Befriending Fear and Darkness:
Mindfulness for Treating Anxiety
By Ron Siegel, M.D.
Why Our Minds Won't Stop
The reason our minds won't stop - just shut-up for awhile - is found deep in our genetic code.
Those among our ancestors whose minds wouldn't shut-up are the ones who survived!
"We are constantly analyzing the past to see what was pleasant or what was painful
and constantly trying to maximize the future, making things better."
Such a ramped-up mind can be most distressing to us when we pick up meditation practice or,
frankly, even when we would just like to have a nice day. But ancestor-wise, this is what has
happened, and it's worked for us - we've survived!
The people who managed not to think didn't realize what was coming next and things didn't come
out so well. You know, they didn't do that analytical planning; they didn't have all that goal
orientation, so when that hungry lion approached, if they thought it was a cute kitty cat - they
were history!
Those who survived know all about the bad stuff, and that's a part of our inherited DNA. When bad
things happen, we "remember" the lions and cliffs - that's our survival kicking in. Our minds have a
remarkable propensity to think about lions and cliffs, or whatever the equivalent is in our daily
life.
So what this leads to in terms of modern psychopathology is what I like to call the "thinking
disease." We are constantly analyzing the past to see what was pleasant or what was painful and
constantly trying to maximize the future, making things better.
As any of our colleagues who are deeply trained in cognitive behavioral therapy would say, one of
the reasons why cognitive behavioral therapy has become so dominant as a therapy system is
because of the "stories we tell ourselves - the narratives going around in our minds contribute
remarkably to the suffering that we experience." And we have our evolutionary past to thank!
So, given the wide range of anxiety disorders that emerge from "the narratives we tell ourselves,"
how can practitioners use mindfulness practice to bring relief?
We'll look at how experiential avoidance is at that the heart of a lot of suffering and how
mindfulness provides both an experiential approach and a way to step out of the "thinking disease"
in a way that is different from CBT.
"...people with anxiety disorders have better risk appraisal skills than people without
anxiety disorders."
As we know, anxiety has three fundamental components - or it can be conceptualized this way.
There's the physiological component which is the arousal that we feel when adrenalin is coursing
through our bloodstream. There are the cognitive and affective components - all the futureoriented thinking and fear - the anticipating of what may go wrong. And finally, there is the risk
appraisal, which can be accurate or inaccurate.
Now, the last is very interesting - the accurate and inaccurate risk appraisal - because it turns out
that, on the whole, people with anxiety disorders have better risk appraisal skills than people
without anxiety disorders.
Let me give you an example of how this works. Let's say you're driving down the Interstate and
you're a person with an anxiety disorder. You might think, "I'm hurtling through space at
sixty/sixty-five miles an hour in a tin can! One moment's inattention on the part of any of these
other drivers and I'm going to be maimed, or killed, or something awful is going to happen! This is
dangerous!"
A person without an anxiety disorder drives down the same freeway or highway and says, "I'm in a
wellengineered automobile. I'm certain that my mechanic is fully attentive to his work and he's
always paying attention whenever he helps me with my car. It's a nice day for a drive." That's how
it looks without an anxiety disorder.
Now, with each of these thoughts comes arousal of the autonomic nervous system.
There's a lot of sympathetic nervous system arousal that happens when we have an anxious
thought. There's arousal of the HPA axis - the hypothalamic-pituitary-adrenal axis. We now think
that the amygdala is very involved in sensing danger; it sends a signal to the hypothalamus; there's
a releasing factor that goes out to the anterior pituitary; ACTH goes through the blood - and it
lands on those little glands on top of the kidneys - the adrenals. And we all know what it feels like
in the body when these get stimulated.
One of the things that we notice when we pick up mindfulness practice is how pervasive and
frightening thoughts of the future really are.
Even the most subtle, even the smallest fear can cause arousal.
And when we start to do mindfulness practice, these thoughts and fears come tumbling forth, one
after the other.
The mind is constantly toppling forward. We are thinking about the future, the future, the future what's next? And we're always hoping for some kind of pleasure and dreading some kind of pain.
There's a wonderful line by Mark Twain around this. Mark Twain said, near the end of his life, "I'm
an old man now. I've lived a long and difficult life filled with so many misfortunes, most of which
never happened."
"...all anxiety is anticipatory."
And that's exactly how it works! The mind is constantly going forward this way. And we start to
notice, in doing mindfulness practice, that all anxiety is anticipatory. Actually, we're not ever
anxious about the past.
Try this out for yourselves for a moment: think about something that you sometimes get anxious
about - being late, not being able to find something, doing (or not doing) something and imagining
the consequences.
It is said - I've been told from people who have investigated this and they've interviewed EMTs the ambulance drivers and professionals - that when they're extricating people even from a
terrible car crash, the person's mind is going already to the future: "Will l be able to walk? Will my
loved one survive? Will it be okay?"
Even in terrible pain at the moment, the mind is on the future. It's remarkable, the degree to
which the mind does this - and it makes total sense in terms of our evolutionary history.
And then there's worry, and I can give you an example from my own experience.
I do a fair amount of teaching and travelling around the country, so I'm often headed to airports.
The only reasonable way to reach Boston's airport from where I live is to go through a tunnel
which has been built under the harbor.
