When you stop and think about it, we human beings are actually remarkably resilient creatures. One way or another we manage to persevere, to survive, sometimes in the face of the full catastrophe writ horrifyingly large, and still have our moments of pleasure, peace, and fulfillment in spite of all the stress, pain, and grief. For one, we are expert copers and problem solvers. We cope through sheer determination, through our creativity and imagination, through prayer and religious beliefs, through involvements and diversions that feed our need for purpose, meaning, joy, and belonging, and for stepping outside of ourselves and caring for others. We cope and are buoyed up by our own tenacious love for life, and by receiving love, encouragement, and support from our family, our friends, and our larger community.
Underlying our conscious engagement with many of the challenges we face is an unconscious biological intelligence that is nothing short of awe-inspiring. This system, which has been honed over millions of years of evolution, functions at the level of perception, motor responses, and allostatic mechanisms, and it can operate extremely rapidly. Neuroscientist Cliff Saron of the Center for Mind and Brain at the University of California, Davis emphasizes that we humans have a marvelous innate capacity to complete patterns on the basis of very partial information. This is an example of the wisdom of the entire body—brain, nervous system, muscles, heart, the works. Everything collaborates for the sake of the whole. As we just saw, some of these systems exert their restorative influences within the body over hours and days, well beyond the immediacy of many threats. When this system is functioning adaptively, our automatic reactions can be life-saving in an emergency in which we have virtually no time to think—for example, when we are driving and the car begins to skid. What this means is that there is nothing wrong with some kinds of automaticity within ourselves. These reactions are biologically trustworthy.
At the same time, however, our innate psychophysiological balance and dynamism, our overall allostasis, stable though it is by virtue of being so adaptable, so flexible, so multifaceted, so reliable without our having to pay conscious attention to it, can be pushed over the edge into disregulation and disorder at every level of our organism if it is driven beyond its capacity to respond and adapt in healthy ways. We see examples of this in the hospital every day. Health can be undermined by a lifetime of ingrained behavior patterns that compound and exacerbate the pressures of living we continually face. Ultimately, our habitual and automatic reactions to the stressors we encounter, particularly when we get in the habit of reacting maladaptively, determine in large measure how much stress we experience. Automatic reactions triggered out of unawareness—especially when the circumstances are not life-threatening but we take them that way all the same—can compound and exacerbate stress, making what might have remained basically simple problems into worse ones over time. They can prevent us from seeing clearly, from solving problems creatively, and from expressing our emotions effectively when we need to communicate with other people or even understand what is going on within ourselves. Ultimately they close down our ability to experience peace of mind, which, when all is said and done, is probably what we most desire. Instead, each time we react habitually in unhealthy ways, without awareness of the patterns of behavior we have fallen into, we stress our intrinsic capacity for well-being and balance a little more. A lifetime of unconscious and unexamined habitual reactivity to challenges and perceived threats is likely to increase our risk of eventual breakdown and illness significantly. More and more evidence suggests that this is indeed the case.
FIGURE 9
THE STRESS-REACTION CYCLE
(Automatic/Habitual)
Consider yourself for a moment to be the person depicted in the center of Figure 9. External events that might be potential stressors—whether environmental, physical, societal, social, emotional, economic, or political—can bear down on us and generate changes in our bodies, our lives, and our social status. These potential stressors are depicted by the small arrows above the person in the figure. All these forces impinge on us from the outside to one degree or another. They are usually perceived and appraised very rapidly as to the level of threat they pose to the organism, especially under extreme conditions of danger.
Our mind and body don’t only change in response to our perception and appraisal of this complex array of outer forces. They are also capable, as we all well know, of generating their own demands and reactive energies, producing another whole set of pressures on the organism. In Figure 9 these are labeled “Internal Stressors” (small arrows inside the box). As we have seen, even our thoughts and feelings can act as major stressors if they tax or exceed our ability to respond effectively to whatever they bring up for us. This is true even if the thought or feeling has no correspondence with “reality.” For example, the mere thought that you have a fatal disease can be the cause of considerable stress and could become disabling, even though it may not be true. In the extreme, it can profoundly disregulate your physiology, as we saw in the story recounted by Dr. Bernard Lown in Chapter 14.
Some stressors affect us over extended periods of time. We call these chronic stressors. For instance, taking care of a family member with a chronic disease or disability is usually an inevitable source of chronic stress for the caregiver. It often goes on for many years, and so requires profound adaptation in order to minimize its rending effects. Of course, having a chronic medical condition yourself is also a source of ongoing stress. On the other hand, some stressors come and go over relatively short periods of time. We call these acute stressors. Deadlines, such as getting your income taxes done on time, are an example of this kind of pressure. Other types of acute stressors stem from daily life and may seem minor, but they occur frequently and thus their effects can add up over time: rushing in the morning, driving in traffic, being late for appointments or meetings, having an argument with a child or spouse. Still others are unusual or onetime matters, such as accidents, losing one’s job, or the death of someone close to you. All can create acute stress for us and require effective adaptation so that we can eventually heal, through a process of coming to terms with what happened. Without such a process, we might fall into longer-term patterns of behavior that result in additional sources of chronic stress.
UCSF stress researcher Elissa Epel describes our interface with acute stress as a kind of sprint. One way or another, it is soon over, and we can go back to our baseline well-being.* Extending the metaphor, Dr. Epel sees chronic stress as a marathon that usually includes multiple sprints within it. For instance, even within an ongoing situation such as being the primary caregiver for a family member suffering with a chronic condition, there will still always be acute events popping up that need to be dealt with. If we don’t realize that we are actually engaged in an ongoing marathon, it is easy to run out of energy, what could be thought of as coping energy, and wind up feeling chronically exhausted and burned out. Long-term stress of this kind requires pacing oneself, and maybe even periodic respite, to preserve the resources in our “bank account” and continue making the occasional bigger deposit when we can. Epel makes the point that one way that an acute stressor can become chronic is though intrusive thoughts, worry, and rumination. These thought patterns themselves become the internal stress events that compound and extend the stress. She points to evidence suggesting that rumination itself is thought to be a pathway through which chronic stress causes hypertension. As we have seen, and will see again, her own research on telomeres and telomerase in chronically stressed populations provides strong evidence for the toxic effects of such ruminative processes when they are unmodulated via more adaptive and intentional psychological processes, such as mindfulness practice.
