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Stress and Heart Disease

Many consider Stress to be a major cause for premature death from heart disease today. Thirty years ago as a medical student, I was taught that coronary artery disease was so rare in a young adult below 40, that it was the last thing considered while making a diagnosis in a case of chest pain. In fact if one mentioned it at an exam one was sure to fail. At that time coronary artery disease in women under 50 was nearly unheard of, though today it is quite common.

Many cardiologists and cardiac surgeons in India have observed that over the last few years people are coming in for bypass surgery at a much younger age and many more women are developing coronary artery disease. They claim that people are developing more severe heart disease than some years ago. Stress and a western lifestyle are often blamed for this increasing incidence and severity of coronary artery disease.

WHAT IS STRESS?

Stress is the demand on the person from the environment that requires an adaptive response. Stress can be caused by both external events and by internal psychological processes. Most people equate stress with having to cope with external crises or demands. It is important to remember that stress can be caused by internal psychological conflict as well.

Human beings have evolved from animals and share a similar biological heritage. Our evolution has provided us with very powerful survival mechanisms. The human species is a rather recent entrant on the evolutionary scheme. Many of the survival mechanisms that served our ancestors well in the jungle are not adapted to the needs of life in the modern age.

THE RESPONSE TO STRESS

Our ancestors lived in difficult and dangerous conditions in the jungle. In order to survive they developed two major mechanisms to deal with danger. The first is the Fight or Flight Response where the organism prepares itself to fight or to run away, whichever is more appropriate to a situation. The fight or flight response is mediated by the sympathetic nervous system. It is associated with the release of catecholamine and corticosteroid hormones.

The second response to stress is a Freezing Reaction, during which the animal freezes, becomes quiet and does not move. This reaction is associated with the stimulation of certain areas of the brain with the release of serotonin. In humans this leads to anxiety and panic.

Following the stress response there is a Quieting Phase brought associated with activation of the parasympathetic nervous system. This brings back the activated physiological reactions to a restful state after the emergency is over.

In the modern world, the ‘fight or flight response’ is activated many times, but the person may not fight or run away. Therefore the quieting response may not be activated. This can leave the person in a state of near constant alarm for hours on end, leading to exhaustion. As soon as the brain detects situations that could be dangerous, it responds by stimulating the sympathetic nervous system. This leads to the release the catecholamine hormones, noradrenaline and adrenaline. These hormones cause the blood vessels to constrict and the heart to beat faster, preparing the organism to deal with an emergency. This sudden release of catecholamines leads to surges in the blood pressure which causes small tears in the endothelial lining of the coronary arteries. These tears are then plugged with cholesterol and fibrous tissue.

On the other hand, during the Quieting Reaction, the parasympathetic nervous system is activated. The arteries dilate, the heart beats slowly and the metabolic rate drops. The practice of various psycho-physiological techniques such as yoga, relaxation and autogenic training help develop the ability to trigger this response.

The fight and flight response’ was useful for jungle survival, in today’s high pressured modern life it can cause a host of health problems. A telephone ringing, the brake-lights of the car in front, a loud noise such as a siren or horn can all trigger this response. In addition are the events which are perceived by the person as dangerous— having to give a speech, appear for examinations, a summon from the boss and innumerable situations in daily life activate the sympathetic nervous system and even thinking about something that annoys you can lead to sympathetic activation.

RESPONSE TO CHRONIC STRESS

The great stress researcher Dr Hans Syle, noticed that people who were ill or under pressure all looked very similar. This observation led him to study the physiological changes and the body’s response to stress and to his identifying the mechanism by which stress causes disease.

Dr Syle identified three phases of the response to chronic stress, which he called the General Adaptation Syndrome or GAS. The first phase is the ‘Activation Phase’, during which the struggle hormones adrenaline and noradrenaline are released. The next phase comes into play if there is repeated activation of the stress response and is called the Resistance Phase. During this phase, in addition to the sympathetic hormones cortisol, a steroid hormone is released from the adrenal glands. This hormone is similar to cortisone and is known to cause high blood pressure, weight gain and atherosclerosis. The third stage is the Exhaustion Phase where the body and mind break down and develop some disease.

STRESS AND DISEASE

Stress has been recognised as a cause of many medical conditions. In addition it influences the course of a number of illnesses. People in certain stressful occupations are at an increased risk of developing various illnesses, for example, air traffic controllers who have to remain alert for long hours and make split second decisions on which many lives rest.

