#59 Dr. Stefan Hofmann on Simple CBT and Mindfulness Strategies to Overcome Anxiety, Fear, and Worry

0:02 hello i'm dr bridget nash and i'd like to welcome you to the therapy show a podcast series that seeks to demystify mental health treatment today i'm honored to welcome dr stefan hoffman who is a professor in the clinical program at boston university and director of the psychotherapy and emotion research laboratory at the center for anxiety and related disorders dr hoffman is the editor-in-chief of cognitive therapy and research and co-author of process-based cbt the science and core clinical competencies of cognitive behavioral therapy i encourage everyone to check out dr hoffman's new book the anxiety skills workbook which was recently published in 2020. dr hoffman welcome to the therapy show thanks for having me can you start by telling us a little bit about your personal background

0:47 and professional development that led to your research in the field of anxiety disorders certainly i was born and raised in germany and came to the states in the early 90s 1992 to first work at stanford university in an area called psychophysiology of anxiety disorders for two years and returned to germany to finish my dissertation on the topic of anxiety disorders my doctoral dissertation that is and then in 96 i returned back to the united states and then i've been working ever since at boston university where i'm directing the psychotherapy and emotional research laboratory studying the mechanisms processes of psychotherapy in particular

1:34 focusing on what makes cognitive behavioral therapy effective and how to improve it further when and how did you realize that a cbt approach to treating anxiety disorders would be an effective form of therapeutic intervention cbt is a very popular modality and every clinical student and every psychiatrist learns about cbt during their education and similar i graduated school i came across this particular treatment cbt that struck me as being really quite plausible and beautiful in its simplicity and clarity and so i was quite intrigued by it which is quite a you know compared to

2:21 other forms of therapeutic models that are really complicated to understand and also not quite as as clear in the way they present themselves including psychoanalysis and other forms of treatments so i studied it further and in fact the simplicity is is quite remarkable yet how to conduct the treatment is quite complicated despite its simplicity that seems to be a paradox but the simplicity suggests simply that the way we think the way we interpret things the way we perceive what we experience this perception has a dramatic impact on the way we feel

3:06 that dates back to the ancient greek epictetus once said people are not moved by things but the view they take of them he's a stoic greek philosopher so simply saying that it's not really the event that causes you to feel emotional or feel and have an emotional reaction but it's rather the interpretation of it this is really simple and really kind of buddhism almost but obviously this is the core the essence of cbt as also as a form of psychotherapy that is sometimes we make in misinterpretation sometimes we misperceive things sometimes we get things wrong you know global level sometimes on a more precise and a very low level of a particular situation that we

3:52 misinterpret we misinterpret a person's facial expression we misinterpret your husband or wife's response to a certain thing and as a result we get into arguments and misunderstandings and the life by understanding these misperceptions and misinterpretations we can very effectively intervene and improve mental health is not to say that we construct our world or that there's no true world out there not at all but rather it is approaching the world in a way that is most adaptive and getting things right if there is reason to feel concerned and worried you should feel concerned but if there's no reason if it's highly

4:37 unlikely that whatever let's say that you're gonna die of a heart attack because you feel the heart computation let's say as in the case of panic disorder if you misinterpreting your bodily sensations this will get you in a constant state of worrying of arousal of running to the doctor and checking taking out your vital signs even though there's nothing wrong with you so if there's something wrong with you absolutely you should intervene and if there's nothing wrong with you just stop worrying and live your life the idea is very simple but translating it into clinical practice can be quite complicated how would you briefly explain the purpose of anxiety and why it is problematic for some people and not others anxiety is

5:25 part of what makes us human and it is a part of what every organism to some extent shows or at least that every living organism has some sort of a threat response that is a response to threat this is not to say that all organisms all living creatures feel anxiety we don't know that we are humans we as humans interpret our threat response as anxiety or fear it is an evolutionary adaptive thing to experience we need to feel fear we need to experience fear we need to have a threat response otherwise we would not survive for long so this is part of what makes us human and is also part of what makes all living beings living beings because they have a threat response