Some stressors are highly predictable, such as taxes. Others are less predictable, such as accidents or other things that come up unexpectedly and that you have to deal with. In Figure 9, the small arrows represent all these internal and external stressors, both acute and chronic, as they are felt at any moment in time. The figure of the person stands for all aspects of your being, the totality of your organism—body and mind. This includes all of your organ systems, of which only a few are labeled (the brain and the nervous system, the cardiovascular system, the musculoskeletal system, the immune system, and the digestive system), as well as the conventional psychological sense of yourself as a person, including your perceptions, beliefs, thoughts, and feelings. Of course, the brain plays a critical and commanding role in regulating the functioning of all these processes that contribute to our being alive and to our integrated experience of life unfolding: the organ systems of the body, including our perceptual systems and neuroendocrine systems, as well as our thoughts and emotions, and the meaning we attribute to events.
When you are stressed in some moment to the extent that your mind identifies, anticipates, or imagines a threat to your being, whether it is a threat to your physical well-being, to the integrity of your sense of self, or to your social standing in relationship to others, usually you will react in a particular way. If it is a passing threat or turns out to be neutral when reappraised in the next moment, then either there will be no reaction at all or your reaction will be minimal. But if the stressor is highly charged for you emotionally, or if you consider it to be threatening, then you usually go through some kind of automatic alarm reaction.
The alarm reaction is our body’s way of clearing the decks for defensive or aggressive action. It can help us in threatening situations to protect ourselves and to maintain or regain control. Our brains and nervous systems are wired to perform in this way under certain circumstances. The alarm reaction enables us to call on the full power of all our internal resources in life-threatening situations. As we shall see, a little bilateral structure deep in the brain, called the amygdala, has a lot to do with it.
Walter B. Cannon, the great American physiologist who worked at the Harvard Medical School in the early part of the twentieth century and who extended Claude Bernard’s original concept of the internal stability of our physiology, studied the physiology of this alarm reaction in a number of experimental systems. In one, he studied what a cat goes through when threatened by a barking dog. Cannon termed the cat’s reaction the fight-or-flight response because the physiological changes the threatened animal goes through are those that mobilize the body for fighting or fleeing.†
We human beings are subject to the same physiological reactions that other animals exhibit. The basic pattern is deeply rooted in our biology. When we feel threatened, the fight-or-flight reaction occurs almost instantly, mediated, as we shall see in a moment, by the autonomic nervous system. It hardly matters whether it is a physical threat or a much more abstract threat to our social well-being and sense of self. The resulting outcomes are very similar: an overall state of physiological and psychological hyperarousal, characterized by a great deal of muscle tension, including in the face, and the activation of strong emotions, which may vary from terror, fright, or anxiety, shame, or embarrassment to rage and anger. The fight-or-flight reaction involves a very rapid cascade of brain and nervous system firings and the release of a bevy of stress hormones, the most well known of which are the catecholamines [epinephrine (adrenaline) and norepinephrine (noradrenaline)], which are unleashed very rapidly in response to an immediate acute threat, and cortisol, which is released a bit more slowly. Hyperarousal includes a heightening of sense perceptions so that we can take in as much relevant information as possible as quickly as possible: the pupils of our eyes dilate to let in more light, our hearing becomes more acute, the hair on our body stands erect so that we are more sensitive to vibrations in the air around us. We become very alert and attentive. The heart rate rises and the strength of the heart muscle contractions (and thereby the blood pressure) increases, causing the output of the heart to jump by a factor of four or five so that more blood and therefore more energy can be delivered to the large muscles of the arms and legs, which will be called upon if we are to fight or run.
At the same time the blood flow to the digestive system shuts down, as does digestion itself. After all, if you are about to be eaten by a tiger, there is no point in continuing to digest food in your stomach. It will get digested in the tiger’s stomach just as well if you are caught. Both fighting and running require that your muscles get as much blood as possible. You may feel this rerouting of your blood flow in times of stress as “butterflies in your stomach.”
Many of these rapid changes in your body and in your emotions come about because of the activation of a particular branch of what is called the autonomic nervous system (ANS). The autonomic nervous system is that part of your nervous system that regulates the internal states of your body such as your heart rate, blood pressure, and the digestive process. The particular branch of the ANS that is stimulated in the fight-or-flight reaction is known as the sympathetic branch. Its overall function is to speed things up. The other branch, known as the parasympathetic branch, acts as a brake. Its overall function is to slow and calm things down. It is the parasympathetic branch that shuts down digestion when we have a fight-or-flight reaction. The sympathetic branch stimulates the heart when we react to stress, and the parasympathetic branch slows it down during the recovery. The parasympathetic branch of the ANS, and in particular the highly evolved vagus (meaning wandering in Latin) nerve, plays an essential role in how we deal with stress. When stressed, most people show a decrease in vagal tone, meaning the nerve is less activated, and that decrease is related to greater threat reactivity. Having a higher vagal tone is associated with greater calm and resilience, as well as recovering from stress more rapidly, greater social engagement, and positive emotions. Interestingly enough, just bringing awareness to your breathing and allowing it to slow down on its own, particularly the outbreaths, increases vagal tone. The ANS is regulated by the hypothalamus, a gland that lies just below the region of the brain known as the limbic system, and above the brain stem. The hypothalamus is the master control switch of the autonomic nervous system, or more accurately, the principle conductor of the ANS orchestra.
