Sutton & Merton IAPT

Stress & Worry Management

Handout
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 The Worry Tree

Notice when you are

getting caught up by
worries

What is my worry actually about?

Can I do anything about this worry?

Now or later?
Now Later

Let the worry

go! Decide on action Decide when to
& do it act and schedule
it

Let the worry

go! Let the worry
go!
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 Strategies for disengaging with worry

Worry Time
The idea of worry time is to prevent wasting time worrying. Instead we try to
contain the worry to an allotted time with a clear beginning and end. You can
use the worry time to address the worries practically, using problem-solving
techniques (to be discussed in depth in the next session). Alternatively, if
your worries do not have practical solutions, you can just worry as much as
you like, but you must keep to the time that you set yourself.

E.g. Fernando decided to set his worry time for between 8-9pm because he
knows the children will be in bed by this time and he will be able to sit
quietly. It is also not too close to the time he usually goes to bed so he
should have let the worries go before he tries to sleep.

N.B. Your worry time must have a clear beginning and end. Plan
time in advance for this and stick to the allotted time.

Writing worries down

It may be useful to have a notepad that you carry around with
you where you can write down the worries that pop into your
head during the day. That way you can say to yourself, “I have
acknowledged the worry, it’s written down so I won’t forget
about it and I can now think about this in my worry time later.”
You can also have a notepad by the side of the bed if you tend
to worry during the night.

- Distract yourself
Go and do something really absorbing, possibly something
active, so that you take your mind off the worry. E.g. play a
sport, make a phone call, read a book, do some housework.

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 Visualisation

Big blue balloon

Visualise a big blue balloon. The balloon contains all your
worries. Watch the balloon gently float off into the distance,
taking your worries with it.

Visualising a specific situation

Imagine yourself in a very calm state in that situation. You feel purposeful and
confident. Imagine the environment you will be in, the room, the furniture. You
feel entirely at home and attuned to that moment, you are able to focus on the
task at hand and communicate effectively. Now practice visualising this positive,
clear, realistic image over and over again.

Your calm, peaceful place

Create a scene in your imagination. This scene can
be real or imaginary and from anytime that makes
you feel safe, warm, secure and peaceful with no
uneasy feelings. Make it vivid – feel the breeze; the
temperature; picture the colours; hear the sounds.

Practice visualising this scene as often as you can. When you want to feel calm
then think of this scene and imagine it for a short while. Then return your
thoughts to the matter in hand. The sense of calm should stay with you and
enable you to cope better with whatever comes.

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 Tolerating hypothetical worries

We know that engaging with hypothetical worries increases our anxiety, but at
the same time we cannot just push these thoughts out of our heads. So what do
we need to do?

We need to find a balance between the two. We can use strategies to not
engage with worries, but at the same time if we notice that worries are there in
our mind we can let them be there, without trying to fight them.

I’m going to give you an analogy that people often find helpful to use when
trying to tolerate worrying thoughts.

Think of a train analogy. When we are on a platform

waiting for our train we may see several trains arrive and
stop at the platform. Not all of these trains can take us to
our destination and we do not get on them. We know that
they are there but we do not pay attention to them, we
wait until they leave the platform. We can treat our
thoughts and worries in the same way - notice them
arriving into our consciousness, allow them to stay for a
while, however long that may be, but do not engage with
them.

Just as you do not get on the train which does not take you to your destination,
you do not need to engage with an unhelpful thought or worry. We know that if
we get on the train of worries it leads to an anxious place but if we can remain
on the platform and not engage with those worries, they will leave the platform.
Just let them come in and go out of your consciousness.

What do you think about this?

Can you imagine using this analogy to think about your own worries?
Do you think it might be useful in helping you sit with those thoughts and
feelings and begin to tolerate them?

This may not be something that you are able to do immediately. It often takes
some practice to be able to tolerate worries so don’t worry if you’re finding it
difficult at first. It will get easier!

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 Attention Training

This exercise involves focusing on the here and now rather than getting caught
up in the past or future. This is an example of a simple technique called
‘Attention Training’ you can use yourselves when you notice you may be getting
caught up in your worries.

1. Pause for a moment and think about an issue that has been particularly
troubling for you (e.g. financial worries, relationship, worries, issues with
your children, stresses at work). How worried do you feel?

2. Look around, and notice the colours you can see. Try to spot as many
different colours as you can. Think about how many colours you can see
around you. Think about the shades of each colour.

3. Now go back to the issue which is concerning to you and try to spend a
minute thinking about it. How worried do you feel? Has your level of
anxiety gone up now you are thinking about the issue rather than the
colours?

4. Listen carefully, and notice as many sounds as you can. Notice the distant
and the closer sounds. Think how you would describe the sounds you can
hear.

5. Think back to the issue that was concerning you and stay with it for a
minute or two. Notice if your anxiety goes back up again.

