* lessens or lifts depression
* improves relationships that were destructive or motivates people to separate
* reduces or eliminates confused and irrational thought processes in some schizophrenic patients
Treating Depression
In particular, running as described here appears to be especially effective in treating depression: "... it's hard to run andfeel sorry for yourself at the same time."[1] Running tends to increase your sense of independence and self-confidence, which have been weakened if you have been depressed. Psychotherapy and drug therapy, in contrast, may encouragedependencyon the therapist or psychiatrist.
[1] James Fixx,The Complete Book of Running(New York: Random House, 1977), p. 16.
Dr. Kostrubala has noticed that long-distance running often greatly reduces or even eliminates the typical early morning awakening and insomnia of the chronically depressed person. This particularly painful symptom involves jarring awake to a new day to be faced—a day of anxiety, fears, and hopelessness to be combated. If you have experienced this, you are probably familiar with waking up too early, at what the Swedes call "the hour of the wolf," lying in bed, exhausting yourself with crushing worries, despair, and tears, and beginning the day in a state of emotional exhaustion. Kostrubala has found that as depressed people cultivate the habit of long-distance running, these early morning ordeals often gradually subside and disappear.
A British medical group led by Dr. Malcolm Carruthers discovered that individuals who exercise vigorously produce increased levels of the hormone epinephrine, which counteracts depression. Apparently, strong exercise for even ten minutes doubles the normal level of epinephrine; the effects of the heightened level of the hormone can be fairly long-lasting.
Another study, by psychiatrist John Greist at the University of Wisconsin, revealed that one group of seriously depressed patients benefited more from a ten-week session of therapeutic running than another group benefited from traditional therapy.
To summarize research findings on exercise as a treatment for depression:
* To be effective, vigorous exercise must be done regularly no less than three times a week, and preferably at least five times a week, for periods lasting between thirty minutes and an hour. (Dr. Kostrubala uses an hour as a goal.)
* Although running and running combined with walking are the most commonly used therapeutic forms of exercise, any regular aerobic exercise is likely to produce the sameantidepressant effects when done for proportional periods of exertion.
* Studies over the past ten years show that lessening depression by means of exercise is most successful for persons with mild to moderate depression, but vigorous exercise tendsnotto benefit patients withseveredepression.[2]
[2] John H. Griest and James W. Jefferson,Depression and Its Treatment(Washington, DC: American Psychiatric Press, 1984), p. 63.
Lessening Anxiety
Therapeutic running also tends appreciably to lessen anxiety. A research study conducted by Dr. Herbert A. deVries of the University of Southern California School of Medicine and Gene M. Adams of USC's Gerontology Center found that fifteen minutes of moderate exercise diminished anxiety more in people aged fifty-two to seventy than did 400-milligram doses of meprobamate, a widely prescribed tranquilizer.
For Schizophrenics
Therapeutic running also seems to benefit schizophrenic patients. Schizophrenia is a complex, difficult-to-treat illness that affects approximately 1 percent of the world's population. It is no respecter of particular cultures. There are many forms of the illness, but all are characterized by disabling blockages to normal human interrelation, strange behavior, loss of contact with reality, and withdrawal, paranoia, or hallucinations. Again, Dr. Kostrubala has attempted to help patients with this condition through a combined program of medication, psychotherapy, and therapeutic running. Although he is careful to emphasize that controlled studies have yet to be made, his judgment about the patients he has treated is that
... using this form of running therapy ... [I] have seen them change dramatically. They begin to lose their symptoms; medication can be reduced and often discontinued; and they have picked up the course of their lives until several are no longer recognizable as schizophrenics at all—even by professional observers.[3]
[3] Thaddeus Kostrubala,The Joy of Running(Philadelphia: J. B. Lippincott, 1976), p. 129.
... I have come to the conclusion that running, done in a particular way, is a natural form of psychotherapy.[4]
[4] Kostrubala,The Joy of Running, p. 119
The Risks
Since therapeutic running appears to be of psychiatric value, it is not surprising that it, like any attempt to heal, may have potential risks. Aside from the obvious potential for sports-related injuries, there is a specific risk: physical addiction. Dr. William Glasser, whose approach to psychotherapy we discussed in the section dealing with reality therapy (Chapter 11), agrees with Kostrubala that therapeutic running is addictive. Glasser calls it apositiveaddiction, since—unlike the use of alcohol, barbiturates, and opiates—running is constructive and therapeutic.[5] However, like alcoholism and drug addiction, therapeutic runningdoesproduce very real withdrawal symptoms if a dedicated runner cannot continue to run, whether temporarily because of an injury or illness, or permanently. Withdrawal symptoms can be surprisingly severe: primarily, strong anxiety and insomnia, but sometimes also restlessness, sweating, weight gain or loss, and/or depression.
[5] William Glasser,Positive Addiction(New York: Harper and Row, 1976), Chapter 5. (Chapter 6 of his book is devoted to another positive addiction, meditation.)
BIOFEEDBACKIn psychotherapy, especially useful for clientswith problems involving anxiety, depression,phobias, and insomnia, who will benefit fromlearning how to lessen their own tension.
Most of us can draw a relatively clear line between the physiological processes we can control and those we cannot. Unless an illness or accident or handicap interferes, we have voluntary control over many muscles, but there are many that, fortunately, work without our conscious intercession: the heart beats day and night, our lungs fill and empty, our digestive processes are automatic. Except for people who have voluntary control over the muscles that move their ears, we are all more orless equally endowed, and equally limited, in what physical processes we are able to influence.
Until the development of biofeedback, there was only one way to extend self-control beyond the normal range: through a disciplined and time-consuming practice such as yoga. Experienced practitioners of yoga claim that studying yoga over a period of years has given them a sense of personal integration and mental centering similar to what we will see in connection with the practice of meditation. Physical and emotional flexibility also seem to result from long-term yoga practice.
