Clinician's Guide to the Worry Less, Live More protocol for Low Intensity CBT for GAD by The CBT Resource by Marie Chellingsworth

The Clinician’s guide to supporting the ‘Worry less, live more with GAD’ protocol

Marie Chellingsworth

Photography by Andy Poplar [Vinegar & Brown Paper]®

© 2020 Marie Chellingsworth. The CBT Resource®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license as a read only document for The CBT Resource Annual CPD & Resources membership holders only. It may be used by the membership holder only for their own individual use in 2020/2021, in the original binding. It cannot be downloaded, photographed, sent electronically, hosted electronically or used by any other party under the conditions of membership. This condition must be imposed at all times and this work cannot be sold for profit, used for training others by the member or any other party, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the individual license holder. The etched glass photography used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper]®. They are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression). All other images are used with permission from Unsplash in accordance with their policy. We would like to thank the focus groups and various service practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score of the associated patient protocol material is 12.9 and the Flesch reading ease is 81, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with the patient workbook material and support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol alongside this guide. Disclaimer: This Clinician’s guide is to be read and used clinically alongside the patient workbook ‘Worry less, live more with Generalised Anxiety Disorder (GAD)’ at all times. It is licensed in conjunction with training in using the protocol from the author. It is not a substitute for training and should only be used by those suitably qualified to support the protocol. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The assessment and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice.

Contents

1-4

Introduction

5-8

Introducing worry management for GAD

9-12

The protocol and session outlines

13-14

Progressive Muscle Relaxation

15-16

Worry classification

17-18

Why thought suppression doesn’t work

19-20

Worry time

21-22

Refocusing attention

23-24

Practical problem solving

25-26

The importance of homework and structure

Managing endings

28-30

Useful references

About the author and Andy Poplar’s work

Introduction

This protocol presents an opportunity for the Low Intensity CBT practitioner and Supervisor to review the skills; competencies and knowledge needed to effectively and efficiently deliver the Low Intensity CBT GAD protocol: ‘Worry less, live more’ 3rd Edition. (Chellingsworth, 2020). GAD patients report feeling anxious most days and experience a range of autonomic, cognitive and behavioural symptoms. As the worry is predominantly future focused, the fear defence cascade is a passive ‘freeze’ based response. Sympathetic and parasympathetic components are coactivated. Vagal inhibition opposes the sympathetic activation to enable the freeze response and make covert the effects of arousal. This prevents external expression of arousal symptoms. The primary autonomic changes of a passive freeze response cascade are aimed to help vertebrates to stay as still as possible, enabling them to be attentive to the threat, scan the environment (or in the case of GAD the threat) and prepare to further respond, without being seen or drawing attention to themselves. The muscles tense further with a heightened muscle tone specific to a freeze response. Attention focuses onto the threat. In GAD this is the content of the worries, so attention is focuses internally, distracting the person from being focused in the present moment. When the threat is further away, a freeze 1

based response makes sense, it enables time to further prepare or assess when you cannot flee to safety (without making it worse) and you cannot fight or deal with it right now, as the threat is in the future and not imminent. The theme of GAD is worry and metacognitive worry (type II worry) where the person begins to worry about worrying itself. People with GAD struggle with situations or events that seem uncertain, unpredictable or uncontrollable (known as the 3U’s). They experience anxiety in response to range of everyday life domains such as relationships, health, finances, school or work. Adaptations to behaviours to try to manage anxiety and maintain a sense of control, certainty and predictability are therefore used. These strategies, such as the worrying itself, avoidance, reassurance seeking, overpreperation and procrastination give some initial symptom relief, but do not resolve the anxiety in the long term, playing a key maintaining the problem and adding further difficulties into their life domains. GAD can often be misdiagnosed, but a through assessment and symptom clustering of situational examples of worry and a timeline assists greatly with this. As does a good understanding of the fear defence responses and themes of each disorder. GAD has a predominant freeze based response as the threat (worry) is future focussed. Some other anxiety disorders also show passive freeze based responses at times, but also active © Marie Chellingsworth (2020). The CBT Resource.

fight or flight responses in other situations depending on the proximity of the threat. This includes social anxiety disorder and health anxiety disorder for example. So the purpose of funnelling in the assessment is to gather specific recent in situation examples to symptom cluster to see if the response differs according to the situation and proximity of the threat, e.g. build up to events, during an event, after an event or as relevant to the patient presentation and symptom profile.

the parasympathetic branch of the autonomic nervous system, responsible for calming organs. It does not operate under conscious control and is responsible for regulation at rest. It also plays a role to reset the immune system and switch off inflammation when no longer needed. A reduction in vagal tone means the body takes longer to relax and regulate after periods of stress or threat and can also lead to chronic inflammation in the body.

The content of the individual worries are the idiosyncratic patient concerns as specific negative automatic thoughts. Worry itself is verbal linguistic, a thought based behavioural activity (Behar, Zuellig, & Borkovec, 2005; Borkovec & Inz,1990). People worry in a chain of words, attempting to problem solve an uncertain, unpredictable or uncontrollable situation. While the chains of worries are a behavioural attempt at problem solving, it is ineffective and both practical and hypothetical worries become treated in the same way.

GAD was only first introduced as a unique diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association [APA], 1980) but was often only used as a residual diagnosis, a catch all for individuals who did not meet the diagnostic criteria for another anxiety disorder (Barlow, Rapee, & Brown, 1992). It was not until the publication of DSM-III-R (APA, 1987) that GAD was uniquely defined by chronic and pervasive worry (Barlow, Blanchard, Vermilyea, Vermilyea, & Di Nardo, 1986). As a result, GAD is still seen as a relatively new anxiety disorder in it’s own right. This can unfortunately lead to a lack of awareness and understanding about the disorder in a minority of health professionals who believe, wrongly, that GAD does not exist or is not possible to treat. This view must be challenged and NICE guidelines (2011, last reviewed July 2019) provide a thorough overview of the evidence to refute this worryingly out of date view.

Worry has also been shown to inhibit vivid mental imagery and associated fear activation and can therefore be seen as an avoidance strategy. In other words, patients with GAD report lower imagery than can be observed in higher active defence response arousal disorders. Research has shown GAD patients to have autonomic inflexibility, with worry causing phasic reduction in vagal tone compared with non GAD populations. The vagal tone is a cranial nerve. It is a fundamental component of © Marie Chellingsworth (2020). The CBT Resource.

