Q&A with Prof. Susan Bögels
The Western world has a higher standard living than at any other time in history, yet self-help sections are overrun with books on depression, stress, burnout and ADHD. What’s wrong with society?
You forgot anxiety disorders, which I think are the costliest illnesses, although they’re always in competition with depression.
That’s a good question. If you look at cultural differences in anxiety disorders and depression, you see that those disorders are most common in individualistic countries, with the highest rates in the United States. If you look at cross-cultural studies, and I’m in an international workgroup where we study social anxiety worldwide, the levels of social anxiety are highest in countries like China and Japan, which are collectivistic cultures. However, the disorders, like social anxiety disorder, where you’re so impaired by the anxiety that it becomes debilitating, are connected with cultural norms and whether anxiety and depression are tolerated. The more individualistic and competitive our societies become, the more instances of anxiety disorders and depression there will be.
Were these problems there in the past or have they really increased exponentially?
If we look at research in the United States conducted before 9-11, anxiety levels in children and adults are now comparable to the levels in the psychiatric population 50 years before, so I think historical analysis shows that anxiety really is increasing. If you look at that research, the increase in anxiety on a societal level was correlated with a decrease in a sense of community. In America, cities are safer than 50 years ago, but people feel increasingly unsafe and that may have something to do with the way that threats, such as terrorist threats, are projected in the media. It’s a perception of safety. And community can help with a perception of safety.
You mentioned you have studied social anxiety worldwide. Are there cultures or countries where these disorders are not so common and harmful?
In China, for example, shyness is considered a positive thing. What we consider a problem in our society, such as stuttering or blushing before speaking, can be considered a great quality in another culture. That’s an example of how anxiety can be a problem in one culture and a blessing in another.
You have conducted a lot of research into the effect of mindfulness in the treatment of children with ADHD and their parents. Could you explain this treatment and mindfulness for the uninitiated?
Mindfulness is the ability to focus your attention on the here and now. For example, I am now trying to focus on this interview and not think about my next appointment or how you will project this in the media. This can make me anxious or stressed, but when I focus on what we are doing here and now I will be happier. Focusing on the here and now has a lot of positive effects on people. It used to be called ‘flow’. Of course, meditation is thousands of years old and comes from collectivistic cultures and it has been imported in a new way to individualistic Western societies. John Kabat-Zinn was the first person really to do this, creating a form of meditation in an eight-week course applicable in Western hospitals and psychiatric institutions. Then, Mark Williams, John Teasdale and Zindel Segal made a version of this programme for depressed people. Since then, it has become a very popular treatment method.
In 2000, before the book of Mark Williams and his colleagues came out, I started to practice mindfulness with young people with severe externalizing disorders, such as ADHD and autism spectrum disorder, and their parents. I called the latter part ‘mindful parenting’. The parents and young people were taught mindfulness methods. People thought I was a bit crazy in the beginning. It took me years to get the first paper accepted by a child psychiatric journal.
We noticed that it had important effects on these young people’s impulsivity and attention problems. That’s an underlying problem that can make people aggressive or even criminal, or withdrawn with more autistic features. Since then, we have set u a special group for children with ADHD and their parents. We also now have a group for young people with autism spectrum disorder and their parents. It turns out to be a very popular treatment. Many parents don’t want to give their children medication for ADHD. Children love it too. We have almost zero dropout and the effects seem to be quite good.
Is that covered by Dutch health insurance?
Yes, although the health insurance companies often ask me to present more evidence for the treatment and don’t want to cover it until they see the evidence. But because the way we conduct mindfulness training for children with executive functioning problems is so cognitive-behaviour based, it is covered under the cognitive behaviour treatment plan.
In your study ‘The effectiveness of Mindfulness training’ from 2011, you note that the two evidence-based treatments have limitations and mention how medication only works short-term and has side effects. So, why do governments and the medical community carry on with drugs such as Ritalin if the evidence states it’s ineffective and costs a lot of money?
