Feeling anxiety is a natural part of being a human being, but for some people it can cause terrible mental and physical anguish and prevents them from leading happy and fulfilling lives. Lucy Foulkes, a psychologist at University College London, talks us through books that can help with anxiety.
We’re talking about books that deal with anxiety. What is anxiety from a psychological point of view?
I see it as composed of two key processes, which can happen separately or together. One of them is the physical manifestation of it, which is known as panic; the other is the cognitive aspect of anxiety, which is worry. Both of those processes exist on a spectrum throughout the general population. At the more extreme end, panic becomes a panic attack. If you start having a lot of panic attacks, that can become panic disorder. Similarly, if you worry excessively that can become various kinds of anxiety disorder, depending on what you’re worrying about. ‘Anxiety’ is a tricky word from a psychological perspective, but also from a philosophical perspective, in that we use the same word for the common everyday phenomenon as we do for the clinical construct.
I suppose depression is a bit like that too. People say, ‘I’m feeling a bit depressed today’, but they don’t mean ‘I’m suffering from clinical depression’.
Exactly, which is precisely the phenomenon that got me interested in writing my book, because now that we’re encouraging everyone to talk about mental health, we’re pumping out this terminology and telling people to talk about it. Overall, this is a good thing. But the accidental collateral damage has been that we’re now co-opting these terms for milder, more temporary anxiety, which can encourage people to think they’ve got an anxiety disorder, when they don’t.
“Worry is extremely enticing, and seductive, and resistant to reason”
I’ve talked about this a lot. People often think, because of the way the public conversation is going, that they’ve got an anxiety disorder, or a problem with anxiety, when actually they’ve just got a very common human emotion that’s unpleasant.
That distinction between panic as a physiological manifestation of anxiety and worry as a cognitive element. That’s a really useful distinction.
Yes. They often feed off each other, but one can happen without the other. An important clarifier about worry is that it’s specifically thinking about the future, even the very immediate future. It’s essentially thinking that something’s going to go wrong.
Can’t you be anxious about the past?
Well, this is an interesting thing. In all the official definitions, it’s about the future. The typical distinction is that repetitive negative thinking about the future is ‘worry’ and about the past is ‘rumination’. The only example I can think of where you might worry about something in the past is worrying about what you’ve said to someone – at a meeting or at a party.
You can be anxious about something that you have done being disclosed in the future.
Exactly. But still, even though the event happened in the past, you’re still worried about the future, the upcoming consequences of the event.
I wondered, also, if there’s a distinction between anxiety in real time—where you’re having a panic attack, or feeling anxious about having left the stove on, or whether the house has burned down, incidents of anxiety—and being an anxious person as a character trait. What’s the connection?
Psychologists make the difference between state and trait anxiety. State anxiety is how anxious you’re feeling right now at this exact moment. You might score highly on a state anxiety questionnaire just before an exam, for example. Trait anxiety is about how likely you are to slip into those states frequently. So people with high levels of trait anxiety are often in a state of anxiety, but it’s less context dependent.
It seems to me that we probably wouldn’t recognize people who never felt any anxiety as fully human, in a sense. It’s almost a robotic indifference to life. But, obviously, as a trait, anxiety can be a very debilitating thing in terms of achieving goals.
Definitely. And the reason why, originally, I read these books was because I had a lot of difficulties with anxiety myself. I had difficulties with worry in particular, as a child and a teenager, that I never talked about or had recognized. And it culminated, between my second and third year of university, in being diagnosed with depression and generalised anxiety disorder, which is characterised by worry—worrying frequently and excessively and not being able to control it.
Could you describe one example of that? Most people have a fear of public speaking. You’d have to do that at university…
The interesting thing about generalised anxiety disorder is that it doesn’t necessarily mean you’re worried about everything. It just means the content of your worrying is relatively broad, compared to, say, having a spider phobia. I was never bothered about public speaking, for example.
People who are extremely anxious about public speaking might have ‘social anxiety disorder’, where you’re very worried about being judged in all sorts of contexts. Public speaking would be your worst nightmare. But even speaking out in a meeting, or at a party, or on a Zoom call with your colleagues. If you’re intensely worried about being judged by other people, or about what other people think of you, then it makes social interactions really difficult, or you try and avoid them.
