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To Mina and Rohan, APPENDIX I: Breaks, Buffers and Protective Factors: A Lightning Round of Proven Strategies APPENDIX II: Resources and Further Reading SELECTED SOURCES ACKNOWLEDGMENTS INDEX INTRODUCTION People often chuckle when I tell them I am a stress columnist. I will grant that it is an odd title, but the job itself--examining stress and its impacts--has become crucial in modern life. My journey into the stress vortex began in late 2010 when I wrote two series of essays for CNN.com: one about the milestones of my brawl with cancer and the other about parenting toddlers in the wake of a health crisis. A few months after the latter, Mary Carter, who ran CNN Health in those days, asked me to give her a call. "We are going back to the basics," she told me. "We have sex and sleep covered. I need you to write about stress." Stress. Her suggestion blindsided me. I was, in spite of my relative youth, already an old pro at full-catastrophe living--that is, constant disaster punctuated by brief periods of quiet. Because of this, stress was my default; it was the "normal" I accepted as status quo and not something to be questioned. The idea of exploring stress, writing about it and finding ways to manage and alleviate it, seemed strange. I was also far more interested in writing about other health topics. Three years out from a scrape with death, I had a bone to pick with our culture's very linear way of thinking about health and illness. "I want you to take our readers into the stress vortex," she continued. "People are half out of their minds with stress. Tell them how to help themselves." I opened my mouth to protest, to tell Mary that I didn't know the first thing about stress. And then closed it. This was not strictly true. I was, in fact, Waldo in the Where's Waldo of stressful life circumstances: As a young child, I had been banished from my homeland because of my faith, then virtually orphaned for years in the wake of exile. In my adult life I spent years as a desperately unhappy Big Firm lawyer, someone who was standing in the shadows of the Twin Towers on the day they crumbled, and who suffered a vicious depression afterward. And then, the final insult: late-stage cancer in my thirties. Surgery, six rounds of high-dose chemo and radiation later, the fact that I was still standing was something of a miracle, given the odds of survival I had been quoted three years earlier. The book of my life was a virtual encyclopedia of disaster. What didn't I know about stress? It was a compelling proposition. I had researched and read reams across a variety of disciplines--science, philosophy, self-help and spirituality--in the wake of my various catastrophes. And all that information and advice resonated, more or less, as I read the books. But it stuck only in the way New Year's resolutions stick--for days, weeks, sometimes months. The clarity was always somehow transient. Eventually it dissipated, and sooner rather than later. Lasting peace proved itself elusive. In the end, it was the name of the column that clinched the deal for me. "Seeking Serenity," we decided after volleying several options back and forth. "The quest for well-being and life balance in stressful times." I remember turning the words over in my head. It was a quest--it said so in the title. No promises. I can do this , I thought. I can seek serenity . As for the prospect of well-being and life balance in stressful times, was that even possible? If so, I wanted it badly. It was not until much later that I wondered at the mysterious forces that had set me on this path. All I knew then was that my editor was sending me on an assignment with stress as a road map. Two weeks later I officially entered the stress vortex. It would be the journey of a lifetime. PART ONE One does not discover new lands without consenting to lose sight of the shore for a very long time. --ANDRÉ GIDE CHAPTER ONE The restaurant is called Café Gratitude. It originated, unsurprisingly, in Northern California. And if the vegan establishment's name doesn't adequately give away its bohemian spirit, the menu puts all doubt to rest. On a given morning, you might decide to order pancakes. "I am openhearted," you will say. Or a bowl of porridge: "I am free." "I am radiant" begets a mimosa; "I am courageous," a coffee. The entire menu forms a small universe of affirmations, mantras that you might whisper to yourself (cringing, perhaps) as you decide what you want to eat. Then you will repeat the mantras once again to the server. You may even giggle or blush as you say them out loud. The idea of ordering food through sunny self-affirmations is rooted in the founders' belief, well established by science, that practicing gratitude in our daily lives is life changing. But there is something else there too: the fundamental truth that our words matter. That the words we repeat to ourselves over and over again surround us, hypnotize us somehow. They take shape to form our stories, the core of our beliefs, the fabric of our existence. "Storytelling is the great democracy," National Book Award-winning novelist Colum McCann once told me. "We all want to--need to--tell our stories. There is a certain catharsis in being able to