NICE recommends the use of supported Low Intensity CBT and states that patients have this treatment using a self-help material of a suitable reading age, with support from a trained practitioner in approximately six 20-30 minute sessions. Treatment can also be delivered in an interactive group format or as a non-supported intervention, defined as having brief telephone support calls of a few minutes duration. The ‘Worry less, live more’ protocol is based upon the avoidance function of worry. It utilises worry management techniques to strengthen the adaptive opposite of the key maintenance symptoms. Due to the lower autonomic arousal symptoms in a freeze response and the inhibition of somatic and emotional experience, this precludes the emotional processing of fear that is theoretically needed for successful extinction (Foa & Kozak, 1986; Foa et al., 2006). Therefore exposure based paradigms are not possible as the person does not exhibit enough arousal for habituation to take place. The avoidance function of worry (Borkovec,1994; Borkovec et al., 2004) is based on Mowrer’s (1947) two-stage theory of fear and the emotional processing model (Foa & Kozak, 1986; Foa, Huppert, & Cahill, 2006). Worry postponement techniques were first described by Borkovec and colleagues (Borkovec, Wilkinson, Folsenbee & Lerman., 1983) with a prescribed method for stimulus

control of worry, deliberately enabling worry to be delayed until a set period each day. Worry postponement has been shown to produce significant reduction in levels of worry each day when applied correctly. An important aspect of the protocol is the Progressive Muscle Relaxation to increase kinaesthetic awareness of tension held in the muscles as a change method from session one onwards. The protocol also involves classifying and postponing hypothetical worries and taking action on practical worries straight away to target procrastination, using practical problem solving if required. It is important that clincians are familiar with all these change methods and the supporting scaffolding techniques such as external focus of attention, as unlike in exposure and habituation for panic and phobias or BA for depression, treatment for GAD requires a multi-strand approach. This requires a thorough understanding of the purpose of each change method and what symptom(s) they target, when they are best introduced and how to implement them correctly to get an adequate treatment dose.

Introducing a CBT approach for GAD Practitioner: “You may have noticed that I asked you about three main areas today, how your anxiety and worries have affected you physically, how they have affected what you are doing or not doing and how it has affected your thinking, as on this diagram here. That is because these three areas are interlinked and can have a knock on effect on each other. For example, when people are feeling anxious and have lots of worrying thoughts, they may notice symptoms physically like muscle tension, headaches and poor sleep. They may avoid doing activities that feel uncertain or not easy to control or predict, they might seek reassurance from other people, put things off, or over-prepare for them. This initially gives some relief from how they are feeling and thinking in the short term. In the longer term however, it leads to more worries, more physical symptoms and more anxiety in a vicious circle of worry that keeps going round and round. Is that something that you feel fits with how you have been feeling?” Patient: “Yes exactly” Practitioner: “Just to check your understanding and that I have explained it well enough, could you perhaps explain back an example of how your symptoms we discussed are affecting each other in the cycle, perhaps using your sleep for example?” Patient: “So I am tense all the time. I worry about work and my students, my own children being at university and things at home. I am not been sleeping well, feel tired all the time and wake up early worrying. I worry I will make a mistake at work and end up getting fired, so I take it home to double check, spending the evenings going over it, which then makes me even more tired. I get horrible headaches and so on....” Practitioner: “Yes absolutely, it seems you have a really good understanding. The good news is that we can do things that will break into the cycle to help to reverse it. I can explain more about the recommended treatment options to do that if you would like me to?……..” Patient: “Yes please”

The ABC maintenance cycle of GAD

A: Physical Symptoms Muscle tension Difficulty concentrating Sleep problems Feeling on edge Butterflies in tummy Restlessness Headaches Gastro-intestinal upset

B: Behaviours Avoidance of situations that are unpredictable, uncontrollable or uncertain Seeking reassurance from others Over-preperation Procrastination Attempts to control worrying

C: Negative Thoughts Excessive worrying ‘What if...’ thoughts (apprehensive expectation) about life situations such as work, finances, health, relationships, work/school Worries about worrying itself

It is helpful to introduce the idea early on that the worry management process focuses on dealing with the symptoms of worry overall, not managing the content of individual worries by using a suitable analogy. The analogy is then something that can be linked back to when explaining thought suppression, refocusing attention, or if the focus of a particular sessions begins to drift onto individual worry content the patient wants to discuss for reassurance, rather than the process of worrying: Practitioner: “In GAD, the worry is it like having a bubble machine in your mind, constantly churning making more and more bubbles of worry......each worry bubble takes your attention and focus away from what is going on around you. The anxiety is distressing and feels really unpleasant. It is understandable that people with GAD often try to push their worries out of their mind. When you try and push the worries away though, your mind will keeps bringing them back to your attention, increasing your anxiety and leading to more worries and more unpleasant feelings that you were trying to avoid in the first place. People also try to control and deal with each new worry as it arrives, by going over and over it in their mind. In the short term this may give some initial relief, but it does not last and more worries come along. If you try to pop each worry bubble by dealing with the content of the thought; it is exhausting and the machine is still churning out more new worries, so there is always something that replaces the worry you have dealt with. The worry protocol helps to switch down the power to the bubble machine, to help you to feel more in control of your worries,rather than them controlling you” Another thing it can also be helpful to address in early sessions of treatment, usually in the first session after setting goals, or when a relevant point comes up, is the role of reassurance seeking and agree how you will manage this together in session. Practitioner: “Sometimes people who worry will try to seek reassurance in sessions without realising they are doing it, because they are feeling anxious at that time. If I give them that reassurance, I am not helping to manage the problem effectively. So, can we agree a way forward with that? The first time you ask a question, I will give you a factually accurate answer, to the best of my ability if I can answer it for you. If you ask me the same question again at any point, I will draw your attention to what may be happening, to help you to break the cycle. Is that OK?”

Creating a problem statement and linked goals in GAD The problem statement is the baseline of the symptoms that the patient presents with at the start of treatment and written in the negative, first person. It should be clearly disorder specific and the recognised ABC symptoms of the disorder visible. These symptoms are then the targets for the intervention chosen and goals are set from the problem statement and written in positive terms of where the patient wants to be if these symptoms improve e.g.: Practitioner: So from the problem statement symptoms, we can move to set treatment goals around these. If you visualise that these symptoms [add relevant patient specific examples here from the statement] have improved, how would daily life be different to now? Where would you be going? What would you be doing? How would you be spending the time that you would have no longer worrying for example? A clear link in the mind of the practitioner and patient to these symptoms and how the planned intervention will target them is essential. The goals the patient is guided to set should be stated in the positive and be things that are realistic and attainable should the symptoms improve. For example, sleeping better, spending more time with their children, able to go on holiday etc.. This is important to outcomes and structure within LICBT work. Unclear or absent problem statements and misaligned or poorly constructed goals that are not linked to symptom reduction contribute to problems managing time or the structure of sessions effectively. The problem statement and clear aligned goals can help patients to recognise the session structure and focus and work within it. It can also enable the practitioner to gently remind the patient of the importance of this focus in the agenda at each session and then to maximise the use of the session to work on these problems. Clear linked goals for the problem statement below, would be a specific, measurable goals on improved sleep, spending more time with their children and their partner, feeling able to meet with their boss and not bringing work home in the evenings and weekends.

