3. Full Catastrophe Living
The title of Jon Kabat-Zinn’s book comes from a line in the movie Zorba the Greek, when Zorba’s new friend asks him “Have you ever married?” and Zorba replies “Am I not a man? Are all men not fools? Of course I’ve been married. Wife, house, kids, everything… the full catastrophe!” In Zorba’s busy life, there have been many stressful events and yet he has been able to face them and continue to celebrate life, laugh at himself, and dance when he feels their weight oppressing him. Kabat-Zinn’s book lays out the 8-week mindfulness program that he taught for 20 years in the stress clinic associated with University of Massachusetts Medical Center, where ordinary Americans learned to face the “full catastrophe” of their pain, illnesses and losses without being ‘stressed out’. Unlike Zorba, they did not learn to dance, but the program focused on attention to the body through meditation, breathing exercises and yoga.
One of the stories in the introduction is about a man in his early seventies, who came to the clinic in a wheelchair because of severe pain in his feet. At first, he did not see how meditation could be helpful for him, but he was at the end of his tether and willing to give anything a try. During the next eight weeks, he was determined to work with his pain, and gradually transitioned from the wheelchair, to crutches, and eventually to a cane. He said at the end that the pain hadn’t changed much, but after he started meditating his feet were less of a problem. His wife, who had been driving him to the clinic and waiting outside, confirmed that he was both happier and more active than before.
Kabat-Zinn mentions the origins of mindfulness in Buddhist meditation, which has been practiced for over 2,500 years in many Asian countries. However, he suggests that the practice of mindfulness is of universal value as a vehicle for self-understanding and healing, and it is not dependent on any belief system or ideology. Instead, it is a method by which Buddhists have learned to relieve suffering and dispel illusions, which are among the major concerns in the practice of their religion.
Full Catastrophe Living is a self-help book, and is designed to provide the attentive reader with the benefits of the 8-week meditation class. There are five sections: i) The Practice of Mindfulness, ii) The Paradigm, iii) Stress, iv) The Applications, and v) The Way of Awareness. These sections are summarized below.
3.1. The Practice of Mindfulness
The first part of the book talks about the benefits of mindfulness and meditation, the difficulties facing practitioners, and the ways in which these practices have been taught at the Stress Management Clinic.
In everyday life we are often unaware of the particular sensations we experience from moment to moment. We are encouraged to work hard for the sake of long term goals instead of appreciating each moment as it comes our way. When we encounter catastrophe, in the form of unexpected obstacles and downturns such as pain, illness and death, we become set in a pattern of stress and tension because we have lost some of our goals, and lack the ability to live from one moment to the next.
Kabat-Zinn teaches his patients to appreciate their moments by giving them a novel sensory experience. He gives each person in the first session three raisins, and instructs them how to eat the raisins mindfully, savoring each moment’s sensations – from the sensation of looking at the raisin, feeling it between one’s fingers, lifting one’s hand up to one’s mouth while experiencing the sensations in the elbow and arm, to thoughtfully chewing the raisins, one at a time, noticing their textures and flavors. He claims that even people who don’t particularly like raisins appreciate this exercise.
From there, he goes on to begin teaching the patients some meditation techniques. The meditation techniques he teaches in the class are the Body Scan, yoga, and sitting meditation. He discusses the importance of breathing, and how focusing on the breath can bring one to a state of mindfulness, regardless what is going on around you. He points out the parts of the body where one can feel one’s breath, the nostrils, the chest, and also the belly. Feeling the breath in the belly can be very relaxing for most people. Focus on breathing is used in all the meditation techniques Kabat-Zinn describes.
The Body Scan is a meditation developed by Kabat-Zinn to help people bring their awareness back to their bodies, and it is the theme of the first two weeks in his 8-week stress reduction program. He says it is based on the ancient practice of vipasana meditation. Many people are not ‘in their bodies’ because they dislike their bodies after comparing them with images presented in the media, or because their bodies have become a source of embarrassment, shame, discomfort or pain. This can happen as a result of sexual or physical abuse, trauma, or accidents, injuries and illness. But the body is essential to experiencing feelings and regaining our sense of identity and wholeness. The Body Scan is practiced while lying supine on the floor or on a mat. In the Body Scan, patients learn to carefully attend to the sensations in each part of their bodies, starting from the toes, to the pelvis, belly and back, and then from the fingers up through the arms to the shoulders and chest, and finally up through the neck and face to the top of the head. Throughout the meditation, patients are instructed to breathe into each part of the body as they attend to it. At the end, the body is imagined as a permeable form, and the patients imagine breathing through the top of the head, like a whale’s blowhole. The meditation ends with silently experiencing the breath through the whole body.
The patients are encouraged to practice the body scan daily for at least 15 minutes during the first two weeks of the course, either alone or using Kabat-Zinn’s meditation audiotape. Kabat-Zinn is impressive in his ability to teach meditation to ordinary people who might not otherwise be interested in this kind of practice. Perhaps this is aided by his discussion of the need for commitment, and the right attitude to meditation. In his chapter on attitude, he lists the foundations of mindfulness in: i) non-judging, ii) patience, iii) ‘beginner’s mind’, iv) trust, v) non-striving, vi) acceptance and vii) letting go. He emphasizes the need to cultivate these attitudes to the practice intentionally, as well as being fully engaged in the practice while doing it, and committed to its regular exercise.
Non-judging can be particularly hard to practice when you are in pain. Kabat-Zinn suggests practicing this by being aware of the stream of thoughts that includes passing judgment on oneself, one’s practice, the instructor, and everything else, and adopting the stance of an impartial witness to this stream. The practice of mindfulness or meditation involves suspending judgment, and just watching one’s thoughts, including judging thoughts, without pursing them, acting on them, or even judging their existence. He suggests returning the focus to breathing after noticing these thoughts.
When discussing patience, Kabat-Zinn invokes the metaphor of a child trying to help a butterfly emerge from the chrysalis by breaking it. Given our wisdom, we know that the butterfly will emerge in its own time, and yet in life we often act like the child, rushing through all the moments to try and reach ‘better’ ones. He suggests treating oneself like the butterfly. It is unnecessary to fill our moments with activity or thoughts, things will unfold in their own time.
‘Beginner’s mind’ is a way of cultivating curiosity about the world, oneself, and others, instead of making assumptions. It can be refreshing to see a familiar person with new eyes. This is an important part of learning the practices that Kabat-Zinn introduces to his class, because many people might have assumptions about meditation.
Trust in oneself is fundamental to the practice of meditation, because not everything in the class might be suited or even possible for everyone, particularly difficult stretches in the yoga, or sitting for a long time without moving. This is where Kabat-Zinn introduces the idea that meditation is not about following everything the teacher says, or submitting to his authority. Each person is the authority on his or her own body.
At the start of the course, the patients are asked to list three goals for the class. Then, they are instructed not to strive for those goals. This seems a contradictory attitude, but meditation is best achieved, according to Kabat-Zinn, if you can back off from striving in order to better be in the moment.
Acceptance means coming to term with often unpleasant facts, such as being overweight, having a headache, or a chronic illness. The initial reaction is often one of denial, and it might take time to reach acceptance of such facts, which is part of a natural process of coming to terms with them. They are often things that we cannot change, although sometimes they will change of their own accord. Kabat-Zinn suggests that acceptance can be cultivated by taking each moment as it comes and being in it fully, accepting whatever the thoughts and feelings are that accompany it.
There is a story from
The Body Scan meditation has proved particularly successful for people suffering pain after experiencing trauma. In a vignette, Kabat-Zinn relates the story of a woman who had suffered for many years from pain in multiple areas of her body, including the hands, feet, shoulders, neck and lower back. During the Body Scan, which she practiced daily for the first four weeks, she kept feeling blocked when she came to her neck, and unable to go up to the top of her head. One day, when she was practicing with the tape, she heard the word genitals for the first time as she was scanning through the pelvic region, and it brought back a memory of being sexually molested by her father. When she was nine years old, her father had a heart attack while he was with her, and died. Her mother came into the room, and blamed the girl for her father’s death because she had not called out for help, beating her around the head and neck with a broom. After recollecting this experience and all of the trauma associated with it, the patient was able to continue with the body scan beyond her neck, and by the end of the course, the extent of her physical pain was much reduced, so that now she experienced pain only in her hands.
Kabat-Zinn’s program centers on the Body Scan for the fist two weeks. In the next two weeks, the class sessions center on yoga. He teaches gentle stretches starting from lying on the floor or mat. Patients are encouraged to trust themselves, and only do what is comfortable for their bodies. However, in the book he also writes about the importance of exercise, and how the muscles of the body can atrophy after a short period of bed rest, which can be a serious risk in patients suffering from serious injuries, illness or chronic pain. The poses he teaches are illustrated in the book, and follow a sequence that includes instructions on how to use the breath and flow from one pose to the next. The patients learn to breathe in as they move into a pose that stretches or opens out the front of the body, and breathe out as they move into a pose that clenches or strengthens the front of the body and opens the back. Once in the pose, they continue to breathe and just notice the sensations in the body that they experience on breathing out and breathing in. He emphasizes the importance of coming to a class to learn the poses, because trying to look at a picture in a book or on a video and then copy it with one’s body is counteractive to the mindful practice of the poses. The tapes he provides include instructions on the yoga, but presence in class is required in order to see how the poses are practiced. During weeks 3 and 4 of the 8-week course, the patients are encouraged to practice the yoga 2-3 times per week on their own, while also continuing to practice the Body Scan meditation on the other days. The yoga is taught as a meditation, and patients are warned not to be competitive about it, to practice mindfully and not judge themselves or others for their ability to move their bodies in line with the teacher. Rest is encouraged between postures, preferably lying on the floor or mat, relaxing, and sinking more deeply toward the ground.
