Worry less, Live more: Managing worry and uncertainty in Generalised Anxiety Disorder (GAD) by The CBT Resource by Marie Chellingsworth

Worry less, live more with Generalised Anxiety Disorder (GAD)

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 for individual clinical use only by subscribed members of The CBT Resource Annual CPD & Resources plan in 2020/2021. It may be photocopied, printed, and distributed to patients only by the subscription holder for their individual clinical use only in the original binding. You cannot host this booklet electronically on any website, or pass it onto any other non-subscription holder for clincial use. This condition must be imposed at all times and this work cannot be sold for profit, used for training, 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 license boundaries. It is the responsibility of the service to ensure that staff who support this material are suitably qualified, have specific CPD training in this protocol and receive regular case management and clinical skills supervision. The main photographs used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper] and 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). Other images are from Unsplash and used with permission in accordance with their requirements. We would like to thank the focus groups and practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score 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 support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol. Disclaimer: This material is provided for information, not advice you should solely rely on. It is not a substitute for a clinical assessment, treatment or the provision of advice by an appropriate health professional. If you have questions about any medical matter or think you are experiencing any medical condition, you should consult your doctor or relevant professional healthcare service provider without delay. It is provided for information purposes only, upon recommendation of and alongside the assessment of suitability and support provided by a suitably qualified clinician. 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. © Marie Chellingsworth (2020). The CBT Resource.

Contents 1-2 3-4 5-6 7 10-11 12 13-16 17-18 19-20 21-22 23-24 25-27 28 29-30 31-37

Understanding Worry and Generalised Anxiety Disorder How worry management can help Meet Amelia & John My own vicious cycle My goals Building motivation to move forwards Progressive Muscle Relaxation (PGMR) Why trying not to worry backfires The two types of worry My worry list Refocusing attention Practical problem solving Hints and tips from Amelia and John Reviewing your progress Relapse management

Where to get more help

39-40

My notes

41-42

Spare worry lists

About the author & Andy’s images

Understanding worry and Generalised Anxiety Disorder (GAD)

We all worry and feel anxious from time to time. It is a normal human reaction to busy or stressful events happening in our life. Usually, this only happens for a short period of time.

People with excessive worry, known as Generalised Anxiety Disorder (GAD) worry more days than not, for many months, or even years. Sometimes they can recognise being a worrier most of their life. Having GAD impacts significantly upon the person’s day to day life. It stops them from doing things in life that they would otherwise do. When people have GAD they worry about everyday things like health, relationships, finances, work or your family - but to a degree that is out of proportion. Worrying can feel very hard to control and impacts negatively on day to day life. It can be hard to imagine not worrying. The anxiety and worry can get worse on the build up to a big life event or situation happening, such as planning to move home, having a baby or dealing with changes at work. People often describe feeling on edge or a sense of dread, as if something bad is about to happen. Situations in life that are unpredictable, uncertain or feel out of control can be particularly difficult to manage. Worrying and the anxiety experienced makes the person feel tense most of the time. They can experience more aches and pains, tension headaches, poor sleep or stomach problems as a result. Worrying takes up lots of time and energy, leaving little room for other things. It can lead to feeling irritable or struggling to concentrate. Worrying distracts the person from what is going on around them at that time. They become caught up in their internal world of worrying thoughts and symptoms of anxiety. People often describe feeling that they cannot fully enjoy or participate in things happening in their life as the worry and anxiety takes the focus away from it for them.

If you have symptoms of GAD, you may understandably begin to avoid things that make you feel more anxious. You may try to push the worrying thoughts out of your mind or do things to try and manage how you feel. You can take more time than usual to get things done, wanting them to be right. You may also over prepare for things or keep putting them off until later (procrastination). People with GAD can also try to avoid feeling anxious by trying to keep a sense of control, and only doing things that feel predictable and certain. In the short term these changes can give you some relief from how you are feeling. So, you keep doing them. In the longer term though it can keep you caught in a cycle of worry and anxiety. You get more worries, more physical symptoms and more anxiety. It restricts the enjoyment you can get from your life, where you can go and what you can do. Worrying itself becomes harder to control and feels more difficult to manage. You get caught in a vicious cycle of worry and anxiety. The good news is that there are treatments that can really help. The National Institute for Health and Care Excellence (NICE) suggests Cognitive Behavioural Therapy (CBT) as a treatment to help to manage worry and GAD as it has a large evidence base. This workbook helps you to use worry management CBT techniques to help to improve your anxiety in easy steps with support from a trained practitioner. Within the workbook you will find examples from two people who have used this treatment to help them to manage their worrying, Amelia and John. As well as sharing their own experiences with GAD and how it affected their lives; they also share their tips for using the techniques. While their personal situations may be different from your own, they both used worry management to feel better. There is no set way for you to use this booklet. You may want to read it all first and then come back to start the treatment, others prefer to begin section by section. Just go at a pace that suits you.

How worry management can help When you have excessive worry it can affect how you feel physically and what you do as a result. It can feel like you are always on edge. These symptoms can form a vicious cycle of worry and anxiety.

