Worry Flowchart

Sibrava and Borkovec (2006) describe the attitude underpinning worry as follows:

The world is potentially dangerous and I may not be able to cope with whatever comes from the future, so I must anticipate all bad things that might happen so that I can avoid them or prepare for them

(Sibrava & Borkovec, 2006).

Various cognitive behavioral approaches to GAD and worry have been described and researched in detail (for a review, see Behar et al., 2009):

• Early cognitive behavioral approaches to GAD were derived from Beck and Emery’s (1985) cognitive therapy for anxiety. They aimed to help clients view their worries from a more realistic perspective and reappraise concerns relating to vulnerability. Key interventions included the analysis of faulty logic, reattribution, exploring alternatives, decatastrophizing, hypothesis testing, self-instructions, and relaxation. Wilkinson and colleagues (2011) describe these as ‘first generation’ treatments; examples include Butler and colleagues (1987), Barlow and colleagues (1992), Zinbarg and colleagues (2006).
• The avoidance model of worry (Borkovec, 1994; Borkovec et al., 2004; summarized in Borkovec, 2006) proposes that worry is a verbal-linguistic, thought-based activity which inhibits vivid mental imagery: worry is seen as an ineffective attempt to solve and remove a perceived threat, while simultaneously avoiding unpleasant somatic and emotional experiences (Behar et al., 2009). Interventions derived from this model include worry self-monitoring, relaxation, self-control desensitization, stimulus control (i.e., worry postponement), worry outcome monitoring, developing a present-moment focus, and expectation-free living.
• The metacognitive model of GAD (Wells, 1995, 1997, 1999, 2004, 2005) proposes that metacognitive beliefs and appraisals are central to the development and maintenance of GAD. Positive beliefs about worry are said to lead to ‘type 1’ worries about non-cognitive (e.g., external) events. People with GAD are also said to have negative beliefs about worry, and may consequently worry about their worry (‘type 2’ worry), which drives ineffective strategies such as reassurance-seeking, thought suppression, and worry avoidance. Interventions derived from the metacognitive model target clients’ beliefs about worry and include tasks such as worry postponement, mismatch strategies, and worry modulation experiments.
• The intolerance of uncertainty (IoU) model (Dugas et al., 1998; Hebert & Dugas, 2019) is sometimes referred to as the Laval model (Wilkinson, Meares, & Freeston, 2011), and it identifies intolerance of uncertainty as a key maintaining factor in GAD. People with GAD find uncertainty or ambiguous situations stressful and upsetting, and use worry to either cope with feared events or prevent them from occurring. In other words, worrying is an attempt to increase certainty. The CBT-IU protocol derived from this model recommends interventions such as discriminating worry types (i.e., differentiating real and hypothetical worries), challenging beliefs about uncertainty, increasing tolerance of uncertainty, challenging positive beliefs about the function of worry, overcoming negative problem orientation, problem-solving, and imaginal exposure to feared hypothetical situations (e.g., Robichaud, 2013).
• Emotion regulation therapy (ERT: Fresco et al., 2013; Menin, 2004) proposes that people with GAD have a lower threshold for experiencing emotion, which tends to occur more quickly and easily, as well as a poorer understanding of their emotions. Consequently, they use worry as a regulatory strategy alongside other problematic behaviors. Interventions derived from this model include self-monitoring, mindfulness skills such as acceptance, allowance and decentering, cognitive reappraisal, values clarification, and acting in accordance with one’s values.
• Acceptance based behavioral therapy (ABBT: Roemer & Orsillo, 2009, 2014) draws upon CBT, ERT, and ACT approaches. It proposes that GAD is characterized by problematic ways of responding to internal experiences, as well as rigid experiential avoidance (e.g., thought suppression and avoidance). ABBT encourages “an expansive, compassionate, decentered … relationship with internal experiences; (b) acceptance of a willingness to have internal experiences; and (c) intentional engagement in personally meaningful, values actions” (Roemer & Orsillo, 2020). Treatment components include psychoeducation, developing habits of awareness and acceptance such as self-monitoring and mindfulness, values clarification, and valued action.

Positive beliefs about worry (which fuel worry) and negative appraisals of problem-solving ability (i.e., negative problem orientation) lead many clients with GAD to experience ‘analysis paralysis’ when dealing with complex or anxiety-provoking situations. To help clients respond more effectively to worry, Leahy and colleagues (2012) present a menu of possible interventions. Butler and Hope (1995) take a graphical approach, describing a series of strategies for helping people to manage worry, including turning “worry into an action”: their ‘worry decision tree’ outlines a sequence of steps for dealing with worry. Informed by this visual intervention, the Worry Flowchart presents a way of structuring some of (what are believed to be) the most important, accessible, and effective steps in treating GAD. In addition:

The key message for the client at this phase in treatment is that there is a better alternative to worrying about life’s problems, and that is to improve the way in which they approach problems and implement problem solving skills

(Wilkinson, Meares, & Freeston, 2011).