Similarly, the incidence of heart attacks among American accountants increases many fold in April around the time they have to file their clients’ income tax returns.

Loss is another cause of stress and it is well known that the incidence of coronary disease is much higher in the year after one loses a spouse. Again, in the months following the loss of a job or retirement, there is a higher incidence of infarctions.

Dr Thomas Holmes and Dr Richard Rahe studied large numbers of people and developed a Scale called the Social Adjustment Rating Scale. In this scale they quantify the stress in life change units (LCU). On the basis of their research on American populations they assigned certain values to indicate how stressful certain events were. For example, death of a spouse is rated at 100 LCUs, a vacation as 13 LCU and the loss of a job at 47 LCUs. Their research shows that people who accumulate more than 300 LCU in a period of six months are much more likely to have an infarction.

STRESS AND SUDDEN CARDIAC DEATH

Sudden cardiac death is often preceded by stressful events that provoke significant excitement, despair or both.

Voodoo death is a well-documented phenomenon and is known to take place in various tribal communities such as the Australian aborigines. It is common for people in these communities to die after they have been cursed by a Shaman. The psychiatrist Dr Eric White of the University of Kansas described seeing a case of a healthy native Australian aborigine who developed severe medical shock and nearly died after he had been cursed. Aggressive medical treatment proved useless and the patient only recovered after the local white doctor threatened to charge with murder, the person responsible for the curse and only then was the curse lifted. This shows the power of belief and the way in which acute stress can kill a person.

Over-stimulation of the sympathetic nervous system can also trigger fatal changes in the rhythm of the heart called ventricular fibrillation.

STRESS AND ATHEROSCLEROSIS

People who are under chronic stress are at a higher risk of developing atherosclerosis, causing the arteries to become narrower. As explained earlier, the inside of the artery has a smooth lining of cells called the endothelium. In response to increased blood pressure brought about by the release of catecholamine hormones when the stress response is activated, the inner lining of the artery develops minute tears. In the presence of stress hormones and elevated levels of cholesterol, the tear in the artery is filled with a cholesterol plug around which fibrous tissue grows and this blocks the artery.

STRESS AND THE CARDIAC PATIENT

Chronic stress leads to an elevation of the blood cholesterol level and increased rate of atherosclerotic changes in the arteries. In addition, the over-stimulation leads to an increased risk of arrhythmias due to high circulating levels of catecholamines (adrenaline like substances).

Experiments on patients with coronary artery disease have shown that even minor stressors can lead to dangerous heart rhythms. Dr Peter Taggart did an experiment with 30 doctors of whom 7 had coronary artery disease. He connected them to a device that recorded their heart rhythms while they were speaking in public. He found that in the majority of doctors the heart rate shot up from the normal 70-80 beats per minute to 150-180. More important all the doctors with coronary artery disease developed abnormal heart rhythms.

Dr Robert S. Eliot, the author of Is It Worth Dying For? was asked to investigate why healthy young space scientists were suddenly dying of heart attacks at NASA in the late 1960s. These men did not have the traditional risk factors such as hypertension or raised cholesterol levels. Even autopsies did not show any significant blockages in their arteries. Finally they found uncommon changes in the heart muscles, now called contraction band lesions. These lesions are caused by the release of large quantities of adrenaline like substances in the blood. On investigation, he learnt these scientists were under intense work pressure to meet project deadlines. This also disrupted their family lives, adding to the stress and worse still many of them were on contract and stood to lose their jobs following a launch. All this pressure and uncertainty played havoc with their hearts.

Dr Robert Eliot has also found that some (20%) of the people he examined responded to stress with highly exaggerated physiological arousal. Their blood pressure and heart rate shot significantly more than others. He noted that they responded minor stresses as if they were emergencies. He found that over time they were more likely to develop high-blood pressure and heart disease.

Other researchers have found that stressful tasks also cause an increased release and activation of platelets in the blood. This causes the blood to clot faster and could precipitate the formation of a clot and infarction.

STRESS AND THE TYPE A PERSON

Dr Meyer Friedman found that the Type A person is likely to react much more violently to stress than a Type B person. Dr Redford Williams of the Duke University Heart Programme observed, “The Type A person reacts as if he is always running from a grizzly.” He noted that they had greater increase of epinephrine and norepinephrine levels in the blood and larger increase in blood pressure and heart rate in responses to stress. Their blood levels of adrenaline, noradrenaline and testosterone increased much more than the Type B person.