The book includes a second sequence of poses starting from standing, with verbal instructions on the tape. What is clear is Kabat-Zinn’s own devotion to yoga, which he himself practices daily, as well as teaching 2-hour long classes separate from the stress management program.
Yoga, according to Kabat-Zinn, is a gentle exercise that promotes full body conditioning, like swimming. But the purpose of the yoga in the program is not only as exercise. The Sanskrit word ‘yoga’ means to yoke together or unify, and Kabat-Zinn sees the practice of postural yoga as yoking together the body and the mind. The vision or goal of unification or wholeness is one that is described in detail in the second part of the book.
Walking meditation is introduced by Kabat-Zinn as a special practice, detached from the day-to-day walking from one place to another. It is described as walking along a simple path, pacing, while paying attention to breathing. Kabat-Zinn’s program teaches walking meditation in weeks 3 and 4.
Sitting meditation is introduced in the second week class, but is not practiced regularly for extended periods of time until week 5. The practice of ‘sitting’ consists in sitting in an upright position, either on a chair or on the floor, or a cushion, and paying attention to the breath. He suggests other sitting meditation practices, with a focus on the workings of the mind, such as the passing of thoughts and feelings. Every time attention is distracted or thoughts take over the mind, attention is brought back to breathing, noticing the sensations of breathing particularly in the belly, as with the Body Scan and the yoga. Kabat-Zinn gives some pointers on how to overcome particular distractions, such as sensations of discomfort or pain in the body, and anxious thoughts. He says that normally when we experience discomfort the impulse is to move something, or change our posture, but instead the practice of mindfulness means experiencing the sensations with curiosity to see where they lead to, before taking any action. Sometimes simply waiting patiently can lead to a reduction in pain, or the pain can begin to seem less important. After noticing the discomfort, he suggests returning the focus to the breath. A stream of thoughts commonly occurs whenever people first try to meditate, and instead of judging oneself or one’s practice as ‘bad’ because of these thoughts and trying to stop them, Kabat-Zinn recommends simply noticing the thoughts and instead of getting caught up in them, returning one’s attention to the breathing. It is natural for thoughts to occur during meditation, and the practice consists in learning to let go of them and return to the sensations of breathing. With practice, he claims that even the more ‘jittery’ patients, those with a lot of pain or anxiety, or the ones who always want to ‘get up and go’ learn to spend increasingly protracted periods of time just sitting and meditating. During weeks 5 and 6, the class is devoted to guided 20-30 minute meditations, and patients are encouraged to gradually replace the Body Scan in their daily practice with sitting meditation.
The final two weeks of the stress management program, weeks 7 and 8, consist in helping the patients learn to continue their practice independently. During week 7, patients are encouraged to practice without using the tapes, and then in week 8 they can return to the tapes. The program is pragmatic, and encourages patients to experiment and learn by practicing the three meditations, the Body Scan, yoga and sitting meditation. Besides these techniques, the first part of the book includes a description of mindfulness in daily life (or informal meditation), walking meditation, and a day of mindfulness. These practices can facilitate patients who might not otherwise continue with the practice to find room for the lessons they have learned from the stress clinic to impact their lives.
Meditation, as attention to breathing, can be practiced many times during each day. It is not necessary to close the eyes, or even keep still, although Kabat-Zinn encourages the practice of non-doing from time to time and as a remedy for many different stresses. Informal meditation just means taking a moment, or as many moments as needed, to focus on breathing and become aware of one’s bodily sensations, thoughts and feelings as an observer, instead of being controlled by them or simply reacting. It can be helpful for people who experience difficulties with anger and heightened emotions, as well as those who experience stress or anxiety. While only a minority of patients were still practicing the more formal meditation techniques four years after the course, nearly all were still using informal meditation from time to time, as a way of responding to the stresses of everyday life.
Kabat-Zinn offers a weekend retreat to the graduates of his course, where they can practice a day of mindfulness, including sitting in silence for six hours. He explains that just coming to the session has been a lesson in simplifying life for some of the patients. He describes many ways in which it is possible to practice mindfulness in daily life, for example cleaning the house mindfully, paying attention to the sensations of each moment, noticing how beautiful it looks, instead of judging how spotless (or not) it is and comparing this with a goal or an ideal. Mindfulness can also be helpful at work, in noticing thoughts and feelings and seeing where they go instead of making rash decisions. In these small ways, every day can be a day of mindfulness, by bring one’s attention back from whatever stresses and pains are occurring, without having to sit silently for six hours.
Kabat-Zinn describes one of his patients, Jackie, who could not stand to be alone and always arranged for her husband or somebody else to be at the house when she was home. She did not understand when her children told her they just wanted to be alone. When Jackie was in her mid-fifties, she came to one of Kabat-Zinn’s workshops and on arriving back home she was about to call and invite a friend over for dinner since her husband was out, but then she suddenly realized that it was not necessary to try and fill up all her time in this way. She decided to be mindful and stay in the present moment, and she found out that she could be happy by herself. Kabat-Zinn states that the challenge is to make such inner peace and calmness part of everyday life, not only these moments of special realization. He describes another patient, George, who because of his COPD (Chronic Obstructive Pulmonary Disease) has to take every single physical action mindfully, even the steps of his weekly grocery shopping, because otherwise he might collapse and need oxygen. Using the practice of mindfulness, each of us can be fully awake and aware of every moment as though it were critical to our being.
3.2. The Paradigm
In this section of the book Kabat-Zinn explicitly undertakes to give the reader a vision or a belief system that can underlie the practice of meditation, so that the patient is motivated for this practice to become a part of his or her daily life after completing the 8-week course. This vision is based on two threads. One concerns how we see things, and presents the philosophies of wholeness and interconnectedness in their impact on health and healing. The second brings to the fore contemporary developments in science and medicine emphasizing the interdependencies of mind and body, health and disease.
Kabat-Zinn recalls a moment when his two-year-old son asked if there was a person inside of their dog. He encourages the reader to remember a time of looking at the world with fresh, child’s eyes and wondering about the connections between things, instead of instantly categorizing ‘that’s just a dog’ as adults are wont to do. He notes that however we think of the dog doesn’t change it, but it changes our minds, just like wondering at flowers, mountains or the sea can make the mind change.
From there, he goes on to point out the wonders of all living things. In particular, he emphasizes the intricacy of the tasks that all biological organisms, and even the organs inside of our bodies, must perform. For example, the liver performs over 30,000 enzymatic reactions per second to maintain metabolic harmony in the body. Kabat-Zinn highlights the role of feedback interactions in all of these tasks – how when you run or climb stairs, the heart will pump more blood through the body to bring oxygen to your muscles, and if your body heats up then the sweat glands will produce sweat, that may lead to feeling thirsty and drinking to replace the lost fluids. All these tasks involve interconnected loops. At a higher level, the individual human being is part of a larger loop that includes one’s family and immediate circle of friends, society, domestic plants and animals and the immediate environment in terms of resources for water, heat and energy, and ultimately the whole of humanity and the entire planet.
Thinking about this wholeness can be healing, two words that sound similar and, according to Kabat-Zinn, might be etymologically connected with the word ‘holy’. He quotes a letter Einstein wrote to a rabbi who turned to him (as ‘the smartest man in the world’) for advice on how to explain to his 19 year-old daughter the death of her beloved 16 year-old sister. Einstein wrote:
“A human being is part of the whole, called by us “Universe,” a part limited in time and space. He experiences himself, his thoughts and feelings as something separated from the rest – a kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole nature in its beauty. Nobody is able to achieve this completely, but the striving for such achievement is in itself a part of the liberation, and a foundation for inner security.”
Kabat-Zinn contrasts his project of meditation as a consciousness discipline with the mainstream paradigm of Western psychological medicine, with its dominant concern for curing pathologies, and therapies aimed at restoring people to ‘normal’ functioning in the usual waking state of consciousness. Instead, the aim of consciousness disciplines is, according to Dr. Roger Walsh who coined this term, to expand our consciousness from what is normally a severely suboptimal state.
Kabat-Zinn presents to his patients the problem of the nine dots, which can be connected with four lines only by ‘stepping outside of the box’ and drawing the lines beyond the boundaries of the figure. Discovering the solution to the problem for oneself inspires an ‘aha moment’ similar, perhaps, to those experienced by Einstein when he came up with his great theories in physics. Kabat-Zinn notes that how we perceive the world and ourselves can profoundly influence what we are capable of doing, and that it takes a degree of effort to see things in an open-minded way to bring about such moments of mind-expanding realization:
“Seeing in this way, we can perceive the intrinsic web of interconnectedness underlying our experience and merge with it. Seeing in this way is healing. It helps us to acknowledge the ways in which we are extraordinary and miraculous, without losing sight of the ways in which we are simultaneously nothing special, just part of a larger whole unfolding, waves on the sea, rising up and falling back in brief moments we call life spans.”