So, there I was getting ready, heading for the airport, and I'm driving into the tunnel and I start to
see red tail lights and suddenly the traffic stops. I hadn't left a lot of time - this was a carefully
planned-out trip, but I was in a traffic jam where people get out of their cars to chat and
speculate about what might be going on.
And I'm thinking, "Oh no. what if I miss my flight? There's going to be this whole room full of
people, and I'm not going to be there. Well, maybe there's a later flight. But it's a pretty busy
travel day. It could be full."
Then, I say, "Alright, Ron. Just come back, follow your breath. Let it rise. Let it fall. There's
noting you can do...rising...falling..."
"But what if I miss my flight? There's going to be a whole room full of people..."
"There might be a later flight, but this is a busy travel day..."
The mind can just do this! And it can just do it over and over. And it comes to the same dead-end
or the same catastrophic fantasy - and yet it starts again.
Why is our mind doing this? Well, sometimes you come up with a novel solution. I'll grant us that
the mind can sometimes do that and help us cope by preparing us for what's going to come. But
really, this kind of mind talk is just another name for worrying.
The same thing happens with agoraphobia. You enter a place and it can be as ordinary as a
supermarket and something triggers your anxiety. The anxiety intensifies with - What's happening?
Are people noticing? And you leave the scene because it's too uncomfortable.
The anxiety abates, and this reduction in anxiety - this "negative reinforcement" - helps us feel
better because a bad thing has stopped happening. But the same thing is going to happen the next
time you enter that situation
Here's what happens in exposure and response-prevention. Exposure means doing the thing and
responseprevention means not doing the thing that we usually do to avoid it. In other words, being
exposed to what we fear and not doing it.
By using a mindfulness-based treatment, we can use a compassionate bait and switch in treating
both the anxiety and worry.
While our patients want us to remove these anxious feelings, instead we're going to increase their
capacity to bear them, and more than that, we're going to change their relationship to the
experience.
And this is not new - here is what the Buddha said twenty-five hundred years ago:
"Why do I dwell always expecting fear and dread? What if I subdue that fear and dread, keeping
the same posture that I'm in when it comes upon me? While I walked, the fear and dread came
upon me. I neither stood, nor sat, nor lay down until I had subdued that fear and dread."
What he's saying is when the fear or dread arises, instead of doing something to feel better and
make it go away - the experiential avoidance - he's going to stay with it. He's going to stay with
the experience, enduring it until it goes away by itself.
So, let me take you through an exercise to do this
We invite a person to start with their breath and just sit still, and when they start to feel some
anxiety within their body, I ask them to notice the sensation of the anxiety and then make it
bigger... and make it bigger still.
You have to do this at the beginning of the session because if you do it at the end of the session,
you're going to wind up creating a state of avoidance learning; you're going to wind up with the
person running out the door at the end of the session in this totally arousal state.
You have the person stay with those sensations and then try to hold them there. And you really
need fifteen or twenty minutes to do this.
"With awareness of present experience with acceptance - you approach the sensations
of anxiety and stay with them."
But if you do that and you continue to coach the person and say, "Now, don't let it subside. Don't
let the anxiety subside at all."
Virtually, everybody will have the experience of, "I'm having trouble maintaining it at this level."
That's because the absolute heart of anxiety disorder is trying not to feel anxious.
But once you reframe it so that you're trying to feel anxious - and mindfulness can be very, very
helpful for this because this isn't relaxation training; this isn't about learning to calm down.
This is about staying with and increasing the capacity to bear the psychophysiological arousal
associated with anxiety and moving toward it. After a while, we just can't maintain it at that level
anymore.
And that becomes enormously useful for people because they start to see the way in which the
avoidance is at the heart of the problem and they develop more and more capacity to feel it.
So, here's the question: on a physiological level, how does the psychophysiological arousal
decrease?
For most of the people we see in treatment, their anxiety disorder is much more powerfully
maintained by their attempts to avoid things that make them anxious than it is by whatever the
original trauma or trigger was to get it started.
So when the tiger or the lion, if you will, that we're facing in the anxiety disorder is, "Oh no, I'll
feel anxious," you can redirect this through using mindfulness practice. With awareness of present
experience with acceptance - you approach the sensations of anxiety and stay with them.
The tiger's gone, because you're no longer trying to run away from the tiger. You're just sitting
with the tiger.
The physiology relaxes when we no longer feel in danger.
Let's take a very concrete situation. If you're driving and somebody swerves in the lane in front of
you and you have a near miss, there's quite a lot of arousal. But if we continue driving and nobody
else does that for a while, the system, by itself, tends to return to baseline - parasympathetic
situation.
"...by changing the relationship to the anxiety sensation - by no longer fearing it but
approaching it - you're no longer experiencing it as though it's dangerous."
So, by changing the relationship to the anxiety sensation - by no longer fearing it but approaching
it - you're no longer experiencing it as though it's dangerous.
A lot of what we're afraid of when we're anxious are threats to our self-image. We can feel threats
to our health, our wealth, or our social standing. We're afraid people will be angry with us,
whatever. Most of it is existential.
Mindfulness practice works because it's embedded in a system of facing existential reality. What
you see when you do mindfulness practice is that everything changes. It's impossible to hold life
still.
"Mindfulness practice works because it's embedded in a system of facing existential
reality."
And you notice this more when you pay attention - even just to the moment to moment unfolding
of experience. We notice that our concepts are actually a conceptual overlay on a much more
fluid reality. So it actually helps us to deal with the existential matters.