Worry Flowchart
Worry is a cognitive process that involves thinking about problems that might happen in a way that causes anxiety. Not all worry is problematic – we all foresee difficulties in our lives and anticipate ways we could address potential obstacles. However, people with generalized anxiety disorder (GAD) worry more often, find it harder to control or interrupt, and experience emotional and physiological consequences such as feeling on edge and having disturbed sleep. They may even worry about their worry! The Worry Flowchart is a way of conceptualizing some of the important steps in the treatment of generalized anxiety disorder (GAD) and communicating them to clients. It systematically guides clients through helpful, empirically supported interventions, including worry awareness training, distinguishing between real and hypothetical worries, worry outcome monitoring, postponing worry, tolerating uncertainty, developing a positive problem reorientation, problem-solving.
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Introduction & Theoretical Background
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
Therapist Guidance
"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
References And Further Reading
- Barlow, D. H., Rapee, R. M., & Brown, T. A. (1992). Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23, 551-570. DOI: 10.1016/S0005-7894(05)80221-7.
- Beck, A. T, & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. Basic Books.
- Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23, 1011-1023. DOI: 10.1016/j.janxdis.2009.07.006.
- Borkovec, T. D., Wilkinson, L., Folensbee, R., & Lerman, C. (1983). Stimulus control applications to the treatment of worry. Behaviour Research and Therapy, 21, 247-251. DOI: 10.1016/0005-7967(83)90206-1.
- Butler, G., Cullington, A., Hibbert, G., Klimes, I., & Gelder, M. G. (1987). Anxiety management for persistent generalised anxiety. British Journal of Psychiatry, 151, 535-542. DOI: 10.1192/bjp.151.4.535.
- Butler, G., Hope, T. (1995). Manage your mind: The mental fitness guide. Oxford University Press.
- Butler, G., Grey, N., Hope, T. (2018). Managing your mind: The mental