Some yogis have extended their range of control over inner, normally involuntary processes in dramatic ways. Some can cause their heart rate to increase to five times its resting rate. Some are able to cause a ten-degree temperature difference between the thumb and little finger of the same hand: one side is flushed and hot, the other side cool and pale. Many other forms of self-control have been documented,[6] but acquiring these special skills through the practice of yoga takes years of discipline, concentration, and tenacity. But the years of dedication seem also to be indispensable if one is to develop the qualities of inner tranquility and strength sought by yogis.
[6] See, e.g., Mircea Eliade,Yoga: Immortality and Freedom(Princeton, NJ: Princeton University Press, 1958).
Biofeedback has greatly shortened the yogis' road to conscious control of some physical processes, and, in turn, it has become the main contribution technology has made so far to psychotherapy. Many of the physical processes that biofeedback training can help you learn rather quickly to control influence your emotional well-being. Biofeedback equipment can enable you to learn, for example, how towilla state of muscular relaxation, how to gain a measure of control over your physical response to stress or pain, even how to raise or lower your blood pressure or heart or respiration rate.
To use biofeedback equipment, electrodes are taped to the areas of your body that are to be monitored. They may measure such things as skin temperature, skin moisture, muscle tension, pulse and breathing rates, or brain wave patterns. The feedback from which you learn to control normally involuntary processes occurs when the measurements made by the instruments are externalized for you: you are able toseea pattern on a computermonitor or oscilloscope orheara changing tone that gives you immediate information about your physical responses. In other words, biofeedback is an electronic way of representing inner processes externally that are usually automatic, involuntary, and unconscious.
PHYSICAL APPLICATIONS
Frequently, and relatively quickly, many people are able to learn how to control many of their internal responses very well. Biofeedback can sometimes be an alternative to using medication to reduce tension or pain. Its range of applications has grown tremendously. Here are some examples of its uses:
A woman was badly injured in an automobile accident. On one side of her face her facial nerve was severed, leaving her unable to move any part of the left side of her face and unable to close or blink her left eye. Surgeons decided to splice the severed facial nerve to a nerve in her neck-shoulder muscle. Once this was done, the woman could shrug or twitch her shoulder, and in this way cause the paralyzed side of her face to move, and blink her left eye. However, the movements of the left side of her face were uncoordinated, spastic, and not synchronous with the movements of the uninjured right side of her face.
Biofeedback training seemed to offer a possible solution. Electrodes were taped to the injured side of her face. The electrical activity of muscles in the damaged area was displayed on a screen, along with the pattern thatwouldbe produced by undamaged facial nerves and muscles. The woman's task was to watch the two patterns and somehow learn by inner experiment how to control the left side of her face so its movements would match the normal pattern and would then coordinate with movements of the other side.
Her training lasted for several months. Because of her persistence and hard work, she was successful in learning to match the "normal" pattern; she was now able to move the two sides of her face in symmetrical harmony.
Other successful physical applications of biofeedback therapy include these:
* controlling high blood pressure
* learning to raise blood pressure in cases of spinal injuriesthat block the automatic raising of blood pressure when a person stands up (excessively low pressure causes them to faint)
* coping more effectively with asthma attacks
* eliminating migraine headaches
* helping children with cerebral palsy control muscle spasms
* helping stroke victims with proprioception problems (in which they lose the sense of where their arms and legs are in space)
* teaching patients with circulation problems (e.g., blood clots in the legs) to dilate their blood vessels, regaining movement and reducing pain
* assisting stutterers by helping them become aware of unnecessary and interfering muscle contractions they have come to make habitually when they speak and teaching them how to relax these muscles
* reducing tension and pain in arthritis patients
To date, of all the areas to which it has been applied, biofeedback has beenmostsuccessful for patients who are physically paralyzed or have movement disorders.
PSYCHOTHERAPEUTIC APPLICATIONS
Biofeedback has been used successfully in psychotherapy in these ways:
* teaching general relaxation methods, which can be useful to many people who have problems that involve anxiety, depression, or phobias
* assisting people with insomnia, also through relaxation techniques
* teaching people how to recognize effective meditation by making them aware of periods during sessions of meditation when their brainwave patterns slow (see the last section in this chapter, on meditation)
Increasingly, biofeedback is being used to treat emotional disorders in conjunction with both psychotherapy and medication. It is one of the ways available to us to enlarge the range of our conscious control over ourselves and our lives.
RELAXATION TRAININGPrimarily a coping strategyto help people continue to functionin an environment of stress.
The pervasive phenomenon of stress is the hidden epidemic of the United States and other highly industrialized countries. It is associated with high blood pressure, hardening of the arteries, strokes, ulcers, colitis, and a host of other physical conditions. And severe stress endured too long leads to emotional breakdown.
All physical materials can be loaded or stressed to a certain point beyond which they distort, snap, fracture, or break. Stress loads human beings physically as well as emotionally. Any change—whether for good or for ill—is a stressor. As human beings, we are not simple engineering materials that form simple cracks or breaks, and when stressful events are strong enough, we begin to crack or break in ways that are considerably more complex. Physical disease, emotional disorders, and mental illnesses are the cracks or breaks that occur in human "material."
Statistics show that common forms of severe stressdocause us to break. For example, compared with others the same age, ten times more people die during the year following the death of their husbands or wives. In the year after a divorce, ex-spouses have an illness rate twelve times higher than married people the same ages. In addition, chronic anger, anxiety, and depression appear to weaken the body's immune system, increasing the likelihood of serious disease.
Individuals do, of course, have different emotional breaking points, but we know that prolonged high levels of anxiety erode a person's psychological integration. What results is "nervous breakdown"—a term that is vague and means little more than a blown fuse due to emotional overload. The aftermath of such an overload may leave a person with depression, anxiety, and the inability to function "as usual" for a considerable period of time.
Relaxation training, along with the other therapies discussed in this chapter, is an antidote or prevention for human breakage brought about by excessive stress. The central belief on which relaxation training is based is that you cannot be tense and anxious if you are physically very relaxed.