6:11 it becomes a problem when we people experience anxiety or fear in situations when it doesn't make sense to feel free to follow our anxious or it might make sense but it's out of proportion or we experience it to such an extent that is too distressing and interfering in all of those cases anxiety and fear will turn into a problem which can have debilitating consequences in terms of quality of life that includes living a life that is worth living with people around you who you care for who care for you feel financially secure you want to feel like the world is to some extent under your control that you have a sense of safety and security if all of this is missing

6:58 anxiety will be the result is fear the same thing as anxiety are they different yeah this is a good question because we use those terms interchangeably and to some extent i use it interchangeably but when you drill a bit more into it you shouldn't be using interchangeably fear is obviously these are words and we need to agree on what they mean so most academics would agree on the fear as being an emotional response to acute threat so if you are actually under threat you experience fear that is an emotion what some people call even a basic emotion next to aggression next to hunger thirst etc anxiety we believe is a future oriented

7:44 much more cognitively immediate emotional response that is anxiety is something that is future oriented a threat is here and now oriented threat is an emotional response that you have in a current state when you're confronted with threat you're in the here and now anxiety is something that you're worried about would happen that is future-oriented emotional response anxiety is often closely linked to for that reason fourier and we don't believe that anxiety itself is a basic emotion but rather an emotional response that is strongly cognitively mediated because worry is involved in that experience what is the difference between normal

8:30 anxiety and generalized anxiety disorder so normal anxiety as i said is something that we should experience in fact if somebody does not feel anxious something is wrong as you grow up as a child you might have separation anxiety strange anxiety all of these things by the way are very normal and predictable experiences and if a child does not have any strange anxiety or separation anxiety something is seriously wrong with a child you need to look into that if the child doesn't care if the parent is there one way or the other then it's a problem so anxiety is a normal response it is a normal experience anxiety disorder is anxiety that is out of proportion that results in significant distress to

9:16 the individual and or significant interference with a person's life so in other words it bothers the person to have that experience to a great degree and also it interferes somehow with a person's life and the word generalized yes so generalized anxiety is a form of anxiety disorder that is described in the dsm-5 and actually included in many of the earlier versions of the diagnostic and statistical manual that is a big book that includes all psychiatric disorders generalized anxieties order the hallmark of that it's excessive worrying in fact we were thinking of renaming that very category that this dsm category as worry generalized worry disorder because warring is such a core part of that problem generalized anxiety

10:02 disorder is just one of many different types of anxiety disorders other common anxiety disorders are the most common one is social anxiety disorder is the fear of being embarrassed or being the center of attention your negative evaluation is the course the social anxiety disorder which is about a lifetime prevalence of around 12 to 13 percent meaning that's about 12 to 13 out of 100 people will have experienced this form of disorder at some point in their lives and this is not just having an episode of anxiety but rather anxiety disorder other forms include panic disorder agoraphobia as i mentioned separation anxiety and other forms of anxiety disorders that are more specifically tied to the signals such as

10:49 trauma post-traumatic stress disorders and other forms of anxiety the category obsessive-compulsive disorder used to be considered to be part of this broad is now a broader category called books as a composite spectrum disorder so all of these are examples of anxieties photos generalized anxiety disorder is one of the men i noticed the first module in your anxiety workbook is called planning your journey why is it important for someone looking to reduce their anxiety to first assess their motivation for change and then set goals everything that you want to reach in life unless you know where you're going you probably shouldn't get started unless you have a plan unless you have a vision where you want to be next there's

11:36 no point in moving otherwise you're just aimlessly drifting around so in other words you should get into a mindset that when you take one step this should be followed with the next step and you want to for yourself reach the goal of getting to a destination rather than just trying something out and then letting it drop as soon as it becomes a little difficult so dealing with your anxiety is not an easy thing in fact the most natural response is to avoid is not wanting to deal with that avoidance is the core that maintains this problem is the main reason why people keep having the problem so in other words if you somehow let avoidance guide you in your journey