The limbic system is a collection of highly interconnected regions located underneath the cerebral cortex and right above the hypothalamus. It has many discrete structures, including the amygdala, the hippocampus, and the thalamus. The limbic system used to be thought of as the “seat of the emotions,” but that view is no longer considered entirely valid, as some of the regions of the limbic system, such as the hippocampus, are known to be essential for higher cognitive functions as well, including spatial cognition and declarative memory. Moreover, the prefrontal cortex, the region right behind your forehead and site of the so-called executive functions, such as perspective taking, impulse control, decision making, long-term planning, postponement of gratification, and working memory, among others, is now known to have an influence on how emotionally resilient a person is in the face of stress and adversity. It has been said that the prefrontal cortex is the part of the brain that confers on us our uniquely human capacities and qualities. Evolutionarily, it was the last part of the brain to develop. It can downregulate stress reactivity via its massive neuronal connectivity with the various structures and regions of the limbic system (including the amygdala, which plays a major role when we feel anxious, afraid, or threatened, as well as in decoding emotional expression on the faces of others). This bidirectional connectivity between the prefrontal cortex and multiple limbic areas allows for both emotion recognition and emotion regulation. The prefrontal cortex is the region where Richard Davidson’s work, including his studies of long-term meditators and with MBSR practitioners, has shown that the left and right sides of the prefrontal cortex regulate emotions differently. Resilience in the face of emotional challenges is characterized by greater activation of the left side of the prefrontal cortex, which is associated with a reduction of fear, anxiety, and aggression (in part perhaps by damping down activity in the amygdala). Recall that a shift in activation from right to left in this region was observed in our collaborative study of MBSR in a corporate work setting. According to Davidson, “the amount of activation in the left prefrontal region of a resilient person can be thirty times that in someone who is not resilient.”‡
One of the major jobs of the various structures within the limbic system is to regulate the functioning of the hypothalamus. In turn, the hypothalamus influences not only the autonomic nervous system, and thus all the organ systems in the body, but also the endocrine system (the system of glands that secrete stress hormones) as well as our musculoskeletal system. The interconnections among these pathways allow us to experience our emotions viscerally, that is, in and through the body and how it is feeling, and at the same time to hold them in awareness and be able to respond in a coordinated and integrated fashion to both external and internal events.
Taken altogether, the deep connectedness of the prefrontal cortex and the limbic system allows for an integrated experience of living, and for the possibility of both using emotional information and regulating our emotional reactivity or responsivity on the basis of a deeper understanding of particular situations and stressors we might be facing. This deeper understanding derives from our values, our sense of who we are (sense of self), and our ability to be aware with intentionality and modulate accordingly the actions we ultimately choose to take. In other words, we can cultivate greater resiliency and well-being, and also wisdom and equanimity, in the face of stressful circumstances. This quality of well-being is sometimes spoken of as eudaemonia. All it takes is practice, practice, practice. We will certainly get plenty of opportunities for that, given how much stress there is in our lives on a daily basis.
When the sympathetic branch of the ANS is triggered via limbic stimulation of specific areas in the hypothalamus, the result is a massive discharge of neuronal signals that influence the functioning of every organ system in our body. This is accomplished in two ways: direct neuron (nerve cell) connections to all the internal organs—including the vagus nerve—and the secretion of hormones and neuropeptides into the bloodstream. Some hormones are secreted by glands, others by nerve cells (these are called neuropeptides), still others by both. These hormones and neuropeptides are chemical messengers that travel far and wide in the body to transmit information and trigger specific responses from different cell groups and tissues. When they arrive at their targets, they bind to specific receptor molecules and transmit their message. You might think of them as chemical keys, turning on or off specific control switches in the body. It may well be that all of our emotions and feeling states are dependent on the secretion of specific neuropeptide hormones under different conditions.§ Some of these hormone messengers are released as part of the fight-or-flight reaction. For example, epinephrine and norepinephrine are released into the bloodstream by the adrenal medulla (part of the adrenal glands located on top of your kidneys) when the adrenal glands are stimulated by signals from the hypothalamus via sympathetic nerve pathways. These hormones give you the “rush” and sense of extra power in emergency situations that we have labeled the habitual or automatic “Stress Reaction” in Figure 9. In addition, the pituitary gland right below the hypothalamus is also stimulated (via the hypothalamus) when we are stressed. The pituitary triggers the release of other hormones (some from a region of the adrenal glands called the adrenal cortex) that are also part of this habitual stress reaction, including cortisol and a molecule called DHEA (dehydroepiandrosterone). The amygdala is a major player too, as was mentioned earlier, activating whenever there is a sense of threat or challenge, or when one feels thwarted or even potentially thwarted.
A news item that ran in the Boston Globe illustrates the remarkable power inherent in the stress reaction. It read as follows:
Arnold Lemerand, of Southgate, Mich., is 56 years old and had a heart attack six years ago. As a result, he doesn’t like to lift heavy objects. But this week, when Philip Toth, age 5, became trapped under a cast iron pipe near a playground, Lemerand easily lifted the pipe and saved the child’s life. As he lifted it, Lemerand thought to himself that the pipe must weigh 300 to 400 pounds. It actually weighed 1800 pounds, almost a ton. Afterward, Lemerand, his grown sons, reporters and police tried to lift the pipe but couldn’t.
This anecdote illustrates the power of the fight-or-flight reaction and the surge of energy it provides in acute life-threatening situations. It also demonstrates that in an emergency, you really don’t stop to think. If Mr. Lemerand had thought about the weight of the pipe before he tried to lift it, or about his heart condition, he probably would not have been able to lift it. But the necessity for action in the face of a life-threatening situation triggered an immediate state of hyperarousal in which his thinking shut down for a moment and sheer, complex, beautiful reacting took over, operating much faster than conscious thought, and bringing with it its own uncanny power and skill—a feat of instantaneous compassion in action. But once the immediate threat was over, he was unable to perform the same feat, even with lots of help.
It is easy to see how the built-in fight-or-flight reaction increases an animal’s chances of survival in a dangerous and unpredictable environment. It works the same way for us. The fight-or-flight reaction may help us to survive when we find ourselves in life-threatening situations. It is not a hardwired reflex of the knee-jerk variety, but a highly evolved intelligent capacity to steer us though complex situations that threaten our survival. So it is not at all bad that we have this vital capacity. We never would have survived as a species without it. What is problematic is when we can’t control it and don’t know how to modulate it, or when we use its energies across a range of situations where there is no immediate and acute threat to life or well-being but we act as if there were. Then it starts to control us.
