Tom Borkovec, Ph.D.

Borkovec: CBT Plus Emotion Processing for Worry and GAD

By Lynn Mollick

            On March 19, a record 71 participants heard Tom Borkovec present NJ-ACT’s 11^th Master Lecture. The topic was Generalized Anxiety Disorder (GAD) and worry. Worry is the central feature of GAD and is pervasive in all anxiety and mood disorders. Borkovec asserted that successful treatment of worry eliminates many co-morbid disorders, but worry will become chronic if left untreated. Worry is of special interest in CBT because it interferes with exposure.

           In Borkovec’s view, worry functions as an escape or avoidance of anxiety-producing thoughts and feelings. But worry interferes with experiencing the present, and worry inhibits spontaneity and joy, and compromises problem-solving ability. In treating worry, Borkovec utilizes both CBT and Interpersonal/Emotional Processing Therapy (IEP) to achieve two goals: 1) To help patients process moment-to-moment experience; and 2) To teach flexible and appropriate responding that replaces rigid and ineffective habits.

Interpersonal/Emotional Processing Therapy

        GAD patients fear social evaluation and hold excessively high standards for themselves. Because they worry about negative responses from others, they fail to pay attention to their own needs, they avoid communicating their needs to others, and they fail to obtain satisfaction. Thinking and worrying also serve as an escape or avoidance of feared emotions. 

The goal of IEP is to help patients shift their attention from anticipation of future danger toward awareness of their current emotions and needs. IEP encourages openness, spontaneity, and vulnerability in relationships. IEP utilizes exposure, feedback, modeling, and skill training to teach the following techniques:

    1) Emotional deepening - slowing down report of an event, repeating emotional statements, re-experiencing an event imaginally, and attending to bodily sensations.

    2) Interpersonal skill training -- active listening, feeling talk, assertion.

    3) Discussing how the therapist experiences the patient.

   4) Double chair techniques – role playing two sides of an internal conflict or both sides of the patient’s significant relationships.

    5) Interpersonal behavior experiments, including identifying and sustaining feelings.  

    6) Empathy training.

        Analyzing “why” reinforces thinking and avoidance of feelings, but experiencing emotions promotes self-knowledge that leads to more effective problem-solving and more satisfying relationships.

CBT for GAD

        The central worry in GAD is: “The world is a dangerous place, and I may not be able to cope with whatever happens, so I must anticipate all of the possible bad things that might happen.” 

Worry is often maintained by the belief that worry is useful (e.g. worry motivates me, or helps me prepare for problems, or prevents bad things from happening). If these dysfunctional beliefs are not addressed, treatment will fail. Useful CBT techniques include: 

    1) Worry outcome diary:

         a) Record worries;

         b) Predict the probability of the worry actually occurring;

         c) Evaluate the accuracy of these predictions.

    2) Imagery. Patients can review the worry diary and imaginally relive events that turned out well. They can then imagine these positive outcomes whenever they begin to worry.

    3) ABAB – patients alternate between worrying and not worrying, and note how each makes them feel.

    4) Distinguish worry from problem-solving, and distinguish problems that can be controlled from problems which can’t.

    5) Worry-free periods: Postpone worry for a specific length of time using perspective shifts, focus on the present, or letting-go. Gradually expand the worry-free period. 

Borkovec sees worry as an

avoidance of emotions

    6) 30-minute worry periods. Establish a time and place to worry intensely.

   7) Relaxation training offers an alternative to worry and raises self-efficacy by showing patients they can reduce their anxiety. High muscle tension and inflexible autonomic responding accompany GAD. Instruction in several relaxation techniques enables patients to determine which they prefer. 

   8) Mindfulness. Teaching patients to attend to their physiology enables them relax before worry incubates. Schedule mini-relaxations throughout the day to reduce anxiety and worry.

   9) Cognitive Restructuring. Catastrophizing, perfectionism, should’s, and selective attention to negative events are common dysfunctional thinking patterns. Borkovec described the following techniques: 

        a) changing “should” to “could”.

        b) questioning what’s good about perfection.

        c) finding something good in a bad outcome. 

        d) focusing on process instead of outcome.

        e) observing the long-term consequences of a bad event instead of just the immediate consequences.

        When should CBT be used and when should IEP be used?  At present, the research does not provide an answer. Borkovec suggested deciding empirically by observing which approach helps the patient at each point in time. 

        One point is clear. Researchers are finally catching up with clinicians. Like humanistic and psychodynamic therapies, CBT now incorporates emotion into functional analysis. But our thinking remains empirical.

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