Healing is not the same as curing. Healing, according to Kabat-Zinn, may involve a dramatic relief from symptoms and illness, but always involves a transformation of emotions and attitudes. He considers it a perceptual shift from fragmentation and isolation toward wholeness and connectedness, which brings about a change from feeling out of control and beyond help to a sense of inner peace, acceptance, and control.
In Kabat-Zinn’s paradigm, healing comes about as people immerse themselves in the mindfulness-meditation practice. This sometimes brings moments of profound transformation, like the ‘aha moment’ with the nine dots, but for most people it simply involves a feeling of deep relaxation and confidence, rather than a specific dramatic moment of experience. He gives the example of one patient with advanced cancer who had the experience of God during the silence of her first Body Scan Meditation, and went on to live for ten years, a much longer remission than expected, enjoying her children and grandchildren in spite of not being anticipated to survive her first surgery. She had an advanced bone cancer (plasmacytoma) that suddenly led to the physical collapse of her thigh bone, after years of caring for her husband while he was dying of esophageal cancer. When she repeatedly told her doctors of the pain in her thigh, they thought it was caused by stress and varicose veins. The mindfulness practice she learned helped this patient through subsequent years of treatment.
The emerging field of psychoneuroimmunology shows that the mind can influence the body in surprising and profound ways. Stressful life experiences increase the activity of natural killer cells, which can lead to reduced immunity against cancer and viruses (Glaser and Glaser). Ader and Cohen showed in the 1970’s that rats given an immunosuppressant together with saccharin were later conditioned to suppress their immune system in response to the flavor of the saccharin alone. Provisional data by Kabat-Zinn, Bernhard and Kristeller suggests that psoriasis patients given ultraviolet light therapy can reduce their skin rash in fewer treatment sessions by meditating and visualizing the effects of the light on ‘jamming’ the excessive growth of their skin cells. Nevertheless, Kabat-Zinn urges caution in marrying such results with the actual practice of meditation. Newcomers to the stress reduction program are asked to bring to mind their goals for the practice, and then let them go. In Kabat-Zinn’s view, mindfulness meditation should be practiced in and of itself rather than as a means to an end, such as physical healing or reducing blood pressure. Although healing can bring about such physiological changes, it acts by means of emotional and mental transformation, which might not be attainable without first letting go of these more mundane goals.
In an effort at outreach, Kabat-Zinn brought his program to hospitals around the country, in the form of a meditation TV-show broadcast on inpatient channels. He quotes a letter from a profoundly grateful cancer patient in the midst of undergoing a series of operations, who thanked him for the words: “There is more right with you than wrong with you.” With the help of the video, she had many “good, in fact wonderful, moments” in spite of experiencing much hurt and fear.
Kabat-Zinn outlines a lovingkindness meditation which, he has observed, has a “softening effect on the heart.” During the meditation, one brings to mind feelings of love, kindness and compassion for oneself, for a loved one and other close friends and family, and then even for an enemy or someone who has abused you, making a purposeful effort to forgive that person, ask forgiveness, and see him or her as a whole person deserving of love, and for all the people and living beings on earth who are suffering. Finally, the focus is returned to the self, and the effects this has had on one’s own inner feelings of warmth, generosity and love. This meditation helps promote kindness to the self and others, and guards against becoming lost in self-serving or self-destructive thoughts.
The science of medicine has advanced tremendously over the past century, particularly since the discovery that DNA encodes the genetic material, with consequent advances in molecular biology. We understand that cancer is a function of mutations in certain genes, known as proto-oncogenes. Enzymes can be injected into the bloodstream of a person having a heart attack to break down the clot and reduce damage to heart muscle. Devices such as CAT, PET and MRI enable doctors to look inside the body and diagnose disease processes. Unsurprisingly, our expectations from doctors have multiplied as a result of these advances, but modern medicine is still nowhere near being able to cure or even understand most diseases. Many diseases are caused by poverty, social exploitation, environmental pollution, and culturally entrenched habits which are outside of the scope of medical practice. While doctors acknowledge the role of mind, in particular the ‘will to live’ in healing from serious illness, this is often a brushing off after the failure of conventional medicine to provide a cure. When treatments fail, the patient might feel (and be) blamed by the doctor for their own condition, and for not responding as well as expected. Medical knowledge has advanced, but with it so has the arrogance of many doctors, who feel pressured by their training to always know best instead of listening to their patients and explaining to them the limitations and risks as well as the benefits of treatment.
The importance of mind in preserving the body, and the significant role of the doctor’s authority, are illustrated by a vignette from cardiologist Bernard Lown. During his postdoctorate training, he witnessed an event where a patient was seen by her doctor of many years who was leading an entourage of visiting physicians. He said to them: “This woman has TS,” before leaving abruptly. The woman, thinking TS meant ‘terminal situation’ became extremely anxious, notwithstanding Dr. Lown’s reassurance that TS stood for ‘tricuspid stenosis’. She went on to have a massive heart attack, and died the same day. If her doctor had been more sensitive or noticed what was happening, his words probably had the authority with his patient to reverse the situation. Had she been more mindful, she might have viewed her thought about the ‘terminal situation’ as just that, instead of holding onto it as a central belief in the face of contradictory evidence. This case illustrates how the patient’s thoughts and beliefs, coupled with the doctor’s authority, can have a drastic impact on the course disease and treatment.
The most common evidence for the influence of mind on the body comes from the placebo effect. When patients believe they are taking a potent medication, they often get better – even during the course of a clinical trial where in fact they are really swallowing only a sugar pill. Patients given no treatment at all rarely heal so rapidly or well. Similarly, hypnosis can modulate many different experiences, including pain perception and memory. Acupuncture is used to provide anesthesia for surgery in
Kabat-Zinn claims that advances in physics resulting from quantum theory have led to a paradigm shift encompassing the whole of scientific thinking, including medical science. Complementarity is the idea that at the smallest level particles can be described as either a wave or a particle but not necessarily both at the same time. The widespread acceptance of this idea has led, according to Kabat-Zinn, to an acceptance that many different perspectives on very real phenomena such as health and illness might all be valid, as different descriptions of the same phenomena. Specifically, this has led to the acceptance of complementary medicine from within mainstream medical practice.
Behavioral medicine is a branch of conventional medicine founded in the 1970’s that explicitly recognizes the interconnections of mind and body, beyond even the systemic view advocated by Dr. George Engel’s biopsychosocial model of the 1980’s. Behavioral medicine acknowledges the impact of people’s beliefs about bodies and illness, and presents patients with the opportunity to complement conventional medical practice with things they can do for themselves, instead of just submitting themselves to the medical ‘expert’ who can ‘fix them’. This includes drawing the attention of the patients to mind-body connections through practices such as the mindfulness meditation taught in the stress reduction course. Science is presented as confirming the common-sense belief that we play an important role in our own well-being.
There are several areas of medicine in which the role of beliefs, attitudes, personal life experiences and personality have been shown to play a major role in the susceptibility to illness and the course of illness and treatment. Martin Seligman coined the phrase ‘attributional style’ to describe someone’s inherent optimism or pessimism, where an optimistic style attributes bad events to a chance occurrence and sees them as stimulating change and challenging, whereas a pessimistic style attributes bad events to personal failure and sees them as confirming prior negative beliefs about the self and the world. Attributional style predicted the survival of cancer patients, as well as the middle age health of baseball players tested when they were young. Pessimists were more susceptible to disease following a stressful event than were optimists, as measured by changes in hormones and in the immune system. Seligman’s work suggests that optimism can protect people from depression, illness and death.
Albert Bandura showed that self-efficacy, the belief that one can do something about one’s situation, is also predictive of greater health. In a study of patients undergoing cardiac rehabilitation after a heart attack, those men who believed their heart could recover were able to accept their discomfort in the exercises without worrying that it indicated further illness, and benefited more from the training. Further studies showed that training people to develop mastery experiences increased their confidence and success in such programs.
Suzanne Kobasa studied workers in stressful jobs such as business executives, lawyers, bus drivers and others. She found that some people were healthier than others, and those that were healthier tended to have a certain kind of personality trait termed ‘psychological hardiness’ or ‘stress hardiness’. They showed high levels of control, commitment and challenge. People high in control held the belief that they could influence their surroundings and make things happen. Commitment was associated with engaging fully in whatever the person was doing. People high in challenge saw change as a natural part of life that afforded opportunities for positive outcomes. Kobasa emphasized that these factors were not static, and that they could be promoted through changes in the work structure of the employing organization.
Aaron Antonovsky studied Nazi concentration camp survivors. He found that those who coped well with their experiences had a high sense of coherence, meaning that they could make sense of their internal and external experiences (comprehensibility), they had the resources to meet the challenges they encountered (manageability) and found meaning in these challenges, to which they could commit (meaningfulness).