Most of the time we do not find ourselves encountering life-threatening situations in civil society and everyday life. We are not running into mountain lions or other threats as we go to work or deal with family life and social situations. But we are still prone, if not hardwired, to go into fight-or-flight mode when we feel threatened or thwarted in our goals, feelings of safety, or sense of control even if we’re just driving on the freeway or walking into work and finding something unexpected that we are going to have to deal with. Our minds still perceive events in terms of mortal threats to our well-being and sense of self, even when there is none. When we go that route, then every stressful situation, even if it is potentially manageable in countless other ways, becomes a threat to the system. Our fight-or-flight pathways no longer shut down, even when there is no life-threatening situation. They can become chronically activated.‖ And when they are, they change our biology as well as our psychology. We become primed, so to speak, for all the problems associated with chronic hyperarousal, right down to the level of which genes in our chromosomes get turned on and upregulated, such as the gene for the glucocorticoid receptors that make us chronically susceptible to stressors, and the genes that produce pro-inflammatory cytokines, which themselves promote a whole range of diseases of inflammation if chronically stimulated. Chronic arousal also shortens our telomeres, as we have seen, and thus accelerates the aging process at the cellular level. All of these consequences of chronic arousal may be avoidable, or at least reducible and ultimately resolvable, if we learn how to recognize the tendency to go directly into a full-blown stress reaction and modulate it with a more mindfully based response. In part, this will involve recognizing that our instantaneous appraisals of threat are often inaccurate and generate unnecessary fear and suffering for ourselves. As we will see in Part IV, just discovering that we don’t always have to believe our own thoughts or emotions or take them so personally when the circumstances and potential challenges we are facing are not in essence personal, even when we are absolutely convinced that they are, gives us other degrees of freedom in terms of responding skillfully to ever-changing life situations. This new way of being in relationship to stress and potential stressors can be hugely liberating.
The fight-or-flight reaction is triggered in animals when they encounter members of another species that might want to eat them for lunch. But it also comes into play when animals are defending their social standing within their own species, and when they are challenging the social status of another animal in their group. When an animal’s social position is challenged, the fight-or-flight reaction is unleashed and the two animals in question fight until one either submits or runs away. The hierarchy of dominance and submission is established. Once an animal submits to another, it “knows its place” and doesn’t keep going through the same reaction every time it is challenged. It readily submits, and that calms its internal biology so that it is not continually hyperaroused.
People have many more choices in situations of social stress and conflict, but often we get stuck in these same patterns of dominance and submission, fleeing, or fighting all the same. Or as some animals do, we can freeze up completely and simply go numb when threatened. Our reactions in social situations are often not that different from those of animals. That is not surprising, given that much of the stress biology is the same. Yet animals of the same species seldom kill each other in social conflicts the way humans do.
As we just noted, much of our stress comes from threats, real or imagined, to our social status, to our sense of how others perceive us. The fight-or-flight reaction kicks in all the same, even when there is no life-threatening situation facing us. It is sufficient for us just to feel threatened.a
By causing us to react so quickly and so automatically, the fight-or-flight reaction often creates problems for us in the social domain rather than giving us additional energy for resolving our problems. Anything that threatens our sense of well-being—challenges to our social status, our ego, our strongly held beliefs, or our desire to control things or to have them be a certain way—can trigger it to some degree. We can be catapulted into a state of hyperarousal, ready for fight or flight, whether we like it or not.
Unfortunately, as we just saw, hyperarousal can become a permanent way of life. Many of our patients in the MBSR program start out by describing themselves as tense and anxious virtually all the time. They suffer from chronic muscle tension, usually in the shoulders, the face, the forehead, the jaw, and the hands. Everybody seems to have particular areas that store muscle tension. Heart rate is also frequently elevated in a state of chronic hyperarousal. You can feel shaky inside, feel “butterflies” in your stomach, experience skipped heartbeats or palpitations, or have chronically sweaty palms. The urge to flee may surface frequently, as can impulses to lash out in anger or to get into arguments and fights.
Certainly these are common responses to everyday stressful situations, not just to life-threatening ones. They come about because our body and mind are wired to react automatically to perceived threat or danger, even though we do not usually run into large carnivore predators in our daily lives. Since the capacity to trigger a fight-or-flight reaction is part of our nature, and since, as we have been exploring, it is liable to have major unhealthy consequences biologically, psychologically, socially, and therefore health-wise if it runs chronically out of control, it is essential for us to be aware of this inner tendency and how easily it can be triggered, if we hope to reverse a lifelong pattern of automatic stress reactivity and the heavy burdens that accompany it. As you will see shortly, awareness is the critical element in learning how to free yourself from your stress reactions at those moments when you feel threatened and your first impulse is to run or take some other kind of evasive action, freeze up, or become aggressive and gear up for a fight. These are not good baseline attitudes and patterns of relating to wake up with and to carry into work in the morning or to bring home at the end of a long and frustrating day. They are not so healthy for others, and they obviously are not in your best interest.
At this point it might be useful to ask, “What do we usually do in all those countless situations when the internal pressures that could lead very quickly to a full-blown fight-or-flight reaction are building up inside of us but we know that fighting (or its equivalent) and/or running (or its equivalent) are simply not options, because both are socially unacceptable and, besides, we already know neither will solve our problems?” We still feel threatened, hurt, fearful, angry, resentful. We still have the stress hormones and neurotransmitters clearing the decks for fight or flight. Our blood pressure is rising, our heart is pounding, our muscles are tense, our stomach is churning.
One common way we often deal with our stress reactions in social situations is to suppress these feelings as best we can. We wall them off. We pretend we are not aroused. We dissimulate, hiding our feelings from others and sometimes even from ourselves. To do so, we put the arousal the only place we can think of: deep inside us. We internalize it. We inhibit the outward signs of the stress reaction as best we can (even though any observant person is going to see it or feel it) and try to carry on as usual, holding it all inside. We suppress our emotions and avoid dealing with them and with the actuality of our situation. You can just feel how toxic that might be, especially if it becomes your default mode for getting through the day.
The nice thing about fighting or running is that, at the very least, both are exhausting, so that ultimately, after the stressful situation is over, you rest. Your parasympathetic pathways take over. Blood pressure and heart rate return to baseline, your blood flow readjusts, your muscles relax, your thoughts and emotions cool, and you move toward an overall condition of recovery and recuperation, right down to the level of your biology, your chromosomes, and the families of genes that are getting turned on or off.b When you internalize the stress reaction, however, you don’t get the resolution that fighting or running brings. You don’t peak, and you don’t get the physical release and recovery afterward, like the gazelles on the savanna. Instead, you just carry the arousal around inside you, both in the form of stress hormones, which are wreaking havoc with your body, and in the form of your agitated thoughts and emotions. This is not your brain’s fault, nor your body’s. High stress and strong amygdala activation simply shut down the activity in the prefrontal cortex, so your executive functions crash and you can’t really think clearly and make emotionally intelligent decisions just when you most need to. But when you bring awareness to the unfolding of such stressful situations in the present moment, and to your unconscious and habitual reactions to them, then the totality of your organism is capable of much, much more. The prefrontal cortex can be reclaimed and its activity bolstered, another signature of resilience.