There are two main approaches to relaxation training. (We have already briefly discussed them in Chapter 12 in connection with desensitization.) In both approaches you begin by reclining or lying down in a quiet room. Relaxation can then be achieved through tension and release or through suggestion. In the former, you tense a given muscle group, holding the tension for five to ten seconds, then release the tension and experience the relief from tension, or relaxation. In the latter, you consciously suggest to yourself that a group of muscles feels warm, heavy, very heavy, and relaxed, sinking into the recliner or bed or floor. Both approaches aim to achieve two things: to bring about deep, progressive muscular relaxation and to increase your sensitivity to the presence of tension in your body when it exists.
Relaxation training is a learned skill. If you practice it regularly—that is, daily, for at least several weeks—you can gain increased control over your major muscle groups—those of the arms, legs, shoulders, back, abdomen, neck, and face. You gradually learn to recognize even low levels of tension in these muscles so that the tension can be eliminated consciously.
Eventually, as you learn how to control physical relaxation, you are able to achieve deep relaxation in increasingly shorter periods of time. After regular practice over a period of months, many people, when they face a suddenly upsetting situation, can quickly offset their emotional and physical reactions to stress by inducing a calm and relaxed state in themselves. They are able to neutralize the stressor's potential for doing damage. If you can learn to do this, you have learned a skill in controlling your own life that is of great value. It is a survival skill that can help you protect yourself against being worn down by stressful events that otherwise eventually lead to learned habits of anxiety and tension. Once formed, these habits can be very difficult to get rid of.
For emotionally disturbed persons, relaxation training techniques are useful primarily as an adjunct to psychotherapy or drug therapy and can be helpful in reducing tension and anxiety. They are ways of treatingsymptoms; they can help you continue to cope with stressful situations. It is another question whether it is in your best interest tocontinuein a situation that causes you enough stress that relaxation training becomes a needed crutch. Sometimes it is wiser to change an unsatisfactory situation or to attempt to change your attitudes, values, or behaviorthan it is to learn skills so that you can keep doing the same stressful and perhaps unsatisfying thing day after day. Relaxation training is acoping strategy. By itself, it cannot resolve the fundamental question: whether it is better to learn how to numb yourself to an unhappy situation, to leave it, or to face the possibility that your stress is caused by inner conflicts and unrealistic attitudes rather than external factors.
If you cannot or do not want to leave a stressful environment, techniques of relaxation training may benefit you. If you feel the main problems are within you, then psychotherapy may be the best alternative. And sometimes, throwing in the towel, deciding in favor of a change of career, marriage, place to live, or way of life may be most therapeutic and personally fulfilling.
It can often be hard to know which alternative is best. Counseling may help. Talking with good friends may help. Letting time pass may help. Usually, ignoring discomfort willnothelp; stress has a way of compounding and wearing you down. Waiting too long, usually out of fear of facing a need for some form of change, is itself a source of internal stress—of worry and anxiety that will not go away until you do something to put a stop to doing nothing.
HYPNOSISAn approach to therapy that can havefar-reaching beneficial effects for people withmany different kinds of problems, especiallyuseful for persons who are strongly motivatedto change and can feel a deep sense ofconfidence in the humanity and competenceof their therapist.
Hypnosis is very old. Ancient Egyptian records indicate that priests maintained temples of sleep devoted to healing the ill and troubled. The priests are thought to have used hypnotic induction of sleep and to have offered assurance that patients would get well.
Many centuries later, Franz Anton Mesmer (1734-1815) developed a method for inducing a hypnotic trance state (he associated it with sleepwalking) and claimed that therapy oftenwas more effective when patients were in a trance. Hypnosis was later used by Jean-Martin Charcot (1825-1893) at the Paris Hospital of Salpêtrière; Charcot was one of Freud's teachers. During World War II, hypnosis was used to treat soldiers with amnesia, paralysis, and pain. Since then, it has been used frequently by clinical psychologists and psychotherapists.
Much is still not understood about the mental and physiological mechanisms involved in hypnosis. They are difficult to define because they seem to assume many different forms in different people, depending on their personalities and their moods at the time.
Hypnosis probably occurs in daydreaming to some extent; it probably is also involved when a mother lulls her child to sleep or when a customer succumbs to suggestions from a salesperson. We all seem to be—vaguely and to some degree—familiar with the phenomenon, yet we remain, paradoxically, ignorant of its existence.
WHAT HYPNOSIS IS LIKE
For most people, the experience of hypnosis is something of a letdown. They anticipate that they will have an extraordinary experience in a trance state, and yet what actually happens is very similar to their probably familiar experience of drifting into a state of relaxed distraction from time to time when daydreaming. Often what happens when we daydream is that our attention is focused on an object, and we gradually relax and begin to drift into a state of partial awareness. The phone may then ring, but for a moment it can be unclear whether we are just imagining this.
The hypnotic state induced by a trained hypnotherapist is very similar. When in a hypnotic trance, you never become unconscious; your mind continues to be active. As you go gradually into a deeper trance, your breathing and heart rates tend to slow, and you feel increasingly more deeply relaxed. Usually, the experience is one of being lulled into a state of calm repose. Sometimes—for example, in former surgery patients who have had unpleasant experiences with anesthesia—hypnosis may cause people to become anxious or frightened and to refuse to continue.
You relax physically while in a hypnotic trance. You will slump in your chair; your breathing becomes slow and deep; you move very little. In other cultures, however, trance states take verydifferent forms. Behavior may become ecstatic, even violent; individuals may begin to dance frenetically and to spin about, as in the case of Algerian dervishes. But in Western society, hypnotic trance usually takes the form of deep, passive relaxation.
After their first experience with hypnosis, most people tend to disbelieve that they have really been in a trance state. They realize they have been pleasantly relaxed, but they feel that "hypnosis" has not occurred. Clients who are suspicious, hostile, or feel threatened by the experience, or who do not trust the therapist, tend to resist hypnosis. Frequently, on the other hand, clients who are extremely anxious and feel greatly in need of help turn out to be especially good candidates for hypnosis.
If their first experience with hypnosis is comfortable, safe, and pleasant, clients will usually allow themselves to drift into a deeper trance state in subsequent sessions.
Many techniques exist to induce hypnosis. Commonly, they make use of the well-known method in which you are asked to fix your attention on an object—a coin, a stone, a pendant—while the hypnotherapist speaks softly in a monotone, suggesting that you are relaxing ever more deeply, that your eyes are getting heavy, and so on.
