Worry Decision Tree
Worry is a cognitive process that involves thinking about problems that might happen in a way that can leave you feeling anxious or apprehensive. Not all worry is problematic – we all foresee difficulties in our lives and spend some time anticipating ways around potential obstacles. However, people with generalized anxiety disorder (GAD) and problematic worry experience it more often, as more uncontrollable, and may even end up worrying about their worry (meta-worry). The worry tree is a way of conceptualizing some of the important steps in the treatment of generalized anxiety disorder (GAD) and communicating these to clients. It systematically guides clients to distinguish whether they are experiencing real event or hypothetical event worry, and then to engage in problem-solving (real event worry) or distraction / worry postponement (hypothetical event worry).
Worry is a cognitive process that involves thinking about problems that might happen in a way that can leave you feeling anxious or apprehensive. Not all worry is problematic – we all foresee difficulties in our lives and spend some time anticipating ways around potential obstacles. However, people with generalized anxiety disorder (GAD) and problematic worry experience it more often, as more uncontrollable, and may even end up worrying about their worry (meta-worry). Psychologists often distinguish between ‘real event worry’ and ‘hypothetical worry’.
- Real event worry. Real event worries are about actual problems that are affecting you right now, and about which you can take action. In response to a real event worry, we can implement strategies to try and solve them and therefore alleviate some of the anxiety that they induce. For example, following an argument with a romantic partner, we can reduce the resulting worry by immediately apologizing to them or attempting to resolve the cause of the argument.
- Hypothetical event worry. Hypothetical event worries are about things which have not yet happened, but which might happen in the future. People with GAD tend to ask more “What if … ?” questions, and to worry about unlikely and remote future events. Their hypothetical worries often ‘chain together’, for example: notices daughter has a rash on her arm > “What if it’s meningitis?” > has image of daughter lying in hospital in intensive care > “I couldn’t bear it if she died”
An important first step in the treatment of GAD is training clients to identify that they are worrying and to learn to distinguish whether the worry concerns a real or hypothetical problem (worry awareness training). Subsequent steps in the worry tree branch in different directions depending on whether a worry is real or hypothetical. If a worry concerns a real event, then helpful strategies may include helping clients to develop their problem-solving skills by coming up with approach-oriented solutions (problem-solving). If a worry is hypothetical, then helpful solutions may include postponing the worry (worry postponement) and engaging in distraction or mindful awareness.
The worry tree is adapted from Butler and Hope’s (1995) approach to worry and anxiety. It is a way of conceptualizing some of the important steps in the treatment of generalized anxiety disorder (GAD) and communicating these to clients. Many clients with GAD suffer from ‘analysis paralysis’ when having to deal with complex anxiety-provoking situations. Using the systematic approach outlined in the worry tree, clients are helped to view these situations as more manageable once they have distinguished what type of worry they are facing, and therefore narrowing down potentially appropriate responses. “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).
The Worry Decision Tree can be used to help clients to conceptualize and manage their worries by following the steps of the flow diagram:
- The initial step is to notice that worry is occurring.
- The next step is to identify whether this is a real event worry about which something can be done, or whether the worry concerns a hypothetical future event about which it is not possible to act.
- If action is possible it must be determined whether this can happen immediately (in which case it is to be actioned immediately), or whether it can happen at some time in the future in which case specific plans are made before the worry is set aside and attention focused elsewhere. GAD clients with negative problem orientation may find approach-oriented strategies such as problem-solving helpful.
- If the worry is hypothetical and action is not possible, then the worry is to be set aside and attention focused elsewhere. Clients may find it helpful to engage in worry postponement as a behavioral experiment, or to practice reorienting techniques such as mindful awareness.
- Butler, G., Hope, T. (1995). Manage your mind. Oxford: Oxford University Press.
- Wilkinson, A., Meares, K., Freestones, M. (2011). CBT for worry & generalised anxiety disorder. London: Sage.