Interrelación con Organismos Nacionales e Internacionales

Has excessive worrying about this topic impacted on your relationships with your family or friends?

Has excessive worry impacted on your work performance? Do you find that it takes you longer to complete tasks than other people who worry less? Has your excessive worry led to high levels of stress and fatigue? How much time and effort do you spend each way worrying about this

topic? Do you get better results from your worrying (for example, a better relationship with your children, superior work or school performance) compared to people who worry less?

they would like to occupy their time if they are not spending hours wor- rying. As such, some alternatives to excessive worry might include tak- ing a class or spending more time with family and friends. As with many clients with anxiety disorders, so much time is consumed by the anxious symptoms that GAD clients have probably not had the time or the energy to set treatment goals for themselves other than symptom reduction.

As a final note, this treatment module, more than any other, should be applied in a flexible manner. Specifically, although the reevaluation of positive beliefs about worry is an important part of our treatment protocol, our research findings (and clinical experience) show that these beliefs are quite variable among clients with GAD. Despite the fact that the majority of GAD clients believe that worrying is highly useful, thera- pists can encounter individuals who hold few, if any, of these beliefs. Thus, the therapist should not assume that all clients believe that worry- ing serves a functional purpose. Nonetheless, given that positive beliefs about worry can interfere with all treatment modules (for example, a cli- ent who believes that worrying less is dangerous may avoid fully engag- ing in treatment), it is crucial that therapists assess these beliefs early on in treatment.

MODULE 4: PROBLEM-SOLVING TRAINING

As noted in Chapter 4, the problem-solving training module is split into two phases: (1) improving problem orientation, and (2) applying prob- lem-solving skills. In the following sections, each one of these phases is presented separately; however, the reader should keep in mind that both phases are inexorably linked. For example, until clients recognize that their problems are not entirely aversive and threatening, they are unlikely to implement their problem-solving skills no matter how good they are.

Improving Problem Orientation

When the concept of negative problem orientation is presented to cli- ents, two main ideas should be initially introduced. First, in terms of the model, an additional factor is being incorporated into our under- standing of GAD and excessive worry. Second, problem solving is intro- duced as a practical alternative to worry if we can agree that worrying about problems is not especially useful. This second idea, that clients can “replace” excessive worry with actual problem solving, should be underscored repeatedly throughout this module. Excessive worry about

problems is not an active strategy, although clients might initially view it as such. On the other hand, the active process of problem solving can actually lead to change in a problematic situation.

Therapist: We have been spending some time talking about whether

excessive worry is actually beneficial. In some instances, we have found that worrying excessively can have the opposite effect to what you previously believed. For example, worry- ing excessively about projects at work can make you so anx- ious that rather than motivating you to work on them, you procrastinate instead. So, if worry is not that useful, what do you think you could do instead?

Client: I don’t know. I have been thinking a lot about that, and I

assume that I should just stop worrying, but that’s easier said than done. How can I just stop worrying?

Therapist: You are absolutely right. It would be great if you could just

shut off worry like a light switch, but it’s not that simple, is it? As I’m sure you remember, I have been having you clas- sify your worries as either being about current problems or hypothetical situations. We are now going to start working on specific strategies for each of those worry types. The first one I will be introducing today is problem solving as a way to deal with your worries about current problems. So you are not simply going to “stop worrying,” but start replacing worry with a more productive strategy.

Client: Well, I’m really not very good at solving my problems.

Therapist: Well, if that’s true, then it is even more important to start

working on this. But what you just said about your ability to solve problems relates exactly to what we will be discussing today: negative problem orientation. Negative problem orien- tation is a factor that contributes to excessive worry, and it interferes with your problem-solving ability on many levels. (See Appendix 5.7 for a copy of the model that includes nega- tive problem orientation.)

Prior to beginning a discussion on negative problem orientation and its impact on both problem solving and the worry cycle, it is a good idea for therapists to briefly discuss with clients some of the research findings in the area. For example, it is helpful for clients to know that the research to date suggests that excessive worriers are just as skilled at problem solv- ing as people who worry less. However, excessive worriers have a more negative problem orientation. In other words, they have more negative

attitudes and beliefs about problems and problem solving. The following is a suggestion for the presentation of negative problem orientation:

Therapist: What is negative problem orientation? It refers to the way

we view problems, and the way we view ourselves as problem solvers. People who have a negative problem orientation tend to (1) view problems as threatening; (2) doubt their ability to solve problems; and (3) believe that problem solving will turn out badly no matter what. In other words, people with a nega- tive problem orientation will say to themselves: “I don’t like problems, I’m not good at solving them, and when I try to solve them, it doesn’t work.” Have you ever thought like that?

Client: Absolutely. I hate dealing with problems and I do think that

I’m not good at solving them. I usually ask other people for advice on how to deal with them.

