David: 0:00

for people who might not be familiar with panic attacks, when someone has one, it's a powerful, powerful physical experience that makes it seem to the individual, I'm going to have some kind of physical or mental catastrophe here.

Cody: 0:31

back to the Mindhack Podcast, where we delve into the minds of some of the most insightful and influential figures in the field of psychology and self improvement. Today we're speaking with Dr. David Carbonell, a renowned psychologist and author of the groundbreaking book, The Worry Trick. Dr. Carbonell has dedicated his career to helping people overcome anxiety and worry. With his unique and practical approach, combining cognitive behavioral techniques and acceptance and commitment therapy, he has transformed the lives of countless individuals. His book, The Worry Trick, is not just a manual for managing anxiety, it's a compass for navigating the complexities of our minds. Beyond his writing, Dr. Carbonell is also known for his empathetic and effective clinical work, guiding people through their anxiety with both wisdom and wit. Whether you're someone who struggled with worry, or you're just curious about the inner workings of the anxious mind, today's conversation promises to be enlightening. So without further ado, please welcome Dr. David Carbonell. Thank you for being here. So I'd like to start off by asking what caused you to specialize in anxiety disorders? Was there a particular moment or experience that drew you into this field?

David: 1:52

Well, there were a long line of small moments. When I was working on my doctorate in psychology, and you go out and you work in practicums, where you see clients on a part time basis, you do a full time internship, and in all those kinds of settings, they want to offer the trainee a variety of problems to work with. So they'll give you a few depressed clients, a few substance abuse clients, a few anxiety clients. And everywhere I went, it seemed that feedback I got from my supervisors, and I could tell this was true myself, was that, well, gee, you do really well with the anxiety clients. You really seem to take to the anxiety clients. Some of these other things, you're not so hot, the anxiety clients you do really well with, we're going to send you more of those. and I liked the work, and I could see that people were getting better and, and it just, made sense to me. I understood it intuitively in ways that I, I didn't understand other kinds of problems and so as I, graduated and started, working in the field. This was in the, the mid eighties, and it was just then that a lot of the original cognitive behavioral approaches to anxiety were starting to come online and people were talking about it, and Oprah had shows about it. Whereas in the years before, there really were no good treatments for anxiety, now there were. And, we discovered that, untold millions of people had been just waiting, despairing even, for some kind of treatment to arrive and here it was. So, each time I just kept saying yes to this and quickly discovered, I could work full time and see only anxiety disordered clients. that's how much of a pent up demand there was. And so Basically, I just kept saying yes to what, life threw at me.

Cody: 3:38

What do you think allowed you to become so good at anxiety and solving these anxiety disorders for the people that you were a therapist for?

David: 3:48

Well, that's an interesting question. I, particularly enjoyed and found interesting the kind of, theoretical models, cognitive behavioral therapy, paradoxical therapy, which, was quite big at that time. those made sense to me and I enjoyed working in those modalities much more than traditional therapies. And those were the ones that. we're particularly well suited for chronic anxiety disorders. I think I also, uh, just got it a little better because I had my own fear of heights and I, better appreciate what is the fear experience like? what's it like to confront these unrealistic thoughts and these weird feelings? in ways that I probably couldn't understand depression and substance abuse and other problems that, that didn't affect me nearly so much. so I think it was a combination of who I was and, fact that I, liked doing the models. And again, as I say, the, the time is where people were literally crying out, where are some good anxiety treatment? so three of those things just fit together for me.

Cody: 4:51

you bring up that you weren't as great at depression or substance abuse, and I'm just hypothesizing here is that I think there's a component that is associated with the subconscious mind for almost any type of psychological issue. And in particular for depression or substance abuse, I think you can be addicted to something, but you can't figure out why you can't turn to thought. in terms of why you continue to take something. In depression, you can realize that depression is irrational and yet you still feel depressed. So perhaps there is more of a unknown chemical component to that. Whereas do you think with anxiety that it's more readily and easily something that can be solved through thought or visualization? To actually kind of think through the problem to mitigate the anxiety or are there other forms of anxiety?

David: 5:48

Yeah, actually I don't think they're quite that different. Clearly, working with the thoughts, the cognitive part of cognitive behavioral treatment, very, very important with chronic anxiety. But that's not going to typically take people all the way they need to go. But if they try and change their thoughts, but leave their anxious behaviors intact. say someone who, is worried about having a panic attack on the highway, and you know, has thought it through and done all the reading and examined this and is satisfied, okay, no matter what happens, I know I'm not going to lose control of myself or the car, when I'm on the highway, I'm just going to be terribly afraid. if they understand that, but each time they have a panic attack, they pull off the highway, that's really going to limit their progress. So we really, even more important, I think, than the, the C part, the cognitive part is the B part, the behavioral part. can I take that knowledge? Can I take that understanding and then go out and literally practice with what I'm afraid of rather than protect myself against it or, avoid what I'm afraid of? So if somebody was afraid of dogs, pretty soon, in treatment, we'd be wanting to, have that person spend time with dogs and somebody whose main problem is chronic worry. Well, those worrisome thoughts are the dogs, and then we got to help them find a different way, literally of relating to the thoughts, even more important than realizing the thoughts are exaggerated as, Finding a different way to relate to those thoughts.

Cody: 7:26

would you describe that as a form of exposure therapy?

David: 7:30

It is, yes, it's very much a form of exposure therapy. If, we think about generalized anxiety disorder, a condition in which, a person just worries a lot. They worry long and hard and often about a wide variety of topics. What if I lose my job? What if my wife becomes ill? What if my son flunks out of school? What if the roof blows off next time we have a tornado? these worries. And they try and get those thoughts off their mind. They try and distract themselves. they try and tell themselves, don't think about it. In the olden days, they might've taken a rubber band and wrapped it on their wrist and snapped that rubber band against their wrist and said, stop thinking that. I went to great lengths to try and oppose their thoughts and it made people worse. So some form of exposure to what they're afraid of, to the thoughts, is really a big part of the treatment of chronic worry. Let me find ways to work with those thoughts rather than against them. And that's what I mean by Change the way I relate to the thoughts. that's so central. Changing the content to the thoughts, not nearly as important as changing the way I relate to the thoughts.

