Topics

A Woman's Heart
Assertion-Saying "No"
Behavior/Time Pressure
Commitment and Self-Regulation
Depression
First Year of Recovery
Hostility/Cynicism
Impatience
Loss and Heart Disease
Maintaining Perspective
Need for Approval
Personality
Positive Emotions
Positive Thinking
Stress Part I
Stress Part II
Support VS. Isolation

Topic: A Woman's Heart

A Woman's Heart
With the help of scientists around the world we've made remarkable progress in understanding and treating a leading health threat - heart disease. Dramatic improvements in diagnostic testing, treatment, and recovery means that every day thousands and thousands of lives are saved. Unfortunately, for a very long time we failed to realize the impact of heart disease on women's health...

Until Now...
Now we know that each year heart disease kills more women than men and that women's rate of survival in the year following a heart attack is about half that of men. We've learned that women are often diagnosed and treated less aggressively than men (e.g., fewer diagnostic tests performed; cholesterol lowering drugs prescribed less often), significantly increasing a woman's chance of death. We've learned that women themselves may limit the opportunity for needed care when they wait longer to get medical help than men do once they begin to feel troubling physical symptoms. We've learned that blood pressure lowering medications may be less effective for women than they are for men.

When in a Woman's Life Might These Factors Become Significant?
It has been widely accepted that women were more likely to experience the affects of heart disease much later in life than the average male. This may be due to the protection afforded by the availability of certain hormones. Women were not expected to begin to show signs of disease until about age 70 and beyond. A woman's age may complicate medical procedures and outcome due to a lack of good health and vigor. Very recently, a study published in the Journal of Women's Health reiterates that women's risk of heart disease is lower than men's during middle age, but - women apparently catch up to men earlier than was previously thought. Instead of 70, it seems that women are likely to begin showing signs of heart disease by the age of 60. Whether 60's or 70's or later, the death rate from heart disease continues to be greater for women than for men.

More Differences...
Women's and men's symptoms of heart disease may be different. (Please ask you physician or cardiologist about this.)

Using traditional methods for diagnosing cardiovascular disease may mean not detecting disease at all in a woman. Apparently women may suffer from microvascular disease - that is, a narrowing of small vessels that is serious enough to limit amounts of oxygen to a woman's heart, but so small that it may not show up on an angiogram - a commonly used test to measure blood flow.

Women's blood vessels are smaller than a man's and small size may mean fewer treatment options when disease is present.

Psychosocial Factors Play a Major Role for Women. Here's Why...
Psychosocial factors may be the area where men and women differ most. What seems to cause the greatest amount of stress in a woman's life are relationships with others - loved ones, friends, co-workers. Social connections often mean constant demands on a woman's time and energy. Women are often less assertive or confident than men. They may avoid speaking up and saying, "no" or asking for what it is they need. Women worry that they're not doing all they can do. They often feel a great deal of guilt related to not getting the job done (too much to do) and not really being able to do it well (too little time).

More Factors...

• When women see heart disease as a threat - and they do - they tend to see it as a threat to others - not themselves.
• Depression is a risk for heart disease and women are twice as likely as men to experience depression at some time in their lives.
• Women, especially those in their 50's and 60's are often the primary caregiver to aging, sometimes ill, parents - a stressful role.
• Women experiencing mild to moderate depression are 50% more likely to die of a heart attack than non-depressed women.
• Women tend to take care of themselves only after they've met the needs of others.
• As "nurturers" women tend to feel "selfish" when taking time for themselves.
• Women's roles are many. Too many roles, too many varying responsibilities may lead to "vital exhaustion" - a possible precursor to heart attack.
• Women may be stoic and tend to downplay symptoms associated with heart disease.
• Insufficient time for self-care may mean no time for exercise, a loss of fitness, increased weight, and negative changes in metabolic function.
• Women's lives are often more similar to "middle-management" than "CEO" - a lot of responsibility with little control - increasing the likelihood of developing heart disease.
• Women may experience "anger-in" - that is, an outward appearance of cooperation with an inward feeling of resentment. Anger in any form may have a damaging effect on cardiovascular structure and function.
• Women tend to drop out of cardiac rehabilitation at higher rates than men.
• Women, in general, are less frequently referred to rehab and may not be referred at older ages even though they may benefit in a significant way from a program of exercise.
• Divorced women are more prone to cardiac illness than divorced men. This may in part be due to a reduction in women's economic and social status following divorce.