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I’ll talk about avoidance and how much of a problem that is later. When you’re anxious, the number one thing you want to do is to avoid doing something. But that’s actually the worst thing you can do in terms of the long-term maintenance of anxiety.
Do you think that books can be helpful in dealing with anxiety?
Yes, I think so. For me, when I was 20, having never had any discussion or understanding at all of what worry was or what you can do about it, it was illuminating to read the first two books on my list. It was so empowering and useful to see discussions of these issues written down, and to see sensible suggestions about what you could actually do about them—that was brilliant. If you’re seriously unwell, then you might need professional help to guide you through a lot of these principles. But for me, reading about other people’s experience of anxiety, and what it is and what you can do about it, was extremely helpful.
Are there general causes of anxiety?
Like everything in psychology, the explanation is a bit to do with your biology and a bit caused by your environment. Children with anxiety disorders are much more likely to have parents with anxiety disorders. There’s interesting evidence about how parental and child anxiety feed into each other. Once your child’s anxious, you want to protect them. And if you’re anxious yourself, you’re even more worried about harm coming to them. Then it can snowball from there. Anxious parents behave in certain ways: they’re more likely to be very over-protective, for example, which might exacerbate a child’s anxiety. So parenting is relevant in terms of genetics, but also in terms of how you parent—how you respond when you or your child is anxious, and how you teach your child to cope with anxiety. Anxiety will also depend on what happened to you in terms of traumatic events, whether you’re bullied, for example. For many difficult life events, it’s understandable that you might become more anxious about how people judge and treat you.
Let’s go to your first choice, Feel the Fear and Do it Anyway by Susan Jeffers.
I have my copy here from when I was 20. I chose this as the first one because it doesn’t really take a clinical approach to anxiety. It very much positions anxiety as something common that lots and lots of people experience. I think that’s an extremely helpful way of thinking about it.
My concern, and what I talk a lot about in my book, is that we’re starting to talk about all anxiety as a medical problem or health problem. And actually, unless you’re right at the extreme end, it’s just part of the human condition. That’s one thing I liked about this book.
Jeffers also makes the point that, whatever it is that you’re worrying about, ultimately all fears or worries are about the fear that you won’t be able to cope if something bad happens. After all, if you believe that you can handle whatever might go wrong, you’d have nothing to worry about. I found that a really interesting concept. I still find it important because, when you worry about something, there are two components. First, you worry that something bad is going to happen. But, secondly, you also worry that if that bad thing does happen then you won’t cope. You can feel one or the other, or both of these. But people generally cope better than they think they’re going to. So first, if you get people who are prone to worry to track what they’re worried about, and then see if it comes true, the vast majority of the time, it doesn’t come true. But even when it does, it’s not as bad as they predicted it would be, or they cope better than they thought they would. In general, no matter how much you worry, things are generally not as negative as you think they’re going to be in advance. That is a concept that’s deeply useful for worrying because you can never fully reassure yourself that a bad thing won’t happen. So it’s a really useful extra step to say ‘okay, but even if it does happen, it won’t be as bad as I’m predicting, and there are ways to cope with it.’ For me that was a very useful aspect of this book.
That sounds like a rational approach, but isn’t anxiety sometimes more like a fear of spiders? In the UK, at least, it’s not rational to have a fear of a spider because no spider here is going to harm a human being. But you can still be absolutely terrified of spiders, despite your zoological knowledge.
This is the truth about so much anxiety. It’s irrational and you know it is, but that’s not enough to stop you feeling anxious. With spider phobia it’s often not that you’re scared that they’re going to hurt you. You’re scared of the physiological reaction they cause, how panicked the spider makes you feel. The worry is not that the spider is going to kill you, but that they have a horrible effect on you, and that you won’t cope if you encounter one.
And when you do, the fear is pretty direct and visceral, that’s the point. You’ve laid out the case that there are no rational grounds, generally, for fearing the future because in general we overestimate the negative and the negative’s effects on us. But that’s not necessarily going to stop somebody fearing the future, or having worries about the future.
If it were that simple, then no one would worry. Worry is extremely enticing, and seductive, and resistant to reason.
Which is presumably the point of the title of the book: you can still feel fear, but you should do it anyway. It’s an amazing title.