Cody: 8:43

That reminded me of a study that I believe happened in the late 1980s with a paper that talked the paradoxical effects of thought suppression and I'm not sure if it was in that study or afterwards they, asked participants, I know that there's variations of this, where they asked participants to, to either think of a white bear to not think of a pink elephant. And the moment you say that, your brain can't help but focus on the thing that you're not supposed to do. And I think that relates to anxiety and often the default attempt at. Suppressing anxiety is to say, I don't want to think about this, which only leads to more of those thoughts. could you explain this?

David: 9:25

Sure. and this is, so central to our understanding of, anxious thoughts and how to, how to handle worry. in particular, and chronic anxiety in general. so the challenge in that study was, think, uh, take one minute to say, and don't think of any white bear, to tell myself or to tell another person, don't think X, Y, Z is really amounts to telling them, do think of X, Y, Z, because. We've already introduced the topic. They probably formed a mental picture of that bear and the instruction, don't think about this. and even if they're making a fairly good attempt at not thinking about it, how are they going to know if they're succeeding? They have to check and see, am I thinking about a white bear? And yeah, now I'm thinking about it again. the instruction, don't think about X, Y, Z. It's probably the least useful instruction known to man. nobody can really do it. so what we have to do is, transform that and find some way to make the experience of having the thought of a white bear or the XYZ or whatever, less and less painful, more and more routine, something. That we can easily discard, treat as unimportant rather than, not have the thought. it's all about exposure, whether it's about, I'm afraid of being on the highway. I'm afraid of dogs. I'm afraid of flying. I'm afraid of public speaking. I'm afraid of my own thoughts. my own chronic worrisome thoughts keep getting to me, across the board. will come in and tell me, well, here's what I'm terribly afraid of, Doc. This is why I've come to see you. I'm afraid of X, Y, Z. As soon as they tell me what they're afraid of in the back of my mind, well, I know where we need to go. we need to go spend time with the dog on the road, on the airplane. Public speaking, and with, chronic worry, playing with those thoughts rather than trying to prohibit them.

Cody: 11:22

So it's with the example of say, those who are afraid to fly. On one hand, there's the exposure component of actually being in an airplane. And therefore having these, these memories that everything was fine. And you build up this history that you can refer back onto that you can kind of alleviate the concern of your subconscious. And yet, there's other forms of, say, anxiety attempting to resolve it, which is even how do you get them on the plane? And there's various methods of, say, should you have that person try and examine what's the basis of this argument? And then say, let's look at the statistics. But I think historically you're unlikely to convince somebody on statistics alone. so how would you go about getting this person on the plane to begin with? What kind of, mental exercises would you have them go through?

David: 12:16

Well, this is real interesting. I do, still do, for a number, of years, and I'm doing it now once or twice a year, I run a class for fearful flyers, and we'll take a small group of people, on a flight and have a practice flight at the end of the class. Now, first thing to notice is, people who are not afraid of flying and don't have any reason to know much about fear of flying tend to assume, those people must be afraid of crashing and dying. but actually, something, between two thirds and three fourths of fearful flyers. They're not afraid of crashing at all. They're afraid of having some kind of panic experience on the flight losing control of themselves, having a heart attack, fainting, jumping up and pounding on the cockpit door and getting subdued by the other passengers and duct taped to a chair and turning up on the local news back in their hometown. they're afraid of, you know, of becoming, afraid uncontrollably. So on the aircraft much more so than, than crashing. and so they, will do a variety of things to try and protect themselves from that. They might take medications, when they fly, take a Xanax or a Klonopin, some kind of a sedative medication like that. They might. Or rely on alcohol. They might grip the armrest of the plane, of the chair in a death grip. They might close their eyes and assume a crash position and just not look around. They'll do all kinds of things to try and protect themselves from becoming terribly afraid. this is why, although they might have quite an experience of flying and never having had that awful experience, they don't trust it. They think they were lucky. They think, well, what if the next time is the one? And I remember a man coming to see me, a very successful businessman. he listened to my explanation of exposure and what we were going to do, and he said to me, well, doctor, I flew a hundred thousand miles last year. How many did you fly? I was more afraid the last mile than I was the first one. so how was exposure? How was more flying ever going to help, me? Uh, and well, it turned out as we looked into how he flew, yeah, he did fly a hundred thousand miles, but he was flying with alcohol and he was flying by holding onto in a death grip and he was flying by closing his eyes. He was flying by only staying in the seats that he, felt were lucky for him. He had certain lucky numbers. I got to, you know, sit in one of those seats. He had certain airlines he thought were friendly and unfriendly airlines. he had a lucky sweater that he would wear, and he attributed his being okay to all of these things. if you attribute your survival, your sanity, to these kind of, uh, these kind of objects and little habits, gee, what if they're not available the next time? You know, what, what if my sweater gets stolen? what if I have to sit in a different seat? What if it's a no drinking flight? it didn't help him at all. and of course what it meant was not only does he have to do exposure, you know, practice flying on the plane. It also means we have to let go of all those, what we call safety behaviors. the alcohol, the lucky sweater, the grabbing onto the seat, the closing of the eyes, so that you can fly and not do any of those protective devices. And still come to see, yep, at the end of the flight, it's all the same. They didn't help me in any way. I don't need them. but holding onto those safety behaviors is what tends to keep a person's fear alive. So it's, it's not just exposure, but what we actually call exposure and response prevention. Let me go spend time on the airplane or with whatever I'm afraid of. and let me refrain from doing anything to try and protect myself.