Therapist: If you remember, when we first talked about intolerance of

uncertainty, I told you that it has a number of effects on your thoughts (i.e., worry) and your behaviors (e.g., reassurance- seeking). Negative problem orientation works in the same way. When you have negative beliefs about problems and your ability to deal with them, this has a strong impact on your emotions, your thoughts, and your behaviors.

Negative Problem Orientation

Viewing problems as threatening Doubting ability to solve problems Pessimism about the outcome of problem solving

Emotional Consequences

Frustration, irritation, anxiety, and depression

Cognitive Consequences

Worries about problem, new problems, new worries

Behavioral Consequences

Avoidance, procrastination, impulsive problem solving

When presenting the consequences of negative problem orientation, it is best for therapists to encourage clients to generate examples through Socratic questioning. This can be achieved by logically linking the beliefs underlying negative problem orientation to the expected impact. For example:

Therapist: So, if a person saw problems as entirely threatening and

believed that she was a poor problem solver, how do you think she is likely to feel when a problem comes up?

Client: Probably pretty annoyed. I hate it when there is a problem. I

also get anxious.

Therapist: Exactly, so the emotional effect for you is that you have lots

of negative feelings like irritation, annoyance, and anxiety whenever you encounter a problem.

When discussing the consequences of a negative orientation, there are several possibilities that can be considered. In terms of behavioral con- sequences, clients have a tendency to avoid or delay solving problems for as long as possible. However, if left unsolved for long enough, one prob- lem can create new problems over time. Other behavioral consequences include asking others to solve the problem rather than dealing with it personally, or solving it impulsively in order to worry about it for the least amount of time. The cognitive consequence of a negative problem orientation, however, is what makes this construct such a central factor in the worry cycle. This can be discussed with clients in the following manner:

Therapist: So what do you think the impact of your negative orienta-

tion toward problems has on your thoughts? Do you think it makes you worry less or more?

Client: It makes me worry more. Therapist: Why do you think that is?

Client: Well, if I’m not solving a problem, I am going to continue to

worry about it.

Therapist: That’s right. So long as you are not using an active strategy to

deal with your problems, you are likely to continue to worry about them. In fact, if you leave problems unsolved for long enough, they can create new problems. On the other hand, have you ever tried to not think about your problems, that is, to ignore them instead of worry about them?

Client: Absolutely. I think I go back and forth between worrying

about problems and ignoring them.

Therapist: That leads to another consequence of negative problem ori-

entation, which involves not being very good at recognizing problems when they come up. If you ignore problems, you are less likely to see them early on and deal with them. Are you starting to see how your attitude toward problems is having a huge impact on your life?

At this stage in treatment, we recommend that therapists incorporate the role of intolerance of uncertainty into the discussion. This will not only highlight the consistency of intolerance of uncertainty throughout treatment, but will also allow therapists to normalize negative prob- lem orientation with respect to GAD. It is important that clients realize that if they are intolerant of uncertainty, then having negative beliefs about problems and problem solving is a natural consequence of their intolerance.

Therapist: Why do you think that people with GAD have such a nega-

tive problem orientation? Why would you be more likely to have negative beliefs about problems and problem solving than someone who worries less?

Client: I don’t know.

Therapist: A major reason for the relationship between GAD and nega-

tive problem orientation has to do with intolerance of uncer- tainty. As we have discussed before, intolerance of uncertainty is the fuel for worry. Even a little bit of uncertainty causes people with GAD to worry, and they tend to view the world through a filter where they are constantly searching out uncer- tain situations. Let’s see how this relates to problems. First of all, how would you define a problem?

Client: I would say that a problem is something that does not have an

obvious solution and that could turn out badly.

Therapist: So a problem is a situation that has no obvious solution and

that could have a negative effect in the future. In other words, the outcome of problem solving is uncertain.

Client: I see … problems are uncertain, so they set off my intolerance

of uncertainty.

Therapist: That’s right. When we look at it this way, it makes sense

that you would find problems threatening. At the same time though, you have been working on changing that intolerance by repeatedly conducting tolerance of uncertainty experi- ments. A good way to see problem solving is as just another one of those experiments.

Client: But how am I supposed to change my negative problem orien-

tation? Will I just have to use positive thinking?

Therapist: That’s a great question. The answer to that is no. We are

now going to start discussing ways to change your negative problem orientation, but that does not mean just “thinking positive.” Instead, it means learning to be more realistic, flex- ible, and balanced in your thinking by acknowledging both the negative and the positive sides of situations.

