22 January 2016

Rumination, the Stress Response, and Meditation

I'm sure I've told this story before, but in sixth-form biology (some 35 years ago now) we studied a plant and an animal in some depth. For our animal we followed Charles Darwin in studying the earthworm. I gained a new appreciation of these creatures through studying their physiology and behaviour. One of the experiments we did was a bit cruel. We studied the stress response of earthworms. I want to begin this essay on rumination by outlining what happens when you pretend to be a predator to an exposed earthworm.


The Stress Response

Earthworms may be exposed on the surface during daylight for a number of reasons. For example rain-saturated soil forces them up to breathe, or some chemical or mechanical irritant may make then break cover to escape it, despite the risk. Not only does sunlight kill them, through exposure to UV light and dehydration, but being on the surface also leaves them vulnerable to one of their principle predators - birds. Back in 1982 we collected earthworms by introducing a chemical irritant into the soil and grabbing them as they popped up, then we rinsed them and kept them in a dark moist environment. After they had time to acclimatise to their new environment, we stressed them by poking them in a way designed to mimic a bird attempting to eat them. Stressed in this way an earthworm goes into a frenzied writhing motion which is obviously designed to make them hard to grab hold of. Once they stopped we poked them again, producing more writhing. And we repeated this several times. On the third time the writhing was noticeably less vigorous. On the fourth time the poor worm was lethargic but moved around slowly. And after that further poking did not seem to produce any response at all.

So what does this tell us?

The father of modern stress research, Hans Selye (1907 – 1982), did much the same thing with rats and outlined threephases of response to a stressor that seemed to apply to many organisms. He defined these largely in glandular terms, i.e. in the type and amount of hormones produced. Nowadays we might characterise the response in terms of the autonomic nervous system (ANS).

1. Alarm reaction. These is an immediate reaction to a stimulus or stressor. In humans the ANS initiates a series of changes: The sympathetic side of the ANS acts rapidly to produce changes: the release of stress hormones such as epinephrine (aka adrenaline) and cortisol flood the blood with glucose, raise our blood-pressure, increase our heart rate. The bronchioles in the lungs expand. Blood is diverted away from the gut, toward the skeletal muscles. The pupils dilate. In the gastro-intestinal tract, sphincters tighten and peristalsis is slowed or suspended, In other words we prepare for action (another term for this is arousal). These preparations are for in-the-moment reactions such as "freezing" and the "fight or flight" response.Without further stressors this reaction is short-lived and the body soon begins to restore normal operating conditions, reversing the changes that arousal produces through the actions of the parasympathetic side of the ANS. Relaxation takes longer than arousal. Short lived stressors may be positive, such as the anxiety preceding a performance (be it sporting or artistic) that allows us to achieve something out of the ordinary - a gold medal winning time in the Olympics or a recital that gains a standing ovation. Selye called this positive side of stress eustress and the negative kind distress.


2. Resistance.With continued exposure to stressors, the body's ability to respond to stimulus changes. We may begin to experience fatigue, lethargy, difficulty concentrating, sleep and appetite disturbance, and problems with homoeostatic regulation, such as high or low blood pressure. We may also begin to experience mood disturbances, such as mood swings, low mood, or anxiety. There may also be impairment to the immune system. This corresponds to the third and fourth stimulus in the worm where the response to the stressor was attenuated and the ability to avoid the threat was significantly degraded.

3. Exhaustion. Finally, prolonged exposure to stressors (or an intense short-term stressor) can cause a complete breakdown in our ability to response to stimulus. Like the earthworm, the behaviour that protects us from threats simply ceases. Glands that produce the hormones become depleted and receptors become unresponsive. Such exhaustion may manifest as what we call "major depression" (sometimes lay people call this "clinical depression"). People suffering from depression typically experience overwhelming fatigue, appetite disturbance, a tendency to sleep too much or too little. They begin to avoid social interactions. Stimulation of any kind may be experienced as painful. The classic image of depression is of someone unable to get out of bed, lying in the dark, unresponsive. Another less known aetiology, particularly amongst men, is of a kind of "always on" anger, an emotional response to stimuli that is stuck on one setting. One suspects that this process may also be implicated in a number of other disease syndromes (i.e. illnesses that are a cluster of symptoms with no known cause) such as fibromyalgia or chronic fatigue syndrome.