Feelings as well as thoughts and beliefs can be important in the development of health and illness. Studies show that certain individuals are more prone to cancer than others. Caroline Bedell Thomas collected data on young medical students at Johns Hopkins from the 1940’s and found that those who lacked close relationships with their parents and had an ambivalent attitude towards life and relationships were more likely to develop cancer later in life. David Kissen found that lung cancer patients who were less able to express their emotions, particularly those about negative events and relationship problems, were more likely to die. In fact, those with the lowest expression of anger were 4.5 times more likely to die each year than the most expressive patients, as compared with a tenfold increase in mortality predicted by current smoking. Greer and Morris interviewed women admitted for tests on a lump in their breasts, and found that those who concealed their anger, and the few who had explosive anger, were more likely to have cancer than the women who expressed their anger normally. Responses to the surgical removal of a breast tumor also depended on attitude, with those women who had a ‘fighting spirit’ or who denied the effects of their illness more likely to survive five years than the women who were stoic and helpless.
Kabat-Zinn cautions that these studies are controversial and that, for example, a link between cancer and depression has yet to be proved. He emphasizes that patients should never be blamed for their illness. Instead, these feelings and thoughts can be explored with compassion and caring by the patient, perhaps with the help of a physician or therapist. Positive emotional factors can enhance healing, and this can be a turning point in the person pursuing greater self-love and acceptance.
Like cancer, high blood pressure (or hypertension) can also be caused by suppressing the emotional expression of negative feelings such as anger (Chesney, Gentry et al.). Dr. Meyer Friedman famously showed in the 1960’s that people with Type-A personality who are more driven by time urgency and competitiveness are far likelier to succumb to heart disease than the milder Type-B’s. However, subsequent work by Redford Williams revealed that the effect was entirely predicted by a single factor, hostility. The reverse of hostility is trust in other people. In fact, far more predictably than the originally conceived Type-A’s, people who suffer from ‘an absence of trust in the basic goodness of others’ are the ones likely to become ill and die young.
David McClelland showed that college students driven by seeking power in relationships (the stressed power-motivation syndrome) complained of more illnesses than those who relished the liking and acceptance of others (unstressed affiliation motivation).
Kabat-Zinn, McClelland and others studied changes in the personality and belief structures of the patients undergoing the 8-week stress reduction program. Surprisingly, preliminary analysis showed that the patients evidenced profound improvements in trust toward others, as well as hardiness and coherence, personality variables that were previously thought to be relatively stable. Mindfulness meditation can have a significantly positive influence on one’s view of the world, oneself and others.
Studies show the importance of connections with others, including pets – both for the humans and the animals. James Lynch studied the effects of a high-fat high-cholesterol diet on heart disease in rabbits, and coincidentally found that the rabbits that had been petted by their caretaker were less likely to become sick. In a controlled study, this effect was found to be as large as 60%.
These studies show that optimism and trust in others play an important role in promoting health, wherever you are on the continuum between health and illness. Kabat-Zinn encourages the reader to become more aware of his or her thoughts and feelings, as they are observed from the perspective of mindfulness meditation, and notice their effects on oneself and others.
Rodin and Langer conducted an experiment with the elderly residents of a nursing home. The participants were divided into two groups. One group was encouraged to make decisions for themselves, including taking responsibility for a plant they were given in their room by the staff. The other group was instructed to allow the staff to make all their decisions, such as visiting hours and entertainment choices, and told to let the staff take care of the plant. While the second group died off at the normal rate for this population, in the first group mortality was halved! The authors of the study attributed this to their increased ability to take control of their situation, similar to Kobasa’s work on hardiness. However, Kabat-Zinn likes to think that instead the people in the first group made meaningful connections with their plants, and having someone (or something) outside of themselves to take care of actually increased their longevity.
Studies show that the number of social connections a person has through marriage, family, churches and other organizations is a strong predictor of mortality. Animals reared in isolation function less well as adults and die sooner than animals reared among littermates or with their parents. Harry Harlow showed in the 1950’s that baby monkeys preferred a soft, cuddly substitute mother to physical nourishment from a hard, impersonal one. Ashley Montagu documented the importance of touch to physical and psychological wellbeing in her book Touching: The Human Significance of the Skin. Physical touch is formalized in greeting rituals such as shaking hands, hugging and kissing. They can become a channel for the expression of feelings when engaged in with awareness. Touch is one of the many ways we connect with others. We also do so through seeing, talking and hearing, our bodies and our minds. Kabat-Zinn observes that touching which becomes perfunctory or habitual can lose its meaning and change from connectedness to disconnection and feelings of frustration or annoyance. He emphasizes that being ‘in touch with yourself’ is crucial in making satisfactory meaning out of connections with others.
Kabat-Zinn points out that everybody’s early experiences of life were experiences of connectedness, through being inside the body of another being. He notes that surgeons respect the ‘useless’ bellybutton by cutting around it if they need to make a midline incision, that this serves as a reminder of our connection with the human race. After birth, babies seek reconnection through nursing and touching, moments that deepen the bond between mother and child as the baby learns to separate. Without someone to care for them, human babies are completely helpless. This love between parents and children, and others, have to be expressed in order to flourish. He suggests that the lovingkindness meditation can provide expression for such feelings, even when their objects are absent.
Until recently pediatricians and child psychologists thought that babies were senseless when they were born, and Western child-rearing practices were dominated by this view. Studies of newborn babies in the past 30 years have disproved this, and show that babies are not only alert and aware but very needy of connection with their mothers and other caregivers. Childhood experiences of isolation, cruelty, violence and abuse can lead to emotional problems later in life. The world might seem meaningless or uncaring after such experiences. Children of alcoholics, drug addicts, and victims of physical or sexual abuse often carry deep emotional scars, but so can others who were less overtly abused or neglected. This can lead to feelings of alienation from one’s own body. Such wounds can be healed by acknowledging their presence and reestablishing a sense of connectedness with one’s body, as well as positive feelings towards it and towards oneself.
Gary Schwartz has proposed that mental and physical illness can result from a disruption of this process of regulation, which echoes the feedback loops seen in the integration of biological organisms and their organs and tissues at different levels of organization. Schwartz emphasizes that disregulation in people comes from disattention to the feedback signals necessary for the mind and body’s harmonious functioning. Meditation practice can help restore the connections missing, perhaps, from childhood, by providing attention to one’s bodily cues and bringing them to conscious awareness.
An important step is to be aware of the distinctions between different needs, such as hunger versus emotional emptiness or loneliness. It is also important to pay attention to connections between pain and feeling sick, and responses to particular stressors or foods. Doctors can become part of this regulatory system, but only function well if we tell them about the effects of the medications that they prescribe. The bodily system normally maintains itself well through the process of homeostasis, without a need for conscious attention, but when it goes out of balance then restoring health requires attention in order to reestablish the necessary connections. The practice of mindfulness can be difficult at first, because most people are not used to paying such close attention to their bodies and thoughts. However, increased attention helps form the connections that lead to learning increased control over these processes, important in the face of the challenges and stresses in which we are regularly and unwittingly immersed.
3.3. Stress
The term stress comes from the research of Hans Selye in the 1950’s. He showed that when animals are injured or placed under unusual or extreme circumstances, they become susceptible to disease as a result of certain physiological process in the body involving the hormones and the nervous system. He defined stress as “the nonspecific response of the organism to any pressure or demand,” and labeled as stressors the stimuli that led to stress. Stressors can be external factors such as a famine or war, or internal factors such as injury or infection. Selye wrote:
“Significantly, an overwhelming stress (caused by prolonged starvation, worry, fatigue or cold) can break down the body’s protective mechanisms. This is true both of adaptation which depends on chemical immunity and of that due to inflammatory barricades. It is for this reason that so many maladies tend to become rampant during wars and famines. If a microbe is in or around us all the time and yet causes no disease until we are exposed to stress, what is the ‘cause’ of our illness, the microbe or the stress? I think both are – and equally so. In most instances, disease is due neither to the germ as such, nor to our adaptive reactions as such, but to the inadequacy of our reactions against the germ.”
It is not the stressor alone that is responsible for the magnitude of the stress reaction, but its interaction with the preexisting conditions of one’s body and experiences. Sometimes a small thing can trigger an emotional overreaction in us, when at other times we may be able to coolly handle a life-threatening emergency. How we perceive and handle the situation often determines how much stress is experienced.
From Selye’s early experiments, it was not clear how much of the stress reaction was physiological, and how much psychological. Animals given more choices and ways to avert the stressor generally respond with less stress, perhaps the same control factor that leads to reduced illness and mortality in the studies of Kobasa and others. Richard Lazarus defines psychological stress as “a particular relationship between the person and the environment that is that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing.” So, by changing the way we see ourselves in relation to stressors in the environment, we can actually modify the stress reaction. We can also build up our resources, such as friends, religious beliefs, and beliefs about the self, and trust in others, as a way of reducing stress. On the other hand, fear, hopelessness, anger, greed and distrust can create additional problems and make a stressful situation seem worse. The psychological appraisal of the stressor itself is also important. We are often unaware of stressors such as poor diet and unsatisfactory relationships, which can lead to increased stress. A negative attitude about what is possible can result in the accumulation of stressors, preventing us from taking control in times of stress. However, catastrophizing and repeatedly appraising situations as more dangerous than they actually are leads to chronic stress.
