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.
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.
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.
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.