your quality of life.
To illustrate how Towards & Away behaviour can feel very different, you can take the behaviour of running, and notice the difference in experience between running Towards something or someone that you want, e.g., partner, versus running away from something you don't want, e.g., a bear!
As the saying suggests, if there is not a destination to move towards then it doesn’t really matter where you go. If you don’t have a good reason or purpose for being on a path that triggers your anxiety, then why would you stay there when anxiety shows up. It makes perfect sense to do whatever you can to move away from the discomfort. However, if the direction you're moving in is meaningful to you to you in some way, e.g., in terms of you career, your relationships, your health, then you are far more likely to be willing to stay and face the anxiety in order to continue along your chosen path.
CBT can help identify the direction to move in and create a clear purpose for the therapy work. It can then help you to develop the necessary skills to effectively handle the anxiety that shows up as you move forward.
In this blog post I will look at how anxiety and the intolerance of uncertainty can impact on our ability to Make decisions.
Making decisions can often be straightforward - you know what you want and make choices that can move you towards this. Decision-making can be tricky though when there is not necessarily a correct choice, just different options. If you then add anxiety into the equation then decision making can become very stressful.
How do you decide?
It can be useful to look at how you go about making decisions, especially when you are not sure what to do, or there is no obvious or right choice.
A useful question to ask is this:
"How do you decide what to do when you don’t know what to do?"
Whilst it is a useful question to ask, often we don’t ask or think about it, we just go about our lives making decisions. This is fine when things are going well and the choices we are making seem to be working out well, however, if we are struggling with decision making, or we are repeatedly making bad choices then this becomes a very important question to look at.
Everyone has their own way of making decisions and the things that influence the choices you make may include any or all of the following:
Thinking about your goals – where do I want to get to?Using your values – what is important to me as a person?Looking at practical factors – time available, finances, resourcesLooking at the potential benefits or costs of a decisionThinking about others involved and what they want or how it will impact themHow do you feel? Mood, energy, motivation….
Anxiety Demands Certainty The above list and other influences may inform or guide the choices that you make, however, when anxiety gets involved in this process and starts demanding certainty around the decisions you’re making, then it can make even the simplest or smallest of decisions challenging. Anxiety wants you to be sure you’re making the right choose, that you’re not going to live to regret the choice you make, and that you’re not going to be responsible for some bad outcome. Anxiety will remind you of previous choices you have made that didn’t work out and where it seems like you didn’t make the best choice. It will tell you about other people you know or have heard about who made bad choices, and the terrible way this worked out for them. It will use this information as evidence to reinforce the need for certainty.
Whilst anxiety is trying to protect you from something bad happening, the problem is life is full of uncertainty, all areas of your life are full of uncertainty, including the areas of your life that matter most, for example, relationships, parenting, career. Anxiety is demanding the impossible, in that there is no way you can know up front that the relationship you are committing to will work out and last. You can feel confident and fairly sure at the time, you can look at how it is currently, e.g., that it is strong, close, supportive etc., but you cannot know for sure that it will work out. Anxiety can tell you that it might not work, that maybe there is someone else out there that you should be with, so you’re making a mistake here. It can also tell you that something bad could happen to your partner, e.g., an accident, illness, that could take them away from you, so it is too risky to make this commitment.
Costs of Needing Certainty in Decision-Making
If certainty and feeling sure or comfortable is the criteria you use to make decisions in your life, or in certain areas of your life in which anxiety shows up, then this is likely to be problematic. If you do use this criteria to make decisions then it can be useful to look at what impact it is having. How does it affect the different areas of your life?
Here are some examples of how the need to remove any uncertainty or doubt can affect different areas of your life.
Should you stay in your relationship?
Have a child?
Move in with your partner?
Work & education:
Should you follow the career path your parents expect you to or not?
Should you change jobs or stay where you are?
Are you going to mess up this piece of work?
Are you doing it right or not?
Trying to give Anxiety the Certainty it needs can be very draining
Trying to give anxiety the certainty it demands can result in you engaging in various efforts and strategies to achieve this. These efforts can include worrying, repeated cost-benefit analyses, reassurance-seeking, researching, “Googling”, procrastinating, avoiding and checking.