Worry management helps you to break into this vicious cycle. It will help you to feel more in control of your worrying, rather than feeling like it is controlling you. Worry management has a range of techniques recommended to help with GAD. The techniques in this will help you to break the cycle. To be able to manage the symptoms you experience and reduce the impact they have upon your life. They will help you to manage and reduce your worrying thoughts, to learn new ways to manage procrastination and deal with situations that feel uncertain, unpredictable or uncontrollable. The techniques can also help to improve your sleep and the other physical symptoms of GAD. After a few weeks, you should start to notice that your symptoms begin to improve. While everyone has their own personal experience of having worry and GAD, there are shared symptoms. Read through the diagram below which shows these typical symptoms:

Physical symptoms Tension in your muscles Feeling irritable or on edge Feeling tired Problems with your sleep Trouble concentrating Digestive upset Nausea Headaches

Behaviours

Altered thoughts

Worrying excessively Putting things off (procrastinating) Over preparing Avoiding things that are uncertain, unpredictable or uncontrollable Seeking reassurance

Lots of ‘what if’ type thoughts about things that may happen in the future and about worrying itself For example: ‘What if I get in trouble at work’ ‘What if my worrying keeps getting worse’.

Worry management uses a range of techniques to target the symptoms you are experiencing and to break the cycle of worry and anxiety. Each one will have a helpful impact on your symptoms in different ways. Using them will help you to take control of your worry and anxiety, rather than it controlling you. The techniques within the worry management process are: Progressive Muscle Relaxation (PGMR): PGMR increases the body’s awareness of early warning signs of tension in the muscles and helps to reduce the amount of tension you hold. It helps with the physical symptoms of worry and anxiety and can help to improve sleep. Over time, using PGMR each day reduces the frequency of worrying thoughts you experience, tension and physical symptoms and improves sleep. You can begin to use PGMR straight away. Worry Time: Worry time helps you to manage your worries more effectively, by giving you a time each day to worry and techniques to manage your worries outside of this time. This gives you back time in your day where you would normally be worrying. It helps to reduce your feelings of anxiety and uncertainty. Over time, worries will begin to impact upon you less and you will notice fewer of them. Refocusing your attention: Used alongside worry time, learning to refocus your attention on the present and away from the distraction of the worrying thoughts. It helps you to be more attached to the world around you and present in what is happening moment to moment. Along with worry time, it helps you to focus and experience and enjoy things, rather than being lost in an internal world of worrying thoughts and physical symptoms of anxiety. Practical Problem Solving: Practical problem solving targets your worries that are about practical, external things to you that you need to take action to resolve. It helps to break into the cycle of procrastination. This is a technique that is there if you need a bit more support with a practical problem to work through what action is best to take to resolve the practical issue at the time. CBT is an active form of treatment. You need to put the worry management techniques into action in your daily life to benefit from them. If used as advised, people usually begin to see improvements within just a few short weeks. Support from a practitioner during this time can help you to make a weekly plan to use them and to overcome any barriers you may experience. You can also see useful hints and tips from Amelia and John throughout this guide and what they found when using them. CBT can really help you to improve how you are feeling, as it has done for many others.

Meet Amelia: I have always been a bit of a perfectionist and liked things feeling in control. It got a lot worse when I got promoted at work and then fell pregnant shortly afterwards. I was worrying all the time about work and what my colleagues thought about me. I did more and more work at home in the evenings. I worried whether my boss thought I was doing a good enough job. I worried she thought I shouldn’t have got the promotion. I also worried if I would be a good enough mum or be able to manage work in the future. I also worried about our finances taking an extended maternity leave or if anything happened to my salary. We wouldn’t manage on just Jamie’s wage. I started to feel tense all the time. I couldn’t get to sleep at night, I couldn’t switch off. I became concerned I was worrying so much it would be bad for the baby. I spoke to my neighbour and she recommended that I went to see the local IAPT service. With their support, I used the worry management CBT techniques to feel better.

Physical symptoms Tension Difficulty sleeping Headaches Aches and pains

Behaviours Re-checking my own and team members work for mistakes Seeking reassurance from my friends and family Procrastinating Looking online about anxiety and being pregnant Taking work home

Altered thoughts “What if I can’t manage?” “What if the team make a mistake, it will reflect on me” “What if I lose my job?” “What if my anxiety harms the baby?” “What if I will never be able to stop worrying?”

Meet John: I had always been a worrier, something my family used to tease me about. I thought it helped me to prepare, be more organised and it made me feel more in control. When I got divorced and retired though, my worrying became much more of a problem. I worried if I would have enough money to live on with just my pension and I was always worrying whether I was spending too much. At the time, I worried I would end up having to leave my flat and have nowhere else to go and no one to turn to. I was becoming irritable and short tempered. My sleep was really bad, I had frequent headaches. I felt anxious most of the time, with a horrible sense of dread. I felt sick with worry some days. I couldn’t concentrate and got really forgetful. I was worried it could be a sign of dementia. I had all the tests, but it wasn’t. I spoke to my GP after the tests and she referred me for help with anxiety.

Physical symptoms Headaches Sleep problems Restlessness Tension in my muscles Sickness

Behaviours Worrying excessively Checking my bank account Calculating my finances Put off calling my children Asking the GP for dementia tests

Altered thoughts “What if I can’t pay the rent and bills?” “What if I spend too much money this month?” What if have dementia?” “What if I am losing my mind with all this worrying?”

My own vicious cycle The symptoms you experience in one area, can impact and have a knock-on effect on the other areas and maintain your worries and anxiety. For example when you have worrying thoughts, you become tense physically. This can lead to further physical symptoms like headaches, aches and pains and disrupt your sleep. In turn, this can lead to more tension and more worrying. Similarly, you may try to avoid situations that feel uncertain, put things off or spend lots of time planning and preparing. You might also seek reassurance from other people. This can reduce how you are feeling in the short term, but keep you in a cycle of worry and anxiety long term. The good news, is that If you break into the cycle using the techniques in this workbook, you can have a positive impact on the other areas and the cycle can be reversed. The worry management techniques in this guide will help you to do that in a personalised way that best fits with your symptoms. Write down the symptoms you are experiencing in each of the areas below.