Cody: 16:04

So in some ways that sounds like that superstition played a role in managing his anxiety to that point. And perhaps it's like putting a band aid on an open wound. It seems like there are a good portion of people, I would presume, that attempt to treat their anxiety by addressing the symptom and not the root Would you say that's an accurate assumption?

David: 16:32

Well, I, I think it's, it's perhaps more that they attempt to treat the symptom by preventing it or protecting against the symptom. I'm not really working with root cause either. I'm helping people to experience, the symptoms. And allow them to subside. but I think the, the more important difference is when they treat the symptoms, they're trying so hard to get rid of the symptoms. They're telling themselves, don't feel that. and getting the same results that you get when you tell yourself, don't think that. so we're going to work with the symptoms in a permissive manner. You know, when, when I take the group of people on the plane, our whole mission is we're going to fly to an airport about an hour from Chicago, turn around take a bathroom break, get on the next plane and then fly back. And I always want to have a discussion with them about this. Why are we going to Detroit or Kansas city? nobody's going to meet us at the airport. We don't have any business to conduct there. No sooner do we arrive, then we're going to get off and get on another plane and come back home. What are we even going for? and that makes it really clear. We're just going for the anxiety. We got to practice having those anxious symptoms on board the aircraft. And seeing that, yeah, they're unpleasant, but they're manageable. And the more I practice with them, the more and more they diminish. So we're going to go right at the symptoms, but in that permissive, let's practice with it kind of way, rather than let me try not to be afraid.

Cody: 18:03

Do you recall any, instances that stand out to you when you're on this airplane and dealing with people who probably, would assume also have had a fair share of panic attacks? I mean, how do you deal with that?

David: 18:15

well, it's kind of surprising probably. but it's not nearly as dramatic. you bring eight or 10, fearful flyers onto the flight. Nothing terribly dramatic happens. You know, even my colleagues will say to me, aren't you afraid to take this group of people onto the airplane? I mean, what if they all start panicking at the same time? it tends not to happen. And in some ways group is taking care of me. They seem to take their turns when they're having a panic attack. but I just haven't seen it happen that a bunch of people have a panic attack at the same time. And for people who might not be familiar panic attacks, when someone has one, it's a powerful, powerful physical experience that makes it seem to the individual, I'm going to have some kind of physical or mental catastrophe here. I'm going to lose control in some profound way. And, Everybody within a country mile must be able to see that something horrible is happening to me. truth is there's very little that's visible about a panic attack. People in the class have had a panic attack sitting next to me and had to let me know that that was what was happening because there's nothing from the outside that's, dramatic or compelling. It's all internal thoughts and sensations. now nothing dramatic tends to happen because. In this class, when we go on the flight, mission, and they're all charged and ready for it by the time we've been through the class, their mission is to go and have some panic attacks on the plane. one of their biggest fears is, what if I go on the flight and I don't have the panic attack that we need? So we've completely turned it around. The idea is to have a panic attack and practice responding to it. and so they're, they're prepared for that. We have a variety of techniques by which to meet and practice with the symptoms of a panic attack. so for the most part, other people in the plane aren't even aware anything is happening.

Cody: 20:07

Now, perhaps before you have a panic attack, there is a prologue to that, which in your book, The Worry Trick, you talk about some concepts of worry and what it is. I'm wondering if you can explain what the main idea is of this trick is that worry tends to play on our minds.

David: 20:28

Sure. and. Even more broadly, chronic anxiety disorder, there's a trick here. trick with chronic worry is this. I experience doubt about what's going to happen. I experience doubt, and I treat that doubt as a sign of danger. and with chronic worry, with generalized anxiety disorder, the doubt principally takes the form of a wide variety of what if thoughts. And they all start principally with what if. What if I get sick? What if I can't handle myself? What if we crash? What if we spend three hours on the tarmac and I go insane? long series of what if thoughts so unpleasant, so much what they hope isn't going to happen, so distressing to the individual. That they try and prove to themselves, they try and satisfy themselves, Well, that's not going to happen. I know that's not going to happen. and the moment they try and prove to themselves, Yeah, I'm sure that's not going to happen. They run into this problem, see? we can't prove the absence of something in the future. we can't guarantee that the law of gravity isn't going to be repealed next Tuesday. Probably isn't going to happen, but if you want to be sure, you can't be sure. and when they realize, I can't remove all the doubt, I can't be satisfied that isn't going to happen, then they flip around and approach it this way. Gee, if I can't prove it isn't going to happen, uh oh, that means it's going to happen. so that, the trick. They try so hard to disprove this, try so hard to disprove that which can't be disproved. That then they become more anxious, that they treat that doubt as a sign of danger, and that triggers them to constantly protect be on the lookout for trouble and that that's the whole vicious cycle that they get into.

Cody: 22:23

It seems like it's a prediction as to What might happen, but it's based more on fear rather than actual probability.

David: 22:34

Yes, that's exactly right. they worry proportional to fear about what it would be like if that thing happened. without regard to how likely or unlikely it is to happen. you know, and, uh, well, one of the things that makes my work, so successful and pleasing really is I pretty much know in advance who's coming to me. People are coming to me who are afraid of things that they themselves can recognize, gee, that's not so likely to happen. nobody comes to me because they have this terrible fear. What, if I to Brookfield Zoo here in Chicago and, climbed into the lion's cage? that wouldn't be so good. Nobody comes to me for help climbing into the lion's cage. That would be dangerous. That would be harmful to their health. People come to me when they recognize, gee, my fear is excessive. I'm overprotecting myself. even though I can't get rid of the fear, I can recognize that my fear is exaggerated.. Years ago, when it was all the thing to have a, uh, an elevator speech to describe your professional life, this was my elevator speech. I work with people who are afraid of things that tend not to happen. that's what we're doing with chronic worry and with phobias and, anxiety of, all kinds. that gives us, a platform, the permission to, well, let me go and practice and play with those thoughts and situations because I already have reason to know, they're not harmful. That's why I'm coming to this doctor and saying, please help me approach that thing that I'm afraid of.