The title in itself is so powerful and so important. Again, I think this is getting lost in the current public conversation about mental health. The goal with tackling anxiety is not that you eliminate it entirely, but that you should try and do things in spite of it. Avoidance is hugely tempting and common when you’re anxious. But it means that you’ll never learn that the thing you fear is not as bad as you think it is, or that you will in fact cope. When you avoid something, in that moment, your anxiety is relieved—for example you don’t have to deal with spiders. But your fear of spiders is maintained in the long run, because if you avoid them all the time you never learn how to cope.
It’s an empowering, useful message to say that the goal isn’t that you get rid of anxiety altogether and can do the things that scare you. The goal is that you do them in spite of being anxious. Maybe, if you have extreme levels of anxiety, you will need a professional to help you do that. But always, always, the goal is to try and do it, even though you’re anxious.
“Trying to change the way you think can be extremely demanding”
Georgia O’Keeffe said, which I absolutely love, ‘I’ve been absolutely terrified every moment of my life, and I’ve never let it keep me from doing a single thing that I wanted to do.’ That’s a message that I wish was out there more in the public sphere. As we try and raise awareness and have sympathy towards mental health problems, I think accidentally we’re saying, ‘It’s okay to be anxious, that’s just who you are’. But actually, always, the goal should be to be sympathetic and to figure out how to help you do it anyway. You should always still try and do it. That’s the key message. Otherwise, the risk is that your life becomes too limited and small.
Your second choice is by Dale Carnegie, How to Stop Worrying and Start Living.
You probably know his classic self-help book, How to Win Friends and Influence People. This was a later book but it’s still old—from the 1950s. Some of the examples are quite dated. But again, as with Jeffers’s book, I really like the way anxiety is not medicalized. It doesn’t open with a list of the different kinds of disorders. And it doesn’t insist on the idea that we live in a newly stressful world and blame that for causing the problem of anxiety. He talks about how it’s useful to realize that anxiety is part of the human condition and always has been, and points out that, actually, there are lots of sensible ideas that you can use, helpful ideas that you can read about and try—again not to eliminate anxiety, but to dampen it down or live a meaningful life alongside it. I loved it for that reason.
Could you give an example? Or an example of a strategy for managing anxiety from the book?
Yes. One thing he talks about is living in ‘day-tight compartments’, the idea that all you can ever do is deal with today. He talks about trying not think too far beyond that, and gives various strategies for doing that. It’s basic things he offers, often based on CBT principles, but this book pre-dated CBT. He talks about how to think about problems differently, to think about how likely the bad outcome is to happen. Part of CBT is to break the problem down and think about how likely it is that your worry will materialise, which is exactly what he suggests.
“If you’re prone to anxiety, you don’t think in terms of best-case scenarios, ever”
He talks about distracting yourself, about writing things down—with the idea that once you’ve written something down, it loses its hold over you. The problem with the worry is that it goes round and round and round in your head. But actually, once you write it down, it loses some of its power. People still talk about these ideas now. What I found appealing, having read a lot of the more recent, clinically-oriented books as well, is realizing that anxiety is something people have always been trying to figure out. There are sensible ways of dealing with it without calling it a disorder or health problem.
Yes, we do have several thousands of years of practical wisdom about something which is fundamental to the human condition. I’m always amazed thinking of soldiers in wartime, by how they deal with the fear of going into action, perhaps parachuting into territory where people are shooting at them. How can you get over that hump of anxiety? I’m not sure I could. But people do, they have found ways to do it. It would be completely irrational not to feel terror in those moments and yet, millions of people have coped with it.
Some people have been totally crippled by that terror and never recovered from it, of course, but certainly not everyone. Another thing I like about his book is that he gives lots of examples of people in really objectively awful, frightening situations and what they learned from that. For instance, someone in the US Navy in World War Two described being in a submarine and being torpedoed. He was basically lying there waiting to die, and it’s about how he dealt with that. The book is useful is terms of realising that some people go through some awful, stressful situations and still find ways to cope.
You mentioned CBT. I think a lot of the principles of CBT had an early formulation of a kind, in Stoic philosophy. Stoics, such as Epictetus, focused on the things that they could change and distinguished those from the things that were perhaps not inevitable, but completely out of their control. There’s no point in focusing on the things that are out of your control, because there’s nothing you can do about them. So, logically, if you can just focus on the things which you can control, which is basically your reaction to the world and to the things that happen to you, you will live a more tranquil and calm life as a result, and not expend energy in a useless way.