Methylphenidate (Ritalin) is not ineffective. Of all the psychopharmaceuticals, next to Lithium for manic depressive disorder, methylphenidates are probably the most evidence-based and have an effect on ADHD. But, who wants to give their child drugs? And we don’t know what the long-term effects are. We know that it has severe side effects like poor sleep and growth disturbances. It’s a big thing to give to a child. At the AMC-UvA they’re doing a study on the effect of methylphenidates on the development of the adolescent brain and it’s very important to study this, because we don’t yet know what the long-term effects are. Any treatment you can offer which has less risks than this medication is welcome in the world of ADHD. I’m not saying it doesn’t work. One of the trials we have submitted for funding compares the effect of medication to mindfulness for children with ADHD. So, if we can conduct that study, we will know a lot more.
In an interview in 'Psychology today' from 2012, Dr Lydia Zylowska (one of the co-founders of the UCLA Mindful Awareness Research Center) points to how meditation affects your pre-frontal cortex, the area affected by ADHD, and a Harvard study from 2006 showed meditation leads to a thicker pre-frontal brain region related to attention and self-monitoring of emotion. Have there been more studies on the effects of mediation on the brain recently?
In general, many studies on meditation show that it has effects on the frontal brain area, and our own research shows mindfulness has effects on the objective attention functions of children with ADHD. So, there is a lot of evidence showing how it affects frontal brain functions, but any good treatment may affect the brain, not just mindfulness.
If mindfulness and meditation could affect your brain structure and have such positive effects, is this leading the government to invest large amounts of money into this as a treatment method?
No, we’re not there yet.
Why not?
We’ve submitted many grant proposals for mindfulness studies, but their feedback is that it’s too innovative. People see mindfulness as ‘soft’, whereas the mindfulness we do here at the UvA minds is a very focused training on attention and impulsivity. What people call ‘mindfulness’ can vary greatly. There should be money invested in this, because it is very important and you see that in the UK and America there is a lot of money going into mindfulness trials, but in the Netherlands it’s a bit disappointing so far.
I saw another study on the use of Mindfulness Based Cognitive Therapy for depression from University of Exeter professor Willem Kuyken, which showed that this treatment was more effective than drugs or counselling. Has something similar been done for ADHD and anxiety disorders?
No. We’ve now finished a trial for mindfulness for social anxiety disorder showing it is as effective as Cognitive Behavioural Therapy, which is the treatment of choice for this disorder. What you see in the mindfulness world is that everybody’s doing it because it’s highly popular, so the implementation goes before the randomized control trials. And we need many more trials like the one conducted by Willem Kuyken. We’ve submitted proposal after proposal, but we have never received the money to really study ADHD in the way that Kuyken did with depression. We hope it will happen in the future.
Is there a danger of mindfulness being wrongly perceived as a panacea for all ills?
I feel it might be a panacea for all ills. I’ve been doing mindfulness trials since 2000 and, as a clinician and researcher, I am so impressed by the results. I see that it doesn’t treat a disease but processes and these processes have an effect on anxiety disorders, depression, attention and impulsivity problems, and criminality. It may also make people happier. It has very broad effects.
Is there a danger of the field of mindfulness being open to con artists or people more interested in profit than the welfare of patients, given that you do not need academic or medical training to call oneself a mindfulness ‘expert’?
There is a mindfulness association in the Netherlands which offers a registered training programme that takes several years to complete for professionals in the field who want to become official mindfulness trainers. Insurance companies could, in the future, choose to solely support these registered professionals. The downside to this development is that it might not always be the best people who receive the formal titles. Ultimately, I think we need to have proper methods, such as the ‘MY mind’ programme we have developed for children with ADHD. If the method can be registered and people are trained in this method by our educational centre then we can guarantee that mindfulness training provided meets the standards of our centre and has similar effects.
Your background is in Cognitive Behavioural Therapy, and you’re editor of well-known Dutch textbook on subject. What are the connections, if any, between CBT and mindfulness?
There are strong connections, but it is a very different method, because in the cognitive method you challenge people’s negative catastrophic beliefs in order to change the conviction of those beliefs. However, in mindfulness training you simply train people to observe their beliefs from a distance and not get lost in that train of thinking. It’s a very different method, but they may have similar effects on catastrophic beliefs. I came to mindfulness because I was a cognitive behavioural therapist and I developed a method called ‘task concentration training for social anxiety disorder’ and that method was somewhere between the CBT methods and the mindfulness methods that were becoming popular.
