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]®

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.

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”

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.

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.