It’s a tricky thing to think about worry, because worry is thought. Things get complicated when we think about our thoughts, let alone try to change those thoughts. This chapter will take a look at the difficulties that can arise when people set out to change their thoughts, and ways around some of these difficulties.
The introduction of cognitive behavioral therapy in the mid-1980s was a major breakthrough for people who suffered with chronic anxiety. Prior to this, there were very few good options for people who suffered with chronic anxiety. Now, for the first time, a method was introduced that offered practical, concrete ways to reduce chronic anxiety.
CBT was a radical departure from previous schools of therapy, and combined a cognitive (thinking) approach with a behavioral approach. On the cognitive side, it said that mistaken and exaggerated thoughts were heavily involved in producing and maintaining anxiety, and it offered a way to help clients identify and change those thoughts. The primary tool it offered was cognitive restructuring, which involved the identification of various “errors of thinking” and the subsequent review and correction of these thoughts.
So, for instance, a person who struggled with lots of worry about money and job security would be directed to identify his key worrisome thoughts on the subject. These thoughts might include statements like the following:
Since emotions are believed to be shaped by our thoughts and beliefs about the topic, his emotions would be shaped by these thoughts regardless of how true or false they were. If this man’s thoughts about finances and employment were exaggerated or unrealistic in some way, he would have an emotional response in his internal world which was out of proportion to his actual circumstances in the external world.
A CBT therapist would ask him to evaluate his thoughts on the topic he worried about to see how realistic or unrealistic they were, and to look for some characteristic errors in his thoughts, as described in chapter 3. If this man found errors in his typical thinking about employment and finances, he would work to correct his thoughts, replacing the unrealistic thoughts with more realistic versions. If these new, and more accurate, thoughts about his situation were less negative and foreboding than his previous thoughts, this would change his emotional response for the better.
On the behavioral side, CBT would suggest changes in one’s behavior that would ultimately reduce anxiety. This would include practicing with the objects, locations, and activities that people fear. So snake phobics would make progress by spending time with a snake, rather than avoiding it, and the same would apply to people who feared heights, shopping malls, driving, flying, and so on. Relaxation and meditative methods might also be used to lower overall anxiety levels, but exposure to what one fears is considered to be the most effective behavioral method by far.
Traditional CBT methods have been of enormous help to millions who had been suffering from chronic anxiety and worry. However, there are a few difficulties when we attempt to apply these methods to chronic worry.
For one, typical worry thoughts usually express uncertainty about a possibility, and most often begin with “what if” as in What if I lose my job? This type of worry isn’t a prediction that can be evaluated and shown to be true or false. It’s an invitation, as I point out in chapter 6, to “pretend” that something bad will happen and to worry about it. Since most hypothetical events, however likely or unlikely, are possible rather than impossible, this makes it more difficult to apply the usual tools of cognitive restructuring.
No matter how much evidence you may muster to show that you’re unlikely to lose your job, chronic worry can always trump that argument by responding, “But what if you do?” This usually leads people to try to become “sure” that the feared event won’t happen. When they can’t do that, it serves to prolong and maintain the worry.
Secondly, the invitation to use cognitive restructuring to correct “errors of thinking” can mislead people into believing or hoping that we can tame, maybe even perfect our thoughts. This contains the implicit suggestion that we can do such a good job of correcting our thoughts as to eliminate dysfunctional worry.
This is a bridge too far, in my view, a hope that is more misleading than helpful. In my professional work as a psychologist, I have seen far too many people who struggled to correct their thoughts, who tried so hard to stop having unrealistic worries and thoughts which daily filled them with discomfort and upset, only to feel like failures because they failed to control their thoughts.
People often mistakenly think of their brain as a computer. Let’s suppose you’re running a program which doesn’t work exactly the way you want. Maybe it has a line of code which converts all your measurements into the metric system, displaying your output in kilograms and meters when you want it to use pounds and yards. You could remove that line of code so that the program only gives output in yards and pounds, and the revised program would run as if it had always been written that way. It won’t “remember” that it used to calculate kilograms and meters, and experience any doubt about which system to use. The computer has no awareness or consciousness, and so it can’t have any thoughts about how the program is running, nor about how it used to run before the correction. It just runs the program as currently written.
Not so with your brain! Your brain records thoughts as memories. While you can literally erase the computer code about the metric system and replace it with American measurements, your brain doesn’t lose memories unless there has been actual physical damage to the brain. It creates new memories, and these memories can become the dominant memory on a subject, but you never lose the old memories. They may occur to you less often, even fall into disuse, but they can always become active again under the right circumstances.
Additionally, you have conscious awareness of thoughts as they occur in your cerebral cortex. This allows you to have thoughts about thoughts. Computers, at least to date (I hope my word processor doesn’t have opinions about my writing), don’t have this conscious awareness—they simply execute instructions without thinking about them.
