Robert L. Leahy

American Institute for Cognitive

Therapy

New York City

Email: Leahy@

CognitiveTherapyNYC.com

What do you worry about?What do you worry about?

How big a How big a problem is worry?problem is worry?

38 % of people worry every day38 % of people worry every day Some worriers Some worriers ““worry all their livesworry all their lives”” Chronic worry leads to depression---Chronic worry leads to depression---

that lasts for years for some peoplethat lasts for years for some people Worry is a core feature of all of the Worry is a core feature of all of the

anxiety disordersanxiety disorders Irritable bowel syndrome, fatigue, Irritable bowel syndrome, fatigue,

depression, digestive problemsdepression, digestive problems

Prevalence of anxietyPrevalence of anxiety

19 million Americans have an anxiety 19 million Americans have an anxiety disorderdisorder

Women are twice as likely as men to Women are twice as likely as men to have GADhave GAD

Many anxiety disorders continue for Many anxiety disorders continue for decades if there is no treatmentdecades if there is no treatment

Historical changesHistorical changes

TwengeTwenge’’s meta-analysis: anxiety has s meta-analysis: anxiety has been increasing since the 1950been increasing since the 1950’’ss

The average HS student today is as The average HS student today is as anxious as the average psychiatric anxious as the average psychiatric patient in the 1950patient in the 1950’’ss

Increases in anxiety are associated Increases in anxiety are associated with historical decreases in social with historical decreases in social connectednessconnectedness

Treatment for anxietyTreatment for anxiety

Most patients with anxiety are not Most patients with anxiety are not accurately diagnosed (especially by accurately diagnosed (especially by primary care physicians)primary care physicians)

Pharmacotherapy is often not Pharmacotherapy is often not effectively administered (duration effectively administered (duration and dosage)and dosage)

Not enough well-trained cognitive Not enough well-trained cognitive therapists availabletherapists available

Worry Examples What You Avoid or Do

Anxiety Disorder

Fear of a specific situation or thing

I’ll fall over the edgeI’ll drownI’ll get trappedThe plane will crashIt’s dangerous

HeightsWaterInsects, snakes, ratsClosed spacesFlying

Specific Phobia

Being evaluated by othersHumiliationRejection

They’ll see I’m nervous. My hands will tremble.My mind will go blank

Speaking in publicMeeting new people

Social Anxiety Disorder

Leaving something undone, of being contaminated, making mistakes, of having thoughts and feelings that you fear

I didn’t lock the doorI have germs on my handsIf I have a violent thought, I might act on it

What You Do:You repeat actions over and overYou checkYou won’t touch certain thingsYou avoid situations or people that trigger your unwanted thoughts and feelings

Obsessive-Compulsive Disorder

Worry that your physical sensations will go out of control and cause you to go crazy or get sick

My heart is beating rapidly—I will have a heart attack.I’m so dizzy I will fall.I’ll get so anxious I’ll start to scream

Being in places—theatres, restaurants, airplanes—where your exit is blocked.Open spaces—streets, malls, fields.

Panic Disorder

Worry that the future is hopeless and bleak. Repetitive thoughts and feelings about your own suffering

Nothing will work out. I’ll end up a failure.What’s wrong with me?Why do I have so many problems?

Doing things to help yourself—meeting people, taking on new challenges, establishing goals and solving your problems

Depression

Worry that intrusive images and thoughts mean that something terrible is going to happen to you. 

I had another image of a disaster—I have to get out of here.I had a nightmare—it’s dangerous. 

Situations associated with your initial trauma—people, places, movies, stories.

Post-Traumatic Stress Disorder

What is the What is the nature of worry?nature of worry?

What if we thought of worry as a set What if we thought of worry as a set of rules that are rigidly followed?of rules that are rigidly followed?

