In the last chapter, we saw a dramatic example of how a thought, triggered by a misunderstood remark, led to an overwhelming mind-body crisis that resulted in a woman’s death. Her single thought, although mistaken, precipitated a chain of events that rapidly and fatally disregulated the normally robust homeostatic processes of the body, including the regulation of how the heart and the lungs function in concert, such that physiological processes that almost never occur occurred, and with great and irreversible rapidity. Although we are often unaware of our thoughts as thoughts, they have a profound effect on everything we do, and they can have a profound effect on our health as well, which can be for better or for worse. Another case in point is the phenomenon of depressive rumination, negative thought patterns that, once they get going, can precipitate a downward spiral into the depths of depression, from which it is exceedingly difficult to extricate oneself. We will visit this subject in greater detail when we discuss how mindfulness training, in the form of MBCT, can make a huge difference in whether or not we let an initial negative thought trigger such an overwhelming chain of events.
Our thought patterns dictate the ways we perceive and explain reality, including our relationship to ourself and to the world. We all have particular ways in which we think about and explain to ourselves why things happen to us. Our thought patterns underlie our motives for doing things and for making choices. They influence the degree of confidence we have in our ability to make things happen. They are at the core of our beliefs about the world, how it works, and what our place in it is. Our thoughts can also carry a lot of emotion with them. Some carry very positive emotions such as joy, happiness, and contentment. Others carry sadness, feelings of isolation and hopelessness, even despair. Often our thoughts build themselves into extensive narratives, stories we tell ourselves about the world, about others, about ourselves, and about the past and the future. Still, when you really examine them by bringing mindfulness to the entire process of thinking and to our emotional lives, a lot of our thoughts are inaccurate, at best only partially true. Many are simply not true at all, although we invariably think they are. This can create huge problems for us, generating certain patterns of believing and behaving in which we can get caught for many, many years. It is very easy to be blind to the ways in which our thoughts create our reality. Our thought patterns can have a profound influence on how we see ourselves and others, what we think is possible, how confident we feel in our own ability to learn and grow and take action in our lives, even how happy we are, or aren’t. Thought patterns can be grouped into categories and studied systematically by scientists to determine how people with a particular pattern compare with those with a different pattern.
Dr. Martin Seligman is one of the principal founders of a new field known as positive psychology. For many years, he and his colleagues at the University of Pennsylvania and elsewhere studied the health differences between people who were identified as being basically optimistic or basically pessimistic in their thinking about why things happen to them. These two groups of people have very different ways of explaining the causes of what Dr. Seligman calls the “bad” events that happen to them in their lives. (“Bad” events include natural disasters, such as floods or earthquakes; personal defeats or setbacks, such as loss of a job or rejection by someone you care about; or an illness, injury, or other stressful occurrence.)
Some people tend to be pessimistic in the ways they explain the causes of a bad event to themselves. This pattern involves blaming themselves for the bad things that happen to them, thinking that the effects of whatever happened will last a long time and will affect many different aspects of their lives. Dr. Seligman refers to this attributional style, as it is technically called, as the “It’s my fault, it’s going to last forever, it’s going to affect everything I do” pattern. In the extreme, this pattern reflects a person who is severely depressed, hopeless, and inordinately self-preoccupied. Some people call this mode of thinking catastrophizing. An example of this style might be the reaction “I always knew I was stupid, and this proves it; I can never do anything right” when you experience a failure of some kind.
An optimist experiencing the same event would see it quite differently. People who are optimists tend not to blame themselves for bad events or, if they do, they see them more as momentary occurrences that will get resolved. They tend to see bad events as limited in time and in how pervasive the damage they cause will be. In other words, they focus on the specific consequences of what happened and do not make sweeping global statements and projections that blow the event out of proportion. An example of this style might be “Well, I really blew it that time, but I’ll figure out something, make some adjustments, and next time it will fly.”
Dr. Seligman and his colleagues have shown that people who have a highly pessimistic attributional style are at significantly higher risk for becoming depressed when they encounter a bad event than are people who have an optimistic way of thinking. Pessimists are also more likely than optimists to come down with physical symptoms and show hormonal and immune system changes characteristic of increased susceptibility to disease following a bad event. In a study of cancer patients, these researchers showed that the worse the attributional style, the earlier the patient died of the disease. In another study they showed that baseball players in the Hall of Fame who had a pessimistic attributional style when they were young and healthy were more likely to die young than those who had an optimistic attributional style.
Dr. Seligman’s overall conclusion from these and other studies is that it is not the world per se that puts us at increased risk of illness so much as how we see and think about what is happening to us. A highly pessimistic pattern of explaining the causes of bad or stressful events when they occur seems to have particularly toxic consequences. Dr. Seligman’s work suggests that this way of thinking puts people at risk for illness and may explain why some people are more susceptible to illness and premature death than others, when other factors such as age, sex, smoking habits, and diet have been taken into account. A pattern of optimistic thinking in response to stressful events, on the other hand, appears to have a protective effect against depression, illness, and premature death.