Milton H. Erickson (1901-1980) has been one of the leading American contributors to recent developments in clinical hypnosis. His ideas have been among the most creative, imaginative, and subtle in the field. He is well known for hisindirectinduction techniques, which, because of the complex and unusual perspective they reflect, we cannot deal with at any length here. They are techniques that frequently induce a trance statewithoutthe client's being in the slightest way aware that this is happening. Dr. Erickson is often able to induce hypnosis only by means of ahandshake. An example may give some general idea of his approach. Dr. Erickson describes this technique:
When I begin shaking hands, I do so normally. The "hypnotic touch" then begins when I let loose. The letting loose becomes transformed from a firm grip into a gentle touch by the thumb, a lingering drawing away of the little finger, the faint brushing of the subject's hand with the middle finger—just enough vague sensation to attract the attention. As the subject gives attention to the touch with your thumb, you shift to a touch with your little finger. As your subject's attention follows that, you shift to a touch with your middle finger and then again to the thumb....
The subject's withdrawal from the handshake is arrested by his attention arousal, which establishes ... an expectancy.
Then almost, but not quite simultaneously (to ensure separate neural recognition), you touch the undersurface of the hand (wrist) so gently that it barely suggests an upward push. This is followed by a similar utterly slight downward touch, and then I sever contact so gently that the subject does not know exactly when—and the subject's hand is left going neither up nor down, but cataleptic. Sometimes I give a lateral and medial touch so that the hand is even more rigidly cataleptic....
There are several colleagues who won't shake hands with me, unless I assure them first, because they developed a profound glove anaesthesia when I used this procedure on them. I shook hands with them, looked them in the eyes, ... rapidly immobilized my facial expression, and then focused my eyes on a spot far behind them. I then slowly and imperceptibly removed my hand from theirs and slowly moved to one side out of their direct line of vision.[7]
Here is a characteristic reaction of one of Erickson's colleagues to his procedure:
I had heard about you and I wanted to meet you and you looked so interested and you shook hands so warmly. All of a sudden my arm was gone and your face changed and got so far away. Then the left side of your head began to disappear, and I could see only the right side of your face until that slowly vanished also.... Your face slowly came back, and you came close and smiled.... Then I noticed my hand and asked you about it because I couldn't feel my whole arm. You said to keep it that way just a little while for the experience.[7]
[7] Milton H. Erickson, Ernest L. Rossi, and Sheila I. Rossi,Hypnotic Realities: The Induction of Clinical Hypnosis and Forms of Indirect Suggestion(New York: Irvington Publishers, 1976), pp. 108-109.
APPLICATIONS OF HYPNOSIS
It is much easier to bring about a hypnotic trance than to know how to make effective therapeutic use of the trance state once it is produced. Depending on the depth of trance that you will accept, these are the kinds of goals that can be achieved:
In a light trance, your eyes are closed, you are physicallyrelaxed, and it is possible to convey to you, for example, that you are unable to move an arm. At this stage, the therapist can often be effective in offering you support and encouraging you to begin to make changes in your behavior.
In a medium trance, relaxation is still deeper. A partial anesthesia of a hand or arm can be achieved, and you will comply in a slow, semiautomatic way with instructions from the therapist. In this state, many clients can learn rather quickly how to bring aboutself-hypnosis, which they can then practice on their own. At this stage, it is sometimes possible to suggest gradual personality changes.
In a deep trance, more extensive anesthesias are possible. A therapist can encourage you to experience emotional changes, to hallucinate, and to regress to a younger age—i.e., to re-experience memories of past events and to feel and behave as you did at that time. In a deep trance state, it is possible to use hypnotic desensitization techniques to help you overcome anxieties and fears.
Hypnotherapy lends itself well to use on your own. Once you have learned how to induce light trance states on your own, you can begin to suggest certain attitudes, feelings, or behavioral changes you would like to bring about in yourself. Being successful at this—as with any skill—requires regular practice and regular and gradual strengthening of the habits that are being formed. Some psychotherapists will make a audio recording for the individual client to use at home on a daily basis.
Hypnosis has been used to treat many problems, including these:
ulcersfrigidityimpotenceheadaches and migrainesinsomniaarthritic paincolitistachycardiaobesitydepressionphobiasantisocial behavior
disturbed childrenamnesiastutteringnervous ticssexual inhibitionsdental anxiety and painheart palpitationsabdominal crampstension and anxietyovereatingreduction or elimination of smoking
Both men and women are equally hypnotizable. Children are generally better subjects than adults. As already noted, clients who are more anxious tend to accept hypnotic suggestion more readily. Clients who are motivated to change respond best to hypnotic suggestion. Individuals who are imaginative, who had fictitious companions in childhood, who read a good deal, and who can become readily absorbed in nature are inclined to make good subjects. Good rapport between client and therapist and a sense of trust in the therapist's goodwill and ability contribute greatly to successful hypnotherapy.
Russian-born Lewis R. Wolberg (1905-1988) was a leading New York hypnotherapist originally trained as a psychoanalyst. He is recognized for the comprehensiveness and eclecticism of his approach. After forty years of practice, he came to see its main limitation:
Because hypnosis is so dramatic a phenomenon, it is easy to overestimate its potential. A great many things may be accomplished with a subject in a trance, even the removal of psychologically determined symptoms.... But almost immediately after hypnosis has ended, or shortly thereafter, the symptoms will returnif the subject has a psychological need for them. [italics added] ...
Quite often patients on disability compensation are sent to me by insurance companies for hypnotic examination and treatment. Almost invariably, these casualties cling to their symptoms with the desperation of a drowning man hanging on to a raft....
There are other secondary gains a person may get out of holding onto his symptoms. The need to punish himself for his guilt feelings, the desire to abandon an adult adjustment andreturn to the protective blanket of infancy in order to be taken care of.... Symptoms do not magically vanish; they must be worn down. It is essential to replace them with productive habits."[8]
[8] Wolberg,Hypnosis, pp. 237-239.