This is similar to Carnegie’s argument, and many other psychological approaches. It sounds good on paper, but of course it’s incredibly difficult to do. You touch on the point that worry is futile most of the time. It’s not a useful thing to do. Often people hold on to it because they think it’s useful to help them solve problems, but it doesn’t really. It has a very limited initial use in helping you identify potential problems, but it doesn’t help you do much about them. Once you’ve identified the issue, you’re better off switching into problem-solving mode. Beyond that limited benefit of identifying problems—which in itself might not be very useful, depending on the situation—worry is just a massive, massive waste of time.
And it feels bad as well. Imagine being an actor who goes on stage. He or she feels that terrible fright and anxiety every time. There are actors like that, who are still brilliant actors. But surely, if you can, isn’t it better just to feel calm before you go on the stage?
It’s awful. I look back on my own experience and it was such a deeply frustrating waste of time. It’s so rarely useful. It makes things so unpleasant while you’re waiting to find out that the bad outcome doesn’t happen. And yet, at the same time, there’s something so captivating about it. If you’re prone to worrying, you have to work so, so hard not to let it take over the way you think or the way you behave.
Do you think that’s why you went into psychology?
I initially wanted to study medicine. I took psychology A-level on a bit of a whim. I’d started doing history and I didn’t really like it, so I swapped a month in and psychology was what was left. But I really fell in love with it. I find people fascinating – the way they think and behave. It wasn’t a direct route from personal anxiety to psychology, although you do get a lot of people in psychology who are prone to these problems, so it may be a way that others come to the subject.
We’ve had two books that are self-help classics so and have stood the test of time. What’s your third choice for books on anxiety?
My third choice is Cathy Cresswell and Lucy Willetts’s CBT book for parents called Helping Your Child with Fears and Worries. I worked with Cathy straight after my undergraduate degree, at the University of Reading, while they were running the trials that inform the book. Their principle is that most anxiety disorders start in childhood and adolescence. You could get the child to go to a therapist, but actually, it’s the parents who are going to be with that child much of the time. So might it not be more useful to teach the parents some of the basic CBT principles, so they can go through them with their child? The book was a result of that work. I chose it for this list partly because I want to cover CBT somewhere here, because it is so useful and so important. But I have always loved the idea that parents can help their children in useful ways with worrying, without pathologising it or telling them they have a disorder. If they can just say, ‘Okay, you’re worrying, but there are more useful things you can do about it, and I’m going to help you do them.’ If they could break it down like that, I think that would go a long way to helping anxious children.
Am I right in thinking the essence of CBT is the emphasis on the cognitive aspects? What it typically does is give you exercises or practices which will allow you to reframe the way you describe the situation you’re in or the situation you might be in.
Exactly. Reframing is the key word for the cognitive side of CBT. It’s first about identifying what your worry is—’I’m worried that a burglar is going to break into my house’; ‘I’m worried that I’ve got a serious illness’; ‘I’m worried that I’m going to go to the party and no one’s going to talk to me.’ You capture exactly what the worry is first. Even that can be quite a tricky or revealing process: to figure out in one sentence what you’re actually thinking and worrying about.
Then you try and figure out if there’s a more useful way of thinking about it. Normally, because the worry is something disastrous, you might ask yourself or write down what the worst thing that could happen is; and then the best thing that could happen; and finally, the most likely thing that could happen. Those second and third questions are a revelation for someone anxious. If you’re prone to anxiety, you don’t think in terms of best-case scenarios, ever. So, you write all this down, or talk it through, and then figure out a more realistic way to think about it. That’s a classic CBT approach.
It’s almost like looking in a mirror to see the patterns of your thoughts.
Definitely. The downside of CBT is that the onus is very much on you. The solution is to think differently, but that can be incredibly difficult. It takes a lot of work. In particular, you might be trying to implement CBT principles when you feel terrible – when you’re depressed, or extremely anxious, or struggling in all sorts of different ways. Trying to change the way you think can be extremely demanding.