Stress is part of the process of adapting to changes. Change is an unavoidable part of life. Physiologically, our bodies are equipped with feedback mechanisms that serve the purpose of homeostasis, the maintenance of a constant internal environment. Levels of oxygen and glucose in the blood are sensed, and the heart rate and blood pressure adapt accordingly. Changes occur to maintain our temperature at a more-or-less constant level, in spite of differences in the climate between the places we live around the planet and seasonal changes. Some processes of homeostasis lead to sensations, feelings and drives, such as hunger and thirst, that then require behavior on the part of the organism to serve homeostasis. We have learnt to assist this by cultural means, for example by wearing clothing when we feel cold, and taking it off when we feel warmer, or by using heating and air-conditioning. Most of these adaptations occur naturally and unconsciously, but when the system is abused it can become disregulated and require attention, for example if the liver is damaged due to excessive alcohol consumption.
There is a relationship between life-changing events such as the death of a spouse, divorce, imprisonment, injury or illness, getting married, getting fired, retirement, pregnancy, or the death of a family member or friend, buying a house, moving, having children, etc. and illness. Studies by Holmes and Rahe from the 1960’s show that the rated magnitude of the change, whether it is good (eustress) or bad (distress) can predict a higher probability of illness. The degree of a person’s adaptation to the stress is what determines their predisposition to illness. For example, somebody that retires is more likely to become ill if he or she does not make new social connections to replace the ones lost from the workplace.
Kabat-Zinn suggests that how we perceive change in the abstract influences our level of stress. If we can avoid mindless reactions when our ‘buttons’ are pushed and we have a philosophical view of change as part of life then we can be mindful of our reactions and responses to particular changes, and feel more in control by regaining control of these reactions.
The stress reaction is a normal part of an animal’s life that actually helps it deal with dangerous or threatening situations. Known as the ‘fight or flight’ reaction, it can be triggered, for example in a cat threatened by a barking dog. In humans, stress can be triggered by predictable stressors, such as the tax deadline, as well as unexpected accidents (external stressors) or internal stressors like the traumatic loss of function in one of the body’s organ systems.
This reaction can be useful, as when Mr. Lemard of Southgate, Michigan, a 56 year-old man who had had a heart attack 6 years prior to this event, lifted an 1800 lb pipe that had fallen on a 5 year-old boy, saving his life. Later, Lemard, his grown sons, reporters, and the police, were unable to lift the pipe, which Mr. Lemard initially guessed weighed 300-400 lb (Boston Globe, Nov. 1, 1980).
During the stress reaction, the sympathetic nervous branch of the autonomic nervous system, the part of the nervous system that usually regulates homeostasis together with the parasympathetic branch, is activated under the control of the hypothalamus. The hypothalamus is part of the limbic system, the emotional center of the brain. Activation of the sympathetic nervous system causes the heart rate and blood pressure to rise, and epinephrine (adrenaline) is released by the adrenal gland. Blood flow to the digestive system is reduced, so that more blood can flow to the skeletal muscles, supplying them with extra oxygen and glucose to prepare for movement and action. This is probably what enabled Mr. Lemerad to lift the 1800 lb pipe.
In animals the fight or flight reaction can be triggered by members of another species, or by situations involving a threat to social status within the group. The two animals fight until one submits or runs away. Our stress is often the result of real or imagined threats to our social status, rather than our lives, as Kabat-Zinn astutely observes. The fight or flight reaction that we have inherited from our primate ancestors often causes us problems in the social sphere, by making us react quickly and automatically.
People frequently end up suppressing these feelings of arousal because they are socially inappropriate, often denying them even to themselves. When the stress reaction is internalized in this way, there is no release by fighting or running. Instead stress hormones can cause lasting damage to the organs of the body, sometimes leading to a state of hyperarousal, chronic muscle tension, elevated heartrate, butterflies in the stomach and sweaty palms all the time.
Many people turn to drugs and medications to try and regulate such feelings. It is easy to take an aspirin or Tylenol when stress leads to headaches, drink coffee to combat the exhaustion of constant stress, and drink alcohol or take anti-anxiety medications to calm the body into a state of sleep. These can become unhealthy because although they bring relief from stress in the short term, in the long term they can compound the problem because the body becomes adapted to them, and the toxic breakdown of such substances stresses the internal organs.
Kabat-Zinn argues that sooner or later cycles of stress and reactivity, together with maladaptive coping mechanisms, lead to physical breakdown because they disrupt homeostasis. Ultimately, the genes and the immune system can be affected, making the body susceptible to cancer and infectious diseases. If this breakdown does not result in death, it ends up causing more stress and stimulating more maladaptive coping. Breakdown can be psychological, rather than physical – what used to be called a ‘nervous breakdown’ but now it is commonly referred to as ‘burnout’. The patient may feel alienated from work, family and friends, after a period of being stuck in a cycle of sustained hyperarousal and stress, with feelings of anger and resentment following life circumstances such as caring for a chronically ill family member. This clinical anxiety or depression can itself become a further source of stress.
According to Kabat-Zinn, getting stuck in the stress-reaction cycle is not ‘normal’ or ‘inevitable’, although it might feel that way to the people who are in it. He suggests a healthy alternative. Instead of reacting to stress, people can learn to respond to it, by bringing mindfulness to their daily lives.
The first step in responding to stress, instead of reacting to it, is to simply be aware of the stress reaction itself. Just bringing awareness to the situation changes it, because the stress reaction is an automatic, unconscious one, and conscious awareness of it in the face of stressful events kicks into place a regulatory feedback system that modulates the rise in heart rate, blood pressure, and cortisol, which are a part of the body’s reaction to the stressor. Kabat-Zinn points out that if you remain ‘centered in the moment of stress and recognize both the stressfulness of the situation and your impulses to react’ then you can choose how to respond, observing any feelings of fear or anger, and sensations of tension in the body, without losing control, and without suppressing these feelings and thoughts.
The expectation of being able to respond to stress mindfully in this way, instead of reacting to it, doesn’t come out of nowhere. The daily practice of mindfulness meditation is what gives the mind the strength and ability to remain centered and calm. When you feel your buttons are being pushed, or other kinds of stress, bringing awareness to the face and shoulders as they tense up, or to the heart as it begins to pound, can alert you to the presence of a stress reaction. You might say to yourself: “This is it.” In such moments, grounding yourself in your body and in your breathing can help you stay in control. This takes practice, and imagination. It takes practice to notice the stress reaction before it has already run its course, and imagination to find new ways of coping with and responding to stressors. Sometimes fight or flight is the best responses, but usually emotion-focused solutions or problem-focused solutions are more appropriate, either working with your own feelings, or figuring out an alternative to the situation and changing it. Either way, with the body and mind calmer, the dangerous cycle of stress reactivity can be avoided. The body and mind regain their balance without spiraling into mounting damage and stress, and without a need for ultimately damaging chemical agents to bring temporary stability.
Kabat-Zinn gives examples of patients from the clinic who learned to respond to stress in this new way. A patient with chronic back pain was able to control his pain while he studied and took exams to become an insurance salesman. A sick patient remained calm while awaiting surgery in hospital. Another patient dealt with the humiliation as her psychiatrist mistakenly called the police to her house, thinking she was suicidal. A patient anxious about her husband’s van, only to drive it into the hospital’s covered parking lot thereby shaving off a window on the roof, was able to come into the session while remaining centered, knowing that there was nothing she could do now about her accident and her husband would also just have to accept it had happened. A patient who wanted to give up smoking noticed that her cravings usually only lasted about three seconds, and by practicing the breathing during these few seconds she remained clear of cigarettes, reporting this at a clinic re-union two and a half years later.
3.4. The Applications
The relief of symptoms is one of the largest industries in the country. Drugs such as Tylenol and aspirin for pain are available over the counter, as well as medications that make the digestive tract slow down or speed up, to relieve heartburn or neutralize stomach acid. The most prescribed medications are Valium and Xanax to relieve anxiety, percodan for pain and Tagamet or Zantac to decrease the secretion of stomach acid. The trouble with the widespread use of such medications that while they are often effective in reducing the annoying symptoms they are taken to remedy, they do little to address the underlying problems.
Patients coming into Kabat-Zinn’s clinic have been ill an average of 7 years and yet, as a result of the short 8-week program, the symptoms they endorse on questionnaires before and after learning mindfulness meditation reduce from an average of 22 out of 110 down to about 14.
Kabat-Zinn observes that left to themselves such a group of 20-35 patients would endlessly discuss what is wrong with them. Instead, he asks them to focus on what is right. Symptoms are rarely discussed in the program. Rather than discuss the symptoms and how to get rid of them, he asks patients to focus on a symptom and really experience it, noticing not only bodily sensations but also the feelings and thoughts evoked by the symptom. For example, if somebody experiences a headache while meditating, she is asked to observe the sensations with wise attention, and not let the mind automatically jump into rejection and judging with thoughts such as ‘I just can’t relax’ or ‘meditation doesn’t work,’ accompanied by feelings of hopelessness and disappointment. If such thoughts and feelings come up, they can be observed just as the sensations of the headache itself are observed. Kabat-Zinn notes that language tricks us into personalizing our symptoms and illnesses, in phrases such as ‘I have a headache’ or ‘I have a cold’ instead of ‘the body is headaching’ or ‘the body is colding.’ These things are all really process unfolding in our body that we happen to be experiencing. The important thing is to listen to what the symptom is trying to tell us, whether it is muscle tension, a racing heart, racing thoughts, shortness of breath, fever or pain. Denying or becoming preoccupied with these symptoms is unhealthy.