Seven Rules of Seven Rules of

Highly Worried PeopleHighly Worried People If something bad could happen—if you can simply imagine itIf something bad could happen—if you can simply imagine it

—then it—then it’’s your responsibility to worry about its your responsibility to worry about it

DonDon’’t accept any uncertainty—you need to know for suret accept any uncertainty—you need to know for sure

Treat all of your negative thoughts as if they are really trueTreat all of your negative thoughts as if they are really true

Anything bad that could happen is a reflection of who you Anything bad that could happen is a reflection of who you

are as a personare as a person

Failure is unacceptableFailure is unacceptable

Get rid of any negative feelings immediatelyGet rid of any negative feelings immediately

Treat everything like an emergency Treat everything like an emergency

But, wait!But, wait!

Did you leave out something? IsnDid you leave out something? Isn’’t t there something you overlooked? there something you overlooked? Can you really trust your memory? Can you really trust your memory? You forgot the most important thing. You forgot the most important thing.

You forgot to You forgot to worry about worry about worryingworrying..

You forgot to say, You forgot to say, ““All of this All of this worrying is going to drive you worrying is going to drive you crazy, give you a heart attack, and crazy, give you a heart attack, and ruin your life completely.ruin your life completely.””

How could you forget the How could you forget the eighth ruleeighth rule—the rule that says, —the rule that says, ““Now that youNow that you’’re re worried, worried, youyou’’ve got to stop worrying ve got to stop worrying completelycompletely or you or you’’ll go crazy and ll go crazy and die?die?””

Worry makes sense to youWorry makes sense to you

1.1. You believe that worry helps you You believe that worry helps you solve solve problemsproblems

2.2. You believe the world is dangerous—You believe the world is dangerous—and and that you are unable to copethat you are unable to cope

3.3. Worry helps you avoid thinking about Worry helps you avoid thinking about the the worst possible outcomeworst possible outcome

4.4. Your worry is Your worry is ““abstractabstract”” thinking thinking rather rather than powerful emotional imagesthan powerful emotional images

5. 5. You are not anxious when you are You are not anxious when you are worriedworried

Worry makes Worry makes ““sensesense”” to you to you

6.6. Worry gives you the illusion of controlWorry gives you the illusion of control

7.7. You feel that worry means you are responsibleYou feel that worry means you are responsible

8.8. Worry is a way to reduce uncertaintyWorry is a way to reduce uncertainty

9.9. You worry to control your thoughts and You worry to control your thoughts and feelingsfeelings

10.10. Worry Motivates YouWorry Motivates You

11.11. How your parents taught you to worryHow your parents taught you to worry

1. If something bad could happen—1. If something bad could happen—if you can simply imagine it—then itif you can simply imagine it—then it’’s s your responsibility to worry about ityour responsibility to worry about it

Nature of intrusive thoughtsNature of intrusive thoughts worriers treat the worriers treat the ““occurring thoughtoccurring thought””

as something that must be attended as something that must be attended toto

Worry is a Worry is a ““strategystrategy””

II’’ll be preparedll be prepared I wonI won’’t be surprisedt be surprised II’’ll solve the problemll solve the problem I will be motivatedI will be motivated

How will my worry help me?

Meta-cognitive Meta-cognitive model of worry model of worry (Wells, 1997)(Wells, 1997)

Positive view of worryPositive view of worry Uncontrollable and dangerousUncontrollable and dangerous Cognitive incompetenceCognitive incompetence Negative beliefsNegative beliefs Cognitive self-consciousnessCognitive self-consciousness

2. Don2. Don’’t accept any uncertainty—t accept any uncertainty—you need to know for sureyou need to know for sure

Worry entails the intolerance of Worry entails the intolerance of uncertaintyuncertainty

Uncertainty is equated with Uncertainty is equated with negative/dangerous outcomesnegative/dangerous outcomes

Sense of responsibility for eliminating Sense of responsibility for eliminating uncertaintyuncertainty

If I get enough information, I can be sure

Generate possible terrible outcomes

Collect information that is negative

Uncertainty is intolerable---it’s dangerous and means you are irresponsible

Are these solutions perfect? Do they eliminate all uncertainty?