“My main problem is being worried and anxious all the time. Physically I feel tense, nauseous and get headaches. I don’t sleep well, waking up worrying. I worry about my job, my partner and my children. I avoid meetings or reviews with my boss, bring lots of work home with me in the evenings and at weekends and seek lots of reassurance from friends and family. As a result, I feel exhausted, struggle to concentrate and don’t spend enough time with my family and I am arguing more than usual with my partner”

The Worry less, live more Protocol for GAD The ‘Worry less, live more’ protocol for GAD is based upon the avoidance theory of worry and targets change by strengthening the adaptive opposite of the key underpinning maintenance symptoms. In line with NICE guidelines, the protocol should be delivered by a trained practitioner, supporting the ‘Worry less, live more’ self help material which has been tested to conform to good practice guidelines in self help and to have a suitable reading age. It is typically delivered in up to 6 sessions of support, dependant upon patient response and engagement to treatment homework (the treatment dose) with each session lasting up to 20-30 minutes for the main protocol change methods, phased out as required as treatment progresses towards discharge. The change methods and scaffolding components of the protocol are:

Change Method/Technique

Target

Duration/Dose

Progressive Muscle Relaxation (PMGR)

To increase kinaesthetic awareness of tension in the body and early warning signs of anxiety. Allows the body to notice early warning signs and to let them go during everyday waking life. Reduces tension and associated physical complaints, irritability and improves sleep. Reduces the frequency of worries over time and breaks into the incubating maintenance cycle of worry and tension.

Once or twice daily at a neutral time over 12 weeks from first session of treatment, so the patient should continue practice post discharge.

Classifying Worries

A scaffolding process to help the patients to classify the two different types of worries and take action on practical worries without procrastination and to learn that they have more hypothetical worries which can then be managed with WT

1 week alongside PGMR practice, then replaced with keeping a worry list for worry time. Should be reviewed in the subsequent session homework review and then the classifying principles reinforced throughout treatment.

Worry Time (WT)

To provide an effective strategy to manage worries more effectively and reduce affect, to decrease worry being interpreted as a helpful strategy and increase aversion through paradoxical intention (deliberate worrying during worry time)

Daily practice until the patient reports they no longer need to use worry time, report fewer hypothetical worries and a decrease in anxiety

Should be task reinforced as a weekly homework item and reviewed with the patient at regular intervals through treatment.

Refocusing Attention

A scaffolding technique to refocus attention on the present with a task, to ensure that patients are able to let go of a hypothetical worry once it is written down in WT and that they do not use thought suppression strategies that take their attention further away onto the content of worries and suspend worrying temporarily.

Used after writing down a worry on the worry list in WT before their next WT period, as needed to refocus to refocus their attention back away from the distraction of the worry content.

APPLE Technique

A scaffolding exercise to help the patient to refocus their attention away from a hypothetical worry about an uncertain situation.

Used after writing down a worry on the worry list in WT before their next WT period, as needed to refocus to refocus their attention back away from the distraction of the worry content.

Managing Thought Suppression A short one-off scaffolding exercise to help the patient to learn why thought suppression is unhelpful and leads to rebound thoughts, increased anxiety and parallel thoughts. Problem Solving (PT)

For targeting procrastination, uncertainty, unpredictability and uncontrollability of practical worries when an immediate solution or action to take to resolve the practical problem is unclear.

Used once if needed as the patient engages in thought suppression and to illustrate why this is not something to use between worry periods in WT. This change method is used for practical problems when the patient is unsure what action to take to resolve a practical worry or is procrastinating on doing so, leading to further uncertainty and anxiety. Teaching of this change method is helpful for all patients, but not all may need to put it into action.

The ‘Worry less, live more’ Protocol for GAD Typical Treatment Outline Note: This is not a rigid, prescriptive list but an indicative treatment structure to enable the correct dose of the change methods as homework during a course of brief LICBT from the first session. PGMR should be front-loaded from the first session in all cases as the first change method. Worry time is also used by all patients. Problem solving is problem solving is there for additional support on practical worries, if required. Session 1: 1. Agenda Setting 2. Socialisation to the CBT maintenance model of GAD 3. Treatment rationale given for worry management techniques 4. PGMR introduced and practised briefly 5. Worry list, the two types of worries and classifying tool introduced 6. Homework tasks agreed and plan written down 7. Ending Session 1 Homework: 1. PGMR daily practice 2. Worry list and catching and classifying types of worry as they occur Session 2: 1. Agenda Setting 2. Review PGMR homework practice, reinforce the benefits of daily practice throughout treatment and that it takes time to reach an optimal dose and the changes happen in the background to reduce early warning signs of tension. Review any learning or manage any difficulties in implementation 3. Review the worry list, classifications and learning that they have taken from this, e.g. that usually most worries are hypothetical. Reinforce the hypothetical nature of worries. Clarify any misunderstandings in classification. 4. Introduce why hypothetical worries stay in the mind and why thought suppression can backfire using the suggested exercise in the patient material with part 1 and 2. Explain trying not to think about an anxiety related thought leads to the rebound effect, increasing emotion and parallel thoughts. Explain how worry management offers a way of allowing worries to take place, but in a controlled way, whilst reducing their frequency and intensity over time. 4. Introduce worry time and refocusing as a way to manage hypothetical worries and what to do within their worry time period. Agree the time they can set aside each day and how to manage worries by refocusing outside of this time and not suppressing thoughts, allowing them to come back and just repeat the process 3.Briefly introduce the principle that for true practical problems the patient should take an action straight away to target procrastination as soon as the worry occurs. If they are unsure of the action to take or feel overwhelmed, problem solving can be used as and when needed, showing the relevant material section 5. Homework tasks agreed and plan written down 11

6. Ending Session 2 Homework: 1. PGMR daily practice 2. Worry Time and refocusing outside of worry time 3. Taking action on any practical worries that arise there and then, with problem solving steps used if required Session 3: 1. Agenda Setting 2. Review worry time homework, pulling out learning and any improvements in frequency of worry or aversion to worrying purposefully and the implications of this 3. Review and reinforce (briefly) PGMR week 2 practice and any learning or improvements in symptoms from practice or any difficulties in implementation and manage these 4. Review worry time homework, pulling out learning and any improvements in frequency of worry or aversion to worrying purposefully and the implications of this 5. Review problem solving (if required) and if procrastination has reduced as a result of classifying worries and worry time 6. Homework tasks agreed and plan written down 7. Ending Session 3 Homework: 1. PGMR daily practice 2. Worry Time and refocusing outside of worry time 3. Taking action on any practical worries that arise there and then, with problem solving steps used if required Session 4+: 1. Agenda Setting 2. 3. Review and reinforce (briefly) PGMR week 3 practice and any learning or improvements from practice or any difficulties in implementation and manage these 4. Review problem solving (if required) and if procrastination has reduced as a result of classifying worries and worry time 5. Homework tasks agreed and plan written down 6. Ending Session 4 Homework: 1. PGMR daily practice 2. Worry Time and refocusing outside of worry time 3. Taking action on any practical worries that arise there and then, with problem solving steps used if required Depending on progress either moving to relapse management and end of treatment or continuation of treatment change methods and homework as needed. © Marie Chellingsworth (2020). The CBT Resource.

