I’ll start with my take-home message: chronic worriers do not want to stop worrying. Instead, they want to stop feeling the need to worry. Most people are unwilling to stop worrying if the need to worry remains in place. This may seem a subtle difference but can have large consequences in terms of understanding chronic worriers and treating them for their worry. Let me illustrate with a made-up clinical discussion.

Worrier: Dr. Jack, I need help with my chronic worrying. It’s driving me crazy. I can’t relax, pay attention to conversations, focus on my work, fall asleep, or have fun.

Dr. Jack: I’m glad you came. I just learned a technique that is nearly guaranteed to stop your worry.

Worrier (with some trepidation): Really? Just like that? How does it work?

Dr. Jack: I hypnotize you to forget to worry. You stop worrying simply because you no longer remember to worry. It takes five minutes.

Worrier: Hold on a second. I don’t want to forget to worry!

Dr. Jack: Why not? I thought you want to stop worrying.

Worrier: Yes, I want to stop worrying. But not because I forget to worry. Just this thought makes me nervous. I want to no longer need to worry.

Dr. Jack: What’s the difference?

Worrier: I worry all the time because … It feels better to worry. I worry because to not worry seems worse, it seems dangerous.

Dr. Jack: Tell me more.

Worrier: Worry means I’m aware. I’m paying attention to various risks. It’s just that there are a lot of risks, a lot of different bad things that can happen and that’s why I NEED to worry. It seems worse, insane in fact, to not worry. If I don’t worry, itsit’s not like all those threats disappear. They’re there all the same. In fact, they’re there and now I’m not even paying attention to them. They are now even more free to attack me, just come right up to me and … take my head off, metaphorically speaking, and I’m just sitting there in Lala Land, pretending everything is fine.

Dr. Jack: I see. You don’t want to stop worrying. You want to be in a position of safety, of paying attention to threats and protecting yourself against them, while at the same time not being consumed by incessant worry. Before I share my thoughts with you, tell me, now that the conundrum is made clearer, can you think of any ways you can be safe – as safe as one can be – while not worrying all the time? …

So, for us clinicians to understand and treat our patients – or ourselves – who are chronic worriers, we need to acknowledge that worry is not the foundational problem. Instead worry is one strategy – and for the chronic worrier perhaps the only one – for managing life’s risks.

What are the implications for us clinicians treating patients with chronic worry? I can think of these:

  • The value of worry must be understood. It is not the most effective strategy and one with substantial adverse effects, but nevertheless it is a strategy. For some patients, it is important for the clinician to acknowledge this and engage patients in brainstorming together for alternative solutions. To place a further emphasis on this point: some patients would benefit from hearing, “I’m not trying to take away your worry or vigilance. I want us to find additional ways of addressing your concerns about various risks, and approaches that will also make you feel less miserable.
  • When recommending CBT, some patients may benefit from this same type of acknowledgement. If the clinician launches into the patients’ ‘illogical’ or ‘counterproductive’ thoughts or beliefs, those patients may reject treatment, for the same reason raised in my vignette: many patients start from a position of believing in the reality and likelihood of the risks that are the focus of their worry and will likely reject approaches to decrease those worries and the existing beliefs about those risks. A patient could very well say, “You want me to change my thoughts about the threats I face. You think this is just in my head! If I worry less, those threats don’t diminish! It’s like you can’t separate the mental from the real. The threats and risks in the world don’t care what beliefs I hold about them.” Well, most patients are unlikely to articulate their concerns about the clinician’s proposed treatment in this way. Instead, they nod and never come back.
  • There are other approaches to managing worry. In acceptance and commitment therapy (ACT) and other mindfulness-based therapies, patients are taught to observe the comings and goings of their thoughts, sensations, urges, and emotions and, not necessarily engage them. This approach also has the downside for chronic worriers who think, “Not engaging with my worries, doesn’t make the threats go away.”
  • Given chronic worriers’ frequent great sensitivity to and rejection of communications that they just need to change their beliefs about threats, in addition to the already discussed interventions – acknowledging the possible upsides of worry and not needing to stop worrying but instead supplement with other strategies – what else can the clinician recommend or do?
    • Teach the patient problem-solving techniques. I mentioned in other posts that often the biggest worriers, the people most sensitive to risk, are the ones who plan and problem-solve the least. This is not surprising because chronic worry is so draining and preoccupying that not much energy is left for mitigating those risks. A clinician who acknowledges the reality of some risks, even if seeing them as exaggerated, can help the patient actually do something about some of them. For example, guiding a patient to get the insurance they need, write a will, talk to family, what to do in case of a disaster that may befall the patient, etc., may decrease some sources of worry. And, in my experience, many chronically anxious patients have a backlog of important things they need to get done.
    • Start a conversation about prioritizing all the things the patient worries about. This prioritization opens up consideration of the fact that some risks are less severe than others in their consequences and/or in their likelihood of occurenceoccurrence. This conversation is a stealth form of cognitive reappraisal that may make cognitive biases more evident, without leading patients to conclude that you’re trying to ‘brainwash’ them out of their current threat beliefs.
    • Instead of indirectly shaming patients about their continued worry – oh, how illogical you are! – the clinician can help patients place some boundaries around their worry. One useful technique is to guide patients to write down all their worry thoughts and underlying beliefs. Once patients see these thoughts and beliefs written in black on white, they often find themselves concluding that these thoughts and beliefs ‘seem silly’ or ‘exaggerated.’ When written down these worries are both distanced from the patient (“They are not me”) and are more easily reflected upon dispassionately. Another technique is to schedule worry time or, instead, worry-free time. The techniques of writing down worries and implementing worry-free times work well together: when worries are recorded, patients can more easily forego the incessant worry thought loops. After all, they can just look them up and read them any time.
    • When starting a medication, a similar sensitivity to patients’ concerns holds. Many patients are fine when told that the medicine will decrease their worries and anxiety symptoms. Other patients, though, may feel that decreasing their worry decreases their vigilance and, thus, increases their vulnerability. In these cases, the clinician can focus on other beneficial aspects of the medication: “This medication can help you decrease your physical tension and problems concentrating and sleeping. It can allow you to better get to the sources of your worries so that you develop other, maybe better, strategies of keeping yourself and family safe while worrying less often.”
  • Last point: through everything I’ve written so far, I don’t suggest that I wish to support patients in their unrealistic or exaggerated worries. Instead, I suggest developing a sensitivity to patients’ frequent discomfort in giving up their worry thoughts. Once patients and I are in conversation, one formed based on that sensitivity, patients will often directly start to question their interpretations and appraisals of risk. Other patients may entirely forego a conscious reappraisal and instead simply start living with less worry, not taking time to wonder how the change came about. I’ll take that too.

Thanks, and I look forward to hearing your comments and own clinical experiences.

Dr. Jack

Language Brief

“Rumination is the coin of my realm. Interiority breeds interiority.” ― Gary Shteyngart 

“A day of worry is more exhausting than a week of work.” ― John Lubbock 

“Her forehead was a maze of anxious little grooves, from a lifetime of wondering about whether everyone within range was OK.” ― Tana French 

“I am a slow walker, but I never walk back.” ― Abraham Lincoln 

“Yesterday I was clever, so I wanted to change the world. Today I am wise, so I want to change myself.”― Rumi