Generate solutions

Reject solutions, reassurance and information

Continue worrying

Model of WorryModel of Worry

3. Treat all of your negative thoughts3. Treat all of your negative thoughts as if they are really true as if they are really true

Thought-action fusion in OCD Thought-action fusion in OCD (Rachman)(Rachman)

Thought-reality fusion in GAD/worryThought-reality fusion in GAD/worryAlsoAlso

Thought-self fusion in worryThought-self fusion in worry

(I am what I think vs. I am what I choose (I am what I think vs. I am what I choose or what I do)or what I do)

Common thinking Common thinking distortions in worrydistortions in worry

Jumping to conclusionsJumping to conclusions CatastrophizingCatastrophizing All-or-nothing thinkingAll-or-nothing thinking PersonalizingPersonalizing Discounting the positiveDiscounting the positive Double-standardDouble-standard

Biased information Biased information processingprocessing

Focus on threatFocus on threat Over-estimation of threatOver-estimation of threat Perception of chain-reactionsPerception of chain-reactions

(this will lead to x->y->z)(this will lead to x->y->z) Slippery slopeSlippery slope Trap doorTrap door Perception of rapid changePerception of rapid change

4. Anything bad that could happen4. Anything bad that could happen is a reflection of who is a reflection of who you are as a personyou are as a person

Intrusive thought--- Intrusive thought--- ““I could make a I could make a mistakemistake”” ““I have a I have a responsibility to make sure it responsibility to make sure it does not happendoes not happen””

Worry is associated with fear of Worry is associated with fear of regret, blaming yourself for regret, blaming yourself for mistakes, overgeneralizing mistakes, overgeneralizing ““failurefailure””, risk-aversion, risk-aversion

Exaggerated sense of self needing to Exaggerated sense of self needing to control outcomescontrol outcomes

ItIt’’s up to me to make sure it doesns up to me to make sure it doesn’’t t happenhappen

Seeing the self as the center of Seeing the self as the center of things—things—““What will people think of me?What will people think of me?””

““How can I make sure it doesnHow can I make sure it doesn’’t go t go wrong?wrong?””

5. Failure is unacceptable5. Failure is unacceptable

““FailureFailure”” is identified with is identified with ““value of selfvalue of self”” Failure is Failure is ““who I amwho I am”” Failure is catastrophizedFailure is catastrophized Worriers discount their positivesWorriers discount their positives Worriers see a small negative change Worriers see a small negative change

as the start of things unravelingas the start of things unraveling Worriers donWorriers don’’t take credit for positivest take credit for positives

Perfectionism and worryPerfectionism and worry

Worry is a strategy to avoid failureWorry is a strategy to avoid failure Worry must Worry must ““assureassure”” a perfect a perfect

outcomeoutcome Reject solutions that are less than Reject solutions that are less than

perfectperfect

How worry worksHow worry works

Will I pass the test?

Worry: I think of all the reasons I won’t pass

I pass the test

My Worry Works !

6. Get rid of any6. Get rid of any negative feelings immediately negative feelings immediately

Worriers are alexithymicWorriers are alexithymic Hard to identify their emotionsHard to identify their emotions Negative view of their emotionsNegative view of their emotions Worry is a form of emotional avoidanceWorry is a form of emotional avoidance Worry suppresses arousal temporarilyWorry suppresses arousal temporarily Arousal incubates and bounces back Arousal incubates and bounces back

Negative view of emotionNegative view of emotion

Worriers think: My emotions donWorriers think: My emotions don’’t t make sense, they will last make sense, they will last indefinitely, overwhelm me, they feel indefinitely, overwhelm me, they feel ashamed, they canashamed, they can’’t stand having t stand having ““mixed feelingsmixed feelings””, their emotions are , their emotions are ““differentdifferent”” from others from others

They think they cannot express They think they cannot express emotion or get validationemotion or get validation

7. Solve every problem immediately7. Solve every problem immediately

Sense of urgencySense of urgency No time to get No time to get ““out of the wayout of the way”” Inability to live in the momentInability to live in the moment

How can weHow can we change worry? change worry?