tell your story, in confronting your demons." But there are stories that serve us. And stories that don't. What are the stories that you repeat to yourself over and over again? How mindful are you of your unspoken mantras? What are the threads that run through your everyday and, eventually, your entire life? I am smart. I am alone. I am always late. I am a fake. Consider this mantra: I am stressed. Think about how many times on any given day you hear some version of it thrown about, whether in casual conversation or grave circumstances. How stressful! I was stressing hard! He stresses me out! Or some other variation of the same: She is so type A. How often do we think about stress, repeat its perverse mantra to ourselves, hear it echoed back to us from a diverse array of sources, both public and intimate, both within our heads and without, written, spoken or otherwise signaled? In what ways does stress weave itself into the fabric of our lives? The View from the Trenches Nor is all that stress just in our imagination. So many of us feel besieged by what the World Health Organization has referred to as the health epidemic of the twenty-first century. Between 70 to 90 percent of primary care doctors' visits are attributed to stress, which is also said to cost American companies as much as $300 billion a year.1 The past few decades have seen increased scientific understanding of stress pathways, the impact of stress on our bodies and minds, and the populations that suffer most from stress and why. Not only have scientists grown highly adept at measuring stress, but soon even the average person on the street will be able to use his smartphone to measure and confirm just how stressed out he might be in real time.2 Americans now suffer from an array of diseases that are either rooted in or worsened by stress. We can trace its pernicious impact as the common thread that runs through some of our deadliest public health crises--obesity, diabetes, depression, suicide, cancer, among others. And the sense of pervasive stress has trickled down to the youngest among us, who are mirroring adults' worries, but with far greater consequence and lasting impact.3 What besieges us so? The common themes emerging from polls and surveys should come as no surprise: health, jobs, finances, relationships, parenting and an ever-present sense of overwhelm regularly top the lists. A July 2014 poll by the Harvard School of Public Health, the Robert Wood Johnson Foundation and NPR found that almost half the public had experienced a major stress in the past year. Of those, nearly half were related to health. Others reported that too many overall responsibilities and financial problems were major contributors to their stress. Also in the highest-stressed categories: people living with chronic illness and disabilities, those with annual incomes under $20,000, people facing potentially dangerous situations in their jobs, single parents and parents of teens. In the face of all this, is it possible to craft a meaningful set of rules to address stressful situations as diverse as job loss, health crises and disobedient teenagers on the one hand, and political discord, global warming and even war on the other? I spent those first years in the trenches writing doggedly about stress from every angle: I filed columns about relationship stress, work stress, job hunting stress, traffic stress, back-to-school stress, recession stress, stress among children, stress among the elderly . . . I wrote about lawyers gone Zen and meditating tech titans, athletes and bestselling authors. In column after column, I provided a laundry list of tips to help people through difficult circumstances. Nearly everyone who discovered what I did for a living asked me some variation of the same question: How can I manage all this stress in my life? It was a veritable feast of distress and, at least according to a couple of surveys, I was a top influencer on the subject. At some point my work began to take on a certain hamster-in-the-hamster-wheel feeling. With each new survey, study and product, the picture of stress grew more dismal and its impact more overwhelming. The sense that things were not adding up began as a background whisper late in Year One and grew into a full roar as the next year wore on. Given how much I had hated being a lawyer, help came from the unlikeliest place: my legal training. In the first year of law school, students are assigned to read cases, dozens and dozens of them. When enough cases are read about a particular area of the law, patterns emerge. Eventually those patterns fit together to form an even larger context and meaning. This process is called "synthesis," and, as you might imagine, most law students become quite adept at synthesizing cases. It becomes second nature. I had started my assignment with the baseline assumptions shared by most of us: Stress is pervasive. It is damaging. It can disable and even kill. We must find ways to avoid and minimize the stress in our lives. These were not unreasonable assumptions, given the vast amount of research that points to the adverse impacts of stress. But there was more--so much more--missing from the larger conversation about this health crisis: critical context that came not just