You can reduce the chances of your heart disease progressing and of having another heart attack by modifying these harmful traits in your personality.
The labels ‘Type A personality’ or ‘coronary prone person’ may make you feel that these traits are unalterable. In fact your personality is a collection of behaviour patterns, each of which can be modified with some effort.
Dr Meyer Friedman and Diane Ulmer’s research proves beyond doubt that modifying Type A behaviour can drastically reduce the risk of further heart attacks and death. They found that within the first and second years of the programme they achieved a 48% to 62% reduction in the recurrence rate and at the end of the third year there was a stunning 372% reduction. Apart from the lower recurrence rate, the patients in the Type A modification group who did have a heart attack had a lower death rate.
Note that this reduction in the recurrence rate in Dr Friedman’s group was achieved without any major effort at modifying the participants’ dietary habits or other risk factors. An intensive programme such as this one aims to modify one’s diet, exercise and stress levels in addition to changing Type A behaviour and is likely to achieve much more.
Dr Friedman’s patients met for 90 minutes once a week for the first two months, then once in two weeks for another two months and finally once a month. Their main focus was on changing Type A behaviour and not on diet and lifestyle.
Dr Friedman analysed the fate of dropouts from his programme and found that their recurrence rate was twice that of those who stayed in the programme. They also analysed the patients who had another infarction and found that in most cases it was associated with poor compliance to the programme.
Modifying your behaviour will require a sustained effort. Practise the techniques daily and you will find that over a period of time your personality will start changing.
The most toxic part of the Type A personality is free floating hostility and self-involvement followed by the need to control and status anxiety. So I would suggest that you aim at modifying these aspects of your personality first.
You first need to convince yourself of the need to change your personality. Many Types A persons refuse to acknowledge having Type A traits. I remember one patient telling me, “Doctor, I’ve read the description of the Type A person. It doesn’t apply to me.” It took him quite some time to admit that he had a number of these traits.
To be able to change your behaviour you must first develop awareness of behaviours you need to change. You will need to develop the observing part of your ego — the ‘witness’. This has also been called the inner observer. It requires practice to develop the ability of objective observation. You will need to learn how to become aware of the harmful patterns at an early stage in the chain from thought to behaviour. This will enable you to change this behaviour and substitute it with more healthy alternatives.
Research on patients’ multiple personalities have shown that they all have an inner self called the Inner Self Helper (ISH), which helps the other sub-personalities heal. The ISH is able to take a detached calm view of feelings such as pain, greed, jealousy and hostility. With practice, one can tap into and utilise this part of one’s personality for inner growth.
A useful way of developing the capacity to observe things objectively is to maintain a daily log. In this log you can note down upsetting thoughts, sensations and feelings and the incidents they are related to. Writing things down will help you distance them and at the same time examine your own recurrent patterns. Mindfulness training is another useful way of developing the ability to observe your thoughts dispassionately.
To begin the process of modifying your Type A behaviour you first need to take a thorough detailed self-inventory. Read through the chapter on Type A behaviour again and note down the traits that you may have.
Get feedback from your spouse and if possible from close friends and even your children. Getting feedback may be a major leap for you, so listen carefully, avoid trying to justify yourself or react to what is being said, try to suspend judgement and listen carefully. Then spend time reflecting on the effect your Type A traits may have had on your job, relationships and health.
You need to motivate yourself continually to change your harmful Type A traits. You will need to carry out the mental drills that are a part of the programme for many months.
Some people are motivated by positive experiences. They make pictures of the positive things that would happen if they were to do something. Others are motivated by thinking of the negative consequences of not doing something. Find what motivates you and set up a system of self rewards and punishments to help you stick to the programme.
Involve your spouse and close friends in this process because they can give you a lot of useful feedback. Others can often see things that you may not notice about yourself and they can remind you to stick to your programme.
Mental imagery is a very powerful tool for building motivation. You can do this by repeatedly and vividly imagining scenarios in your mind’s eye. While practising imagery, it helps to sit comfortably and put yourself into a state of deep relaxation. Then imagine the scenarios as vividly as possible. At first you may be a little unfamiliar but with practice you will find the imagery becoming clearer and more real. Soon it will start driving your behaviour. The more vivid and real you make the imagery, the sooner you will find yourself experiencing the benefits.
Start by imagining the effect of continuing with your present Type A behaviour. See the effect of your behaviour on your health and relationships with your wife, children, other family members and friends. Create vivid scenarios that will dramatically bring home the message and set up a causal chain between continuing your present unwanted behaviour and the negative future consequence. You may, for example, imagine that you keep getting angry at your wife’s or co-worker’s mistakes. See how continuing this leads to a heart attack. See yourself lying in a hospital bed. Make up a number of such scenarios so that whenever you become aware of any Type A traits in your everyday behaviour you will recall the possibility of ending up with a heart attack.