STRESS IS CREATED IN THE MIND

One must remember that stress is a response to a situation and the amount of stress experienced is related to the person’s mental appraisal of the situation. It is important to realise that the perception of threat is a subjective reaction. For one person, the death of a spouse is a tragedy and the person may die soon after. For another person, the death of a spouse could be a release.

It is important to be aware of the fact that we can change our perception of events and how we evaluate them. The only thing that we can really learn to control is the way we choose to see or feel about a situation. By learning how to have this choice, we can reduce the amount of stress we experience.

Because the Type A person places so much importance on achievement, work is likely to be a major source of stress for him. A dead-end job, working under an incompetent boss or being in a situation where one’s role is unclear, can all be chronically stressful.

Loss is another form of stress that the Type A person has great difficulty in dealing with, especially if the loss affects the person’s identity and the person feels a failure. Sometimes the loss of a dream can trigger an intense reaction, especially the realisation that one may never realise one’s dreams.

STRESS LOCUS OF CONTROL

The most important thing in dealing with stress is to feel in control. People with an internal locus of control feel they can do something about difficult situations and engage in problem solving behaviour. People with an internal locus of control have an unshakeable belief that they can find solutions to any problem.

On the other hand, people with an external locus of control have a different way of dealing with stress. They may take on a victim’s role or blame others or fate for their problems. They expect someone else to rescue them and they see solutions coming from outside.

Persons with an external locus of control are likely to use methods of repressive coping such as alcohol, tranquillisers, procrastination, sleeping excessively and complaining. Some deny that there is a problem and most expect others to solve their problems. This style of coping is known to be associated with much higher levels of stress.

Having choices gives one a sense of control over one’s life. It is possible to learn how to develop the beliefs and attitudes that facilitate an internal locus control. In our stress management training programmes people learn how to switch from an external to an internal locus of control within a short period of time.

HOPELESSNESS AND HELPLESSNESS

Stress researchers have identified feelings of hopelessness and helplessness as the two most toxic emotions. One feels hopeless when one feels one cannot personally do something about the situation. Helplessness, on the other hand, is a feeling or belief that nothing can be done about a situation. Even people with an internal locus of control may find that when their usual problem solving routine fails they may develop a sense of futility.

In his book about his experiences in Nazi concentration camps, Dr Victor Frankl, a well-known psychiatrist, observes that those who found some meaning in life were the ones who survived under the most inhuman conditions. Speaking about helping someone Dr Frankl says, “I aim at giving him inner strength by pointing out to him a future goal to which he could look forward. Instinctively some of the prisoners tried to find one of their own. It is a peculiarity of man that he can only live by looking to the future.… And this is his salvation in his worst months of existence, although he sometimes has to force his mind to the task.”

My own experience with the Type A person leads me to believe that he is afraid of experiencing the emotions of hopelessness or helplessness. To avoid them, he adopts a strategy of keeping himself busy and in control of things. Often at the bottom of this is a deep fear of death or not amounting to anything.

Some of Type A behaviour is motivated by trying to avoid the sensation of despair. Dr Frankl’s advice about finding ‘meaning’ in the most trying and difficult situations is the best antidote for a feeling of futility.

UNCERTAINTY AND STRESS

One must recognise that uncertainty is a fact of life. Rapid social and cultural change is part of contemporary living and with it comes uncertainty. Dr Dennis Jaffe of the Centre for Health Studies in San Francisco, maintains that the Type A person’s behaviour is an attempt to cope with uncertainty by using a strategy of over-control. Dr Jaffe recommends a strategy of optimal control learning to recognise what one can control and to do something about one’s uncertainty and learn to recognise, accept and let go of things that are beyond one’s control.

My experience with patients indicates that learning to recognise and conquer one’s fear of death is the best way of learning how to live with uncertainty. Then the crucial question that you need to be able to ask yourself is, “What is the worst that can happen in this situation?”

A heart attack always reminds people of the possibility that they may die. Each person reacts to it differently. For some, it is a window of opportunity. They recognise that they may have a short time on the planet and make the changes that are required to enhance their health and quality of life. Others react in a fatalistic way continuing their old unhealthy lifestyle waiting for their end. The fatalistic reaction is a denial of death.

