Stress

I understand that stress plays an important role in the development of disease.

It is an important issue, although not a simple one.

None of these issues is simple.

The dietary principles-10 percent calories from fat and similar guidelines for cholesterol, sodium, and other nutrients-are reasonably simple, although the scientific evidence justifying them and the means of implementing them in our lives are more complicated. Articulating the essential role of stress in our health and well-being is more difficult

Perhaps that just reflects the state of our knowledge in this area. Nutrition can also seem confusing if you are lacking the right road map.

That is very well put. The difficulty is that we cannot simply say that stress is bad for you. In certain circumstances, some forms of stress can be very damaging to one’s health. In other situations, circumstances that we would consider very stressful may not be damaging or can even be energizing. Consider the example I cited in Chapter l: the experience of the European populations during World War II-populations hiding in subway tunnels while their homes were firebombed, other populations fleeing their homes when caught between opposing armies. Yet the rate of heart disease did not increase during those terrible years. The only impact that has been noted was the dramatic decrease in heart disease in those countries in which food rationing was imposed during the exact period of time in which rationing was in effect. And we know that the principal consequence of the rationing was the limitation of precisely those foods that are high in fat and cholesterol, meat, eggs, cheese, butter, milk, cream, and cooking oils.

On the other hand, there are many examples of life situations, and perhaps most important, our reactions to them, that appear to have a profound effect on our ability to resist or overcome disease. Many studies have shown that certain types of chronic stress can contribute to disease. Conversely, studies have shown the ability of the mind to assist in both resisting and overcoming disease through such methods as meditation and other relaxation techniques.

Just what is stress?

Essentially, stress is the arousal of the body and mind to demands and challenges that present themselves.

That doesn’t sound like a bad thing.

Stress is not necessarily harmful. We need a certain amount of challenge to avoid apathy and boredom. Even positive changes in our lives represent stress. The term eustress refers to our reaction to constructive change: a job promotion, an award, getting married, even going on a vacation. The type of stress that appears to be harmful to our health is the excessive activation of our fight-or-flight response.

Fight or flight?

Fight or Flight

That refers to the primitive origins of this mechanism. When our paleolithic ancestors confronted a menacing foe, whether animal or human, they had the choice of confronting the danger or fleeing; thus the term fight or flight. The process starts with our pattern recognition and cognitive faculties perceiving danger. Once that judgment is made, the rest is automatic. A perception of danger triggers a chain reaction of neural and hormonal changes that puts the body into a state of readiness for action. The hypothalamus signals the pituitary gland, which produces a hormone, which in turn stimulates the adrenal cortex to produce cortisol. Cortisol is carried in the bloodstream and causes a dramatic but temporary increase in metabolism. A spinal reflex signals the adrenal glands to produce adrenaline and noradrenaline, also known as epinephrine and norepinephrine. These hormones have a dramatic effect on the body, including nearly halting the digestive process and increasing blood pressure, blood sugar, cholesterol levels, and breathing and heart rates. Other effects include dilation of the pupils, the activation of blood clotting mechanisms to prepare for the possibility of injury, and the mobilization of internal energy stores for the possibility of extreme physical exertion.¹

I take it that these changes are harmful.

Not necessarily. We need the fight-or-flight mechanism to survive, otherwise we would not have the capacity to respond appropriately to danger. A problem arises when this mechanism is overutilized. It is chronic stress that is harmful. It’s as if your body is in a constant state of emergency. Then the temporary effects, such as increased blood pressure and cholesterol and decreased blood flow to the liver and digestive organs, can become permanent.

Does this have to do with the type A personality?

The Type A Personality Revisited

The so-called type A personality gained publicity in the mid-1970s and is described as a person who is hard driving, overly ambitious, impatient, competitive, aggressive, always working to a deadline, and generally possessing the traits of a workaholic. In contrast, type B personalities are described as relaxed, easygoing, accepting, and complacent. These early studies suggested that having a type A personality was a risk factor for the development of heart disease. More recent studies have cast doubt on the type A personality as a risk factor, at least as it was originally defined. The contemporary research indicates that of all the aspects that make up the classic type A pattern, the only ones that appear to be related to an increased risk of heart disease, are those involving anger, cynicism, and hostility.² People with hot tempers and/or suspicious, angry, hostile natures are more likely to die from heart disease. Other type A characteristics, such as competitiveness, ambition, even workaholism, were not found to be risk factors.

For example, a long-term study was conducted on a group of 118 lawyers who had taken the Minnesota Multiphasic Personality Inventory, a standard personality test, 25 years earlier, while in law school.³ Those who had higher scores for hostility had a death rate from heart disease that was more than four times higher over the subsequent 25 year period than those with low scores for hostility.

Another dramatic study was a 25-year follow-up study of 255 physicians.⁴ Here the hostile physicians were 6 times more likely to die than the group who scored low on the hostility characteristic.

Hostility and anger. Are those the only personality traits linked to disease?