Progressive Muscle Relaxation

Progressive Muscle Relaxation was first published by Jacobsen (1934) and subsequently adapted by Wolpe (1948) and Bernstein and Borkovec (1973) in their guidebook. It is recommended in clinical guidelines as a change method for both GAD and insomnia difficulties and has a wide supporting evidence base if used correctly. It is also widely used for anxiety management in cancer care, irritable bowel-syndrome and other conditions. PGMR is not to be confused with applied relaxation, in which patients tense muscles whilst using imaginal techniques to reduce fear outside of the evidence base for GAD and the focus of the patient during treatment is on these images or relaxing sounds. Some confusion exists in published worksheets and materials where these techniques can wrongly be assumed the same, but they target different things. In PGMR the aim of the intervention is to reduce tension and full focus should be on the muscles throughout treatment, in the present moment. The person using PGMR should not be distracted by any music, imagery or other alterations to the protocol. Tension is a primary autonomic symptom in GAD, due to the ‘freeze’ response to the future focused apprehensive expectation. PGMR directly targets tension and the impact it has both on incubating more worries and its secondary physical symptoms like pain, headaches, irritability or sleep difficulties. We all have a natural tension level load with carry with us in our bodies, much like a coiled spring. This tension load becomes higher in GAD and leads to more and more anxiety as a result, forming its own maintenance vicious cycle. Tension itself can be incubative and begin to trigger worrying at neutral times. PGMR helps the body to increase kinaesthetic awareness of early triggers of tension and anxiety and to let them go. As a result, enabling the person to be more calm and relaxed throughout the day and reducing symptoms as a result. This method has been found to be more effective than other methods of relaxation, which can actually increase the symptoms unhelpfully in the body due to their internal focusing effects and are not working on enabling the muscles to notice early warning signs of tension and let this go. In PGMR you firstly tense (5 seconds) and then relax (15 seconds) individual muscle groups in the body each day, paying careful attention to the differences in both tensed and relaxed muscle states. PGMR requires daily practice, once or twice per day and builds to an optimal dose in up to twelve weeks, therefore the patient should be encouraged to get into a routine with it and to continue it post treatment for as long as they find it beneficial. The patient should be advised the effects may take time to become noticeable and to continue their practice. Due to the dose of PGMR and its ease of being taught and its benefit across symptoms, PGMR should be introduced as the first change method to the patient at the start of treatment from the first session. 13

Practitioner: “From what you have said about your symptoms, this is something I would recommend may be useful for you to begin using. Would you like to make a plan to give this a try this week between now and our next appointment?” Patient: “I will try anything to sleep better and feel less tense and irritable.” Practitioner: “You can begin to use the PGMR technique straight away from today. It is tensing and relaxing the tension in each muscle group in turn. You tense for 5 seconds and then relax for 15, really noticing the difference between the two. We can practice today if that would be helpful, so you have experienced it?” Patient: “Yes that would be great.” Practitioner: “You do it daily, once, or ideally twice a day at first, at a set time each day when you are not feeling anxious, like after brushing your teeth to get into a routine with it. You only need to set aside around 10-15 minutes for each PGMR practice. PGMR isn’t a technique to practice when you feel anxious, it is a skill that needs practicing daily at a neutral, regular time to help your body to learn early warning signs of tension and relax your muscles more easily. Then it will enable your body to let go of tension earlier at other times during the day, including early signs of anxiety, helping you to feel less anxious and more relaxed during the day with regular practice.” Patient: “Great, yes.” Practitioner: “All the instructions are in the booklet that I will give you too, so that you can go through them again if you need to. Does it sound like you can set aside a few minutes each day for this.?” Patient: “Yes, mornings would be good when my husband is dropping the kids off at school and I can probably practice in the evening before bed too.” Practitioner: “Great, you can fill in the plan on the worksheet. You may want to set a daily reminder just before on your smart phone or device, this can really help to get into the routine of doing it the practice.” Patient: “That’s a good idea I can do it on my phone and watch.” © Marie Chellingsworth (2020). The CBT Resource.

Classification of worries

The next step in the worry management protocol, is to introduce the patient to the concept of catching their worries. Noticing when they have one, classifying it as practical or hypothetical. This is a simple scaffolding part of the protocol, to prepare the patient for the relevant change methods of either worry time for hypothetical worries or problem solving for practical problems that they procrastinate over as they are unsure of the solution to take. The patient keeps a simple worry list for a week and classifies the type of worry, as near to the time as possible, as either practical or hypothetical. This can usually be given as first homework in treatment session 1, alongside introducing PGMR daily practice as the change method, depending upon the time available in the session. The aim of classifying for a week is to help the patient to begin to notice when they are worrying early, rather than getting caught up in it, which will help with the worry time process. It also sets up the scene for the worry time change method and problem solving on practical worries to be introduced at the next session with a strong rationale. Often patients with GAD struggle to recognise hypothetical worries are not practical at the time they are worrying, as the content of their worries are about real life events in their day. The aim of keeping the list and classifying in the first week, is not so that the patient classifies every worry correctly straight away (although some manage to do so). It is beneficial for the patient to notice earlier when they are worrying and begin to question their worry and any actions they may or may not take. The action they may believe they need to take for a hypothetical worry is often unnecessary, does not resolve the worry, they may take an unhelpful action that is not their responsibility and the worry takes their attention away from where it should be at the time. Often patients with GAD take over control and responsibility for situations that are not necessary for them to take on, as a way of managing the anxiety they cause. Clinicians can also fall into an understandability trap with GAD. They fail to spot a worry is actually hypothetical, not practical, due to the practical nature of the situations people worry about being similar to those we also face. They may think ‘Well that is understandable, if I was in that situation, I would think/do the same too, so it is practical’. The clinician should remember that the beliefs in worry are shared by those without GAD and that treatment requires you to step back from applying your own views onto these situations and apply the criteria to classifying worries. 15

It is also helpful for the patient to learn to spot worries in the moment, as post treatment the aim is for them to be able to automatically classify them in their everyday life as they arise. To be able to reduce early signs of anxiety, let go of any hypothetical worries and not procrastinate on taking the actions needed to resolve truly practical worries. There is learning to take from the process of recording and classifying for the patient, giving them an opportunity to be able to see just how often they worry during the day, how many of these worries are hypothetical and what else they notice as a result of these observations e.g. they could be doing something else with all the time spent worrying, they felt anxious all day when they didn’t need to, things they worried about never happened or they coped with it if it actually did etc. This learning can be teased out in the next homework review, whilst setting up their worry time change method. Consider for example, someone who was worrying, as a manager, that her colleagues would not finish their work on a project she had given them on time as it was very busy period at work. In the end, she resolved this by stepping in and doing it herself. Therefore was this a practical worry? She describes feeling very anxious that if the work isn’t done on time, she would get into trouble with her manager. She thought it would be easier to do it herself and get it right, so she postponed her tasks to do the project work and took this back off her colleagues. Taking the work back, she described feeling more in control of the situation and this reduced the anxiety that she felt. However, was this a practical worry, something she could and should have taken action to resolve straight away? Was it really something that was her responsibility to do? Or was it an example of safety seeking by trying to gain control and certainty that the work would be done on time. Would her colleagues whose work it was definitely not have completed it? Or was this just a hypothetical worry? Of course, its easy to get into the patients perspective and the realness of the situation and miss the key facts surrounding hypothetical worries. When reviewing their worry classifications, time should be spent going through these to clarify the true definition of a practical worry being one they can and should deal with straight away, that does not take their attention away from where it should be at that time © Marie Chellingsworth (2020). The CBT Resource.