We encounter a lot of different situations from day to day, many of which tax our resources to one degree or another. If each time we run into some aspect of the full catastrophe our automatic response is a mini (or not so mini) fight-or-flight reaction, and if most of the time we inhibit its expression outwardly and just contain its underlying energies, by the end of the day we will be incredibly tense. If this pattern becomes a way of life, and if we have no healthy ways of releasing the built-up tension, then over a period of weeks, months, and years we will more than likely drift into a perpetual state of chronic hyperarousal from which we rarely get any break and that we might even come to think of as “normal.” We are normalizing a huge allostatic load that we are carrying around, without even knowing it in many cases, and certainly without having any kind of systematic and reliable antidotes in the form of practices and skills that we can call upon at such times to restore us to a stress-free baseline. This really compounds unnecessary wear and tear on both the body and the mind.
There is mounting evidence that chronic stimulation of the sympathetic nervous system can lead to long-term physiological disregulation, resulting in problems such as increased blood pressure, cardiac arrhythmias, digestive problems (usually due to inflammatory processes), chronic headaches, backaches, and sleep disorders, as well as to psychological distress in the form of chronic anxiety, depression, or both. When this level of damage happens, we call it allostatic overload. Of course, having any of these problems creates even more stress. They all become additional stressors that just feed back on us, compounding our problems. This is illustrated in Figure 9 by the arrow going from these symptoms of chronic hyperarousal back to the person.
We see the results of this way of living every day in the Stress Reduction Clinic. People come to us when they have had enough, when they get desperate enough, when they finally decide that there just has to be a better way to live and a better way to handle their problems. Nowadays, maybe it is because they have read something about mindfulness and the science of meditation in the newspaper, or seen something about it on television or on YouTube. In the first class, we sometimes invite people to describe what they are like when they are their most relaxed selves. Many say, “I can’t remember, it’s been so long,” or “I don’t think I have ever felt relaxed!” They instantly recognize the hyperarousal syndrome sketched out in Figure 9. Many say, “This describes me to a T.”
We all use various coping strategies to stay on an even keel and to deal with the pressures in our lives. Many people cope remarkably well with extremely trying personal circumstances and have developed their own strategies for doing so. They know when to stop and take time out; they exercise regularly, meditate or do yoga, they pray; they share their feelings with close friends, have hobbies and other interests to take their mind off things; and they remind themselves to look at things differently and not to lose perspective. People who do this tend to be the stress-hardy ones.
But many people cope with stress in ways that are actually self-destructive and just make matters worse on virtually every front. These attempts at control are labeled “Maladaptive Coping” in Figure 9 because, although they may help us to tolerate stress and give us some sense of control in the short run, in the long run they wind up compounding the stress we experience. Maladaptive means that these responses are unhealthy. They cause more stress and only compound our difficulties and our suffering.
One very prevalent maladaptive coping strategy is to deny that there is any problem at all. “Who me, tense? I’m not tense,” says the denier, all the while radiating body language and facial expressions that speak of stored muscle tension and unresolved emotions. For some people it takes a long time to even come close to admitting to themselves that they are carrying around a lot of body armor or that they feel hurt and angry inside. It’s very hard to release tension if you won’t even admit that it is here. And if you are challenged by others regarding your patterns of denial, your unwillingness to even take a look at certain areas of your life, strong emotions can surface that can take many forms, including anger and resentment. These are sure signs that you are indeed resisting looking at something deeper within yourself. Therefore, if you are serious about finding a new way of being in your life and in the world, these signs of resistance are really worth paying attention to. They can become your friends and allies if you can turn toward them, make space for them, and welcome them into awareness with kindness and self-compassion. You could experiment with tending (or better, attending) and befriending them, intentionally. It’s not as hard as you might think.
All the same, it is important to keep in mind that denial is not always maladaptive. It is sometimes an effective temporary strategy for coping with relatively unimportant problems until you can’t deny them anymore and have to pay attention to them and to their consequences, and find more effective ways of dealing with them. And, sadly, heartbreakingly, sometimes denial is the only recourse a person may have or believes he or she has in the face of an impossibly harmful situation, such as the child who is being sexually abused and threatened with death or some other awful consequence if she divulges anything. Some of the patients we see who had such experiences as children had no other options when they were young, especially if their tormentor was a parent or someone whom they were supposed to love—and often did. This was the case for Mary, whose traumatic experiences as a young girl were discussed in Chapter 5. Denial allowed her to keep her sanity in a world of madness. But sooner or later denial stops working and you have to come up with something else. And in the end, even if denial was the best you could do at the time, there is usually a serious price to be paid for it. This is where trauma-oriented therapies can be so valuable, and where mindfulness-based approaches may be of particular value. More and more research in both animals and in people is showing that early stressful and traumatic experiences predispose an individual to a heightened vulnerability later in life if he or she encounters high-stress situations. In low-stress situations, a person can be fine and healthy. But in high-stress situations it can all come crashing down, unless, that is—and now we are talking about people, not animals—they cultivate mind-body strategies such as mindfulness for consciously regulating their emotions, thoughts, and body states.
There are many unhealthy ways we seek to control or regulate the stress in our lives in addition to denying that it exists and pretending that everything is fine. They are unhealthy precisely because, in one way or another, they avoid naming, facing, and dealing with the real problems. Workaholism is a classic example. If you feel stressed and dissatisfied by family life, for instance, then work can be used as a wonderful excuse for never being home. If your work gives you pleasure and you get positive feedback from colleagues, if you feel in control when you are there, if you have power and status and feel productive and creative, it is easy to immerse yourself in work. It can be intoxicating and addicting, just like alcohol. And it provides a socially acceptable alibi for not being available for the family, since there is always more work to do than you can possibly get done. Some people drown themselves in their jobs. Most do it unconsciously, with all the best intentions in the world, because deep down they are reluctant to face other aspects of their lives and the need to strike a healthy balance. This maladaptive pattern is powerfully documented in Arlie Hochschild’s book The Time Bind: When Work Becomes Home and Home Becomes Work.
