Generalized Anxiety Disorder 435
Risk and Uncertainty Inoculation
Another component of cognitive therapy for GAD that is related to metacognitive beliefs
is targeting the chronic worrier’s heightened sensitivity or intolerance of risk and uncer-
tainty. In their cognitive- behavioral treatment program for GAD, Robichaud and Dugas
(2006) first educate the client on the role of intolerance of uncertainty in the persistence
of pathological worry. They explain that chronic worriers have a strong reaction to even
small amounts of uncertainty that causes them to ask “what if” questions. These “what
if” questions then trigger a cycle of excessive worry. Robichaud and Dugas note there
are only two ways to reduce the role of uncertainty in worry: either reduce uncertainty
itself or increase one’s tolerance of uncertainty. It is explained to clients that the former
option is unrealistic because uncertainty is an inescapable part of life.
In our cognitive therapy approach to worry, changing risk and uncertainty beliefs
begins with an explanation of intolerance of uncertainty based on Robichaud and
Dugas (2006). Next the therapist collects data on the idiosyncratic uncertainty beliefs
associated with the client’s primary worry concerns. The Risk and Uncertainty Record
Form (Appendix 10.4) can be assigned as homework in order to gather the necessary
information. The “what if” questions generated during a worry episode will provide
insight into the client’s risk aversion and intolerance of uncertainty. The column labeled
“Responses to Uncertainty” directly assesses intolerance of uncertainty beliefs and the
client’s attempts to reduce or avoid uncertainty.
Cognitive restructuring of intolerance of uncertainty beliefs examines evidence that
uncertainty can be reduced or eliminated, that living with uncertainty is intolerable,
and that one has sufficient control over future events to ensure desired outcomes. Leahy
(2005) asks clients to examine the costs and benefits of accepting uncertainty versus
striving to eliminate uncertainty associated with worry concerns. The objective of cog-
nitive restructuring is to teach the individual with GAD that uncertainty is a natural
part of life and that tolerance of uncertainty is the only option because humans have
limited ability to determine future events.
One of the most useful interventions for intolerance of uncertainty involves a form
of “uncertainty inoculation” in which clients are exposed to ever increasing amounts
of uncertainty in their daily experiences (Robichaud & Dugas, 2006). For example,
a student worried that she did not understand what she was reading in her anatomy
textbook. Her “what if” questions included “What if I don’t understand everything?”,
“What if I forget what I’ve studied?”, “What if I get mixed up on the facts?”, and
“What if I become so anxious and confused that I blank out on the final exam?” Her
catastrophic outcome was “I’ll forget everything and fail the final exam and the course.”
She believed the uncertainty of the exam outcome was intolerable because it interfered
with her ability to study and concentrate. She also believed that the only solution was
to reread and repeatedly study the same material over and over again until she was
certain she would never forget it. After engaging in a cognitive restructuring exercise
in which the therapist challenged the client’s belief that she could attain certainty in
her knowledge of the subject matter, a series of behavioral exercises were introduced in
which the client reduced her checking and rereading responses and worked on tolerat-
ing increasing amounts of uncertainty about the anatomy material she had just studied.
A target was set for what constituted a reasonable study strategy that was not based
on eradicating all sense of uncertainty about the outcome of the final anatomy exam.