IDENTIFYING YOUR SOURCES OF STRESS

The first thing is to develop an awareness of the fact that you are under stress. Many people block out or dismiss that fact. Awareness is the key to identifying the stressors that affect you. Keep a log of the things that get you worked up, worried or that are related to physical symptoms. By maintaining a stress log you will be able to discern patterns and become aware of the things that upset you. Writing them down has the added advantage of allowing you to look at it later more objectively.

I remember Fr Ramesh, who was referred to me for psychiatric help after his doctors, on investigating the chest pains he had developed, could find nothing physically wrong with him. As a senior administrator, a large part of his job was to discipline people. His stress log revealed that whenever he had to punish someone he would develop symptoms.

For Fr Ramesh, the role of a manager was very stressful. In his own mind, he saw himself as a ‘kindly, humanitarian Man of God’. Having to punish and remove people from their jobs was not a part of his identity. While he was not consciously aware of it, each time he had to scold or discipline someone he developed symptoms.

Fr Ramesh’s superiors were not very sympathetic and maintained that he must do his duty and fulfil his responsibilities. After a great deal of soul searching, he decided that responsibility was of lesser value than being humane and decided that he would learn to take a relaxed attitude towards discipline, whatever the consequences. Instead of punishing people, he started giving gentle feedback to anyone who required to be disciplined. He started feeling better about his job and not surprisingly found himself transferred to a new assignment after a few months.

The first step one needs to take then is to pay attention to your body, for body tension, headaches, worry, anxiety, and fear, all signs of stress. By keeping a brief log of the happenings of the day along with the things you were worried about and the symptoms you experienced you will become aware of those things that are sources of stress and work out a plan for dealing with them.

PSYCHOLOGICAL HARDINESS

Dr Salvatore Maddi and Dr Suzanne O. Kobasa at the University of Chicago interviewed a large number of managers and other professionals. They evaluated them on their scores for stress and illness and divided them into two groups—high stress high illness and high stress low illness.

They found that about 25% of people studied were healthy despite high levels of stress. They labelled such people ‘Psychologically Hardy People’. They found that this group of people had a sense of control over their lives. They were fully committed to their jobs and saw difficulties as a challenge. For them, many events that others found stressful were sources of novelty and surprise. The main difference was that these people rated high on traits such as challenge, commitment and control.

The Psychologically Hardy People viewed change as a challenge. For example, when a person is cheated he can either see it as a disaster or an opportunity to learn something. The hardy one is committed to something beyond himself and takes an active role in work and family life and believes both to be important. Such people had a sense of control and felt capable of bringing about change, especially in difficult situations. In the face of difficulties hardy people took an active problem solving approach as opposed to the stress prone individuals who indulged in regressive coping tactics such as withdrawal, distraction (watching television) or use of drugs and alcohol.

These attitudes can be learned in a few weeks if one applies one’s mind to the task. Certain advanced psychological techniques make it possible to internalise the psychological attitudes of hardy people into the core of the personality in a short time. At training workshops people have learnt the skills and attitudes of the hardy in a short period.

DEALING WITH STRESS

A useful way to remember the basic stress management skills is the acronym READ, which stands for relaxation, exercise, awareness, diet.

At stress management workshops, I tell participants that learning stress management is like learning to READ. It is difficult at first but soon becomes second nature. The crucial skill is to learn how to READ one’s own body signals that let you know that you are under stress and what to do about it.

RELAXATION

Regular practice of deep relaxation lowers arousal and causes many psychological and physiological changes in the body. In states of deep relaxation the parasympathetic nervous system is activated and the heart rate, blood pressure and oxygen consumption of the body decreases. Regular practice of deep relaxation leads to a lowering of blood pressure in hypertensive patients and a 10-20% reduction in blood cholesterol levels. In addition, deep relaxation induces healing in a variety of physical and psychosomatic illnesses. MUSIC

Good music is an important way of inducing relaxation. As Nietzsche said, “Life without music would be a mistake.” Relaxing music reduces arousal and makes you feel good. You should choose music that you like and that makes you feel calm. Do not be taken in by the claims for special types of music that are supposed to make you feel relaxed.

EXERCISE

Exercise is another important method of stress reduction. During exercise certain chemical neurotransmitters called endorphins are released in the brain. Endorphins are a powerful substance that regulate pleasure, mood and reduce stress. Due to the release of endorphins, aerobic exercise is one of nature’s best antidepressants.