Steps in the Worry Flowchart branch in different directions depending on whether a worry is real or hypothetical. Once a worry has been addressed, the Worry Flowchart prompts clients to direct their attention away from worry and toward what is important to them (consistent with the notion of ‘valued living’ in ACT; Hayes et al., 2016). Similarly, Butler and colleagues (2018) offer a helpful quote from the Buddhist monk Santideva, who said, “If the problem can be solved, why worry? If the problem can’t be solved, worrying will do you no good.” They suggest that, once other strategies have been used (or ‘exhausted’), distraction can be helpful.

"Worry is a way of thinking about potential problems that leads to anxiety. It’s not always unhelpful – sometimes it motivates us to solve problems – but it can be a big problem. For instance, your mind might make scary predictions about the future, which chain together and branch into increasingly extreme scenarios. Does that sound familiar to you? This Worry Flowchart describes some of the ways you can deal with your worries when they show up. Would you be willing to go through it with me?"

Are you worrying?

Clients begin by answering the question, “Am I worrying right now?”. If they are unsure, remind them that worry involves thinking about things that might happen and often takes the form of “What if… ?” statements. Some protocols recommend pausing three times daily at predetermined times to record any worries that are present (e.g., Robichaud & Dugas, 2006). For example:

• "The first step of this flowchart is asking yourself, “Am I worrying about something?” Is there something you are worried about right now?"

Describe what you are worrying about

Encourage the client to write a short description of what they are worrying about. The aim is not to write an exhaustive statement, but instead to capture key worry themes in sufficient detail so that the client can judge the next step:

• "The next step is writing a brief summary of your worry. Can you describe what it’s about in just one or two sentences?"

Is your worry about a current real problem or a hypothetical situation? 

Help the client distinguish between a worry about a current, real problem, and a worry about a hypothetical situation. Wilkinson and colleagues (2011) argue that this form of worry awareness training is an essential step in treating GAD. You might say:

• "You need to decide if your worry is about a current real problem or something hypothetical. Real event worries are about actual problems that you are currently facing. An example of a real event worry might be how you will afford to pay a very expensive bill. Hypothetical event worries are about problems that don’t currently exist but could happen in the future. An example of this might be worrying about becoming seriously ill and not being able to look after your family."

Robichaud and Dugas (2006) note that clients sometimes find it difficult to make this distinction because it isn’t always clear-cut. In this case, they recommend reinforcing the importance of taking action despite uncertainty, which is an important component of their treatment program.

Strategies to manage a hypothetical worry

If the client’s worry relates to a hypothetical event, the flowchart guides them towards appropriate strategies. They include:

• Record the worry in a Worry Outcome Record. Worry outcome records (also referred to as ‘worry outcome journals’, ‘worry outcome diaries’, or ‘worry logs’) are worksheets in which clients record the predictions associated with their worries, alongside actual outcomes. Later approaches to treating GAD emphasize focusing on the process of worry rather than the content: monitoring the outcomes of worries (i.e., whether predicted outcomes materialize) can help to challenge positive beliefs about worry and to “recognise that their worries are both highly unlikely and costly” (LaFreniere & Newman, 2020). Wells (1997) describes a similar technique called the ‘worry mismatch strategy’: positive beliefs about worry are modified by comparing the content of worry with actual events, demonstrating that they are not an effective way of anticipating or coping with future problems.
• Postpone the worry. Borkovec and colleagues (1983) describe ‘stimulus control’ for worry, which involves postponing worries until a pre-determined, half-hour ‘worry period’ to help reduce their occurrence. A similar technique is used by Wells (1997) but is framed as a behavioral experiment to test beliefs about the uncontrollability of worry.
• Practice tolerating uncertainty. The IoU model emphasizes that clients with GAD are especially sensitive to uncertainty – an analogy is sometimes made to allergies whereby even a small amount of exposure can lead to a strong reaction. Clients can be reminded that tolerating uncertainty will help adjust their attitude towards it. Tolerance of uncertainty is enhanced using a variety of methods, including deliberate exposure to ambiguous situations and behavioral experiments to test negative beliefs about uncertainty (e.g., Robichaud & Dugas, 2015).