12:22 you will not get there you will not reach that goal in other words you should put yourself in a mindset that you will give it a really good shot you will give it a really good try and see if it works so don't get started without convincing yourself all you want to do is trying it out and all you have to do is giving it a good shot so for that reason it's really quite important to motivate yourself to prepare yourself that things will get also rough and it's okay and you can get through that and that you want to simply try it out what are some of the risk factors that can make a person vulnerable to anxiety there are many risk factors for anxiety disorders both biological as well as psychological obviously

13:08 genes are important are not the main predictors but we know that there's a decent amount of heritability involved in other words if you come from a very anxious family do you have a greater likelihood of also having anxiety these what we would call biological vulnerability factors there are the psychological vulnerability factors the most important one that is often discussed in the literature something called anxiety sensitivity this is a general tendency to not liking anxiety all people feel anxious there's no unique physiological symptom that some people with anxiety disorders have another stone we all know what it feels like to feel anxious but some people just really don't like it at

13:54 all and dislike it so much that they're doing things to avoid it at all costs and there are others who also feel the same problems and it's not that they like it but they simply accept it and they live with it they find a way around it and most importantly they accept these symptoms to some extent so anxiety sensitivity is a general tendency to you're strongly distressed when you feel anxiety symptoms and for that reason finding ways to avoid it and to prevent it that is a very powerful psychological vulnerability that can be measured actually with a simple questionnaire that predicts very sensitively whether people might develop these problems later on in life even if they've never had it before there are general vulnerabilities a general term that we use as neuroticists

14:40 these are people who are through a general negative effect broadly speaking we know that anxiety is highly overlapping with depression many people with anxiety symptoms also feel depressed and many people with depression also feel anxious what seems to link those is a general negative effect that means that they have a relatively low level of feeling pleasant sensations also meaning also low positive aspect but also at the same time a high negative effect that seems to be a risk factor for them even on a genetic level there are certain vulnerability factors that we have identified there are also cultural social factors environmental factors that also play a role your upbringing plays a role how you're

15:27 raised is an issue how your parents respond to those adversities that you encounter in life that also plays a role i think that's important too to differentiate yeah so dr hoffman you mentioned avoidance can you talk about its relationship to anxiety a little bit more avoidance is really the key to understand why anxiety problems are being maintained avoidance is a behavior that we choose to engage in and we often use avoidance strategies to reduce our feelings of anxiety or prevent the anxiety to arise avoidance is key because it in a way keeps anxiety alive i often tell my patients

16:14 avoidance is your anxiety's best friend without avoidance anxiety couldn't exist there's a famous experiment done in the 70s and i'll just describe it because it so nicely illustrates the role of avoiding these are fairly cruel experiments so i apologize especially for those who are animal lovers and dog owners i'm a dog owner myself and i wouldn't do this experiment but it nicely illustrates the stigma you put a dog in a cage and this cage is separated in the middle by a compartment where the dog can easily jump over you put an electric grid underneath this one half where the dog sits and you turn on an electric current that shocks the dog very unpleasant not to the level that

17:00 you would hurt the dog but clearly the dog doesn't like getting an electric shock now every time the light goes off it signals that the electric current will come up so the light goes off the dock gets shot the dog learns to jump over this barrier to get into safety into the other part of the cage we do this for a few times and the dog would learn very quickly to jump over as soon as this light goes off now what happens if you turn the light on but do not send electric current through the electric grid well the dock will still chum because the dog does not know whether it's going to get shocked or not it's enough to see that the light goes off to go over into the other part of the cage as a result avoidance it persists

17:45 avoidance keeps this cycle alive the dog assumes that the light would signal shock therefore the dog jumps over to the other side avoidance therefore maintains that very response anxiety response if you will and it's very difficult for the doctor unlearned the only way to unlearn that is to stay in that place where to experience whether or not it gets shocked or not after the light goes on this is called exposures in other words if you force the dog to stay in place and not jump that's the only way for the dog to learn that the light no longer signals shock so in essence avoiding exposure is a way to prevent avoidance for the