Most anxiety has an object, it’s about something—I’m worried that something will happen. But sometimes I have just felt anxious and it seems to be just a state. I don’t see how CBT could help me in that state because my anxiety doesn’t have an obvious target.
I guess that’s maybe more related to the physical side of things, feeling physically keyed up. CBT might help there with interpreting those feelings, which could escalate to becoming a panic attack if you interpret them in the wrong way. You might think, ‘My chest feels tight,’ then ‘Oh, my God, I can’t breathe properly’, and then you hyperventilate…
…and you’re anxious about the process itself.
That is exactly what a panic attack is: a catastrophic overinterpretation of bodily signals which then escalates. Panic disorder is an extension of that, where you get into a horrible cycle of having panic attacks, and then being worried that you’re going to have panic attacks, which then causes you to have panic attacks. If the problem is more about those kinds of physiological aspects of anxiety, it’s still possible that CBT could help.
Is CBT an approach that, empirically, has had good results in this area?
Definitely. Cathy’s work, along with colleagues, has shown that CBT given by therapists is helpful for anxious children. They’ve also shown that therapists can teach parents CBT principles so that the parents can go and do it with their children, and that’s effective too.
So, the ‘C’ bit is about breaking down your thoughts. And then the ‘B’ bit is particularly about exposure—we discussed earlier the importance of avoidance in anxiety, and the need to expose yourself to the things that you’re scared of. And what this book is so good at is taking you through ‘graded exposure’. Often, if you have a child who’s terrified of doing something, it can feel like the only options are to push them to do something they’re terrified of or, conversely, tell them they never have to do it. Actually neither are helpful because both of those maintain anxiety. The same is true for teenagers and adults who are anxious.
“We’re starting to talk about all anxiety as a medical problem or health problem. And actually, unless you’re right at the extreme end, it’s just part of the human condition”
So, graded exposure—for a child or with an adult—involves working out steps that become increasingly hard, that make you increasingly anxious and taking one at a time. So, for example, with the spider phobia, you might begin by doing things like looking at pictures of spiders, or looking at cartoon drawings of spiders, then being in the same room as a spider in a jar, and so on. You then very gradually move up the ladder. You do each step repeatedly, and relax at each step and reward each step until they (or you) feel safe enough to move up to the next level. In theory, by doing that, you can eventually tackle the thing that you couldn’t go near before. You eventually move to level 10, which might be having a spider on your hand. It can be extremely empowering. It’s so useful to know that there’s this principle, this thing that you can try. The options aren’t just ‘do it and be terrified’ or ‘avoid the thing forever’. You don’t need to avoid it forever. You just might need some help to do it more slowly and with more support. But the goal is always that you should try and do the thing that you’re scared of. And when you do it, and you realise you coped—that’s an amazing feeling.
I’m not great with heights, but I’ve been able to go skiing—graded exposure to increasingly steep slopes, and so on. But then I was walking in the Lake District once and I suddenly got a panic attack about a steep drop next to a path. It was completely irrational. I didn’t know how to get out of it and started worrying there was something up with me. I can see that for people who haven’t had this kind of experience, it might seem that with a bit of common sense and some gradual process, you can get it solved. But I think a lot of us have areas where something can happen that just triggers a response that produces extreme anxiety. We don’t know what the causes are, we don’t really know how to get out of it. Obviously, anything we can do to eliminate that pattern is great. But I like the idea that you shouldn’t over-medicalise this. It is just that things happen. A lot of people have anxieties; it’s a very common thing. But there’s still the sense that it can take you by surprise. You can have policies to deal with it, but it can still really take you by surprise.
That’s also important. I think we shouldn’t over-medicalize it, but we also shouldn’t under-medicalize it either, because it is a spectrum. At the extreme end, anxiety is awful—it’s all-consuming. When you’re in that state of anxiety it takes over your body and your mind, it’s incredibly difficult to cope with. It feels absolutely horrendous.
It comes back to the idea that this is about navigating and managing anxiety. The goal, especially if you’re at the sharp end of things, cannot be to eliminate it. The last book I’ve chosen is about someone who’s very much at the severe end of anxiety, and a demonstration of just how serious it can be. In the current public conversation, the problem is that people will say, ‘Just have CBT’ or, ‘Just do this, and then you’ll solve your anxiety.’ For some people that works, but for others the anxiety is just too overwhelming. It’s not their fault; they just can’t solve it in a straightforward way.