These can be introduced in the following terms:

• "If your worry is about something that might happen, the flowchart takes you to a few strategies that might be helpful. Let me explain them to you so you can decide which ones you’d like to try."

If this problem was solved, how would your life be improved?

If the client’s worry relates to a current, real problem, the flowchart prompts them to consider what would improve if it was solved. The IoU model proposes that a key maintaining factor in GAD is a ‘negative problem orientation’: individuals who worry not only tend to view problems as threats rather than challenges to be overcome, but also doubt their capability to solve problems effectively (Dugas & Robichaud, 2007). One technique for helping clients develop a positive problem orientation is to consider the potential benefits of solving it and/or rate problems on a continuum from ‘threat’ to ‘opportunity’, so they are no longer seen as entirely threatening (Robichaud, 2013). Questions could include:

• "If your worry is about a real problem you are facing, think about how your life would improve if you solved it:"
  • "What benefits would come with addressing this problem?"
  • "Are there any other opportunities in this situation for you?"
  • "Imagine a line that goes from 100% threat at one end to 100% opportunity at the other. Where on that line would you put this problem? If it is not 100% threat, what opportunities might it offer you?"

Can you take action right away to solve this problem?

Solving a problem can terminate a worry. Research suggests that negative problem orientation and intolerance of uncertainty is associated with poorer problem-solving (e.g., Robichaud et al., 2006, cited in Dugas & Robichaud, 2007). Accordingly, the next step in the flowchart asks clients to consider whether they can act immediately to solve the problem they have identified. Consider asking:

• "The next step is thinking about whether you can do something to solve the problem right now. Is there an immediate action you could take to fix it?"

Strategies to manage a current real problem which cannot be solved right away

If the client does not believe they can take action right away, they are directed to other interventions for managing real event worry. They include:

• Problem solving. Making a practical plan – or ‘turning a worry into an action’ – is an effective strategy for resolving problems that can’t be immediately addressed (Dugas & Robichaud, 2007). Clients are asked to list potential solutions, identify the best (or least bad) option, and plan when they will put it into action.
• Postpone the worry. Clients can practice postponing the worry to reduce its occurrence and test their beliefs about the uncontrollability of worry (Borkovec et al., 1983; Wells, 1997).
• Practice tolerating uncertainty. Finally, clients are reminded that tolerating uncertainty is beneficial in terms of testing negative beliefs about uncertainty and reducing worry in the long term, as well as increasing their self-confidence.

These interventions can be introduced in the following way:

• "If your worry is about a real problem that can’t be addressed right away, the flowchart outlines some strategies that could be useful. Let me explain them to you so you can decide which ones you’d like to try."

Decide what you will do to solve the problem right away

If the client believes that they can act to resolve the problem immediately, they are encouraged to outline what they intend to do. Unfortunately, individuals with GAD often struggle to use their problem-solving skills effectively due to their negative problem orientation and intolerance of uncertainty (Dugas and Robichaud, 2007). Accordingly, they may need support working through the steps of problem-solving systematically. Detailed guidance on problem solving is available in the Psychology Tools’ Problem Solving exercise. Consider asking:

• "If your worry is about a real problem that can be addressed right away, the best thing you can do is take immediate action. You can use the box in the flowchart to write your plan of action, including what you will do and when. If you’re unsure of what to do, problem-solving can help. Would you like me to explain the steps of problem-solving?"

Take action now to solve this problem

Encourage the client to take action to solve their worry:

• "Now that you have an action plan, the only thing left is to do it and see what happens. Are you ready to take action?"

Are you still worrying?

This step aims to establish whether taking action has resolved the client’s worry and if there are residual worries that need to be addressed. If the client identifies additional worries, they are directed back to the beginning of the flowchart. If not, they proceed to the next step. You might say:

• We’ve almost reached the end of the flowchart. Are you worrying about anything? If so, you can go back to the beginning of the flowchart and use it to address your other concerns.

Choose to focus on what is important to you right now

ERT and ABBT (as well as ACT more broadly) identify values clarification and valued action as important components in the treatment of GAD. At a more surface level, clients are encouraged to shift their focus of attention away from worry and towards something more meaningful. Alternatively, some clients may benefit from a more in-depth exploration of their values and potential valued actions, as well as acceptance of the anxious feelings that might ‘show up’ in the process of doing so. Suggest that the client focus on what really matters to them:

• "Rather than focusing on your worries, how could you move in the direction of your heart’s deepest desires in this moment?"
• "What steps could you take towards living the most meaningful life possible?"
• "If worry weren’t a problem, what would you choose to do right now?"
• "Would you be willing to accept worry if it meant being the kind of person you want to be?"

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