Modern urban life is increasingly stressful. City living is already stressful for us as social primates, because we are crowded in with a lot of strangers. As well as being surrounded by strangers, increasing numbers of people are socially isolated for one reason or another. We don't get enough of the right kind of contact with human beings. Older people in particular may never experience physical contact with another human being except the functional touch of carers (who are also likely to be strangers). Loneliness is epidemic in modern life. For many people social bonds are weak, a vulnerability and a stressor for a social primate.

In modern cities we are hammered by sights, sounds, and smells. Everywhere we go there is noise pollution, visual pollution, air pollution and so on. Teams of psychologists work to tune advertising to grab our attention and manipulate our emotions, often utilising highly sexualised images. News media focus on stories that will elicit the basic emotions of fear, anger, and disgust, making news a stressor. Too many of these stimuli are noxious and trigger our alarm reaction too often. Everything in modern life is designed to cause arousal and this can leave us in a state of hyper-alertness. Or in Selye's terms, leaving us in the state of resistance or exhaustion. The body's natural relaxation response (mediated by the parasympathetic nervous system) is overwhelmed by the sheer volume of arousing stimuli that we meet in a day).

Almost nothing is designed to help us get back to a resting state. Indeed many of us attempt to do this through drugs and alcohol. This is problematic in many ways, but in the case of alcohol, being a poison, it is also a stressor! Clearly the inability to self-regulate emotions and to relax back to a calm resting state is a serious problem in modern urban life. Another way people try to calm down is through eating.

In the UK 24.3% of men and 26.8% of women were obese in 2014 (Public Health England). By 2050 these figures are predicted to be 60% and 50% respectively.Every day I see children being unconsciously being taught to use food as a means of regulating their levels of arousal, i.e. being given food to quiet them down and get them stay calm while strapped into a pushchair. I suspect that this is partly why we see more and more fat people who find dieting almost impossible. They've learned from infancy that eating is a way to regulate emotions, to calm down. And this is true to some extent, the satiation response that comes after eating does relax the body, causing what is sometimes called the postprandial dip. On the other hand, dieting is a powerful stressor, partly in its own right and partly because it removes one of the most effective means people have of calming down. Exercising is also a stressor, at least until one can build up the intensity enough to reap the reward of endogenous opioids,. It may be some time before an obese person can achieve this and in the meantime it's just painful and stressful. So I imagine that the average obese person is caught in a vicious cycle of eating as a first choice aid to deflating arousal and being stressed by the supposed cures for obesity (dieting and exercise).

For those of us who are hyper-stimulated, sleep may become elusive or ineffective. We may wake without feeling refreshed, use coffee of some other stimulant to try to spark ourselves into action and stumble through our days without ever feeling fully awake. Along with depression, anxiety and obesity, insomnia is a major problem in urban populations. Chronic stress leads to all kinds of illness, often with no obvious cause and no consistent aetiology, which thus leaves the medical profession scratching their heads.

If all this external stress were not bad enough, many of us use our imaginations in such a way that our own thoughts become stressors. And this brings us to the problem of rumination.


Rumination
bovine stomach

The word rumination comes from rumen,a word of uncertain origin. Some animals, often referred to collectively as ruminants, have a multi-compartment stomach and typically eat grass and leaves. Food from the oesophagus goes into the first chamber, or rumen,where it is fermented by microbes to break down cellulose. No animal can digest cellulose, the major constituent of plants, without help from symbiotic microbes living in their gut. After fermentation the wodge of partially digested food, or cud, can be regurgitated to be further chewed. This act of re-chewing food is called "chewing the cud" a characteristic of ruminant animals. When it is re-swallowed it carries on through the alimentary canal.

