Cognitive Behavioural Therapy for Anxiety Liverpool city centre

First off, anxiety on its own is entirely normal. We all have it on occasion and, in the right circumstances, it can be an incredibly useful emotion to alert us to and enable our response to danger.

Anxiety evolved as an emotional and physical response to danger in the world. It keeps us safe. It is the product of millions of years of evolution and has been designed via natural selection as a quick fire system to get us out of danger whenever it presents.

When we experience something as being a potential threat to our safety, the parts of the brain responsible for emotional processing trigger off a series of changes within our body which enable us to respond to the threat in a way which increases the possibility of us staying alive.

The brain sends a signal to the adrenal glands, activating what is commonly called the “Fight or Flight” response. This adrenaline alerts other parts of the body, and the body responds with such changes as increased heartrate, faster, more shallow breathing, increased physical tension and “butterfly” feelings in the stomach, amongst other things. All of the things that our body can use to effectively deal with the threat – We either fight it or we flight it (escape).

When faced with actual, real danger, anxiety gives us the physical tools we need to survive.

Therapy for Anxiety Liverpool: For many of us today, it is generally rare to experience a real physical threat – if we’re lucky, we may only experience this maybe a few times in our lifetime – and yet, the experience of anxiety is more prevalent than ever.

Why is this? Well, unlike other animals, we are gifted with fantastic reasoning and mental problem solving skills. We are able to respond to problems as they emerge and we can generate solutions based upon our existing knowledge, experiences from the past and our expectations about the future. These mental skills have served us well, contributing to our highly developed languages, our societies and cultures.

However, it is because of these more highly developed mental skills that Generalised Anxiety (and other mental health issues) can occur.

Worry (and its counterpart, rumination) is a type of thinking process which moves our attention onto problems which are not happening in the here and now. When we worry we are casting our mind into the future and attempting to work out and solve any and all possible problems that may occur around a particular theme in the future.

The problem with trying to predict and solve any and all problems in the future is that

1. a) Most of these problems will never arise.
2. b) Focusing upon future threat (the possible problem) in the here and now, even when the problem is not here, creates stress and anxiety for us in the here and now.

Worry Training

First off, lets think about how we deal with worry.  As mentioned above, worry is a key feature of generalised anxiety disorder and so it makes sense that we would want to start to get to grips with it as soon as as possible.  Here, we are looking to evaluate individual worries with a view to finding out whether they are “hypothetical” worries or “real” problems.

Here are some definitions:

• Hypothetical worry:  A worry that has not actually happened in the real world as yet and may never happen.
• Real problem:  The problem has happened.  It is real and out there in front of us.  There is something we can do about it.

For people with generalised anxiety disorder, distinguishing between hypothetical worries and real problems can be a challenge.  Often, hypothetical worries can feel as though they are real problems, despite that fact that the only place that they exist are in the minds of the worrier.  This is why we need to train ourselves to notice the difference.

Intolerance of uncertainty

As mentioned earlier, studies suggest that people who experience high levels of generalised anxiety have a low ability to tolerate uncertainty in the world.  Because of this, this treatment approach places a big emphasis upon teaching you how to notice when you are changing your behaviour in relation to Intolerance of Uncertainty and how to then increase your tolerance.

What is meant by Intolerance of Uncertainty?  Intolerance of uncertainty can be thought of as being a little bit like an allergy. Consider a peanut allergy for example.  When someone with a peanut allergy is exposed to even a tiny piece of peanut, what happens?  Typically they will have an allergic reaction – runny nose, itchiness, possibly even going into anaphylactic shock.  So a small amount of peanut leads to a big response.

Similarly, in someone who is Intolerant to Uncertainty, when they are exposed to even a small amount of uncertainty, they have a big response – Worry, Anxiety, needing reassurance, avoidance, etc. People who then develop GAD use mental processes like Worry and behaviours such as Avoidance, Reassurance Seeking, Checking and Overcompensating as a way of managing their intolerance to uncertainty.  They are trying to use these strategies as a way of reducing the uncertainty in the world.  For instance, if they avoid uncertain situations then they will not have to worry about the uncertainty of how the situation may develop.  If they seek reassurance from people, they can reduce the uncertainty that they may or may not have made a correct decision.

There are couple of problems with this strategy however.  Firstly, the behaviours themselves become problematic – the GAD sufferer may be constantly seeking reassurance or checking, or they may be avoiding so much that it has a real negative impact upon their lives.

The second problem with this strategy is that the individual with generalised anxiety disorder never escapes or reduces uncertainty in the world entirely.  In fact, this would be impossible.  Despite all of their best efforts (both consciously and unconsciously) the world remains uncertain.

So, we need to develop a different strategy.  Rather than trying to reduce uncertainty in the world, we instead need to increase our tolerance.  Returning to our peanut allergy metaphor again, modern treatments for peanut allergy help people develop tolerance to peanuts by exposing them to really, really tiny pieces of peanut protein.  This happens again and again, with gradually larger and larger pieces of peanut until the sufferer’s body has gotten used to it.  Until their body can tolerate it.  This is exactly what we do with uncertainty – We expose you to little pieces of uncertainty and gradually turn the dial up.  Week by week, your tolerance of uncertainty increases and there is less and less need to respond with avoidance, checking and reassurance seeking, etc.

