Intolerance of uncertainty (IU) is a disposition – or character trait – which develops from one’s beliefs about uncertainty and its consequences (Dugas & Robichaud, 2007). Some people have a positive attitude towards uncertainty (“It’s boring to always know what’s going to happen”, “I like to trust my intuition and go with the flow”) whereas people who have high IU tend to have more negative beliefs about uncertainty (e.g. “It’s unbearable not knowing”, “Uncertainty ruins everything”) and may find it hard to tolerate even a small amount of uncertainty.
Intolerance of uncertainty has long been part of cognitive models of generalized anxiety disorder (GAD: e.g. Dugas, Gagnon, Ladouceur, Freeston, 1998) and there is a strong relationship between IU and GAD (e.g. Donegan et al, 2010; Dugas & Ladouceur, 2000). It is also increasingly recognized as a transdiagnostic risk factor for many clinical conditions, including anxiety, depression, obsessive-compulsive disorder, and eating disorders (Carleton et al, 2012; Toffolo et al, 2014; Renjan et al, 2016).
In 2018, Hebert & Dugas published an updated model of GAD which clarified the relationship between the state of uncertainty, beliefs about uncertainty, and anxiety, which gave more prominence to clients’ appraisals. The model proposes that situations which are uncertain, novel, or ambiguous trigger a state of uncertainty. Individuals with dispositionally high IU appraise the uncertainty in catastrophically negative ways which then lead to emotional, cognitive, and behavioral sequelae. The model suggests that two categories of beliefs about uncertainty are clinically important:
- Beliefs that uncertainty has negative implications for oneself and one’s behavior.
- Beliefs that uncertainty is unfair and spoils everything.
Clinically, the intention of the updated model is for therapists to help their clients address their appraisals of uncertainty directly by using behavioral experiments. Hebert & Dugas suggest that although the practical result of this approach may appear superficially similar to earlier exposure-to-uncertainty treatments for GAD, it reduces clinical time spent focusing on the specific content of worries, may be more effective than situational exposure, and may encourage patients to identify and modify unhelpful safety behaviors. The Uncertainty Beliefs – Experiment Record is a worksheet designed to help clients and therapists design and conduct behavioral experiments that target beliefs about uncertainty. Although it targets client appraisals of uncertainty, the format of this worksheet differs from the treatment approach referenced in Hebert & Dugas (2019).
“People sometimes react strongly to uncertainty because of what they believe about it. While some people are OK with uncertainty and ‘not knowing’, for other people it is almost as though they are allergic to uncertainty – even a small amount can cause a powerful reaction. People who are ‘allergic to uncertainty’ often spend a lot of time trying to avoid it, either by worrying about what might happen, or by thinking of coping strategies for uncertain situations they can’t avoid. Can you relate to this? The problem is that these ‘solutions’ to uncertainty come with their own costs. This exercise is designed to help you to explore some of your beliefs about uncertainty – would you be willing to do that with me?”
1. Uncertainty beliefs. Explore the client’s beliefs about uncertainty. Hebert & Dugas recommend that clients can be encouraged to complete the Intolerance of uncertainty scale (IUS) and to use self-monitoring to understand more about situations and triggers for their anxiety and worry. The clinical aim at this step is to identify one of the client’s beliefs about uncertainty, and to rate how strongly they believe it.
- What is it about uncertainty that bothers you?
- Why is uncertainty so bad?
- Could we read some of these items from the Intolerance of Uncertainty Scale and see which ones resonate for you?
2. Situation & feelings. Help the client to describe an uncertain situation that triggers their uncertainty belief. Encourage them to describe how the uncertainty makes them feel, both emotionally and physiologically. Categorize what makes the situation uncertain: is it a novel situation for them, or is there some kind of ambiguity?
- Tell me about a situation in your life that triggers this belief about uncertainty.
- Can you tell me about a recent situation where you felt that way about uncertainty?
- What do you feel emotionally in a situation like that?
- What do you feel in your body when you are in that situation?
3. Coping responses. Help the client to describe how they normally cope when confronted with uncertain situations like they have described. Explore what safety behaviors they use to cope with the uncertainty. Consider safety behaviors including: avoidance, checking, information gathering, planning, procrastination, reassurance seeking, worrying.
- What would you normally do if you were faced with an uncertain situation like this, and you couldn’t avoid it?
- In this situation, is there anything you would do to feel more certain?
4. Experiment. Help the client to devise a behavioral experiment that would create a state of uncertainty, which they could use to test their uncertainty belief.
What type of experiment would best test the belief? For example, it could be a direct hypothesis testing experiment, a survey, or a an observational experiment.
- Can the experiment be conducted in the therapy office, or outside? Quick in-office experiments can help to generate momentum for more substantial out-of-office experiments.
- Where will the experiment be conducted, when will it take place, how will it be conducted (consider what data will need to be recorded: their own thoughts, feelings, body sensations and behavior; as well as the behavior of others ; the environment), and who will need to be present?
- Consider safety, client readiness, and additional practicalities.
- Prepare for problems. Helpful questions include “What problems might arise?” and “How would you deal with that?”.
5. Outcome and learning. Take time to understand the meaning of the experiment and the data. What sense has the client made of it? What do they believe the result says about them or other people? Encourage reflection on what has been achieved, and what has been learned.
- What happened?
- What did you learn?
- How much do you believe the original uncertainty belief now?
- How does the outcome of the experiment affect the belief you identified?
- What does the result say about your previous belief?
- Is there a new belief that better captures how you feel about uncertainty now? How strongly do you believe that new belief?
- How could the results of this experiment affect your daily life now?
Carleton, R. N., Mulvogue, M. K., Thibodeau, M. A., McCabe, R. E., Antony, M. M., & Asmundson, G. J. (2012). Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26(3), 468-479.
Donegan, E. (2010). Cognitive-behavioural therapy for generalized anxiety disorder: Examining the patterns of symptom change and the role of intolerance of uncertainty (Doctoral dissertation, Concordia University).
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36(2), 215-226.
Dugas, M. J., & Ladouceur, R. (2000). Treatment of GAD: Targeting intolerance of uncertainty in two types of worry. Behavior Modification, 24(5), 635-657.
Hebert, E. A., & Dugas, M. J. (2019). Behavioral experiments for intolerance of uncertainty: Challenging the unknown in the treatment of generalized anxiety disorder. Cognitive and Behavioral Practice, 26(2), 421-436.
Renjan, V., McEvoy, P. M., Handley, A. K., & Fursland, A. (2016). Stomaching uncertainty: Relationships among intolerance of uncertainty, eating disorder pathology, and comorbid emotional symptoms. Journal of Anxiety Disorders, 41, 88-95.
Toffolo, M. B., van den Hout, M. A., Engelhard, I. M., Hooge, I. T., & Cath, D. C. (2014). Uncertainty, checking, and intolerance of uncertainty in subclinical obsessive compulsive disorder: An extended replication. Journal of Obsessive-Compulsive and Related Disorders, 3(4), 338-344.