Kabat-Zinn relates the story of a priest who was his patient and described his medical history as follows:
“…his body had been trying to get him to slow down his fast-paced, Type-A lifestyle by giving him headaches at work. But he didn’t listen, even though the headaches got worse. So his body gave him an ulcer. But he still didn’t listen. Finally it sent him a mild heart attack, which scared him so much that he started to listen. He actually said that he felt grateful for his heart attack and took it as a gift. Because, he said, it could have killed him, but it didn’t. It gave him another chance.”
Kabat-Zinn suggests that the reader play a little thought experiment, next time he or she hits a thumb with a hammer, bumps into a car door, or has another little physical accident or mishap that causes pain. You can observe the sensations of pain, the ‘expanding shell of epithets, groans, and violent body movements’ that follow from the outside. You may notice that you become completely detached from your sensations and calm, as though it was just pain, not so much your own pain. Some people feel a sense of calmness ‘within’ or ‘behind’ the pain, and this calmness can actually reduce the degree of pain experienced and the resultant expressions of pain.
The kind of pain described above is acute pain, and can be well managed by modern Western medicine. If the pain persists, and does not respond well to medications or even surgery, lasting for six months or more or returning intermittently over extended periods of time, it is called chronic pain. Chronic pain usually starts out as acute pain. Mindfulness meditation is particularly effective in the treatment of chronic pain.
Patients coming to the stress clinic have already undergone a thorough medical investigation, and it is important to purse this in order to rule out or treat diseases that require immediate medical attention.
Kabat-Zinn notes that pain is often instrumental in preventing tissue damage and seeking treatment for serious injuries and diseases, but in this society we have an aversion to pain, not even wanting to talk or think about it. He suggests that this societal aversion to pain is really an aversion to suffering, where suffering is only one of the many possible responses to pain. In fact, chronic pain is extremely common, and costs society in this country over $30 billion per year in medical expenses and lost productivity, not to mention the emotional and psychological costs of chronic pain. While acute pain can be useful, it is hard to see how chronic pain can be useful. Patients are understandably disappointed and upset when medical treatment involving surgery and drug interventions fails to fix or get rid of their pain, and they are told to ‘learn to live with’ it. One of the problems is that we tend to see the body as a machine that can be taken to the doctor and fixed, much like you would take your car to a mechanic. Instead, the body is part of a larger system including the mind, our thoughts, feelings, and relationships with others. The processes of chronic pain are usually too complex to unravel by means of diagnostic tests such as MRI, CAT scans and X-rays, and surgery for pain is rarely successful because pain is part of an intricate and poorly understood system involving both local neural feedback and central control and regulation through the nervous and hormonal systems. The good thing about this is that learning to calm the mind can actually impact the experience of pain throughout the body.
Outcome studies from Kabat-Zinn’s stress clinic show a 50% or greater reduction in pain on the McGill-Melzack Pain Rating Index (PRI) in 61% of patients, with a further 11% of patients achieving a 33% or greater reduction in pain. The patients also end up perceiving their bodies as 30% less problematic than at the start of the 8-week program, and there is a 55% drop in negative mood states. Follow-up studies show that these improvements are maintained for several years, and that over 90% of the patients continue to practice breathing awareness and informal mindfulness practices on a daily basis, with 40-70% maintaining a formal practice as well. Most patients attributed the reduction in pain to what they learned at the stress clinic.
Kabat-Zinn encourages the pain patients to practice the Body Scan meditation daily for at least 45 minutes, six days per week. They should first treat the pain just like any other distraction, returning the focus to the breath and to the body part that is being attended, being sure to let go of it and spend some moments in stillness before transition to the next region in the scan. If the pain becomes too intense, they should instead focus on the pain itself, noting its intensity, and whether it is tolerable. He says that usually while the pain may be intense, most people find it is tolerable when they focus on their sensations in the moment that they are happening. He recommends deliberately observing any thoughts and feelings that are associated with the pain, as well as being particularly vigilant for even minor changes in sensation, such as the degree of pain, or other sensations in the affected body part like tingling, burning or numbness. After a time, if and when the intensity of the pain subsides sufficiently to move the attention elsewhere, one should first deliberately let go of the painful part of the body and just experience the sensations when the attention is quiet and relaxed, before moving on to the next region of the body scan. The pain might continue, and still be noticed, during the scan of the other regions.
At the end of the Body Scan, as taught by Kabat-Zinn, there is a moment of letting go of the body, including the breathing, and just being. He argues that if one can sense oneself as a pure ‘being’ beyond the body, then one must be something other than the body and its pain. He suggests gently working towards this enhanced awareness though the daily practice of meditation, without expecting ‘results’ in terms of pain reduction. He says: “Mindfulness does not bulldoze through resistance. You have to work gently at the edges, a little here and a little there, keeping your vision alive in your heart, particularly during the times of greatest pain and difficulty.”
Kabat-Zinn discusses particular strategies to use for different pain syndromes. First of all, he empathizes with people who suffer from low-back pain, which is a common and debilitating condition. He notes that such patients typically have good and bad days, over a period of months or years, and should view rehabilitation as a long-term process rather expecting pain reduction in the few weeks of the stress reduction program. For these patients, he recommends being particularly mindful of their bodies on a daily basis, while doing any physical task such as vacuuming. He suggests vacuuming like doing the yoga, breathing with each movement, listening to the body, and being gentle with it. Working around the edges of the pain, even if this means doing some of the vacuuming one day and then waiting weeks before continuing with the task. As inspiration, he tells the story of a
For patients who suffer from chronic headaches and migraines, Kabat-Zinn recommends becoming mindful of emotional and environmental variables that may trigger the onset of an episode. He notes that some people with tension headaches are already aware of these cues, but others deny them and insist on the organic, physical nature of their headaches. He points out that even though the headaches are real, physical events they can be modulated by emotions, so knowing when it is time to go and lie down can be important. For headaches, he recommends that the meditation at the end of the Body Scan, where one imagines breathing through a blow-hole at the top of the head.
In addition to working with physical pain, the techniques of mindfulness meditation can be useful for working with emotional pain and suffering. Kabat-Zinn suggests, as with physical pain, to focus on mindful awareness in the part of the self which is separate from the painful thoughts and feelings. Just being aware that there is such a perspective, from which thoughts and feelings can be observed, is helpful. He proposes a specific meditation for emotional suffering, a “what is my own way” meditation, noting that often our emotional suffering comes from feeling that things ‘go against us’ when really we are rarely aware, in the moment, of exactly what we really want. Further, he outlines two strategies for dealing with emotional pain: problem-focused coping, and emotion-focused coping. Problem focused coping consists of problem-solving around the situation and considering what actions can be taken. Emotion-focused coping involves ‘sitting with’ the hurt, being aware of the source of the suffering and all the thoughts and feelings it evokes, and accepting them, feeling compassion and lovingkindness to oneself in the midst of the pain. Kabat-Zinn emphasizes the importance of using both strategies in life, and notes the shortcomings of excessive reliance on one or the other.
He gives an example by telling a story about a backpacking trip with his 11 year-old son. They were stuck on a ledge, clinging onto a tree, in the middle of climbing up a tall mountain. Kabat-Zinn noticed that both of them were filled with fear, observing the view of brewing storm clouds, and weighed down by their heavy packs, but also filled with determination to scale the mountain. He sat with his son and they talked about the fear the both felt, as well as their desire not to be defeated by the fear in their quest to reach the peak. They listened to their feelings and decided to turn back, camping in a shelter just as the heavy rain started to fall. The next day, they used problem-focused coping to climb up the mountain, abandoning their heavy packs and shoes at the tree in order to reach the top easily. Once the path had been found, Kabat-Zinn climbed back to the packs and brought them up, one at a time, so that they could continue on their hike.
Bringing mindfulness to bear on emotional problems is not easy. It takes practice, but it can be very fruitful. “Times of great emotional upheaval and turmoil, times of sadness, anger, fear, and grief, moments when we feel hurt, lost, humiliated, thwarted, or defeated, are times when we most need to know that the core of our being is stable and resilient and that we can weather these moments and become more human in the process. It helps to come to stillness in such moments.”
Studies have shown that Kabat-Zinn’s stress reduction program is highly effective in the treatment of panic and anxiety. A group of 23 people referred to the program for their anxiety and diagnosed by a psychiatrist or a clinical psychologist were found to have a reduction in anxiety and depression at the end of the 8-week program, and follow up after 3 months showed that they not only maintained their improvements, but that most of them were ‘virtually free’ of panic attacks.
Kabat-Zinn relates in detail the case of Claire, a young married mother who had suffered debilitating panic attacks for 11 years and wanted to be free from medication because she was pregnant. She not only learned to control her feelings of anxiety without resorting to drugs, she was later able to handle the stressful birth of her second child who had pyloric stenosis and needed surgery in the first few days of his life.
Kabat-Zinn emphasizes that during the meditations, bodily sensations and anxious thoughts and feelings can be observed, without feeling a need to ‘do’ anything about them, as can judging, self-critical thoughts that might occur in these moments. He reminds the reader of Gregg, the firefighter who was made more anxious by the focus on the breath, but eventually learned to get ‘underneath’ his agitation and reach a state of deep inner calm. Looking at thoughts as just thoughts, rather than believing their truth or validity helps one to become free from their attraction or repulsion. It is important not to reject or try to control strong feelings. Sometimes they need to be expressed. But observing them in this way can bring into balance the separation between thoughts and feelings, and between the ‘I’ and the fear confounded in the statement ‘I am anxious’.