One thought pattern that appears to be extremely powerful in improving health status is what is called self-efficacy. Self-efficacy is a belief in your ability to exercise control over specific events in your life. It reflects confidence in your ability to actually do things, a belief in your ability to make things happen, even when you might have to face new, unpredictable, and stressful occurrences. Classic studies by Dr. Albert Bandura and his colleagues at Stanford University Medical School showed that a strong sense of self-efficacy is the best and most consistent predictor of positive health outcomes in many different medical situations, including who will recover most successfully from a heart attack, who will be able to cope well with the pain of arthritis, and who will be able to successfully make lifestyle changes (such as quitting smoking). A strong belief in your ability to succeed at whatever you decide to do can influence the kinds of activities in which you will engage in the first place, how much effort you will put into something new and different before giving up, and how stressful your efforts to achieve control in important areas of your life will be.
Self-efficacy increases when you have experiences of succeeding at something you feel is important. For example, if you are practicing the body scan and, as a result, feel more in touch with your body and more relaxed, then that taste of success will lead you to feel more confident in your ability to relax when you want to. At the same time, such an experience will make it more likely that you will keep practicing the body scan.
Your self-efficacy can also increase if you are inspired by the examples of what other people are able to do. For instance, in the MBSR classes, when one person reports a positive experience with the body scan, say in regulating pain, it usually has a dramatic positive effect on other people in the class who may not yet have had such an experience. They are likely to say to themselves, “If that person can have such a positive experience, even with all of his problems, then I probably can as well, even with all of my problems” So seeing one person with a problem succeed, in the sense of having a positive experience, can boost everybody else’s confidence in their own ability and in the efficacy of the practices they are working with.
Dr. Bandura and his colleagues studied self-efficacy in a group of men who had had heart attacks and were undergoing cardiac rehabilitation. They were able to show that those men who had a strong conviction that their heart was very robust and could recover fully were much less likely to be derailed from their exercise programs than were those who were less confident, even though the severity of heart disease in the two groups was the same. Those with high self-efficacy were able to exercise on the treadmill without worrying or feeling defeated by the discomfort, shortness of breath, and fatigue that are a natural and normal part of any exercise program. They were able to accept their discomfort without worrying that it was a “bad sign” and could focus instead on the positive benefits of their exercise program, such as feeling stronger and being able to do more. On the other hand, the men who did not have this kind of positive conviction tended to stop exercising, mistaking normal discomfort, shortness of breath, and fatigue for signs of an ailing heart. Further studies showed that when people who have low self-efficacy undergo training to develop mastery experiences, their confidence in their ability to function successfully and to positively influence areas of their lives that once felt out of their control grows and flourishes.
Another interesting line of research on the effects of thoughts and feelings on health involved studying people who seem to thrive on stress or who have survived extremely stressful situations. Here the goal was to see whether certain people have particular personality characteristics that may account for their apparent “immunity” to stress and to stress-related illnesses. Dr. Suzanne Kobasa of the City University of New York and her colleagues, and Dr. Aaron Antonovsky, a medical sociologist in Israel, both conducted studies in this area.
Dr. Kobasa studied business executives, lawyers, bus drivers, telephone company employees, and other groups of people who lead high-stress lives. In every group, as you might expect, she found some people who were much healthier than others experiencing the same amount of stress. She wondered whether the healthier people had some personality characteristic in common that might be protecting them from the negative effects of high stress. She found that a particular psychological characteristic differentiated those who got sick often from those who stayed healthy. She called this characteristic psychological hardiness (sometimes also referred to as stress hardiness).
As with the other psychological factors we have looked at, hardiness also involves a particular way of seeing oneself and the world. According to Dr. Kobasa, stress-hardy individuals show high levels of three psychological characteristics: control, commitment, and challenge. People who are high in control have a strong belief that they can exert an influence on their surroundings and can make things happen. This element is similar to Dr. Bandura’s notion of self-efficacy. People who are high in commitment tend to feel fully engaged in what they are doing from day to day and are committed to giving these activities their best effort. People who are high in challenge see change as a natural part of life that affords at least some chance for further development. This perspective allows stress-hardy individuals to see new situations more as opportunities and less as threats than might other people who do not share this orientation toward life as an ongoing challenge.
Dr. Kobasa emphasized that there are many things a person can do to increase his or her level of stress hardiness. The best way to develop greater hardiness is to come to grips with your own life by being willing to ask yourself hard questions about where your life is going and how it might be enriched by specific choices and changes you could make in the areas of control, commitment, and challenge. She also proposed that hardiness could be improved in high-stress work settings by restructuring roles and relationships within organizations to promote a greater sense of control, commitment, and a sense of challenge among employees. More and more, these principles are finding their way into present-day work settings as the complexity of work and its various challenges increases.