Managing thought suppression when introducing worry time

After the patient has begun to classify their worries as a scaffolding process, worry time can be introduced as the next change method. Worry time involves setting a period of time, once a day, in which they can worry as much as they want to. Outside of the planned worry time, it is important that the patient does not engage in thought suppression so this needs discussion. We are not telling the patient to ‘not’ think about their thoughts until their worry time. We are telling them they can worry about them later as much as they need to, by postponing them to a planned time they feel more in control of. It should be discussed with them that the same thoughts will likely pop back in, due to the nature of attention in anxiety and that is to be expected. We prepare the patient in advance and explain that we are not stopping the thoughts from coming, we are changing the time in which we respond to them. With practice, this will naturally begin to reduce the frequency of the worries and the time spent worrying about them. We also need to explain why thought suppression is unhelpful and backfires. We have to create an image of something in our minds to think about it (try it now, thinking about a yellow tennis ball). The same happens when we try not to think about something too (try not thinking about a pizza next for example). So it backfires from the very start. Research also shows that by telling ourselves not to think about something anxiety provoking, we get the rebound effect. The thought keeps bouncing back in, each time with more attached emotion - as the threat cascade response tells our body that is where our focus of attention should be. When we ignore it; it gets louder and louder, wanting our attention like an alarm. If we do manage to suppress a thought, it takes excessive energy and concentration. We also get more parallel thoughts, in the same theme. So, we may manage to not think about a white polar bear, but still end up thinking about ice, a penguin, a brown bear etc. for example, which then just brings our attention back onto the avoided thought. The brief scaffolding exercise to illustrate why thought suppression backfires and these pitfalls is provided within the patient workbook, before the worry time change method is introduced. This is ideally done within session using the exercise in the patient material and then discussed: Practitioner: “Just like in the exercise we just did, research has shown that trying to suppress or ignore thoughts with anxiety attached to them actually leads to more thoughts, the emotion grows stronger, making someone increasingly more anxious. If someone manages to push out the worrying thoughts, their new thoughts tend to stick around a similar theme, which then brings them back to the thought they were trying to push away in the first place, maintaining the cycle of anxiety. Worries are hard to switch off and trying to push them out of our mind just backfires.' 17

Patient:”Yes, I can’t switch them off once I start worrying.” Practitioner: “It can also be exhausting trying to push these thoughts away . It is hard to concentrate on anything else at the time, leading to feelings of fatigue. You become focused on your internal world, not on what is going on around you. So to manage worries more effectively, we want you to use a process called worry time, where you can delay your worries until later, knowing you can worry about them as much as you want during that time; but outside of your worry time, to be able to let them go and refocus, without getting caught up in a cycle of worry and worry suppression.” Patient:”Ok” Practitioner: “What we know about worrying is it is like a switch, we worry more when we are not focused and often at times when we are trying to relax and not engaged in a task, such as when we try to get off to sleep, often worries are worse then for example.” Patient:”Yep, totally.” Practitioner: “When refocused and engaged in a task external to you in the present moment, worry switches right down, so people worry less. So, after writing down a worry, we can give you a technique to refocus your attention on a task. The same hypothetical worries may come back lots of times, that is to be expected as these thoughts bounce back in as the mind tries to resolve something it can’t resolve right now...Just rewrite it down again and then refocus, as many times as you need. In worry management you are not telling yourself not to worry, you are telling yourself it is ok, it is your mind trying to solve a worry that cannot be solved right now, you can worry as much as you want to about it, but just in a planned way, at a set time. You are giving yourself permission to worry at the planned time. it takes the power away from your worries. Letting you feel more in control of them, than them controlling you.” Patient: “That would be great.” Practitioner: “There are some examples of refocusing in the guide and we can go through some of the techniques today after we plan your first worry time.” © Marie Chellingsworth (2020). The CBT Resource.

Worry Time

Worry time is an effective change method technique for managing and reducing hypothetical worries and their impact. To use worry time, a patient sets a worry time period once a day. They keep a list of hypothetical worries that they notice during the time between their planned worry time and refocus their attention on the present. During the planned worry time they purposefully worry about the items on their list and focus on the worries (paradoxical intention). A paradoxical intention is the deliberate practice of a habit, in this case worrying, to remove it by increasing aversion to it and breaking the reliance upon it as a beneficial strategy. Worry moves from being seen as a helpful, necessary action in the persons life, to being seen as unnecessary, difficult and unpleasant to try to do during worry time. When setting up Worry Time, the patient should be asked to set the time they need for the first week as a question based on how much they are currently worrying. They should be encouraged to remember the time is for nothing but worry, they need to be undisturbed and able to set aside the time with no other demands on their time such as eating dinner, children’s bed times or TV shows. Therefore they need to balance the time they think they need with how much time they can realistically give each day. Usually, the estimate they give is still above the amount is over the time they will find they actually need, but the learning that takes place by setting it up collaboratively in this way is important. The time can be reduced down to 20-30 minutes in week two of worry time onwards. Worry time periods should be used for worrying purposefully only, not be used for problem solving, this is adding to procrastination, not reducing it. Practitioner: “Based on how much you are currently worrying, how much time do you feel is realistic to set aside as your worry time period each evening.?” Patient: “Well I worry a hell of a lot, so maybe a couple of hours, or an hour an a half.?” Practitioner: “The important thing to consider is that during this time you will need to be free and undisturbed, where you will purposefully worry. You will be focusing only upon your worries and not any other activity, so no TV or putting the children to bed etc., the time is only for worrying in a set way. With that in mind and the current demands on your time, what feels realistic for this week, we can always adjust it next week if you find you need more time for example.?” Patient: “OK, realistically with work, tea, bathing the kids and putting them to bed, maybe 45 minutes would be the most time, but I can’t imagine needing less either with the amount of worries I have each day.” Practitioner: “We can set it up this week and see if 45 minutes is OK and change it if we need to after that. So, for this week, if you set aside 45 minutes each evening just for worrying, where you will get out the list of worries you have kept throughout the day and since your last worry time period and in that time, I want you to worry about them purposefully as if they have just occurred and will happen, 19

really focus on worrying about each one. You may notice a range of things in doing this, we can talk next time about what you noticed and how this went in our review and if we need to adjust things we can....” Patient:”How do I manage all my worries though during the day....” Practitioner: “Outside of your worry time, each time you notice a hypothetical worry you write it down. The same worry may come back lots of times, that is OK, just write it down as many times as you need and then refocus your attention back on a task in the here and now. As we discussed, these worries distract you from what is going on around you and other tasks that should have your attention. Then, refocus your attention on the here and now around you, we can look at some techniques for this together today. The important thing is we are not saying not to worry or to try to control the worries as they occur, the worries can come, but we are giving them their own planned time in which they are attended to and enabling them to be postponed. If it is hypothetical, you write it down and then do a refocusing task, knowing you have time to worry about it as much as you need later.” Patient: “OK, that makes sense and any practical worries that arise.... Practitioner “You deal with them there and then as they occur to target procrastination, and can use the problem solving steps if you need to...” From a review perspective, the learning that the patient will take away from worry time may include noticing that purposefully trying to worry is not nice and the mind tries to take them off it when they try to do it purposefully. They may also find most of their worries have naturally resolved, that they don’t need as much time as they first predicted and that they begin to find purposefully trying to worry aversive and unpleasant. It is not uncommon for patients to say things such as ‘its horrible’ or ‘I really struggled to worry about it, my mind kept wandering off...”. You should tease the learning they take from this, for example, so before this technique, you worried most of the day you said, but now you notice when you worry it does not feel nice and was hard to maintain, is that right?.....What does that tell you about your worrying? What do you take from doing this? ‘What does that mean going forwards in your everyday life?”In subsequent sessions, they should notice fewer worries on their list. The aim is that worrying becomes aversive and unhelpful - the adaptive opposite of feeling they need to worry and that worry is helpful. They feel they don’t need to worry and worrying has no benefit. When the patient begins to notice that purposeful worry makes them feel worse and they learn they can manage their worries and are having fewer of them over repeated practice of worry time periods, this should be normalised and continuation encouraged until worry and anxiety reduces and relapse management can be initiated once fewer daily worries are reported and this learning has taken place. © Marie Chellingsworth (2020). The CBT Resource.

