Saturday, February 5, 2022

Mental Immunity

I read The Book of Joy by Dalai Lama and Desmond Tutu and I am currently reading Daniel Kahneman Thinking, Fast and Slow. A common theme emerged among the two books that impacted my own views and perspective. Specifically, I've come to develop my higher levels of control through practicing mindfulness through meditation, which then allows me to regulate my emotional range and mental well-being.

More so in the past, and especially during residency, fellowship and early years of clinical practice, the successes and failures impacted me significantly. When I decided to switch from urology residency to radiology residency, I had major doubts about myself, confidence, and competence which created a fiery amount of stress and pressure to work harder, be better, and to "succeed". When I got rejected by the first several grants, I got down and discouraged. Eventually, I came to secure successes with clinical excellence, papers, grants and awards. With each success, I got elated, excited and encouraged. The ebb and flow of career (and perhaps personal) life feels like riding the hamster wheel. It felt like a trap, a dungeon of sorts, being influenced by the successes and failures of my efforts, and being like a boat in the open waters, controlled by the tides.

Over the past year, I came to learn a Buddhist teaching about the value of staying calm and still. Instead of letting mental well-being depend on the pendulum swings of various challenges we face and successes we achieve, we practice control of our natural emotions. By doing so, we can graciously accept both our success and failures equally, recognize the merit in both with the same amount of respect and thought. We no longer suffer disappointment with failure nor do we live with the highs of our success. Instead, we treat both as equal, stay unperturbed and adjust our course as needed.

In the Book of Joy, the Dalai Lama describes "Mental Immunity" which is controlled by our higher level thinking. In Kahneman's idea of fast and slow thinking, he defined systems 1 and 2, and the latter (system 2) can support the Dalai Lama’s idea of mental immunity. System 1 is our automatic, subconscious, intuitive mental state, controlled by our limbic system brain…our “fight or flight” system. Some refer to system 1 as the “lizard brain” and reacts unconsciously to things like threat and other intense emotional states. For example, if you see the tiger, your system 1 will kick in automatically and you’ll react. System 1 is flawed and has many pitfalls in our lives. For example, if you get a nasty email with degrading words from a colleague, system 1 will kick in and we may respond in ways that we may regret later if we don’t override our natural tendencies. In contrast, System 2 makes up our higher level, conscious thought, and is regulated by the prefrontal cortex. In the email example, we may decide to wait 1 day to let the emotions subside so that we can let system 2 think through the best way to respond and ensure we preserve good relationships. Perhaps, we decide to meet the individual in person or talk over the phone instead of an email response to resolve the concerns. The emotional center, our amygdala, is like the traffic control and supports our emotional reactions or responses to events and signals.  We can strengthen the signals and tracks that connect our amygdala to prefrontal cortex (higher level thinking) and limbic system (fight or flight thinking). 
The Dalai Lama draws an analogy of physical well-being to mental well-being, and coined the term “mental immunity”. We develop good habits (eating well, exercising, sleeping, etc) to be physically healthy, to boost our physical immunity to fight off colds, sickness and feel good. In the same way, he urges us to develop mental immunity, practicing our mental state to develop and focus on attention and concentration through meditation, so that we can develop mental immunity to struggles we will encounter. The mental immunity refers to system 2, our higher level control center of mindfulness. Activation of system 2 requires focused attention, concentration which ultimately yield mindfulness and awareness. Mindfulness is defined by two components: attention and concentration. When we have mindfulness, we can pause, reign in our intuitive and natural tendencies, and redirect our attention and concentration to the productive path, free of emotional swings. Practicing mindfulness through meditation allows us to strengthen our ability to access and control system 2.

We have different intrinsic ability to control our mental state, system 2, and more importantly we can develop this ability through practice. The famous Stanford Marshmallow test of a bunch of 5 year old kids illustrated our intrinsic ability to control our behavior. Each kid was put into an empty, boring, white, and bland room with a marshmallow on a plate, placed on the table. The rest of the room remains void of toys, or any other attention seeking play things (e.g. iPad). The kids were told to either wait 5 minutes and get 2x marshmallows, or eat 1 marshmallow within 5 min. In a series of hilarious and cute videos (check out YouTube) of little kids doing various maneuvers to delay gratification for a bigger reward (e.g. licking the marshmallow without eating it, and distracting themselves), we see something more profound emerge decades later. The minority of the kids who successfully delayed the 5-min collectively achieved higher level education, higher pay and higher successes than the majority, who failed the marshmallow test, and gave into their system 1 natural tendency to eat the sweet and delicious marshmallow immediately. More importantly, and the key message of the study was the 2nd phase of the study. The research team taught kids mental hacks to help redirect their attention, and practiced these exercises with the kids. In subsequent studies, the kids who received the attention training did significantly better in all the measures compared to their baseline. Nowadays, this study has major implications on the attention of kids growing up with iPads and uncontrolled access to YouTube, where their attention and concentration is drawn to most attention-seeking videos often displaying behaviors that taps into our natural, hard to control tendencies (system 1).