Dr. Aaron Antonovsky’s research focused on people who have survived extreme, almost unthinkable stress, such as prisoners in Nazi extermination camps. In Dr. Antonovsky’s view, being healthy involves an ability to continuously restore balance in response to its continual disruption. He wondered what allowed some people to resist very high levels of stress even as their resources for coping with the stress and tension were constantly being disrupted during their imprisonment in the concentration camps. Dr. Antonovsky found that people who survive extreme stress have an inherent sense of coherence about the world and themselves. This sense of coherence is characterized by three components, which he termed comprehensibility, manageability, and meaningfulness. People who have a high sense of coherence have a strong feeling of confidence that they can make sense of their internal and external experience (that it is basically comprehensible), that they have the resources available to meet and manage the demands they encounter (manageability), and that these demands are challenges in which they can find meaning and to which they can commit themselves (meaningfulness). These qualities are beautifully encapsulated in the famous statement of Victor Frankl, himself a survivor of Auschwitz (and a neurologist and psychologist): “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”
For a number of years we measured both stress hardiness and sense of coherence in our patients going through the MBSR program. We found that both measures increased over the eight weeks of the program. The increase wasn’t large—it averaged about 5 percent—but it was significant. This was notable because both stress hardiness and sense of coherence are considered personality variables; in other words, they are traits that are unlikely to change in any significant way in adulthood. That is why, for instance, sense of coherence was used as a variable to distinguish those who seemed to survive the death camps with far less psychological damage from the trauma than other survivors who were more seriously affected. However, in MBSR, in eight short weeks, we were seeing a small but undeniable increase in these variables, which were not really supposed to change if they were fixed traits. Moreover, when we conducted follow-up studies, we found that even three years later, the increases in stress hardiness and sense of coherence had been maintained or had even increased slightly, up to about 8 percent on average. This was a rather remarkable finding. It suggested that something our patients were experiencing during MBSR was having a much more profound effect on them than merely reducing their physical and psychological symptoms—something more akin to a rearrangement in the way they were seeing themselves and their relationship to the world.
We shared these findings with Dr. Antonovsky a year or two before he died. He expressed surprise that we had observed such changes after such a brief intervention, especially one based primarily on non-doing. He had thought that only major social or political events on a large, disruptive, and transformative scale could result in such changes across the board in people. However, we had felt all along, based on anecdotal reports from our patients over the years, that they really were experiencing a profound shift in how they saw themselves as individual beings, as individual beings in relationship with other beings, and in relationship with the larger world. In fact, this intuition was the major reason we began looking at stress hardiness and sense of coherence in our patients in the first place, and specifically at the question of whether these measures would change over time. Perhaps future studies will support these early findings by correlating changes in these two measures with changes in particular brain regions known to be associated with the sense of self and relationality. But for our patients it won’t matter. What matters is that such transformations can and do occur, regularly, and that they endure and even continue to deepen, especially with ongoing practice.
The studies we have looked at so far have had a predominantly cognitive focus, that is, they have looked primarily at thought patterns and beliefs and their effects on health and illness. A parallel line of research has concerned itself with the role of emotions in health and illness. Obviously our thought patterns and our emotions shape and influence each other. It is often difficult to determine in a particular situation whether one is more fundamental than the other. We will now take a look at some research findings from studies focusing primarily on the relationship between emotional patterns and health.
For some time now, there has been an ongoing debate about whether certain personality types are more prone to certain diseases. For instance, some studies suggested that there might be a “cancer-prone” personality, others that there is a “coronary-heart-disease-prone” personality. The cancer-prone pattern is frequently described as someone who tends to conceal his or her feelings and is very other-oriented while actually feeling deeply alienated from others and feeling unloved, and unlovable. Feeling a lack of closeness with one’s parents when young is strongly associated with this pattern.
Much of the evidence in support of this link comes from a forty-year study conducted by Dr. Caroline Bedell Thomas of Johns Hopkins Medical School. Dr. Thomas collected large amounts of information on the psychological status of incoming medical students at Johns Hopkins starting in the 1940s and then followed these individuals periodically over the years as they got older and, in some cases, got sick and died. In this way she was able to correlate particular psychological characteristics and early family life experiences that these doctors reported when they were young (around age twenty-one) and healthy with a range of different diseases that some of them experienced over the next forty years. The results demonstrated, among other things, that there was a particular constellation of features in early life that was associated with an increased likelihood of having cancer later in life. Prominent among these characteristics were a lack of close relationship to parents and an ambivalent attitude toward life and human relationships. The conclusion, of course, is that our emotional experiences early in life may play a strong role in shaping our health later in life.
As we examine research relating thought patterns and emotional factors to health, it is important for us to keep firmly in mind that it is always dangerous and almost always wrong to assume that because a connection has been found between certain personality traits or behaviors and a disease, this means that being a certain way or thinking a certain way causes you to get a particular disease. It is more accurate to say that it may or may not increase to some extent (that extent depending on the strength of the correlation and a lot of other factors) your risk of getting the disease. This is because research studies always result in statistical relationships, not in a one-to-one correspondence. Not all people who have a particular personality trait that has been shown to be associated with cancer always get cancer. In fact, not all people who smoke cigarettes die from lung cancer, emphysema, or heart disease, even though smoking has been proven beyond all doubt to be a strong risk factor for all of these diseases. The relationship is a statistical one, having to do with probabilities.
Therefore it is wrong to conclude from any of the evidence pointing to a possible relationship between emotions and cancer that certain personality traits directly cause the disease. Nevertheless, there is mounting evidence that certain psychological and behavioral patterns may predispose a person to at least some forms of cancer, while other personality attributes may protect a person from cancer or increase the chances of surviving it. In this regard the feelings you experience toward yourself and other people and how you express or don’t express them seem to be particularly important.