18:32 person for the organism for the dog for the person to learn that nothing bad is going to happen i do not need to avoid and it's gonna be just fine it's safe it is safe to stay here it is safe to go there etc so in a way you learn safety as part of the exposure treatment so for that reason exposure is a very crucial part of treating anxiety source so it's like you're relearning something you're relearning that's correct you're learning an alternate alternative association the association light the light is associated with shock and pain versus light is the alternative associated with light is associated with safety with no shock with no pain and this alternative association needs

19:20 to be learned strengthened and this needs to override this old association and that is the essence of exposure therapy can you describe how the physical cognitive and behavioral components of anxiety interact distinguishing cognitive behavior emotional physiological in a way these are artificial distinctions we're all one body and we are in a way a network of things that happen in us our thoughts obviously sometimes precede sometimes our consequence of other things that happen in our body such as logicals and say experiences or behaviors important thing is that we can intervene at various levels so it is meaningfully for the clinician to

20:05 distinguish these things often we use it as a tripod type model we call it thoughts behaviors and physiology and bodily sensations these are three things that are meaningful to separate when we explain things to clients however on an experiential level it is these are artificial distinctions nevertheless in cbt we believe that one very effective way to intervene the system is through re-examining the thought patterns it's not to say that you ignore behaviors or your physiology not at all you actually integrate it into treatment as well but this is what's really directly under our control is the way we behave and what we think in a way we can direct it this is under our

20:52 own voluntary control less so how we feel and our physiological response this is much more difficult to directly control meaning that is being controlled through our thoughts and our behaviors for that reason we intervene on the cognitive and behavioral level that's why we call it cbt cognitive behavioral therapy why is mindfulness important well it's a very old intervention if you will you know this goes back to the indian and buddhist traditions but it has become more popular in recent years partly because people realize that we don't need to respond every time to we don't need to fix everything we don't have to have a immediate response to something that happens to us

21:38 we don't have to respond all the time in fact if we don't do that we live a much easier and better life so you don't we don't have to be responsive what we want to become is more reflective meaning that we want to experience things as they are we've learned that simply doing nothing is actually the best thing to do by simply experiencing your emotions as they are and you accept them they become much more manageable so by not wanting to fix them by not wanting to manage them you actually have a much better way of managing them that is a paradoxical thing the harder you try to not feel certain things the more difficult it is actually to not

22:23 feel it and the more you welcome it the more you simply accept it and let it be the more manageable it becomes that is also true for anxiety the harder you try to control your anxiety the less you are able to control because it has a paradoxical effect same is true for other emotions not at all you need to impact anxiety same is true for anger when you feel angry and you don't want to feel angry you will feel more angry same is true for many other emotions they can be positive and negative you don't want to feel in love with this person and you fall in love and you don't want to and it happens and then you feel so distressed because now you're falling more and more in love i don't want to give you guidance how not to fall in love but this is a human

23:09 experience the more we try to control our emotions the harder it is to control them and the more these emotions control us and by letting it go by letting it be there by letting anxiety come over and experience it then the easier it gets you have a module in your book called rethinking thoughts can you tell us a little bit about that section of your book yes errors in thinking coming two types so meaning we make mistakes in the way we try to make sense of what happens around us and the two broad categories two broad types of mistakes we make include probability overestimation and catastrophic thinking probably the overestimation means that you

23:56 overestimate an unlikely event so in other words you believe that is that impossible that airplanes do crash they do we hear that certainly on a yearly basis maybe more than once a year it is not impossible that an airplane crashes because they do when you go next time on an airplane i cannot tell you for sure that you will not crash but the likelihood is extremely low extremely low in fact air travel is considerably safer than automobile truck airline industries have worked out every single accident improves the safety of the upfront and