The Seven Steps to The Seven Steps to Stop WorryStop Worry

1)1) Identify Productive and Unproductive Identify Productive and Unproductive WorryWorry

2)2) Accept Reality and Commit to ChangeAccept Reality and Commit to Change

3)3) Challenge Your Worried ThinkingChallenge Your Worried Thinking

4)4) Focus On The Deeper ThreatFocus On The Deeper Threat

5)5) Turn Turn ““FailureFailure”” Into Opportunity Into Opportunity

6)6) Use Your Emotions Rather Than Worry About Use Your Emotions Rather Than Worry About ThemThem

7)7) Take Control of Time Take Control of Time

The Seven Steps to The Seven Steps to Stop WorryStop Worry

Step One Step One

1) Identify Productive and 1) Identify Productive and Unproductive WorryUnproductive Worry

What are the costs and benefits to What are the costs and benefits to worrying about this?worrying about this?

CostsCosts BenefitsBenefits

The Signs of The Signs of Productive WorryProductive Worry

There is a question that has an answerThere is a question that has an answer You are focused on a single event—You are focused on a single event—

not a chain reactionnot a chain reaction You are willing to accept imperfect You are willing to accept imperfect

solutionssolutions You do not use your anxiety as a guideYou do not use your anxiety as a guide You recognize what you can control You recognize what you can control

and what you cannot controland what you cannot control

The Signs of The Signs of Unproductive WorryUnproductive Worry

You worry about unanswerable questionsYou worry about unanswerable questions You worry about a chain reaction of eventsYou worry about a chain reaction of events You reject a solution because it is not a You reject a solution because it is not a

perfect solutionperfect solution You think you should worry until you feel You think you should worry until you feel

less anxiousless anxious You think you should worry until you You think you should worry until you

control everythingcontrol everything

Once you categorize this Once you categorize this as unproductive worry, as unproductive worry,

then what?then what?

Step TwoStep Two

Accept Reality and Commit Accept Reality and Commit to Changeto Change Mindfulness Mindfulness Become an observer Become an observer Gain Distance Gain Distance Describe What is in Front of You Describe What is in Front of You Suspend Judgment Suspend Judgment Take Yourself Out of It Take Yourself Out of It Disappear to see reality Disappear to see reality

Step TwoStep Two

Why You DonWhy You Don’’t Accept Reality t Accept Reality

You DonYou Don’’t Like What You See t Like What You See You want THE ANSWER You want THE ANSWER You WonYou Won’’t Settle For Less t Settle For Less You have to control everythingYou have to control everything

Step TwoStep Two

Accept Limitation Accept Limitation

Accept unsolvable problems Accept unsolvable problems

Know what you can never know Know what you can never know

Step TwoStep Two

Uncertainty training - tolerate Uncertainty training - tolerate uncertainty and experience emotionuncertainty and experience emotion Learn how to tolerate Learn how to tolerate

uncertaintyuncertainty 1. Examine the costs and benefits 1. Examine the costs and benefits of accepting uncertainty of accepting uncertainty

2. Practice the emotional image 2. Practice the emotional image

3. Flood yourself with uncertainty 3. Flood yourself with uncertainty

Step TwoStep TwoCommitting to changeCommitting to change

The Power of Doing What You DonThe Power of Doing What You Don’’t Want To Do t Want To Do

1. The power of choice 1. The power of choice

2. Successful Imperfectionism 2. Successful Imperfectionism

3. Constructive Discomfort 3. Constructive Discomfort

4. Take Your Discomfort History 4. Take Your Discomfort History

5. Discomfort Diary 5. Discomfort Diary

Step ThreeStep Three

3. Challenge Your Worried Thinking3. Challenge Your Worried Thinking

Keep Track Of Your WorriesKeep Track Of Your Worries

Your Worry Record Your Worry Record

Set Aside Set Aside ““Worry-TimeWorry-Time””

Test Your Predictions Test Your Predictions

Step ThreeStep ThreeTen Ways to Defeat Your WorriesTen Ways to Defeat Your Worries

1. What thinking distortion are you using? 1. What thinking distortion are you using?

2. How likely (0–100%) is it that this will actually 2. How likely (0–100%) is it that this will actually happen? happen?