Cody: 24:05

Now, everybody experiences anxiety in one degree or another throughout their lifetimes. believe the recent or very popular well known study is that most people fear public speaking more than death, if that's accurate, but What I'm getting to is that even in the case where we have something in the future, such as a planned public speaking event, we tend to worry so much up to that event, and if we, and we might also be in a situation where we are worrying about something that might happen in the future, and then it doesn't pan out, and therefore we end up suffering more as a function of that worry than even the thing that we were potentially afraid of. what are some of the techniques, or highlights of things that you think are most helpful for situations where we're afraid of something that might happen in the future?

David: 25:01

Uh, well, one of them is helping the client, to realize what you just described, we'll look at their history public speaking. and I'll ask people to consider. You know, when, uh, the anxiety they experienced a month before, a week before, the day before, and compare that with the anxiety they experience once the speech starts. and what we find is ahead of time, people suppose, well, once I start that speech, that's when my anxiety is going to go through the roof, that I'm going to be nervous all the way up to it. And my anxiety is going to reach a peak just around the time have to stand up and approach the microphone and say, thank you for having me. that's going to be, the high point of my anxiety as I talk. what we find though, as they look at their actual experience, is that their anxiety level actually peaks before they talk. And once they start talking, it drops a little, it doesn't go down as far as they want, but it doesn't keep going up the way they feared it actually drops a little. so what's one of the indications of this? Gee, if, if in two weeks from now, I have a speech to give and I'm terribly afraid of it, or I have a plane to take and I'm terribly afraid of it. If there's a way I could move that event up and do it sooner, I'll be better off because I'll spend less time worrying about it. And once I actually get on the plane, once I actually start the speech, odds are my anxiety level is going to come down. And this contrasts favorably with what their gut instinct is. Their gut instinct is, let's postpone it. Tell them I'm sick. Ask if we can do the talk next month. Can't postpone this trip for another month without realizing, gee, that expands. The volume of painful worry that I'm going to experience. so we want to help them move up if at all possible, a time when I can get to that sweet spot where I'm really anxious. And now I start, and my anxiety level is naturally going to come down. So on the plane, people dread that moment when they hear the door slam shut. Cause that means they're committed to the flight, but you know what? that's the high point of the anxiety. Then once the plane takes off. still don't like it. They're still afraid, but their anxiety level tends to go down a little bit because they're no longer sitting there wondering, should I stay or should I go? Should I stay or should I go? Oh, the door's closed. I'm committed. Oh, well, what can you do? And it's the same with giving the speech. public speaking in particular, one of the things that makes it such a thorny problem for people is that they're so concerned with feeling afraid. They're so concerned with looking afraid. that they struggle against that. they struggle against all their emotions. And so, I'm going to encourage people, to think of public speaking for the most part as well. You've been invited to come here and talk on some topic because they would like to hear something about the topic that you know something about. they want you to come and give them a little gift of something. Uh, maybe they're going to love the gift. Eh, maybe, hopefully not, but maybe they'll hate the gift. Whatever, you just have to show up and give the gift. You can talk when you're happy, you can talk when you're sad, you can talk when you're angry, you can talk when you're afraid. This is a come as you are party. Show up, bring whatever emotions you have to have, and focus in on the task of, I have a gift for you, let me tell you ten things about my topic. They're not coming to look at you and see, well, how's he feeling these days? We want to kind of get into his psyche and see what he's like. No, they want to hear the time, unless you're Barbra Streisand. They're not coming look into your soul. They're coming to hear the topic, give them the topic. and whatever emotion you bring to the occasion, that's okay. let that be there while you do your work. probably the most universal experience that people fear as part of public speaking is, so frequently they seem to run out of air. Because they breathe badly, and breathing short and shallow and having chest discomfort and feeling lightheaded and feeling like I'm gasping, very commonly a part of panic disorder. And, when we work with breathing, we're going to see a very concrete example of a much larger picture that the anxiety disorders are all counterintuitive. Every last one of them, they're counterintuitive. Meaning, my gut instinct of what will help It is dead wrong and I should do the opposite of my gut instinct. If I'm out driving on an icy road and I start skidding towards a phone pole, well, where should I steer? My brain is probably screaming at me, steer away, steer away. But if I do that, I'll be talking to the insurance agent soon. Best case scenario. where do you steer when you're skidding towards a phone pole? You aim for the phone pole. takes some getting used to, but that's how you get out of a bad skid on an ice. If, you get a new puppy. And then you bring it home and the puppy gets off the leash and runs down the street. He's having a wonderful time running away from you. How are you going to get that puppy back? probably your gut instinct is to run after that puppy, but he's got four legs and you got two. That's not going to end well. what's the best way to get that puppy back? You run the opposite direction. And now we're playing chase the owner. Counterintuitive. My gut instinct is dead wrong. I should do the opposite of my gut instinct. The anxiety disorders are all counterintuitive, and this applies to something as physical, as behavioral as the breathing. When people breathe and they get anxious, they tend to breathe short and shallow from the top of their chest. They're not getting a lot of air. It's uncomfortable and they have the feeling of running out of air. And if you're speaking, I can barely make it to the end of the sentence before I run out of air. so what do they do? They try harder to suck in some more air. And guess what? That makes it worse. what would be the opposite? Do you think Cody of breathing like this?