He tells the moving story of a woman referred because of anxiety and panic following a cerebral aneurysm. She was still undergoing extensive tests and scans to determine the likelihood of another aneurysm, while suffering from frightening seizures, dizzy spells, and visual symptoms. She learned to separate her inner self from the strange things her body was doing, by focusing her mind on her feet when she was in the CAT scanner, or on the sounds of the machine itself during an MRI scan. She liked the image of a stable ‘inner mountain’ that she could meditate on in the midst of this chaos, which gave her more peace of mind even though her ‘full catastrophe’ was still unfolding.
“Practice not-doing and everything will fall into place.” Kabat-Zinn quotes Lao-Tzu’s Tao Te Ching, proposing a drastic solution to the time pressure that almost all of us inevitable feel in this society. Whether the time pressure comes from having too much to do, through work, relationships, and other commitments, or from not having enough to fill one’s time, a sense of isolation and boredom, the solution is the same: do nothing. Because “inner peace exists outside of time” only by setting aside time for not-doing can one escape the tyranny of time.
Too much doing and being filled with time-related anxieties can lead to illness and even death. Dr. Robert Eliot, a cardiologist, tells how he was feeling mounting time-stress as he felt ‘behind-schedule’ in his career, gaining the chair of cardiology only at age 43 instead of by his planned 40. Then he felt unable to turn the position into the leading research institute of his dreams, and felt a sense of disillusionment and “invisible entrapment.” He ignored his wife’s gift of an exercise bike, lacking time for such a frivolous activity and relying instead on the fact his parents had both lived long and he was not overweight, and did not smoke, to protect him from heart disease. Finally, after an angry confrontation and a busy afternoon lecturing and diagnosing cases, he started to feel dizzy before suffering a massive heart attack shortly after he turned 44. In his book, Is It Worth Dying For, he described his life before the heart attack as a “joyless treadmill”.
The immense time pressure of our daily lives, and the strivings for material achievements, are transmitted to our children from an early age. Human beings are not accustomed to living this way. In an earlier time, our rhythms were tuned to the rhythms of nature. Many activities were limited by daylight, and at night our ancestors were probably drawn to the campfire for its heat. Staring at the flames might have been one of the earliest experiences of meditation. Few people traveled far from their homes, and even with the help of animals their rhythms and needs dictated our limits and slowed us down. Now we do things as fast as our imagination allows, and often feel expected to do so by our superiors, families and peers, doing many things at once with the aid of electricity, cars, cellphones, and the internet. Kabat-Zinn emphasizes that while this keeps us perpetually in touch with the world, we are rarely in touch with ourselves.
He outlines four common-sense ways to free yourself from the tyranny of time. The first is the realization that time is only a product of thought and has no absolute meaning, as Einstein was fond of pointing out. The second is to live in the present moment more of the time. Living in the present moment can mean focusing on one thing at a time, whether it’s eating dinner and really savoring the food instead of watching TV, talking with your family and spending the time to sit together and look them in the eyes instead of glancing by on your way to somewhere else, or taking time to do nothing. The third way is taking time intentionally every day to practice meditation. The fourth way is to simplify your life by, for example, examining the things you do with your time and giving up the ones that are not really big priorities as far as their meaning to you. He gives the example of a judge who complained he had no time for himself and his family, and then found he was spending 2.5 hours a day reading the news in three different newspapers and watching it on TV. When he cut back to one newspaper he had an extra 2 hours for other things. Sometimes this can involve a reexamination of one’s whole life, including the tradeoff between time and money. Kabat-Zinn himself worked only 3-4 days a week when his children were young, and was paid accordingly, even though he admits that he needed the full-time money.
A patient at the stress clinic who had been in pain for many years experienced no pain at all after an all-day session. When her son called to ask her to mind his children, she said no for the first time ever. He was shocked, but the woman’s husband uncharacteristically backed her decision. Protecting these precious moments of stillness was her priority.
“ Time past and time future
Allow but little consciousness.
To be conscious is not to be in time.” (T. S. Eliot, Burnt Norton, Four Quartets).
Sleep is often one of the first things to become disrupted by a stressful lifestyle. Instead of turning to the readily available medications that allow us to regulate this pattern of disregulation, Kabat-Zinn suggests becoming less attached to the notion that we know exactly how much sleep we need, and when. Meditation can help with sleeplessness, and many people attending the stress clinic for sleeping problems fall asleep during the Body Scan. They are allowed to use the meditation tape for this purpose, but instructed also to practice the Body Scan during the day, at a time when they can remain awake and alert.
Kabat-Zinn reminds the reader that mindfulness meditation is derived primarily from the Buddhist tradition. Buddhism is a religion that has no God, and there is a story in which somebody approached the Buddha, who was a great sage and teacher, and asked him “Are you a God?” To which he replied: “No, I am awake.”
Kabat-Zinn himself suffered from interrupted sleep for a period of 11 years, starting when he and his wife were determined to be available for their young children, who woke and needed comfort and feeding during the night. Later, he continued to sleep intermittently, and would use this time (after he realized that his tossing and turning were to no avail) to practice sitting meditation or yoga. Sometimes this can bring the calm and relaxation needed to get back to sleep, but other times he remained awake and was able to get quiet tasks accomplished while everybody else slept. Kabat-Zinn points out that sleep cannot be forced, it involves an element of letting go, as implied by the phrase ‘falling asleep.’ This time when we leave our bodies for hours on end is a sacred time. He suggests using the mindfulness meditation to explore our relationship with sleep, worrying less about losing sleep and paying more attention to being fully awake.
The fifth week of Kabat-Zinn’s 8-week program is devoted to communication. Over the week prior to the class, participants are encouraged to keep a log of their stressful communications, noting an awareness of the person with whom there is a difficulty, how it came about, what you wanted from the person or situation, an awareness of what was actually going on and what came out of it, as well as your feelings at the time it was happening. People and relationships can result in a lot of unnecessary stress. Some people realize that they were not clear about their own priorities, and may be afraid of expressing their feelings or asserting their needs in the communication. Men frequently deny or repress their feelings, because they were trained that expressing certain kinds of feelings was ‘unacceptable’. Kabat-Zinn teaches the participants the importance of making ‘I’ statements rather than ‘you’ statements when being assertive. He also emphasizes that while people may find they need to say ‘no’ more often, there are different ways of saying no, some of which may come out as unnecessarily aggressive. It can help to acknowledge the other person’s feelings and needs.
During the class, patients enact the different ways of reacting or responding to an aggressor using aikido. The one taking on the role of attacker comes at the defendant head-on. The first strategy is to lie down, roll over, and either submit or blame somebody else. This is found by both participants unsatisfying. The second strategy is to slip out of the way the moment before the attacker reaches you. This passive (or passive-aggressive) defense similarly leaves both participants unsatisfied, although it is often what happens in many of our relationships. The third strategy is to take the attacker head-on and wrestle. While this is more satisfying for both parties, there is rarely any resolution of the conflict this way. The fourth strategy, from Aikido, is to grab the attacker’s wrists and swing around using his or her momentum so that for a moment both people are looking the same way. The results are unpredictable, but there is a sense of ‘hearing’ the attacker while defending oneself and changing their course at the same time. In aikido, this is called ‘blending’ and for Kabat-Zinn it represents the relational equivalent of the stress-response, instead of the stress reaction.
Kabat-Zinn describes his relationship with an immediate supervisor who smiled while making aggressive comments like “you son of a bitch”. Kabat-Zinn felt stressed by his hostility, and it prevented an effective working relationship between them. Then he came to realize that his supervisor was unaware that he was being hostile, driving away many of the people he supervised who tried to argue with him and ended up feeling hurt, angry, frustrated and unsupported. One day Kabat-Zinn simply asked the supervisor if he was aware that he was constantly putting him down, and that he felt as though the supervisor did not like him or appreciate his work. The supervisor genuinely had no idea that he had been calling him names. After that, their working relationship became a great deal less stressful for Kabat-Zinn. Relationships, like bodies and minds, can heal – by paying close attention to your own body, mind, thoughts, feelings, words, likes, dislikes, motives and goals – as well as those of other people.
Some of the stress that we experience comes from being stuck in a certain role, whether at work or in the family, or the community. We might feel that we need to do good, or be a ‘good’ husband, wife, manager, etc. This need to be someone or doing something for somebody else can feel constraining, and lead to restrictive patterns of thought and feeling. An example was a mother who came to the clinic filled with anxiety about her grown son who would not leave the home, but was making it uncomfortable for her. She learned that she needed to stand firmly in her request for him to go instead of retreating to her role as a ‘good’ mother and backing down repeatedly.
Kabat-Zinn describes a Rabbi who was a reluctant participant in his program after suffering a heart attack. During the aikido training, the Rabbi had a sudden revelation: “I never turn,” he said, figuring out why he was unable to ‘blend’ with his partner. He realized instantaneously that this was the same problem he encountered in all his relationships outside the stress clinic. By talking himself into trusting his partner, he learned to turn and blend his energy with his partner’s energy, instead of always confronting him or walking away.