For example, Dr. David Kissen and his collaborators at the University of Glasgow in Scotland conducted a series of studies on men with lung cancer starting in the late 1950s. In one study they analyzed the personal histories of several hundred patients taken at the time they entered the hospital with chest complaints, but before any diagnosis was made. The men who were later found to have lung cancer reported significantly more adversities in childhood, such as an unhappy home or the death of a parent, than had those who turned out to have other diagnoses. This finding is consistent with Dr. Thomas’s findings from the Johns Hopkins medical student study, in which she found that cancer later in life was associated with a lack of closeness to parents and ambivalent feelings toward relationships reported forty years earlier. In the Kissen study, those men who were found to have lung cancer had also reported more adversities as adults, including disturbed interpersonal relationships. The researchers observed that, as a group, those with lung cancer showed particular difficulty in expressing their emotions. They did not express their feelings about bad events, especially those that involved bonds with other people (such as marital problems or the death of somebody close to them), although, to the researchers, these were obviously sources of current emotional upset in their lives. Instead, the patients tended to deny that they were feeling emotional pain, and during the interviews they talked of their difficulties in matter-of-fact, emotionally flat tones that seemed inappropriate to the interviewers under the circumstances. This was in marked contrast to the patients in the control group (who were later found to have diseases other than lung cancer), who described similar situations with appropriate expressions of emotion.
The inability to express emotions was strongly linked to mortality among the lung cancer patients in this study. Those lung cancer patients who had the poorest ability to express emotions had more than four and a half times the yearly death rate of those with the highest ability for emotional expression. This finding held true regardless of whether or how much they smoked cigarettes, although, as you might expect, the heavy smokers had ten times the incidence of cancer as those who had never smoked.
More evidence relating emotional factors to cancer came from researchers at King’s College Hospital in London, who conducted a similar study on women with breast cancer. Drs. S. Greer and Tina Morris conducted in-depth psychological interviews with 160 women when they were admitted to the hospital for a lump in the breast, before it was known whether or not it was cancerous. At the time of the interview, all the women were under the equal stress of not knowing whether they had cancer or not. The interviews with the women and with their husbands and other relatives were used as a means of measuring the degree to which the women concealed or expressed their feelings.
The majority of women who were later found not to have breast cancer had what these researchers termed a “normal” pattern of emotional expression. However, the majority of women who were later found to have breast cancer had a lifelong pattern of either extreme suppression of their feelings (for the most part, anger) or of “exploding” with emotion. Both extremes were associated with a higher risk of cancer. However, it was much more common for these women to suppress their feelings than to be “exploders.”
In a five-year follow-up of fifty women with breast cancer, all of whom had been treated surgically, the researchers found that the women who were judged to be facing their situation three months after surgery with what they called a “fighting spirit,” that is, a highly optimistic attitude and a belief in their own ability to survive, were much more likely to be alive than those who at three months post-surgery either had adopted an attitude of stoic acceptance toward their disease or were completely overwhelmed by it and felt helpless, hopeless, and defeated. Women who denied altogether that they had cancer, refused to discuss the subject, and showed no emotional distress about their situation also were much more likely to survive to five years. The results of this study suggest that emotions may play some role in cancer survival, with strong positive emotions (a fighting spirit, total denial) appearing protective and blocked emotional expression (stoicism or helplessness) decreasing survival. However, as these researchers themselves pointed out, their study was of a relatively small number of people and thus their findings can only be considered suggestive.
For unequivocal links to be established between a psychological characteristic and an illness, very large (and often extremely expensive) clinical trials need to be conducted. The results of one such study looked into the relationship of depression to cancer in more than six thousand men and women in the United States. Although many smaller and less well-designed studies had reported an association between depression and cancer, no link was found in this larger study. The group of people with symptoms of depression and the group that did not both had cancer rates of around 10 percent. Yet in animals, many well-designed studies do show an unequivocal link between the behavioral pattern of helplessness (which is related to depression), reduced immunological functions including natural killer cell levels, and increased tumor growth. Further research needs to be done on how these findings, along with work that has shown a link between helplessness in human beings and reduction in immune function, may relate to the apparent lack of correlation between depression and cancer seen in this clinical trial. This is an area of continued controversy.
Cancer is a condition in which cells within the body lose the biochemical mechanisms that keep their growth in check. Consequently, they multiply wildly, in many cases forming large masses called tumors. Many scientists believe that the production of cancerous cells in the body is happening at a low level all the time and that the immune system, when healthy, recognizes the abnormal cells and destroys them before they can do any damage. According to this model, it is when the immune system is weakened, either through direct physical damage or through the psychological effects of stress, and can no longer effectively identify and destroy these low levels of cancerous cells that the cancer cells multiply out of control. Then, depending on the type of cancer, either they develop a blood supply of their own and eventually form a solid tumor or they overwhelm the system with large numbers of circulating cancer cells, as in leukemia.
Of course, it is possible for a person to be exposed to such massive levels of carcinogenic substances that even a healthy immune system would be overwhelmed. This happened to people living in areas where there had been toxic dumping, such as the infamous Love Canal in New York State. Similarly, exposure to high doses of radiation, as occurred following the bombings of Hiroshima and Nagasaki and following the nuclear accident at Chernobyl, can provoke the formation of cancerous cells and at the same time weaken the immune system’s ability to recognize and neutralize them. In short, the development of any kind of cancer is a multi-stage, complex occurrence involving our genes and cellular processes, the environment, and our individual behavior.