For obvious reasons this process has been seen as analogous to cogitating on something repeatedly or continually turning a thought over in the mind. And thus we metaphorically call this process rumination. Rumination refers to a particular type of mental process. For example when we turn over a problem and work through it, this is not really rumination. Nor is it rumination if we plan out an event or period of time. The crucial feature of rumination is repeatedly going over the same thoughts, particularly memories of past events. Like a cow chewing its cud - swallowing and regurgitating.

When we recall a memory, the content of it may be impressions from any of our senses: visual, aural, tastes, smells, and tactiles. But along with these images come the associated emotions. When we recall a pleasant meeting with friends, we experience a measure of the joy and happiness that we experienced during the original event. Equally, if we remember some unpleasant event then we will experience the associated emotions, such as fear, anger, or disgust. In other words thoughts and memories can lead to arousal, can be stressors.

Some people are prone to rumination, prone particularly to bringing to mind the unpleasant events of their lives. Events may haunt them. They may endlessly relive past shame, humiliation, fear, or helplessness. And with the memories come the emotions associated with these events. Such memories and emotions are stressors. While an event such as an assault produces very strong emotions, bringing to mind the assault can be almost as intense if the memory is vivid. And though perhaps less intense than the original experience, when we repeatedly bring these events to mind, time and again, one after another, or when they persistently intrude seemingly of their own volition, the repeated stimulation of our alarm reaction can lead to exhaustion.

A related problem is worry. Worry about what might happen in the future can create chronic anxiety. This can sometimes be a problem if our past experience means that we expect our future experience to be stressful. Especially if we have a good imagination, we can create vivid scenarios in imagination that also give rise to emotions and act as stressors. When we allow them to play out repeatedly, they may tax our ability to respond and eventually lead to exhaustion.

Although depression may have other causes, these two routes to depression—through rumination on the past and worry about the future—seem to me to be especially significant. For example the correlation between depression and low serotonin levels is often assumed to be causal in a particular direction: low serotonin causes depression. In fact it may be the other way around, that depression causes low serotonin. The body chemistry of someone suffering from an overload of stressors, from distress, resistance and exhaustion may deplete serotonin leaving the person with low serotonin levels. Even so, serotonin ought not to be seen in isolation because it is involved in a complex, highly interrelated system of internal regulation. If one part of that system is malfunctioning then chances are the rest of the system is also malfunctioning.The relation between neurotransmitters and depression is in fact poorly understood and messing with neurotransmitters always has unpredictable, unintended consequences.

Medications which raise serotonin availability are often seen as the first line of treatment for depression even though there is now serious doubt about their efficacy. The historical non-reporting of negative trials made anti-depressants seem much more effective than they are because when it came time to do review studies they only considered published rather than unpublished results and these were very heavily biased towards positive results. The movement to pre-register all drugs trials and to publish negative results has altered how we see the efficacy of these medicines. When we add in all the trials in which anti-depressant medications had no discernible effect beyond what might be attributed to the placebo effect, then the picture changed. This seems not to have filtered down to the GP level were anti-depressants are still the first line treatment for depression as well as being liberally prescribed off label.

Buddhists often see Buddhism as a panacea for stress,. One prominent translator of Buddhist texts goes so far as to translate dukkha as "stress" making stress the fundamental problem of human existence. So next I want to look at meditation from the point of view of someone suffering from rumination and/or depression.


Depression and Meditation

As well as the symptoms described above, depression often manifests in a distorted inner-dialogue. The depressed person may experience feelings of worthlessness accompanied by self-talk that reinforces this feeling. It may also distort a person's sense of perspective, so that the present seems unrelated to the past or future. One may find it difficult to recall things ever being different or to imagine them getting better. The combination can be unbearable and result in thoughts of suicide, though the suicidal thoughts themselves may be a symptom of depression.