Researchers have discovered a similar link between “suspicious” personalities and increased mortality rate, although suspiciousness is linked to hostility and anger. A study reported in 1987 at Duke University followed 500 men and women with an average starting age of 59 for a period of 15 years.⁵ Men who were characterized as having a suspicious personality were twice as likely to die as their more trusting peers. The suspicious women were 29 percent more likely to die than their more trustful peers. There are other studies that demonstrate the healthful benefits of a positive and trusting outlook on life.

So the original idea of the type A personality was not accurate.

The Four Cs: Challenge, Commitment, Curiosity, and Creativity

It was only partially correct. The health implications of having characteristics we associate with being competitive and ambitious depend on why the person has those characteristics. There are, after all, constructive reasons why a person might be eager to achieve a set of goals. These can be characterized by the four Cs: challenge, commitment, curiosity, and creativity. A challenge is a goal that, while difficult to achieve, is worthwhile and meaningful to that individual. Commitment is the ability to place an overriding priority on attaining a challenging goal, to see progress toward a goal as more important than sacrifices that may be required. Curiosity is a desire for knowledge and an openness to life’s wonders. Creativity is the ability to create knowledge, to harness one’s curiosity to discover new wonders. People who are characterized by the four Cs often appear to be type A in that their high level of commitment and willingness to take on challenges cause them to appear driven and hardworking. But their work is rooted in a strong sense of self and purpose. The negative type A pattern is driven by something different-by cynicism, anger, and hostility, by a persistent sense of being treated unfairly and a need to be aggressive to get what is due.

Meyer Friedman, a cardiologist and one of the originators of the type A concept, has spent the past thirty years studying the research on the link between behavior and personality and heart disease. Friedman describes the negative type A as a one-dimensional personality, someone with a profound absence of spiritual life.

You have to be religious to avoid heart disease?

By spiritual life, Friedman is not referring specifically to a life with strong religious beliefs, but rather a life that has meaning, that attaches importance to human relationships and to other social and cultural concerns that enrich our lives.⁶ If the hard work and apparent impatience of the type A person emerges from concerns and beliefs that are deeply rooted in their own structure of values, then this commitment to achievement is supportive of cardiac health. If the pattern is the result of the “erosion of personality” that results from chronic suspiciousness, then it is destructive. You might say it has to do with whether or not our energy is directed out toward the world in a constructive fashion or directed inward in a destructive fashion.

This perspective sheds light on why the years of World War II, as stressful as they may appear, did not cause an increase in heart disease. The populations in these wars were not passive bystanders. In previous centuries, war was an activity engaged in primarily by professional armies. But in this century, war has been a struggle of entire societies. The first two Cs, challenge and commitment, certainly characterized the attitude of these populations in that circumstance. And since we might regard war as the father of invention and a major impetus to the creation of technology, we can include creativity as well.

Still, it is hard to avoid stress in our society.

The Stress Scale

True, stressful change is a part of life, particularly in the rapidly changing technology-oriented society we live in. Researchers Thomas Holmes and Richard Rahe studied five thousand individuals-the events in their lives and their reactions to them. They developed a stress scale ranking various events ranging from Christmas to the death of a spouse. They found that the higher your total stress score in any particular year, the more likely you were to become ill.

Based on what you said earlier, it would seem that different people would experience different levels of stress when faced with these events.

TABLE 9: STRESSFUL EVENTS AND HOW THEY RATE

Data from: T. H. Holmes and R. H. Rahe, “The Social Readjustment Rating Scale,” Journal of Psychosomatic Research 11 (1967):213-18, esp. 216.

These ratings represent average stress levels, which Holmes and Rahe were able to statistically associate with levels of disease. But it is certainly true that we each have different capacities to cope with stressful change. Stress is inherently an internal phenomenon. How we experience events depends on our outlook, perspective, and personality.

It would seem that the easygoing type B personality might have an easier time accepting change than the type A.

Not necessarily. The passivity of some type Bs may enable them to cope with change. On the other hand, a secure and well-grounded type A person may see change as a challenge and use his or her creativity to effect a positive result from an otherwise difficult situation.

How can you tell if you are not dealing constructively with stress?

The Symptoms of Stress

Physical symptoms can include high blood pressure, headaches, rapid heartbeat, aches and pains, muscle tension, and gastrointestinal discomfort. Behavioral indications would include difficulty sleeping; compulsive behavior, including compulsive use of food, drugs, alcohol, sex, or gambling; problems in concentration; accident proneness; and social withdrawal. Emotional signs include nightmares, crying spells, feelings of worthlessness, excessive or compulsive worrying, mood swings, restlessness, and anxiety. Spiritual signals include a sense of emptiness, loss of life’s meaning, excessive confusion, and doubt about one’s direction in life.

Those are all pretty general symptoms.

Yes, there is no simple test to determine how well you are dealing with the stress in your life; it is a matter of judgment. But it is a crucial judgment because the link between our health and our ability to deal constructively with our lives is now strongly supported by a growing corpus of scientific literature. Most of us can benefit from improving the balance of our lives and our ability to cope with life’s challenges.