24:41 when you consider the number of times airplanes leave just out of logan boston and coming back every day and you project it over to the us in general and over the entire world you have thousands and thousands many many hundreds of thousands of airplanes taking off and landing very safely within just a day or so consider that and the occasional crash that happened airline safety is extremely extremely safe yet people with fear of flying they would say oh i'm so scared of getting on this airplane because they overestimate the unlikely event that the airplane is in fact crash this error that we're committing here is

25:26 called probability overestimation there's not a probability doesn't exist but you overestimate this unlikely catastrophic thinking is an error that we commit that we do if we make a big deal out of something that is really not so it's not to say that some unpleasant things happen they happen to us all the time we make blunders we lose our train of thought we stumble we spill over coffee and maybe we spill over some water on nuclear people standing next to us now these are all unpleasant things but making a big deal out of that is another story so if you think now that because your boss called you into your office saying that he was not happy with one particular performance you did that is certainly not a pleasant thing but

26:12 now thinking that this also means that he's gonna fire you that you're gonna be laid off and lose your job and lose your marriage and end up on the street and as a homeless person never finding it in other words that is a different story so making a big deal out of something that is really not that is called catastrophe what is detached awareness and why is it important detached awareness is a part of what we observe in mindfulness practice so mindfulness is both a state a process where people just accept whatever is happening to them so this experience of accepting it being aware of it but not responding to it but being an observer a curious observer that is called detached awareness you detach yourself from the experience but you're aware of it just sit there

26:59 and observe it in a curious open-minded way who would benefit from the anxiety skills workbook that you just published last year anybody with anxiety with worry some thinking anybody who believes that they don't have to be a person with suffering from generalized anxiety disorder but i think anybody who feels like anxiety gets in the way with their lives occasionally would benefit from it can you share any poignant examples of how this workbook had a major impact in someone's life well we developed this workbook as a result of a treatment protocol so i wrote a treatment protocol specifically to guide therapists in a randomized controlled trial where we studied a large group of

27:44 patients with generalized anxiety disorder and we assigned them to one of three conditions the cognitive behavioral therapy condition and again this was the workbook that was derived from this particular treatment protocol or they received a 12-week course of kundalini yoga or they received a 12 week course of stress education training this trial was recently published last year in jama psychiatry it is the largest study comparing yoga and cognitive therapy we wanted to learn whether yoga is as effective as chronic thera therapy and whether both treatments are more effective than stress education the answer is both treatments are in fact more

28:30 effective than stress education we also learned that cognitive behavior therapy is still the gold standard treatment resulting in up to 75 percent of people through a significant market reduction in their symptomatology so they are classified as treatment responders that is a very large percentage that you typically do not see in trials examining generalized anxiety disorder kundalini yoga is also effective but not as effective as cbt which was in the 60 range and breast education about 40 of people respond to it these treatment gains were maintained at six months follow-up so cognitive behavior therapy using this particular protocol

29:16 was very effective we integrated now also the mindfulness part in this particular book because this was a critical piece in this trial because we also asked whether mindfulness which was part of the yoga intervention had a strong effect that might be even as effective as cbt but it turned out not to be but combining it with cbt should result in really good treatment gains can somebody use the anxiety skills workbook without a therapist or does it require working along with a therapist through the book so we designed this book to work as a standalone guide for people the idea was to give people something to help them to try it out on their own we believe that

30:02 many people will benefit from it by simply reading through that and using these practices and if they feel like it's not quite enough i would suggest and that's what is so exciting for me as a therapist because of and also now a podcaster and one of the biggest issues is access to mental health care and when i saw your book and i read through it i just saw how putting these theories and making them understandable to the average person is exactly what we need right now and again such an important piece of work thank you yes it is especially with the access issue so and also i want to mention that anxiety disorders are the number one the national institute of mental health they're listed as the am i right the number one mental disorder that people experience in this