from science but also philosophy, history, religion and other disciplines. Once these new pieces entered the equation, the picture of stress--our current cultural narrative of stress--began to change and a new picture began to emerge, as yet hazy and uncertain, but something important nonetheless. Then, one day, more than a year after I had begun my journey into the stress vortex, the pieces finally took shape for me. There, suddenly, it stood: the reality of stress. And it was not at all what I had imagined it to be. The Elephant in the Room There are many variations of the tale of the wise men and the elephant. The version I heard as a child in Iran, "An Elephant in the Dark," is by the Sufi mystic and poet Rumi: Some Hindus have an elephant to show. No one here has ever seen an elephant. They bring it at night to a dark room. One by one, we go in the dark and come out saying how we experience the animal. One of us happens to touch the trunk. "A water-pipe kind of creature." Another, the ear. "A very strong, always moving back and forth, fan-animal." Another, the leg. "I find it still, like a column on a temple." Another touches the curved back. "A leathery throne." Another, the cleverest, feels the tusk. "A rounded sword made of porcelain." He's proud of his description. Each of us touches one place and understands the whole that way. The palm and the fingers feeling in the dark are how the senses explore the reality of the elephant. If each of us held a candle there, and if we went in together, we could see it. For many of us, stress has become that unknown elephant in a dark room. We do our best to feel around in the dark, to understand the whole by fumbling at pieces. Ultimately it is ever present--too close for comfort and too big to ignore. And yet a sense of the beast in its entirety eludes us. This is why most of us cannot find lasting relief from stress. This is probably why you have picked up this book. Why it may not be your first (or fifth, or tenth) attempt to address the constant sense of overwhelm in your life. Why you may well have a nightstand/bookshelf/cupboard/desk/computer/smartphone overflowing with books/articles/apps promising relief. And why you are here, at this pass, yet again. You are not alone. Since 2007 the American Psychological Association has conducted an annual survey called "Stress in America." As you might imagine, the survey findings do not bode well for us. The 2013 survey reported "a scenario in which Americans consistently experience stress at levels higher than what they think is healthy."4 We are constantly exhorted to "avoid all stress." We do our best to follow this advice--so much so that stress and ways to relieve it have become big business. Entire industries have sprung up, simultaneously promising greater happiness and less stress. The books, apps, gadgets and gizmos intended to help with stress relief and, more generally, happiness could fill a small warehouse. At last check, Amazon had more than thirty thousand books on the subjects. There are books by scientists, books by spiritualists, self-help books, stress reduction workbooks for women and for children; there are tomes on decluttering, mindfulness and yoga, books on stress physiology and stress management for dummies, not to mention memoirs devoted to stress relief and its first cousin, happiness. Billions of dollars, millions of Google search results, dozens of bestsellers and self-styled gurus later, and yet the stress-free lives we long for continue to elude us. All indications are that the advice to "avoid stress" is a futile strategy when it comes to the runaway anxieties of our modern lives.5 Which only makes us doubly stressed: We are now also stressed about being stressed! "Is 'Stressed Out' the New Normal?" asked the American Psychological Association in 2013. Why? Why exactly is stress so bad now ? Didn't our ancestors have to outrun a mountain lion or two on their way back from fetching dinner? Didn't they have to survive plagues, floods, famines and depressions? Fight world wars? Compared with our hardy forebears, we live in relative ease. How did we end up with this modern burden of living in one of the most trying times in the history of humankind? What changed? CHAPTER TWO In his 1948 Pulitzer Prize-winning poem The Age of Anxiety , W. H. Auden sought to examine humanity's quest to find its way in a modern, fast-changing and increasingly industrialized world. Auden wrote: We would rather be ruined than changed We would rather die in our dread Than climb the cross of the moment And let our illusions die. The Age of Anxiety , observes journalist and author Daniel Smith, came to "characterize the consciousness of our era, the awareness of everything perilous about the modern world: the degradation of the environment, nuclear energy, religious fundamentalism, threats to privacy and the family, drugs, pornography, violence, terrorism . . . As a sticker on the bumper of the Western world, 'the age of anxiety' has been ubiquitous for more than six decades now."6 "We see ourselves as living in more stressful times," James Gross, one of the world's top experts on emotions and emotion regulation, once told me in an interview. "But it is also true that in many historical periods people