Anxiety and Mindfulness

News Flash

I was quoted in an article on CNN about a recent research article showing that an 8 week mindfulness course was as good as escitalopram for treating anxiety. Here is some additional information about anxiety.

We can think of four types of anxiety. Mindfulness will help relieve one type of anxiety, but it will not help with the other three types.

Anxiety: Unease and Difficulty

Anxiety can come from two sources: Unease and Difficulty. Briefly, unease is an uncomfortable feeling that comes from desire and aversion. Desire is wanting something we do not have. Aversion is having something we do not want. Unease is the feeling associated with those.

Difficulty comes from our assessment of the demands we face compared to our assessment of the resources we have to meet those demands. More demands or fewer resources means higher difficulty.

Difficulty and unease are two components of stress and interact with each other and our body, causing a large number of effects. Anxiety is one of them.

4 Types of Anxiety

Unease high, difficulty low

The first type of anxiety occurs when unease is high but difficulty is low. The unease is not about any imminent danger but rather about numerous situations that might occur, commonly called “what if’s”. This is a core feature of “generalized anxiety disorder.” This kind of anxiety responds well to mindfulness because we need to ignore the anxiety. The anxiety is just an uncomfortable feeling and the anxious thoughts are just thoughts. We get anxious about the anxiety, and that is a reinforcing loop that makes the anxiety worse. Mindfulness breaks that reinforcing loop and the anxiety decreases. We can call this “The Ancient Art of Not Making Things Worse.”

We don’t need to use mindfulness to relieve this type of anxiety. Any activity that has the following three characteristics will be helpful.

  • The activity is not unhealthy
  • The activity is enjoyable
  • The activity does not involve stress about a score or outcome.

Another technique that is extremely simple, and that doesn’t require any formal training, is to remind ourselves that it is safe to feel the anxiety.

Unease artificially high

The second type of anxiety occurs when unease is artificially high because we, or other people, or advertising companies convince us to want things that are not helpful, or that make our lives more difficult in the long run.

In this case we need to reflect on what we are trying to obtain and appraise the value of that in light of our core values and long-term goals. This takes reflection and judgment. Sometimes we need to talk with others who have more experience or wisdom to find guidance. Mindfulness is not helpful for this kind of anxiety. Mindfulness involves acceptance and non-judgment. For this type of anxiety we need to judge, or discern, which thoughts and emotions are helpful and which are not. We need to then focus on the helpful thoughts and emotions (such as gratitude) that reduce our inappropriate levels of unease.

Difficulty artificially high

The third type of anxiety occurs when unease is high and difficulty is low but perceived as artificially high. This occurs because we often overestimate demands or underestimate resources. The old saying “Don’t make mountains our of molehills,” refers to this tendency.

The solution for this type of anxiety is to assess our demands and resources more accurately. Cognitive and behavioral techniques are helpful for this type of anxiety as they include testing and correcting our assumptions about the difficulty of a situation.

We can also use cognitive techniques to change the context of the unease. For example, this can make anxiety become excitement.

  • Anxiety is unease and the thought “I can’t do it.”
  • Excitement is unease and the thought “I can do it.”

Difficulty truly high

The fourth type of anxiety occurs when unease is high because difficulty is truly high. This occurs when we have barely sufficient or insufficient resources to meet important demands. Such situations include

  • People facing insecurity about housing, food, medical care, or safety
  • People with children who are struggling with medical, mental health, or scholastic difficulties
  • People facing insurmountable demands at work

Many people have this type of anxiety. They are the working wounded, not the worried well. In these situations it would be abnormal not to be anxious.

This type of anxiety does not respond to mindfulness, and mindfulness can actually make the situation worse. “Acceptance without judgment” is dangerous for someone who is facing insecurity about food, clothing, shelter, medical care, or safety. Telling people who are being hammered by their environment to “accept without judgment” can be a form of abuse, as described by Ronald Purser in his book McMindfulness.

For people with this type of anxiety, therapy is useful when it helps them be find resources and utilize them more efficiently. Therapy also helps when the therapist can use their social standing to reduce demands on the person or help them obtain resources. For example, as a physician I can often help a patient have a reduced workload for a period of time so they can have some relief and heal. Or, I can let a patient know about community resources and advocate for them to obtain these resources.

We need to remember that we are a resourceful species. We survived the Ice Age with spears and torches. Creativity and cooperation are our greatest strengths, and methods that facilitate those will be helpful.


The four types of anxiety can co-exist. Each uses a different type of intervention. When the appropriate intervention is used, then we are more likely to deal with our anxiety effectively.