Work is another source of stress for many people. Most of us have no choice about working for a living, and end up on ‘automatic pilot’ doing jobs that may once have been meaningful, but have long since lost their interest for us. Kabat-Zinn recommends focusing on the good we are doing for society and others in our role in the workplace, creatively making a meaningful product or connections with others, using our carefully acquired skills and expertise to provide meaning or to teach beginners. Alternatively, if the work we do is monotonous or lacks freedom of choice for us, we can learn to treat the drudgery of work itself as a meditation, just like the movements of the yoga. Sometimes walking to work or to public transport can be a meditative introduction to the workday that helps calm the mind, while also doing good for the planet. Breathing while driving to and from work can help relieve work stress. Some people take on too much responsibility at work, and learning to communicate more effectively and delegate some of that responsibility onto others reduces the stress of work.
Kabat-Zinn stresses that you cannot live a healthy life in our society without paying attention to food. We are surrounded by many readily available foodstuffs that differ markedly from those our ancestors used to eat for thousands of years. Many contain chemicals that have only been invented in the past 5-25 years, and their effects on the human body are at best unknown, in spite of reassurances from the profitable food and agrochemical industries. Our bodies adapted over millennia to limited foods from particular regions and climates, and now we live far from this balance with nature and the sources of food production. Moreover, many people use food as a naturally rewarding remedy for stress, particularly the rich sugary and fatty foods we have grown accustomed to associate with comfort and self-soothing. People eat when they feel anxious, bored, lonely, or empty, because food triggers the reward systems of the body and thus helps calm the stress reaction. However, at the same time the metabolism of all this food itself stresses the body, increasing the risk of heart disease and other chronic illnesses. In 1977 the Senate Select Committee on Nutrition, acknowledging that Americans were killing themselves by overeating, recommended cutting the fat intake from 40% to 30% of daily calories. A later study by Dean Ornish showed that an intake of 30% did not slow the progress of atherosclerosis, the clogging of arteries with fat that eventually leads to heart attacks. But daily yoga and regular exercise combined with a vegetarian diet containing only 10% fat not only slowed the disease, it resulted in improvements in blood flow over the course of a year. Kabat-Zinn observes that changing your diet without the support of such a controlled program is hard, as evidenced by the fact that so many people are constantly on diets, trying to lose weight. He makes some suggestions as to how mindfulness and awareness can be used to change our relationship with food.
One class in the 8-week stress clinic program is devoted to food, and its relationship with the body and health. Kabat-Zinn suggests not making any changes to begin with. Instead, you simply observe the food that you eat, noticing how it looks, smells, and tastes as you are eating it. Notice colors, shapes, and textures, as well as aromas and flavors. Then you observe the sensations and feelings in the body immediately after eating, and also an hour or two later. What effect did the food have on your energy level? Did it make you feel energized, or sluggish and fatigued? How does your belly feel? Are there any other sensations in the body, following eating this particular food? What are your thoughts about what you ate? People in the stress clinic often realize that they were eating on automatic pilot before, things that they did not particularly enjoy or even things that made them feel bad. Many people deliberately slow down their eating, and some people lose weight just by paying attention to their food without consciously trying to lose weight.
Kabat-Zinn deplores the societal focus on body image and weight, particularly for women. He notes that even suggesting we tend to overeat can trigger women and girls with eating disorders, such as anorexia and bulimia. These conditions usually have a strong underlying emotional component, according to Kabat-Zinn. Nevertheless, he emphasizes that just eating a little less, like the people who slow down their eating as a result of the stress management course, can extend lifespan and increase the body’s immunity to certain illnesses.
According to Kabat-Zinn, food includes not only those things we take in for energy and nourishment, literally, but also everything we take into the body and mind, such as the water we drink, the air we breathe, and the information we consume. He points out that we often have little control over pollutants and chemicals in our food and our environment, which can endanger the body even if we eat a healthy diet. Pesticides such as DDT and PCB’s, although banned in this country, are sold by American manufacturers in the Third World and find their way back here in imported foods such as coffee, pineapples, bananas, peppers and tomatoes. These pesticides poison thousands of people around the world each year, saturating the environment and the food chain, and causing effects which, Kabat-Zinn points out sarcastically, are “unknown, but… not likely to be beneficial.” We are exposed to gases and particles that visibly pollute the air, to the degree that on some days people living in
Kabat-Zinn offers some practical suggestions for dealing with ‘world stress’. These include paying attention to the water and air quality where you live, and choosing to drink bottled water or filter the water if necessary, perhaps even move to a healthier place. He recommends becoming aware of your relationship with information – how much time is spent reading newspapers and magazines (or nowadays news on the internet), and how you feel or react to the information you receive, noticing whether there is a craving for information which is like an addiction, or if you keep the radio or TV on all the time even when you are not listening. The same with TV, observing the states of mind that cause you to turn it on or off, and the effects it has on the body and mind. In particular, he suggests observing the effects of taking in bad news, and any accompanying feelings of powerlessness, and instead identifying issues that really matter to you and becoming engaged in some activity toward changing the world, even in very small ways.
3.5. The Way of Awareness
The end of Kabat-Zinn’s eight-week program is a new beginning for the participants. From here, they embark on their own, independent meditation practice. Unlike conventional psychotherapy or many other branches of behavioral medicine, this planned endpoint is not expected to leave them ‘better’ but instead to launch them on their own path of spiritual as well as physical and mental recovery.
Kabat-Zinn relates a story told in the last session by the Canadian truck driver with low back pain, who found he could reduce his pain through the Body Scan meditation. He remembered when, as a child of about 10, his father took him and the rest of his family to a small church in the middle of the countryside when their usual church became riven with strife. The people in the small church, a group of about 20 farmers, waited patiently for the arrival of a visiting minister, not having their own resident priest. After waiting for some considerable time, somebody started to lead hymns. Eventually it became clear that no minister was coming, and one of the parishioners asked if somebody there could read from the bible and lead the sermon. A farmer stood up. He was uneducated, and reluctant to read, but he said that he knew which passage he wanted, and asked someone else from the congregation to read the relevant text, which was about giving. Then he went on to tell the following parable. He said it was as though the pig said to the cow, “How come you get fed nice, fresh grain every day, whereas I have to eat the garbage and scraps from the farmer’s table?” The cow replied, “I also give every day, whereas you eat and eat, and give nothing until the day you die.” The moral of the story which the patient took home at the time was the importance of giving to the Lord every day. During the stress management program, he realized that the Body Scan was like giving thanks, sensing your toes, or hands, or eyes every day, instead of waiting until you became blind before noticing that you had them. He had come to see the Body Scan as a spiritual practice, doing it every day as a way of giving, even when it did not immediately bring relief from his pain.
Kabat-Zinn stresses the importance of maintaining the daily formal practice, by sitting or doing the Body Scan as well as the yoga a few times each week. He says that time must be put aside daily for not-doing. As one’s practice deepens, it may be necessary to keep in mind the finer points such as letting the thoughts pass, rather than trying to stop them. In fact, thoughts and feelings can be the focus of meditation, providing you see them from the perspective of observing their coming and going, instead of being attached to or invested in particular thoughts. Some people will feel that their meditation is very successful, or that they are becoming good at it, and it is crucial to learn to let go of such judging thoughts and concentrate on the meditation as not-doing rather than doing. Sometimes skipping the daily practice can make you even more aware of its effects.
Many people leave the stress reduction program, and continue to practice the breathing. Kabat-Zinn points out that the informal practice of mindfulness can be much more than just that. It can involve moment-to-moment awareness of all the sensations of the body, of thoughts and feelings, during times of relative inactivity such as while traveling, and also during times of activity, while doing household chores, tasks at work, or even during communication with others. As a continuation of the informal practice, he suggests taking a week to notice a pleasant event every day, including all the sensations, thoughts, and feelings associated with it, and on another week to notice a stressful event every day. As discussed in the section on communication, one can note a stressful communication each day, including the verbal and non-verbal contents of the communication, and the associated mental states of the participants. He also suggests keeping a calendar of physical symptoms for one week, noting the preceding mental states. Kabat-Zinn cautions that mindfulness meditation is not the same thing as relaxation, because if you try relaxation you expect to end up feeling relaxed, whereas meditation might bring about a different outcome.
Kabat-Zinn talks about ‘The Way of Awareness’ as an acceptance that the Tao of the world unfolds according to its own laws, and everything, including our lives, just comes about. “To live in accord with the Tao is to understand non-doing and non-striving.” He laments that little in our education system prepares children and adults to just be, instead there is a focus on doing and achievement without much thought to “who is doing the doing”. He suggests that instead we should each see ourselves as Odysseus, on our individual paths home after a series of adventures at sea. Mindfulness is, according to Kabat-Zinn, a lifetime’s journey that leads nowhere except to who you are. Sometimes facing a stressful situation mindfully involves not-knowing, creatively encompassing confusion, despair and agitation. “This is Zorba’s dance in the face of the full catastrophe. It is a movement that carries us beyond success and failure, to a way of being that allows the full spectrum of our life experiences, our hopes and our fears, to play itself out within the field of our own living.”
No comments:
Post a Comment