To build ‘positive motivation’ utilise mental movies of you changing your behaviour and the pleasant consequences that follow. For instance, you will find that by imagining yourself delegating work you get a feeling of calm and relief from pressure and see yourself enjoying time with your family. If you make the imagery (images, sound, feeling, taste and scent) real and positive, you will find yourself following the programme automatically.
Most people fear change. Usually the known is familiar and comfortable. Therefore do not be surprised if your mind brings up objections to your changing. The commonest resistance is denial, not acknowledging the fact that you have Type A traits. While you may not be a full-fledged Type A person, there is a strong likelihood that you have some traits that have contributed to your coronary artery disease. Hence to improve the quality of your life it is advantageous that you aim at transforming your personality into a Type B personality.
You may find that you give yourself excuses not to change such as “if I did not get angry, people would take advantage of me” or “there are many evil people in the world and they need to be reformed” or “I would get very little done if I do not do as much in the same time.” While all these reasons seem rational, the basic question you need ask yourself is, “Is this worth giving up my life for?”
Another trap to avoid is that of trying to type others, making them aware of their harmful personality traits, rather than your own. You need to focus on changing yourself first, not the world.
The basic cause of Type A behaviour will vary in each person but quite often related to a sense of insecurity and inadequacy.
Dr Meyer Friedman believes it is due to inadequate self- esteem. Others feel it is due to a cynical mistrust of others. Dr Dean Ornish is of the opinion that “Self-involvement, hostility, cynicism, are really the effects of a more fundamental cause, the perception of isolation.” He is of the opinion that the heart patient is isolated from himself, others and something spiritual.
My own feeling is that the hostility is due to low self- esteem which causes the insecurity. The person feels that he is not good enough and has to keep struggling to feel good by proving that he is better or different from others. One way is through achievement or gaining power or status, the other is by feeling superior to others. But you must remember that this may not be true in your case. Generalisations are useful as a guide but need to be checked out before they are accepted by an individual.
Self-hypnotic explorations of the unconscious mind are one way of determining the root cause of your heart disease. You will also be able to explore the genesis of certain personality traits that maybe contributing to your illness. Your symptoms and upsetting emotions can be used as a gateway to the core of your illness. In this way you avoid the danger of falling into the Procrustean bed of any therapeutic system.
You need to learn to trust people, especially their motives. Letting go and forgiveness are other skills that you may need to learn.
If you follow this you will gradually start seeing the world as a more friendly place and it will allow you to open up to others and appreciate them.
These attitudes are very similar to those taught in the Buddhist tradition where forgiveness and compassion are a part of the training. By practising Mindfulness meditation one often comes to this realisation by oneself.
Become aware that you have hostile, critical, or angry thoughts towards others. Note them down in telegraphic form in your diary. Write a short description and the upsetting thoughts that were triggered by it. Next to these thoughts write down a more rational alternative, giving the other person the benefit of doubt and trying to see the other person’s point of view with compassion. This process is called cognitive modification and it is a very effective way of modifying your upsetting thoughts.
For example, if you notice a taxi driver speeding and overtaking you, your automatic upsetting thought is, “Foolish taxi drivers don’t care for anyone else.” One could replace it with the thought, “Unfortunate person probably isn’t educated or he would not be doing this” or “Perhaps he’s taking someone to the hospital.” Often this is all it takes to calm you down.
Another way of dealing with the upsetting, hostile thoughts is to use the Stop Technique. Repeat the word ‘stop’ mentally and simultaneously visualise a stop sign. Often this will abort the obsessive preoccupation with that event and an internal temper tantrum. The trick is to try to abort the thoughts as early as possible. You can tell yourself that you will examine the upsetting feelings later during your self-hypnotic or meditation sessions.
Practise the ‘Quieting Technique’. Recall an amusing thought and smile inwardly; then take a deep breath. Repeat ‘amused mind, calm body’ a few times and sense your body becoming calm as in your relaxation sessions. Practise this technique several times a day whenever you become aware of any upsetting thoughts or tension in your body.
Once you can do this automatically, spend a few moments at night reviewing all the upsetting things that happened during the day and practise the Quieting Technique as you think of each of them.
Maintaining a log of hostile thoughts or behaviours in your diary is a very important tool. By studying your hostility log every few days you will be able to identify certain theme patterns and notice certain triggers. For example, you may notice that you get angry when people keep you waiting or when people overtake you. You can then work on modifying them in your Self-Hypnosis and Imagery sessions or using Cognitive Modification.