If a person suffering from depression induced by the chronic stress of rumination and/or worry takes up meditation the results can be disastrous. Attempting meditation while being prone to rumination can bring on or exacerbate any problems they may be experiencing. Without considerable experience of dealing with the hindrances the mind simply goes to its well worn habits of rumination and worry. Only now in a more intensive way than usual because meditation encourages us to focus on the object of awareness. Focus on rumination or thoughts of worthlessness or even suicide may lead to acute distress as a result. Going on retreat with this habit is like being in a pressure cooker and can lead to severe acute distress. It's important to begin breaking the habit of ruminating before setting out to do any meditation practice, be it concentration or just awareness based. One needs practice stabilising the mind and dealing with the hindrances or one simply dwells in negative states. Rumination will subvert this practice unless it is addressed directly. Simply trying not to think about something for someone in the habit of ruminating won't work. They will be drawn inexorably back to the same old subject. There is recent research which supports this conclusion.
"The results suggest that, contrary to expectation, strong concentration on the present, perceived as an important and unique time area, by highly neurotic individuals intensifies the negative relationship between neuroticism and self-esteem, satisfaction with life and life engagement." (ScienceDirect pre-pub)
When we add some of the more nihilistic Buddhist doctrines such as non-self or emptiness then we can create real havoc in a person's psyche. Of course such doctrines are not intended as nihilism, but they are so often interpreted and taught nihilistically that they are worse than useless and can be positively dangerous to someone prone to psychological distress. To some people these doctrines say "you are nothing", which is just what their depression-influenced inner-dialogue is telling them.

In a religious context, especially in a Buddhist context, the conversion to and practice of the religion are supposed to cure one of psychological distress. That's what it says on the tin. If someone does the Buddhist practices, but they still get depressed then that threatens to undermine the faith of the rest of the community. It intimates the fragility of some of the claims made by Buddhists. The religious whose faith is threatened by the mere existence of another person can react unpredictably. They may angrily reject the depressed person in a catastrophic way, pushing them out of home or religious community for example.

Another area of confusion is ethics. Buddhists of my acquaintance are both too slack in their own practise of the precepts and too rigid when viewing the practice of others. The result is a kind of lazy hypocritical judgement and criticism of others. The precepts are phrased as personal undertakings, not externally imposed rules. We undertake to practice them, usually because we see mentors exemplifying the practice and being attractive as a result. If we fail to uphold our precepts then this is not an opportunity to put the boot in, for the Buddhist this ought to be seen as an opportunity for offering a helping hand. Someone committed to ethical behaviour is unlikely to suddenly act unskilfully for no reason. In fact it may be the environment the person is in which is undermining their practice, in which case the community ought to be doing some soul searching rather than sitting in judgement. All too often Buddhists use the precepts as a stick to beat someone with or to place an unbearable burden on them. Most of us are at least as likely to be responding to our social environment as acting on some internal motivation. Unfortunately Freud and other Romantics have rather blinded us to our social nature and the importance of environmental factors in determining behaviour.

If we are suffering from stress to the point where it affects our behaviour, then it is deeply unhelpful for our friends and mentors to sit in judgement and criticise our ethics. Of course there may be a need to set limits and boundaries. Simply tolerating destructive behaviours is counter-productive. But there are ways of achieving this without cutting off from the person. The most important thing a community can do is let the suffering person know that they are loved and appreciated. In my experience Buddhists can be quite good around people who are dying or severally physically ill, but they are crap, really crap, at responding to severe psychological distress. Death is something we want to face with grace. It's the ultimate test of our test of our faith. We can feel good about ourselves if we face death with equanimity. Depression and other forms of psychological problem seem to be something we don't want to face at all. Since happiness is said to be the result of being a Buddhist, then a Buddhist suffering from distress is a kind of anathema. The reaction seems to be to pull away and isolate the person, perhaps with a sense of preventing the spread of the negativity contagion. Fear is a common reaction.

The point is that traditional approaches to meditation assume fairly good mental health from the outset. And it's doubtful at best to assume that everyone who signs up for a meditation course at an urban Buddhist Centre is in good mental health. In fact I would say that many people sign up for meditation precisely because they are not in good mental health and have been told that meditation is the cure for what ails them. And that is confusing for everyone involved.