Women Talk…But Mainly to Each Other...
When women join together to talk about heart disease, interesting comments can be heard. Here are a few I've recorded in group sessions:

"I'm afraid to ask questions. The doctor will think I'm a baby."

"Our culture beats us down at a certain age. Society backs off - so I have to make sure I do what I want to do. I try to tell my doctor I don't want to talk about poor health. I want to talk about wellness."

"I asked my doctor, "What's the difference between an Echo and an EKG?" and he said, "Oh, Marsha, don't overthink!"

"If they see you face-to-face they'll see you as vibrant and give you better care." (75-year old woman discussing getting less aggressive care due to her age)

"Women tend to be less assertive. It's gender as well as age."

"Information is healing. I want the doctor to give me more information. If they explain what happened when you're in the hospital, you don't understand because you're still confused."

"I was complaining of shortness of breath. They kept telling me it was something else - it can't be my heart. Just because I'm less than 50 and female doesn't mean it couldn't be my heart". (Woman in cardiac rehabilitation program after myocardial infarction)

It's Up To You!

TheGoodheart wants you to begin to take action when it comes to your heart health.

During the next two weeks, take a life inventory.

Record each time you exercise - what did you do and for how long?(Current guidelines suggest 5-6 times weekly, moderate to brisk - consult with your doctor about what's right for you).

Monitor stress - what troubles you most? Are you irritable? Hostile? (Try to change the way you perceive what stresses you most or eliminate or avoid the stressful trigger).

What did you do to nurture yourself? (Build in time each day to do something that is health-promoting).

Now that we see that the medical profession is paying more attention to the health of a woman's heart, please don't assume that your caregivers will think of everything. Be a wise consumer. When you go to the doctor bring your list of questions. You're less likely to forget what it is you want to know if it's written down.

When you're unsure about any test results you've been given, ask questions. "It looks as though I'm out of range on this measure. What does that mean?" "How did my tests compare this time to those I took six months ago?" "Is it necessary for me to continue taking this medication now that my blood pressure is lower?" "Since I'm having these feelings, should I have another stress test?"

When you're not feeling well, let your doctor know. He or she cannot read your mind. If you're feeling depressed, please don't take this lightly. Treatment can be very successful and it might save your heart. If you don't tell your doctor, he may never know.

If it's hard for you to assert yourself with your doctor - maybe you feel inadequate in some way or you think he'll think you're being a pest - ask yourself - what's more important, your health or the impression you make on the doctor and whether or not he likes you? You're not visiting the doctor so that he'll like you. You're seeing him so that he can monitor your health, treat you when necessary, and collaborate with you as you give each other information and ask each other questions.

If you're a woman with cardiac risk factors (e.g., age, heredity, obesity, smoking, job strain, etc.) do all that you can to educate yourself about women and heart disease. As the woman said, "Information is healing." It may also be life saving!

Please let us hear from you at The Message Board. We would love to get your feedback, answer your questions, and share your concerns with other Goodheart readers. Have a heart healthy month!



---Austen Hayes, PhD

Topic: Assertion-Saying "No"

"Real" Stories from a Cardiac Support Group...

Your sister asks you to visit. You always enjoy time spent with your sister, but you've traveled to see her three times this year and she lives a thousand miles away. You respond gently, politely, "No... I can't, I have to work", or, "I can't afford it right now", or, "I'm taking a week off but I would really like to stay home and rest. You know I'm still recuperating from my heart surgery." Whatever you say, whatever "explanation" you offer, your sister may not be satisfied and persists in her request. You start to feel worn down. The next thing you know, you're sitting on a plane, thinking about how much you really don't want to be there - you want to be home. You're angry at your sister for not understanding and you're angry with yourself for giving in. You feel inadequate. You feel tense. You feel down.