Having thoughts about thoughts is what opens the door to worrying and arguing with yourself. Having thoughts about thoughts is what makes it so difficult to remove an “error of thinking” from your thoughts. Your effort to remove a thought will inevitably remind you of the thought you don’t want to have. This is often typified in the classic, paradoxical instruction: “Don’t think of a white bear.”1
A different school of psychotherapy which appeared about the same time as CBT was paradoxical therapy. This method didn’t attain the same mainstream prominence that CBT has achieved but, in my opinion, can be a more powerful and direct way of working with chronic anxiety and worry. Paradoxical therapy takes a different approach to the problem of correcting your thoughts. It leaves thought alone and requests action instead. And it requests action in a paradoxical way, a request that is difficult to fully accept or reject.
A paradox is a seemingly logical request or instruction that leads to a self-contradictory result. A typical paradoxical request might be: “Be spontaneous now!” or “Listen carefully to what I say and don’t do what I tell you.” These kinds of instructions create confusion within the listener and make it difficult for her to keep doing the same old thing that she was doing before. “Act natural” is another example.
The principal tool of paradoxical therapy is called “prescribing the symptom.” This has an astonishing amount of power in helping people overcome chronic anxiety. Here’s an example of prescribing the symptom. When I work with a client who is struggling to overcome chronic worry, I might ask this person to deliberately keep her worries in mind as we have our conversation.
When I first do this, people have two principal reactions. First, they think I’m crazy, but I’ll clear that up with them later. Second, they find it hard to keep that worry thought in mind and may find that they keep forgetting about their worry, even though I’ve asked them to pay more attention to it.
How does this work? My odd request for them to focus more on their worrisome thoughts interrupts and disrupts their internal effort to “stop worrying.” And, it turns out, this effort to “stop worrying” is a major factor in maintaining chronic worry! When I disrupt it with my unexpected request, the worry actually becomes less persistent.
Paradoxical methods are powerful in working with chronic anxiety and worry because chronic anxiety is itself such a paradoxical experience. By that, I mean these two things:
In a larger sense, all the therapies mentioned above, including CBT, have a paradoxical aspect to them, because they all encourage the client to experience the anxiety in some way, to practice with it, in order to reduce it over time. This is why we invite the snake phobic to sit with a snake, the flying phobic to go for an airplane ride, the agoraphobic to go to the shopping mall, and so on. In my view, the elements of these therapies that encourage a person to work with the anxiety, rather than against, are the most powerful elements of those therapies. It’s this paradoxical element of anxiety and worry that explains the observation “The harder I try, the worse it gets.” It’s the paradoxical element of anxiety that gives the Rule of Opposites its power.
CBT has been the treatment of choice for anxiety for the past thirty years. As its strengths and weaknesses have become more apparent, new ideas and models of how to work with anxious thoughts have appeared, including acceptance and commitment therapy, metacognitive therapy, dialectical behavior therapy, and narrative therapy, among others.
These models embody a different attitude toward thoughts than does traditional CBT. All these methods see thoughts as central in the production of emotions, but these newer methods take a much more skeptical attitude toward thoughts, and particularly toward our ability to control thoughts.
From this perspective, the brain produces thoughts in the same manner the kidneys produce urine and the liver produces bile. It’s just what the organ does. And because you can only evaluate your thoughts with the same organ that produced those thoughts in the first place—your brain—you don’t have a way to form an independent evaluation of your thoughts. None of us do. This is the reason people so often act as if their thoughts are a good, accurate model for the external world even when they’re not.
This is also why we’re so often attached to our thoughts, take pride in them as we would an important creation, and tend to find more value in our own thoughts than in anyone else’s. So we have this problem, as expressed by Chicago comedian Emo Phillips: “I used to think that the brain was the most wonderful organ in my body. Then I realized who was telling me this.”2
And we have the second problem that it isn’t always so easy to directly change a thought. All too often the efforts people make to change their thoughts begin to work like thought stopping and, as I’ve previously noted, thought stopping is almost always unhelpful. The main result of “thought stopping” is “thought resumption.”
If you use cognitive restructuring and find it helpful in modifying your worries without getting involved in a lot of arguing with yourself, without a lot of back talk from the worries, that’s good. Keep doing that! However, if you find that you get bogged down in arguing with your thoughts when you seek to “correct” the errors, and that the worrisome thoughts continue to recur to you, then cognitive restructuring might be starting to work just like thought stopping for you. If that’s the case, you may be better off using some of the acceptance-based techniques I present in chapters 8 to 10 rather than trying harder to make the cognitive restructuring work.