seemed to think they were in the most stressful times ever." I had been busy typing notes as he spoke, but this stopped me cold. "What are you saying?" I asked. "It's actually a very common experience to see yourself as living in a particularly stressful period," he continued. "I'm questioning the premise that we are living in necessarily more stressful times." It was the first time I had questioned the assumption that we are living in "the most stressful times." This notion of stresses and stressors, of feeling constantly overwhelmed, has become so commonplace in our society that the terrible anxiety of our times and the havoc it wreaks on our mental and physical health is a given, widely accepted as near dogma. Yes, things seem bad--and, at times, awful. But if it is true that our circumstances are not, taken on the whole, better or worse than our predecessors', then why the stress epidemic? Did we just get better at identifying and diagnosing? Leaving aside the unanswerable question of just who had it worse--us or our ancestors--let us consider for a moment what is an irrefutable fact of our times, and unprecedented in the history of humankind: that we are now much more aware of events, both global and hyperlocal, than ever before. We have unparalleled access, in real time and conveyed through image and sound, to polarizing and upsetting events near and far, streamed to us through media on a slew of devices, including one most of us carry on our bodies constantly, as if it were an appendage. Our nervous systems, built to seek out information all around us in an adaptive way, have a field day with this level of access. By knowing about threats, we reason, we may be able to prevent them from happening to us, so we seek out bad news, effectively bombarding ourselves virtually around the clock with negative information.7 So while in this era we must deal with our own specific set of stressors both big and small--traffic gridlock, constantly buzzing devices and multitasking in the best of scenarios; economic meltdowns, global warming and terrorism in the worst--our brains process these stresses in the same way as our ancestors' brains did when they faced dire life-or-death circumstances. The difference is, we endure them constantly. Echoes from the Past Continual access means that we are exposed to more potential stressors throughout the day, but access alone does not solve the puzzle of why, within one century, our leading causes of death shifted from tuberculosis, pneumonia and influenza to a range of maladies that can be caused or made worse by stress: heart disease, cancer, adult-onset diabetes and Alzheimer's.8 An important clue to this question lies in the era of Mad Men , with an unlikely set of malefactors and their nefarious agenda. Yes, this book has a villain and that villain is not stress. While the stress response itself is as old as life, our concept of stress is reasonably modern. It hails back to a group of hapless rats in a 1950s science lab and a researcher named Hans Hugo Bruno Selye.9 Selye was an Austrian-born physician and biochemist. He attended university in Prague, but was forced to flee the Nazis in the early 1930s. He found his way to Canada, where he accepted work in the endocrinology department at the University of Montréal. As the junior member of his team, Selye was tasked with the unenviable chore of venturing out to a slaughterhouse each day and returning with a bucket of freshly harvested cow ovaries. The scientists in the lab would then process the organs into an extract and inject them into female lab rats. They were looking for evidence of a new female hormone. Over the course of the many autopsies that ensued, Selye failed to find any such evidence, but he did observe something else rather interesting. The injected rats suffered from a "curious triad of symptoms: peptic ulcers in the stomach and upper intestine, enlarged adrenal glands and shrunken immune tissues."10 To determine whether these symptoms were related to the specific substance being injected or not, Selye began injecting the animals with extracts made from other organs. The same trio of symptoms appeared once again. Emboldened, Selye expanded his inquiry further, to see whether the symptoms would also result from other trauma. And so he began inflicting a variety of stressors on the rats and examining their responses. "[N]o matter what type of damage I inflicted on an experimental animal, if it survived long enough and the stressor was sufficiently strong, the typical combination would be produced: adrenal hyperactivity, lymphatic atrophy and peptic ulcers," wrote in his 1979 memoir, The Stress of My Life. Years later Selye would recall how as a young medical student in Prague he had observed patients with different diseases presenting a common set of symptoms--feeling weak and listless, having similar facial expressions--which he identified generally as "the syndrome of just being sick." He suspected then that the symptoms were connected somehow. He wrote: "I asked myself . . . why so many people suffer from heart disease, high blood pressure, arthritis, or mental disturbances. These are not completely stereotyped signs of all illness, yet they are so frequent that I could not help suspecting