Cody: 31:08

Probably I know a common breathing is to breathe in, or box breathing, to breathe in a count number of seconds, to hold your breath, and then to slowly exhale, perhaps as if you're breathing out through a straw,

David: 31:22

Yeah. Yeah. And, and that, you know, people, if people get into that early enough, they can interrupt the short and shallow breathing with that, but if they're already, they're already breathing short and shallow and they realize I can't catch my breath, they're going to try harder. What I'm going to ask them to do. Is the opposite of that. I'm going to ask them to exhale. Your brain is screaming at you. Take a deep breath, take a deep breath. Well, that's a good idea, brain. But first I need to relax the muscles of my upper body before I can breathe more comfortably. And that's the exhale. And then having exhaled, then I can start to breathe more diaphragmatically. So across the board. With respect to thoughts, with respect to behaviors, when a person afraid in this manner, their gut instinct is typically dead wrong. And I'm going to suggest to them, rule of opposites. My gut instinct of what to do when I'm terribly afraid is dead wrong and I should do the opposite. and that's gonna probably be the best piece of guidance that they can get, about what to do when they're stuck in a worry cycle, what to do when they're having panic attack. what am I motivated to do? And let me do the opposite. So breathing is a real important tool, for people who are struggling with public speaking because they literally will. get to the point where they can't generate enough air to finish that sentence, and then they feel very self conscious and embarrassed about that, and then they're fighting with their body rather than delivering the speech.

Cody: 32:52

And then in some ways also seen speakers externalize their anxiety while they're in the middle of their talk. I remember one person who apologized halfway in that he forgot his notes and so he wasn't really exactly sure where all of his points were and and so in some ways when you externalize that anxiety I think it's an attempt to soothe yourself but now Nobody else probably saw the thing that you saw and now everybody else is looking for it. And so have you seen that as an attempt to solve anxiety in one way or another?

David: 33:31

Uh, yeah, some people, sometimes people will take this kind of apologetic, stance, you know, oh, I'm sorry, I, you know, I forgot my place, I don't know, and, kind of put their troubles out, out to dry so everybody can see them. That's usually problematic. That's not usually so useful. what I find more useful, well, let me back up. and another difficulty with public speaking anxiety is people will still try to hide, whatever they're feeling that they'll try not to look anxious. I don't promote going out and advertising your anxiousness. but I certainly don't promote trying to hide it either because Then you're up there when you should be focused on your content. You should be focused on, is the audience understanding me? Do I need to go slower? Another story? Are they ready to move on? They're focusing on their, their anxiety. so I, I always want to encourage people to use the anxiety that comes along. And if, you're at a point in your talk and you suddenly realize, Oh my gosh, I've lost my place. not sure what my next piece is. You could stand up there and interrogate yourself, and try and bully yourself into remembering, or you could turn to the audience and say, just forgot what I was saying. What was the last point I made? And you know what? They'll tell you. and now you've got a dialogue going with the audience and they're giving you the information you want, and you can pick up on that and continue. As compared to you being up there trying to pull a fast one and pretend you're not afraid and wondering if they can tell anyway. so anything that leads a speaker to keep focusing on themselves, probably bad. Anything that leads a speaker to engage more in a dialogue with the audience, probably good.

Cody: 35:19

Yeah, I remember an interesting study that asked Various people and audience members from various conferences Which people they liked more and they tended to like the people who actually messed up on their talks You and they reason is that it's because when they mess up that person is more relatable to the audience, they relate more to them.

David: 35:43

Absolutely. Sure. that's very understandable. the audiences. Generally pullin with thee for the speaker. I think from a fearful speaker's perspective, they enter into that like it's a lion's den. Like here's another group of people that have turned out, you know, paid 25 bucks, just hoping to see me fall on my face. There are very few audiences that actually are rooting for you to fall on your face. Most of them are hoping, well, I hope you'll have something interesting to say and, teach me something. I hope you'll make this enjoyable experience because after all, I paid for the ticket and I'm spending an hour here, so I'm rooting for you to do a good job. speaker's perspective. They feel under the gun. and I think that's a big part of public speaking. so much of the situations, the objects that we fear, have some, origin in our evolution as a species. So very easy to become, say, afraid of snakes. that's presumably because for large parts of our history, if there was a snake near you, you were in danger, very difficult to become afraid of rabbits. Rabbits have never been a threat in all our time as a species. And if you think about position of a public speaker, uh, well, the public speaker is going to stand there in front of a whole bunch of people looking at them. And for much of our evolutionary history, If it was you standing there by yourself looking at a big crowd of people, this was not going to end well for you. they were probably going to pick up sticks and clubs and make a meal out of you. and that's little scary piece behind, mind of the fearful speaker. Oh my God, look at all these people coming for me. Well, actually they're sitting. Or they're not going to advance, but that's an intimidating kind of circumstance that gives rise to all kinds of scary thoughts.

Cody: 37:33

And now I have to ask this, idea has become popularized by, TV and culture. Does picturing the audience in their underwear or naked actually help at all?

David: 37:44

well, wouldn't completely discount it. but I, think, it's too much work. it's too much work. takes you away from what you want to do as compared to, you know, I want to win this audience over. I got a couple of really key points. I think they're going to like. So, no harm picturing the audience in their underwear, I suppose, but, I'd be surprised if it's of any significant value.

Cody: 38:07

And now I'm sure a lot of the patients that you deal with have some form of generalized anxiety disorder. What I'm curious is, say they have an anxiety for flying and then you work with them to dissipate that anxiety. Does working on one anxiety tend to affect other anxieties or do you have to work on them kind of one on one when it's somebody who's, generally of high anxiety?