Acceptance and commitment therapy has a lot to say about working with thoughts. ACT identifies thought and language as key sources of human misery. From this perspective, thought and language are the suitcase by which you can pack up your troubles and move from, say, New York to Los Angeles, yet experience the same thoughts and emotions in L.A. that you did in N.Y.
ACT identifies “cognitive fusion” as a principal problem.3 What is cognitive fusion? It’s when we give properties and characteristics to words and thoughts which only really belong to the objects those words describe.
What does that mean? Consider the example of a young child who gets scratched by the family cat. Young Susie may feel afraid of that cat for a while, might feel afraid of other cats and dogs in the neighborhood, might run from the room when a cat food commercial comes on television, and might even burst into tears or show signs of distress when someone mentions the word “cat.” She can feel fear when she hears the word, even when the cat is outside. Susie has given the word “cat” the properties of scratchiness and “biteyness” that only actually belong to the animal. In ACT terms, she has “fused” the word “cat” with those properties. As a result, she can become afraid in the absence of the cat, just from hearing the word, or maybe even thinking the word. She no longer makes a distinction between hearing the word “cat” and seeing a cat leap at her, claws outspread.
As her parents notice this, they may try to help keep Susie calm by using some code to refer to “cat” when they find it necessary to mention that word in her presence. Maybe they use pig latin (ixnay with the atcay!) or refer to it as a banana rather than a cat. They’re trying to care for Susie and protect her from upset. But they are also, unwittingly, strengthening the association Susie has formed between the sound of the word “cat” and those hurtful properties of “biteyness” and scratchiness, because they’re depriving her of opportunities to get used to hearing the word.
You can see the same thing in anxiety and panic support groups all around the country, many of which discourage or prohibit the use of certain words that might bother their members. For instance, some support groups for people with panic attacks ask members to refrain from using the word “breathing” because some members are sensitive to this word and will have trouble catching their “b” if someone uses the “b” word! The group has fused the word “breathing” with the sensations of hyperventilation and all the symptoms that accompany it. Just as we saw with Susie and her parents, here we see people, intending to be kind and protective, acting in ways that lead people to feel more vulnerable, rather than less, to the “b” word.
Do you have some “hot button” words that you prefer to avoid, to skim over if you see them in print, words you don’t want to say aloud because they might lead you to feel anxious?
You probably do, if you let your mind ponder it for a few moments. People with panic attacks often want to avoid words like “faint,” “cerebral hemorrhage,” “screaming insanity,” and so on. People with social anxiety aren’t so fond of words like “sweat,” “tremble,” and “blush.” People with intrusive obsessive thoughts tend to avoid the key words from those thoughts, like “murder,” “poison,” “stab,” “insecticide,” and so on. Even people with just basic, garden variety anxiety have words that carry some special, “fused” feeling for them.
Want to try an experiment?
I hope by now you can guess where I’m going with this, and what the experiment is.
The experiment is: take one of those words and repeat it, out loud if you have the privacy to do that—twenty-five times.
If young Susie does that with the word “cat,” the word will probably start to lose its claws.
By the way, if you did guess what the experiment would be, or something close, that’s great—you’re getting used to using the Rule of Opposites!
ACT seeks to help people undo this kind of cognitive fusion by fostering defusion—or as I call it, “de-fusion,” since the technique aims to break the link you may have established between a word or thought and the actual properties you have come to associate with that thought. For instance, Susie’s parents might help her to de-fuse the word “cat” from those properties of scratchiness and “biteyness” by making nonsense rhymes with the word cat, singing songs about cats, rhyming the word “cat,” making artwork based on the word “cat,” and so on. Panic support groups could help their members de-fuse the word “breathing” by similarly engaging in playful exercises that use, and overuse, the word.
De-fusion can be a powerful method by which you can reduce the misery you have come to feel in response to chronic worry. Misery often accompanies, for instance, disease, especially when it’s a serious disease. However, people who struggle with chronic worry about disease can experience the same misery they associate with disease even when they are healthy, just from having thoughts about disease. That’s why they tend to avoid watching medical shows on TV. They’re trying to avoid anything that might remind them of disease. All that is necessary is to “fuse” the thought of disease with the misery of actually being ill. De-fusion is a method by which you can greatly reduce the amount of misery you experience in response to your unwanted thoughts.
ACT also seeks to help people spend more time in taking action with the external world around them and less time trying to rearrange or change the thoughts and feelings they experience in their internal world. In this sense, ACT has at least a superficial resemblance to the Serenity Prayer:
God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
When I received some ACT training, one of the general principles I took away was that it’s probably more useful to help people examine how their thoughts influence their behavior than it is to spend time challenging the accuracy of the thoughts. (These characterizations of ACT and CBT are my own view and, while I think they’re reasonably accurate, they represent how I use these methods, rather than how ACT and CBT experts may teach and use them.)