Your neighbor has taken a new job that keeps her away from home for long hours Monday through Friday. She asks if you would mind walking her dog a few times each day until she can make other arrangements for her pet's care. You're home, recuperating from a heart attack. You're first thought - "No - things are too uncertain - this will be too difficult." A second thought - you don't want to let your neighbor down in her time of need. You say "yes". Then you start convincing yourself that this is the right decision. "She's been out of work for such a long time. She needs the money. I hate to interfere with her good news. I'm retired - I'm home all day. Even though I'm feeling pretty tired these days - I guess I can do it for a while. It's no big deal". Weeks and months go by. Your neighbor never mentions finding someone else to walk the dog - never offers to pay you for your time - and says nothing more about the other "arrangement". You start feeling that you're being taken advantage of. You harbor negative thoughts about her lack of consideration. Still, you say nothing. You don't want her to be angry with you. You tell yourself that saying nothing is easier than "getting into an argument".

Could This Be You?
These are actual stories reported by recovering heart patients in a cardiac support group. What does this have to do with cardiac health? A lot. People with heart disease often have an "overdeveloped" sense of responsibility and when it comes to personal conduct, standards are high. That means being dependable, considerate, cooperative, and moral. Unfortunately, this emphasis on being considerate and dependable may reflect much more than just wanting to be a "good" person. It may signal an unhealthy dependence on others for approval and support. It may indicate a need to be liked - by pretty much everyone - people you don't know very well (the waiter in the restaurant) and people you're not sure you want as a friend. It may mask an effort to avoid conflict - no matter what the cost. Of course, if you're asked to do something you would rather not do but you do it anyway, no matter how "good" you may want to be, you're likely to find yourself feeling the conflict and turmoil you're hoping to avoid. Guilt may be the driving force behind the decision to say "yes" - guilt provoked by your perception that saying "no" isn't the "right" thing to do. Whether it's a need for approval, fear of conflict, or guilt, failure to assert one's needs can foster a bubbling undercurrent of negative feelings.

Are You Mistaken?
Saying "yes" is, of course, something we all do and really must do in order to survive in a cooperative society. But, as with all good things - acts of kindness can be overdone, wearing down the giver. Is it possible that you're wrong - that the assumptions that drive your struggle with assertion may not always be true?

Assumption 1: "If I don't do what people want me to do, they won't like me anymore."
Assumption 2: "If I don't do it their way, there'll be mad at me."
Assumption 3: "A nice person always helps when asked."
Assumption 4: "If someone asks me to do something and I turn them down, I feel miserable."

The Reasons For Fatigue Are Many…
The inner voice of the overly "responsible" person calls out - "just one more time" - as you once again agree to do all that is asked of you - in spite of fatigue, in spite of a need to simplify rather than complicate, in spite of your wish to have more time for yourself. We struggle to understand fatigue in relation to heart function and heart disease. It's not always clear. Sometimes it is a result of a heart that's been damaged during a heart attack. Sometimes fatigue is an indication of a low level of fitness - the heart has to work too hard to accomplish its job of circulating blood throughout the body. Certain heart medications - for example, beta-blockers may lead to mild to moderate feelings of fatigue. With the increased likelihood of depression accompanying cardiac illness, this too, should be considered as a cause for fatigue. Or...

Is It Possible You're Doing Too Much?
Asking a heart patient whether or not they're "overextending" themselves - for their children, their parents, other family members or friends, or their work - is usually met with, "No. I'm o.k. I'm taking care of myself."; "I feel o.k. This isn't too much for me to do."; "Sure, I do a lot, but I always find time for myself." The need to be needed, the fear of letting others down, avoiding guilt, avoiding conflict, denial about one's own physical condition - all come into play with one reason or the other interfering with the ability to say "No, I'm sorry. I can't." or, "I must rest today."

