STAFF INFORMATION LEAFLET

A COGNITIVE BEHAVIOUR THERAPY GROUP FOR MANAGING WORRY

The CBT group for managing worry is an 8 week group programme targeted at people who experience uncontrollable, excessive worry and anxiety, occurring more days than not; and triggered by a number of different events and activities; for at least 6 months duration.

The actual worry, anxiety or somatic/physical sensations causes significant distress or impairment in functioning.

Generalised anxiety is the most frequently presenting anxiety disorder in clinical settings, and it is chronic and unremitting without treatment.

The clinical picture can typically revolve around:

-Worry, even over minor matters,

-Difficulties with decision-making

-Living in the future

-Not being able to see the wood for the trees

-Emotional and experiential avoidance is also a feature

The group uses a Cognitive Behavioural approach based on a treatment protocol developed by Michel Dugas, and recommended for people with Generalised Anxiety Disorder. Outcomes of randomised control trials have shown that the percentage of participants no longer meeting GAD diagnostic criteria following group CBT was 60% or more. However, over a two-year follow up period, treatment gains in terms of diagnostic remission, GAD symptoms, associated anxiety, and depression are maintained and further gains are made in terms of pathological worry for 95% of participants, who no longer meet diagnostic criteria for GAD.There is some evidence to suggest that group CBT leads to greater reductions in worry in the longer term, than one to one CBT. Furthermore, dropout rates for the group did not exceed 10%.

It is primarily a process-driven model, which emphasises the process of worry rather than focusing on the content and details of each worry. The focus on pathological worry rather than on the physiological symptoms of anxiety enables people to distance themselves from their worrying thoughts through ‘decentering’ strategies, and it increasestheir tolerance to uncertainty.

It is a structured group with a strong focus on the here and now. It will provide a supportive learning environment to equip members with the skills necessary to manage their anxiety and worry more effectively. The group will not focus on past, painful life events, and will not expect anyone to disclose personal information if they do not feel comfortable. It will have a strong psycho-educational component with an emphasis on home practice of skills in between sessions.

The main topics covered will be:

  • Psycho-education on the nature of anxiety and worry
  • Worry awareness training
  • Working with intolerance of uncertainty
  • Behavioural Experiments to increase tolerance of uncertainty
  • Re-evaluation of the usefulness of worry
  • Problem solving training
  • Imaginal Exposure to feared images, thoughts and emotions
  • Relapse prevention planning

What to do next?

If you and your client believe that this group may be helpful,proceed as follows:

  1. Send your client a letter to confirm that they have been referred to the group.
  2. Enclose the patient leaflet entitled: “Cognitive Behaviour Therapy Group for Managing Worry”
  3. Inform client that they will be contacted by telephone by one of the group facilitators for a brief orientation prior to the group starting.This will be an opportunity for clients to ask more questions about the group.
  4. Following triage, clients may benefit from recommended self-help material. The following title will complement the group treatment approach: “Overcoming Worry: a self-help guide using CBT” by K. Meares and M. Freeston.
  5. See below for more detailed information on Referral Pathway and Criteria.
  6. If you are unsure, administer the Penn State Worry Questionnaire in IAPTUS. A total score of 45 or above, means they are above the cut off point for GAD.

REFERRAL CRITERIA AND PATHWAY

Inclusion criteria: who would benefit from the group?

  1. Anyone presenting with generalised anxiety, excessive worry or mixed anxiety and depression, where the primary problem is anxiety.
  2. Pure GAD is rare. Co-morbidity will be common, as 90% of those presenting with GAD will have at least one other DSM-V diagnosis. Depression and Dysthymia will be the most common co-morbid conditions; and another anxiety disorder will be present in over 50% of people presenting with GAD.
  3. Some of the co-morbid anxiety disorders can improve by simply treating GAD treatment, with the exception of panic disorder.
  4. Presence of an Axis II disorder(e.g., avoidant / dependent personality disorder) should not be an exclusion criteria, as findings have shown that it has a negligible impact on efficacy of CBT for generalised anxiety disorder and approximately 50% of GAD presentations also have Axis II symptomatology. Bowlby (1982) suggests that diffuse anxiety problems are the consequence of insecure attachment in childhood affecting self-confidence, ability to regulate emotions and self-sooth.
  5. Co-morbid presentations will be accepted, only if the co-morbid problem is less severe than the generalised anxiety.
  6. A willingness to attend sessions regularly and apply the skills learnt in between sessions

Exclusion Criteria: general guidelines for exclusion from the group?

  1. Persistent self-harm or suicide risk requiring management
  2. Misusing substances on a regular basis
  3. Moderate to severe Dyslexia may impede learning and practice of skills in between sessions, requiring more one to one support, unavailable within a group context. Consider individual HI CBT
  4. Chronic, longstanding and/or significant depression will need to be treated first. Consider the BA group or individual HI CBT instead.
  5. If other co-morbid anxiety disorders are more severe and prevalent than generalised anxiety, and in particular panic disorder, the more prevalent disorder needs to be addressed first.

Referral Pathway:

  1. Place referral on IAPTUS waiting list group called: “CBT for Managing Worry”
  2. If unsure about suitability email/approach course facilitators and/or read the patient information leaflet and this referral criteria for staff
  3. Move down care pathway to WL HI Group Therapy (WLHGT)
  4. Send client leaflet entitled “Cognitive Behaviour Therapy Group for Managing Worry”
  5. Group facilitators to make contact with client and offer a brief telephone screening and orientation session following referral
  6. Invite letter to be sent by group facilitators with group information, venue, times, dates, etc.
  7. Clients will be asked to contact group facilitators to confirm or cancel group attendance prior to group commencement date.
  8. Telephone follow-up will be provided by group facilitators 4 weeks upon completion of the 8 week group programme. This period of time will allow for consolidation of skills learnt and to fully integrate the implications of the underlying principles of the CBT approach. Follow-up will consist of a telephone review of progress and any troubleshooting required, plus collection of MDS scores.
  9. Clients may then be discharged from the service; or if deemed appropriate, stepped down, across (another Step 3 group) or stepped up for individual HI CBT or PT.
  10. Group facilitators will then send letters confirming outcome of telephone follow-ups/review sessions and adjust care pathway on IAPTUS.