In his book The Andidote: Happiness for people who can’t stand positive thinking, English journalist Oliver Burkeman interviewed CBT founder Albert Ellis who stated ‘As the Buddha said two and half thousand years ago. We’re all out of our fucking minds. If you accept the universe is uncontrollable, you’re going to be a lot less anxious’. This also reflects the new Acceptance Commitment Therapy (ACT) school of thought. To what extent would you echo this opinion?
Well, first of all positive thinking is not evidence based. It doesn’t help. I don’t think we’re out of our fucking minds. I think we’re too much into our minds. What mindfulness can teach us, and Eckhart Tolle is a very important writer on this subject, is that 80 or 90% of our thinking is completely unnecessary. We are constantly thinking. When I cycle to my work, I’m often thinking the whole way from home to work. Mindfulness teaches you to just cycle. Mindfulness teaches us to be less into our thinking and more into where we are (in the present moment).
To accept that life is uncontrollable is very important for anybody suffering from anxiety. We try to control our lives by continually thinking.
So acceptance is key?
Yes. Mindfulness has a lot to do with acceptance. Acceptance of what we call ‘universal suffering’. It’s important to understand that we all suffer, not only patients, but also the therapist. Once we can accept our suffering, we can become happier.
Your other main research area is intergenerational transmission of anxiety from parents to children, with a particular focus on fathers. Could you explain research results so far?
We’ve been conducting this research for seven years now and built a special lab for this research. The idea, which was quite innovative at the time although it may not sound innovative, was that fathers are different to mothers, and that fathers may have a unique important role in helping their children build confidence and reducing anxiety. They can do this by, for example, challenging the child, playing rough-and-tumble and stimulating the child to take risks. There is a strong evolutionary background to this idea, whereas the mother’s function is to protect, feed and sooth the child. If children get both these influences it helps them develop into confident, non-anxious beings.
Our research, which is quite innovative because it is the first study where both father and mothers were involved starting before the birth of the first child, shows that at a young age (4 months and 1 year) fathers are as important as mothers. This is a very important finding, as for the first four months mothers take the lead and take care of the child. The research also shows that fathers who are more anxious and over-protective have more anxious children and we don’t find that for mothers. We don’t yet know the causal relationship, but we do see the association. So, we have some support for our theory.
If there is danger of parents transmitting their disorder onto children, to what extent might it be advisable for some people not to have children?
The general hypothesis in Science is that parental anxiety gets transmitted to children through overprotective parenting. However, there’s almost zero evidence for that idea. We all have this idea in our minds, but the evidence is lacking. Parental over-protection is correlated with child anxiety, but not with parental anxiety disorder. So, I certainly wouldn’t advise people with anxiety disorders not to have children (laughs). And besides, we all have anxieties.
Why don’t more parents receive parenting classes? Isn’t this costly in many ways to society?
This is an interesting but complex question. Our own research shows that the best way to treat a child with anxiety is not to involve the parent and just treat the child. That’s a highly effective method once a child has an anxiety disorder. So, although parents may influence anxiety in children, for good and for bad, once a child has severe anxiety it’s very treatable and it’s not clear whether we need the parents. The interesting thing is that not only the child's anxiety disorder improves. When an anxious child is cured, it helps the whole family, alleviating the anxiety disorders of the parents. It’s not only the case that anxiety gets transmitted from parent to child, but it also gets transmitted from child to parent.
You advocate the need for fathers to be role models and more visible. How would you advocate achieving this?
A lot of mothers take maternity leave. Fathers don’t use that arrangement much. I would encourage fathers to spend more time with their children from a young age onwards so they can have that influence. Another way is to teach mothers that fathers are important. If fathers do things differently to mothers, it doesn’t mean it’s not good. Our society tends to see raising children as a ‘mother thing’. I think we have to think differently about that and acknowledge the importance of fathers to children.
In Scandinavian countries fathers are given extended paternal leave and have a greater role in children’s upbringing. Should we follow that model?
Absolutely! I love that model. It would be very helpful. In Sweden, fathers take much more leave to help raise their children and the arrangements support this. I think that Dutch society is different to most countries in the West in terms of encouraging mothers to stay at home. In Belgium, mothers often work full-time, but if a mother works full-time here people think ‘what’s wrong with you?’ The role of the mother is much over-stated in Dutch society. It would help to emphasise a child has two parents.
What differentiates the UvA from other universities?
In many ways it is a very free university. Initiatives are really supported by the leading people at the university. They like you to think up new initiatives and there’s space to start new things.