What We Believe Is Evident In What We Do…
Time to take a belief inventory. Do you believe that your needs are important? Do you exercise that belief or do you find yourself too frequently behaving as though others' needs are more important than yours? Do you believe you have a "right" to put yourself first - at least some of the time? On an intellectual or "knowing" level we may say that our needs are important, however, our self-doubt is evident in the need to defend choices, explain decisions, and justify what it is we do. Your need to stay home to rest is equally as important as your adult child's need to be picked up at the airport late at night. If you don't believe that, you may find the only way to say "no" is to create an elaborate story about why you can't be there. Revealing the truth - fatigue and a need to be quiet - may seem trite or self-centered. Your need to meet a friend for a fun-filled day having lunch and catching up on favorite topics is as important as your other friends need to be driven to an appointment with her doctor. You might argue - "Choosing a day of fun when my friend has something "serious" to deal with - isn't that selfish?" How often do you reach out to help your friends? How often do you plan a day of leisure for yourself? Do you believe that "fun" adds to quality of life and is quality of life important to your recovery? Making time to "play" contributes to your health.

Is Your Willing Attitude In Balance?
Look for balance and common sense. Balance means meeting your friend's request when you can, once in a while. Common sense means paying attention to the way you're feeling physically and declining others' requests when you know you should. Take the "always" out of what you do - try not be the one who "always" meets everyone else's needs or the one who "always" puts everyone else first. Balance for a healthy heart.

Avoiding Conflict, Disappointment, Disapproval…
When doubt appears when someone has asked you to do something - you're facing conflict (the thing you want to avoid) - but it's with yourself... "I should do this... I don't want to do this. What will happen if I don't do this?" Ask yourself why you must say "yes"? If your answer is, "She'll be angry with me if I don't" - that's not a "healthy" motive. You may be attempting to "control" the other person's mood by giving in. That is, if you believe that people will be happy when you do what they want and unhappy when you don't, then your choice of always saying "yes" may be your way to manage others' feelings - at least that's what you think. Are you responsible for the way others respond? Reverse this. You ask someone to do something for you. They respond, "No, I'm sorry. I can't". Do you immediately get angry? Is there always conflict? If the way you respond to the other person saying "no" is with understanding and acceptance - did that person cause you to be understanding? The way you perceived that persons refusal is what led to your feeling of understanding. The way you processed their response is what led to your acceptance. What's the evidence that you're causing other people to be angry? Try this. As you practice taking better care of yourself, observe the variety of responses you receive when you say "no". You may be surprised to see that others are not always annoyed, that there isn't necessarily conflict, and friendship continues. You may also find that your friends don't ask so much of you as they once did.

The dictionary defines "friendly" as "ready to approve or help". Does this mean in one direction - no, it means in both - that is, "mutual" availability - "mutual" satisfaction.

Suggestions for Behavior Change…

Develop a New "Habit"
If your habit is to (almost) always cooperate, you'll quickly and repeatedly say "yes" - before considering how your response might impact your life. The next time someone asks a "favor", you might try a new habit - "I need a little time to think about this. May I get back to you?" You'll have the chance to think about your decision and whether or not you might be overextending yourself once again.

As You Decline, Show That You Care
Use empathic assertion. Include a sincere expression of consideration with your response. For example, "I know how hard you've been working on this project. I wish I could help, but I just don't have the extra time."

Avoid Explaining or Justifying
If when you say "no", the person making the request persists in asking again and again - in different ways and form - repeat what it is you said the first time - with no explanations. For example, first request... "No, I'm just not able to help right now." Second request... "I understand, but as I said, I simply can't be there." Third request... "Yes, I see that you're in need of help. I just can't join you." If with your refusal you offer "explanations" - "I don't have transportation", "I'm working that day." "It's too late at night." It's likely that all of your objections will be met with solutions. Repeat your apology with your refusal.