6. Now look around you and notice how many different objects you can see.
Focus on their shape and see if you can spot their shadows. Notice the
lines of the objects, their corners and edges.

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 Avoidance

Often when people are worried about a task they can fall into a pattern
of avoiding it. This can feel like a relief in the short-term but in the
long-term just prolongs the problem and leads to more anxiety. Use the
table below to list some of the things you have been avoiding. The
example may help you to think of something.

Things I am avoiding Reason for avoidance

e.g. Opening post There is a bill I haven’t paid and I’m

worried that the bank will have
charged me
e.g. Calling the doctor for test results I’m worried that it will be bad news

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 Worry Diary

Date & Time Worry Anxiety Worry Type Strategy used to Comments
(what you are worrying about) 0 – 10 (Current problem to disengage from (e.g. how useful the strategy was, were
(None to or Hypothetical worry you able to disengage etc.)
Extreme) Situation) (e.g. worry tree, worry
time, relaxation)

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Date & Worry Anxiety Worry Type Strategy used Comments
Time (what you are worrying about) 0 – 10 (Current problem to disengage (e.g. how useful the strategy was,
(None to or Hypothetical from worry were you able to disengage etc.)
Extreme) Situation) (e.g. worry tree,
worry time,
relaxation)

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Date & Time Worry Anxiety Worry Type Strategy used to Comments
(what you are worrying about) 0 – 10 (Current problem to disengage from (e.g. how useful the strategy was, were
(None to or Hypothetical worry you able to disengage etc.)
Extreme) Situation) (e.g. worry tree, worry
time, relaxation)

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Date & Worry Anxiety Worry Type Strategy used Comments
Time (what you are worrying about) 0 – 10 (Current problem to to disengage (e.g. how useful the strategy was,
(None to or Hypothetical from worry were you able to disengage etc.)
Extreme) Situation) (e.g. worry tree,
worry time,
relaxation)

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Intolerance of Uncertainty

Dealing with uncertainty is an unavoidable part of daily life. Because we can’t see the
future, we can never be certain about what exactly is going to happen day to day.
Research has found that people vary in their ability to tolerate uncertainty. That is, some
people are okay with having a lot of uncertainty in their lives, and other people cannot
stand even a small amount of uncertainty.

Anxious people, particularly those people who worry excessively, are more likely to be
very intolerant of uncertainty. They will often try to plan and prepare for everything as
a way of avoiding or eliminating uncertainty.

Uncertainty as an allergy…
Being intolerant of uncertainty is a lot like having an allergy; if you are allergic to
pollen for example, what happens when you are exposed to even a small amount of
it? You will sneeze and cough, and your eyes will probably get red and teary. When
people who are intolerant of uncertainty are exposed to a little bit of uncertainty,
they also have a strong reaction: they worry, and do everything they can think of to
get away from, avoid, or eliminate the uncertainty.

But being very intolerant of uncertainty can cause problems, since it leads to a lot of
time-consuming and tiring behaviours, causes stress and anxiety, and is the major fuel
for worry.

Note down any of your worries that you think might fit into the category of “Uncertain”.

E.g. What if I fail my exams?

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What do people who are intolerant of uncertainty do?

If you can’t stand having uncertainty in your life, you are probably doing things that are
designed to either remove all uncertainty in daily life situations or you are outright
avoiding uncertain situations.

Some of the behaviours that people do when they are intolerant of uncertainty include:

1. Seeking excessive reassurance from others: this might be asking friends or family
their opinion on a decision that you have to make
2. List-making: as a way of eliminating uncertainty, some people will make long and
detailed “to do” lists, sometimes several lists every day.
3. Double checking: for example, calling loved ones repeatedly to “make sure” that
they are okay, or re-reading emails several times to check that they are perfect
and that there are no spelling mistakes.
4. Refusing to delegate tasks to others: many people who are intolerant of
uncertainty will not allow anyone either at work or at home to do certain tasks;
this is because they cannot be “sure” that it will be done correctly unless they do
it.
5. Procrastination/avoidance: because being uncertain can cause anxiety, some
people simply procrastinate or avoid people, places, or situations. If you do not
do something, then you don’t have to feel uncertain.

You probably noticed that all of these behaviours require a lot of time and energy.
Needing to be certain about everything can often take the fun out of life, since surprises
or unexpected events become something threatening. Also, if you avoid or
procrastinate, you might miss out on a lot of good opportunities in life simply because of
a dislike of uncertainty.

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Another problem with intolerance of uncertainty…

If you can’t stand uncertainty and do everything you can to get rid of it, you might have
noticed a problem… it is IMPOSSIBLE to get rid of all uncertainty in your life.

What this means for you is that all the work that you are doing to get rid of uncertainty
is useless; IT JUST DOESN’T WORK! If it did, you would probably not be struggling with
anxiety and worry.