Just what can I do to relieve stress?

False Stress Relievers

Let’s talk first about what not to do.

Don’t eat a high-fat diet?

Food

I’m not sure I would have listed a high-fat diet first on a list of false tension relievers, but it certainly should be included. Compulsive eating in general is not an effective way to reduce stress. Even if the foods you overeat are healthy ones, this habit will contribute to excess weight and will stress your gastrointestinal system. Moreover, the foods that people eat when combating tension and anxiety tend to be high in fat, cholesterol, sodium, sugar, and calories. Finally, it just doesn’t work. You may feel some temporary satisfaction while you are eating, but when you’re done you are likely just to have added the feeling of being stuffed and the associated feelings of guilt to your original anxiety.

So what is first on your list of false stress relievers?

First, second, and third on the list are the three drugs most abused in American and most other advanced societies: tobacco, alcohol, and caffeine.

Tobacco

Nicotine appears to ease anxiety and promote a sense of alertness by stimulating the production of a variety of hormones, including adrenaline. Smoking also provides an oral gratification linked to our earliest feelings of satisfaction from sucking. Yet cigarette smoking is linked to more than 350,000 American deaths a year from heart disease; lung, larynx, and other cancers; emphysema; and other respiratory and circulatory problems.⁷ Even putting these devastating diseases aside, smoking substantially reduces the oxygen available to the body’s tissues, and the constant assault of carbon monoxide, nicotine, tar, and dozens of other poisonous gases dramatically reduces one’s sense of well-being. This deterioration of virtually all of the body’s systems clearly adds to the overall level of stress.

Alcohol

Alcohol is a close second to tobacco as our most abused drug, accounting for more than 100,000 deaths per year. Alcohol abuse is a major risk factor in heart disease; can cause severe liver damage, hypertension, gastrointestinal disorders, and brain damage; and contributes to a variety of cancers.⁸

I thought moderate use of alcohol was found to be beneficial to one’s heart.

This issue has not been resolved. A variety of studies on alcohol and its effects on health discovered what is called a J curve (sometimes called a U curve).⁹ The incidence of heart disease was found to be lowest in those individuals who consumed a moderate amount of alcohol. Those who did not drink at all were found to have a somewhat higher rate of heart disease. Those who drank heavily, that is, more than the equivalent of two glasses of wine or beer a day, also had higher rates of heart disease, with the rates dramatically increasing with increasing usage. Thus, the disease-incidence curves looked like the letter J (or U).

That sort of makes sense. People who don’t drink at all must be a bit uptight.

Perhaps, but a group of English researchers began to suspect the data. They began to think about what types of individuals would abstain completely from alcohol. They reasoned that there must be two very different groups: one that has always abstained and another that is presently abstaining for health reasons because they are recovering alcohol abusers or have heart or other problems and thus need to reduce or eliminate alcohol consumption. This latter group clearly includes individuals whose health has already been damaged (from alcohol abuse or otherwise). They reran the data, removing the men with previously existing cardiovascular-related conditions from consideration, and the curve flattened out. Having corrected this methodological flaw, no benefit was seen for moderate use of alcohol.¹⁰

A more recent study, which followed fifty thousand men for two years, claims to have controlled for any bias caused by preexisting disease in the participants. This major study, conducted at the Harvard School of Public Health and reported in the August 1991 issue of the British journal Lancet, again reported a protective effect from moderate use of alcohol.¹¹ Those who drank the equivalent of one or two glasses of wine a day had a 26 percent reduction in the risk of heart disease compared with those who drank no alcohol. The researchers attributed this benefit to the ability of alcohol, when it is metabolized in the liver, to cause an increase in levels of HDL (the good cholesterol) in the blood, as well as to cause a possible blood-thinning effect that would reduce the likelihood of a blood clot causing a coronary event. At higher levels of consumption, the researchers found the usual harmful effects of alcohol seen in cirrhosis of the liver, high blood pressure, and behavioral problems.

The methodology of this study can also be criticized, however. Because the researchers eliminated anyone with any signs of preexisting disease from the group of drinkers, they may have eliminated from this group precisely those people for whom the alcohol had been harmful, leaving only those who were not negatively affected by many years of moderate drinking. Thus, this attempt to control the composition of the group for preexisting disease may have made the group of moderate drinkers look healthier than they otherwise would have been. Eliminating those with preexisting disease from the group of nondrinkers may not have helped the apparent health of this group as significantly (as the group of moderate drinkers) because the non-drinking group probably had fewer people negatively affected by alcohol to begin with. Also, former alcohol abusers were not explicitly excluded from the teetotaling group. This was presumably controlled for by excluding those with evident disease, but former alcohol abusers with incipient disease would not necessarily be excluded. Finally, the study looked at short-term effects, not long-term potential problems resulting from liver damage or cancer.

