Healing Emotions: Conversations with the Dalai Lama on Mindfulness, Emotions, and Health – Daniel Goleman

Part Two
Biological Foundations

Chapter 3
The Body’s Self – Francisco Varela

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The first question we ask about a system is: What is its organ? Like the components of the nervous system, the organs of the immune system are dispersed throughout the body. They include the thymus and bone marrow, the sources from which the system is constantly renewed; the spleen; and the lymphatic system, a network of tissue nodes connected by conduits through which the lymph fluid circulates.

The cells that constitute the immune system are called lymphocytes, or white blood cells, and are circulating all the time, unlike the fixed neurons of the nervous system. Most lymphocytes are produced in the bone marrow and therefore are called B-cells. Thymal cells, or T-cells, are produced in the thymus. Although fewer in number, the T -cells control the B-cells, like officers regulating soldiers.

The cells of the nervous system are distinguished by their shape and location. For instance, the neurons in the visual cortex are distinct from those in the hippocampus. Lymphocytes are not identified by location, since they circulate, but by their cell receptors. These are macromolecules on the cell’s surface that interact with the receptors of other cells as they circulate. The cell receptors are markers that enable us to identify a cell’s specific function, much as we can recognize a specific neuron in the brain.

Among these markers are the macromolecules called antibodies. B-cells are identified by unique antibodies, shared by as few as twenty or thirty other cells in the immune system. They are little families of B-cell clones producing identical antibodies that are markers, like a unique family name. In a normal immune system, there are about a 100 million different clone families circulating, each distinguishable by its unique antibodies. Imagine a large city of 100 million families, each with specific affinities to others, and all of them moving around. It’s quite complex.

Like other receptors on the surface of the cells, antibodies have a very specific shape that can bind with any of a variety of molecules whose shapes are complementary. As an analogy, if I cup my hand slightly, an apple or an orange would be able to enter that space and bind for a moment, but the same hand position would not be a good fit for a pen. A B-cell binds very quickly with any cell or bacterium, or anything floating in the blood with the specific molecular shape that fits. There is a very rapid exchange, back and forth, binding and unbinding. These interactions are a method of communication, just as neurons communicate by sending electrical impulses.

In the nervous system, the most important events are the activation and inhibition of neurons. Most of neuroscientific analysis focuses on measuring this relative amount of activity.There is an exact analogy in the activation or suppression of B-cells and T-cells in the immune system. Here, activation refers to the cells dividing so that the clone family increases in number. Suppression means a decrease in the number of clones as the cells die off.

The normal life span of a B-cell in a human is between one and two days, although some live slightly longer. This means that the system is renovated very rapidly on a vast scale. After a week or two, the lymphocytes have all been replaced. What remains, therefore, is a pattern: the kinds of clones and their degree of activation. This, of course, is unlike the brain, where by and large the neurons neither die nor reproduce.

There are still other important analogies between the nervous system and the immune system. The sense organs that relate the brain to the environment, such as the eyes and ears, have parallels in a number of lymph organs. These are distinct regions that act as sensing devices and interact with stimuli: for example, patches in the intestine that constantly relate to what you eat.

Likewise, both systems have effectors. In the nervous system, these are typically the muscles that contract to produce behavior, although there are also other types. The equivalent in the immune system is the maturation of B-cells, an effect that is very important to health. In maturation, a B-cell suddenly changes state and becomes a factory producing about two thousand antibodies per hour instead of the usual dozen. These antibodies are released into the bloodstream independent of any cells; this effect is what we know as an immune response.

The Body’s Self

We can now begin to look at a deeper analogy between the nervous system and the immune system. Just as the function of the nervous system takes on a cognitive identity, a sense of self, with its own memories, ideas, and tendencies, the body also has an identity or self with similar cognitive properties such as memory, learning, and expectations. This identity functions through the immune system.

The nervous system includes a number of simple mechanisms concerned with defending integrity. An animal avoids a painful stimulus; a driver turns the wheel to avoid a sudden collision. Biologists consider these emergency responses to be simple escape reflexes that happen at the lowest level of the nervous system, with very little sophistication. But the nervous system also has another side: all the emotion, imagination, desires, and memories that are part of ordinary life and are not concerned with urgent defense. There is a continuous inner life, an internal sense of identity, which is far more complex and interesting than simple escape reactions, and which involves most of the cortex.

In the immune system, we have exactly the same situation. The defensive aspects of the immune system respond to urgencies such as infection. For example, when bacteria enter the body, your immune system suddenly recognizes an unusual molecular entity. This recognition of an unfamiliar profile is a very simple cognitive operation. The B-cell clones that can bind to the bacteria start maturing and produce many, many antibodies. Each bacterium is completely surrounded by antibodies sticking to it, and is immediately washed away by fluids. This immune response is the basis of vaccines.

The outer-directed defenses have dominated the study of immunology for 100 years, and awareness of the inner or autonomous aspect is very new, unlike in the neurosciences. Most immunology today is still concerned with immune responses, and it is based on the so-called Clonal Selection Theory, clearly formulated by MacFarland Burnet in the 1950s. I don’t mean to imply that the immune response is not important. It is as necessary to life as are the neurological reflexes that propel one to run away from danger; but it would be silly to reduce our cognitive life to escape responses. Just as escaping danger and predators is only a small part of our cognitive life, we are often not confronted by serious infections. What happens to the immune system when there are
no immune responses taking place? What is its equivalent of the inner cognitive life?

