Category Archives: Stress

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.

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.

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.

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

Paced Breathing for Brief Relaxation

Our parasympathetic nervous system helps us recover from stress. When we breathe at a slow pace, generally between 5 and 7 breaths per minute for adults, our physiology shifts into a recovery state in which natural restorative processes become more active. This is associated with activation of the parasympathetic nervous system and it will occur within a few seconds of beginning that breathing pattern.

The link below points to a page with a series of videos that you can use to breathe with.  Pick a pace and breathe with it. If a particular pace does not feel soothing then try a different pace. You are looking for a breathing pace that feels effortless and soothing. Your body should settle into it effortlessly. Most people like a pace between 5 and 7 breaths per minute. Continue reading Paced Breathing for Brief Relaxation

Research Article Published – Finally

After months of work the research article I was working on has been published in Frontiers in Psychiatry. The article describes a new model for stress by breaking stress down into several components. These components are:

  • Difficulty
  • Unease
  • Sympathetic Activation (SMP)
  • Parasympathetic Activation (PMP)
  • Reserves

These components affect how we experience the world and how we respond to it. Unease has more influence and so learning to modulate unease is the most important part of dealing with stress.

The article is free to read and the link is

The Unease Modulation Model – A New Theory of Stress

Stress and Resilience v1

I had taken this video down because I have some important revisions to make, however I received a few requests from people who wanted to review it. So I am reposting it. I hope to get the revisions done by next month.

Stress and Resilience

The video here introduces a model of stress, strain, and resilience. It breaks stress down into three components, pressure, strain and feeling, and the processes from which those components arise, assessment, activation and appraisal. It then introduces some methods for developing resilience. Continue reading Stress and Resilience v1

Changing Habits 3

This is a summary of what we covered in the last class on changing habits. I was impressed by how engaged people were and how many ideas they shared. (I apologize for the delay in posting.)

Everyone caught on to the concepts well. We could all see how the various types of stress, i.e. pressure from demands, distress from negative emotions, and strain from sympathetic activation could all make it difficult to change a habit. With this framework people came up with ideas for reducing these different components in order to make developing a healthy habit easier and more successful.

One of the more subtle and more important points that I want to emphasize here is how the feedback between distress from negative emotions and sympathetic activation can be a major source of difficulty.

Continue reading Changing Habits 3

Changing Habits – II

We had a lot of discussion in class. Many people talked about how much difficulty they had making a habit of exercising or of avoiding certain eating habits. We came up with some points to help with these.

Some principles involved in changing a habit are:

  1. The habit reduces discontent and that is what reinforces the behavior. The greater the reduction in discontent and the faster the reduction the greater the reinforcement.
  2. Negative emotions increase discontent and so we need to find ways of dealing with them that do not involve the habit we want to change.
  3. Pressure tends to increase discontent, so if the habit causes an increase in pressure then the discontent will come back quickly. We need to make sure that we find new habits that decrease pressure in the long run.
  4. Sympathetic arousal also tends to increase discontent. So when we are feeling tense, stressed or in pain we may be more likely to engage in the habit. We need to work on healthier ways to deal with those.
  5. We need to practice experiencing discontent without having our body respond with tension or strain. We develop discontent tolerance.

Continue reading Changing Habits – II

Changing Habits – I

Many of us have habits we think we would be better without.  Usually we have tried to change those, but too often without long term success. In this and the next two classes we will be looking at habits, the ways that habits develop, and methods and techniques for changing habits effectively and sustainably.

In our first session we will explore habits and the processes which create and maintain them. Continue reading Changing Habits – I