Physical symptoms

Behaviours

Altered thoughts

John: “It helped to set goals of what I wanted to be able to do when my symptoms in the cycle improved. This really helped me focus. I also knew I was making progress by looking at them every so often.” © Marie Chellingsworth (2020). The CBT Resource.

Amelia: “I knew that if I wasn’t so anxious, I would be doing a lot more. If I was honest with myself, it really held me back in life. I wanted to progress further in my career for one. Even though I got promoted within my current job, I had put off applying for great opportunities with other companies because of it. It zapped my confidence. I also realised I avoided us doing lots of things as a family, just in case something bad happened. I missed out on holidays, days out and social events. Once my GAD improved, all those things became possible again” 9

Setting your goals Imagine into the future. The symptoms you listed in your vicious cycle have improved and you feel better again. Your routine for each day is back on track. What will life be like for you when these symptoms improve? What things that are important in your life will you be doing again? Answer the questions below to help you to set your goals for using worry management.

Where would you be going?

(For example, I would be socialising with friends, I would be going to the gym again. I would be back at work etc.)

What would you be doing?

(For example, I will be able to do the food shop on a Sunday. I will be cleaning each week. I will be spending more time with the children having fun etc.)

Who would you be with?

(For example, I would be spending more time with my flat mates going to the cinema, I would be spending more quality time with my husband, I would be back at the social club etc.)

The next step is to turn these things into goals. Then to spot the steps you can take towards this in the short, medium and longer term. Breaking things down really helps us to get where we want to be. Think what is realistic for you based on where you are now.

Goal 1: for example, see my friends once a week. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 2: for example, to get a good nights sleep and wake refreshed Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 3: for example, have regular meal times each day. Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Building motivation Thinking about the problem and beginning to work on the goals you have set. On a 0-100 scale rate: How much impact does the problem have on my life currently? 0 50 100 not at all affects everything

How important is it for me to reach my goals? 0 50 100 not at all totally important

How willing and able am I to set aside enough time to get better? 0 50 100 not at all totally willing

How much of a priority is getting better for me at the moment? 0 50 100 not at all complete priority Activity: Some people find it helpful to complete the following exercise. This is useful if you are struggling with your motivation because of how you are feeling. Write two short letters short letter to yourself. In the first letter, you are writing to yourself now as if it is five years into the future and you haven’t set aside the time to get better or improve your symptoms. What would life be like? What would you like to say to your current self to get you to set some time aside for feeling better? Next, in the second short letter to yourself. It’s five years in the future and you have made the changes to break the vicious cycle and feel better. How pleased are you? What changes has it opened up in your life? What would you be doing? Where would you be going? Visualise your life improved as a result. Turn to the next page to get going towards that now. Every step is a step in the right direction. © Marie Chellingsworth (2020). The CBT Resource.

Progressive Muscle Relaxation (PGMR)

PGMR is an effective technique that breaks into the vicious cycle of worry and anxiety in GAD. Practiced daily, it targets the physical symptom of tension, can help reduce the frequency of worries, the physical symptoms of tension as well as improve your sleep. You can begin to use the PGMR technique straight away. Aim to do it once, or ideally twice a day, at a set neutral time. You only need to set aside around 10-15 minutes for each PGMR practice. You should do it at a planned time, like after brushing your teeth in the morning, to get into a routine with it. PGMR isn’t a technique to do when you feel anxious, it is a skill that builds up over time, that teaches your body to notice early warning signs of tension in the muscles and let them go. This helps your body to learn early warning signs of tension and to let it go earlier through a process called kinaesthetic awareness. PGMR is an evidence based tool that is recommended in clinical guidelines to reduce tension symptoms, worry and improve sleep. It can also help you to feel less irritable and more able to deal with the stressful situations we all have to deal with in our daily life. We carry a tension load in our bodies, this can build up like a coiled spring when we are under stress and worrying. When we worry, we feel tense. In turn, tension can then lead to aches and pains, headaches, gastro-intestinal upset, disrupt our sleep, and lead to even more worrying, in a vicious cycle of symptoms. PGMR can really help with this. It can take a while to reach its full effects, so keep going with it. Many people use it everyday in their lives to help them to manage tension and stress, even when they feel better.

John: “I made sure I set time aside each morning and evening for PGMR. I was extremely tense from all my worrying, causing my muscles to ache, headaches and had poor sleep too. At the start, I found it quite hard isolating just one muscle. I found this became easier with practice. Your body will slowly learn how to relax your muscles and keep you more relaxed.”

PGMR has a 5/15 time limit. Tense a single muscle group for 5 seconds, noticing how it feels tensed and then rapidly drop the tension, paying attention to how it feels relaxed for a further 15 seconds

How to do PGMR: You work through your body to really tense a single isolated muscle group for 5 seconds, then you rapidly drop the tension and release it for 15 seconds. You really focus your attention on the muscle and how it feels both when tensed and relaxed. You tense the muscle as much as you can for 5 seconds to help your body to notice the signs of tension and then rapidly drop it, so your body is registering it held tense and then the contrast with the muscle in a relaxed state afterwards. Then you move to the next muscle group, following the PGMR worksheet on the next page. Sit down comfortably in a chair and remember to take off your shoes. Use a quiet place, free of any distractions where you can really focus your attention on your muscles. Starting at your head or feet, whichever you prefer, you tense and then release one muscle group at a time. Many people find starting PGMR from the head down You don’t want to hold a muscle tense for more than 5 seconds as it could lead to stiffness or cramping. 5 seconds is enough time for the body to register the tension in the muscle in comparison with it relaxed. PGMR takes regular practice, keep it going for at least three months to get the maximum benefit from it. For the first two weeks aim to do it up to twice a day if you can, then move to once per day.