A 1987 study found that women who consumed the equivalent of even a single drink per day had a significantly higher risk of breast cancer.¹² Other studies show increased risk of hypertension and stroke from moderate consumption of alcohol. So I would say that the impact of moderate use of alcohol on health has still not been clarified, although it may be the case that there is a marginal positive impact on the risk of heart disease for those who eat the “normal” high-fat diet. For those who follow the 10% solution, I don’t see any positive effect.

So you don’t recommend any use of alcohol.

No, I wouldn’t say that and I do consume alcohol in small quantities. Excessive consumption of alcohol always made me fall asleep anyway, so I was never prone to abusing it. My recommendation is to limit alcohol to no more than two drinks (6-ounce glasses of wine or beer or mixed drinks) per day, with less preferable. Keep in mind that alcohol does contain calories and the calories have no nutritional value.

Although occasional use can provide a feeling of relaxation and euphoria, it should be noted that alcohol is basically a depressant. It is not an answer for chronic feelings of stress and tension. Any attempt to use it for this purpose will only deepen one’s feelings of anxiety and depression. Beyond the long-term damage to one’s health, alcohol abuse is noted for damage to one’s ability to maintain relationships and has well-known behavioral consequences.

What about coffee?

Caffeine

Caffeine-found in coffee, tea, colas and other soft drinks, chocolate, and other foods-is probably our most commonly abused drug. Virtually the entire adult population uses it, and tens of millions of Americans abuse it (more than 22 million Americans drink five or more cups of coffee per day). It is commonly used to combat chronic sleep deprivation, although ironically it is a major contributor to sleeplessness. Caffeine appears to improve alertness, but it really just creates a jumpy, yet still tired, person. It can cause headaches, a sense of restlessness, digestive problems, heart arrhythmias, and hypertension. Even a single cup of coffee can significantly elevate blood pressure and adrenaline for more than two hours, adding significantly to the effects of stress.

Caffeine is surprisingly addictive, more so than most people realize. Even very small amounts can contribute significantly to problems of chronic anxiety and panic disorders.¹³ One psychiatrist who specializes in panic disorders indicated that at least half his patients were able to eliminate their symptoms by completely eliminating caffeine from their diet. He also found that even a single cup of coffee or one caffeinated soft drink could reactivate panic disorders and sleeplessness. It is fair to say that people suffering from chronic anxiety, panic disorders, and sleeplessness should at least test the impact of eliminating caffeine from their diet.

Are there any other drugs on your list of false stress relievers?

Benzodiazepines (Tranquilizers and Sleeping Pills)

Perhaps the quintessential class of drugs that appear to relieve anxiety in the short term, but can create a chronic pattern of heightened anxiety and drug dependence in the long term, are tranquilizers and the closely related class of sleeping pills. In both cases, the most widely prescribed drugs are the benzodiazepines. In 1986, approximately 86 percent of the pills prescribed as tranquilizers or antianxiety medication were benzodiazepines, such as Valium (diazepam), Librium (chlordiazepoxide), and Tranxene (clorazepate). About 75 percent of the sleeping pills were also benzodiazepines, particularly Dalmane (flurazepam) and Halcion (triazolam).¹⁴ While these drugs may have some value in assisting someone through a brief period of acute stress, sustained use can be both ineffective and dangerous. First of all, benzodiazepines rapidly lose their effectiveness as sleep inducing agents. They actually often result in persistent insomnia, thus turning an acute problem into a chronic one. Other common effects include restless or fragmented sleep, nightmares, lethargy, and daytime fatigue.¹⁵ Perhaps most serious, these drugs are addictive and can cause chronic depression. They can start a cycle of drug dependency.

A particularly dangerous benzodiazepine is Halcion (triazolam). Because of its rapid withdrawal from the body, it can cause acute problems of disorientation, panic, aggravated nightmares, severe feelings of depression, and even suicide. Oddly, it is the most widely prescribed sleeping medication in the United States, although it is banned in a number of European countries.¹⁶

Are there other sleep and anxiety medications other than benzodiazepines?

Yes, examples include barbiturates such as phenobarbital and meprobamates such as Miltown. Each such drug has its pros and cons, but there is widespread agreement in the medical community that a safe and effective sleeping or antianxiety medication simply does not exist. These drugs should be used with extreme caution in acute situations.

So why are these drugs so widely used?

That tells you something about our society. We expect quick and immediate cures for whatever troubles us. We tend not to want to struggle with problems.

There are situations where certain psychotropic drugs work when nothing else does. One important example is lithium, which is used for manic-depressive disorders.

You haven’t mentioned any illegal drugs.