Let me use an analogy to illustrate the answer. What is the nature of the identity of a nation? France, for example, has an identity, and it is not sitting in the office of Francois Mitterand. Obviously, if too much of a foreign entity invades the system, it will have outer-directed defense reactions. The army mounts a military response. However, it would be silly to say that the military response is the whole of French identity. What is the identity of France when there is no war? Communication creates this identity, the tissue of social life, as people meet each other and talk. It is the life beat of the country. You walk in the cities and see people in cafes, writing books, raising children, cooking-but most of all, talking. Something analogous happens in the immune system as we construct our bodily identity. Cells and tissues have an identity as a body because of the network of B-cells and T -cells constantly moving around, binding and unbinding, to every single molecular profile in your body. They also bind and unbind constantly among themselves. A large percent of a B-cell’s contacts are with other B-cells. Like a society, the cells build a tissue of mutual interaction, a functional network, as the work of several groups is showing. And it is through these mutual interactions, that lymphocytes are inhibited or expanded in clones, just as people get demoted or promoted, families expand or contract. This affirmation of a system’s identity, which is not a defensive reaction but a positive construction, is a kind of self-assertion. This is what constitutes our “self” on the molecular and cellular level (including genetic determinants and “self” markers).

An experimental illustration that will make this more clear. Antonio Coutinho and his colleagues at Pasteur Institute in Paris raised mice in a bubble environment with no risk of infection, where they are exposed to no antigens (external molecules) other than air and very simple food. If you apply the classical view of the immune system as purely defensive, you would expect the mice to have no defense system. But if you see the immune system as having a cognitive inner core as well as outer defenses, you would expect these antigen-free mice to have a normal immune system. The results of the experiment are 100 percent clear: you can hardly differentiate between the immune systems of these antigen-free mice and those of mice raised normally. Obviously, outside of the chamber they will die, just as if you raised a child in an environment with no challenges, it would not know how to escape from danger. However, you can hardly distinguish its nervous system from that of a normal child. If a bubble mouse is gradually acquainted with antigens, it will survive-all it lacks is learning, essentially.

The classical view holds that antibodies are, just as the name suggests, directed against something else. It wouldn’t make sense for them to bind to your own body. But in this alternative self-directed or network view of the immune system, dating back to the early seventies, from the work of Danish immunologist Niels Jerne, you would expect to find I-cells that can bind to every single molecular profile in the body. Just as for every aspect of French life-museums and libraries, cafes and pastries-there must be French people who deal with it. From the point of view of classical immunology, this is heresy. Paul Ehrlich, the founder of immunology, spoke of horror autotoxicus, the horror of responding to oneself. He saw the immune system as solely directed at invaders. The fact is, you do find antibodies to every single molecular profile in your body (cell membrane, muscle proteins, hormones, and so on). Instead of horror autotoxicus, there is a “know thyself” tendency between the immune system and the body. Through this distributed interdependence, a global balance is created, so that the molecules on my skin are in communication with the cells in my liver, because they are mutually affected via this circulating network of the immune system. From the perspective of network immunology, the immune system is nothing other than an enabler of the constant communication between every cell in your body, much as the neurons link distant places in the nervous system.

As I mentioned, the cells of the immune system die and are replaced roughly every two days, just as in a society people die after a number of years and children are constantly being born. Society in some complex way trains this pool of children to fill different roles. Similarly, the bone marrow is constantly producing what are known as infantile, or resting, B-cells. Some of these resting B-cells are recruited by the existing immune network and activated, or trained, to specific roles. This is how the system renews its components. Learning, or memory, happens because new cells are being “educated” into the system. The new cells are not identical to the old ones, but they fill the same role for the overall purpose of the emergent global picture.

The distinction between resting and active cells is important to the larger distinction between the outer-directed immune system, which is concerned with defenses, and the inner-directed immune system, which is concerned with molecular identity, or the assertion of the body’s self. There is a close parallel here with the peripheral and central nervous systems; we can call them the peripheral immune system and the central immune system. The central immune system consists mostly of activated lymphocytes, which are larger and have more receptors on their surfaces. The peripheral immune system consists mainly of resting lymphocytes, which have fewer molecular profiles on the surface. So the two systems are distinguished not just metaphorically, but by criteria that are concrete and can be seen experimentally.
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Part Three
Skillful Means and Medicine
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Chapter 7
Behavioural Medicine – Daniel Brown

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Headaches: A Detailed Look at Treatment with Behavioral Medicine

About 60 percent of the people who come to our outpatient department come in with headaches; it’s our most frequent referral. There are three major kinds of headaches that we understand. The first has a strong biological basis to it, such as the headache that accompanies a tumor or an illness like the flu or other infection, or the headache that comes with a hangover. These are all examples of headaches caused by the release of chemicals in the body or by tissue changes. We can’t treat these headaches with behavioral medicine, but they constitute perhaps only 5 percent of all the cases that come to the clinics. The other two types are muscle tension headaches and vascular headaches. Muscle tension headaches, caused primarily by the contraction of muscles within the head, neck, and scalp, are the most common, accounting for about 85 percent of all headaches. Vascular headaches are caused by changes in the blood flow. Most people who come to our clinic have a mixture of muscle tension and vascular headaches, not just one or the other.

Treatment needs to involve both the factors that caused the headache and those that maintain it. Any of the types of stress mentioned earlier can cause headaches by producing changes in the muscle tension level and blood flow. People who have chronic headaches have certain bands of muscles in the head, neck, and scalp that remain contracted; the high levels of muscle tension are there all the time, even when they’re free of headaches. If they’re under stress, then a little bit more change causes perception of the pain. That muscle tissue is different from healthy muscle tissue. It’s much harder to the touch because it’s filled with fluid from a build-up of certain saccharides in the tissue.

There are also changes in the blood flow patterns of the vasomotor system. When a person is vulnerable to a vascular headache, like a migraine headache, there is a characteristic pattern of changes in the size of the blood vessels that goes along with the headache. First the blood vessels in the skin constrict, typically in response to some sort of stress. The constriction of the blood vessels in the skin is a prodrome, an early warning phase. For some people this constriction also extends to the cranial arteries and interferes with blood flow to the brain, causing changes in visual perception or even nausea. These early symptoms indicate a classic migraine headache. About twenty minutes to half an hour later, the cranial arteries expand. That’s the point at which the person starts to report the headache.