MEDITATIONFor individuals who are able to make along-range commitment to the practice of adiscipline that, over a period of many monthsand years, can strengthen them and help themto become more fully integrated and centered.
Don't go outside yourself, return into yourself. The dwelling place of truth is the inner man.Saint Augustine,The True Religion
Meditation is a systematic discipline that attempts to help people move toward the goal of self-realization. It is not the creation of one individual or group. Techniques of meditation have evolved over many centuries and in different parts of the world. And yet these techniques bear striking similarities to each other, whether they originated in the temples and monasteries of India, Japan, Europe, or the Middle East.
Meditation is not a relaxed act of "contemplating one's navel"; it more closely resembles athletic training. It is a form of progressive mental exercise that has as its goal a strengthening of a person's self-confidence, inner strength, and the mind's ability to focus and concentrate. Meditation takes considerable endurance. It is essentially a discipline. It requires fortitude, perseverance, and a strong will. Like athletic ability, skills in meditation cannot be developed without regular practice. Because its effects are felt only gradually, meditation needs a long-term commitment to sustain it, and this ultimately must be based on faith in its eventual value.
The disciplined and regular practice of meditation over a period of many months appears to lead to a sense of personal integration, a sense of being more firmlycenteredin yourself,more confident and aware of your connection with all that is. Experienced practitioners of meditation claim to feel a greater degree of personal security; they feel more at ease with themselves. They claim to feel serenity, zest in living, and inner peace and joy in work, which they seem to be able to do more efficiently, with greater energy and interest.
WHAT THE PRACTICE OF MEDITATION IS LIKE
Techniques of meditation share the goal of disciplining the mind to do one thing at a time. Until you have made a serious attempt to meditate, you will very likely be unaware of how perpetually distracted your attention is. We seldom make the effort to stand apart from our thoughts, to take note of how numerous and varied they are and how chaotically they tumble into and out of our consciousness. It is exceedingly hard work to quiet these "chattering monkeys of the mind." Quieting the overactive and undisciplined mind is a challenging task. It takes energy and a great deal of practice.
There are many approaches to meditation. Here, we will look at three.[9]
[9] See the excellent introduction to the practice of meditation by Lawrence LeShan,How to Meditate: A Guide to Self-Discovery(Boston: Little, Brown & Co., 1974). Dr. LeShan is a psychotherapist in New York City who teaches many of his clients meditation as part of their therapy.
Breath Counting
Breath counting is one way to train your mind to control and focus attention. The object is to be doing one thing, and one thing only, becoming fully involved in that single purpose. Start by finding a comfortable position, sitting or lying down. Place a clock or watch where you can see it without having to turn your head. Usually with eyes closed, you then begin to count your breaths, silently: "one" as you slowly exhale the first breath, two as you exhale the second, etc. After you get to "four" start with "one" again. The purpose is to be doingonlythis, only breathing and counting. You will quickly find that your mind rebels; it will stray and wander whenever your concentration and attention falter. It is a recalcitrant entity. You will be doing well in the beginning if you can succeed for only a few secondsat a time in being consciousonlyof your counting. Distractions will subvert your will in a split second. You will find yourself thinking of a host of things: what to do tomorrow morning, whether you are doing well or badly at meditation, whether it is silly to be doing this, what's for dinner, taxes, work, or that itch on your forehead. Again and again you will have to return your mind to the task at hand. Very quickly, you'll begin to realize that meditationishard work. It is frustrating and demanding.
Practice doing this for fifteen minutes a day. After a few weeks, increase to twenty minutes. After another four weeks, spend twenty-five to thirty minutes a day. Once you can do this, continue to practice daily for another month. It will take that long before you will begin to sense whether this approach to meditation is going to be useful to you.
The Meditation of Contemplation
This is an alternative approach to meditation. Again, the purpose is to discipline your mind by means of focused attention. In this approach, you try to focus attention on a physical object. Pick a natural object—a shell, a small stone, a pressed leaf. Now, with the object a foot or two from you, simplylookat it. The purpose is to look at the object actively, to keep your attention fixed on it, but to be wakeful and alert. Do not stare at one place on the object or strain your eyes. Explore the object,lookat it, attend to it. As usual, you'll find plenty to distract you—stiffness, the need to move, sleepiness, slipping into thinking about problems you need to solve. Each time your mind drifts out of track, gently bring your attention back to the object. Try this for ten minutes a day for two weeks, then fifteen minutes a day for a month, then twenty minutes for the next month. By then, you will know if this approach will help you. Be prepared for some effective sessions and some discouraging ones. Remember that no one said meditation would be easy.
The Meditation of the Bubble
This is an ancient form of meditation that, again, seeks to discipline the mind by developing your ability to focus on one thing at a time. In this meditation, you concentrate on your own stream of consciousness. Imagine yourself sitting quietly on the bottom of a clear lake. Each of your thoughts and feelings forms a bubble that slowly rises to the surface of the lake. As eachcomes to your mind, watch it closely and think only of it for the five seconds or so that it takes to rise to the surface. Be aware of the slow rhythm of the bubbles. Try to spend approximately equal amounts of time attending to each bubble. If the same thought, the same bubble, rises several times, this is OK. If you continue, the repetition will pass. If nothing comes to mind for a time, this, too, is OK. Form an empty bubble. Try this meditation for ten minutes a day for two weeks, then increase to twenty minutes a day for one or two months. By then, you will know if this approach to meditation is beneficial to you.
THE BENEFITS OF MEDITATION
Howwillyou recognize whether an approach to meditation has value for you? Any changes that occur in you will be gradual; you must be patient. If, after most sessions of meditation, you feel generally more integrated, calmer, more at ease, this is a good sign. Over a period of time, if you are working hard at an approach to meditation that seems to fit your temperament, these periods of feeling peaceful, alert, and comfortable in the world will gradually become more evident to you.
Physiologically, meditation appears to lead to a deeply relaxed state of alert concentration. Your respiration and heart rates slow, the level of lactate in the blood (associated with tension and anxiety) drops lower, and there is an increase in slow alpha brain waves, associated with profound relaxation.