PGMR exercise sheet My forehead: lift my eyebrows as high as I can and tense. My face: tighten up the muscles in my face, around my cheeks and nose and hold it tense. My jaw: hold my jaw slightly open and tense it. My neck: gently lean my head right back, stretching my neck and hold it tense My shoulders: lift up my shoulders to my neck and tense. My upper back: push my arms backwards at chest level, with elbows towards each other My right arm at the top: tighten my bicep muscle and tense it as if showing someone my muscles. My left arm at the top: repeat as above with my left bicep muscle. My right hand and forearm: make a fist and tense my lower arm and stretch it out, keeping it tense. My left hand and forearm: repeat the above with my left hand and forearm. My upper back and shoulder blades: stretch up my back and shoulder blades and hold them tense. My abdomen and lower back: pull in my tummy muscles and hold them tight and tense. My buttocks: tighten my buttocks and tense them up. My entire right leg: put my leg out and tense it all the way down. My entire left leg: repeat the above on my left side. My lower right leg and calf: tense my calf muscle in my lower leg. My lower left leg and calf: repeat the above with my left side. My right foot: curl up my toes and tense my foot. My left foot: repeat the above with my left foot.

John: “I found I often felt overwhelmed and put things off that I needed to deal with. That just backfired as I then spent ages worrying about them anyway and felt worse and worse. Learning to separate if I am having a practical or a hypothetical worry and taking action on the practical ones straight away really helped me to break that cycle. Even when taking the action is hard, it is better than feeling terrible all day. I have learned to break things down and stop procrastinating.” © Marie Chellingsworth (2020). The CBT Resource.

Why just trying not to think about a worry backfires

When you feel anxious, your thoughts become more focused on the things that make you feel that way. Its a natural reaction to try to push anxious or unpleasant thoughts out of your mind. This is known as thought suppression.

Thought suppression, trying not to think about something that causes anxiety or an unpleasant emotional reaction is understandable. Research has shown however, that thought suppression when you have an anxiety disorder like GAD or depression actually backfires. A good way to show how this happens is to do a quick exercise. The exercise is in two parts: Part 1: You have 5 minutes to think about anything you want to think about. You can plan a holiday, think about something lovely that happened to you recently, maybe your favourite memory or place. How you spend this five minutes is entirely up to you. You may think about a white polar bear. If the thought of a white polar bear comes into your mind, just make a note of how many times it does on a tally list. You can stay thinking about one for the entire five minutes if you want to, or just make a note and then go back to spending the rest of the time as you want to. At the end of the five minutes, answer the questions below: 1) Did you have any thoughts of a white polar bear? If so, how many are on your tally? 2) Were you able to think about what you wanted to during this time? 3) Did it use up all your energy and concentration when having the five minutes to think about what ever you wanted to? 4) Did you feel any different emotionally during the five minutes? If so, was this positive or negatively? Was the thought of the polar bear anxiety provoking in any way? Now, once you have completed part 1, it is time for the second part of the activity.

Part 2: You have another 5 minutes, but now you must not think about a white polar bear. Do everything in your power to push the thought out of your mind. If you do think of a polar bear, make a tally each time, then stop thinking about it in any way you can. At the end of the five minutes, answer the questions below: 1) How many thoughts of a white polar bear did you notice this time? How does this compare with part 1? 2) Were you able to think about what you wanted to during this time? 3) Did it use up all your energy and concentration trying not to think about it? 4) Did you feel any different emotionally during the five minutes? If so, was this positive or negatively? Was the thought of the polar bear anxiety provoking in any way this time? Research shows that when someone is anxious, the mind wants to prioritise attention to thoughts that link to feeling that way. So worries are prioritised. This is because it is what is known as mood congruent information. It is information the brain thinks that it should be paying selective attention to, over other things happening at that time. Studies have shown that trying to push these types of negative thoughts out of your mind has the opposite effect. Trying not to think about them is like ignoring an alarm clock. It grows louder and louder, to try and get your attention back. You end up with more of the thoughts getting bounced back into your mind. The emotion attached to it, how you are feeling, also goes up with it each time it bounces back in. If you do manage to suppress the thought, it takes all your mental energy. It can be exhausting and leaves no room for concentrating on other things. You also tend to have thoughts along a similar theme. So you manage to not think about a white polar bear, but think about a pink polar bear or a penguin, for example, but then your mind takes you back to the very thing you were trying to push out in the first place. So trying not to think about a worry, to suppress it, only serves to give more worries, more emotion and more impact on your symptoms as part of the vicious cycle. Instead, learning a helpful way to manage worries can ensure you can postpone your worries in a way that helps you take control of them, rather than them controlling you. Let’s look at how to do this next. © Marie Chellingsworth (2020). The CBT Resource.

The two types of worry We have two main types of worries. Practical worries and hypothetical ones. When people worry a lot and have GAD, they tend to treat both types of worries the same, keeping them in a vicious cycle of worry and anxiety. Knowing which type of worry you are having, can then help you to manage each type more effectively. Practical Worries Practical worries, are worries about external practical problems that we can do something about, right there and then. For example, we may worry about having enough money in our account to cover a bill going out this week. We go and transfer some money in from another account to cover it, arrange an overdraft or arrange with the company a new date to pay. This stops the worry and deals with the problem, leading us to feel better. These worries resolve and go when you have taken the action to solve the problem. When you worry a lot, or have a situation in life to deal with that is overwhelming it can be hard to deal with practical worries. People with GAD often procrastinate (put off) dealing with practical worries, which leads to feeling worse.