When the cranial arteries expand, a series of biochemical changes occurs. The platelets, which are cells floating in the bloodstream, stick together and then release catecholamines into the bloodstream and the tissue. These chemicals are part of the body’s stress-response cycle. They in turn release other chemicals that lower the pain threshold, so the person becomes more sensitive to the perception of pain. The tissue becomes inflamed; this is a sterile inflammatory response similar to the inflammation caused by bacterial infection. That’s why people who have vascular headaches have very intense pain that can last for hours and sometimes even several days. The release of these biochemicals makes the pain more intense and inflames the tissue.

Once the headache forms, there are a number of factors that can make it continue over time. For example, worrying about the headache itself can cause dysregulation of the autonomic nervous system, which causes the muscle and blood flow changes that set up the whole pattern. Headaches can be conditioned, so the whole pathway can happen without the stress. People who keep diaries in the first year that they have headaches can usually identify an event that causes the headache about 70 percent of the time. If those same people keep diaries five years later, they can only identify events that caused 30 percent of their headaches. Ten years later, they can identify causes for less than 10 percent. The whole physiological response pattern becomes conditioned, and all the changes occur with very little provocation from an external event. People who have had headaches for five or ten years say they don’t know what causes them any more, they just happen, and in fact they do. That’s why we have to appreciate the role of learning in understanding these headaches.

One of the first things we do with a headache patient is to have him or her keep a daily diary. We find that for any given patient with a headache, there are usually from four to six factors, some more important than others. After several weeks of monitoring, we can identify the risk pattern for that individual. Then we recommend changes in the factors associated with the headache.

They keep a headache diary on a series of cards with a picture of a head. They can color in or use numbers to indicate the area where they have a headache. It shows the hours of the day, and has a rating of headache intensity from no headache to a very severe headache. Each hour of the day they have to give a rating of how intense the headache is. The diary of one of my patients showed that when she woke up in the morning she had a very excruciating headache. It went down somewhat during the day, and then at night it came back.

If a person keeps a daily diary like this for several weeks, you can usually identify a pattern specific to that person, but it’s not the same for everybody. So for that one patient, for example,  there are certain high-risk times, morning and night. Then we have to ask, why is the pain worse in the morning and the evening and not during the day?

Dalai Lama : In this case, is the patient working?

Daniel Brown : The patient is working. This particular patient is a mother, a single parent with three children who has to work and take care of these kids.

Dalai Lama: So during the day her mind probably just gets distracted as she just thinks about other things? Would that account for a decrease in the headache?

Daniel Brown : We looked at this for several weeks: every time she has the pain, she’s getting her children dressed and off to school, or fixing them breakfast or dinner. Almost every day you see the same pattern, so we’ve identified a high risk situation. The pain is the worst whenever she’s worried about getting her kids settled.

Dalai Lama : How is she spending her time right there in the midpoint of the day when the headache is the least?

Daniel Brown: She’s working.

Dalai Lama : And not thinking about her children?

Daniel Brown : That’s right. We wondered just as Your Holiness is wondering about it: what is the pattern?

Examples of typical physical causes of headaches are certain foods, including foods high in nitrites, and a variety of environmental factors, such as cigarette smoke or exhaust fumes from cars. Caffeine causes constriction of the blood vessels, and alcohol causes expansion of the blood vessels. If people use a lot of caffeine or alcohol, or both in combination, which is common, the blood vessels are constantly changing size, so they get less stable over time. In this case the person’s behavior makes the headache worse. Hunger and fasting lower blood sugar levels, which can trigger headaches in some individuals. Hormonal changes around menstruation cause headaches for some women. Exercise can be a factor, also sometimes oversleep. When people lie awake in bed in the morning, their breathing gets very shallow, which reduces the amount of oxygenated blood going to the brain. This can trigger the blood flow changes because the blood vessels in the brain open more to adjust for this.

Some individuals are sensitive to changes in the cardiovascular system that are caused by repressing their anger. This is a factor only for about 20 percent of all people with vascular headaches. Headaches that have to do with emotions are much less common than we used to think. Medication abuse is another possibility. Ergot, derived from a common bread mold, is a medication that causes the blood vessels to constrict, so it is used to stop headaches caused by expansion of the cranial arteries. But people get worried about the headache coming on and take the medication unnecessarily, which makes the blood vessels less stable, so the very treatment then becomes the cause of the illness.

The next phase of the treatment is to identify the pattern of muscles where the spasm is, and for this we use an electromyograph. A muscle that is active or spasmed gives off much more electrical activity than one that is relaxed. We use a scanner, simply touching the electrode to the head and scalp, to get a reading of the muscle activity involved in a particular headache pattern for a given individual. We need an objective way of finding out exactly the muscles involved, because people often perceive referred pain at a point different from where the muscle tension is.

After we identify the pattern, then we use biofeedback. We put the electrodes on a particular muscle, and when its activity is above a certain level, the machine makes a blipping noise. When the spontaneous activity of the muscle drops below that level, the noise stops. We ask the person to make the machine be quiet, which is another way of saying to decrease the muscle activity. After the individual learns to do this, we repeat the process, setting the machine to give feedback at progressively lower levels of muscle activity. It usually takes five to ten sessions to learn to reduce a muscle’s activity to normal, and we develop an individualized program to address each muscle that’s high for an individual.

Treatment of Chronic Pain

One man came to our laboratory with chronic pain that was caused by an injury but had lasted for four or five years and prevented him from working. The reading we took of this muscle was five microvolts. When we asked him to make the machine be quiet, it jumped up to almost ten. This person didn’t have any idea how to relax. He was trying very hard, which made him less relaxed, and it got much worse. We explained that you can’t try to relax, that relaxation means calming both the body and the mind, and it’s something that you have to let happen rather than make happen.