Cocaine and Heroin

I have discussed abuse of legally available drugs first because they are the biggest problem in terms of health. Probably because illegal drugs are illegal, their use and abuse is somewhat less frequent. However, I do not mean to minimize the problem of illegal drugs, particularly cocaine. Cocaine upsets the regulation of dopamine, norepinephrine, and other neurotransmitters in the brain, which are vital for one’s ability to think as well as for one’s sense of well-being. Early use causes a surge of dopamine, which is experienced essentially as a strong sense of pleasure. This high is followed by a reduction in dopamine and other neurotransmitter levels, which is unpleasant. This cycle can lead rather quickly to dependency. Ultimately, extensive repeated usage can diminish and possibly deplete the brain’s supply of dopamine. At this stage, a person requires a large dose of the drug just to achieve neurotransmitter levels that are merely not agonizing. The situation of the cocaine addict is quite desperate; his or her regulation of dopamine and other neurotransmitters is out of control. Regaining that control is, unfortunately, very difficult.^l7

The social urgency of the problem stems from the psychological and behavioral impact of cocaine addiction. Unlike heroin, which produces a relatively withdrawn state (at least for those four-hour periods during which a heroin addict’s need for heroin is satisfied), cocaine produces a state of paranoia, irritability, and aggressiveness. This can be a dangerous state of mind, particularly when combined with one other attribute of cocaine-induced psychosis, which is a loss of certain inhibitions, such as those concerning interpersonal violence. Crime related to heroin addiction is typically economic: The heroin addict is desperate for his or her next fix. But the potential violence of a cocaine addict is worse: He or she is dangerous with or without the drug.

So which problem is worse, legal or illegal drugs?

In terms of lives lost and sheer impact on health and well-being, one would have to say legal drugs. Fifty million Americans smoke, and any regular use of tobacco would have to be considered abuse. There are about 20 million Americans who abuse alcohol. More than 20 million Americans abuse caffeine. About 20 million abuse prescription drugs, with some estimates running much higher. There is, of course, a great deal of overlap in these numbers, in that the average number of drugs abused by abusers of drugs is approximately two. Nonetheless, the number of Americans that abuse one or more legal drugs is approximately 75 million, or nearly half the adult population!

There are about 6 million “drug addicts,” individuals addicted to cocaine, heroin, and other “hard” illegal drugs. About 20 million Americans make some regular use of cocaine. So the health implications are comparably smaller. But when assessing the problems of illegal drugs, you have to add the compounding social dislocation, crime, and violence.

I don’t think it is useful to try to rank these two aspects of our drug problem. The more important perspective is to see the abuse of drugs, both legal and illegal, as part of the same problem, rooted in the same quest, however misguided, for a sense of well-being. Our society is awash in drugs. Any discussion of the “drug problem” that ignores the abuse of legal drugs is bound to be ineffectual, not to mention hypocritical. One observer compared our national “war on drugs,” which largely ignores the overarching problems of tobacco and alcohol addiction, to a naval strategy that ignored the Atlantic and Pacific oceans.

Okay, I think we all understand what not to do. Just what do you recommend as sources of relief from our often stressful and harried lives?

I’m glad you asked that question. I have a ten-point program for effectively managing stress.

Okay, let me guess, your first guideline is to eat a diet that is low in fat, cholesterol, sodium, sugar…

Diet

That is certainly a reasonable place to start. Ending the assault of a poisonous diet on one’s body and mind will end an enormous source of stress. The greater sense of well-being and the reality of health that results will go a long way in reducing stress. You will sleep better. Your brain and other tissues will be better oxygenated. Blood pressure and atherosclerotic plaque development will all be greatly alleviated. These and the many other benefits we have discussed all have a bearing on one’s level of stress.

Following the nutritional guidelines of the 10% solution will also enable you to maintain an ideal weight. Avoiding excess weight will eliminate another chronic source of stress.

Worrying a lot less about heart disease, cancer, stroke, and these other diseases should also reduce one’s level of stress.

Good point–it certainly does so for me.

Drugs

The second guideline, closely related to the first is to ingest a “diet” that is also low in tobacco, alcohol, caffeine, benzodiazepines, cocaine, and other drugs. For most of these drugs, particularly tobacco and cocaine, “low” means none.

Okay, what’s new?

Aerobic Exercise

The third guideline is the other cornerstone of my recommendations in the 10% solution: aerobic exercise. Aerobic exercise will directly and immediately provide tangible benefits in reducing stress and promoting relaxation. The natural release of endorphins from continuous exertion is a healthy alternative to artificial stimulants and depressants. Exercise also promotes a natural cycle of sleep. Anyone with difficulty sleeping should stop ingesting caffeine and boost their aerobic exercise. I do not recommend exercising just before retiring, however.

Sleep

The fourth guideline is to sleep.

Sleep?

Yes, make sure you get adequate sleep.

But isn’t it stress that may cause an inability to sleep in the first place?

Yes, I understand that, and the other guidelines will help you to attain a natural and healthy sleep cycle. My point here is that you should allow enough time for an adequate amount of sleep-to give a high priority to obtaining a healthy quantity and quality of sleep. If you have not slept adequately, even minor problems feel quite stressful and your entire outlook is colored negatively. Researchers have estimated that more than a third of the population is chronically sleep deprived. And consuming a lot of caffeine in the morning will only aggravate the inherent stressfulness of inadequate sleep.

How much sleep is enough?

That varies from individual to individual, although seven to eight hours a night is typical. If you stop consuming a toxic diet and get in touch with your body and its feelings, you will know when you have obtained adequate rest.