The major peaceful religions of the world such as Jainism and Buddhism recognise the importance of compassion in the reduction of suffering. The most artful practitioners of compassion are the Tibetan Buddhists who suffered untold brutality at the hands of the Chinese. Yet Dalai Lama does not get angry about the horrific acts. In fact Dalai Lama is said to pray for the Chinese leaders so that they might be enlightened. When someone asked Dalai Lama about this he is reported to have said, “They have taken away everything we have, should I let them take away my mind as well?” This is an attitude that you can learn how to respond with compassion rather than anger. Practise forgiveness when you find yourself getting angry, even if you are in the right!
Many therapists have taught of the healing qualities of love. Dr Gerald Jamplosky, who runs a centre for attitudinal healing in California and is the author of a number of well known books on healing such as Love is Letting Go of Fear, teaches patients with chronic illness the principles of attitudinal healing. The basic goal is to attain inner peace and to achieve this he suggests that one let go of negative feelings such as fear, hate and guilt and replace them with love.
The body is a self-regulating system and once the system is in balance, the natural healing capacities are released. Dr Bernie Siegel, author of Love, Medicine and Miracles, also reports the cases of cancer patients who have had spontaneous regression in their illness after learning experience inner peace.
You have learned the meditative technique to generate compassion. Use it frequently to deal with upsetting people and upsetting situations. Use it even when you are angry with yourself.
Self-hypnosis is a very useful way of changing your behaviour as will be explained later. Hypnosis is also a good way of exploring the root cause of any unpleasant feelings or behaviours.
You will learn how to do this in the chapter on ‘Mind-Body Healing’ and to use self-hypnosis in order to change your behaviour, and to explore the unconscious causes of unwanted feelings and behaviours.
There is a difference between being assertive and being aggressive. An assertive person learns how to express his anger in a constructive way. On the other hand, an aggressive person usually gets worked up and has explosive outbursts of anger. People who cannot be assertive often become hostile.
The major skill in being assertive is to recognise that it is possible to express one’s irritation or anger in an appropriate way. For example, it is possible to use ‘I’ language to express one’s irritation. If someone has kept you waiting for a long time, instead of exploding or internalising the anger and feeling hostile it is possible to tell the person after listening to his reason, that ‘I’ got upset that you kept me waiting. Please do not do it in future.”
Being assertive also helps you avoid getting into situations that upset you. With someone who is chronically late you can clearly specify how much time you have and how long you will wait and what will happen if the person is late.
Assertiveness training includes information on deciding which situations it may not be possible or desirable to be assertive in, such as when you have to sell something to a person.
Assertiveness is also a core skill for time management as many people are not able to say ‘no’ and take on too many assignments and social engagements.
The Type A person is often driven by the need for power, control and influence. This often leads to a situation where the person delegates things but is not able to let go.
This also leads to an uncomfortable relationship with one’s juniors and they do not grow to fulfil their full potential.
The way to deal with this is to be aware of the need to be in control and to take the risks involved to learn how to trust people. To start with it may be difficult, but as you grow to trust people, you will find that it becomes easier to give up control and delegate.
To reduce stress and the feeling that one is constantly struggling, one must learn time management. One must also prevents a one-sided emphasis on work and bring more joy and balance into ones life.
You may find that you schedule too many things to be done in a short period of time so that you always feel pressured.
You will need to learn how to differentiate between things that are important or which have to be done immediately and unimportant tasks that can be put off for another day or scrapped altogether.
Work out your long-term goals and values. See that your goals are balanced and include family, recreation exercise and fun. This will help you manage your time better by being able to determine the importance of the things that you do. To start off it is useful to maintain a written list that you can follow.
It is worth attending a time management training course so that you can learn the inner skills of time management, especially the one which teaches you to make internal changes so that you do not require external aids like planners.
You will also need to examine your deeply-held beliefs about time and achievement. A number of people with coronary artery disease strongly believe that their worth as a person is related to their achievements.
Mr Velu is an example of this. A few weeks after his heart attack he was back at work and within the month he was working 16 hours a day. His wife got extremely worried but he kept telling her, “If I don’t, who will? The company will go to pieces and I will be a failure.” Mrs Velu kept after him, telling him it was better to be a failure than to die before his 50th birthday, but to no avail.
Mrs Velu consulted a counsellor who suggested she shift tack, “Wake him up earlier than usual in the morning and pack him lunch and dinner giving him the message that you want him to work harder.” At first Mr Velu was puzzled but a few days later he asked why she was no longer complaining. Mrs Velu replied “This way I’ll have you out of my life sooner; I’m fed up competing with your company. You can die in ‘her’ arms. I’m still young enough to enjoy a few years of fun with the money you leave me.”