some nonspecific common factor in their causation."11 Selye formalized this nonspecific common factor in a word he borrowed from metallurgy. That word was "stress." In a conceptually groundbreaking paper published in Nature in 1936, Selye observed that stress "as a whole seems to represent a generalised effort of the organism to adapt itself to new conditions." It was, therefore, a "general adaptation syndrome" that unfolded in three stages. During the first stage, the "alarm phase," the animal perceived a threat and underwent the physiological changes needed to either fight or take flight. (The fight-or-flight response had already been described by scientist Walter Bradford Cannon in the 1920s.)12 Next came the "stage of resistance," where the animal's body effectively adapted to the threat, reversing the physiological changes it had gone through during the previous phase and reverting back to normal. But if the threat continued beyond the animal's capacity to handle, a third phase--a "stage of exhaustion"--would trigger symptoms very much like those that had manifested during the alarm phase. It was here, in the exhaustion stage, that adaptation would fail and the body wear down, thus opening the door for disease and even death. The key, Selye wrote, was adaptation: "The secret of health and happiness lies in successful adjustment to the ever changing conditions on this globe; the penalties for failure in this great process of adaptation are disease and unhappiness."13 Selye was incredibly proud of his new discovery, deeming it "my child [who] will outlive me."14 He even took great pride in recounting how some of his earlier theories about the "syndrome of just being sick" had been met with scorn by his professors. Years later, he would feel vindicated: "Stress will have been my cathedral. I shall polish and perfect it." According to historian Anne Harrington, Selye faced serious doubts among his fellow scientists early on. Many of Selye's colleagues, including Cannon, were skeptical about his theories: "They suggested that Selye had exaggerated the uniformity of the response seen in different experimental situations, had not adequately defined stress as a concept, and that in any event, many of his experiments were highly artificial and had little if anything to say about patho-physiological processes seen in a clinical context."15 Selye would not be ignored. He stopped trying to convince skeptical scientists and began instead to look beyond his peers for support. His ambitious campaign involved cultivating an extended audience that included military psychiatrists. Selye also appealed to popular magazines and their broad base of readers. Very soon Hans Selye would also catch the eye of another group: the tobacco industry. And that particular coupling would profoundly impact our culture and the way we experience stress today. The Rise of the Culture of Stress At the turn of the twentieth century cardiovascular disease was relatively rare, responsible for fewer than 10 percent of deaths worldwide. By mid-century, however, coronary heart disease had skyrocketed, particularly in the American and European populations, now suddenly representing the single greatest cause of death. A number of epidemiological efforts were launched to determine the cause of the disease's sudden rise. Among these, the Framingham Heart Study was the first to confirm a clear link between smoking and heart disease. As researchers began to cast a wary eye at cigarettes, the tobacco industry was caught in a dilemma. With lawsuits nipping at Big Tobacco's heels, tobacco companies began doing what vulnerable corporations trying to protect billions in profits have done before and since: attempt to lay blame elsewhere. Two San Francisco cardiologists, Ray Rosenman and Meyer Friedman, formed an alternate theory about the high incidence of heart disease based on their observation that the front edges of their waiting room chairs were worn down by fidgeting, impatient patients, many of whom happened to be white-collar managers. Could it be, the doctors mused, that it was personality traits shared by those who held particular jobs that put them at risk for heart attacks? To validate their theory, Rosenman and Friedman surveyed several hundred San Francisco businessmen and general practitioners. From a list of personality characteristics, an overwhelming majority of respondents selected the characteristic of having "excessive competitive drive and meeting deadlines." The doctors ran with this, coining the clever moniker that would become embedded in our lexicon to describe the competitive and the deadline-driven: The type A personality had entered the room. By this time, Selye's relentless efforts had paid off. His theories had "permeated medical thinking and influenced medical research in every land, probably more rapidly and more intensely than any other theory of disease ever proposed."16 Selye traveled the world preaching the gospel of stress, and when all was said and done, his academic oeuvre would include more than fifteen hundred books and articles.17 Excerpted from Seeking Serenity: The 10 New Rules for Health and Happiness in the Age of Anxiety by Amanda Enayati All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.