The Outcome May Not Always Be What You Expect, But…
As you gain confidence in your ability to say "no", as you begin to value your time, your need for self-care, and your personal limits, it certainly doesn't mean the world will be perfect. People will still "push" in order to get their way. Friends and family will indicate their displeasure if you're not always available. Your boss may directly or indirectly let you know that you've let him down. You may continue to feel unsure and conflicted about your decisions and choices. But if you persist - the rewards will be great. People who care about you will still care. You'll learn that you're valued for reasons other than what you can "do" for other people - you're valued for you. Friends who repeatedly asked for favors may ask less frequently and continue to like you for the right reasons. You'll have more time to put your feet up on a Sunday afternoon and read the paper. You won't be rushed when you go out for your walk deciding this time is for you and that's "o.k." (no guilt). You'll have a renewed sense of freedom. Self-worth will grow as you recognize your "right" to have needs. You'll be pleased to see that you're still a "good person" and that can include being "good" to yourself.

When you value your time, you can value your health. Have a wonderful - Heart Healthy Month!

Austen Hayes, Ph.D.

Topic: Behavior/Time Pressure

Doing More and More...Still, Never Caught Up...
Are you guilty of "multi-tasking"? Do you often find yourself trying to do more than one thing at a time? Are you rushing around but never feel that you've "caught up"? Industrial psychologists are looking at "multi-tasking" in the workplace and find that not only does it reduce productivity and diminish accuracy, but while an individual is engaged in such behavior there can be as much as a ten point drop in IQ! In or out of the work environment, those more likely to develop cardiovascular disease tend to be achievement-oriented, future-oriented individuals who frequently engage in, "multi-tasking". Most people today are attempting to accomplish more and more - doing one task and thinking of the next. We're highly conscious of time, how it may best be used and never "wasted". We're urgent, pressured, out of breath. We quickly grow impatient with others we think are too "slow". We aren't able to do things as thoroughly as we would like. We see our lives as "out of balance". People in my psychology practice ask how I might help them be less easily distracted, more efficient, more focused and better at managing their time (so they can "get more done"). I don't believe poor time management is the problem as much as it is a shortage of time resulting from too much to do.

We Live in A Complex World…So Much To Do…So Many Choices...
We live in a complex, ever-changing, demanding world. In the recent twenty years we possess and use many more pieces of technology than at any time before. We receive more mail, much of it "junk", than ever before. There are more product choices presented to us every day. Information comes to us more frequently and more quickly from many more sources than ever before. In subtle and not so subtle ways we're encouraged to be more productive and to work faster. In his book, "The Paradox of Choice - Why More is Less", Barry Schwartz*, a professor of social theory, makes a very interesting point when he tells us that over time we've been able to "reduce the time and energy, as well as the number of processes….for each of us to obtain the necessities of life." When we had reached the point where we were able to purchase what we needed rather than make it or hunt for it, "The variety of offerings was meager, but the time spent procuring them was minimal as well." The "variety of offerings" is no longer "meager". If you read "Paradox" you may be astounded when you see the multitude of choices we have for almost every purchase we make (e.g., types and colors of "t-shirts" listed in one LLBean catalog). As Dr. Schwartz describes an amusing but clearly frustrating experience attempting to purchase a new pair of "dungarees", you'll identify with what it was he faced (and we all face) when he set out to complete what really should have been a simple task - buying new jeans.

Do You Suffer from "Hurry Sickness"?
In the field of psychology, especially behavioral health or health psychology, the depleting, pressured, rushing that we do has been referred to as "time-pathology", "time-urgency", and "hurry-sickness". For some time the "Type A" or "coronary prone" personality, has been characterized by the presence of an aggressive, hard driving competitive, "time-urgent" approach to every-day living. While it seems that this style of personality may be partly due to one's genetic history, the environment also has a strong influence on its expression and enhancement. Actually, whether you have this personality style or not may make no difference. If the end result is that you find yourself in a chronic state of mental and physical "rushing" just to keep up, you may experience the same added risk for developing heart disease as the stereotypical, "Type A".

As your thoughts signal your body that you have "this much to do" (too much), and "that much time to do it in" (not enough), the pressure you feel may have a seriously negative effect on your social, psychological, and physical well-being. What are the effects and what might they do to your heart?