This represents perhaps the sharpest contrast between a traditional CBT or cognitive restructuring approach to thoughts and an ACT approach. Let’s consider the example of a client who struggles with thoughts of being a coward. A CBT therapist would probably ask that client to define what he means by coward and then compare the client’s behavior to that definition, taking note of when the client acted like a coward and when he did not. In this way, the therapist would help the client to get a more balanced and accurate view of his behavior with the ultimate goal of helping the client to achieve more accuracy in his thoughts.
An ACT therapist, on the other hand, isn’t going to get involved in looking at the accuracy, or lack thereof, of that thought about being a coward at all. An ACT therapist is more likely to ask a question like this: “This thought you have about being a coward—is it getting in the way of you doing anything that’s important to you?”
In other words, an ACT therapist will help you look at your thoughts in terms of how they influence your behavior, rather than how accurate or inaccurate they may be. The implicit goal is to help you to behave, in the external world, more in keeping with your own hopes and aspirations for your life rather than being limited by whatever thoughts happen to crop up in your internal world.
I happened to be working with a client who was continually worrying about his retirement plan around the time I was first learning about ACT. This man wasn’t close to retirement, nor did he have any financial problems. In fact, he was relatively well off. But he was obsessively preoccupied with this worrisome thought: What if my retirement plan turns out to be insufficient by the time I retire? This worrisome thought, and his ongoing efforts to rid himself of this thought, were his near-constant companions, and he used all the anti-worry responses we looked at in chapter 3, with little benefit.
He and I worked cognitive restructuring really hard. We looked at his thoughts about how terrible retirement might be if he had less money than anticipated. We reviewed the options he would have then to cut back his expenses and considered how those lifestyle changes might affect his mood and thoughts. We considered cutbacks he could make in his current spending patterns in order to give him a higher probability of a solid retirement income, and how he would think and feel about that set of changes. We reviewed his thoughts about working part time in retirement, should he feel that necessary, and the possibility of his spouse playing a large role in moneymaking. He found neither comfort nor reduction in worry from these efforts.
I suggested the potential benefits of getting an expert review of his plan from a financial planner, only to learn that he had already done this several times. The problem he experienced with this attempted solution was that, when you consult a financial planner, they typically want you to sign a document acknowledging that their forecasts are built on certain assumptions which might not turn out to be accurate, and promising you won’t sue them for that. “Not accurate?” he said. “That was why I went there in the first place, to get an accurate prediction!”
We were getting nowhere slowly! One day it occurred to me that an ACT therapist wouldn’t be doing all this work of looking at how true or false his worries about retirement were. I remembered the ACT question, “Is having this thought getting in the way of you doing anything important?” And so I asked him that question.
It turned out it was getting in the way of him doing something important, and when I heard what it was, I realized immediately that I had misunderstood the problem. You can try to guess what it was before I tell you, but I doubt anyone will guess it correctly.
It wasn’t preventing him from working, or retiring, or saving money. It was preventing him from doing something else, something that made me realize I had been approaching the wrong problem.
What was it? When you belong to a retirement plan, either on your own or through an employer, you get a periodic report about how your plan is doing. It shows the contributions you’ve made; the contributions your employer’s made, if any; and the change in the market value of your stock and bond holdings in the plan. This is the information people use to monitor and change their investment strategy as needed.
This man’s worrisome thoughts prevented him from opening the retirement report when it came in the mail. He would put it in a filing cabinet unopened.
I realized then that I had misdiagnosed the problem. I had been proceeding as if this man needed to feel more secure in his financial planning. But now I could see that he was so intolerant of worry and uncertainty that he was willing to give up control of his finances, if only that would relieve his worry!
He didn’t need to become more confident and sure—he needed to become more willing to feel unsure, and live with that set of thoughts and feelings. He needed to do more work with the worry, and less against.
Thinking about your worries, in an effort to evaluate and correct them, has some limitations, and these limitations may hamper your effort to calm worrisome thoughts with cognitive restructuring.
For one thing, thinking objectively about your thoughts is quite difficult, maybe impossible, because the tool you use to evaluate your thoughts—your brain—is the same tool that created them in the first place. For another, your efforts to evaluate and correct your worrisome thoughts will often produce a kind of internal arguing with your thoughts, rather than the calm resolution that you originally hoped for.
If you find that these limitations hamper your efforts to reduce chronic worry with cognitive restructuring, you might find more relief with the techniques of cognitive de-fusion. Working with (rather than against) the key words and thoughts of your chronic worry, particularly in a playful, humorous manner, may well give you better results than efforts to rationalize and correct the content of your worries.