Even if it turns out that there is a statistically important relationship between negative emotions and cancer, to suggest to a person with cancer that his or her disease was caused by psychological stress, unresolved conflict, or unexpressed emotions would be totally unjustifiable. It amounts to subtly or not so subtly blaming the person for his or her disease. People often do this unwittingly, perhaps in an attempt to rationalize a painful reality and to cope with it better themselves. Whenever we can come up with an explanation for something, it makes us feel a little better because we can reassure ourselves, however wrongly, that we “understand” why that person “got” cancer. But doing this amounts to a violation of the other person’s psychic integrity, based merely on ignorance and surmise. It also robs people of the present by directing their attention to the past just when they most need to focus and face the reality of having a life-threatening disease. Unfortunately, this kind of thinking, which seeks to attribute a subtle psychological deficiency as the “cause” of the cancer, has become fashionable in certain circles. This attitude is far more likely to result in increased suffering than in greater healing. From everything we know about the relationship between our emotions and our health, acceptance and forgiveness are what we need to cultivate to enhance healing, not self-condemnation and self-blame.
If a person who has cancer believes that stress or emotional factors may have been a factor in his or her illness, that is his or her prerogative. It may be very helpful to explore this question, and it may not be, depending on the person’s life and on how the subject is approached. Some people are empowered by the realization that their handling of emotions in the past may have contributed to their illness. For them, it means that by becoming more aware of these particular issues and areas now, and making changes, they might be able to enhance their moment-to-moment quality of life and thereby, to whatever degree possible, their healing and recovery. But this perspective should not be imposed by someone else, however well-meaning the impulse behind the gesture may be. Explorations in this domain need to be undertaken with great compassion and caring, either by the person or with the help of a physician or therapist. Inquiry into possible factors that might have contributed to one’s illness can help only if they come out of non-judging, out of generosity and compassion, and acceptance of oneself and of one’s past, not out of condemnation.
Whether psychological factors played a causal or exacerbating role in a particular disease in a particular person will never be known with certainty. Since mind and body are not really separate in the first place, one’s state of physical health will always be affected to some extent by psychological factors. But by the time a person has been diagnosed with a particular illness, the issue of causal psychological factors can be at best of secondary importance. At that juncture, it becomes much more important to take responsibility for what needs doing in the present. Since there is evidence that positive emotional factors can enhance healing, a diagnosis of cancer can be a particularly important turning point in a person’s life, a time for mobilizing an optimistic, coherent, self-efficacious, and engaged perspective, and a time for working at being less susceptible to the pull of pessimistic, helpless, and ambivalent mind states. Purposefully directing gentleness, acceptance, and love toward oneself is a very good place to begin.
How do we go about that? We go about it by dropping in on ourselves in this moment, and befriending it; by taking up residency in awareness itself, resting in it, using any or all of the methods described in Part I to re-mind ourselves and re-body ourselves. In some profound sense, the rest takes care of itself.
There are now a number of mindfulness-based approaches developed specifically for people who have cancer and want to work with it in the ways we have been describing. One is the Mindfulness-Based Cancer Recovery Program, developed by Linda Carlson and Michael Speca of the Tom Baker Cancer Center at the University of Calgary. They have published a number of papers showing major improvements in patients with breast cancer and prostate cancer on a range of physiological and psychological measures as a result of their cancer-oriented MBSR program. These include a one-year follow-up study showing enhanced quality of life, decreased stress symptoms, altered cortisol and immune patterns consistent with less stress and less mood disturbance, and decreased blood pressure. Another mindfulness-based program for cancer patients is MBCT for Cancer, a program developed by Trish Bartley and based on work at the University of North Wales in Bangor. Both teams have recently written books to make their programs more widely accessible.
There is evidence that suppressing emotional expression may play a role in hypertension as well as cancer. In this area the focus has been primarily on anger. People who habitually express anger when provoked by others have lower average blood pressures than people who habitually suppress such feelings. In a study of 431 adult men living in Detroit, Margaret Chesney, Doyle Gentry, and their collaborators found that blood pressure was highest in men reporting high job or family stress and a tendency to suppress feelings of anger. It seems that in high-stress situations, an ability to vent one’s angry feelings is protective against high blood pressure. Other studies suggest that high blood pressure may be associated with both extremes of emotional behavior, either always suppressing anger or always expressing it overtly.
Perhaps the greatest scientific scrutiny of personality factors in relationship to chronic disease has focused on the question of whether or not there is a heart-disease-prone personality. For some time it was thought that there was conclusive evidence of a particular behavior pattern associated with increased risk of coronary heart disease, known as type A behavior. Further research, however, showed that it was not the entire type A pattern that was related to heart disease, but only one aspect of it.
People with so-called type A personality are described as driven by a sense of time urgency and competitiveness. They are characteristically impatient, hostile, and aggressive. Their gestures and speech tend to be hurried and abrupt. In this terminology, people who do not show the type A pattern are referred to as type B. According to Dr. Meyer Friedman, one of the originators of the type A concept, type B’s are more easygoing than type A’s. They are not driven by time urgency and are free from a generalized irritability, hostility, and aggressiveness. They are also more inclined toward periods of contemplation. Yet there is no evidence that type B’s are any less productive or less successful than type A’s.