David: 38:35

well, particularly with people who have maybe multiple phobias, that are marked by a lot of strong physical sensations that are kind of, panic attack phobias. somebody who's afraid of flying very likely to also be afraid of elevators, very likely to also be afraid of other claustrophobic or, circumstances from which it's difficult to leave as quickly and quietly as they might want, say, a crowded movie theater and you have to sit in the middle of the aisle. making headway with any one of those is gonna tend to carry over quite a bit to the other circumstances, because. The same kind of responses that are useful, to dealing with fear of a panic attack on the airplane will help you with fear of elevators, will help you with fear of being stuck in a crowd, help you with, uh, being on an express train, that's going to go for three hours before you can leave and so on. So yeah, what we often like to do, uh, when somebody has those multiple phobias, if the client is willing, would usually prefer if they're willing. To tackle the one that they find the most difficult right at the top, because then they're going to have all the power from overcoming that it's going to make the other ones so much easier to overcome.

Cody: 39:51

Now, I can imagine two main ways of absolving anxiety prior to the thing that the people are or the event in the future that people are anxious for. One, I could see as a sort of visualization of visualizing yourself in that position in that future situation. And, , Perhaps visualizing what if it doesn't work out? What if you do fail? What is the worst that could happen? is this going to matter 10 minutes, 10 days, 10 weeks, 10 years from now? And perhaps the other one is this sort of rational logical approach, which is asking yourself, does this fear really make sense? What about it doesn't make sense, and then breaking it down. Can you describe what are the most common and typically the most effective forms of anxiety mitigation?

David: 40:43

Yeah. of those two, would tend to favor the one that encourages the individual, okay, let's suppose, you do have this feared outcome and you are unable to finish your talk or you. You do walk away from the gate without getting on the airplane. or you have, a panic attack and a crowded in theater. They, probably haven't come to the point of asking themselves and thinking about, well, what happens next? when people are afraid of a panic attack, the moment of the panic attack, that's, as far as they see into the future, don't see what happens moments after is the anxiety level starts to come down and they feel uncomfortable, they feel embarrassed. They may feel ashamed. But they walk on and life resumes as normal. they don't, stop to see that. so I, think that can be a big help in mitigating anxiety. I think the most powerful means, involves going even beyond that, and doing, exposure, to the triggers of the anxiety. Let me see if I can't have a panic attack, get anxious, allow the anxiety to build. do nothing to mitigate it and allow it to decay on its own. because now a person is not simply changing some of the thoughts they have about it, but they're developing a muscle memory of, I get afraid and then I calm down. I get afraid and then I calm down. And I get better and better at calming down, almost immediately after I become afraid. So, I, think certainly, the literature seems to suggest that this is our most powerful form of treatment, what's called exposure and response prevention, and that's just fancy talk for if I'm afraid of dogs, I go and hang out with a dog and then multiple dogs in multiple settings, and I don't have anybody confine them, I don't bring my lucky sweater, I don't stand behind a fence. I allow myself to get afraid, remain in place, and give it time to subside. that's the most powerful form we have.

Cody: 42:41

Now, there's certainly forms of anxiety that everybody experiences that isn't necessarily, say, afraid of an animal or a Or an airplane, things that might occur in the future that are situations that they might find themselves in. I can imagine one many years ago when I received letter from the IRS is that I was being audited. And I remember I couldn't, I couldn't really go to sleep because all the thoughts are what if, know, what if this happens? What if I, what if they, they seize my bank account? What if I didn't do my taxes right? And one thing, I was actually studying Stoicism at the time, and I remember this, thought, I think it was from Marcus Aurelius that mentioned, if you have this worry, we tend to suffer more from the, anxiety prior to whatever happens than, the event itself. And one way to mitigate that is to ask yourself, is there anything I can do about this in this moment? And so I, I just more or less did like a meditation on that very question. Is there anything I can do about this right now? And the conclusion was that I couldn't. And almost instantaneously, I felt this, emotional release that my mind was no longer obligated to obsess over this potential problem. It was able to release it. I'm wondering if you can describe the psychology of that or even how somebody might overcome these, what ifs that maybe you just, what if I get sued? What if, what if this happens?

David: 44:13

Yeah. so one of the first things we want to do there, is help people recognize the role of, literally the words, the two words, what if in that worry thought, because almost all of the thoughts, of a chronic worrier are going to take that format. Now I'm of an age where. When I grew up, they taught me grammar by having us diagram sentences. I'm guessing that you didn't have that in your grade school. they dropped that out somewhere in the 70s. but, I like to invite clients who struggle with chronic worry to literally diagram that sentence. and the, the typical worry sentence has two parts. It's got the what if clause, and it's got the catastrophe clause. and what goes in the catastrophe clause? Any. terrible thing that isn't happening now. That's what goes in there. what if building burns? What if airplane crashes? what if earthquake? What if, uh, cancer? What, what if bankrupt? What if death? all these terrible calamities preceded and introduced by what if, and I want the client, I'm going to ask them, well, what does the what if add to the sentence? What meaning does what if input into the sentence? How does what if describe these catastrophes? Because these catastrophes are basically, uh, replaceable items. Any old thing fits in here as long as it's bad and not happening now. These are the mad libs of chronic anxiety. what does the what if part mean? and I'll spend time discussing that with people and what they're going to come to realize is the what if part literally means, here's something. terrible that isn't happening now, and why don't you pretend that it is? And it's in that pretending as they visualize You know, the audit, and the bankruptcy, and the jail time, and then the family leaving you and changing their name, all those terrible things, as they imagine that. and try and justify it in their mind, and they try and explain it away, and they wonder how their friends and neighbors will think of them. They're making a big scary movie in their mind. about this catastrophe cause that isn't happening now. Because what if has said, Eh, here's something that's not happening, but why don't you pretend that it is? I want them to notice the what if part as plainly and consistently as they can, because that's the part that's going to tell them, Here's something terrible that ain't happening. most people when they get caught up in chronic anxiety, they don't even notice the what if part. They just noticed the catastrophe clause because it's so terrible. It's so horrifying, it's so flamboyant. And in their mind, their worries are like a series of, banner headlines, uh, of terrible disasters. without noticing that, gee, this is the Daily Onion. This isn't a real newspaper. This is a pretend newspaper. So they gotta get that pretend piece back in. And when they can recognize the pretend piece, That's what will give them license and encouragement. Go ahead and play with this thought. You don't have to defend against it. You don't have to stop thinking of it. this is your own little scary movie in the mind. can play with it. And that's where we're going to go with those thoughts.