Positive beliefs about worry

This stage of treatment aims to understand and change the individual’s positive beliefs about worry.  When suggested to client’s that they have positive beliefs about worry, this can sometimes create a bit of confusion.  They know that their worry and anxiety is causing them problems – surely they don’t believe that this is a positive thing?  Well, this is not always the case.  Dugas and Robichaud propose in their GAD treatment model that people with GAD can have a number of different types of positive beliefs about worry which serves to maintain their use of worry as a strategy for dealing with the world.  Here are some examples or positive beliefs about worry:

• The belief that worry can protect us from negative emotions.
• The belief that worry motivates us to resolve problems.
• The belief that worry helps us to resolve problems.
• The belief that worry can actually prevent bad things from happening.
• The belief that worry is a positive personality trait.

At this stage, we aim to understand if the GAD sufferer has any degree of belief in these positive beliefs about worry and if so work to evaluate their true costs and benefits.  For instance, somebody who believes that worry is a positive personality trait (e.g., “I worry because I’m a caring person”) can be supported to explore whether they would still be a caring person whether they worried or not.  We may look at examples of people who appear to be caring and yet worry very little and consider whether it is the worry that makes someone caring, or whether it is an example of their values.  We would evaluate any other positive beliefs about worry in a similar way.

The aim in this part of the treatment is not necessarily to do away with the client’s positive beliefs about worry completely.  There may even be an element of truth in the positive belief.  But rather, we are aiming to consider and explore the strength of belief and consider if the costs of the belief outweigh the benefits.

Negative problem orientation

We’ve established that people with generalised anxiety disorder tend to have big responses whenever they’re exposed to uncertainty in the world.  This part of the treatment model looks at how being exposed to uncertainty through everyday problems can be helped in a proactive way.

Problems are a part of life.  You have them, I have them, your neighbour’s dog has them.  There’s no escaping from the fact that we are always going to have to deal with different degrees and types of problem as we progress through our lives.  The Dugas GAD treatment model suggests that people who have high levels of GAD are generally as good at solving problems as the general population.  If we think about it this makes sense – Worry is a form of mental problem solving (although many of the problems that we are solving are possibly never going to materialise).  The difference in GAD is the individuals’ perception of what a problem means for them.  Quite often, when faced with a new problem, people with GAD will catastrophise, avoid.

Avoidance

This next intervention is, in our opinion, probably the part of the treatment which creates the biggest benefit.  This part of the treatment really gets to the nuts and bolts of Worry and renders it powerless.

If you’ve ever really paid attention to worry (and if you’ve followed the steps above then hopefully by now you have!) then you may have noticed that worry is a verbal, word-based process.  We worry in words. Now, the theory is that we worry in word form because it is less anxiety provoking than worrying in the form of images.  That is, our What ifs? actually protect us from the far more anxiety provoking form of Imagery.

So, worry is what we call Cognitive Avoidance.  Verbal Worry is a Cognitive Process that enables us to avoid imagining the worst possible fears and outcomes.  Based upon this idea, we can then begin to think about what would happen if we were to stop using Worry as a form of Cognitive Avoidance and dig a bit deeper to face, and get used to, our true imagined fears.  To do this we use something called Imaginal Exposure.

Let’s say that I spend a lot of time worrying about my finances.  I get a letter through the door and straight away this triggers a What if? “What if that’s a bill?”  I then start to worry about about what would happen next if that was a bill.  “What if I can’t pay it?”  “What if I do pay it and then I’ve got no money for food?”,  “What if it leaves me with no money for rent?”, “What if?…What if?…Etc.”

What happens in this process is that we have a worry, we briefly solve it in our minds and this then leads to another worry, and so on.  But in this process, we are cognitively avoiding imagining the deeper, core fear.  To find out what the core fear is we can use a technique which we call the downward arrow.  The downward arrow helps us to find the deeper meanings we give to things by simply asking, “and if that were true, what would be the worst thing about that?”

Using this technique we can, with just a few questions, go from the surface worries all the way down to the deeper fear of becoming homeless, not being able to feed the children and living on the streets.

So, now that we have identified the deeper fear, we want to create a way in which we can expose ourselves to it.  To do this we create an “exposure script”.  The exposure script is a written piece of work in which we write down exactly what happens if the feared scenario were to occur.  The exposure script deliberately provokes our physical anxiety feelings using explicit imagery so that we can get used to thinking about these deeper fears without reverting back to endless verbal worry and also learn that we can tolerate the physical sensations associated with the image.

Anxiety disorders are a type of mental disorder that can cause physical symptoms. These physical symptoms can include:

• – Sweating
• panic attacks
• – Rapid heart rate (heart beat faster)
• – Shortness of breath
• – trembling or shaking
• – feeling lightheaded or dizzy
• – nausea or upset stomach
• – feeling like you need to go to the bathroom often

• obsessive compulsive disorder – OCD
• feel worried, mild anxiety and generally feeling anxious
• emotional distress
• severe depression or low mood
• Devopling specific phobias
• lack of control in stressful situations