Hypothetical Worries Hypothetical worries tend to be about situations in the future that are currently uncertain, unpredictable or out of our control; things that we cannot do anything to change at that moment. They are usually about practical situations in our lives, like our work, finances, education, employment or our health. Unlike practical worries though, there isn’t a helpful action we can take to resolve them at the time we have the worry, or our attention should be elsewhere in that moment. Our mind tries to treat hypothetical worries in the same way as practical ones by attempting to find a solution. This leads to keeping worrying about it. It is just our minds way of trying to deal with and gain control over a situation that is unpredictable, uncertain or out of our control, but, unlike dealing with a practical worry, it does not lead to use feeling better. These worries can quickly escalate in our minds to the worst case scenario, making us feel even more anxious, tense and stressed. Hypothetical worries are hard to dismiss, they keep bouncing back into our mind as they are unresolved. These worries take our attention and focus away from the present moment. They make us focused internally on our worrying thoughts and how we are feeling, rather than what else is going on around us. We get caught up going over and over the worries, keeping us in the cycle of stress, tension and worry. If we suppress a hypothetical worry, by trying not to think about it, without using a strategy to refocus our attention, it backfires and leads to increasingly more worries and more anxiety. It takes up lots of energy and concentration. Hypothetical worries can also lead us to take actions that are less helpful or make us feel worse in the longer term.

Is it a practical or hypothetical worry?

Is the worry a practical worry that I can take an action to solve straight away and that should be the priority of my focus of my attention right now in this moment, rather than it being on anything else?

Yes

This is practical worry I can do something about right now that should have my attention.

I can’t do anything helpful about it right now or solve it. This is a hypothetical worry.

Take action on practical things you can do something about at the time. Try not to put it off until later, as this can make you feel more stressed and anxious.

For these worries, use the worry time technique. Write them down knowing you can worry about them as much as you want in your planned worry time. Then refocus your attention back onto the present.

My worry list Worry time is an effective way to manage hypothetical worries. You set a time once a day where you can worry as much as you need. Outside of that time, you write down your worries and refocus your attention on the present.

When you worry, it distracts you from present moment and focuses your attention internally, on your worries and anxious feelings. When we are truly paying attention to what is going on around us, and engaged in a task, we don’t worry. Writing down your hypothetical worries and then refocusing on a task externally, helps you to break the cycle. Using worry time helps you to feel more in control of your worrying instead of feeling like it is controlling you. Over time, the amount of hypothetical worries that you have will reduce. You will find you are more focused on other things happening around you at the present moment, instead of distracted by your worrying. You plan a time each day where you can worry in a managed way. During your worry time, you can worry as much as you want about the worries that you have had during the day. It is up to you how much time you set aside for your worry time each day. The important thing is that it is a time that you will not be disturbed and can focus your attention fully on your worries. Make sure that the amount of time you set aside feels realistic. You need a time when you are not at work, busy with the children, cooking or watching TV. This time is just to purposefully worry about the hypothetical worries you have had in your day, even if they have resolved, not for dealing with practical worries. These should be dealt with as and when they arise at the time you had the worry to not procrastinate on them. There are three steps to put worry time into action: 1. Set a planned worry time once a day where you can really focus on your worries. 2. Outside your planned worry time, you are going to write down any hypothetical worries that come into your mind. Use the worry type diagram if you are unsure if a worry is practical or hypothetical. If it is practical, take the action there and then. If it hypothetical, write it down, knowing you can worry about it as much as you need to later. 3. When you have written down your hypothetical worry on your list, you then need to re-focus your attention on the present. Keep your worry list by the side of the bed and write down any worries then too, then refocus your attention back on a task in the present. The APPLE technique can help you to do this. Keep the list with you throughout the day. Each time you have a hypothetical worry, write it down. Try to be as specific as possible and record the real thought that went through your mind. For example, ‘What if my manager is angry with me’. You may find that you have worries when you try to get off to sleep. You may also find you wake up in the night with a worry on your mind. Keep your worry list and a pen at the side of the bed and make a note of these too. The same hypothetical worries may come up multiple times, that is OK and to be expected, just like the polar bear example. Just write the worry down as many times as you need to and then refocus your attention.

My worry list Write down any hypothetical worries that come into your mind until your next planned worry time. Remember to re-focus your attention onto the present moment once you have written a worry down. The same worries may come back. That’s OK. If they are hypothetical, just rewrite them on your list as many times as you need to and re-focus your attention again. You can use the tips provided to help you to refocus or the APPLE technique. At your planned worry time, you can sit and worry about the things you have written here as much as you want or need to. At the end of your worry time, throw this list away and start with a fresh worksheet.

“John: I found it useful to keep a pen and notepad at the side of my bed. I could then make a note of the worries I had when I was trying to get off to sleep and then refocus on the task at hand – sleeping! It took practice though but it helped lots. The diary helped me to record down all my worries throughout the day.” © Marie Chellingsworth (2020). The CBT Resource.

Refocusing your attention When you have written down a hypothetical worry, refocusing externally helps you to break the cycle of worry and reconnect with what is happening around you. Using your senses to focus on a task is a great way to do this.