Conclusion

My view is that this kind of problem is widespread. Modern urban life is organised in such a way that many people suffer from hyper-stimulation and chronic, generalised stress reactions. We are constantly being intensely stimulated and don't know how to effectively calm down. In addition many of us develop the vicious habits of rumination or worry which are themselves stressors. We may not have enough resilience or know ways to calm ourselves down. Without acknowledging this, Buddhism as widely taught is unintentionally creating a significant amount of confusion and misery. It is a significant barrier for many people who might otherwise benefit from our practices. And the idealism of Buddhists, who tend to see meditation as a kind of panacea—saving not only individuals, but the cosmos itself—doesn't help matters. For many people attempting meditation does not bring any of the promised benefits and but contrarily introduces new stressors and/or intensifies old ones. We cannot continue to teach as though we are living in pre-modern Asia. Unfortunately the negative changes are ramping up as time goes on and we need to adapt to rapidly changing times.

Fortunately there are a number of auxiliary practices that are also frequently taught alongside Buddhism. I'm thinking of yoga and taichi for example, both of which indirectly enable a person to manage their mental states better by grounding them in the bodily experience (I've praised cultivation of the body previously). But I'm also thinking of what we call mindfulness (in the John Kabat-Zinn sense). With this kind of practice of paying attention to our bodies and our movements we prepare the ground for going deeper by allowing ourself to experience a stable mind. The physicality of bodily awareness often short-circuits rumination and worry. We enable a person who is prone to rumination to stop the vicious cycle and experience themselves anew. Recent research has shown that paying attention to the body increases resilience, where resilience refers to the body's ability to rapidly return to a resting state after encountering a stressor. See for example:To Better Cope With Stress, Listen to Your Body. (New York Times, 13 Jan 2016)

Another task I find helpful is writing. This forms an integral part of my strategy for avoiding rumination and worry. The linear nature of the process of writing about ideas is perfect for preventing the downward spiral of negativity. Always having something to think through that I can switch to if I notice an unhelpful trend building up in my thoughts has been essential to my well-being for over a decade now. I heartily recommend this practice to anyone who is thoughtful, but struggles with rumination or worry. Creative writing may suit other people better. But writing epitomises an approach to moving away from vicious spirals into more virtuous progression.

Knowing, as I do, the pitfalls of rumination and worry, I'm in favour of these auxiliary practices becoming much more prominent in our teaching. My opinion is also that we ought to teach very little theory to beginners and focus on mindfulness practices, particularly related to the body. All one needs to do, initially, is to start paying attention and to note what happens when we do pay attention. Everything should be based on this. Once someone achieves a measure of success in this, then we can move them onto more intensive practices. New techniques should only be introduced on an individual basis, by an experienced mentor, when the practitioner is ready. Indeed I would advocate that everyone be introduced to these practices by a mentor who can function a bit like a sponsor in AA. Someone who is experienced enough to offer guidance, but also sufficiently available for the guidance to be timely. Someone who can take an active interest in that individual's life. As it is I suspect many Buddhists are way ahead of themselves and floundering because the foundations of their practice are not sound. Any theory that we do teach should tie directly into experiences we've already had rather than hypothetical. Buddhists should not be allowed to teach what they do not know from personal experience. We need fewer teachers and more demonstrators. More people who show us what to do, and fewer who can only tell us. 

Simplicity and experience ought to be at the heart of what and how we demonstrate Buddhism. If we much teach "History of Buddhism" we ought to structure our approach to highlight experience and draw people into paying attention to their experience. We should never teach anything that is not part of a coherent program of taking people towards insights into the nature of experience. We must refocus on what Buddhists do rather than what they believe - it's only by doing what we do, that what we believe what happens becomes relevant. And we should be guided by critical scholarship rather than traditional accounts of history. Of course to some extent this horse has already bolted. There are uncounted books describing Buddhism, its history and practices to anyone with the money and time to read. Books that are often simply parrot the traditional stories and/or are misleading. Chances are that new people are showing up at our centres having crammed their heads with useless information about Buddhism that gets in the way of their understanding the Dharma.