Refocusing attention after writing down a hypothetical worry Reduce the threat: To help refocus without thought suppression after writing down a worry, the patient should remind themselves that they can worry about it as much as they want to later. It is important that the clinician and patient are both aware and remember that they are not trying to stop thoughts or push them away using this change method, they are allowing thoughts to come and let them be, they are only postponing when they choose to focus their attention on worrying about them, without taking a suppressing action that will lead to more thoughts and more anxiety. They are allowing themselves to worry, but in a controlled way. Over time, this process reduces anxiety and leads to fewer worries. To take the threat away from the thought (like in the polar bear exercise 1), it is helpful that they are reminded that the aim isn’t to stop worries coming, the same thought may bounce back in and that’s OK and to be expected, that’s what these types of worries do. The aim is postpone the worry until a planned time that feels more in control. Refocus attention: It is also important the patient then refocuses their attention on an external task in the here and now. It should be a task that takes their full attention back into the moment. Attention onto an external task been shown to be like a switch that controls worry and rumination. Attention internally increases anxiety. Clinicians can sometimes conflate the task as the distraction from the worry. This is not the case. The worry is the distraction, the task is not. The worry takes their attention away from where it should be to their internal world. They become lost up in their heads worrying, distracted from right now, onto future apprehensive worry. The refocusing technique is based upon attention training and should always have an external focus of attention onto a task, not onto any internal feelings or inside the body. The task reorientates attention back where it should be in the moment. In panic disorder during an exposure and habituation session, refocusing on a task would take the persons attention away from where it should be, on their symptoms and affect level. In that instance, the task would indeed be a distraction at that time and reduce the effectiveness of the whole intervention. In the same way, thought suppression or keeping the focus internal would be or this disorder at this time. It can be easy to misunderstand attention focusing with others that may appear vaguely similar but are carried out for different purposes, such as some mindfulness components. These tasks can actually increase anxiety and worry in GAD and other anxiety based disorders due to internal focus in that moment. It is important therefore that the patient (or indeed the practitioner) does not confuse this technique with some mindfulness treatment techniques they may find online that are suitable for use in depression, but not in GAD or other anxiety based disorders to use at this specific time for this purpose.

The evidence on attentional focusing in anxiety has shown that an internal focus of attention onto internal thoughts or part of the body or symptoms has been shown to increase affect in anxiety disorders. So, any internal focused tasks would be unhelpful after writing down a worry and increase symptoms at this time, undermining the change method. This includes things like focusing on the breath (internal focus) body scans (internal focus) or allowing thoughts to float down a river (internal focus) amongst others. PGMR is practised at a neutral time for this very reason and should never be paired with being practised after writing down a worry, it is for a different change method, done at a different time, with a distinctly different purpose. The key is that after writing down a hypothetical worry, the patient refocuses on an externally focused task, back where their attention should be at that specific moment. So, if they were worrying in a meeting at work, they should refocus on the meeting and do a task that keeps their focus there. A simple task of noticing what is being said and for a minute or so noticing when people use a word that begins with their first initial for example, is enough to provide a refocus away from the worry content. If they were watching a film or TV, they would refocus onto that and could count the times someone blinks for a moment or so. Another helpful strategy is to keep a sudoku or crossword book at home and this can be used if the patient was not engaged in a particular task or activity at the time of the worry. Obviously at night, the patient needs to refocus on being in bed and going to sleep, knowing they can worry about it tomorrow. A simple task of noticing 5 things beginning with a certain letter or 5 things of a certain colour can help in this instance, without being an awakening activity that would impact on them dropping off to sleep. The senses can be a useful way of doing a task. The APPLE technique is a way that patients can take a step back from their worry after writing it down, not get caught up on it and then do a task. The patient can either write the worry down and refocus straight away, or, if needed, put the APPLE technique into action to help them with worries that feel uncertain and that are hard to refocus away from. The other important aspect is the patient knows this is for hypothetical worries only, they do not need to refocus or write down a practical worry, then need to take the action on a practical worry there and then. If they need help with knowing what action to take, the problem solving should be initiated there and then for these worries. Practical worries should not be solved in worry time or the action delayed as this is adding to procrastination of them, not reducing it, defeating the object! Practitioner: “Once you have written down your hypothetical worry and refocused your attention onto a task, the same or similar worries may come back into your mind afterwards, that is to be expected and this will decrease over time with the worry management techniques you are using. Remember the aim isn’t to stop worry, or push them away, as that will backfire like in the experiment we did. The aim is to allow worries to come, but to have a planned period in which you worry once a day. You are giving yourself permission to worry as much as you need to. If the same hypothetical worry comes back, or any new worry enters your mind outside of your planned worry time, just write it down as many times as needed and then refocus your attention, knowing you can worry about it later. The aim isn’t to stop the worries coming, but to learn a way of managing them better when they do. Over time, the worry management techniques all work to reduce the frequency of your worries and the impact they cause. You will have fewer worries over time by allowing them to come and not getting caught up in them in the moment” © Marie Chellingsworth (2020). The CBT Resource.

Practical Problem Solving

Problem solving as a change method targets procrastination on practical worries. Worry has been shown to be related to a deficiency in problem solving ability. In GAD, the person becomes locked into a cycle of worry as a preventative measure to cope with anxiety, uncertainty, unpredictable and uncontrollable situations. Both types of worries become treated the same way, with doubt and procrastination stopping relevant action being taken at the time to resolve truly practical worries. The person is pulled between positive and negative beliefs about worry. It can be easy for clinicians to fall into the understandability trap, as most GAD beliefs are shared with the general population. The comparison between actual problem solving, which leads to an action that resolves the worry at and worrying with procrastination and the impact this has on maintaining symptoms often needs drawing out with the patient socratically. For some patients, once the role of procrastination on practical worries keeping the cycle of worrying going is explained, they may be able to break this cycle themselves by taking the action when they notice the practical worry once they classify it. Therefore they may not require to use the problem solving steps in this case. They are there if they have a practical worry where they are unsure what action to take at the time. It is important the patient (and clinician) are clear that at the time of the worry, the relevant action should be taken there and then. The problem solving steps, if required, should not be put off until later. This is simply maintaining procrastination. If they are needed, they should be done there and then at the time. The process for hypothetical worries and refocusing on a task, should not be conflated here. Neither should problem solving be done in worry time, this is an inaccurate use of the change method of purposefully worrying and increasing aversion to worry at that time. The steps of problem solving are a skill that can be easily explained with the patient. They help to make concrete the solutions available, generate ideas and assist them to take action to resolve a practical problem in a way that feels manageable. Worries tend to be structured more as ‘What if...’ thoughts with a future focus, therefore making it harder to solve the problem. Whereas normal problem solving has 7 steps, within management of 23