Before we get to that one, what’s your fourth choice in this list of books on anxiety ?
My fourth book is about mindfulness. Mindfulness for Health by Vidyamala Burch and Danny Penman. I chose this one because a lot of my own difficulties with anxiety have been to do with managing chronic pain. I have a couple of health problems which mean I’m often in pain, most days, to varying degrees. So I read this book to try to understand and deal with that. Mindfulness is a very different approach to CBT in that CBT is about latching on to the anxious thought, figuring out what it is, breaking it down, and changing it; whereas mindfulness is almost the opposite of that, learning not to get caught up in your thoughts and letting them just wash over you. It’s interesting in that respect. I think if you don’t get on with CBT, mindfulness-based approaches can be useful to explore.
“Beyond that limited benefit of identifying problems…worry is just a massive, massive waste of time”
Both of the authors have had awful accidents, and both have used mindfulness to cope with chronic pain. The main thesis of their mindfulness approach to pain is that you have primary pain or primary suffering, which is the actual uncomfortable feeling in your body. But then you pile on top of that a lot of worry and distress about being in pain. You can’t make the primary pain go away, but there’s some room for movement with the secondary stuff, with your relationship with pain. Being in pain and not knowing when it’s going to come or how bad it’s going to be and how long it’s going to last for is a really worrying thing. But, if you add all that on top of the primary experience of pain, you make everything worse. So, it’s a book about trying to understand that you can’t make pain go away, but you can change your relationship with it, and that, by doing that, you end up making the pain less upsetting.
I don’t know if this is fair, but my experience of reading about mindfulness and having a go briefly, is that it’s obviously hugely influenced by an Eastern tradition of meditation. There’s an emphasis on distancing yourself from your perceptions, as it were, so that you can be in the moment and observe it happening. It’s almost as if there’s some part of you that isn’t so involved with what’s happening to you.
Yes, exactly. And the Western word for that is de-centering—the idea that you are not your thoughts, and you can step back and watch them and not get tangled up in them. By changing that relationship with your thoughts, they have less power over you.
So there’s a kind of impersonality, almost, about the observation.
The idea with mindfulness is that thoughts are just noise, passing mental events. And that’s very different from thinking, ‘Okay, I’m having a thought that my pain is getting worse. I’m going to go and write it down. What’s the evidence that it’s getting worse?’
Which is the more rationality-driven CBT approach, with its emphasis on reasons and verbal formulation.
Exactly. It depends on who you are and what you find helpful. I found it very useful to be aware of both approaches, because you can’t CBT your way out of everything. That’s why I wanted to include this book on mindfulness here. Sometimes things you’re worried about are real, they are really difficult situations. But there’s still room for movement in how you think about them.
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It’s interesting, I hadn’t realized how personal this is for you. All your book choices have been practically useful to you personally.
Definitely, yes. It’s funny, because I was in two minds about whether to admit it in this interview, because I don’t talk about my own experiences usually. I talk about them a bit in my book, because admitting that I’ve had my own difficulties made it easier to make the argument that I make in the book. But with this interview, in particular, I think it would be weird and wrong to talk about these books without saying why I’m personally endorsing them. They absolutely have been personally useful. Especially those first two, which I read when I was 20 and I had had no education whatsoever about what worry was or what to do about it.
Any other observations about Mindfulness for Health before we move on?
Only that it’s inspiring to read about people who have overcome such immensely difficult circumstances. I think that’s useful to have as part of the public conversation—to have examples to show that you can live a meaningful life, even in very difficult circumstances.
And overcoming doesn’t mean eliminating necessarily, but finding ways to act and, as you say, lead a worthwhile life, despite certain phenomena that you may have no control over.
Yes, to identify what your values are and figure out how you can achieve them and live them in spite of all the difficulties that you might be going through. That’s a central tenet of acceptance and commitment therapy (ACT), which has lots of overlap with mindfulness approaches.
What’s your final book choice?
My last one is a more recent one, by the journalist Bella Mackie, called Jog On. It’s about how she used running to cope with mental health problems. I wanted to include it because it’s a great example of what anxiety is really like when it is very severe. She’s had far worse problems than I have ever had. In the book she describes having OCD, generalized anxiety disorder, panic attacks, and experiencing dissociation or feelings of unreality. Her whole life was dictated by these symptoms and disorders, to the point where she dropped out of university and was very limited in the things that she felt able to do because of her anxiety.
