Robert Leahy Speaks on Cognitive Therapy
For Worry and Rumination
By Lynn Mollick
On Sunday, December 7, Dr. Robert Leahy, Director of NYC’s American Institute for Cognitive Therapy, addressed 112 NJ-ACT members on worry and rumination.
Dr. Leahy defined “worry” as repetitive and recurrent thoughts about the future. He defined “rumination” as repetitive and recurrent thoughts about the past. Worry predisposes people to anxiety, and rumination predisposes people to depression. Techniques that are useful for worry are also useful for rumination.
In contrast to obsessions, patients often view worry as positive. Dr. Leahy described 7 dysfunctional beliefs about worry:
1) “Worry will prevent something bad from happening.” Worry creates a false sense of control, a belief that the mere fact of worrying prepares worriers to cope with a problem effectively.
Treatment should help patients learn that worry doesn’t necessarily solve problems or make problems easier to handle. Many problems have no solution, and 85 percent of the things people worry about never occur. People are more resilient than they imagine. Ask patients to keep a worry log and record whether the things they worry about actually occur.
2) “I can’t handle uncertainty. I have to know for sure.” Uncertainty leads to a relentless search for reassurance and better information to prevent negative outcomes. For this cognition, teach patients adaptive ways to handle uncertainty.
3) “All my negative thoughts are valid.” Worriers over-estimate threat. They believe that “one bad thing inevitably leads to another,” often very quickly. The functional alternative is to accept thoughts as just thoughts, not necessarily as facts.
4) “Anything bad that happens is a reflection of who I am.” Worriers often suffer from inflated responsibility and exaggerated self-importance. They tend to blame themselves and label themselves failures if anything bad happens. Worriers also fear regret, which therapists should acknowledge.
5) “Failure is unacceptable. Perfection is required.” Worriers catastrophize mistakes. They are risk averse. Help them see that there is risk in doing nothing and worry prevents success by inhibiting action.
6) “I must get rid of all my negative feelings immediately.” Worriers have difficulty experiencing and identifying their emotions. They think their emotions are shameful and intolerable. Worry functions as an emotional avoidance strategy by temporarily suppressing unwanted emotions. Helping patients to experience and express their emotions diminishes worry.
7) “I must solve every problem immediately.” Often the best strategy is to do nothing, to wait. When worriers wait and do nothing, negative outcomes seldom occur.
Dr. Leahy asserted that CBT’s purpose is to help patients cope with worry rather than to banish all worry. During the second half of his workshop he outlined many therapeutic strategies and techniques. A sampling follows:
1) Distinguish between productive and unproductive worry. Worrying is productive when it results in a solution to a specific problem. Worrying is unproductive when worriers reject solutions that are imperfect or uncertain, or when they insist on worrying until they find a solution that makes them feel comfortable.
2) Accept reality. There is no benefit in worrying about things you can’t change. People don’t accept reality when they cannot tolerate unfairness, ambiguity, or situations they cannot control. Techniques to promote acceptance include: Ask “what are the advantages and disadvantages of accepting ambiguity or unfairness?” Have patients imagine the worst case scenario. Try flooding (loop tapes), describing the worry until it becomes boring.
3) When intrusive worries interfere with attention to reality, practice mindfulness. Acknowledge the intrusion and do nothing. Patients can also ground themselves in the present by describing what is in front of them. Two useful metaphors for accepting worries are: treat intrusions as you would treat telemarketers (hang up and forget about them) or like a missed train (get on the next train without worrying about the train you missed).
4) Commit to change: Focus on “what am I willing to do” instead of “what I should do.” Learn to do hard things by doing something you don’t want to do every day. Keep a discomfort diary to strengthen the belief “I can do hard things.” Point out that patients can choose to change or choose not to change.
5) Use Socratic questioning to restructure thinking errors. Collect information about the actual probability of feared outcomes. Evaluate the likelihood of possible outcomes (0 to 100%). What is the worst? What is the most likely? What is the best? What is the evidence the worst outcome will occur? Is the bad outcome really that bad? How many times have you been wrong in the past about your worries? How would you cope if the worst outcome did occur? What advice would you give a friend who had the same worry?
6) Turn failure into an opportunity to learn. What worked and what didn’t? Was this the right goal? Were your standards too high? Focus on things you can control that are likely to succeed. Re-evaluate: Is this really important? Maybe this really isn’t a failure? Did you do better than before? Failure isn’t fatal. At least you tried; doing nothing is much worse. Everyone fails at something.
Motivate yourself. Be challenged by failure. Look at what worked and what didn’t, and try harder next time.
7) Take control of time. Worriers often over-schedule and experience time urgency. Antidotes include focusing on the present, learning to turn off urgency, and planning time effectively.
Dr. Leahy also discussed gaining perspective by “stretching” time, thinking about what you will be doing in a day, a month or a year, and how you will feel about this outcome in the future. Also consider the importance of yesterday’s, last week’s, or last month’s worries.
8) Use your emotions instead of worrying about them. Worry diminishes or avoids emotion and many worriers are unaware of their emotions. Help patients learn to experience their feelings by keeping an Emotion Diary. Explore and modify irrational beliefs about emotions such as they are shameful/weak/confusing or don’t make sense.
For further information about Dr. Leahy’s approach read “The Worry Cure: Seven Steps to Stop Worry from Stopping You,” New York: Three Rivers Press, 2005.