With some instruction, he began to become calm, and in the same session he was able to drop the muscle level down to three microvolts, learning voluntary control. In the next biofeedback session, he was able to drop it down to about two microvolts, and it continued dropping as he learned. At first, the muscle activity was still high when he came in and dropped during the session, but then gradually the learning became generalized. By the seventh or eighth session, the muscle activity remained low during the week. We also had him keep a daily record of the pain, rating it from zero to five, and then we averaged the ratings for each week. The average for the first week was about four, which means very intense pain. It decreased steadily so that by the eighth week his pain estimate was generally very mild. There were times during the week where it was still very high or low, but on the average it was much less. As he taught the muscles to relax, the pain perception also dropped.

When he felt confident enough to go back to work, the muscle activity level and the pain both increased sharply, because the work was stressful for him. But he was able to generalize what he had learned and apply it to the new situation. Two sessions later, he had taught the muscle to remain relaxed even in a high-stress situation, and the pain readings went down again. At follow-up sessions after three months and six months, there was no high muscle activity. The pain was relatively mild and eventually disappeared.

So far I’ve talked about teaching the patient to gain control over muscle activity, but that’s only half the problem. We also have to teach control over the blood flow patterns of the vasomotor response. We use thermometers on your fingers for this, because skin temperature is a function of the size of the blood vessels. When the blood vessels are open, the increased flow of warm blood raises the skin temperature. When the blood vessels are constricted, the temperature drops. The temperature is also related to stress, which causes the blood vessels to constrict. When a person is relaxed, the blood vessels open and the temperature goes up, so the temperature reading provides feedback. We ask people to see if they can make their hands get warm. They visualize warming their hands over an imaginary flame or a hot stove, or they imagine being out in the warm sunshine. After three to five minutes, they open their eyes to see if they’ve changed the temperature.

Visceral Learning: The Importance of Practice

In visceral learning, teaching the body a new physiological habit, the magnitude of the change is not as important as the consistency of practice. For the body to learn a new habit, doing a little bit each day is better than making a big change and then not doing anything for a few days. So we have people take the thermometers home and practice six times a day for three to five minutes. By producing a change of only two degrees, they become skilled at gaining voluntary control over the blood flow pattern, using the mind to control the body. Once they get skilled at doing this with the thermometers on the fingers of both hands, we then tape them to the hand. Then we move them to the wrist, and eventually they can change the temperature of the entire lower arm by one or two degrees. Once they can do that at will, we tape the thermometers on the toes, which are much harder to do, and then the feet. Gradually they learn to change the temperature of larger and larger surface areas of the body. The more skillful they become, the greater the likelihood for improvement of their headaches, because they’re gaining control over the whole blood flow pattern. Since headache is caused by a local dysregulation of the blood flow, this puts things back into balance. On the average it takes about twenty weeks. Some people are much quicker and some are slower, but most people can learn this.

The next thing we teach people is diaphragmatic breathing exercises. They learn to breathe in and out slowly with the hands on the abdomen, using the expansion of the hands as feedback. When they do this regular breathing for about twenty minutes a day, it causes a rapid uptake of catecholamines. These are chemicals involved in the stress response cycle, so that the breathing actually helps prevent the build up of the very things that inflamed the tissue. While they’re doing the breathing exercise, they focus on the movement of the diaphragm. If they do the breathing exercises while they actually have the headache, it makes it worse. Also, if they are shallow breathers, that can sometimes make it worse, so they have to be carefully instructed in the breathing exercises. If they do them correctly, over time it works preventatively so that the headaches become less frequent and less intense.

Discovering the Sequence of Symptoms

The first part of the treatment is getting rid of bad physiological habits and teaching the body healthier responses, using the techniques of muscle relaxation, blood flow change, and breathing exercises. The next part of the treatment is to work with the acute headache while the symptoms are actually present. We try to identify the behavioral chain leading up to the headache. We ask the person to identify the earliest symptom before he or she actually feels the intense pain. Over time, people learn to identify earlier and earlier symptoms. For example, they might first feel a little funny; then ten minutes later, they notice some nausea and visual changes. Five or ten minutes after that, they realize a headache is coming on. There is a point of recognition, and then the negative thoughts begin: “Oh no, this is going to be the worst headache ever. Here we go again. There’s nothing I’m going to be able to do about it.” The negative thoughts make it much worse, and at this point they feel a lot of pain.

After we construct the behavioral chain of events, we have them work out healthy strategies to cope with each step. When they start feeling a little funny, they remind themselves to practice relaxation; calming themselves may prevent the headache from happening. If they notice changes in the visual field and also nausea, that’s a good time to practice with the thermometers to voluntarily change the blood flow before the headache builds up. If they notice the negative thoughts coming, they can cut them off by reminding themselves of positive, confident things.

Coping Strategies to Counteract the Sequence of Symptoms

Finally, they practice pain coping strategies. We teach people ways of attending that alter the actual perception of pain. We find that people are very different in their abilities to alter pain perception. There are essentially four different approaches, and what works for one person may not work for another. Some people can use avoidance: distracting themselves, fantasizing, thinking about something other than the pain, or focusing on outside events. Some people can alleviate the pain by imagining their hand getting numb, and then transferring the numbness to d:e location of the pain, like a visualization on lack of sensation. A third approach is to directly alter the perception of the pain, focusing on the pain and imagining it as a tingling sensation or warmth rather than pain. A fourth approach is mindfulness: to simply place the awareness fully on the pain until it shifts. We teach people whatever method works best for them, using a neutral pain that isn’t an area of conflict for them, rather than the headache. We create the pain by simply pinching, and then assess different pain-coping strategies. Most people find one or two of these strategies will work for them, and then we apply them to alter the pain as they’re actually having it.

An example of the results can be seen with the mother of three children who had the headaches in the morning and evening. She engaged in a daily practice of calming the body in general, doing breathing exercises, and working specifically with the muscles and blood flow in the head. But her pattern of headaches didn’t change very much until about twenty weeks later-to the point where she didn’t have any more headaches, after thirteen years of daily headaches. We followed up, and she did not have a headache for six years, until she got pregnant. The headaches came back then, but went away when she practiced, and she has not had a headache since.