Our ability to control our attention and direct our concentration is the engine that drives our mental well-being. We have baseline levels of control we are born with, and we can cultivate the control through practice. Mindfulness is housed in System 2, and can be easily hijacked by system 1. For example, if something disastrous happens (e.g. our child was in an accident, or fall in love), then we can no longer think coherently and rationally. Our system 2 (higher level thinking) malfunctions due to a tremendous amount of signal from system 1 (lizard brain), suppressing any ability of system 2 to regain control. In the same way, extreme and intense emotional experiences (e.g. anger, depression, love) can make us vulnerable and lead us to make poor choices, say unintended words, entertain terrible thoughts and take regrettable actions. 

Acknowledging this Achilles heel common to all of us, how do we protect ourselves? How do we strengthen system 2 (higher level of thought) and protect it from being hijacked? A simple and easy way is to practice meditation. Meditation consists of putting our attention on a fixed object, and then concentrating on that object over a period of time. A timeless fixed object is our breath. The advantages of the breadth is that it's accessible, and always with us. Others focus on the heart beat, the ticking clock, the feel of the air on your skin, etc. You can also focus on things beyond our senses too, like loving kindness, empathy, compassion. The basic concept is to sit, cross your feet, close your eyes, and set your attention on something (e.g. your breath) and sustain it (concentration). Meditating is like running, remember to keep your expectations appropriate to your level to avoid being discouraged. With time and practice, we can develop our stamina and gain benefits from this exercise. The endurance, speed and stamina will develop over years, not hours. We know meditation works. After 6 weeks of practiced meditation, functional MRI studies demonstrate both increased activity AND volume in important brain centers like the amygdala (our emotional traffic control center).

The benefits of practicing mindfulness are subconscious, and not apparent to conscious mind. When I lift weights, I can feel the muscle pain after a work-out; however, we do not have the same sensory receptors in our brain, so we do not have the same tangible bodily sensation after meditation. I started meditating during residency. I was studying for the radiology boards, and my stress was 11/10. I came across the book, The Art of Learning by Josh Waiskin. His thoughts of performance resonated with me, and I found out that he's a devout meditator. He and other other high performers like Ray Daylio, Steve Jobs, John Lennon, all regularly meditated. Even though Buddha vehemently advocated for us to meditate, the activity in itself is free of religious connotation. I started meditating for 1 minute. Meditation is.the.most.underwhelming activity for a novice. I am accustomed to the feeling of getting things done. Meditation did not give me that rewarding feeling. I guess if you want to know if meditation is working, you can get a functional MRI exam before and over time like the Hopkin group did when they studied the effects of meditation. In addition, meditating is really hard. Keeping my attention on my breath for a period of time took practice. Thoughts, to-do lists, ideas floated into my head. When distraction happens to you, remember that meditation benefits the most distracted minds (that's me, you, and everyone like us). Guided meditation, for example offered through Headspace app, is another way to get into meditation. Headspace is a good app. After a while, I abandoned the app and was able to practice on my own, no longer needing to put the extra steps to find my phone, and turn on the app.

Since starting to meditate about 7 years ago, I can now practice meditation for about 20-30 min everyday. To give you a comparison, the Dalai Lama meditates for 5 hours every day, the first thing in the morning. He wakes up very early (like 3 or 4 am), and meditates till 8 or 9 am (read his Joy's amazing). I've benefited significantly from the positive impact of meditation and would argue the inflection point in my life and career occurred after starting this habit. The slope was gradual and very subtle but over the past 7 years, the trajectory has been striking.

Just as we have different levels of running (5k, 10k, half marathoners, marathoners, ultrathoners, etc), I came to realize there are increasing levels of mindfulness. In Indian and Buddhist traditions, "Samadhi" refers to the highest of the 3 states of self-collectiveness, a luminous mind which is "equanimous and mindful". The first stage is Dharana, being able to hold your attention on an object over long periods of time free of distraction. For example, being able to focus on the breath. The second stage, Dhyanam, occurs when there begins to be a relationship between the mind and the object of attention. You gain insights about yourself from concentrating on the object. For example, by meditating about loving kindness, you gain insights about your ability to process these experiences. The third and final stage is Samadhi. With Samadhi, you and the object become very close, as if they have merged. At that point, the mind sheds its conditioning and the object shines forth as it is. For example, if you meditate about loving kindness in the state of Samadhi, you take on the qualities of loving kindness. At this point, we can see things for what it is (neither good nor bad) and see ourselves for who we are. Ultimately, meditation is about removing our conscious and unconscious biases, and refining our perception like wiping of the dust surrounding a transparent crystal (reference

Regarding Mental Immunity and the pendulum of emotions, what we know is that through practiced mindfulness, we develop our system 2 (self control, emotional regulation, etc), and can develop a mental immunity, of sorts, to the fluctuations of life, and reign in our system 1 (natural, automatic, reactive tendencies). We can narrow the swings of the pendulum a little bit over time and develop our higher order systems (calm ourselves), and rise above these struggles, and recognize them for what they are, rather than become emotionally linked and reacting to them (which we naturally do due to system 1). All of this feels unnatural and takes conscious effort. Eventually, we recognize failures and success as equals, and stay level headed and calm, like the stillness under the surface of the ocean during a thunderstorm. Major struggles no longer cause us emotional harm, and major wins no longer make us elated and high. We remain grounded, at peace, and immune.

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