Filling up your time with busyness is another self-destructive avoidance behavior. Instead of facing up to your problems, you can run around like crazy doing good things until your life is overflowing with commitments and obligations and you can’t possibly make time for yourself. Despite all the running around, you may not really know what you are doing. This kind of hyperactivity sometimes functions as an attempt to hold on to a feeling of control or deeper meaning in your life when it seems to be slipping away. But it may do just the opposite by obliterating our opportunities for rest and reflection, for non-doing.
We also love to look outside ourselves for quick fixes when we feel stressed or uncomfortable. One popular way of handling stress is to use chemicals to change our body-mind state when we don’t like how we are feeling, or just to make our moments “more interesting.” To cope with the stress and distress in our lives, we use alcohol, nicotine, caffeine, sugar, and all sorts of over-the-counter and prescription drugs. The impulse to go in this direction usually comes from a strong desire to feel different at a low moment. And we have lots of low moments. The level of substance dependency in our culture is dramatic testimony to our individual pain and our yearning for moments of inner peace.
Such low moments or moods are also at the root of the thought pattern known as depressive rumination. If not recognized and held lovingly in awareness, such low moments can trigger a downward spiral of toxic and highly inaccurate thoughts leading to episodes of major depressive disorder in some people—especially those who are predisposed to this condition from earlier life events and experiences that were not fully met and resolved on an emotional and cognitive level. This is now the domain of much fruitful research and clinical work in the field of mindfulness-based cognitive therapy (MBCT), described in Chapter 24.
Many people do not feel that they can get through the day, or even the morning, without a cup of coffee (or two or three). Having a cup of coffee becomes a way of taking care of yourself, a way of stopping, a way of connecting with others or with yourself. It has its own beauty, its own inner logic, its own culture, and in moderation it can be very effective at helping you pace yourself as you face the demands of the day. Such daily rituals can deepen a sense of pausing to take in the moment. Other people use cigarettes in a similar way. Cigarettes are commonly, if unconsciously, used to get through moments of stress and anxiety. For many years, one tobacco company ubiquitously advertised its brand as “the pause that refreshes.” You light up, take a deep breath, the world stops for a moment, there is a momentary sense of peace, of satisfaction, of relaxation, and then you move on … until the next stressful moment. Alcohol is another chemical means that is widely used in attempts to cope with stress and emotional pain. It offers the added elements of muscle relaxation and temporary escape from the weight of your problems. With a few drinks inside you, life can seem more tolerable. Many people feel optimistic, social, self-confident, and hopeful when they have been drinking. The people you drink with are likely to provide emotional and social comfort and to reinforce the idea that drinking can help you to feel in control and is a normal and good thing to do. Of course, that may be true, again in moderation and under circumstances that are not habitually self-destructive.
Food can also be used to cope with stress and emotional discomfort in a similar way, almost as if it were a drug. Many people eat whenever they feel anxious or depressed. Food becomes a crutch for getting through uncomfortable moments and a reward afterward. If you have a feeling of emptiness inside, it’s only natural to try to fill it. Eating is an easy way to do it. At least you are literally filling yourself. The fact that it doesn’t really make you feel better for long does not prevent lots of us from continuing to do it to one degree or another. Using food for comfort can become a powerful addiction. It has been shown biochemically to stimulate the reward center in the brain to release opioids that damp down the hypothalamic-pituitary pathway that triggers stress reactivity. That makes us feel at ease, comfortable, good. And guess what? The foods that deliver this stress-reducing feeling are precisely those foods that are highest in fat and sugar, the so-called comfort foods that we are usually most drawn to, especially when we feel down or stressed. As with any addiction, it is very hard to break out of such cycles of eating to reduce the feelings of stress temporarily, then having to eat some more when they return all too soon, even when you are aware of the pattern. That is, unless you have a strategy for doing so and the strong determination to stick with it over the long haul. More on this subject in the chapter on food stress.
People are also accustomed to using drugs to regulate their levels of psychological well-being. Pain medications (such as the narcotic Vicodin) and tranquilizers are among the most widely prescribed medications in the United States, and the most widely abused. In Britain, there is a widely acknowledged epidemic of doctor-prescribed tranquilizer use, with people often suffering extremely debilitating side effects and developing addiction to the drugs, making it very difficult to taper off of them. Tranquilizers (such as Valium and Xanax) are most often prescribed for women, and for longer periods of time than for men. The message is that if you are feeling some discomfort, are having trouble sleeping, are anxious, are yelling at the kids all the time, or are overreacting to little things at home or at work, swallow a pill to take the edge off things, to be your old self, to get things under control. This attitude toward using prescription drugs as the first line of defense to regulate anxiety reactions, depression, and symptoms of stress is very prevalent in medicine. Drugs are convenient and they work, at least for a while. Why not use them? Why not give someone a convenient and effective way of feeling more in control?
For the most part this perspective goes unquestioned in medicine. It is a tacit framework within which the daily work of medicine is conducted. Doctors are bombarded with drug advertisements in medical journals, and drug salespeople are always dropping off free samples of the latest drugs to try out on their patients, as well as notepads, coffee cups, calendars, and pens, all emblazoned with drug names. The pharmaceutical companies make sure that medicine is practiced within a sea of highly visible drug messages.
There is nothing wrong with drugs per se. In fact, as we all know, medications play an extremely important role in medicine. But the climate that is created by aggressive advertising and sales tactics can have strong subconscious influences on the practitioners of the art, leading them to think first and foremost about which drug they should be prescribing rather than whether they should be prescribing any drug at all as the first line of approach to a particular problem—especially if there is a major lifestyle component to the condition or illness, or if the problem and troubling symptoms have been shown to be positively and in some cases dramatically affected by non-pharmacological means, such as mindfulness practices for pain and anxiety (see Part IV, and in particular, Claire’s story in Chapter 25).