Balance

The fifth guideline is to achieve to balance in your life. Stress is not an isolated issue that you can deal with once a week. Dealing with stress effectively is a matter of dealing with your life effectively. That is why these recommendations cut across fundamental issues of lifestyle. By balance, I am referring to work, family/friends, and self, and the need to keep these three poles of one’s life in balance. The balance will differ from person to person, and there is great overlap, to be sure. If one’s work, for example, is raising one’s children, then the poles of work and family overlap, but there is still a distinction to be made between the work of child raising and the opportunity to experience moments of love and sharing. Freud said the two great issues in life are work and love, which are the first two of the three poles I have mentioned. The third pole-one’s self-refers to the importance of integrating one’s life into a pattern that is satisfying and meaningful, of taking the time to assess one’s values and goals, to understand one’s own needs and to give them priority.

One obvious form of imbalance is represented by the workaholic, but excessive dependence on social forms of gratification (family/friends) or excessive concern with one’s own needs and desires (self) to the exclusion of others can also represent a lack of balance. This guideline is perhaps different from many of the others in this book in that it is impossible to quantify, but it is important nonetheless to consider the importance of balance and to assess this issue for oneself periodically.

Fair enough.

Vacations

The sixth guideline is to take a vacation.

Terrific–too bad I don’t work for you.

The point is to take time periodically to change your routine. A vacation does not need to involve lying in the sun, although that may be what you enjoy doing. It could involve taking a week to work in your yard, paint your garage, take a course. It could even involve sorting out old files. Just do something different from your usual routine.

The seventh guideline is to talk with someone.

You mean like we’re doing now.

Not exactly. I mean, talk about your true feelings, share on a regular basis your fears, your worries, your hopes, what delights you, and what scares you. It is important to have someone you can really talk to without worrying about being embarrassed, making a good impression, or appearing silly.

So just who might that be?

Good question. It is not always obvious who can fulfill that role. Sometimes it is a relative, although family members are often the ones creating the feelings that you need to talk about and may not provide the kind of nonjudgmental attitude called for. A good friend, perhaps, can provide the necessary trust and confidence. A spouse or lover can provide the requisite intimacy, and it is certainly desirable that you talk about your feelings in such a relationship. As with a relative, however, you may still need someone you can talk to about your spouse/lover. Other possibilities include one’s pastor or teacher, maybe even your boss.

No, I don’t think my boss would be high on my list for this purpose.

Very often, this role can be filled by a therapist, psychiatrist, psychologist, social worker, or counselor, who is trained to provide exactly this kind of supportive and understanding relationship. Unfortunately, the idea of talking to a therapist has negative associations for many persons. It is a common perspective that there has to be something wrong with you to have regular sessions with a therapist. It must mean that you are mentally ill, or at least neurotic. Yet, for most of us, our lives are sufficiently complex and demanding that having a professionally trained person, capable of being objective, to share our feelings and important life decisions is bound to be helpful. We don’t hesitate to hire professionals to assist us with our taxes, legal problems, house selection, money management, and many similar issues, so why not professional consultation on the most important issues facing us: dealing with our own emotions. Our internal life is at least as complex as our tax returns and even more confusing. My own feeling is that most everyone can benefit from a relationship of this type.

That’s not inexpensive, you realize.

This is true, although some therapists will provide a sliding scale based on need and ability to pay, and some clinics provide these services on a reasonable basis.

But regardless of who can fill this role for you, everyone has the need to share their most intimate feelings. Just the act of articulating one’s feelings-fears, hopes, desires–to another human being has an enormously beneficial impact provided, of course, that the person you are talking to is truly listening. It helps put difficult issues into perspective. Even painful subjects can begin to be seen in a constructive context once you articulate them. One’s perspective can become increasingly distorted if this type of intimate sharing is routinely ignored in one’s life.

Okay, what’s next?

Listening

The opposite of the seventh, the eighth guideline is to listen. It is very therapeutic to listen, to truly listen, to what others have to say. And when people feel that you are really listening, they will start to open up and share their inner feelings. It’s just a natural human response and need. Don’t be so enamored with what you have to say that you fail to listen to others. They say a wise man can learn more from a fool than the other way around.

Being a good listener is more difficult than it may appear. The first challenge is to simply allow the other person to talk, by not interrupting and by paying close attention. The more important challenge, however, concerns what you do with the information you receive. You need to keep an open mind, to try to perceive the world from the other person’s perspective. Even if you don’t agree with everything that is being said, provide feedback that lets the other person know you understand what he or she is saying and feeling and the derivation of his or her thoughts. The most critical aspect of creative listening is empathy,

Time Management

The ninth guideline is to give some explicit thought to your own time management. How you spend your time reflects your priorities. As an exercise, write down your priorities, in terms of work, family, friends, exercise, sports, relaxation, and so on. Then, for the following week, write down how you actually spend your time. How does your allocation of time match your intended priorities? In terms of the fifth guideline, above, how well does your time management reflect an optimal and comfortable balance between work, family/friends, and self? With all of the pressures of modern life, it is easy for your allocation of time to stray substantially from what you desire, and also from what is healthy. If you find a discrepancy, consider how you would like your time commitments to change and then develop a strategy for making the change. On the one hand, it is often not possible to make significant changes overnight. After all, we have responsibilities and obligations that cannot just be dropped. On the other hand, given a well thought-out plan, most people have a greater ability to control their destiny, not to mention their daily schedule, than they realize.