What is important, no matter what approach to meditation you try, is to stay with that approach long enough to determine its potential value for you. Doing a meditation once or a few times is like jogging once or twice: you can't expect to derive any benefit from exercising a couple of times. Meditation is the practice and expression of discipline; deciding to practice regularly and then carrying out your decision are just as important as the approach you take to meditation.
16DRUG AND NUTRITIONTHERAPIES
DRUG THERAPY:BALANCING EMOTIONS WITH CHEMISTRYOften especially helpful to people who areemotionally very upset so that they may beginto benefit from psychotherapy.
During the past thirty years, biochemistry and pharmacology have made many important contributions to the treatment of mental and emotional disorders. There is no question thatpsychotropic—literally "mind-turning" or mind-influencing—drugs can help many people during periods of emotional or mental suffering.
Psychotropic drugs can be used by themselves or in conjunction with psychotherapy. Frequently, drugs are used to help reduce the severity of symptoms in patients so that they may benefit from psychotherapy. Effective psychotherapy requires you to be comparatively calm, rational, and able to make well-thought-out decisions. These things are not possible if you are terribly agitated, are despondent and crying much of the time, ormay, for example, have disturbing hallucinations and are no longer in touch with reality.
The aim of drug therapy is, eventually, to eliminate the need for medication. In this respect, psychopharmacology is similar to psychotherapy: both would like to help the patient so that he or she no longer needs either one. It is not always possible to do this, however. Some disorders are, at present anyway, chronic conditions. People with parkinsonism or epilepsy may have to take medication indefinitely. But the general trend is to use psychotropic drugs as temporary measures to bring symptoms quickly under control so that psychotherapy can be started.
The only professionals who are legally authorized to prescribe psychotropic drugs are physicians and, in particular, psychiatrists. However, psychotherapists are now being trained to be sensitive to conditions that may have an organic basis. Certainly, it is wise to have a thorough physical exam to rule out organic problems that can cause emotional or mental upset (see Chapter 8). Numerous studies have shown that up to half of the individuals who are referred to a psychotherapist have undiagnosed organic problems.[1] This is an important caution to bear in mind.
[1] See, for example, L. Small,Neuropsychodiagnosis in Psychotherapy(New York: Brunner/Mazel, 1980).
TYPES OF PSYCHOTROPIC DRUGS
There are nine main classes of psychotropic drugs:
Antianxiety, or Anxiolytic, Drugs
These are the so-calledminor tranquilizers. They are sedatives for the waking hours that are prescribed for people who have excessive tension and anxiety.
Neuroleptics, or Antipsychotics
Psychosis is a disorder that impairs a person's abilities to think, remember, communicate, respond with appropriate emotions, and interpret reality without great distortion. People who have these difficulties can often be treated effectively with neuroleptic or antipsychotic drugs, also known as themajor tranquilizers, which have specific effects on the brain's activity.
Sedative-Hypnotic Drugs
These drugs act as sedatives at low doses and produce a "hypnotic" action at higher doses. (The wordhypnoticas used by pharmacologists does not refer to a hypnotic trance but means simply that a drug causes drowsiness and reduces motor activity.) In even larger doses, these drugs act as anesthetics. Antianxiety drugs, the minor tranquilizers, can be grouped with these drugs because of their sedative effect.
Antidepressants
These drugs are used primarily to treat what psychiatrists callendogenousdepression—that is, major, incapacitating depression that is not associated with an outside event or situation. Depressions that occur after the loss of a job, the death of someone close, or some other external event are calledexogenousdepressions. They can sometimes be treated effectively with antidepressants, but drug therapy forsituation-induced depressiongenerally is less successful.
Lithium therapy is a specific treatment primarily for manic-depressive disorders. Lithium carbonate is a naturally occurring mineral salt. For manic-depressive patients—with wide swings of mood from feeling extremely energetic and emotionally high to feeling seriously depressed—lithium therapy may offer help as a mood stabilizer.
Stimulants
Caffeine and nicotine are the best known of the stimulants. In therapy, stimulants are used in the treatment of narcolepsy (individuals suddenly fall asleep for short periods of time, even when engaged in activities), some forms of epilepsy, and, paradoxically, hyperkinetic children (who are excessively active and have short attention spans and explosive irritability).
Antiepileptic Drugs
For many of the two million Americans with epilepsy, these antiseizure drugs are very helpful. Epilepsy does not tend to shorten an individual's life, but it is a severe, troubling, and often disabling condition for which drug therapy can be a blessing.
Antiparkinsonian Drugs
These drugs have helped the lives of many people who areaffected by the characteristic involuntary tremors of this disease, which can cause abnormalities in gait and trembling of the voluntary muscles.
Psychedelics
Psychedelic drugs are also calledhallucinogens. They produce altered states of consciousness and sensory distortions. Psychedelics have no established use in psychiatry at present in the United States. Great Britain and Canada, however, have experimented with psychedelics in the treatment of alcoholics, whom they sometimes appear to help. Psychedelics have also sometimes been used for the terminally ill and in certain cases of autism.
Drugs for Headache, Migraine, and Neuralgia
Drugs for these common kinds of pain are widespread. Migraines (which may cause blurred vision, vertigo, and even temporary deafness) and cluster headaches (which cause severe pain around the eyes, tearing and reddening of the eyes, and runny nose) frequently can be treated successfully with specific drugs. Neuralgias are recurrent knifelike facial and head pains that can last for days and even months. They can be difficult to treat successfully.
WHAT DRUG THERAPY IS LIKE
In this section, we'll look at some of the main emotional and mental symptoms that are often helped by means of drug therapy. Since all medications have potential side effects, we will look at these as well.
Anxiety
Excessive anxiety causes very unpleasant symptoms: dizziness or light-headedness, sweating, pounding heart, vomiting, diarrhea, shaking, muscle tension, inability to sleep. Many of these symptoms can be controlled by antianxiety drugs. All of these drugs can lead to psychological dependence when they are used regularly over periods of time that vary with the person and the medication. For this reason, they are normally used for short periods, often at the beginning of psychotherapy.