practical worries in GAD, an 8th step is often required first, to turn the practical worry into a problem to be solved. To do this, the patient should be encouraged to make the practical problem specific and time dated: Practitioner: “OK, so the practical worry you mentioned you got stuck thinking about was ‘What on earth am I going to do about the car, what if I can’t afford it and can’t get to work”. From what we have discussed, when you had the worry it was one where you could take action and that should be your focus, but you weren’t sure what do, have I understood that right?” Patient: “Yes, its in the garage now, but the work is so expensive, I am just not sure what to do and so I haven’t called them. I just keep worrying about it and I need to tell the garage to do the work or not and if they don’t, then the car isn’t even drivable as it is, I don’t know if I can afford it, but I can’t leave it there. I just feel really overwhelmed with it all and I know I am putting it off. I need the car to go back to work next week too or I am stuck as there is no bus route nearby.” Practitioner: “That sounds like a lot to deal with, so I understand it feels overwhelming. When you have a practical worry like this, but are not sure about the action needed to take in that moment, you can then use the problem solving steps to think through potential solutions and plan out the best action to take at that time and then take the action once you have done the steps. We can do that now together for this practical problem, if that would be helpful so you can see how you would use it. It breaks into the cycle of procrastination when we are unsure what to do to resolve a practical worry” Patient: “That sounds good yes. I get so worked up and then end up doing nothing but fretting.....” Practitioner: ‘Ok so the first step is to clearly define what the practical problem is and when it has to be completed by. You mentioned the car is in the garage and needs to be back on the road by Wednesday for work and you are unsure if you can afford the work. Have we been specific enough here for defining the problem and the deadline?” © Marie Chellingsworth (2020). The CBT Resource.

The importance of homework and structure

It should be remembered that homework is an essential component of all CBT based interventions. Research tells us that patients who are compliant with homework get the best outcomes and that when practitioners review homework increases the patients view of its importance and makes them more likely to complete it. Homework is not an optional extra to be used as and when it suits around unstructured conversations in sessions, but must form the start and end of every session focus. Unlike high intensity CBT approaches, where the session time is longer and somewhat more flexible in terms of some change methods being used within sessions which does not occur in LICBT, the focus should always be on the tasks that the patient does between sessions due to the time and evidence of Low Intensity CBT and the way in which it brings about change. Effective Low Intensity CBT treatment sessions, whether 25

delivered via email, on the telephone or face to face should always use a Plan, (Do) and then Review structure. This means the focus of the first treatment session should be on making an effective plan for the inter-session task that the patient is to carry out between your sessions ideally front-loading the first change method to achieve an active dose of treatment. Whether you use the term homework or intersession task is entirely down to you and what your patient would prefer. Some patients with negative experiences of school may prefer the latter. Any potential internal things that may get in the way of their plan (things within them like confidence or understanding for example) or external things (like neighbours popping round or a friend calling on the telephone) that are outside of their control should be considered and problem solved when homework setting.

Review h/w and learning

Plan next h/w

Patient will do h/w plan between sessions The patient should then go off and carry out their plan. The focus of subsequent sessions should be to review the tasks completed, problem solve any difficulties that have arisen and then make a new plan for the patient to go off and do (and so on....). At times, the person we work with may not be used to a structured approach or may find it difficult to work within it and present challenges. When this occurs sessions can easily drift away from homework planning and reviewing into eclectic and non-evidence based support. If drifting from the agenda becomes problematic in a session, having already outlined the structure and way of working in the approach from the outset with the problem statement and linked goals, allows a gentle but clinically important reminder to be made such as in these examples:

“As I mentioned when we first met, to effectively treat your worry and anxiety, we need to treat the worry as a process, rather than getting caught up in individual worries when reviewing and planning the homework. That means we can work to switch off the worry machine, rather than popping individual bubbles and more still coming out. With that in mind, can I just bring us back to the homework first and then at the end of the agenda we can discuss what happened this week in more detail. I will write us a note to ensure we speak more abut this in the time we have left......” “It is important to me that you get the most from the sessions and time that we have together. I would like us to look at your homework next. It sounds important what you have told me so far. But to make sure that we have time to complete the agenda, can we move back to your worksheets and then if there is some time left at the end we can pick up this discussion if you would like to?” 26

Managing endings When working briefly or remotely like in LICBT, practitioners can find it challenging to raise the issue of discharge, particularly if the patient is socially isolated or lonely as a result of their difficulties. Relapse management of key learning and consolidation of the process in which change took place is an essential last step. However planning for the ending should really start from the first contact to aid agenda setting and the important structure of this way of working. Patients may wrongly assume that treatment will go on for longer than the short-term nature of Low Intensity CBT. A clear discussion at the start of treatment about the structure of the approach can stop this from feeling abrupt when it arises. Practitioners may also find it helpful to remind patients at each subsequent contact about the number of sessions before a review will take place (usually at session 4 of treatment). Remembering the focus of LICBT should be on the symptoms identified and improving these through the use of the intervention is key. Practitioners cannot alone solve every aspect of the patient’s situation through treatment and indeed may not be the most skilled person to do so. The use of signposting for practical difficulties such as debt or housing issues and referral to local community groups and befriending for patients’, whose social situations have not improved through the intervention for example, should be used to manage this.

Useful references on GAD American Psychiatric Association (Eds.) (2013) Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. Amir, N., Elias, J., Klumpp, H., & Przeworski, A. (2003). Attentional bias to threat in social phobia: facilitated processing of threat or difficulty disengaging attention from threat? Behaviour Research and Therapy, 41, 1325–1335. Arntz, A. (2003) Cognitive therapy versus applied relaxation as treatment of generalized anxiety disorder. Behav Res Ther. 41(6), 633-646. Barlow, D. H. (2000) Unravelling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55, 1247–1263. Barlow, D. H., Rapee, R. M. & Brown, T. A. (1992) Behavioral treatment of generalized anxiety disorder. Behavior Therapy, 23, 551–570. Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study. Psychological Bulletin, 133(1), 1-24. Bishop, S. J., Duncan, J. & Lawrence, J. D. (2004) State anxiety modulation of the amygdale response to unattended threat-related stimuli. Nature Neuroscience, 7, 184–188. Bitran, S., Barlow, D. H. & Spiegel, D. A. (2009) Generalized anxiety disorder. In New Oxford Textbook of Psychiatry (eds M. G. Gelder, M. G. Andreasen, J. J. Lopez-Ibor & J. R. Geddes), pp. 729–739. New York: Oxford University Press. BMJ Best Practice (2017) Generalised anxiety disorder. BMJ Publishing Group. bestpractice.bmj.com/ info/ Bond, A. J., Wingrove, J., Curran, H. V., et al. (2002) Treatment of generalised anxiety disorder with a short course of psychological therapy, combined with buspirone or placebo. Journal of Affective Disorders, 72, 267–271.32 Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983). Preliminary exploration of worry: some characteristics and processes. Behaviour Research Therapy, 21, 9–16 Borkovec, T. D. & Costello, E. (1993) Efficacy of applied relaxation and cognitive- behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61, 611– 619. Borkovec, T. D. & Roemer, L. (1995) Perceived function of worry among generalized anxiety disorder subjects: distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26, 25–30. Borkovec, T. D., Newman, M. G., Pincus, A. L., et al. (2002) A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298. Bowman, D., Scogin, F., Floyd, M., et al. (1997) Efficacy of self-examination therapy in the treatment of generalized anxiety disorder. Journal of Counselling Psychology, 44, 267–273. Butler, G., Fennell, M., Robson, P., et al. (1991) Comparison of behavior therapy and cognitive behavior therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 59, 167–175. © Marie Chellingsworth (2020). The CBT Resource.