A task that you really have to focus upon is best. For example, if you were watching TV when you were worrying, write down your hypothetical worry and then refocus your attention, listening to a conversation on screen. To really refocus, add a task that means you need to pay more attention that you would normally do. You could listen out for how often the people speaking use the neutral word ‘and’ or perhaps keep a tally of words spoken that start with the initial of your name. Then, after a few minutes change the neutral word or initial, then switch it back. If you are listening to music, focus your attention in on just one instrument such as the drums or baseline for a few minutes and try to zone out the other instruments, then switch and try to focus on the piano or guitar for example. This really helps you to learn to focus your attention. It is a skill that needs practice, so you can also do this at other times to strengthen your ability to do it. The same worry may keep popping back into your mind. That is OK and may happen for a while, due to the nature of hypothetical worries. When a hypothetical worry comes back, just write it down again and refocus, as often as you need to. Remember worry time takes practice, as does learning to refocus your attention on the present. Over time, your worries will become less frequent and bothersome. The last part of worry time is to take out your list of hypothetical worries that you have written down since after your last scheduled worry time. Then, for the full amount of time you set aside, you are going to do nothing but worry about the things you wrote down. Read through the worries on your list and purposefully worry about each one in turn. Keep your attention focused on the worry. Ask yourself how you felt at the time when you wrote down the worry and how you feel about it now. Did what you were worrying about happen? If it did, how did you manage it? If it is no longer a worry for you, why is that? What would have happened differently if you had worried about them at the time instead of using worry time? At the end of your planned worry time, throw your worry list away. Then spend a few minutes reflecting upon how your worry time went. Did you need all the time you set aside? Was it enough time? Have you noticed anything with how you are managing your worries or how you feel able to deal with them? What other things have you done in your day as result that you may not have otherwise been able to do? Then get a new worry list out and ready. Always start again with a blank worry list after your worry time. Any worries you have afterwards or that night belong in the next day’s worry time.

Use APPLE for thoughts about uncertainty, uncontrollability and unpredictability Another helpful technique you can use for refocusing away from thoughts about uncertain, unpredictable or uncontrollable situations is to use APPLE. It helps you to refocus when you have a hypothetical worry about a situation that you cannot gain certainty or control over right now, or when you can’t fully predict what the outcome may be. It enables you to refocus your attention on the external world and not inside your own internal world of anxious thoughts and feelings.

Acknowledge and notice that what is in your mind right now is a hypothetical worry. A worry

about an uncertain, unpredictable situation that is not within your control right now. There is no action that could or should be taken to resolve the worry and your focus is needed elsewhere. You are taking all the recommended actions to manage your worries. You can worry about it as much as you like in your planned worry time later.

Pause for a few moments and don’t react to the thought or feeling in any way, just let it be.

Pull back from the thought or feeling you are having after writing it down. Tell yourself that these are just a result of your mind trying to gain control, certainty and predictability over a situation that you cannot control right now. Remember that thoughts are not facts. Be compassionate to yourself for how you feel. Let your mind and body do its thing. You can pull back from it.

Let the thought and emotion go, watch it fade into the distance. The thought or feeling is not

harmful, although it may feel unpleasant right now. You can pause, allow the thoughts and feelings to just be and then choose to let them go by now refocusing your attention onto a task in the present.

Explore what is going on around you right now. Refocus your attention out of your own internal

world, to what is happening outside of you at this moment. Notice things with your senses. What can you hear? What can you see? What can you touch and feel that is physically present? What can you smell? What task can you now do to take your full attention back into the present moment? Do a task that takes your full attention. The same worries or feelings may come back, that is OK. Just notice when you are going inside yourself to your worries and feelings of anxiety and repeat the process as many times as you need. © Marie Chellingsworth (2020). The CBT Resource.

Managing my practical worries: Problem solving Problem solving is an effective way to break into the vicious cycle of procrastination, uncertainty and avoidance of practical problems.

Practical worries are worries that we can and should act on when we are having them. They are worries that we should focus on dealing with when we experience them, rather than worrying about them. It allows a step by step approach to be taken. This helps to create ideas that will help solve the problem. The pros and cons of each solution can be weighed up before deciding which action to take. When we worry a lot, our ability to problem solve as well as we usually might be able to can be affected. This can lead to not taking the action you need to. This can undermine your confidence when the next practical problem comes along. To use problem solving, you define what the practical problem is and what date it needs to be done by from your worry. You then think through and list as many solutions as possible. These may even be silly ideas at first, things you would never do, as these help to create your ideas and get you thinking of what would be possible. Then put these into the order you would feel able to carry them out. Finally, make a plan to put your solution into action.

Problem solving my practical worry

1 2 3

Turn my worry into a practical problem

• What do I need to do and when do I need to do it by?

List as many solutions as I can on the table

• Don’t rule out any yet, even ones that seem impossible or not sensible help to generate my ideas

List the pros and cons on every solution I have come up with

• Then number them: with 1 being the one I feel most able to try out that is likely to solve the problem I have Potential solution

Pros

Cons

Number

Make a plan to carry out the solution I have chosen

• What am I going to do? When am I going to do it? Will anything get in my way? How can I overcome that? • Now put it into action - time to carry out my plan!

How did my plan go?