Dalai Lama: Wonderful. It worked.

Daniel Brown : So, this is a strong example of the learning, but it takes time to teach the body better habits.

Reducing Hypertension with Behavioral Medicine

We also use this same approach for treating hypertension, or high blood pressure. We start first by having people keep a diary of their blood pressure, which they measure three times a day, as a baseline. The steps in the treatment are general calming, followed by warming exercises, which are the most important part of the treatment: the hands, up the entire arm, and then the feet, for about twenty weeks. Patients use simple thermometers to measure the warming. We also do the breathing exercises. The treatment is similar to that for head. aches because hypertension also has a lot to do with blood flow patterns.

One person came in with a systolic blood pressure of 180, which is high, and diastolic blood pressure of 100, also quite high. We wanted to get his diastolic pressure down from about 100 to about 80. When he started keeping a baseline for six weeks, there was a small drop in blood pressure simply as a result of observing it; the mindfulness already caused some change. At the end of the twentieth week of training, his diastolic blood pressure dropped from 100 to 82, and the systolic pressure also went down to about 150. Now 150 may seem high, but this is a 70-year-old.

Many of these patients are on medications already. During the treatment, we do not ask them to change their medications at first. For many patients, the effects of the drugs and the behavioral training eventually combine, dropping the blood pressure too quickly. They start getting symptoms of postural hypotension, getting dizzy when they sit up too quickly. At that point, we cut back the drugs and let them use the mind instead. Whenever the diastolic blood pressure drops below an average of eighty for two weeks, we cut the medications by 20 percent. If the pressure stays down, two weeks later we’ll cut the medications by another 20 percent. If it goes back up, we’ll adjust the medications again. About one-third of the patients can drop below the goal of eighty in a stable way with no medications. Another third can achieve this with a reduction of medication, and for another third this treatment doesn’t work.

I chose the next example of a hypertensive patient for the benefit of our wonderful translators this week. This particular patient is an interpreter who works in the court system. This is a very stressful situation. He has to translate very accurately because his words are recorded into the legal record, and he always worries about getting it just right. During the self-monitoring, we identified that translating in court was the most important trigger that made his blood pressure rise. We taught him to practice, and the diastolic and systolic pressure dropped as a result. When he reached the goal of eighty, we then asked him to take the thermometers into the courtroom and practice during the free time. From then on he recorded his blood pressure only in this high-stress situation. Gradually he became skillful at lowering his blood pressure even in this most stressful situation. He’s been able to generalize the learning to a new situation, applying the new habit not only in a calm state but also in a high-stress situation.

For the person who practices very inconsistently, often skipping a couple of days, the results are choppy. You can see a large difference if people practice regularly. The consistency of the change is more important than the magnitude. For the body to learn a new habit, doing a little bit each day is better than making a big change and then not doing anything for a few days.

The Treatment of Asthama

Asthma is a condition in which the smooth muscle tissue lining the air passages contracts in a spasm. The air is trapped inside the bronchial passages, so the person has difficulty breathing out. Asthma may be chronic or acute. In the chronic condition, some of the smaller branches of the airway passages contract. It varies over time, sometimes more, sometimes less, but a person who is vulnerable to asthma will have some degree of contraction much of the time.

An acute asthma attack is more than contraction of the small air passages. The main large air passage contracts and causes such an obstruction of the airflow that the person can’t breathe, and it becomes a crisis. When we treat asthma behaviorally, we consider both the chronic small air spasm as well as the acute condition. We begin, again, with self-monitoring, teaching people to be aware when their air passages are more contracted and when they’re less contracted. Most people perceive this poorly, so we use a device called a peak flow meter, which measures how much air you can force out with effort in a short amount of time. The peak flow meter is accurate but not very expensive, so people can take them home and keep a diary to monitor themselves. Again, for the first two or three weeks, we have them record a baseline. Many asthmatics show improvement already during this time. Because they start to recognize their own patterns, they don’t worry so much in anticipation of an asthma attack. As they learn to accurately perceive the symptoms, the awareness training itself already has a beneficial effect.

That’s the first step. Then we teach them relaxation and peak flow biofeedback. They use the peak flow meter while they do special breathing exercises, visualizing forcing the air out gently. If they try too hard the spasm increases, but if they’re in a very relaxed state, they may be able to find just the right amount of effort so the bronchial spasm decreases and the reading goes up. They can teach themselves a certain breathing technique, which is often very individualized. They’re teaching themselves voluntary control over the smooth muscle response. This doesn’t work for asthma related to allergy and inflammation, but it is very effective for asthma related to stress symptoms.
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Part Five
The Nature of Awareness

Chapter 10
Mind, Brain, and Body in Dialogue
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Dalai Lama: Isn’t it the case that when you go down to the most elementary level, to elementary particles, for example, that the elementary particles one finds in the human brain are indistinguishable from the elementary particles you find in stone?

Franscisco Varela: The same, up to atoms and molecules.

Dalai Lama : As you move from the elementary-particle level up through atoms, molecules, and so forth, at what level do you start speaking of the emergence of awareness?

Franscisco Varela: Your Holiness, there is no consensus in neuroscience even as to what awareness is.

Dalai Lama : Coming from the level of elementary particles on up, at what point do you find evidence for the presence of awareness?

Franscisco Varela: This is something people have done research on. Evidently, everybody accepts that humans have awareness.

Dalai Lama : When many particles join together, they become lifelike, don’t they? There are two categories, plants and animals, and both have life. But one category of organisms developed awareness, and the other did not. What’s the main cause for this, and at what stage does it occur?

Franscisco Varela: The classical answer, and I think a very good answer, is that cognition or awareness (whatever it may be) is an emergent property of a specific pattern, or aggregation, or systemic configuration, which requires a nervous system. It requires sensory and motor devices and interneurons. Plants never developed nervous systems, but animals did. The nervous system then evolved and created different capacities for cognition. At one point, something happened-that’s the big debate-that made humans aware. Most people would agree there is awareness and also compassion in some animals, such as the great apes or dolphins.