Mr Velu got very upset as he realised, for the first time, that his wife and children were strangers. He started coming home earlier but made no other changes and died of an infarction two years later.
Usually the years of struggle leave their mark. The constant striving for status and power often leaves the Type A person tired, exhausted and alienated. At some point, the lack of meaning in his one-sided life starts impinging on his consciousness and arousing anxiety.
He starts craving for an escape from the treadmill. One way is to have an infarction, the other is to do something that is self-destructive such as having an affair, making risky or foolhardy decisions or doing something illegal.
It is important that you recognise this aspect of Type A behaviour and keep a track of your own. This self-destructive urge may also manifest itself as smoking, eating high fat meals and exercising or drinking too much.
Once you develop awareness of this trend, you can stop yourself. You need to deal with the underlying feelings of futility by re-engineering your life as to increase the amount of joy in your life.
Spirituality, rather than religion, offers a way to repair the damage to one’s life and personality by turning inwards to find peace and processing negative emotions such as envy, greed, paranoia, possessiveness and anger.
Doing something helpful for others can provide meaning to one’s life. It also reduces the self involvement which has been correlated with an increased risk of a recurrent attack.
Creating something that awakens a sense of awe or wonder at existence is helpful in making life more joyous and worth living. All these are important if you wish to regain a strong will to live. Without the will, you are unlikely to make the effort to heal yourself.
Meditation is one method of experiencing spirituality in your own life. If you meditate regularly you will find that your mental attitudes will gradually shift so that you become more spiritual.
There is nothing soft, foolish, or weak about being spiritual. In fact it makes you a much stronger and more effective person as you are more comfortable with yourself.
Often people with coronary artery disease find life very grim and tiring. Many feel there is little to live for and at some level may be seeking a way out. Therefore it is important to bring back a sense of joy to your life.
You will need to re-establish links with friends who you can communicate with. You may need to change a judgemental way of relating to people. Friendship is one of the greatest joys in the world, but one should be careful to avoid negative, judgemental and toxic people, who feed your sense of hostility.
You will also need to find other ways of nourishing your life, good books, communion with nature and the ultimate high of helping others and leaving the world a better place.
All this takes time and if you are in the habit of evaluating things in terms of numbers or money, you will have to change. It would be absurd to think that the only purpose of life is to accumulate things or earn more money. Research has shown that except for the very poor, making more money has no relationship to happiness, especially for the middle class or the rich. Hence one needs to think about the purpose of life and one’s most cherished and deepest values, for it is only if these are being satisfied that you will find true satisfaction and happiness in life.
Dr Meyer Friedman’s programme used quotations as a therapeutic technique. Patients were given four or five quotations every month, which they were advised to read daily. Every month they were given a new set of quotations to help them re-examine their philosophy of life.
Many hostile people are exceedingly proud of their ideals and get angry at people who do not live up to them. Reading the sayings of wise men who contradict their views can force you to re-evaluate your own philosophy and ideals.
I suggest that you collect quotations with the help of a friend or your spouse. Write them down in your diary and read them regularly. I have collected a number of quotations that my patients have found useful. For a free copy write to me care of the Institute of Psychological Medicine (see appendix).
A support group can be very helpful and therapeutic. Dr Dean Ornish’s programme for ‘Reversing Heart Disease’ uses the therapeutic group as a major instrument for change. The patients first meet for a week-long retreat and then meet twice a week for 4 hours as a group, which is a major source of change in the Ornish Programme.
Dr Ornish does not target Type A behaviour for change but most patients report that their Type A behaviour is transformed to Type B in the group. In the group patients learn to deal with the fear of death, express their emotions and learn how to trust and help others.
Dr David Spiegel of Stanford University has done research with breast cancer patients who were included in a group where they could express their feelings and get support from the group. He feels that expressing upsetting emotions in the group helps get them out of one’s system. Unless expressed in some way, painful emotions retard healing. Dr Spiegel found that the average survival rate for patients in his group was twice that of a group which received ordinary medical treatment without group support.
Psychotherapy is the most useful method of psychological change, especially if you find a good individual or group therapist who is familiar with mind-body healing. Hypnotherapy is especially useful for this condition. It might be better to avoid the older schools of psychotherapy as therapeutic change can be slow and often brings up intense feelings that may trigger an attack.
The programme in this book is designed so that you can work on it yourself. This is because there are few psychotherapists that have experience dealing with the medically ill. Most psychiatrists are biologically oriented and mainly prescribe medication for psychological disorders. Psychotherapy is not a regulated profession in India and anyone can set himself up as a psychotherapist, hence one needs to be careful about who one consults. However if you can find a good therapist it will make this programme much more effective.