• Reflect here how it went, what do I need to do next? • If it went to plan, what has it taught me? • If I didn’t solve the problem I should choose solution 2 and put that into action

“Amelia: If your first solution didn’t work out, don’t let this get you down. Go straight to solution 2 and try this. Put this into action and see if this works out better for you.” 27

Hints and tips from Amelia and John

Amelia: “I found I would worry sat in certain places in the house, like before getting out of bed in the morning and when trying to get off to sleep. Keeping my list with me helped. As well as getting out of bed when I woke up instead of lying there. If I noticed myself worrying sat in a 17 chair, I would” John: “You don’t need to use the problem solving steps if you already know what action to take to solve a practical problem, but they are there if you need them. I found they really helped me to not procrastinate on the ones where I was unsure or felt overwhelmed by. It helped me to break things down, but I didn’t need to use them for every practical worry I had” Amelia: “Learning to refocus your attention can be hard. At first, I got really frustrated with myself that my worries came back after I refocused my attention. My practitioner explained that is to be expected and just to re-write them down and refocus. I also found the thought suppression exercise helped me to see that battling with my worries, trying to push them away, was actually making it worse!” John: “I had been worrying for hours a day. I didn’t think I could save them all up for worry time, or that I would have enough time to worry about them all. I wondered if not worrying about them until later was really a good plan initially. Well, I quickly realised that trying to worry on purpose and focus attention on them in worry time was so hard, it wasn’t easy to do and certainly not nice. I started to not feel as worried about not worrying anymore! ”

Reviewing your progress Carry on with your worry management until you feel you are no longer struggling with your worry and anxiety. PGMR you can make part of your daily wellbeing.

Keep going with your worry management tools. There are spare worry lists in the back of the booklet. Once you have used the worry management techniques for about 4 weeks, it is a good time to review your progress and then decide if you want to continue with all the techniquea for longer, or you feel ready to move onto relapse management. PGMR: Keep up your PGMR practice each day, this is something that you may want to continue even after you feel better. For best results, PGMR should be practiced for at least three months. At first you may not notice any difference from the practice, but it will be working in the background to help you to release early warning signs of tension building up. It will also benefit your sleep and help to reduce worries. Worry Time: Carry on using worry time until you are having fewer worries to write on your list each day and they do not bother you as much anymore. When you find yourself able to refocus away from hypothetical worries easily is also a good sign of progress. Don’t forget to write down your worries and then refocus your attention on a task in the present when you write down a worry. People often find after the first week, that the time they thought they needed for the worry time itself is too long. This means that they can reduce this down to 20-30 minutes after the first week or two if this is the case. Remember, the worry time should still be spent purposefully worrying about the thoughts that you have collected throughout the day, until you are having fewer worries and less impact. A good sign that you have broken the cycle is fewer worries and worry time itself starting to feel more unpleasant, unecessary and not enjoyable than you feeling it is necessary anymore. Practical Problem Solving: Practical problem solving is a technique that you only need to use for practical worries that you are unsure of what action to take to resolve them. It is to break the cycle of procrastination. If you can manage a practical worry and know what action to take in the moment, you do not need to use the problem solving steps. You may find you use this less often, or that you are able to solve the problems that arise without it as the cycle begins to reverse. Look at whether your symptoms are improving. Go back to the vicious cycle you completed at the start • Are you worrying less, noticing fewer worries than before? • How are your physical symptoms of anxiety and behaviours? • What changes have you noticed?

• Are you sleeping between 7-9 hours a night and waking feeling refreshed? • Do you feel less tense and having fewer headaches, gastro-intestinal upset or aches and pains? • How far have you moved towards your goals? • Have you met any of these? • If not, are you close to meeting any? • Are there any which need more work? If so, what are you going to do and when are you going to do it? When you feel you are ready, you can move on to the staying well section. It is fantastic that you have put in the hard work and effort and you are ready to make a plan for the future.

What is a relapse? Can I really go it alone or will I become unwell again?

I would like to keep working on feeling better

Am I ready?

I feel so much better! But will it come back?

I don’t want to look back….I want to look forwards, how can this help me?

It is great news that you have completed your worry management treatment and feel better! Now it is time to think about staying well in the future. Next, we will learn more about everyday mood fluctuations. It is also important to know when you may be having a lapse or a relapse. You should know what the differences are between them. Using this relapse section will help you to manage your mood in the future. You can put your worry management skills back into action at any time you need them. Everyday mood changes It is normal for our mood to change day to day. Often more than once a day, depending on what happens to us! We all have times when we feel anxious for a few hours or even a few days at a time. We also have worries, a level of worrying is normal!. We just don’t pay so much attention to them as they pop back out of our minds again. What do you do when you have a day like this? Try not to let how you are feeling, or any worries affect what you do. That’s when that vicious cycle can take hold again. It is part of everyday life to feel this way from time to time. Be kind to yourself. Don’t put yourself under too much pressure that your mood has always got to be positive and you won’t worry – you will. This is OK, we all worry! They key is not to let it form a cycle again and affect what you do. You have the skills to manage it. What is a lapse? Sometimes, you can lapse back into old ways for a few days. For example, you may avoid things because of worrying. A lapse does not mean that you have relapsed. Spotting it means you can act to break the cycle before it takes hold. Recognise a lapse for what it is. Try not to worry that it is a sign that you have gone back to square one. It isn’t! If you spot this happening, it’s a sign to put your skills into action again. What is a relapse? A relapse is when you start to feel the way you did before. Your physical symptoms and worries may return for several days in a row. If this should happen, you have the worry management skills to put back into action again. That should mean that the problem doesn’t get as bad or last as long. Completing this guide can help you to spot early warning signs before that vicious cycle has a chance to take hold again. 31

My early warning signs Make a note of the things that you noticed first when you were becoming unwell. How did it affect you physically? What where you doing or not doing because of this? How did it affect your thoughts? Sometimes others around us noticed these things before we do. Ask those close to you what they noticed first. These are things to look out for as early warning signs in the future. Remember though, that you may have some of these symptoms as part of a normal mood pattern. If they are affecting how you are feeling and what you are doing more days than not, it is time to act.