Dalai Lama : I feel your usage of the term awareness is a bit too lofty, because we all certainly agree that a lot of other animals are conscious in some sense of the term, maybe even going down to the hydra.

Franscisco Varela: Yes, but you cannot say they are conscious of themselves.

Dalai Lama : I’m not referring to consciousness of themselves, but rather awareness in any sense of the term. Animals are sentient beings in that they feel, they experience.

Franscisco Varela: I’m sorry. Whenever you use the word aware in the neuroscientific context, it has the connotation of self-awareness. You could use the term cognition or perception and everyone would agree that animals with nervous systems have a form of cognition. Many people would even say that unicellular animals like the ameba have a very primitive form of cognition.

Dalai Lama: But plants don’t?

Franscisco Varela: No. The main difference, Your Holiness, has to do with a sensorimotor correlation, so there must be some possibility of motion. In behavior, this is a key element that allows us to recognize cognition. Since amoebas can move around and search for their food, they are very different from a plant that receives it passively. Being able to move around creates the possibility of a nervous system. Beyond that, it’s difficult to say where it begins or ends. For example, the sum of the B- and T-cells could be said to have a very minor form of cognition, knowledge, and also stimulation.

Dalai Lama : So, when you were saying some scientists agree great apes also had awareness, you meant self awareness similar to humans.

Franscisco Varela: Yes, a form of self-reflection that might be similar to our own experience. This probably would not be the case for a cat, or less so, and even less for an ameba.

Emotions Triggered by Thoughts

Cliff Saron: Your Holiness, we’ve talked about internal causes and external causes of emotion, but what movement of mind specifically triggers an emotion?

Dalai Lama : It is difficult to say. One can ask first of all whether emotions exist in the mind of an arhat, a liberated being, or in a buddha who is free of all obscurations. If one includes things like loving kindness and compassion as emotions, then the answer has to be yes, those are present in the mind of a highly enlightened being. So you can’t say, for example, that egotism is a necessary cause in the arising of emotions, because enlightened beings don’t have egotism, but they do have emotion. A sense of self is not necessarily deluded, as egotism is, so enlightened beings may have a nondeluded sense of self. But it’s an open question whether that triggers emotion, or whether emotion is simply in the nature of awareness itself, or whether it’s triggered by the apprehension of a specific object.

There are different levels of consciousness. On the one hand, there is a level of consciousness that is very directly contingent on the body. For example, there are cases in which a physical dysfunction, such as an imbalance in the body, is the chief cause for mental distortion such as craving.

Now, if you look at sensory perception, Buddhist psychology speaks of three types of contributing causes, which together give rise to the continuum of sensory awareness. For example, in visual perception, the first cause, known as the dominant condition, is the physical visual faculty. Second, there’s the referential condition, which is the external stimulus. The third cause, called the immediate condition, is the immediately preceding event of clarity or the knowing quality in the sensory perception. This event of clarity also has its contributing causes, and its immediate cause is the preceding moment of perception. So, one of the three conditions is cognitive, this preceding moment of perception.

From experience, it’s certainly true that you can be sitting very quietly with no particular stimulus coming in, when a thought arises and causes you to be startled or jump, or have some kind of physical reaction. It seems that first of all there is a subjective cognitive event, which then acts as the cause for the physical, and not vice versa. Then, of course, it can also happen that activity within the body enhances that emotion, and it can also modify or change the emotion. It is common experience that awareness seems, by its nature, to be vacillating or fluctuating. It seems to be oscillating even faster than ten cycles per second. [laughter] Now, in meditation, the cultivation of mindfulness serves to contain one’s awareness and dampens the vacillations so the awareness or attention can become stable. If this is the case, it would seem that the very nature of awareness has been changed by freshly introducing this purely subjective mental means, namely the cultivation of mindfulness. It seems plausible that this in itself would also bring about changes in the brain and in the body as a whole.

Franscisco Varela: In that case, does the emotional state cause the vacillation in awareness?

Dalai Lama : In terms of causal sequence, you first of all have the basic contact, then you have the actual cognition, and this induces the emotion.

Franscisco Varela: So the emotion comes after the ascertainment. What about the situation when, for example, we suddenly hear a sound, a crack, and the attention changes? It seems we first have some kind of alert, panic, fear-an emotional state-and only after that, we realize that the roof is about to fall. Doesn’t the emotion precede the ascertainment in this case?

Dalai Lama : If you did a very precise momentary analysis, it seems you would find some cognition of something happening there. You hear an anomalous sound, even if you haven’t identified it as the roof collapsing, and this incites the emotion. Then comes the more detailed awareness of what’s going on. It’s a matter of complexity: you do apprehend the sound, but only later do you know what it might mean.

Franscisco Varela: How would you analyze the situation at the other extreme, when there is no particular event? You are just sitting there, or walking, when a change of mood occurs. All of a sudden you feel lonely, or maybe depressed, or happy, or whatever. What would be the contributing cause for that emotion shift?

Dalai Lama : It may be thoroughly internal, or it may be very subtly externally induced. On the one hand, we have accustomed ourselves to certain habits of conceptualization that build up predilections. So, even in the absence of any explicit external stimuli, the force of your previous habituation may give rise to a seemingly spontaneous shift of mood. Another possibility is that the environment may have some very subtle quality that arouses this emotion. It could be subtly pleasant or have some kind of faintly depressing quality to it, even though you may not consciously be aware of it.

On my first visit to Moscow, my mental function was very dull. Other Tibetan lamas who visited that area have described a similar experience of unprecedented emotion during their daily prayers. Of course, it might have been because breakfast was very late that morning. [laughter] But unfortunately in that area, there has been so much killing, so much negative human emotion. In that situation, even though there’s nothing manifest or evident that you’re conscious of, the effect can still be there. You can translate it roughly as gloom, but literally it means something that obscures, or veils, or clouds [Tib.: sgrib pa]. Likewise, Tibetan practitioners who remain in the mountains can usually predict when somebody is about to come, either the next day or later in the evening. This definitely happens, so there’s some influence from the environment, whether negative or positive, even though it’s not a conscious stimulus.