Our Brains Are Not Shrinking

False Alarm

Last year a research article made headlines because it reported that starting about 3000 years ago the human brain started shrinking. The authors hypothesized that this may have occurred “from the externalization of knowledge and advantages of group-level decision-making due in part to the advent of social systems of distributed cognition and the storage and sharing of information.” They came up with this conclusion because that is what occurs in ants, ” the insights ants offer can broadly inform us of the selective forces that influence brain size.”

Not So Fast

The fact that the researchers are making a global statement about humans and the fact that the basis for their hypothesis comes from ants suggests that this finding about our brains shrinking should be suspect.

And in fact is should be. A recent research article rebuts this finding. The original article used flawed analyses to arrive at a false conclusions. There has actually been no change in human brain size in the last few thousand years. I am quite sure that this rebuttal will not generate headlines though, unlike the flawed findings of the original article.

Social Sciences Need Discipline

In physics and other physical sciences, experimental results are not trusted unless they have been replicated independently at least once, and preferably more often. This tends to reduce the frequency at which mistaken results are published.

Social sciences need similar self-discipline. This is difficult because the results from social science have more emotional charge and therefore are more likely to be picked up by the popular press. Social scientists also, like most humans, enjoy attention and therefore may promote their work to the public before any independent validation supports their findings. This tendency is compounded when the findings have commercial applications.

None of this is going to change quickly. We can protect ourselves from being misled to some extent by having a doubtful attitude toward social science research that makes global statements about humans or large groups of humans.

Indie Sellers Guild

Stress and Health

A lot of my patients have been “working wounded”. They were struggling financially and experiencing stress-related conditions from the constant unease caused by insecurity about basic necessities. Another factor was that they had little influence over their working conditions.

The combination of insecurity about meeting their basic needs and not having the ability to influence their condition had a significant negative impact on their health and the health of their family members.

Reducing Stress – Improving Health

This organization, The Indie Sellers Guild, appears to be helping indie sellers gain more ability to improve their working conditions and pay. This is likely to have a positive effect on their health.

Medical Misinformation

Helping patients deal with medical misinformation can be quite frustrating, especially when it causes them to act in ways that are dangerous. Here is a metaphor that helps me avoid getting into arguments and do something helpful.

Imagine that you have fallen off a sheer cliff. You have managed to grab hold of a tree limb that has grown out of the cliff face. If you look up you see nothing but sheer rock. If you look down you see a dense cloud concealing everything below your knees. Your legs vanish into that cloud, and no matter how far you extend your legs, all you can feel under your toes  is empty space.

You hear a voice telling you, “The ground is only a few inches below your feet. Just let go.” What would it take for you to trust that voice? What would you feel as you loosened your fingers?

A patient who clings to medical misinformation is in the same position, whether the misinformation is about vaccines, pain medications, food, etc. . In order for us to help them change, we don’t need to prove that we are right, that we know more, or that we are so smart. We need to prove that we will be there to catch them

The “Have Done” List

For about 20 years I have been telling my patients to use a “have done” list, instead of a “to-do” list. Sometime during the day, usually near the end, they are to write down any tasks they completed or made progress on. The feedback has been extremely positive. People feel more hopeful and more energized from their “have done” list, and knowing what they have done helps orient them to what to do next. Its much less stressful than staring at a “to-do” list.

Apparently there is now some research support for this. The authors of the following article use a more structured process than I do. I simply ask people to write down what they have done, without planning to do something first. But I imagine their version may work too.


I had the privilege of meeting Alexi a few years ago and she sent me a copy of her book, Bravey. This is an unvarnished, touching, and amazing story of courage and hope by an even more amazing woman.

Review and Redo

The “review” and “redo” techniques are powerful ways of training helpful habits. I received a request for instructions on these techniques from a participant in an online course on resilience that I am co-facilitating.

The instructions are adapted from a presentation I gave in Helsinki in Jan 2019 to health care professionals who worked on rapid resuscitation teams in hospitals.

For those who want to download a pdf of the instructions you can find that here:

Outline for Review and Redo

Continue reading Review and Redo

Breathing for Recovery from Stress

The following instructions are to help with stress and are not meant as treatment for any medical conditions. If you have any discomfort from any technique then stop using it.

Recovery breathing maintains our reserves.

Stress tends to wear us down physically and emotionally. In the model of stress that I use, this comes from our reserves being depleted. When our reserves are depleted we feel physically exhausted or emotionally drained. Even thinking about doing something can feel too much for us.

We need to maintain our reserves no matter what type of stress we are dealing with. Breathing techniques can help us do that.

We can optimize the rate we recover from stress by developing three aspects of breathing. These are

  1. Enjoying the breath
  2. Pacing the breath
  3. Deepening the breath

Continue reading Breathing for Recovery from Stress

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