Question 1

How do you see the difference between a mindfulness influenced CBT and ACT?

Seth Gillihan · Accepted Answer

There's probably more overlap than difference. Both emphasize the central importance of being fully in our lives and opening to our experience. Both acknowledge the importance of leading with action and not taking our thoughts as absolutely true. But there's a difference in emphasis. It's probably a bit analogous to cBT vs. CbT—CBT that emphasizes cognition vs. emphasizing behavior.

So for mindfulness-centered CBT, there tends to be more of a focus on identifying and changing thoughts and traditional behavioral techniques like exposure. Mindfulness may be used to supplement or support these approaches.

ACT, on the other hand, is a fuller immersion in the world of acceptance and present focus. It also emphasizes psychological flexibility to a greater degree. There's some evidence that ACT might be a bit more effective than traditional CBT, but the differences are generally small and not statistically significant.

Question 2

How do you feel about the use of supplements specific to stress reduction?

Seth Gillihan · Accepted Answer

There's some evidence that supplements can help with dealing with stress—the work of Dr. Julia Rucklidge and others stands out (see my discussion with her here: http://sethgillihan.com/ep-29-dr-julia-rucklidge-can-nutrition-prevent-depression-and-promote-resilience/). She and her team found that high doses of a broad range of micronutrients helped in the aftermath of major life stresses.

In terms of specific supplements for stress reduction, the evidence is mixed. There can be a danger of relying on pills to manage our stress, rather than changing our lives in helpful ways to reduce the stress we encounter. We also want to be careful about where we get our supplements, since they generally are not tested for purity or safety. I would be highly skeptical of any promises from someone selling supplements that they're "guaranteed to reduce your stress."

There's an argument to be made that some of the reason that there's aren't a lot of high quality studies about  the efficacy of supplements may be from the lack of financial incentive that manufacturers have in running these studies. If someone finds something helpful to them, there's probably not much harm in using it.

Question 3

When would you choose to take a more behavioral vs cognitive approach for someone presenting with stress symptoms? Thank you for your response.

Seth Gillihan · Accepted Answer

Good Q. It would depend on whether their life seems to be overloaded with stresses, some of which are optional, in which case a more behavioral approach focused on setting boundaries and prioritizing their well-being would be useful.

But if it's more a matter of the way they're thinking about their unavoidable stresses—like seeing every opportunity as a chance to fail, for example—then in that case we would probably start with their mindset.

In practice, as you probably know, we'll typically use some combination of the two. There are almost always ways we can improve our actions that will help us deal with stress, and our thoughts usually have some degree of distortions that amplify the stress we encounter.

Question 4

Are there certain clients presenting with stress where you Wouldn't take a mindfulness approach?

Seth Gillihan · Accepted Answer

No, but of course it depends on what we mean by a mindfulness approach. In my view it will always be useful to ground our work in mindful presence, but that won't always mean that we spend a lot of time talking about mindfulness or that we focus on meditation practices.

Sometimes we'll work mostly on thoughts, or on changing behavior, but again, with mindful awareness. Some clients are really skeptical about mindfulness, and we would explore their reservations but I would also respect their preferences since something won't be helpful if it's unwelcome.

In my practice it's usually a matter of degree. For some clients the mindfulness component is front-and-center and explicit. For others it's humming in the background. We might not even talk about "mindfulness," but will talk about obviously related concepts like acceptance and letting go.

Question 5

Why is cognitive behavioral therapy for stress effective?

Seth Gillihan · Accepted Answer

CBT addresses all the components that make up the stress response—body, mind, and emotions.

The cognitive part of CBT helps us to address unhelpful thoughts that contribute to stress, like expectations of failure, or telling ourselves we "don't deserve to take a break" from all the busyness.

The behavioral part can help in two major ways. First, it helps us to move through our tasks efficiently and effectively, so we don't experience the stress of tasks we're avoiding. For example, we can break down overwhelming tasks into manageable ones, so they're easier to approach. It's way more relaxing to complete a task than to avoid it.

And second, we can use behavioral principles to figure out which activities are stress inducing and which are stress reducing, and do more of the latter. We follow sound behavioral principles, like carving our dedicated time for stress management, to up the odds that we'll follow through on our intentions.

And finally, the mindfulness component of CBT helps us find peace in the present moment, and let go of the added layer of stress that comes from projecting into the future and trying to control things we can't. The acceptance aspect of mindfulness also helps us to receive stress (or at least part of it) as inevitable, rather than fighting against it and adding unhelpful resistance to an already stressful situation.

Question 6

Is there usually underlying anxiety or depression in people presenting for treatment for stress?

Seth Gillihan · Accepted Answer

I wouldn't say as a rule that anxiety or depression is usually there, but it's very common for those conditions to occur when our stress is really high for long periods of time. And being anxious or depressed can make it a lot harder to deal with stresses.

Anxiety and depression can also amplify the stress response, leading to more anxiety/depression, and more stress, etc.

Thankfully the treatment approaches for managing stress and reducing anxiety/depression overlap to a large extent, so working on one is likely to help the other. And as one condition improves, it can feed into a "virtuous" (as opposed to vicious) cycle of relief.

