Cognitive Behavioural Therapy strategies for worry
Worry is one form of anxiety that can be targeted with CBT interventions such as exposure, problem-solving and cognitive change techniques. What is worrying, and when is it a problem?
Worrying is thinking too much about what might happen – usually leaning to anything negative. Everyone worries sometimes; but excessive worrying (rumination) is upsetting and makes it more difficult to think clearly about the situation. Worry is often a feature of anxiety disorders.
Focus on what you can control, not what you can’t
For worries about a problem that can be solved, use the technique of problem solving:
Some worries are about current or future situations that someone has some control over. People who perceive they have some control and have a plan worry less.
1. Identify the problem
2. Brainstorm possible solutions
3. Evaluate the solutions (pros and cons) and select one or two to try
4. Make a solid plan to try those solutions, practicing any new skills that might be needed
5. Check back to see if adjustments or new solutions are needed
For worries about unlikely, hypothetical or uncontrollable events:
A. Have a conversation about the worry. The goals of the conversation are to better understand the worry and to provide exposure to the worry content so it becomes less scary. (“The bad outcome is likely” and “I could not handle the bad outcome if it happened”).
Elements can include:
1. Identify and clarify the feared outcome(s). What are you worried will happen? What is
the worst thing that can happen? Use follow up questions (“And what would be so bad about
that?”) to find out what is the real fear.
Often talking through the feared outcomes and how to cope if they did occur helps someone see these outcomes as less likely and more manageable.
2.Find new information. When worries reflect misunderstandings, clear them up with information. For example, someone who fears choking, dying in their sleep, or being harmed in other unlikely ways may be unaware of what would be involved for these events to actually happen and what is in place to keep them safe. This does not always work, but is worth trying.
3. Use Socratic questions (why, what, who, when and where?) to explore evidence that the feared outcome will happen, would be as bad as imagined, or could not be coped with if it did.
4. Know that it’s okay to talk about the feared event/worry. Think about and find meaning in difficult topics. For example – talking about a taboo subject like death.
Socratic questions might include: What would the world be like if no people or animals ever died? How would you live if you thought you would never die? The more we ‘approach’ the less scary the worry will seem.
5. Exposure without avoidance/safety behaviors. Those with high worry are likely engaging in avoidance behaviors or unhelpful safety/reassurance behaviors that maintain the fear. Identify these forms of avoidance and “ride the wave” of fears in the situation without engaging in them. You will notice that the bad things don’t happen or that you can handle it if they do. The preoccupation will quickly decrease. Example: If you keep going to the bathroom during social events because you feel anxious, this is called a “safety behaviour”. Try to drop this behaviour or reduce it to help ease the anxiety.
Safety behaviours encourage us to focus more on the anxiety and end up maintaining the behaviour.
6. Make tolerating uncertainty the goal. Many worriers are very uncomfortable with uncertainty
about the future. Worrying is trying to find reassurance that the future can be controlled. Because
the future IS uncertain it is best to learn how to cope or accept it. Exposure in this case would be
thinking about the feared outcome and instead of reassuring oneself, saying “maybe that will
happen” and riding the wave of fear that produces.
7. Intensive imaginal worry exposure (if needed). Describe the worry in detail repeatedly, write it down, record and listen to it, or concentrate on/discuss it without distraction
or self-reassurance until distress goes down. Say “maybe that will happen” during imaginal exposure.
B. Structured worry time
Set a particular time of day and brief length (20 mins) for worrying. Write down the worries that pop up during the day to be worried about during the “worry time.” Worrying is not allowed at other times. A “worry box” can be created (a shoebox or Kleenex box) in which to place the recorded worries. You are allowed to worry for the duration of “worry time,” but most find that they become bored of worrying
and stop early.
Bedtime Worries: Special Considerations
It is common for worries to crop up and be difficult to control at bedtime, when there are few distractions and the brain is tired.
Strategies for worrying at bedtime:
Write down worries or things to address in the morning.
Create distance from the day’s worries by building calming activities into the bedtime routine, like reading. or a warm drink.
Try a calming mental task such as calming imagery, body scans, progressive relaxation, listening to calming tape.
People with a history of difficulties falling asleep may worry about falling asleep which usually makes the
Try to not try to fall asleep. Instead, focus your mind on other calming tasks (see above).
Not sleeping well is not a big deal. Poor sleep one night usually means better sleep the next night (as long as you don’t sleep in, nap, or overuse caffeine the next day).
No clock watching. Move clocks so that you cannot become preoccupied by the time.
The above techniques are proven to work and are regularly used by CBT therapists – try them for yourself! You can learn to self administer CBT.
Photo by Evil Erin