AWARENESS

Probably the most important skill that you will need to learn is awareness. Most people, especially patients with coronary artery disease, are cut off from their body and its signals. For example, many Type A persons tend to ignore feeling tired. It is only when they are exhausted that they relax. Dr Dean Ornish feels that isolation from oneself (lack of awareness) is one of the important unconscious sources of stress for most heart patients.

Develop the ability to become aware of the early signs of stress and take corrective action. Becoming aware of the beliefs and thought patterns that lead to stress is another crucial skill. For example, having the belief “I must perform perfectly in all situations”, can lead to considerable stress.

Awareness of one’s habitual patterns of dealing with stress such as withdrawal, blaming others, finding excuses or bewailing one’s fate, ruminating over the past or escaping into fantasies of the future, are the first steps towards change.

It is very important for you to develop clarity about your goals and values. If you are not aware of what you really want in life it can lead to excessive confusion and stress. It helps you realise what is important and what is not. You can first do the important things and drop the unimportant ones to simplify your life and reduce the amount of stress you experience.

Clarity about ethical values are also important. Of recent, I have been seeing an increasing number of people who have been doing things that they know are unethical— taking bribes, marketing cigarettes, telling half-truths and even polluting the environment. Often they had complex rationalisations to justify their behaviour to themselves. However, at some level, it affected them. I recently saw a surgeon who had been giving other doctors commissions and had often done surgery for questionable indications, ‘To be on the safe side’ as he put it. It is only when he was laid up in the Intensive Care Unit with an attack of severe angina, did he realise that this way of being was most stressful for him.

DIET

A balanced diet low on fat, sugar and alcohol, is important to reduce the effect of stress on your body. A low intake of caffeine in the form of cola drinks, coffee and tea is also important. The diet recommended in the chapter on diet in this book would be useful.

MEDITATION AND STRESS REDUCTION

Meditation is an effective means of self-transformation and stress reduction. A number of studies have shown that regular meditation leads to lower levels of anxiety and better physical and mental health. There are many different techniques of meditation and most of them are useful. As with yoga, it is important to have a teacher to help you avoid the mental traps that exist in the practice of meditation. There are two major forms of meditation: Concentrative and Contemplative. In the concentrative form, one meditates upon a symbol or a sound such as ‘Om’. During contemplative meditation, one’s awareness is more diffuse and includes everything that enters into consciousness.

Meditation helps to gain insight and clarity into oneself and one’s mental processes. The regular practice of meditation will help you gain control of your mind and develop greater equanimity and inner peace.

Meditation often leads to an experiential understanding of the spiritual dimension that many people lack. Many forms of meditation lead to personality transformation and deep psychological healing. The direct insight that one gains during meditation is very different from anything one can learn from reading and listening to lectures.

The psychological healing and deep relaxation that many people experience during mediation facilitate inner homeostatic healing processes. For example, Dr Ainslie Meares, the famous Australian psychiatrist, taught terminal cancer patients a meditative technique that induced profound states of relaxation. Dr Meares observed that in most of the patients who practised regularly, the “span of life far exceeded the prognosis given by an experienced oncologist”. More important, some of these patients who had been given up by orthodox medicine, had dramatic regressions of their cancers.

Dr Meares states “another more profound reaction was taking place without any direction from me whatsoever … the patient … comes to have a slightly different, but at the same time profoundly significant, experience of life. Living comes to have a meaning that it previously lacked. There is an experience of inner philosophy. This is a pre-verbal experience and in no way is it related to the logical formulations of philosophical ideas … it is common for the relatives and friends to comment to me that the patient has in some way changed in himself: ‘A better person’, ‘More understanding’, ‘when things go wrong he no longer gets upset …’ These outcomes are of course the exteriorisation of inner changes in the individual’s psychological, philosophical and spiritual integration … I must emphasise again that this experience comes about without any conscious guidance from me.” This indicates that meditation causes personality modification and is more than a tool for stress management.

MEDITATION BY CONCENTRATION

Transcendental Meditation (TM) is a form of concentrative meditation that has been popularised by Maharishi Mahesh Yogi. TM involves meditation on a mantra or mental sound. Other forms of concentrative meditation have been found to bring about similar changes to TM. While there is no doubt that it is useful to learn meditation from a knowledgeable guide, especially if one wants to explore it deeply, many people find they can learn simple meditative practices and practise these by themselves to experience healing. Experiment by concentrating on a sound (mantra) as per the instructions given below. I personally think that mindfulness meditation leads to greater awareness and healing but many people find that they respond better to a focused concentrative meditation. Experiment and then practise the one that you are most comfortable with.