It is a worthwhile exercise to try to develop a schedule that will accommodate the various objectives you have. This is particularly important if you are attempting to make a change-adding a regular aerobic exercise program, for example. In terms of avoiding unnecessary sources of stress, try not to overschedule and overcommit. Projects and commitments often take more time than initially anticipated. Also, it is desirable to leave time free for problems and opportunities that arise. An overscheduled life does not leave time for spontaneity.

The value of a schedule is that you avoid procrastination that will only exacerbate stressful situations. You have the opportunity to establish your priorities. You decide what responsibilities you need or want to accommodate. You also learn when and how to say no. After all, you can’t please everyone.

Often I can’t even please myself.

That shouldn’t necessarily be your last priority.

I’ll keep that in mind. So, what’s the last guideline?

The Relaxation Response

The tenth guideline is to evoke the relaxation response.

You’ll have to explain that further.

I was planning to. The relaxation response was discovered when Dr. Herbert Benson, then the director of the hypertension section of Boston’s Beth Israel Hospital and now at New England Deaconess Hospital in Boston, and other researchers at the Harvard Medical School and Boston’s Beth Israel Hospital studied the physical and mental effects of a variety of methods of evoking a calm state, including yoga and several forms of meditation. They discovered a hypothalamic response that was the converse of the fight-or-flight response: reduced levels of epinephrine and norepinephrine and, in turn, lowered levels of blood pressure and blood sugar and breathing and heart rates.^l8 Moreover, they discovered that regular use of these techniques and regular elicitation of this response were able to produce permanently lowered blood pressure levels, improved sleep patterns, improved gastrointestinal functioning, improved blood flow, and other benefits.^l9 A recent study of the elderly found that regular use of a meditation technique that elicited the relaxation response resulted in a dramatic reduction in deaths during the three-year period of the study, as well as substantially improved mental acuity and mental outlook.²⁰

How do you achieve this relaxation response?

Research directed by Benson has cataloged a number of techniques that demonstrably and reliably produce the relaxation response. One such class of techniques is yoga, which combines meditation with stretching exercises and breathing control. Benson has also documented the health benefits of people experiencing the relaxation response on a regular basis.²¹

I understand that yoga is not easy to learn.

Yoga, Biofeedback, and Visualization

Yoga involves an extensive body of knowledge and skill, and one can certainly devote many years of study and practice to mastering this school of thought. Indeed, there are several different schools of yoga which comprise this ancient tradition. However, to simply evoke the relaxation response does not require becoming a master of these techniques. A beginner can learn enough in a relatively short period of time to begin to achieve some of the benefits of the relaxation response.

Another technique is biofeedback, which involves the use of equipment to provide visual or auditory feedback reflecting internal states of tension, such as blood pressure and heartbeat. Usually performed at a clinic, biofeedback techniques have been shown to be effective in treating hypertension, headaches, and other stress disorders.²²

Another method is called visualization, which involves using all of the senses to imagine a desired result. This is often used by athletes to improve performance. When used as a method for treating anxiety, the desired result one visualizes is a situation that is peaceful and serene.

It sounds as if all of these techniques require professional guidance and instruction.

In general, that’s true. Learning yoga, biofeedback, or visualization techniques from a book is certainly not as effective as obtaining the guidance of a skilled practitioner. However, I will describe here one technique that Dr. Benson has extensively studied. It is a simple method that Dr. Benson derived from transcendental meditation and other sources, with a concentration on its applicability as a treatment for stress.²³ Dr. Benson and his colleagues at the Harvard Medical School have spent more than twenty years studying the physiological changes produced by this and other relaxation techniques and the health benefits of experiencing the relaxation response, a term that Benson popularized, on a regular basis. By studying the practices of both Eastern and Western religions and other lay practices that produce the relaxation response, Benson sought to find and describe a simple method that would capture the essential components necessary to produce the physiological changes of the response.²⁴

Okay, I’m game, let’s hear it.

Meditation

The technique involves the following elements:

First, find a quiet and comfortable environment, preferably one in which you feel safe and in which you enjoy being. It is also desirable that you not be disturbed by other persons, the phone, or other distractions.

Second, sit comfortably and close your eyes.

Relax your muscles, starting with your feet and working up to your face.