Question 7

Hi Dr Gillihan, do you have some strategies for helping people to stop ruminating? Thanks.

Seth Gillihan · Accepted Answer

Hello. It's a great question, and something a lot of us deal with. Here are my favorite approaches.

Please note that these practices are adapted from The CBT Deck for Anxiety, Rumination, and Worry (https://www.amazon.com/CBT-Deck-Anxiety-Rumination-Worry/dp/1683733096/).

Start with *recognizing when you're ruminating*. Telltale signs include: 
1. Repetitive or unproductive thinking that leads you in a circle
2. Negative emotions
3. Feeling stuck in your head
4. Being cut off from your sensory experience

When you find yourself ruminating, *become aware of your senses*: What do you feel, see, and hear? Doing so can get you out of your mind and back into the present moment. Try this three-part exercise:

1. LOOK: Take a breath and notice what you see around you.
2. LISTEN: Close your eyes, take a second breath, and attend to the sounds around you.
3. TOUCH: On the third breath, feel the points of contact between your body and where you’re sitting (or standing).

Repeat this exercise as often as needed.

We can also watch out for unhelpful thoughts, like *hindsight bias*,  where we judge decisions we've made based on things we couldn’t have known at the time. Once we know the outcome, it’s easy to assume we “should have known better.” But we probably made the best real-time decision we could have at the time.
  
Change the Conversation

Rumination often makes our emotions the center of our attention, leading us to ask questions like:
“Why do I feel so anxious? How can I stop feeling sad?”We can interrupt this process by asking a different question: “What task needs my attention right now?” Then redirect your energy toward doing what needs to be done, allowing emotions to exist in the background.

Let Go

When you notice that you’re holding onto thoughts, squeeze your hands into fists. Imagine you’re gripping the ruminative thoughts as you feel the tension in your hands. Then relax your hands as you allow the tension to melt away, and watch the thoughts dissolve at the same time.
 
Change the Mental Channel

Unhelpful repetitive thoughts can distract you from your tasks. When you notice you’re stuck in a mental rut, interrupt the rumination by changing the scenery. Move to another room, sit in a different seat, or step outside. Take in what you see around you as the physical change encourages a mental shift. When you go back to your task, open your attention to it as fully as possible.

Social Rumination

We all make mistakes in our interactions at times, like forgetting someone’s name or saying something a bit foolish. You might replay your mistake over and over, cringing each time. But when the roles are reversed, you probably don’t dwell on the other person’s misstep. The next time you’re ruminating about a conversation, remember that the other person has almost certainly moved on.

Question 8

Are there any resources that you would recommend for coping with exam stress?

Seth Gillihan · Accepted Answer

Exam stress and test anxiety are so common. Effective techniques will generally include what I summarize as Think Act Be. That's shorthand for COGNITIVE, BEHAVIORAL, AND MINDFULNESS practices.

Here are some examples.

THINK: Try a practice called "What's the Alternative?"

When anxiety tells you something bad is going to happen, write down the prediction. For example, “I’m going to get so nervous during my exam that my mind will go blank." Then write down a different possible outcome. You don’t have to make yourself believe the alternative. Simply realize that your feared outcome is one of many stories about how things might go.

ACT: This practice is called "Change the Conversation"

Test anxiety often makes itself the center of our attention, leading us to ask questions like “How can I stop feeling anxious?” The next time you're facing test anxiety, ask a different question: “What task needs my attention right now?” Redirect your energy toward doing what needs to be done, allowing anxiety to exist in the background.

BE: "Open to Not Knowing"

Worry about exam performance comes from uncertainty about how you'll do. Practice opening to this uncertainty, rather than making it a problem to solve in your head. Remind yourself that you can’t see the future, and choose to focus on the reality of now.

I imagine there are some excellent books specifically on the topic, but I don't know them well enough to make any recommendations.

At the risk of self-promotion, my books and card decks, including the CBT Deck for Anxiety, Rumination, & Worry, offer many practices that can be applied for coping with exam stress. Here's the link: https://www.amazon.com/CBT-Deck-Anxiety-Rumination-Worry/dp/1683733096/. The practices I offered here are adapted from this deck.

Question 9

Can I do CBT for stress on my own.. Are there any apps or books that you recommend? I am a medical student interested in mental health. Thankyou

Seth Gillihan · Accepted Answer

Yes, self-guided CBT for stress can be very effective.  The app I'm most familiar with is one I actually work for—Bloom CBT. The lessons are video-based and grounded in mindfulness-centered CBT: https://apps.apple.com/us/app/bloom-cbt-therapy-self-care/id1475128511

This book has many terrific resources: https://www.amazon.com/Relaxation-Reduction-Workbook-Harbinger-Self-Help/dp/1684033349/.

And my own CBT Deck is good for on-the-go simple CBT practices you can take with you each day:
https://www.amazon.com/CBT-Deck-Practices-Improve-Thoughts/dp/1683732464/

Best wishes with this and with your medical education. We need great doctors, and doctors need ways to manage their stress!

CBT for Stress

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