The original evidence relating type A behavior to coronary heart disease came from a large research project known as the Western Collaborative Group Study. This study characterized 3,500 men as either type A or type B when they were healthy and had no signs of disease. Eight years later they looked again to see who had developed heart disease and who had not. It turned out that the type A’s developed coronary heart disease at two to four times the rate (depending on age, the younger men having the greater risk) of the type B’s.
Many other studies confirmed the connection between the type A behavior pattern and coronary heart disease and demonstrated that it was true for women as well as for men. But other studies, particularly those by Dr. Redford Williams of Duke University Medical School and his collaborators, looked at just the hostility component of the type A behavior pattern and have found it to be a stronger predictor of heart disease all by itself than the full type A pattern. In other words, you are at less risk of heart disease as a type A if you are low in hostility, even if you feel a strong sense of time urgency and are competitive. What is more, high hostility scores predicted not just myocardial infarction and death from heart disease but also increased risk of death from cancer and all other causes as well.
In one fascinating study, Dr. Williams and his collaborators did a follow-up study on male physicians whose level of hostility on a particular psychological test had been measured when they were medical students twenty-five years earlier. They found that those men with low hostility scores when they were in medical school had about one-fourth the risk of having heart disease twenty-five years later as those with high hostility scores. When they looked at death from all causes, the results were also dramatic. Since they had graduated from medical school, only 2 percent of the men who were in the low-hostility group had died, whereas 13 percent of those in the high-hostility group had died in the same time period. In other words, those who showed high hostility on a psychological test they took twenty-five years in the past were dying at a rate six and a half times the rate of those whose hostility was low at that time.
Williams describes hostility as “an absence of trust in the basic goodness of others,” grounded in “the belief that others are generally mean, selfish and undependable.” He emphasizes that this attitude is usually acquired early in life from caregivers such as our parents or others and that it probably reflects an arrested development of basic trust. He points out that this attitude has a strong element of cynicism in it as well as hostility, as exemplified by two typical items on the questionnaire they used to measure hostility: “Most people make friends because friends are likely to be useful to them” and “I have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them.” Anyone who strongly believes these two statements probably has a very cynical view of people in general. With such a view of the world and other people, hostile and cynical people can be expected to feel anger and aggression much more frequently than others, whether they express it outwardly or attempt to suppress it under some circumstances.
The study of these doctors provides strong evidence that a hostile and cynical outlook on the world may, in and of itself, put one at much greater risk for illness and premature death than a more trusting view of people does. It seems that an ingrained cynical and hostile attitude is highly toxic to well-being. These and other findings are detailed in Dr. Williams’s book The Trusting Heart, in which he also points out that all the major religious traditions of the world emphasize the value of developing qualities that science is now showing are good for your health, such as kindness, compassion, and generosity. In fact, there is a growing interest among researchers in studying the effects of such prosocial emotions (sometimes referred to as positive emotions) or virtuous qualities in parallel with research on the cultivation of mindfulness itself.
For example, Barbara Fredrickson and her colleagues at the University of North Carolina at Chapel Hill have shown that nine weeks of training in lovingkindness meditation practice increased a sense of purpose and reduced symptoms of illness. The work of Paul Gilbert in the United Kingdom, Kristin Neff in Texas, and Christopher Germer at Harvard is showing that training in self-compassion and compassion for others results in major changes in physical, psychological, and relational well-being. Interestingly enough, a recent clinical trial conducted by researchers from Northeastern University, Massachusetts General Hospital, and Harvard,* demonstrated that training in mindfulness over eight weeks, compared to training in compassion over the same time period, resulted in similar overt acts of coming to the aid of a person who appeared to be in a great deal of pain, even though others in the room were intentionally (because of the design of the experiment) ignoring that person’s suffering. The meditators in both groups responded by helping more than five times as often as the subjects in a wait-list control condition who had not undergone either of the meditation trainings. There was no difference in the degree of helping displayed by the mindfulness group or the compassion group. This finding supports the view that mindfulness itself is an expression of kindness and compassion and can be deepened through ongoing practice.
Many other lines of evidence suggest that there is a strong relationship between emotions—and what is called emotional style—and health. These are expertly and compellingly described in the book The Emotional Life of Your Brain, by Richard Davidson, with Sharon Begley. Davidson’s work has elucidated six dimensions of emotional style, which they describe as follows: Resilience: how slowly or quickly you recover from adversity; Outlook: how long you are able to sustain positive emotion; Social Intuition: how adept you are at picking up social signals from the people around you; Self-Awareness: how well you perceive bodily feelings that reflect emotions; Sensitivity to Context: how good you are at regulating your emotional responses to take into account the context you find yourself in; and Attention: how sharp and clear your focus is. As you can immediately see, these dimensions are all either aspects of the cultivation of mindfulness or stem from it. Most importantly, Davidson and Begley present convincing evidence that one’s emotional style can be both accepted and, at the same time, transformed through meditation training.
Motivation is another psychological characteristic that has been implicated in health. Dr. David McClelland, a renowned psychologist at Harvard in the 1960s and 1970s, identified a particular motivational profile that seemed to convey a greater susceptibility to disease than others. People who strongly display this characteristic, termed the stressed power motivation, demonstrate an intense need for power in their relationships with people. This power motive typically outweighs any need they might have for affiliation with people. They tend to be aggressive, argumentative, and competitive, and they are likely to join organizations in order to increase their personal status and prestige. But they also get very frustrated and feel blocked and threatened whenever stressful events occur that may challenge their sense of power. People with this particular motivational pattern get sick when under such stress much more readily than others who do not share this drive.