Now become aware of your breathing. As you breathe out, say a particular word or sound to yourself. This is the heart of the technique, so this aspect bears some discussion. Most any sound that you like will do, although I suggest a one- or two-syllable sound that contains no hard consonants (such as b, d, g, k, p, q, t, x). A suitable sound would be “oh one” or “ah one.” Another possibility, which Benson himself recommends, is simply the word “one.” When you say the word to yourself, do not actually say it aloud, just think it. Let the sound say itself. Just start the sound off in your mind and let it repeat itself with your breath. It is important to let your mind feel free to wander where it may, so you do not want repeating this sound to be difficult. Once you start it up, it should just repeat itself naturally. If, after a while, you notice that it has stopped, gently start it up again. Do not force the sound to repeat itself. Just let it happen.

A vital aspect of the method is a passive attitude. The technique used here is essentially the opposite of a mental discipline. This technique is considered nonconcentrative as opposed to concentrative. For people who are used to disciplining themselves both physically and mentally, this can be confusing. Don’t worry about how well you are doing. Let thoughts come and go. Some will be pleasant some may be distressing. Both will pass and will lead to other thoughts. The repetition of the sound with your breathing should also not be a discipline; just let it happen, and when you notice that it is not happening, just gently start imagining the sound again repeating itself with your breath.

As you gain experience meditating, the sound (sometimes called a “mantra,” although, technically, a mantra is a Sanskrit word from a specific tradition) will become more subtle and less clearly articulated. This is desirable–eventually the sound will become just a feeling of the sound. To assist with this process of the sound becoming more subtle, it is desirable not to say the word (s) out loud (even when not meditating).

If you find certain thoughts to be disturbing, let them pass. If that fails, try returning to the sound that is repeating itself with your breath. If you really want to stop, then stop the sound, wait a few seconds, and end the meditation by gradually opening your eyes.

Continue this process for fifteen to thirty minutes. You can open your eyes briefly to check the time if you wish, but do not use an alarm. When you are done, stop the sound and just sit quietly with your eyes closed for a couple of minutes. Then open your eyes gradually and sit with your eyes open for a few minutes. Then gradually stand up. If you are tired, you may find yourself falling asleep. While the purpose of meditating is not to get additional sleep, if you do find yourself nodding off, that is okay.

To obtain a health benefit the technique should be practiced once or twice a day. In general, avoid a period of two hours after each meal, since the digestive process may interfere with your ability to elicit the desired response. It makes sense, therefore, to practice this meditation technique prior to a meal.

The key to the technique is the passive attitude. This includes not worrying about how well you are doing and letting thoughts, positive or negative, wash over you.

Benson’s research has uncovered a wide range of subjective experiences that occur during meditation, although a feeling of peacefulness and tranquility is not uncommon. However, because the method specifically does not include trying to elicit peaceful thoughts or feelings, your experience may vary from session to session and from minute to minute. The research has demonstrated that the physiological changes associated with the relaxation response are elicited regardless of the subjective experience, whether it be tranquil or otherwise.

This method contrasts with other mental techniques that involve disciplining the mind to concentrate, whether it be on a particular sound or even on the idea of relaxation. In the reference notes, I provide information on where you can receive training in this type of meditation.

Wouldn’t I do just as well to use these twenty minutes to get some extra sleep? Isn’t sleep a relaxation technique?

As we discussed, getting an adequate quantity and quality of sleep is very important as one element of a life-style that deals effectively with stress. Not sleeping adequately is indeed very stressful. Both sleep and the relaxation response involve significant and measurable physiological changes, which have been extensively studied. They are not the same, however. And while sleep is necessary, getting additional sleep will not achieve the beneficial endocrine changes that are achieved through regular elicitation of the relaxation response.

The only problem I have here is that, between following the nutritional guidelines, exercising, spending time with my family, getting adequate sleep, and now practicing relaxation techniques, when I am supposed to find the time to do anything else, like earn a living?

That’s a reasonable challenge. Let’s take these issues one at a time. The nutritional guidelines may take some time at first, in terms of learning the fat content of foods and exploring the world of foods that comply with the guidelines and that you enjoy. But I can share with you from my own experience and that of many others that after a period of learning and adjustment, following the guidelines does not involve a time investment on an ongoing basis. Spending time with your family or friends is, presumably, something you want to do. If you really believe you have no desire or need for this type of interaction with others, then you need to examine that in yourself. As for sleep, this is also something you need, and it is counterproductive to try to cutback on it. Similarly, I have found that exercise more than pays for itself in terms of greater energy, better sleep patterns (meaning you will get more sleep without spending more time in bed), and a more positive attitude about each day’s challenges

Relaxation techniques offer the same promise. The time spent on them will repay itself in terms of demonstrable physiological, mental, and emotional benefits, seen in greater effectiveness in other spheres and an enhanced sense of well-being. That is why I emphasized time management earlier. You would be surprised at how much you can accomplish and how many things you have time for, if you carefully consider the management of your time. Most people waste enormous amounts of time and personal energy in ways that are both unproductive and that do not contribute to the sense of well-being that everyone seeks. The different elements of the program I have outlined–diet, exercise, balance, relaxation-work synergistically. Rather than interfering with your life, a healthy and well-balanced life-style will make you more effective in achieving your personal goals and enhancing your life. There is really no alternative.