The problem with these efforts is that whilst they can feel
productive or helpful at the time or in the short-term, they can actually create more questions than answers, and more doubts and uncertainty. You then need to engage in more efforts to try to answer these questions, and you are then stuck in a vicious cycle. Even if you come to a decision, you are likely to then start doubting it and going back through the same repetitive process. It can be the mental equivalent of the hamster in the hamster wheel.
The more you get stuck in these cycles the more you can feel paralysed around decision-making, feeling unable to decide, or making the decision that feels least risky or scary. A problem with making decisions in this way is that the decisions being made are not necessarily going to be the most rewarding or life-enhancing. The effort involved in making decisions can become draining, demoralising, and make you more anxious about decision-making. The more anxious you become the more you might try to avoid having to make decisions, for example by staying within your comfort zone, or by getting others such as a partner to make the decisions, as then you won’t be responsible if they don’t work out.
CBT and Decision-Making
Whilst feelings are important to pay attention to and acknowledge, they are not the only source of information in decision-making, and often not the best source of information. In addition to anxiety, feelings such as guilt, anger, and sadness can all exert an unhelpful influence over the choices you make if they are the main or only influence.
In CBT we look at ways of being able to step back and disengage this struggle with anxiety and the need for certainty, and whilst acknowledging the anxiety, we also want to use other sources of information, for example your values, your current life situation (finances, commitments) to help make a more informed choose, and to be have the skills to be able to handle the doubt and uncertainty as you do this.
This is the fourth post in the series looking at the intolerance of uncertainty in anxiety problems. In this post I will look at some of the ways the intolerance of uncertainty is a problem in OCD.
Obsessive Compulsive Disorder
OCD is a problem in which the sufferer experiences recurrent obsessions or intrusive thoughts, and engages in physical and/or mental compulsions.
An Obsession is a recurrent thought, images, impulse or doubt, that is experienced as unwanted and intrusive, and leads the individual to become aware of a potential danger which the individual believes they can cause or prevent. The obsession will cause marked anxiety or distress.
A Compulsion is an action carried out in response to the obsession which is intended to prevent the perceived danger, and to diminish the sense of responsibility for it. The compulsion can take the form of a physical action, or a mental action - carried out in the mind.
OCD & Uncertainty
OCD used to be called the "doubting disease" and this points to the centrality of the role of doubt and uncertainty in this problem. The obsession or intrusive thought results in doubt or uncertainty about the possibility of a bad thing happening, and due to the intolerance of this doubt or uncertainty, the individual will engage in compulsions or rituals to try to remove the doubt. The table below gives some examples:
Whilst at one level the person with OCD may know that the feared outcome hasn't happened or is highly unlikely to happen, the fact that they can't be 100% certain and there remains a possibility the bad thing could happen, then even this level of doubt feels to great or risky. The compulsion is then carried out to try to eliminate the remaining doubt and anxiety, and it feels like the responsible thing to do. For example, it checking the oven is turned off then removes the doubt about a possible fire, the anxious feelings this doubt generates, and also removes the fear of being responsible for a fire, then it makes perfect sense to carry out the compulsion. The problem though, is that the compulsion reinforces that it was necessary to take the doubt/intrusive thought seriously or as a sign of danger, which reinforces that there was a real danger, and that the checking was necessary to keep safe. The OCD learns that it was the checking that prevented the feared outcome, and therefore will demand further reassure the next time there is doubt. The illustration below shows how the maintenance patterns can occur in OCD.
The above illustration is a simplified one, and the reality is that the individual with OCD may find they engage in a serious of efforts at removing the uncertainty, for example, trying to replaying in their mind if they turned it the oven off, trying to rationalise the thought, trying to suppress the thought, seeking reassurance against the thought. The most effective strategy though will be to physically check in this case, but even then the checking may take a while to complete.
The efforts at getting rid of the uncertainty, and feeling sure that they are not going to be responsible for something bad happening can work in the short-term, e.g., washing hands until feeling sure they are not contaminated feels safer in the moment, but in the long-term it reinforces the fear, and it reinforces the need to to sure the next time they have the doubt.