The most commonly prescribed antianxiety drugs include these (trade names):
AtaraxAtivanCentraxClonopinDalmaneDoridenEquanilLibriumLoxitanePaxipamRestorilSeraxTranxeneTybatranValiumValmidXanax
Although relatively small percentages of patients experience them, as with most drugs, there may be side effects, including drowsiness, impaired judgment and performance, nausea/vomiting, ataxia (loss of voluntary muscle coordination), and agitation (paradoxical restlessness).
Patients who have taken an antianxiety drug for a period of time are often instructed to reduce their dosage gradually to avoid mild, infrequently severe, withdrawal symptoms.
Antianxiety drugs can reduce agitation and produce a relative sense of calm. But, unfortunately, patients usually develop a tolerance to any antianxiety drug after three to four months, and then the drug loses its effectiveness. Antianxiety drugs are usually limited, then, to short-term treatment. Long-term recovery from the symptoms of anxiety is the task of psychotherapy: to help clients change their attitudes, behavior, or way of life.
Depression
Depression can be a seriously incapacitating emotional disorder. Depression can range from a lingering sense of sadness or grief to a feeling of utter hopelessness, guilt, despondency, uncontrollable crying, and suicidal thoughts. The following symptoms are typical: insomnia or early waking, loss of appetite and loss of interest in sex, inability to concentrate, great difficulty in making decisions, and a reduced desire and ability to assume job and family responsibilities. Though depression is called "the common cold of emotional illness," it is not to be taken lightly, since severe depression is life-threatening, as manysuicides testify. Depression affects one out of five people during their lifetimes; more women suffer from depression than men.
At the time of this writing,[2] the most widely prescribed antidepressants are the tricyclics. They are most effective in treating endogenous depressions; MAO inhibitors (see below) are more useful in cases of "atypical" depression, which frequently is associated with a situation the patient cannot come to terms with, such as the loss of a job or of a loved one.
[2] Since this book was published, SSRIs orselectiveserotoninreuptakeinhibitors, have become the most commonly prescribed antidepressant medication in the U.S and many other countries. For readers interested in more information about SSRIs, see Wikipedia's article, http://en.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor.
Tricyclic antidepressants include these (trade names):
AvenylElavilNorpraminPamelorSinequanSurmontilTofranilVivactil
Approximately 70 percent of patients who take tricyclics improve. Several newer drugs—the tetracyclics, dibenzoxapines, and triazolopyridenes—are similar to the tricyclics in their effects. They include these (trade names):
AsedinDesyrelLudiomil
If tricyclics do not help, MAO inhibitors (monoamineoxidaseinhibitors) are usually tried. MAO inhibitors must be used with great caution because they can interact with certain foods, beverages, or drugs to produce severe high blood pressure. Many foods and beverages are prepared by fermentation processes; e.g., cheese, anchovies, pickled herring, pastrami, olives, beer, and wine, all of which patients who take MAO inhibitors must avoid. These foods and beverages contain a chemical compound, an amine calledtyramine, which can cause dangerously high blood pressure, a hypertensive crisis, in people taking an MAO inhibitor. Furthermore, MAO inhibitors cannot be taken with antihistamines; patients who take MAO inhibitors may be warned to avoid other drug interactions. These warnings should be taken seriously because MAO inhibitors are one of the most potentiallytoxicgroups of psychoactive drugs. Yet they can make the difference between night and day for many cases of depression.
There are common side effects caused by all the antidepressants we've mentioned, including an uncomfortably dry mouth, dizziness, especially when standing up quickly, headaches, difficulty in urinating, nausea/vomiting, constipation or diarrhea, impotence, inability to reach orgasm, agitation/shaking, and rapid heartbeat.
Some of these side effects can be annoying but will often diminish or disappear once the patient becomes accustomed to the medication. When side effects are not tolerable, the physician or psychiatrist will usually prescribe a different antidepressant that may have fewer, or no, side effects for a given patient.
One of the drawbacks of antidepressants is that there is a waiting period of days or weeks before physician and patient know whether a particular drug is going to help. If, after four to six weeks, an antidepressant has not reduced a patient's depression, then a second drug may be tried, and, again, there will be a delay of days or weeks before it is clear whether the medication is going to work. One needed area of research in psychopharmacology is to devise tests that will help to tell a doctor what antidepressant is most likely to be effective for the individual patient. At present, though some general guidelines exist, matching patient with an effective and tolerable medication is a process of intelligent trial and error.
Lithium has been used to treat manic depression since 1954. Lithium is absorbed quickly from the gastrointestinal tract, but it acts slowly, so it also takes time to know if it is going to be of value. Blood levels of lithium need to be checked once or twice a week during the first month, twice a month for the next month or two, and then once every one to two months.
Lithium is sometimes helpful in treating chronic simple depression, that is, depression that is not associated with periodic "highs."
Unlike most drugs used in psychiatry, lithium usually has few noticeable side effects and does not tend to produce a feeling of sedation or stimulation. When side effects occur, it is usually because the lithium level in the blood has become excessive. Side effects then can include vomiting, lack of coordination, muscular weakness, or drowsiness.
In addition to antidepressant drugs, electroconvulsive therapy (ECT) is sometimes used to treat severe depression, as it is to treat some other conditions, including schizophrenia. Although ECT is not itself a form of drug therapy, it is important tomention it here since it is one of the mainmedicaltreatments (as opposed to the "talk therapies" of psychotherapy) used by psychiatry today. ECT is administered after a patient has been sedated and given a general anesthetic.
The main advantage of ECT is that it acts much faster than any of the antidepressants. For a seriously suicidal patient, this can be important.
The main disadvantages of ECT are that it can cause temporary memory loss, temporary disorientation and confusion after treatment, and possible permanent changes in brain function—regarded by many psychiatrists as "subtle," i.e., fairly minor. Another discouraging finding is that depression recurs after ECT in many patients—in up to 46 percent within six months after ECT.
ECT has received "poor press." As now administered, the actual treatment is painless. It is, nevertheless, a forceful, "invasive" approach, so many psychiatrists prefer not to use it if medication can be successful. As more biochemical methods of treatment are discovered, ECT very likely will be used less and less.
