In part two of this three-part series, we discussed cognitive strategies to improve the Intolerance of Uncertainty (IU) and, ultimately, reduce worry in your life. Recall that IU can have a negative impact on your ability to enjoy life. There is simply no way to escape the inevitability of uncertainty in life and, thus, it is in your best interest to learn how to embrace it. In the last post, we talked about cognitive strategies that can help you become more comfortable with uncertainty. In this post, we will discuss behavioral strategies.
It is critically important to emphasize that this step must be taken. Although cognitive restructuring is important, it is only one part of the process. Our learning is reinforced most powerfully through experiential knowledge. It is through the experience of testing out our thoughts and beliefs about uncertainty that we learn how inaccurate they actually are.
Similar to what we talked about when discussing cognitive strategies, we will want to use information from your “worry profile” (gathered through the worry log and other strategies to develop awareness of your specific worry content) to develop effective behavioral interventions. Even within the specific group of those who meet the criteria for Generalized Anxiety Disorder (GAD), worries are incredibly unique. The type of worries that consume one person with GAD are entirely different from those of another person with GAD. Thus, the behavioral strategies should be designed based on the client’s most debilitating worry content areas (e.g., worries around health symptoms, being unsafe or in danger, social situations, work or school tasks, interpersonal relationships).
Thus, we introduce the exposure hierarchy! Exposure hierarchies are used to treat all types of anxiety. In the context of addressing the intolerance of uncertainty, exposure hierarchies are used to allow the person to repeatedly expose themselves to uncertain situations. Exposure hierarchies are a list of 10 to 20 exposure tasks/items created with the intent to systematically expose someone to uncertainty in a variety of ways. The therapist and client collaboratively design such tasks based on the typical types of uncertain situations that the client often worries about. The items/tasks that cause the least amount of distress are lowest on the hierarchy and the client gradually works their way up the hierarchy and through each task until they reach the most distressing item at the top of the hierarchy. This allows the client to experience empowerment with the completion of each task, which gives them the confidence to face the next, more challenging task. We typically start with an item that brings an anxiety level of about 20 on a scale of 0-100 (with 100 being the most anxiety they can imagine). The final item at the top of the hierarchy should be at around 100 on the anxiety scale.
To understand how exposure hierarchies work, let me use the example of treating someone with a specific phobia (as this is much simpler and more obvious than treating the intolerance of uncertainty). Let’s explore how we might create an exposure hierarchy for someone who is afraid of dogs. We might start by having the person listen to audio clips of a dog barking or watch video clips of a dog playing catch. We might then move to having someone go to a pet store and look at puppies, and then might eventually have them pet a dog. We also might start with smaller dogs and then progress to larger dogs. Makes sense, right? Similarly, with the intolerance of uncertainty, we would have someone be exposed to uncertain situations that bring minimal anxiety and then progress to their most feared uncertain situations. Of course, as mentioned, an exposure hierarchy targeting the intolerance of uncertainty looks completely different for each person. So, what are some potential items on this type of exposure hierarchy? Below are a few examples.
- Delegating more work to others
- Saying what you think in a conversation
- Trying out a new activity previously avoided
- When experiencing a new symptom, do not google the symptom, seek reassurance from loved ones or visit the doctor for 24 hours
- Go for a walk by yourself downtown during the evening
- Avoid checking your earthquake preparedness kit or survival materials for at least a week (or month or two months)
- Take a vacation to a new city without researching the frequency of natural disasters in your area
- Talk about more ‘risky’ subjects
- Shopping somewhere new
- Acting spontaneously
- Refraining from checking over work
- Having a brief conversation with someone new without rehearsing or preparing for the conversation in advance
- Give your opinion to a friend or group of friends without waiting for everyone else’s opinion first
- Hand in a work task without seeking reassurance from others
I could go on and on! There are so many options because it completely depends on a given person’s individual worries related to the intolerance of uncertainty. One of my favorite tasks to do with a client is to develop their exposure hierarchy. It is such an interesting and creative process! But it is also a little scary at first. Many of my clients have told me that their experiences with the exposure hierarchy have been extremely difficult at times (how could it not be when you are facing your fears?) but also the most rewarding. If intolerance of uncertainty is something you struggle with, I highly encourage you to use these cognitive and behavioral strategies with a skilled cognitive therapist.