Write down all of the things that you do to try to feel more certain, or to get around or
avoid uncertainty. You can use the sample of behaviours listed above as a guide.

A good way to compose this list is to be a detective in your daily life: notice when you
are feeling anxious, and what it is that you do to try to feel less anxious. For example, if
you have to buy a present for someone and you start to feel anxious about what to buy,
what do you do? Do you call your friends and ask for advice about what to get? This
reassurance-seeking behaviour can then go on your list.

Behaviour Consequences? (Did it remove the

uncertainty? Did it help your anxiety?)

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So what is the solution?

Increase certainty

Intolerance of Uncertainty

Increase tolerance

Well, if you can’t get rid of uncertainty in your life, then the only way to manage your
intolerance of uncertainty is by learning to be more TOLERANT of uncertainty.

How Can I Learn to Become More Tolerant?

Obviously, even if you agree that being more tolerant of uncertainty would be helpful, it
is not so easy to just change an attitude. However, in CBT we know that our thoughts,
feelings, and actions are all inter-connected, and that if you change one, you can change
the others.

So the best way to learn to become more tolerant of uncertainty is to start acting “as if”
you are tolerant of uncertainty. That is, you can change your behaviour around
uncertainty, and this will eventually help you to change your thoughts and feelings
around uncertainty.

Learning to Act "As If"

STEP 1: With the list of behaviours you’ve identified above, rank them according to
anxiety

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 If you want to start acting “as if” you are tolerant of uncertainty, it is best to start small.
That way, you are more likely to do it, and to succeed. If you pick something too
difficult, you might be unable to do it, and you probably won’t want to try it again.

With this in mind, look at the behaviours that you do that might be easier to try to
change. You can then rank your behaviours on a scale from 0 (“no anxiety at all”) to 10
(“extreme anxiety”) by imagining how anxious you would become if you could not do
them.

Here is an example:

Behaviours to Reduce Uncertainty Anxiety Level (0-10)

Delegating important tasks at work to others, without checking up on
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how it was done
Not calling kids on the cell phone when they are out with friends 8
Going out with friends and letting them make all the plans 6
Going to the grocery store without a shopping list 4
Sending an email to a friend without checking for spelling mistakes 3
Going to a movie without knowing anything about it 2

Behaviours to Reduce Uncertainty Anxiety Level (0-10)

STEP 2: Practice Tolerating Uncertainty

Once you have a list of behaviours that you do to reduce or avoid uncertainty, then start
picking small items that you can do to practice tolerating uncertainty. Try to do at least
three things a week.

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For example, you might try going to a restaurant and ordering a meal that you have
never tried, and then you might send a few emails without checking them first (and no
cheating! Don’t send the email to yourself as well so that you can check it later…)

STEP 3: Record what happened - Keep a record of all the times you were acting “as if”
you were tolerating uncertainty.

If you write things down, you will be able to see all the work that you did in facing
uncertainty, and as you keep practicing, you will see how things that you once thought
were difficult in the beginning are now much easier.

What did you do/not do?

How did you feel while doing it/not doing it?

What happened?
- Did things turn out ok even though I was not 100% certain?
- If things did not turn out ok, what happened? What did I do to cope with the
negative outcome? Was I able to handle the negative outcome?

What does this tell me about my ability to cope with uncertainty?

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If you are taking some risks and not being 100% certain in your life, there is the chance
that things will not go perfectly. For example, if you tolerate uncertainty and go to a
movie without reading a review, you might not like the movie. If you go grocery
shopping without a list, you might come home and realize that you forgot something.

When you allow some uncertainty in your life, sometimes things go wrong! For this
reason, it is important to write down the outcome of your tolerating-uncertainty
exercises, and what you did to cope. For example, if you forgot an item from the grocery
store, what did you do? Did you pick it up the next day? Did you go back to the store?
How horrible was the outcome?

REMEMBER: Sometimes things will not go exactly as planned if you allow some
uncertainty into your life. But this is not a sign of failure on your part. Most
people who tolerate uncertainty learn that even if bad things happen, they can
cope with them.

It is also important to realize that even when you were trying to make everything
certain, things often still didn’t always work out. It just took a whole lot more energy
and time trying to be certain. By becoming more tolerant of uncertainty, you get to let
go of all of the problems associated with being intolerant, and you get to realize that
you can deal with things, even when they don’t go perfectly.

STEP 3: Build Momentum!

When you feel comfortable with the small steps that you have taken to tolerate
uncertainty, gradually try more difficult things.

Look for opportunities to tolerate uncertainty in daily life. For example, if someone asks
you to pick up a bottle of wine for a party, try going to the store and buying a bottle
without asking for anyone’s advice.

As you start acting more and more “as if” you are comfortable with uncertainty, it will
get easier and become a part of your life. Think of it like building a muscle; you need to
do your exercises every day if you want that muscle to get strong!

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