My regular review

Write yourself a letter about how far you have come, how you are feeling and how you made that happen. Then, pop it into an envelope and address it to yourself. Put a reminder on your calendar or on your phone. This can remind you to open it and enjoy reading it again in 3, 6 and 9 months from today’s date. Once opened, reflect on how you are feeling. Also reflect on the impact that making the changes you have put into place has had on your life since. Then re-seal it and put it somewhere safe you will remember for next time! You should take out your letter and read this again if you notice any early warning signs. This will motivate you to put your worry management skills back into action. Remember, you have helped yourself before. You can do it again!

“Amelia: I found it useful to write a letter to myself. It enabled me to see how my worries had improved and how far I had come. I knew I would be able to put my skills back into practice if I experienced any early warning signs.” 33

My regular review Keeping check on my mood How has my worry and anxiety been this month?

Have I had any of my early warning signs?

YES

For how many days?

Reflect on the progress you have made since your last review and take a moment to think about what you would like to do in the next month to keep moving forwards

Am I feeling tense? Am I avoiding things because of how I am feeling? procrastinating or over-preparing? Am I having a high level of worries?, or doing things to feel better, that only work in the short term?

YES

If yes: Do I need to put my worry management skills back into action? If so what am I going to do and when am I going to do it?

Move to the next question and use the worksheet to keep your GAD toolkit fresh

My GAD first aid tool kit

Think of your worry management skills as a first aid tool kit for your GAD. They are always there if you need them. You just need to remember how to use them and to keep your worry management skills fresh.

What are the key points of worry management and how you use it? Remember you can go back to the pages in this guide at any time to refresh your understanding. This is a great way to make sure you know what you need to do, if you need to put the skills into action again. Even if you are feeling well, a review day is helpful once a month to spot any early warning signs. Ideally, plan 6 months ahead of dates now and pop them in your calender or on your phone to remind you. Date of my next review day. Put this on your calendar or somewhere you will see it as a reminder.

Date of review 1: Date of review 2: Date of review 3: Date of review 4: Date of review 5: Date of review 6:

Keeping my worry management skills fresh What do I remember are the key points of the worry management techniques that I learnt? Take a few moments to read through your intervention booklet again and practice the technique. Even if you are feeling well, this is a great way to make sure you know what you need to do if you need the skill again in the future. Do I feel confident enough to be able to use the techniques again if I needed to?

Date of my next review day. Put this in your calendar or somewhere you will see it as a reminder.

DATE:

“John: Remember to keep your skills fresh. Make sure you feel confident enough to be able to use the techniques again. This is important in case any of your early warning signs appear again. When I found I was starting to worry and avoid things again, I knew I could apply the techniques I had learnt in this booklet.” © Marie Chellingsworth (2020). The CBT Resource.

Where to get more help Emergency help If you, or someone you are worried about, need support in an emergency situation, do not put off getting help. The following can be used in an emergency: • • • • • •

Emergencies: 999 An Emergency appointment with your GP Fast medical advice in a non-life threatening situation: 111 Samaritans: 116 123 (24-hour service) SHOUT Crisis support: Text 85258 (24hrs) CONNECTION for Dorset 0300 123 5440 (24hrs)

Remember, do not be afraid to get help. Feeling this way doesn’t last forever and there are things that can be done to help! Below are some useful web links with good quality information for anxiety and depression and what treatments are recommended if you want to learn more:

Useful websites on Generalised Anxiety Disorder and its treatment • The NHS: https://www.nhs.uk/conditions/generalised-anxiety-disorder/ • The National Institute for Health & Care Excellence GAD information: https://www.nice.org. uk/guidance/cg11/ifp/chapter/About-this-information • The Royal College of Psychiatrists: https://www.rcpsych.ac.uk/mental-health/problemsdisorders/anxiety-panic-and-phobias • MIND The mental health charity: https://www.mind.org.uk • The Mental Health Foundation: https://www.mentalhealth.org.uk/a-to-z/a/anxiety Other useful helplines: • National Domestic Violence Helpline: 0808 200 0247 • Forced Marriages Unit: 0207 008151 • Support for Lesbian, Gay, Bisexual & Transgender (LGBT) Victims- Broken Rainbow: 0300 999 5428 or 0845 260 4460 • Support for Male Victims. Respect: 0808 801 0327 • Help for the Perpetrator. Respect: 0808 802 4040 • Childline: 0800 1111 • Debt helpline: 0808 808 4000 • Family lives (formerly Parentline): 0808 800 2222 • Citizen Advice Bureau: 0344 411 1444

Your notes

Marie Chellingsworth The CBT Resource ® Marie is a CBT author and academic and the Founder of The CBT Resource and Subject Matter Expert for a number of CBT and digital mental health services. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments. She has over twenty years experience, 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 to maintain standards for CBT based approaches and was Consultant to the Australian Improving Access to Psychological Therapies programme. Prior to developing The CBT Resource, she was the Executive Director of Evidence Based Programmes at UEA, Senior Lecturer and Course Director at the University of Nottingham. Her passion for CBT 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, renovating her home and also spending time on local beaches and countryside with her Irish Setters. www.thecbtresource.co.uk

Andy Poplar [Vinegar & Brown Paper]® The photographs of etched glass 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

Worry less, Live more: Managing worry and uncertainty in Generalised Anxiety Disorder (GAD)

Articles inside

Spare worry lists

The two types of worry

Refocusing attention

My notes

Relapse management

Reviewing your progress

Hints and tips from Amelia and John

My worry list

Meet Amelia & John

My goals

Understanding Worry and Generalised Anxiety Disorder

My own vicious cycle

Why trying not to worry backfires

Building motivation to move forwards

Progressive Muscle Relaxation (PGMR

How worry management can help