Of course, this attitude toward drugs pervades the entire society, not just medicine. We are a drug-ingesting culture. Patients often come to the doctor with the expectation that they will be “given something” to help them. If they don’t leave with a prescription, they might feel the doctor is not really trying to help. The over-the-counter products for pain relief, for controlling cold symptoms, and for speeding up or slowing down movement through the colon alone constitute a multibillion-dollar industry in this country. We are inundated with messages telling us that if our body or mind is not feeling the way we would like it to feel, we should just take X and we will be in control once again.
Who could resist? Why would anyone go through the discomfort of a headache when you could take an aspirin or a Tylenol? The fact that we take drugs on many occasions just to suppress symptoms of disregulation usually goes unnoticed. We use them to avoid paying attention to the headache or the cold we have, or to our GI tract when it is problematic, instead of asking ourselves whether there is a deeper pattern and meaning underneath our immediate symptoms and discomfort that might be worth attending to. That doesn’t necessarily suggest you shouldn’t take the aspirin or the Tylenol. But you could bring awareness to the impulse to go for the quick fix (and your strong desire to suppress the symptoms), and before you take the drug you could at least experiment with bringing a self-compassionate and non-judging awareness to the experience you are having as best you can, at least for a time, and see what happens.
Given the dominant attitude toward drugs in our society, it is little wonder that there is an epidemic of illegal drug use in our country. The driving force among the consumers of illegal drugs is ultimately the same mind-set: that is, if you don’t like things as they are, take something that will put you in a better state. When people feel alienated or excluded from the dominant social institutions and norms, they are likely to explore ways of relieving those feelings of alienation through the most convenient and immediately powerful means available. Drugs are convenient and they have very immediate effects. Illegal drug use is presently occurring at all levels of society, beginning with widespread abuse of drugs and alcohol among teenagers. According to a 2010 National Survey on Drug Use and Health, more than twenty-two million Americans age twelve and older—nearly 9 percent of the population—use illegal drugs.
Many of the ways people use chemicals, legal and illegal, for attaining a sense of control, peace of mind, relaxation, and that good feeling inside themselves are potential examples of maladaptive coping attempts, especially when they are unexamined or lead to an unhealthy dependency. They become particularly unhealthy when they drift into the realm of the habitual and become the only or the dominant means we employ for controlling our reactions to stress. They are maladaptive because they can compound stress in the long run, even if they provide some relief in the short run. They can rapidly become impediments to adapting effectively to the stressors we live with and to the world as it is. In the long run, as a rule, they don’t make us healthier or happier because they don’t help us to optimize our own capacity for self-efficacy, self-regulation, emotional balance, and the cultivation of our own deep biological capacity for homeostasis and allostasis.
In fact, they ultimately add to and compound the stress and pressure we are under. This is indicated in Figure 9 by the arrow going from substance dependency back to the person. Reliance on chemicals easily leads to a false sense of well-being, distortions in perceptions, and clouding our ability to see clearly, thus undermining our motivation to find healthier ways to live. In these ways, they can prevent us from growing and healing—at least until we realize that there are other options.
The substances we seek out to relieve stress are also stressors on the body in their own right. Nicotine and the other chemicals in cigarette smoke are implicated in heart disease, cancer, and lung disease; alcohol plays a role in liver, heart, and brain disease; and cocaine can result in cardiac arrhythmias and sudden cardiac death. All are psychologically addicting; nicotine, alcohol, and cocaine are physiologically addicting as well.
A person can live for many years cycling through episodes of stress and stress reactivity followed by maladaptive attempts to keep body and mind under control, followed by more stress, followed by more maladaptive coping, as shown in Figure 9. The habits of overworking, overeating, hyperactivity, and substance dependency can keep you going for a long time. If you choose to look, it is usually evident that things are getting worse, not better. Your body can tell you a thing or two, if you are willing to listen. And if you are in this situation, the people closest to you are probably trying to get you to see it and seek professional help. But when your habits have become a way of life, it is very easy to discount what other people are telling you, and even to deny what your body or mind is trying to tell you. Your habits provide a certain comfort and security that you don’t want to give up, even if they are killing you. Ultimately, all maladaptive coping is addictive, and we pay a huge price for it both physically and psychologically. Basically, it keeps us disregulated and prevents us from living our way into the potential fullness of our lives and loves and into freedom from untold delusion and suffering.
As Figure 9 suggests, sooner or later the accumulated effects of stress reactivity, compounded by inadequate and ultimately toxic ways of dealing with it, lead inevitably to breakdown in one form or another. Mostly it will happen sooner rather than later because our internal resources for maintaining homeostasis can take only so much overload and abuse before they succumb and collapse. Research in the new field of epigenetics is showing this very clearly. It is in the interaction of our genes with our environment—which includes our lifestyle choices, how we behave, even how and what we habitually think, and, it appears, whether or not we practice mindfulness and other forms of meditation—that the genome is regulated and our susceptibility to various diseases made more or less likely.
When we are not optimizing our epigenetic options to promote and nurture our overall health and well-being through the choices we make about how to be in wiser relationship to our own body and mind and to the world—in the face of our chronic stress reactions and our often less-than-helpful attempts at coping—what gives out first will depend to a large extent on our genes, on our environment, and on the particulars of the way of living we have settled on. The weakest link is what goes first. If you have a strong family history of heart disease, you might have a heart attack, especially if other factors that increase the risk of heart disease—such as smoking, a high-fat diet, high blood pressure, and cynical and hostile behavior toward others—are prominent features of your life.
Alternatively, you may reach a state of disregulation of immune functioning, which may make cancer of some kind, or an autoimmune condition, the more likely outcome. Here too the interaction of your genes, your exposure to carcinogens during your lifetime, your diet, and your relationship to your emotions might make this pathway either more or less likely. A stress-provoked drop in immune function could also lead to greater susceptibility to infectious diseases.
Any organ system could be the ultimate weak link that leads to disease. For some it might be the skin, for others the lungs, for others the cerebral vasculature leading to a stroke, for others the digestive tract or the kidneys. For others it might be an injury, such as a disk problem in the neck or lower back, made worse by an unhealthy lifestyle. Or it might be the burden the body faces by carrying unnecessary weight and excess fat in the wrong places, in particular the abdomen.