Chellingsworth, M. (2019) Worry Less, Live More. Helping you to manage worry and Generalised Anxiety Disorder. The CBT Resource. Chellingsworth, M., Farrand, P. (2015). How to beat depression one step at a time: Using evidence based low intensity CBT. Robinson. London. Chellingsworth, M., Farrand, P. (2016). How to beat GAD and worry one step at a time: Using evidence based low intensity CBT. Robinson. London. Dugas, M. J., Brillon, P., Savard, P., et al. (2009) A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 10, 1–13 Hayes, S., Hirsch, C. R., & Mathews, A. (2010). Facilitating a benign attentional bias reduces negative thought intrusions. Journal of Abnormal Psychology, 119, 235–240. Hirsch CR, MacLeod C, Mathews A, Sandher O, Siyani A, Hayes S. (2011) The contribution of attentional bias to worry: distinguishing the roles of selective engagement and disengagement. J Anxiety Disord. 2011;25(2):272– 277. doi:10.1016/j.janxdis.2010.09.013 Hoffman DL, Dukes EM, Wittchen HU (2008) Human and economic burden of generalized anxiety disorder. Depress Anxiety 25: 72–90. Kroenke,K., Spitzer,R.L., Williams,J.B., et al. (2007) Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine. 146(5), 317-325. Mitte K (2005) Meta-analysis of cognitive-behavioural treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychol Bull 131: 785–795. McManus,S., Meltzer,H., Brugha,T., et al. (2009) Adult psychiatric morbidity in England, 2007: Results of a household survey. The Health & Social Care Information Centre. www.ic.nhs.uk Mogg, K., Holmes, A., Garner, M., Bradley, B.P. (2008) Effects of threat cues on attentional shifting, disengagement and response slowing in anxious individuals. Behaviour Research and Therapy, Volume 46, Issue 5. Mogg, K., Mathews, A., & Eysenck, M. (1992). Attentional bias to threat in clinical anxiety states. Cognition and Emotion, 6, 149–159. National Collaborating Centre for Mental Health (2011a) Generalised anxiety disorder in adults. The NICE guideline on management in primary, secondary and community care (full NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk National Collaborating Centre for Mental Health (2011b) Common mental health disorders. The NICE guideline on identification and pathways to care (full NICE guideline). National Institute for Health and Clinical Excellence. The British Psychological Society and The Royal College of Psychiatrists. www.nice.org.uk NICE (2014) NICE Quality Standard QS53, Anxiety Disorders. NICE. www.nice.org.uk NIHR Signal (2019) Various drugs are effective and well-tolerated for generalised anxiety disorder. NIHR Signal. discover.dc.nihr.ac.uk Robinson, E., Titov, N., Andrews, G., McIntyre, K., Schwencke, G., Solley, K., (2010) Internet Treatment for Generalized Anxiety Disorder: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance. https://doi.org/10.1371/journal.pone.0010942 Slee, A., Nazareth, I., Bondaronek, P., et al. (2019) Pharmacological treatments for generalised anxiety disorder: 29

a systematic review and network meta-analysis. The Lancet. www.thelancet.com Stein, M.B. and Sareen, J. (2015) Generalized Anxiety Disorder. NEJM 373, 2059-2068 Tait,L. (2011) Generalised anxiety disorder: the importance of life context and social factors. British Journal of General Practice. 61(587), 378-379 Titov N, Andrews G, Robinson E, Schwencke G, Johnston L, et al. (2009) Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: a randomized controlled trial. Aust N Z J Psychiatry 43: 905–912 White, J. (1995) Stresspac: a controlled trial of a self-help package for the anxiety disorders. Behavioural and Cognitive Psychotherapy, 23, 89–107. White, J. (1998) ‘Stress control’ large group therapy for generalized anxiety disorder: two year follow up. Behavioural and Cognitive Psychotherapy, 26, 237–245. White, J., Keenan, M. & Brooks, N. (1992) Stress control: a controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97–113. Wittchen,H.U. (2002) Generalized anxiety disorder: prevalence, burden, and cost to society. Depression and Anxiety. 16(4), 162-171

Marie Chellingsworth The CBT Resource ® Marie is a renowned CBT and IAPT consultant, academic and author. She is the Founder of The CBT Resource and an invited Subject Matter Expert (SME) for a number of digital therapeutic and mental health services. She is a co-author of the IAPT PWP curriculum and high and low intensity CBT with older people curricula as well as many resources for patients with anxiety and depression. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments and ensure practitioners are supported to get optimal outcomes through CPD training and supervision, run as a social enterprise approach all profits are reinvested into the work of the organisation. She has over twenty years experience in the field, publishing a wide range of CBT self help packages and national training for practitioners supporting people with these difficulties. She has worked with UK national bodies and the IAPT workforce and training groups within the Department Of Health to maintain standards for CBT and IAPT based approaches and was Consultant to the successful implementation of the Australian IAPT programme. Prior to developing The CBT Resource, she was Executive Director of Evidence Based Programmes at UEA and Senior Lecturer and Director of Training at the Universities of Nottingham and Exeter. Her passion for CBT and working in this field first came after hearing a song called Howard Hughes (a B side of a band called Ride in 1992!). Outside of work she loves music, interior design, gardening and spending time on the local beaches and forests with her Irish Setters and with family and friends.

Andy Poplar [Vinegar www.thecbtresource.co.uk

& Brown Paper]®

The photographs of etched glass and objects throughout this programme are the work of Andy Poplar from [vinegar & brown paper]® ideas etched in glass. Special thanks and credit goes to him for enabling us to use these images. An award winning advertising creative, he set out to mend his head with [Vinegar & Brown paper] after his own experience with anxiety and depression. At the heart of Andy’s work are his reflections upon his own experiences that led to his career change into etching glass. As [vinegar & brown paper], Andy has spent the last 8 years taking vintage or iconic items of glassware and bringing them to life with the tools of typography, wit, word-play and a slightly askew way of looking at the world. You can now find pieces of [vinegar & brown paper] on bookshelves everywhere, from York to New York (and a much happier man too). You can find more of Andy’s work on his website and his Facebook and Instagram pages on the links below. Website: www.vinegarandbrownpaper.co.uk Instagram: instagram.com/mendyourhead Facebook: facebook.com/mendyourhead