Daniel Brown : Some Western theories of emotion also talk about different levels of information processing.They may not agree on whether the cognition takes place on a pre attentive level, before it is conscious, or after conscious recognition when the thought is more elaborated. But there’s a common assumption, as in the Tibetan tradition, that there is always some cognition involved.

Daniel Goleman: A study done by Richard Davidson throws some light on repression and brain function. You know that the right side of the body is controlled by the left side of the brain, and vice versa. That’s true also for what you see, so if you divide what comes into each eye into a left side and right side, what comes into the right side goes to the left side of the brain and what comes into the left side goes to the right side of the brain. In this study, they used a device to show a word to one side of the brain or the other side. Words shown to the right side go into the left side of the brain, where the center that controls speech is located. On the right side of the brain, as Cliff told us, is the center for negative emotion. This means that if the word you see on the right side is upsetting to you, the information about what that word is goes first to the left side of the brain and then to the right, where the emotional reaction occurs. They were able to measure the exact time lag between activity on the left and right sides, and a very interesting thing happened. With a neutral word like glass there was no difference between the repressors and the other people. With a very disturbing word such as kill there was a noticeable increase for repressors in the time that information took to get across from one side to the other. This may mean that somewhere in the brain there’s something like a censor that says, “You can’t print that; you can’t know that.” So it may be true that repressors actually do not experience what they are denying.

Dalai Lama: What happens if you show that same word to the left side of the eye?

Cliff Saron: It would project from the left visual field to the right side of the brain. These were right-handed people whose speech apparatus is presumably controlled by regions of the left side of the brain, so in order for them to speak, the information would have to transfer from the right side to the left side.

Dalai Lama : How about a pleasant word? Is that the same as a neutral word in terms of the speed with which it goes from right to left?

Daniel Goleman: I don’t believe there were differences between pleasant words and neutral words. The finding of the study was that neutral words, when presented directly to the left side of the brain, produced a certain speed of response that was not different from that of pleasant words, but unpleasant words presented to the right side of the brain were slower than pleasant words.

Cliff Saron: The idea was that this censor decreased the transfer of negative emotional information from the right to the left side of the brain, where we are allowed to speak the response.

Daniel Goleman: I don’t know if we can say where the censor is located, if anywhere.

Cliff Saron: The test was a free-association test: you see a word and you have to say the first word that comes to your mind. The measurement that we’re taking is not an electrical measurement of the brain but of how long it takes to speak. It’s the reaction time.

Dalai Lama : For instance, if a neutral word is shown on your left, it goes to the right side.

Cliff Saron: That’s right. It will always take a little longer for a word that goes to the left visual field to be spoken.

Franscisco Varela: If there is always a reaction time, why should one speak of censorship? Strictly speaking, it would be more like a sluggishness than a censorship.

Cliff Saron: There’s a gate. It takes time to go over, or to lift it up.

Daniel Goleman: You could say there’s just more processing going on for unpleasant words than for pleasant words. We don’t exactly know more than that.

Bob Livingston: His Holiness may be interested to know that all of us have some degree of censorship operating on seeing words and pictures, and I’ll give two examples. A combination of words like hero and fame are seen very quickly, with a short reaction time. A combination like lady and slut takes about four times as long to read in milliseconds. This is true for all of us in a normal population. If you ask a person to identify what he or she sees in a picture, it makes a great difference whether it’s a pleasant picture or one that gives rise to negative feelings. If you show four pictures in a group and ask people to tell you as soon as they can identify any of them, they see the positive pictures very quickly. But it may take a whole second to be able to see a negative picture. This is an operation that occurs before awareness.

Daniel Goleman: Since you’re interested, I’ll tell you about another study. When you focus or look at something, the eye makes tiny little movements. Ophthalmologists have a device that allows them to track the eye’s movements exactly., without interfering with what you see. When people who were known to be very anxious looked at a picture that had both unpleasant and neutral sections, the eye would go only to the neutral area. It wouldn’t even look at the unpleasant area. When asked what was in the picture, they would describe all the pleasant things, but have no memory of the unpleasant things. We don’t know exactly how that happens, but it suggests again that prior to full awareness, part of the brain can know what’s going on and guide perception away from something unpleasant.

Dalai Lama : From a Buddhist point of view, the question would be whether the person hasn’t seen that image or cannot recall it. It might be that the person has visually seen it, but because he or she hasn’t paid enough attention to that particular section, the person hasn’t made the connection. So, at the sensory level, there is no judgment involved.

Daniel Goleman: This is the point. Sometimes it’s true that the person doesn’t see it at all. That’s what they could tell with this device. Other times they may see it, but they don’t recall it.

Dalai Lama : How can you tell the difference?

Jon Kabat-Zinn: In point of fact, the experiment is showing you that they do see it. If the eye-tracking movements did not censor, they would distribute over the whole field. In this case, you’re finding that these people’s eyes are selecting for the pleasant, which tells you they have to have seen it.

Daniel Goleman: That’s the next point.

Cliff Saron: There is a point of clarification I could make, Your Holiness. The device that’s used tracks the center of vision, the very small area of the clearest vision. But you also see information with your peripheral vision, which informs you very consciously not to move in that direction.

Sensory Perception and Consciousness

Franscisco Varela: It’s also fair to say there is an enormous amount of judgment made at what we call very low-level vision, even at the level of the eye or just the retina. For example, already in the retina you can determine where there is an edge and where there is none, before it’s a fully configured object, for example. You won’t know whether it is a glass or a microphone, but if there is an edge in your visual field, that is already an important decision made in a few milliseconds. That’s very important from the neuroscientific point of view. The building-up of the full visual field happens at many stages. What is low can be very elaborate, with a lot of judgment, construction, and interpretation involved, even way before awareness.