I think this means starting from scratch and redesigning Buddhism. Including, I may say, the approach of the Triratna Buddhism Movement. Unlike most religious groups, for example, we use our centres primarily as classrooms. Events are almost always structured with active teachers and passive students. I personally find almost no opportunities to engage. There is almost no opportunity to simply socialise with experienced Buddhists for example. If I could go back, I would do everything differently. If I could advise my younger self, I would be emphasise physical cultivation, mindfulness, and sustaining social connections. Meditation was not what I needed back then. Had I established better foundations, my life might be very different now. The most effective practices I have are not ones that I learned from my Buddhist teachers, but one's I figured out for myself based on wide reading and reflection on my life. It was difficult and took a long time to get this far. And most of the time enlightenment is not at all relevant to my daily practice. I'm working at a very different level. Everyone ought to be aiming to work effectively at the level that they are at, rather than getting caught up in the interminable babble about enlightenment.

So much for my opinions on Buddhism. But make no mistake. Rumination is a serious problem. Having our own thoughts as a constant stressor can have serious health consequences. It can be debilitating. And I don't think it is widely enough understood by those who merely "teach" Buddhism.

~~oOo~~

Update 25 Jan 2016

“Pathological anxiety and chronic stress are associated with structural degeneration and impaired functioning of the hippocampus and the prefrontal cortex, which may account for the increased risk of developing neuropsychiatric disorders, including depression and dementia.” - The Independent


update 24 Jan 2016

In case anyone is in any doubt, please see the UK National Health Service's definition of depression. It's quite important when considering this discussion to have a clear idea of what I mean by the word. And I mean what the Brits call Clinical Depression or what the DSM-IV calls Major Depression. It is a profound disease that manifests in changes to thoughts, emotions, and bodily systems. It represents a powerful perturbation of our homoeostatic systems. And it can be fatal. 


update 23 Jan 2016.

As it happens the day after I published this essay, the Guardian newspaper published one of their regular scare stories, this time about mindfulness. 
Is mindfulness making us ill? It’s the relaxation technique of choice, popular with employers and even the NHS. But some have found it can have unexpected effects. by Dawn Foster (23 Jan 2016)
My view on the UK press is that they thrive of fear, anger, disgust. It's an extreme form of entertainment which is not peculiar to this country, but does exist here in a particularly refined form. They tailor their stories to produce these emotions in their readers - different types of reader respond to different stimuli. One has to take this into account reading newspapers. They will always pitch the information in a way designed to elicit fear, anger, and/or disgust. All the UK papers are extremely unethical in this sense. They fuck you up.

However my attention was also drawn to this article in The Atlantic which comes closer to some of my concerns. 
The Dark Knight of the Soul. For some, meditation has become more curse than cure. Willoughby Britton wants to know why. 25 Jun 2014. 
As far as people having psychotic breaks after starting meditation I think this must be read with caution. As I understand it, someone prone to have a psychotic break was going to have one anyway. I've certainly found myself in some extremely painful and distressed states while trying to meditate, especially on retreat, but I don't think meditation is a practice that by itself will cause a psychotic break in someone that was otherwise unlikely to have one. Again The Atlantic is a newspaper.

Readers who find this material rings bells may also like to look at the story of Sally Clay, particularly her story The Wounded Prophet.

If you have a psychiatric diagnosis then meditation may not be for you. You need to work closely with your support people and a mentor who has some experience in mental health. And most meditation teachers have no fucking clue. So be warned.

If you are prone to rumination and/or worry then you really need to address that before taking up meditation and, again, work closely with an experienced mentor. Something I wish I had done. 

I would also add that despite having some very difficult experiences around meditation and particularly retreats, I still think of meditation as an extremely positive and helpful practice on the whole. I see it as essential for the process of awakening (however we interpret that). Everyone needs to have good foundations before they dive into practices that can disrupt their sense of identity and embodiedness.


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