Strategies for Improving Problem Orientation

Although there are a number of different strategies that can be used to help clients improve their problem orientation, we typically focus on three of these strategies. Specifically, we believe that it is beneficial to assist clients in (1) recognizing problems before it is too late; (2) see- ing that problems are a normal part of life; and (3) seeing problems as opportunities rather than threats. For additional therapeutic strategies, the reader is referred to the work of D’Zurilla and Nezu (1999) on prob- lem-solving therapy.

Recognizing Problems Before It Is Too Late

One of the consequences of finding problems aversive is the tendency to avoid recognizing problems as they come up in daily life. Often, prob- lems can start out small and it is only when they are ignored that they begin to grow and become more serious and complex. For example, a cli- ent might have had a misunderstanding with a colleague at work. If left unsolved, the colleague might begin to hold a grudge and believe that the client is an uncaring or selfish person. The colleague might then begin to tell other coworkers about the problem, thereby making the problem more complex as other people are brought into the situation. From this example, it is evident that if the problem had been dealt with immedi- ately, it probably would have been easily resolved. Instead, by ignoring or failing to see the problem, it developed into a “minor crisis” at work, with many people involved. This example clearly shows the importance of dealing with problems as soon as they arise. In order to assist clients in improving their ability to recognize problems when they arise, we recommend using two strategies: (1) using one’s emotions as cues, and (2) developing a recurrent problem list.

In terms of the first strategy, a common obstacle to identifying prob- lems is the tendency that many people have to interpret their negative emotions as the problem. For example, many clients identify their prob- lem as frustration or stress. However, these emotions are not the problem (in terms of problem-solving theory). Rather, they are likely to be the by- product of the actual problematic situation. For example, if a person has many reports to do at work and he is very anxious and stressed about it, the problem is not that he is stressed. Instead, the problem is that he has to complete the reports; his anxiety and stress are due to the fact that he has this particular problem. With this in mind, clients can begin to use their emotions as a cue that there is a problem in their social environment:

Therapist: The first strategy is to use your emotions as cues. Your nega-

tive feelings can be used to let you know that there might be a problem. When you are feeling anxious, stressed out, or demoralized, you can ask yourself: “Is there a problem I am not seeing that is leading to these emotions?” Our emotions, when we are attentive to them, can be very useful in help- ing us to recognize problems. This strategy has two advan- tages. First, it will allow you to recognize your problems more quickly and potentially avoid having a small problem become a big problem. Second, it will help you to see your negative emotions in a more “positive” light. In this case, they serve an important function as an early detection system.

The second strategy is to encourage the client to write a list of recurrent problems. It is common to almost everyone that certain problems keep coming up again and again. Examples of recurrent problems include difficulties with a work colleague and end-of-the-month financial prob- lems. However, every time problems recur, most of us have a tendency to react to them with surprise and disappointment, as if they were occur- ring for the first time. By writing out a list of recurrent problems, clients will be better able to recognize them quickly when they arise. In addi- tion, the accompanying feelings of surprise and disappointment are less likely to develop simply because the problem is expected. This second strategy can be incorporated into a between-session exercise whereby clients are asked to keep the list accessible at all times in order to be bet- ter able to recognize problems quickly and react to them with less anger and disappointment.

Seeing Problems as a Normal Part of Life

It should come as no surprise that individuals with a negative problem orientation have a tendency to feel resentful when problems develop. One of the reasons for this is that they will often view problems as abnor- mal (“If I plan for everything and reduce all uncertainty in my life, no problems should ever arise. It is not normal for me to have unexpected problems come up.”). However, one of the difficulties with believing that problems are abnormal is that the individual will expend a great deal of energy trying to avoid problems rather than dealing with them. As with attempting to eliminate uncertainty, this is an exercise in futility. Having to deal with problems is a normal and unavoidable part of life. As such, therapists should spend some time discussing this issue with clients. The goal is to allow them to see that everyone has problems to varying degrees in their lives:

Therapist: Having to deal with problems is a normal and inescapable

part of life. Try to find someone who has no problems and you will come to the same conclusion. If a person believes that it is abnormal to have problems, that person will spend more time feeling annoyed by the problem than trying to solve it. It is much more useful to put that energy into solving the prob- lem, getting it over with, and not worrying about it anymore. For some people, the reason why they feel that problems are abnormal is because they attribute their problem to personal incompetence or deficiencies. For example, if you believe that you have problems because you are flawed in some way (“I just don’t have it when it comes to getting along with people”), you will tend to see your problems as being abnormal. However, it is important to remember that all of us have problems no matter how intelligent, sociable, attractive, or skillful we may be. It might seem that some people do not have problems, but this is probably because they deal with them quickly and effi- ciently. By not attributing your problems to “who you are,” but instead to the fact that you are a human being (and all of us have problems from time to time), you will be better able to see your problems as a normal part of life and to start dealing with them more efficiently.

Seeing Problems as Opportunities Rather Than Threats

This final strategy for addressing a negative problem orientation is