3. What is the worst outcome? The most likely 3. What is the worst outcome? The most likely outcome? The best outcome? outcome? The best outcome?

4. Tell yourself a story about better outcomes4. Tell yourself a story about better outcomes 5. What is the evidence that something really bad is 5. What is the evidence that something really bad is

going to happen? going to happen?

Defeat your worriesDefeat your worries6. How many times have you been wrong in the past 6. How many times have you been wrong in the past

about your worries? about your worries?

7. Put predictions in perspective 7. Put predictions in perspective Turn catastrophes into detours Turn catastrophes into detours Use realistic probabilities Use realistic probabilities Get off the Slippery slope Get off the Slippery slope DonDon’’t fall through your Trap Door t fall through your Trap Door

8. How could you cope if the bad outcome actually 8. How could you cope if the bad outcome actually happens? happens?

9. What advice would you give a friend who had your 9. What advice would you give a friend who had your worries?worries?

10. Show yourself why this is not really a problem10. Show yourself why this is not really a problem

The Seven Steps to The Seven Steps to Stop WorryStop Worry

7. Take Control of Time 7. Take Control of Time

I need it right nowI need it right now WhatWhat’’s Your Sense of Time?s Your Sense of Time? Turn the urgency offTurn the urgency off Step away from timeStep away from time

 

1. Do you often feel pressured for time?

2. Are you often thinking about things that might happen in

the future?

3. Do you have a hard time staying in the moment?

4. Do you find yourself frustrated with how slowly things are

going?

5. Do you feel like rushing people through their

conversation?

6. Are you often worried about deadlines?

Step SevenStep Seven

Step SevenStep Seven

7.7. Are you often over-scheduled?Are you often over-scheduled?

8.8. Do you show up a lot earlier—or a lot later—than other people?Do you show up a lot earlier—or a lot later—than other people?

9.9. Do you keep checking your watch or the clock?Do you keep checking your watch or the clock?

10.10. Do you get frustrated when you are Do you get frustrated when you are ““behindbehind”” someone in traffic someone in traffic

or walking down the street?or walking down the street?

11.11. Do you feel you just canDo you feel you just can’’t stand waiting?t stand waiting?

12.12. If you think that something bad could happen, do you feel you If you think that something bad could happen, do you feel you

need the answer right now?need the answer right now?

Step SevenStep Seven

Use Mindful DetachmentUse Mindful Detachment Improve the momentImprove the moment Stretch timeStretch time Plan timePlan time

Stretch TimeStretch Time

How will I feel about this in a month? How will I feel about this in a month?

A year? Five years?A year? Five years?

What will you do five hours from now? The next What will you do five hours from now? The next

day? The day after? day? The day after?

What are all the positives that could happen What are all the positives that could happen

between now and then?between now and then?

What are all the positives that could happen this What are all the positives that could happen this

moment? In a month, a year, in ten years?moment? In a month, a year, in ten years?

To take control of timeTo take control of time

Turn the urgency off

Accept Impermanence

Appreciate the moment

Improve the moment

Stretch time

Plan time

1) Identify Productive and Unproductive Worry

2) Accept Reality and Commit to Change

3) Challenge Your Worried Thinking

4) Focus On The Deeper Threat

5) Turn “Failure” Into Opportunity

6) Use Your Emotions Rather Than Worry About Them

7) Take Control of Time

SummarySummary

Robert L. Leahy

American Institute for Cognitive

Therapy

New York City

Email: Leahy@

CognitiveTherapyNYC.com

Thank you