As I’ve mentioned before in different blog posts, anxiety and worry are comorbid, or occur together, with depression about 60% of the time.  Also, as I’ve mentioned, I’ve found it interesting as a behaviorist to watch people engage in behavior over and over again that does not work, yet they continue to do it.  As the punchline to one of my favorite stories goes, “If it makes you sick, why do you do it?” 

I’ve been taught that behaviors that are not reinforced should die out, so the question is why does worry continue?  I’ve mentioned that one of the reasons is that people who worry look at the reasons for, or antecedents to, their worry as opposed to looking at the consequence of their worry.  In a similar vein, I’ve talked about how people will worry because it gives them something to do when there is nothing to do, and it may be this aspect of thinking they are doing something that is partly reinforcing.

The other aspect is that the consequences of worrying are delayed, indirect, and appear to have little effect on decreasing worry.  The other observation is that people who worry tend to do so multiple times a day about multiple issues as opposed to just one primary worry.  Although if someone is sick, that may be the focus of worry all day. 

Take, for example, a person who worries about their child traveling home from the place they currently live.  Some people will make themselves upset a day or so before the journey, be upset the whole day, and finally be relieved when the person arrives.  This behavior could be reinforced by escape conditioning that I’ve talked about previously when the child arriving causes a significant reduction in anxiety, the behavior they have engaged in, worrying, is reinforced; thus, increasing the likelihood they will worry when the child heads back to their home. 

As a person who has been known to place a wager on a football game, I look at this behavior through the eyes of a sports wager and ask myself if the bet you make is wrong 100% of the time, why do you keep making it?  Well, the answer here is that there is no consequence for being wrong.  Clearly the person is upset, clearly they have been unhappy and it has caused them distress, but also obvious is the fact that those consequences do not change behaviors.  My question became; what if there was a more immediate and direct consequence to their being wrong?  What would happen to their worry if they had to pay a price?

I developed a program called betting on predictions.  It involved the patient making a monetary wager or bet with themselves every time they worried.  To do so, I would give the patients three Ziploc bags that had been stapled together.  One was labeled “Bank”, another labeled “Good” and the last bag labeled “Bad.”  The patient was instructed to go to their bank and get fifty $1 bills and put them in the first bag called the “Bank.”  Every time the person began to worry, they had to take a dollar bill out of the Bank bag and deposit it in one of the two remaining bags.  If they were really going to worry about the child driving home or some other worry, they had to put the dollar in the “Bad” bag, meaning they expected a bad outcome as demonstrated by their worrying.  If they took the dollar bill out, thought about their worry and decided that they either thought the negative outcome would not occur, or change what they said to themselves (cognitive restructuring—something like ‘my worry is not going to protect my child, so I’m not going to do it’), they would put the dollar in the Good bag, which stands for an expected good outcome.  For people who worry a lot, the Good and Bad bags began to fill with lots of dollar bills. 

Now comes the consequence.  If the patient put the money in the “Good” bag and nothing bad happens, the patient takes that money and spends it on themselves buying a new CD or book they want, or some other positive reinforcement for their change in behavior.  If something bad does happen, I facetiously say that it’s good because they get their dollar back.  But if nothing bad happens and their prediction was incorrect, that money has to go somewhere they don’t want it to go.  When explaining this program to the patient, initially I’ll ask them who they dislike most in the world.  And when I get a response that is clearly not very negative, I press for people or organizations they truly don’t like.  Once a black patient had to send his lost “bad prediction” money to the Ku Klux Klan, and another patient had to send his money to the guy who slept with his wife.  Once the consequence is significant enough, people are motived to stop making predictions that do not come true.

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In summary, people often make themselves miserable by worrying about the future when there is little they can do about it.  In essence, they're making predictions about bad things coming and, fortunately, these anticipated bad experiences rarely ever occur.  As a scientist, it is easy to ask the question that if a person is always wrong, why don't they change their behavior or prediction?  The reason is there is no consequence of being wrong.  And they are generally relieved when nothing happens, there is not a consequence for being wrong so it does not keep them from making themselves miserable in the future. 
 
 By having people wager money when they are making a prediction/bet and then losing it and having their money sent to someone they despise, it will hopefully be punishment enough that this consequence can change the future predictions they make.  By no longer making predictions that don't come true, the patient feels better and does not put them at risk of having avoided an action that needed to be taken.  It is the consequences of our behavior that determines whether the behavior continues.  When there is no consequence, the behavior continues. 
 
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Topics: TMS Therapy Treatment

Robert A. Sammons, Jr., M.D., Ph.D.

Written by Robert A. Sammons, Jr., M.D., Ph.D.

Dr. Bob Sammons received a bachelor's and master's degree from Auburn University, a PhD in clinical psychology from the University of North Carolina at Greensboro, and a medical degree from the University of North Carolina at Chapel Hill. He did a residency in psychiatry at the University of Virginia as well as a forensic psychiatry fellowship. While a Captain in the Air Force he helped set up and run the treatment phase of the Air Force Drug Treatment program in 1971. He has practiced adult psychiatry in Grand Junction for 29 years. He received training in TMS in 2006 from Dr. Alvaro Pascual-Leone, from Dr. Mark George in 2017 and returned to Harvard for Dr. Pascual-Leone's intensive course in TMS in 2018. He is Medical Director for TMS Solutions with TMS offices in various locations in the West. He has been known to cook a little BBQ.