McClelland also identified an opposite motivational pattern that seems to confer hardiness or resistance to illness. He called it unstressed affiliation motivation. People who display high levels of unstressed affiliation are drawn to being with people and want to be friendly and liked by others, not as a means to an end (as with the cynical type A’s) but as an end in its own right. They are also free to express their need for affiliation, since it is not blocked or threatened by the advent of stressful events. In a study of college students, those scoring above the average in stressed power motivation had more reported illness than other students, while those who were above average in unstressed affiliation motivation reported the least illness.
Once again, as with stress hardiness and sense of coherence, we find that there is convincing evidence that certain ways of looking at oneself and at the world can predispose a person to illness, while other ways seem to promote greater resilience and health. In an early pilot study in collaboration with Dr. McClelland and his colleagues, Joel Weinberger and Carolyn McCloud, we found that most people taking the MBSR program showed an increase on a measure of affiliative trust over eight weeks, while a group of patients waiting to get into the program and who were tested over the same time period showed no change on the same measure. This finding is emblematic of our patients’ reports that their experience with MBSR often has a long-lasting and profoundly positive influence on their view of themselves and of the world, including an ability to be more trusting of themselves and of others.
We have reviewed some of the evidence suggesting that our thought patterns, our beliefs, and our emotions—in short, our very personality—may affect our health in major ways. There is also considerable evidence that social factors, which of course are related to psychological factors, also play a major role in health and illness. It has long been known, for instance, that, statistically speaking, people who are socially isolated tend to be less healthy both psychologically and physically and more likely to die prematurely than people who have extensive social relationships. Death rates from all causes are higher in unmarried people than in married people at all ages. There seems to be something about having ties to others that is basic to health. Of course, this is intuitively understandable. It is deeply human to have a strong need to belong, to feel a part of something larger than oneself, to be in relationship with others in meaningful and supportive ways. The research on affiliative trust, compassion, and kindness suggest that these kinds of social bonds are extremely important for people’s health and well-being.
Evidence supporting the importance of social connections for health has been bolstered by a number of major studies involving very large populations in this country and abroad. All show a relationship between ties to others and health. People who have a very low degree of social interaction in their lives, as measured by marital status, contacts with extended family and friends, church membership, and other group involvements, are between two and four times as likely to die in the succeeding ten-year period as are people who have a very high level of social interaction, when all other factors such as age, prior illness, income, health habits such as smoking and alcohol consumption, physical activity, race, and the like are taken into account. Social isolation and loneliness are now considered demonstrated risk factors for depression and cancer.
There are a number of studies that suggest why this might be so. Dr. James Lynch, of the University of Maryland and author of the classic text The Broken Heart: The Medical Consequences of Loneliness, has shown that physical contact with or even the presence of another person has a calming effect on cardiac physiology and reactivity in a stressful intensive care unit. More recently, as we saw earlier, David Creswell and his colleagues at Carnegie Mellon and UCLA have demonstrated that participation in an MBSR program can reduce loneliness in an elderly population. They were able to show not only that loneliness was reduced simply by participation in the MBSR program but also that the MBSR group had lower production of pro-inflammatory cytokines, compounds that are associated with many disease processes within the body, than those in a wait-list control group. Since loneliness is a major risk factor in the elderly for cardiovascular disease, Alzheimer’s, and death, these findings are potentially very important, especially given the fact that, according to Dr. Creswell, efforts to diminish loneliness through social networking programs and developing community centers to encourage new relationships have not been effective.
In a series of on-going studies, Philippe Goldin, James Gross, and their colleagues at Stanford University are studying people diagnosed with what is called social anxiety disorder (SAD) before and after undergoing MBSR training, using fMRI brain scans. They found that people who completed MBSR showed improvements in anxiety and depression and an increase in self-esteem. When asked to practice awareness of breathing in the scanner, the MBSR group also showed what the researchers describe as decreased negative emotion experience, as well as marked reduction of activity in the amygdala, and increased activity in brain regions involved in regulating where one’s attention goes. They also studied self-referential processing in the narrative brain region described earlier in the Toronto study (page xlii), which is involved in mind wandering in general and, in people with social anxiety, with an exaggerated and highly critical self-focus that makes social interactions very challenging and unsatisfying for them. They showed that activity in this narrative region was reduced after MBSR, suggesting greater control over such negative self-perspectives.†
In another classic study, Dr. Lynch showed that people lived longer after a myocardial infarction if they had a pet than if they didn’t. He also showed that just the presence of a friendly animal can decrease one’s blood pressure. This is suggestive evidence that relationality is key to our health. And it is relationality above all else, we might say, that is at the heart of mindfulness.
Interestingly, and not surprisingly, human-animal contact seems to benefit not only the humans but the pets as well. According to Dr. Lynch, petting reduces cardiovascular reactivity in stressful situations among dogs, cats, horses, and rabbits. One remarkable study of human-animal interaction came about after researchers at the University of Ohio noticed that rabbits on a high-fat, high-cholesterol diet designed to give them heart disease had much less severe heart disease if they were in lower cages in the room rather than higher ones. This finding didn’t make any sense at all. Why should the position of their cages make a difference in the degree of heart disease when the rabbits were all genetically identical, were on the same diet, and were being treated the same way? Then one researcher observed that they were not being treated in exactly the same way. It turned out that one of the members of the team was taking out the rabbits in the lower cages from time to time, stroking them, and talking to them.