Psychosis
Psychosis is the most serious and incapacitating degree of mental illness. Emotional problems with symptoms of anxiety or depression, or both together, are calledaffective disorders. People who have affective disorders make up the majority of clients seen by most psychotherapists; these clients arenotout of touch with reality. The problems that they have—though painful and sometimes obstacles to normal living—are essentially different from the difficulties that patients with psychoses have. Though there is no unanimity about this among health care professionals, we will distinguish between these two kinds of problems by calling a psychosis amental illness, as opposed to anemotional disorder. It is a matter not only of degree but of kind. A person who is severely depressed or extremely anxious is usually still able to communicate rationally, and distinguish what is real from what is fantasy or delusion.
Psychoses, on the other hand, are disorders that impair a person's abilities to think, remember, communicate, respond with appropriate emotions, interpret reality coherently, and behave in a reasonably "normal" way. People with psychosesoften have difficulty controlling their impulses, and their moods may change quickly and radically. Psychotic individuals often believe things to be true that are not, and they may hear sounds or voices that are not there.
There are many theories about the causes of psychosis. Recently, research studies in psychiatry have shown that psychosis may be due to an excess of certain chemical substances calledneurotransmitters(such as norepinephrine or dopamine) in the brain. Another theory is that the brain of a psychotic person may be excessively sensitive to the action of certain neurotransmitters.
The antipsychotic drugs, or neuroleptics, reduce the brain's sensitivity to one or more of these chemical substances. Some of the best-known antipsychotic drugs are these (trade names):
CompazineHaldolMellarilProlixinStelazineThorazineTrilafonVesprin
Antipsychotic drugs frequently can clear thought processes, reduce or end hallucinations, relieve agitation and anxiety, and generally help patients return to the world of reality, communicate with others, and behave in a more reasonable and stable way.
Antipsychotic drugs have many possible side effects. They may produce drowsiness, dizziness and nausea, fainting, muscle tremors, a shuffling gait, blurred vision, insomnia, sensitivity of the skin to sunlight, and other effects. Particularly disturbing side effects can often be avoided by changing to a different medication. Some people with psychotic symptoms may need to take antipsychotic medication for only a few weeks or months. Recurrent or chronic illnesses, however, may require drug treatment over a long period.
WHEN DRUG THERAPY IS APPROPRIATE
Since psychotropic drugs can be prescribed only by a physician or psychiatrist, his or her judgment will determine whether a patient's difficulties seem to lend themselves to drug therapy. In cases involving serious anxiety, depression, or psychosis, it isroutine to expect drug therapy to be used, often in conjunction with psychotherapy. As we noted earlier, it is the hope of drug therapy that it will be needed only temporarily, but some chronic or periodically recurring conditions may be best treated by continued medication for a number of years. Since many of the psychotropic drugs are new, it is not known whether long-term use by some patients may ultimately affect their health adversely. Unless we decide to do without medication that can be a blessing in relieving great suffering, until long-term studies can be completed, the potential risks are there. It is a matter of weighing alternatives: on the one hand, perhaps incapacitating emotional or mental distress, and on the other, side effects that cannot be fully predicted.
THERAPY THROUGH NUTRITION
There is no question that nutritional deficiencies can influence the functioning of the brain and affect the personality. There are clear-cut cases, for example, of vitamin deficiencies that result in symptoms of psychological disturbance. The majority of these cases involve people who suffer from very evident malnutrition.
Unfortunately, the connection between nutrition and mental health is still vague; biochemists are becoming more aware of the need to take into accountindividual variations. It is not always possible to specify exactly how much of a mineral, a vitamin, or an amino acid a person requires for good health. Some people, for many different reasons, cannot effectively utilize the food they eat. Others have allergic reactions to certain foods; some allergic reactions appear to be subtle, affecting a person's moods. Still other people seem to be especially sensitive to only moderate changes in their blood sugar levels. We have a great deal in common as biological organisms. Yet our biochemistries may be finely tuned in individual ways that would require a detailed and sophisticated understanding of an immense number of interrelated factors that boggle the mind in complexity.
Psychonutritionhas a long road to follow before it will be a science. So-called holistic or orthomolecular (the "right" molecule) physicians and psychiatrists attempt to take individual variations and sensitivities into account. The need to do this may be essential in many cases, but dependable and exact methods ofevaluation and treatment simply do not exist as yet. Except in cases of outright malnutrition, finding connections between nutrition and emotional health is still an art.
Some orthomolecular psychiatrists appear to have been dramatically successful in helping some patients with certain mental or emotional problems. But because psychonutrition is still a borderline discipline, it is an area where controversies abound and results are often open to question.
Many physical conditions can be influenced greatly by nutrition. Among these are the metabolic disorders diabetes and hypoglycemia, both of which can affect a person's emotional life (see Chapter 8). In addition, relationships have recently been discovered between lowered blood pressure, reduced cholesterol and triglyceride levels, and a diet high in fiber. A thiamine (vitamin B1) deficiency—which causes pellagra, a chronic disease that leads to skin lesions and gastrointestinal distress—can produce depression, mania, and paranoia. Another example is pernicious anemia, in large part due to vitamin B12 shortage, which can cause moodiness, difficulty in remembering and concentrating, violent behavior, depression, and hallucinations. But the fact that many physical disorders, some of which can cause psychological disturbances, are treatable in part through nutrition does not, unfortunately, imply that emotional disorders in general can be treated by means of diet. This may be the case for some individuals for whom special diets can influence a specific biochemical imbalance. But research is just beginning to develop tests that can detect these sensitive individual variations. Once they can be identified a more difficult step has to be made: to determine how this information can be used to select an effective treatment.
Nutritionists and physicians agree that good physical and mental health depend on a combination of proper body weight, adequate exercise, good diet, and decreased stress. But beyond this, an emotionally disturbed person who seeks help through dietary therapy—for example, through megavitamin doses—should realize that he or she is really involved inself-experimentation. Some orthomolecular psychiatrists may be very talented in treating some of their patients. These patients are very fortunate; it is hard to avoid saying they are lucky. The main problem that faces this new area of psychonutrition is one of general reliability and credibility.