30:47 country yes especially now i mean has always been one of the top three but now with the pandemic that had written to the top is great can you share any point and examples of how this workbook had a major impact in someone's life i couldn't pick out uh particular individuals i know i'm getting occasional letters of people simply thanking me for this book i know for sure that there's a good number of people out there who have benefited from it i couldn't uh really share with you aside from individuals who participated in our trial which i'd rather not protect the privacy but it does change people's lives in a dramatic way imagine that you know you've been living very isolated and lives that for some people don't even feel like worth living life is becoming a struggle life is becoming a drag and there's no joy so having such a

31:36 really brief intervention and getting people into a completely different mindset not only one life and you choose what you're doing with this and you don't want to suffer the entire time you're on this earth this is not worth it so it's a rewarding experience to see people who have seem to have benefited greatly from it and i hope more people hear about it and more people are being helped because anxiety makes your life smaller and smaller anxiety and avoidance makes your life smaller and smaller and having tools and skills that you own really can open up your life like you said and make it worth living so what are you most excited about in mental health treatment today many things obviously i think we are in the midst of nothing less than a revolution in treatment delivery i believe that psychology has so much to contribute

32:23 and i think people have fun to realize the psychological dimension is really much more significant and much more important than we estimate even though we are all in the mental health field among social workers psychologists we know that but often we are not quite as outspoken and loud enough to claim that so i think this is now changing i think even the most reductionistic biologically oriented mental health providers who are pushing pills and there's nothing wrong with it by the way but medication do have a role in the field so we need to work together and figure out what works for the individual and what is most helpful for an individual patient um in order to do that we need to step away from sort of a very simplistic psychiatric idea of what mental

33:09 disorders are they're not just a result of them genetic abnormalities or brain circuitry abnormalities and again i i'm a brain scientist myself i study the brain and i study genetics and so forth so it's not to say that there's no role in it absolutely there is but we need to integrate these things we need to figure out what are actually those what are the most important elements for an individual in order to do that we need to what i would call a a process-based approach step away from a simple biological model or a dsm icd latent disease model that that you have depression you have generalized anxiety disorder is not helpful these kind of labels have only been helpful to an extent and

33:56 i think we are beyond that now we need to understand how these problems are network and individual and once we understand this network we can intervene in a much more efficient way in a much more also humane way to that integrates biological genetics social cultural psychological behavioral cognitive you name it dimensions once we understand this network we understand what works for this individual city in front of us using a dynamic idiographic approach to understanding mental health problems with a goal to treat everybody 100 of people not just this number that i said 75 these are people who responded to treatment these are not people who don't

34:41 have the problem in you these are simply significant reductions of symptoms based on dsm but we need to understand how to move people beyond that also to be honest not just to focus on reducing symptoms based on icd or dsm but rather enhancing their lives moving toward prosperity and happiness and fulfillment that's what psychology is all about that's what treatment is all about so i'm excited about that because it opens up a whole new world for us and in a way we've been doing that many of many practitioners have been doing that to some extent but they weren't bold enough to speak out and i think we have a way of doing it and i'm working with colleagues on that very issue and we call this new approach process-based therapy so i'm most excited about

35:27 i really like that so if you had a magic wand and could improve one thing about mental health treatment today what would it be convince our politicians that mental health is a serious problem that needs our full attention and also financial support and let us do our job and we can do a lot of things i agree with that so how can my audience learn more about your work either online or in print more than welcome to visit the show notes and you can also learn more about what i'm doing on my website austinanxiety.org that's one word austin anxiety.org center for design the latest orders at boston university has a lot of additional resources for people in need and we are happy to also for those living in the boston area to

36:13 provide direct services thank you so dr hoffman on behalf of myself my listeners and all of the people that you've helped your work i want to thank you for your contributions to mental health treatment and for taking the time out of your busy schedule to help me and my audience better understand the field of anxiety disorders thank you richard it's been a pleasure talking to you be sure to check out my website therapyshow.com which has many resources about mental health including a page for anxiety under disorders there you will also find how to submit questions stories or insights that you have about the mental health system or suggestions about who else i can interview and how i can improve the show i'd like to close by reminding our listeners to please subscribe share and review this podcast so you someone you love and the people around the world can gain more benefit

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