INSTRUCTIONS FOR MEDITATION BY CONCENTRATION

Choose a place where you are unlikely to be disturbed. Turn off the telephone and leave instructions that you should not be disturbed. Go to the bathroom if you need to and then get ready to meditate.

Sit erect in a chair or on the floor and adjust your body till you are relaxed. Meditation is better done in the sitting position than lying down as you might go to sleep.

To focus your attention, mentally repeat a single word (mantra) such as one, peace, love or Om. A word with some symbolic meaning is preferable. You can synchronise the word to your breathing or just keep repeating it. There is no need to make an effort to keep your attention on the mantra. If you find your mind wandering gently bring back your attention by repeating the word.

Meditate for 10 to 20 minutes twice a day if possible.

You will find that as you keep repeating the word, you begin to relax and go deeper into the meditative state. With practice you will find that it becomes easier and that you get more absorbed in the meditative state.

It is preferable not to meditate for two hours after having a meal or drinking alcohol as it interferes with the process.

MINDFULNESS TRAINING

One of the most effective meditative methods is mindfulness training — an ancient Buddhist practice. Mindfulness Training is aimed at developing ‘insight or awareness’ into the nature of reality by direct experiencing. It is a useful technique for developing a contemplative attitude and resolving pain, anger, greed, envy, and other negative emotions. The heart of mindfulness training is learning to live in the present and to be able to watch one’s thoughts with detached awareness.

One form of Mindfulness Training known as Vipassana is taught in India in ten-day camps that are held regularly. If your doctor allows you to go for the camp and endure the rigours of the training, it is well worth attending.

Many cardiac patients find getting up at 4 a.m. and meditating throughout the day for ten days too much for them. Others find the rules that disallow talking to anyone besides the instructor difficult and some are worried that in case of an emergency, help may not be available. Hence many prefer to learn and practise the method at home. A few excellent books are available from which you can learn and the technique but there is no substitute for an experienced teacher.

In our workshops, we teach participants a few of the basic techniques which they can practise by themselves to produce psychological healing and growth. The crucial skill one needs to learn is the ability to ‘witness’ one’s thoughts with detachment. Participants later practise these techniques on their own and many report that they are very effective in helping them gain peace of mind. The basic objective is to develop the ability to be fully involved in the present and realise that change is a part of life at a deep level.

MINDFULNESS IN EVERYDAY LIFE

While doing things we often find that our mind is preoccupied with something else. During the day decide to do at least one activity with full awareness. For example eat with full awareness, pay attention to the taste, texture and reactions to food as you eat it. Choose other activities such as walking, brushing your teeth, talking to someone else to allow yourself to experience the present moment fully.

Spend a few minutes a number of times a day using both practices to enhance your awareness. The basic philosophy behind this is that each moment is precious and can be experienced fully. Life is not only about great or special moments but the fact that each moment is important. As you start becoming more aware you will find a subtle shift in the quality of your life.

BASIC MINDFULNESS MEDITATION

The aim of these practices is to develop conscious awareness. This type of meditation also helps you develop the ability to stay centred in the present. During the mindfulness exercises, most people find that they are either thinking about the past or planning and escaping into the future. They find that these thoughts trigger unpleasant emotions such as regret, guilt or anxiety. When they learn to focus their mind they find that they experience fewer negative feelings and start experiencing inner peace. In this form of meditation, the breath functions as an anchor to the present and the goal is to learn how to keep your focus on it for increasing lengths of time.

These instructions are not intended to be a substitute for meditation training which is a part of a spiritual and philosophical system. In the traditional form, ‘desire’ is seen to be at the root of problems and meditation is seen as a way of transcending it. Therefore spiritual teachers consider ‘desire’ a barrier to spiritual growth. We, on the other hand, teach these techniques for healing and have modified them for this purpose.

In contrast to mantra-meditation or self-hypnosis, when doing mindfulness-meditation you will have to make an effort to keep your attention on the object of your concentration.

Prepare yourself in the same manner as for concentrative meditation. It is important that you sit in an upright position while doing this meditation.

Sit and become aware of your thoughts. Notice any tendency to avoid doing this by escaping into fantasy. Do this for a few minutes a few times a day. You will become aware that your mind is chattering in the background all the time. You may then start labelling the type of thoughts passing through your mind such as remembrance, hostility, fantasy, greed and envy. Do this for a few days.