Dalai Lama : Before the information even reaches the brain?

Franscisco Varela: The image that goes out from the optic nerve is not the raw set of light that has come onto the retina. It’s already extremely textured and elaborated before it reaches the central brain.

Dalai Lama : But isn’t the position of modern neuroscience that it’s not actually the eye but the brain that sees?

Franscisco Varela: It is neither the brain nor the eye, but the fact that the two of them are working together. As much as there is activity going up from the eye to the brain, there is activity going down from brain out toward the senses. There is as much of what we call the central control of sensory afference as there is of the sensory afference that goes into the brain. It is the coming together of these two things that makes vision, so it is neither in the eye nor in the brain. It’s everywhere; it’s an emerging property.

Dalai Lama : The question is whether there is a possibility of judgment within visual perception, independent of mental perception. There seems to be some uncertainty as to whether this is asserted in the Prasangika system, which we regard as the most sophisticated philosophical system in Buddhism. What is certain, from the Prasangika perspective, is that the appearances to the various senses are already tainted by the influence or latent propensity of one’s previous ignorance, grasping onto existence as true. Appearances certainly do affect the various senses, and these senses are not mental awareness. But it remains an open question whether, in terms of their actual mode of apprehending objects, the various senses are in any way modified by judgment.

Franscisco Varela: The neuroscientific point of view would say, absolutely, that they are. When you touch your skin, for example, the activity of the receptor that feels is under direct control of the upper brain. The brain regulates what constitutes data. For a neuroscientist, what counts as information coming from the senses is always a two-way affair: both the impact of my finger, and the control of the receptor that interprets the impact. Even at that low level, beyond the point of sensory impact, there is an enormous amount of treatment of this activity.! For example, in the retina, what goes out from the optic nerve is not just the activity of the receptor. If we could compare images of receptor activity and nerve activity, the two would look very different. Edges and demarcations of textures and surfaces would already appear at this level.

Alan Wallace: Are you saying that even very primitive visual awareness is conditioned by previous experienced.

Franscisco Varela: Some low-level treatment is not even dependent on previous experience, it’s just wired in.

Cliff Saron: It’s a function of the way the cells are connected.

Franscisco Varela: For example, when you look at the optic nerve in the retina of a frog, you see activity that pertains only to things that count as flies. You don’t see these “fly detectors” in the retina of humans or monkeys.

Dalai Lama : If, for example, you’re suddenly burned, and the limb naturally contracts very rapidly, and pulls away from the source of heat, is this immediate reaction connected to the brain or is it not?

Franscisco Varela: Both are true. If the connection to the brain is cut and your leg is burned, it will still contract, because that’s a low-level reflex. It is also true that the low-level reflex is normally under modulation of the higher centers, so that if you are burned, the low-level reflex overrides the higher control. Afterward, the higher control can say, “You’re exaggerating, it wasn’t that bad.” There are levels of interdependence, and different levels are more important at different points on a continuum. Immediately on burning, the low-level reflex takes over; the higher centers take over in normal activity such as walking. At the opposite extreme of the continuum is the artist walking on a tightrope in a circus, who performs a creative act in using higher levels to resist the very strong tendencies of the low-level reflexes.

Whatever counts as a perception is not really localized, but is in fact a collective affair with everybody doing their part. That’s very important in neuroscience. By and large, the brain works as a distributive device. We speak about localization only because when you damage a location, you stop a function, and not because it works right there and only there. It’s a common mistake; the language we use to describe this reduces it to something that isn’t true.
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Chapter 11
Subtleties of Consciousness
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Brain Activity and Meditative States

Dalai Lama : Has there been any research done on [brain activity of] people who are practicing samatha, or meditative quiescence?

Daniel Goleman: There are not yet very good studies of brain activity during a state of one-pointed concentration. There are, however, some good studies of the effects of vipassana practice. In general, they find that the calming practices turn out to be very calming physiologically. The heart rate and breath rate slow down. The body’s metabolism slows down.

Daniel Brown: From the perspective of brain activity, we don’t know what happens to emotions during calming meditation practice. I have done some studies where people report verbally on their subjective sense of what happens. We devised questionnaires and looked at how people’s responses to the same questions changed over time as they gained experience with meditation. One of the things that clearly changes is the skill at attention and awareness. People find that despite internal changes in their state, they can still maintain a steadiness of awareness. The other thing that became very clear was that people developed flexibility; when they experienced some distraction, they could bring their mind back more easily. We found that emotions continued to occur. People reported the emotion with greater intensity, but let it remain in their awareness without reacting to it as much. We looked at the reactivity on two levels: on a gross level of evaluative thoughts, such as negative judgments about what was happening, and on the more subtle level of aversion and clinging. On both levels they had less reactivity, and yet the feeling was still very present in their awareness, often with even greater intensity. The subjects were skilled mediators from a Western perspective, but not with the level of experience that you would find represented in the Tibetan Buddhist tradition, where people meditate much more intensively over many more years. We don’t know what happens to emotions in people who are very advanced in meditation.

Daniel Goleman: In another study on concentration, it was found that when people concentrated very hard the brain became quieter, with less activity.

Dalai Lama: What about the case of people who are normally quite dull? Is it possible to do comparative research on the brain activity of people who are mentally dull and those who are very bright and have trained the mind to a very concentrated state?

Cliff Saron: There have been some studies of brain activity in experts who are extremely proficient at a particular task, as well as novices who are not very good at a task. The experiments show that the brain uses more energy in the case of novices, and for experts the brain seems to operate more efficiently in metabolic terms, measured as the amount of glucose the brain needs. But the whole idea of activity is a very complicated issue because of the tremendous complexity of the brain and the different ways the neural tissue can function.

Daniel Goleman: But there is a general principle that the skilled brain, whether it’s a meditator or chess player, uses less energy to do a better job.

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