Learning to live with the Uncertainty & Doubt
Through the use of exposure and behavioural experiments, CBT helps to develop the skills to accept and live with the uncertainty in the feared areas, for example, the fear of the home burning down if don't return and check the cooker/iron... OCD becomes quite predictable in terms of what it says might happen - something bad will happen (fire, illness, death, cause harm) and it will be your fault! It can be helpful to develop new ways of responding to your OCD to break these vicious cycles of fear - compulsion - fear - compulsion, and an important part of this is learning to handle the uncertainty.
It is teaching the brain that whilst a fire may be dangerous, the worry or doubt about a fire is not the same thing!
In this third post looking at the role of the intolerance of uncertainty in problems with anxiety I will be looking at how it relates to Emetophobia.
Emetophobia is the common name for a Specific Phobia of Vomiting. If you have this phobia then you experience an intense fear of vomiting and will be engaging in various efforts to prevent yourself from being sick. (Click here for more information on Emetophobia).
In emetophobia, anxiety is demanding certainty that you will not vomit or be put at risk of vomiting. Any doubt or uncertainty can feel too risky. The problem with this demand is that anxiety is asking the impossible, in that no matter what you do, you cannot know in advance what will happen. There is no way of being certain, so anxiety will make you work very hard to try to reassure it and make it feel that the risk is removed.
If you can't be certain then be very careful and cautious!
One way anxiety will get you to try to reduce the risk and remove some of the doubts is by being very careful and vigilant. If you keep a look out for any potential threat, then you can keep away from it or escape it. The increased vigilance will be applied to both the external and the internal world. Anxiety will want you to pay attention to the environment you are in, don't risk touching things or surfaces that might not be clean, don't go too near to someone who looks ill or might be unwell, don't shake hands with or touch others just in case.....
Anxiety will also want you to be cautious around food. Don't eat food that could potentially give you food poisoning, for example, fish, poultry, don't eat food that you haven't seen being prepared, or better still, only eat food that you have prepared or someone you trust.
In order to avoid the risk of encountering someone who might vomit, it is best not to go to places where alcohol is being served, especially later at night. Additionally you might vomit if you have a drink of alcohol or drink too much, so it would be safer not to drink.
Travel is also another risky area with a lot of uncertainties. You might get travel sick, or someone else might. You could be stuck on a tube, train, coach, or airplane with someone who is ill or vomiting. Again it would be safer to avoid, or at least do it when it is quieter. It may be too risky to travel abroad, due to possible problems with the food or water.
Avoidance removes Doubt and Uncertainty
In fact, if you look at it, there is uncertainty in everything that you do, and the most effective way of getting rid of the uncertainty - at least in the short-term - is to avoid. Avoidance is a big problem with Emetophobia, and this makes it a very disabling problem as it can really restrict your activities. It can interfere in all areas of your life, for example you career, relationships, family, getting pregnant or having a child would be very risky.
Anxiety will also want you to be checking in on how you are feeling, scanning your body for any signs of feeling sick. The problem with this increased vigilance is that you will notice more things which can then make you feel more anxious, and one of the symptoms of anxiety can be feeling nauseous! The scanning of your body can also impact on your eating, being careful not to get too full or bloated as this may increase your anxiety as there can be more uncertainty around whether you might vomit or not.
If you can't avoid then use a Safety Seeking Behaviour
Avoidance is always anxiety's favourite strategy to get you to engage in, as this removes the uncertainty, for example, if you don't eat at the restaurant, then you 100% won't get food poisoning from the food there. The problem is some things are impossible to avoid, so the next best thing is to get you to use strategies that make feel safer - Safety Seeking Behaviours. There are many different types of Safety-Seeking Behaviours that anxiety might want you to use, including cleaning - surfaces, hands, food, restrict your food intake, seek reassurance that others are well, plan an escape route, or take an anti-nausea medication. The problem with Safety-Seeking Behaviours is that whilst they might reduce the sense of threat and uncertainty in the short-term, they reinforce the fear and the ongoing need for these strategies in the long-term.
Learning to live with Uncertainty
As described in the previous post, Cognitive Behaviour Therapy (CBT) can be an effective approach for learning to break the anxiety cycles that maintain the problem. Learning ways to stop trying to give anxiety the certainty it demands is one of the important skills to develop to help overcome problems. If you are going to eat in a restaurant, then you can never be certain that you won't get food poisoning, as it is possible, no matter how unlikely.
The reality is that you already live well with uncertainty in many areas of your life.