Then for the next few days meditate on your breath every day, for increasingly longer periods. Notice the breath going in and out without trying to change it in any way. Notice if the breath is short or long, from the chest or abdomen and the pause between the in breath and out breath. Make an effort to keep your attention on your breath. If you find your mind wandering bring it back to your breath. Start with ten minutes each time and gradually increase the length of your meditation sessions till you can do this for half an hour. Do not expect that you will be able to keep your attention focussed on the breath all this time.

Next focus your attention on your nostrils at the point where you feel the breath most intensely or at the bottom of your chest, where your breath ends. Focus your attention, on the sensations there as you inhale and exhale while breathing. You should try and focus on the pure sensations rather on thoughts or concepts. Your mind will wander each time you notice another distracting thought or sensation and bring your attention back to your breath. Do this about half an hour daily for at least two weeks. Repeat this a few times a day for shorter periods even only for a few minutes. This will help you develop your ability to focus awareness.

Once you have spent a few weeks of meditation using the breath as a focus switch to using your body sensations as a focus for your meditation. Scan your body and become aware of any sensations such as pain, discomfort, the urge to move and use that as the focus of attention. You will probably notice that the sensation will build up to peak and then gradually die down. Sometimes as you do this you may become aware of long forgotten memories and develop insight into the source of that sensation and associated feelings.

Once you are able to focus on your feelings start looking at your thoughts in a detached manner as you continue to meditate. Notice how your thoughts arise, build up and die out just as your body sensations did. Use your breath to bring you back to the present if you find yourself getting drawn into your thoughts or feelings. As you develop your ability to witness your thoughts in a detached manner you will start becoming more aware and getting insight into yourself.

Once you can do the above for five to ten minutes at a time. Just sit and watch whatever enters your consciousness, awareness of breathing, feelings, body sensations or thoughts. Do this daily for as much time as you can. It is better to do it for a few minutes than not to do it at all. Expect that on some days you will be able to do this well while not on others. Also do not expect that this form of meditation will relax you initially, in fact initially you may find yourself becoming a bit tense or upset when you do this practice. It is important to persist with your practice. However, if you find yourself getting upset or depressed consult a teacher or stop this practice.

DEVELOPING COMPASSION

Use a separate meditation session to develop this ability. This ability is very important for Type A persons as it helps reduce hostility.

First think of someone you love. Become aware of the feelings that arise when you think of that person, concentrate on the feeling and let it build, do this for a few days till you can generate these feelings with ease.

Then think of someone you feel sorry for. Put yourself in their shoes and try to feel their sorrow and generate the feelings of love towards them. This is the feeling of compassion.

Once you can do this with ease think of some one you mildly dislike and generate the feeling of compassion towards him or her.

Next, while breathing, consciously think of someone you hate and generate feelings of compassion towards that person.

This is one of the most important meditations to overcome hostility and gain inner peace. One needs to see one’s enemies as teachers on the path to inner peace. Mentally thank them for providing you the opportunity to develop this before you start this meditation.

Note:

Ideally you should spend at least an hour every day meditating. For many people this may not be possible, in which case you could spend 10-20 minutes once or more each day. Some people find that in addition to spending an hour by themselves meditating, adding a few short 5-10 minute meditation breaks helps develop a sense of inner peace. You could schedule more time initially and then after you have gained some degree of control over your mind, cut down the time spent daily. Some patients find that they are able to meditate for short periods on weekdays and meditate for longer periods 2-4 hours on weekends.

SIGNS RESISTANCE TO AWARENESS

When you start any type of meditative practice your mind is likely to resist and many people stop meditating when they run into resistance. Remember most people are afraid of the unfamiliar and they try to avoid anything that causes change.

Boredom is the most common difficulty people experience. The solution is to persist and continue meditating. After some time it passes away. Another way is to meditate on the boredom, be aware of and learn from it. Gradually it will yield.

Restlessness overcomes many people when they start thinking of things that they need to do right away. Continue meditating on your breath or on the feeling of restlessness till it passes.

Anxiety is another problem for some people. Often they are unable to identify the source of their anxiety. Frequently one may have troubling thoughts or memories that arouse anxiety. Concentrating on your breath often helps. Over a period of time, as you continue meditating, your anxiety becomes less and dies out. Another approach is to meditate on the anxiety and anxiety-provoking thoughts and more often than not they gradually die out.