Whatever the actual form of the crisis, maladaptive attempts to cope with stress ultimately culminate in breakdown of one kind or another. If the breakdown does not result in death, then it just becomes one more major stressor that you now have to face and work with on top of all the others you already had in your life. In Figure 9, breakdown itself becomes the source of one more arrow feeding back on the person, necessitating even greater adaptation.
There is another branch of the stress reaction pathway, not depicted in Figure 9, that becomes important when a person is faced with unavoidable stress sustained over long periods of time. Examples might be caring for an elderly parent who is ill or who has Alzheimer’s disease, or caring for a disabled child. Here all the stressors of daily living are compounded by a whole other set of potentially overwhelming stressors associated with the long-term demands of the situation. If adequate short- and long-term strategies for adapting to the situation are not developed, the pressures of daily living can mount to the point where the person is constantly in a state of hyperarousal, reacting repeatedly to even insignificant stressors with tension, irritability, and anger. Continued arousal with little ultimate control over the fundamental stressor can reach the point where feelings of helplessness and hopelessness begin to dominate. Rather than hyperarousal, chronic depression can set in, leading to a different spectrum of hormonal and immune system changes that, over time, can also undermine health and lead to breakdown. This is clearly demonstrated in a study of mothers caring for children with chronic health problems, in which the rate of degradation of telomeres in leukocytes and of oxidative damage were significantly higher than in mothers of healthy children—but, amazingly, only for those mothers who reported high levels of perceived stress. In other words, those who had found ways to see stress as an expected part of life and manage it effectively and therefore did not report high levels of perceived stress, did not show the high rate of telomere shortening, nor did they show oxidative damage.c
Breakdown in the stress reaction pathway does not have to be primarily physical. Too much stress and not enough effective coping can lead to a depletion of our emotional and cognitive resources to the point where you might experience what is sometimes called a nervous breakdown, a feeling of being completely unable to function in your ordinary life anymore. This condition may reach the point of requiring hospitalization and drug treatment. Nowadays it is fashionable to use the word burnout to describe a similar state of near or total psychological exhaustion with an accompanying loss of drive and enthusiasm for the details of your life. What used to give you pleasure no longer does, and your very thought process and emotional life are severely disregulated.
A person experiencing burnout feels alienated from work, family, and friends; nothing seems meaningful anymore. A deep depression can set in under these conditions and can lead to a loss of ability to function effectively. Joy and enthusiasm disappear. As with the physical examples of breakdown, if psychological breakdown occurs, it becomes one more major stressor that the person now has to deal with, one way or another.
This cycle of a stressor triggering a stress reaction of some kind, often accompanied by an internalizing of the stress reaction, leading to inadequate or maladaptive attempts to keep things under control, leading to more stressors, more stress reactions, and ultimately to an acute breakdown in health, perhaps even to death, is a way of life for many of us. When you are caught up in this vicious cycle, it seems that this is just the way life is, that there is no other way. You might think to yourself that this is just part of getting older, a normal decline in health, a normal loss of energy or enthusiasm or feelings of control.
But getting stuck in the stress-reaction cycle is neither normal nor inevitable. As we have already seen, we have far more options and resources for facing our problems than we usually know we have—creative options, imaginative options, healthy options. The healthy alternative to being caught up in any of our self-destructive patterns is to stop reacting to stress and to start responding to it. There are lots of ways to do this, not one. This is the path of mindfulness in daily life.
* Think of acute stress as like a gazelle that mobilizes a huge fight-or-flight reaction to escape from a lion on the savanna; once a safe distance has been attained, it goes back to quiet grazing as if nothing had happened. For us humans, it is somewhat different, because we can think about what might have happened, even after the immediate threat is over, and drive ourselves crazy in the process. The trauma of the near miss can stay with us for a long time, and needs a certain kind of attention if we are to effectively work with it and resolve it to one degree or another.
† For our purposes here, I am labeling it a reaction to emphasize its often automatic and relatively unconscious nature. That way, I can reserve the term response for a relatively more conscious course of action in the face of a challenge or threat. But the fact is that whatever we choose to call it, fight or flight is an extremely complex phenomenon in both the brain and the body. It has highly evolved and vital elements of perception, appraisal, evaluation, thought, and choice associated with it, even though we may be, on the whole, unaware of these processes—unless we cultivate the capacity to pay close attention from moment to moment, through the application of mindfulness, to our actual experiencing of what is unfolding in our mind and body. In this way, we can transform habitual and unexamined reactions—many of which we may have acquired and reinforced through repetition over the course of years and decades and only recently realized are unhelpful, if not toxic, in particular life situations—into more appropriate, skillful, and mindfulness-mediated responses…
‡ Davidson and Begley, The Emotional Life of Your Brain, 69.
§ For instance, dopamine is secreted by the hypothalamus, as well as other regions of the brain, and is known to function in attention, learning, retaining information in working memory, and pleasurable experiences. Serotonin regulates mood, appetite, and sleep and is associated with feelings of well-being and happiness. It is primarily secreted in the intestinal tract.
‖ This is also the case for social stress, which can also be hugely threatening. One of the most common ways in which we feel threatened is when our social identity, our sense of how others are perceiving us, is threatened. Embarrassment, shame, being rejected by others, and negative thoughts about ourself are all potent triggers of the habitual stress reaction and of its downstream consequences in the body. We understandably take all this very very personally. Yet it might not be the complete story of who we are. This will be a major theme in Part 4.
a The situation may be a bit more complicated than this model suggests, since women may react differently than men in some kinds of challenging situations. The psychologist Shelley Taylor of UCLA suggests that women also have a tendency to “tend and befriend” in threatening situations—taking care of their young and seeking social support. For more on this and on the complexities of stress biology and psychology, see Sapolsky R. Why Zebras Don’t Get Ulcers. 3rd ed. St. Martin’s Griffin, New York; 2004.
b See for example: Bhasin MK, Dusek JA, Chang, BH, et al. Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways. PloS ONE 8(5): e62817; May, 2013. doi10.1371/journal.pone. 0062817.
c Epel ES, Blackburn EH, Lin J, Dhabhar FS, et al. Accelerated telomere shortening in response to life stress. PNAS. 2004;101:17312–17315.