Cody: 47:26

And for the record, the IRS determined that I didn't owe them money. They actually determined at the end of that audit that they owed me money.

David: 47:36

Isn't that just funny?

Cody: 47:38

Yep.

David: 47:38

Yeah, yeah.

Cody: 47:40

And so I'm wondering if you can recall a memorable case or personal experience where your methods significantly helped someone overcome their anxiety.

David: 47:50

well, thinking of a woman I treated here in Chicago. Uh oh. And she was somebody who came to me, uh, principally about, panic attacks and phobias. and as happens with a lot of people, as she reached, her mid twenties, she started having these fearful episodes where she was afraid she was just going to lose control of herself. and her world started getting smaller as she began to avoid situations, crowded grocery stores with long lines, drives on undivided highways, train rides. Her world got smaller and smaller and smaller the direct result of all the avoidances that she was using to try and prevent having any more panic attacks. she, you know, discovered from that bitter experience that when you try and, you know, narrow your world to stay away from panic. Panic will come looking for you, that, you know, you're either expanding out or you're shrinking in. there's no compromising. There's no reaching a steady state panic. It will keep shrinking your territory if you allow it. and, uh, gosh, I worked with her for a long time that this was much earlier in my career. I think I'm probably more proficient at it now. but we did it step at a time, the, breathing, the understanding of. what the scary thoughts meant and what they didn't mean. And then the steady, step at a time of moving back into the circumstances that she was afraid of, driving, taking trains. there was a point at which, she got as far as, Manheim Road, maybe about a mile or so from where she lived. and she'd been making steady progress. And for some reason, she got to Manheim Road and. It was a wide road. It seemed like a longer road. she spent weeks going up to Manheim road and stopping and looking out, looking out and turn around and coming back. and she had to just persist with that until she could finally cross Manheim road. and eventually she got to the point. She was able to drive so far, she came back to me one day and she said, You know what, Dr. Carbonell, I had this experience, I've never experienced this before. I saw a cow. I saw a cow. And you would have thought that she'd seen a dinosaur. She was, you know, so shocked and excited by this. She'd never driven far enough outside of Chicago. to see a cow. And here now, not only was she overcoming the panic, but she was driving further than her parents had taken her as a kid. that's pretty exciting when people can have that kind of a breakthrough. it's not an unusual story that these are surprisingly treatable kinds of problems. If people just pick up on some of the basics, the most important being this thing tricks me. into acting in ways that make a prisoner out of me. This thing tricks me into behaving in ways that make my troubles worse rather than better. it's counterintuitive, and so I have to, reply with counterintuitive responses. I gotta use the rule of opposites. Uh, if I'm afraid of some place, some place, I'm gonna go there rather than shrink from it. If I have a thought that's irritating me, I'm going to make a poem or a song, or I'm going to play with that thought and drain it of its meaning. once people get that understanding, Oh, this has tricked me into acting in ways that make it worse. Now I know what to do. that's the linchpoint. but that's what makes it so satisfying as a form of work. people are in terrible need of help with this. And people can get radically better, sometimes, surprisingly, in a short period of time.

Cody: 51:33

Yeah, I, had a, a small period in my life where, I started to become afraid of the balcony because I had this as my, my, therapist helped me understand it at the time is that this is an intrusive thought because I, I, would feel like if I'm on a balcony, I started to have this fear of heights because I started to fear that I would jump over. Even though I had no suicidal tendencies, no desire to jump over, but I started to have this fear and this thought, what if I jump over? And so the recommendation was first start visualizing myself on the balcony. And then to more or less just do that is to go out on a balcony and have these experiences where I see that this is an intrusive thought that has no basis in reality. Is if I have no desire for this, it's that exposure of exposing myself to that fear that really helped to mitigate it. And now it pretty much is non existent in my life today.

David: 52:31

Mm hmm. Yeah, yeah, that's a form of exposure to thoughts. and if the whole problem is a thought, then we're going to do exposure to that, just the same as doing exposure to water or heights or dogs or whatever. you know, tell me what you're afraid of and now I have an idea where we need to go that's going to help you. And that's so counterintuitive, so counterintuitive. It's sometimes it takes a while for people to, to wrap their head around it. You know, so many people have said to me, well, Dave, I'm not sure you understand. That's what I'm afraid of. That's what I'm afraid of. You, you want me to go there, but I came here because I, I don't want to go there. Yeah. I, well, that's how you're going to get over that.

Cody: 53:14

And now in your experience, as you've been, practicing for quite a while, I imagine, is that you've seen changes in society. And so I'm wondering, has Anxiety gone up? And if so, what do you think has contributed to that?