“Everyone I know who’s prey to these problems finds exercise an essential part of their toolkit to help them cope”
There’s a quote from the book: ‘I begged to be committed, to be sectioned. Anything to quit this life, which I found too hard. I felt like I hadn’t been given the requisite armour for the game, and I didn’t want to play.’ I think it powerfully captures how, when you are in such a full-blown state of anxiety, even walking to the shops is too scary, answering the phone is too scary, sleeping in a room on your own is too scary. She conveys how it feels when everything’s just too loud and too difficult. It’s a useful part of the public conversation, to have these memoirs and examples of people who really do experience extreme anxiety.
Does the book show how she used running to deal with her problems?
A relationship broke down when she was in her late 20s. And she describes that as her lowest point. Then, to try and climb out of that hole, she started running. It’s a memoir about anxiety, but it’s also about how running helped her cope. It’s an important book in that way, because everyone I know who’s prey to these problems finds exercise an essential part of their toolkit to help them cope. It’s a hopeful book. It’s a good message about coping mechanisms and how exercise can be a part of that.
The other thing I wanted to say about it is that she’s honest about saying that her anxiety hasn’t gone away completely. She says: ‘It’s vital to find the thing that alleviates your mental health issues. And it’s just as important to recognize that you will still have these issues.’
That’s useful and important. She describes her worries at some point as a shadow of what they were before, which I think is a good analogy. You can do all sorts of things to cope and to dampen down and manage anxiety, and to live alongside it, but the goal is never to eliminate it. It’s a very accessible book and it’s been extremely popular. It’s one of the few things that I’ve read recently where I’ve really felt the author captures what it’s like to be in that extreme state of anxiety.
You’ve written about depression as well. What is the connection between anxiety and depression? Are they very intimately connected?
Yes. Often, if you have one, you’ll have the other. They’re both examples of repetitive negative thinking. If you have a brain that’s prone to repetitive negative thinking, and/or life experiences that have reinforced these negative thoughts, then you’ll be doing that with respect to the past—which is key to depression—as well as the future—which is key to anxiety. They’re both about being negative, having a kind of negative bias, seeing the worst in things and viewing things badly.
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They’re also both physical disorders. It’s a bit of a misnomer when we say ‘mental disorders’ because both depression and anxiety are felt in the body as much as in the mind. Finally, the two disorders can play off each other. You can become anxious about the fact that you’re depressed and depressed about the fact that you’re so anxious that you can’t leave the house, for example. If you feel that trapped by anxiety, that’s going to have a knock-on effect on your mood.
We haven’t mentioned the possibility of pharmaceutical intervention at all. Some musicians whose anxiety affects their performance, for example, use beta blockers effectively to have a professional musical career and reach the heights. They probably don’t advertise it. But I know that occurs. I wonder, if there’s anything to be said for that? All these books emphasise cognitive or behavioural ways of addressing anxiety. Is there a role for pharmaceutical approaches as well?
Definitely. Bella Mackie talks about how important it was to have both therapy and medication. I did both. I think the funny thing is that, if you do both in parallel and your anxiety improves, you never really know which one was most important. But there should be absolutely no shame in considering medication as an option. It’s essential for some people. It’s good to do both at the same time, because the medication puts you in a better headspace that allows you to engage with the therapy. The most important thing is to find out what works for you. Everyone is different. It’s a case of finding the best approach for you that helps you manage anxiety.
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Dr Lucy Foulkes is an academic psychologist with expertise in mental health and social development, particularly in adolescence. She is an honorary lecturer in psychology at UCL. Her book What Mental Illness Really Is And What It Isn't (2021), is out now. Lucy is on Twitter at @lfoulkesy and Instagram at @drlucyfoulkes.
Dr Lucy Foulkes is an academic psychologist with expertise in mental health and social development, particularly in adolescence. She is an honorary lecturer in psychology at UCL. Her book What Mental Illness Really Is And What It Isn't (2021), is out now. Lucy is on Twitter at @lfoulkesy and Instagram at @drlucyfoulkes.
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