When we work with anxiety problems in Cognitive Behavioural Therapy (CBT), there will always be two factors to consider, one is obvious, and the other is more hidden. The more obvious one is the specific threat that lies within an anxiety problem. In OCD, the particular threat may be the thought, “I worry that I will contaminate others. What if they then become ill. It will be my fault”. The second less obvious factor is, in many ways, more challenging to overcome – it is uncertainty.
The elusive and problematic nature of certainty
Uncertainty is about the future, and none of us can know for certain what will happen in the next minute or the following year. For someone who has OCD, there will ‘always’ be a faint possibility that their contamination will make someone ill. This ‘certainty' that the future will always be uncertain makes some of the behaviour in an anxiety problem more understandable. Focussing on a behaviour such as checking in OCD will manage the anxiety about the uncertain future for a short period of time. This fear of uncertainty had always been there for people who have anxiety problems. However, in the era of Coronavirus, it is something that affects everyone.
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The work of the Uncertainty in Coronavirus Research Network or UNICORN has been helpful in looking at how techniques that have been useful in dealing with uncertainty within the field of CBT can be generalised and applied to deal with the broader social uncertainty of the Covid-19 pandemic.
The researchers in UNICORN state that people manage uncertainty in three different ways. They can ‘over-engage’ with uncertainty. They may undertake extensive research on a particular subject in order to make themselves feel more ‘certain’ about it. They may plan in great detail what it is that they need to do, or they may, if they have problems such as OCD, develop a series of complicated rituals. We know that over-engagement doesn’t work. The rituals in OCD offer temporary relief but do not provide a long-term solution.
Researching a subject such as Coronavirus is problematic. Certainty about the facts on anything is a ‘moving target’. Once we know one thing, different questions about what we ‘do not know’ will then be thrown up. Equally problematic will be those people who under-engage with uncertainty. They may behave more impulsively than the over-engagers and choose to ignore the research. The third group will be those who ‘flip flop’ between these two extremes.
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How can we begin to plan certainty into our lives? Or live with uncertainty?
A starting point in dealing with uncertainty is to de-couple it from the idea that it is dangerous. If something is uncertain, it will, of course, be new. However, ‘newness’ is not the same as dangerous. Behavioural experiments in CBT are useful. These can include any activity where there is an uncertain outcome, such as playing a game. As people become more used to this level of uncertainty, then new activities with ‘higher stakes’ are introduced. This can involve activities where there is a small element of risk, such as turning up late for an appointment. The important point in these activities is staying with a feeling which may be uncomfortable but is not necessarily harmful. Additionally, there are other approaches to the uncertainty that similarly begin to build back structure into people’s lives.
Prior to Coronavirus, the future was, in a general sense, felt predictable. We knew what we were doing during the week, at the weekends, and we were aware of how far that rhythm changed according to the seasons. Now, however, with the wake-up call of Covid-19, we know how hard it is to trust the future. Suppose we begin now to set meaningful but flexible goals to take into account a future, which is less certain than before. By building these bridges back into the future, we can slowly start to feel more certain and confident.
*The author of this article Mr O’Sullivan is an experienced CBT therapist, who has written multiple books on CBT, depression, and anxiety, such as ' A Practical Guide for Working with Depression' and 'Working with Compassion'.