David: 53:30

Well, there's, there's certainly. more demand than ever for help with anxiety. I don't know. And, and really it's impossible to know, cause you know, we don't have the kind of statistics, uh, that go back far enough that would tell us. but I, I tend to guess, that has more to do with, the way this has become an acceptable topic for people to disclose. The way this has become a more available topic in mass media. I started doing this, it's hard to appreciate how shamefully this was regarded. You know, when I was a kid, in the 50s and 60s, cancer was regarded as a shameful disease for some reason. you don't see this so much anymore, but, for somebody to die of cancer, it was kind of treated shamefully. they wouldn't mention it in the obituary. A lot of weird ideas about what was shameful back then. and being anxious was something that, that people regarded with shame. so, you know, in, in those time, in the mid eighties. when treatment became more available, there were their studies. David Barlow's work with, cognitive behavioral treatment. And then, people like Oprah and all kinds of magazines start publishing articles. You hear people discussing agoraphobia. That was a word, hardly 20 years before. it moved into the, public media. Yeah. I remember there was a movie came out, I don't know, in maybe the early eighties. There was a Xanax scene, and somebody yelled out in the movie, I'm having a panic attack. Does anybody have any Xanax? And all the people surrounding this person pulled out a bottle of Xanax. It's become part of the common zeitgeist that we recognize. Lots of people can have unreasonable levels of anxiety, and we see it in our movies. And, we saw it in The Sopranos with Tony Soprano, having a panic attack every time he saw a duck. I mean, that, that was an absurd depiction of a panic attack. It was unrealistic. But now, it's part of the parlance. People don't have that kind of shame to struggle through. Puss in Boots. There was a panic scene in the Puss in Boots cartoon that came out a couple of years ago. So this has removed an enormous barrier to people's willingness to ask for help and also people's ability to get better. So it more common now than before? don't know, but certainly, people feel much more empowered, to speak out about it and ask for help.

Cody: 55:55

as we get near the end, I'd like to ask, how do you see the future of anxiety treatment? Especially with advancements in technology and our understanding of psychology and even perhaps the additional research that's going into various psychotropic drugs.

David: 56:12

Well, think on the therapy side, people are just going to continue to refine what we know and then have better ways to deliver it. That now we're, you know, we're, seeing lots of digital apps, Well, we have a lot of treatment online, you know, on virtual treatment on zoom, and such that wasn't available 20 years ago. So I think, lot of the ways that we know we can successfully help people are going to, be offered in various ways to make a more accessible to the consumer. researchers will continue to look for additional ways to tweak what we know that if you show up and have the fear and work with it. You can get better. I'm sure there's plenty of ways that will be discovered to make that more palatable, and more effective. I tend not to think that the future is so much with medications. I don't think, you know, I'm, not fond of medications as a principal form of treatment in the present. the problem with using a medication treatment for an anxiety disorder and I want to separate this from depression and lots of other reasons for medication. The problem is that medications all too often become another safety behavior that people deploy to protect themselves from the anxiety. And so if that becomes the treatment to first resort, people use medications first, even when it works, as it often doesn't. But even when it works. it intervenes to insulate them from the anxiety in ways that never helped them really lose their fear of it. it's like now I have a bodyguard. He goes with me everywhere. I'm not afraid because my bodyguard, well, gosh, I hope my bodyguard doesn't call in sick tomorrow. What if my bodyguard calls in sick tomorrow? What if my medication stops working for whatever reason? What if the manufacturer stops making it? they're protected. rather than improved. So I, I think that's a real limitation. I think better use of medication as a backup treatment, I'd much rather see people do exposure work first. And if that fails, or it doesn't produce sufficient results, try medication as a second case. I think it's a mistake to use medication as a first line treatment.

Cody: 58:28

And now, are there any specific modalities that you could recommend people might research that might include ACT or CBT? And also, what are some of your resources, books, or, your website that people can go, and find you?

David: 58:42

Oh, sure. Well, I, think, you know, the last, oh, probably 20 years, ACT has kind of been on the, the leading edge of, work with anxiety. in many ways, ACT has taken, the CBT of the 80s, and made it, I think, more powerful, with the idea, we don't want to use these CBT techniques to remove anxiety. The goal is treatment. isn't to remove anxiety or prevent anxiety. The goal of treatment is more aimed at, enabling you to live the life you want undeterred by anxiety, that everybody's going to have some anxiety, and offers this notion of, well, there's clean anxiety and there's dirty anxiety. Clean anxiety is, The original anxiousness of, gee, I feel uncomfortable in crowds. I feel uncomfortable standing on a ledge. I'm afraid of this or that, or so on. Dirty anxiety is when it becomes, I'm afraid of getting afraid. I'm afraid of having anxiety. and that's hallmark of an anxiety disorder. So ACT. took, baseline CBT and moved it forward in the sense of, let's learn to work with anxiety rather than against it. And

Cody: 59:53

what are some specific modalities that people can research like ACT or CBT?

David: 59:59

Okay. Yeah. I would, strongly endorse looking into ACT. Now, it's probably simpler to direct people to, an organization or to the Anxiety and Depression Association of America, formerly the Anxiety Disorders Association of America. nonprofit organization, sponsors research, does even more to publicize bring research results to the general public. So I, think anybody that wants to appraise themselves of what's available in the way of anxiety treatment. How can I find a practitioner? What are some good books and resources? the Anxiety Disorders, the Anxiety and Depression Association of America, ADAA. org. Excellent resource. they're the place to go if you wanna find out what's most current. In terms of, my own resources that I offer to people. They're all principally through my website at anxietycoach. com. I have a lot of free self help materials description of what people can do there at anxietycoach. com. And I have a series of self help books and they're all available at the site as well. But I think, you know, the main message I want people take away with respect to any of the anxiety disorders, common and treatable, common and treatable. there's no longer any reason, to hold back. because, uh, well, it's just become much more commonplace for people to be able to recognize their anxiety and seek help for it because there is good effective help now.

Cody: 1:01:28

And perhaps one way to summarize anxiety is that We just need to learn to become comfortable with it. And

David: 1:01:35

Yes. Yeah. Yeah. it's a piece of life and not a threat.

Cody: 1:01:39

and with that, I'd like to thank you for being on the podcast, Dr. Carbonell. Your, insights and contributions to understanding and managing anxiety have helped many, and I'm sure will help many more to come. Thank you for being on the podcast.

David: 1:01:53

Well, thank you so much. I feel honored to be here.