This led the researchers to perform a carefully controlled experiment, petting some rabbits and not others while keeping them all on the same high-fat, high-cholesterol diet. The results demonstrated conclusively that affectionate stroking of rabbits made them much more resistant to heart disease than their unpetted kin. The petted rabbits had 60 percent less severe disease than the unpetted ones. They repeated the whole experiment a second time to make sure it wasn’t a fluke and got exactly the same result.
To summarize, all the studies we have discussed and many others support the notion that our physical health is intimately connected with our patterns of thinking and feeling about ourselves and also with the quality of our relationships with other people and the world. The evidence suggests that certain patterns of thinking and certain ways of relating to our feelings can predispose us to illness. Thoughts and beliefs that foster hopeless and helpless feelings, a sense of loss of control, hostility and cynicism toward others, a lack of commitment to meet life’s challenges, an inability to express one’s feelings, and social isolation all appear to be particularly toxic.
On the other hand, other patterns of thinking, feeling, and relating appear to be associated with robust health. People who have a basically optimistic perspective, or at least those who have the ability to let go of a bad event, who can see that it is impermanent and that their situation will change, tend to be healthier than their pessimistic counterparts. Optimists know intuitively that there are always choices that can be made in life, that there is always the possibility of exercising some control or agency. They also tend to have a positive sense of humor and are able to laugh at themselves.
Other health-related psychological traits include a strong sense of coherence, the conviction that life can be comprehensible, manageable, and meaningful; a spirit of engagement in life, taking on obstacles as challenges; and confidence in one’s ability to make changes that one decides are important; cultivating health-enhancing emotional styles, such as greater emotional resilience.
Healthy social traits include valuing relationships, honoring them, and feeling a sense of goodness and basic trust in people.
Since all the evidence we have looked at is only valid statistically, that is, for large populations of people, we cannot say that a particular belief or attitude or emotional style causes disease, only that more people get sick or die prematurely if they have strong patterns of thinking or behaving in such ways. As we will see in the next chapter, it makes more sense to think of health and illness as opposite poles of a continually changing and dynamical continuum rather than to think that you are either “healthy” or “sick.” There will always be a flux of different forces at work in our lives at any given time; some may be driving us toward illness, others shifting the balance toward greater health. Some of these forces are under our control, or might be if we put all of our internal and external resources to work for us, whereas others lie beyond what any individual can influence. The degree of stress the system can take before it breaks down completely is not precisely known, and is very likely different for different people, and even different at different times for the same person. But this dynamical interplay of multiple forces that influence our health is happening wherever we are on the health-illness continuum at any particular time, and it goes on changing throughout our lives. The whole point of this book, and of MBSR, is that there is a lot that you can do to gently, lovingly, and firmly—through non-striving and non-doing, coupled with doing when taking action with awareness is called for—influence how things unfold across the life span, tilting them in the direction of greater well-being, self-compassion, and wisdom to whatever degree possible, always unknown.
The relevance of the evidence presented here to us as individuals lies primarily in our ability to bring awareness to our own thoughts and feelings and their physical, psychological, and social consequences as we observe them. If we can observe in ourselves the toxicity of certain beliefs, thought patterns, emotional patterns, and behaviors as they arise in the moment, then we can work to lessen their hold on us. Knowing something of the evidence, we might be motivated to look a little more closely at those moments when we find ourselves thinking pessimistically, suppressing our feelings of anger, or thinking cynically about other people or about ourselves. We might bring mindfulness to the consequences of these thoughts, feelings, and attitudes as they arise in us.
For instance, you might observe how your body feels when you hold in your anger. What happens when you let it out? What are its effects on other people? Can you see the immediate consequences of your hostility and distrust of others when these feelings surface? Do they cause you to jump to unwarranted conclusions or to think the worst of people and to say things you later regret? Can you see how such attitudes cause pain to others in the moment that they are happening? Can you see how these attitudes create unnecessary trouble and pain for you at the time that these feelings surface?
On the other hand, you might also be mindful of positive thoughts and affiliative emotions as they occur. How does your body feel when you see obstacles as challenges? How does it feel when you are experiencing joy? When you are trusting others? When you are generous and showing genuine kindness and concern? When you are loving? What are the effects of these inner experiences of yours and their outward manifestations on others? Can you see the immediate consequences of your positive emotional states and of your optimistic perspective at those times? Do these have an effect on other people’s anxiety and pain? Is there a sense of greater peace within yourself in such moments?
If we can be aware—especially in our own personal experience, as well as from the evidence from scientific studies—that certain attitudes and ways of seeing ourselves and others are health-enhancing:—that affiliative trust, compassion, kindness, and seeing the basic goodness in others and in ourselves has intrinsic healing power, as does seeing crises and even threats as challenges and opportunities, then we can work mindfully to consciously develop these qualities in ourselves from moment to moment and from day to day. They become new options for us to cultivate. They become new and profoundly satisfying ways of seeing and being in the world.