Remembering painful memories. It rarely helps to push these into the background. A good method is to meditate on the upsetting memories for a short while till they become unbearable and then change your focus to your breath (or mantra). Over a number of sessions, you will find that you will be able to integrate those memories. If they are too painful or upsetting, you may want to consult a psychotherapist who uses hypnosis to help you resolve the issue and then start meditating again.

Rarely, you may experience powerful electric sensations shooting up your spine. Occasionally you may see flashing lights or mythological visions flashing through your mind. These spiritual experiences are often mistaken for psychological illnesses and could be Spiritual Emergence phenomenon. It is wise to consult a therapist to help you integrate these experiences.

Note:

Remember to consult your physician before you start a programme of meditation or deep relaxation. If you have diabetes or hypertension you must have your blood sugar and blood pressure checked regularly after you start meditation. The lifestyle changes and stress reduction usually cause a lowering in blood pressure and requirements of insulin or anti-diabetic medication.

SELF-HYPNOSIS AND STRESS REDUCTION

Self-hypnosis is a powerful method of stress reduction and it is possible to achieve deep states of relaxation which can be very therapeutic. In addition, it is possible to modify your personality and resolve unconscious conflicts. This can give you much more energy to cope with the stress of daily life and make you feel vibrantly alive.

The technique of self-hypnosis is detailed in the chapter on mind-body healing. I would recommend that you practise both at different times as they compliment each other. Hypnosis helps heal unconscious trauma and change personality patterns. Meditation helps achieve powerful states of inner calm and of insight into the true nature of reality. Meditation also puts you in touch with your inner spiritual sense.

DEALING WITH SPECIFIC STRESSORS

Very often the general stress management programme of relaxation, exercise, awareness and diet may not be enough to deal with specific stressors. You will need to work out a specific plan to deal with any difficult situation that is causing you a lot of stress. The experience of Jess Lair, the author of I Ain’t Much Baby But I’m All I’ve Got is an example. At the age of 35, he had his own advertising agency, a huge house in one of the best areas of town and could afford to give his wife a new expensive sports car for her birthday. Jess had decided to work another 10-15 years at a business he hated and detested. One day, after meeting a client, on his way back to the office Lair had the strange feeling that his heart was speaking to his head “Now look, if you’re crazy enough to throw your whole life down a rat hole, chasing something that you don’t believe in, that’s fine, you can throw your life away for money and material gains. But this Norwegian heart, it ain’t going to go along with you.” Soon after that he had a heart attack in the elevator.

While lying on the hospital bed he decided that he was never going to do anything that he did not deeply believe in. He sold his house and business and moved with his family into a small house. He decided to go back to college and study psychology and spent the next few years getting a Ph.D. He started helping people put their lives back into order. He tells others how he decided “I’m going to grow. Because if I don’t I’m going to die here. I was escaping all responsibility for my actions”.

The cardiologist Dr Robert S. Eliot author of Is It Worth Dying For? had a similar experience at the age of 44 when he suddenly had a heart attack. While recovering from he realised that his professional life had become a ‘joyless treadmill’ a state of mind he describes as ‘invisible entrapment’. He had been unable to establish a cardiac centre in his community and this for a person who ‘defined life in terms of victory and defeat’ was a bitter pill which left him feeling bitter and disillusioned. He realised that this was not worth dying for and decided to ‘stop sweating the small stuff’ and as he says, “Pretty soon I saw it as small stuff.”

Like Jess Lair or Dr Eliot you may have to make some difficult decisions like giving up a stressful dream, job or relationship. The key question that you need to continually ask yourself is, “Can I improve the situation so that I am happy? Is it worth giving up my life for the situation?”

Sometimes it can be a difficult situation as the one that confronted Sudha. She had been having an affair with her married boss Anthony, who had been promising to marry her for some years. Eventually Anthony told Sudha that he could not leave his wife Puja as he was worried that she might commit suicide. Anthony claimed that Puja had given him permission to continue his relationship with Sudha since she could not keep him happy. Sudha was very upset on hearing this and developed severe chest pains for which her doctor could not find any cause. She was referred to psychiatrist Dr Nishant as she had become addicted to the tranquillisers prescribed by her family physician.

Under hypnosis Sudha discovered that her chest pains were a response to pain she felt at the realisation that Anthony’s had been exploiting her. This was something she had not allowed herself to acknowledge consciously. This knowledge enabled her to leave the organisation and stop seeing Anthony and then her pain disappeared. mmm