Social Effects...
Diane Ulmer and Larry Schwartzburd** think of "hurry sickness", as a way of responding that leads to "a loss of interest in aspects of life except those connected with achievement". In some cases, this means not enough time spent with family and friends. It may mean losing touch with feelings of closeness and intimacy. An extremely interesting idea that these authors point to is that as a result of the daily race to get everything done, we may tend to family and friends in response to a crisis, neglecting or putting off time spent with them for pure, simple pleasure. As we store more and more memories of these crises, we may associate "relationships" with stress and strife. Memories of difficult rather than pleasant times further encourage a wish to be separate and create distance between ourselves and those we care most about. Indeed, there have been studies indicating that people may find home life far more stressful than work life - another reason to work more, harder, faster….later. Being connected, feeling supported, is a buffer against the progression of heart disease. Exchanging a life filled with tasks accomplished for a life filled with social connectedness, may actually pose a serious risk for your heart. Many studies support the relationship between cardiac illness and lack of support or isolation. For example, one study found that women with coronary artery disease who have a small social circle die at two times the rate of women with a larger number of social contacts and ties. Being connected benefits health in many ways but it's hard to nurture relationships when we're always in a hurry.

Psychological Effects...
The busier you are, the more pressured you feel, the more fragmented your thinking. When you're constantly thinking about all that you have to do, when your mind is racing, concentration and focus are impaired. With mental, "multi-tasking" your ability to pay attention to the task at hand may be seriously limited. If you happen to be in the grocery store, making a good effort to purchase heart-healthy items, and your mind is running away with thoughts about calling your friend when you get home and sending an e-mail to your office, and then returning those nagging unanswered phone calls - you're not shopping - mentally you've already left the store. You return home and realize that you've forgotten certain items, perhaps you were given the wrong amount of change from the cashier, and picked up the "whole" rather than "fat-free" milk for your morning breakfast. Your quality of life feels less than good. Many of you may be saying, but really, "shopping for groceries isn't so important. It's not such a bit deal!" That may be true, however, it's an example of the many things you do throughout the day - nothing is done fully - very few activities get our complete attention. As a result your meals are a little less satisfying, you're not fully "there" during the call to your friend, and the e-mails you send are interfered with as your mind is racing thinking about the calls you have to make. You're always ahead of yourself. You laugh at yourself when your memory fails and when you simply cannot concentrate on the book you're reading. Dr.David Perlmutter*** calls this "a brain in distress". You're not your best. Ulmer and Schwartzburd suggest that "Inner peace and time urgency are quite incompatible."

Physical Effects...
A full understanding of the underlying mechanisms driving this relationship between stress and cardiovascular disease is not yet available. Still, we do know that when an individual is vigilant, experiences chronic feelings of pressure with thoughts of never catching up, never being able to do all that needs to be done, the level of arousal associated with this pattern of thinking and behaving is brought about through the release of stress hormones. We refer again and again to what these hormones trigger and what this process may lead to in terms of your health. Let's review the relationship between stress, stress hormones and markers of cardiac illness.

The Markers of Cardiac Illness

Weight	Sedentary Living	Blood Fats (Cholesterol, Triglycerides, etc.)
Blood Pressure	Inflammation	Poor Metabolic Function
Smoking	Blood Clotting	Diabetes

When we experience stress we tend to eat poorly and exercise less. Becoming a smoker or finding it difficult to stop smoking is often related to stress. "Rushed", pressured individuals (exposed to stress hormones) will tell you that a cigarette "calms" them down. During a stress response fat is deposited in the more central portion of the body and through some failure in the overly worked metabolic function, becomes a very efficient fat-producing engine. This may lead to the development of further vascular complications in the form of diabetes. During acute bouts of high arousal blood pressure rises and for some, may become chronically elevated as stress itself (pressure/rushing) is more chronic. The stressed cell reacts to "injury" and becomes inflamed. This may result from turbulent blood flow within artery walls or possibly excess body fat. With vigilance comes a greater tendency of blood to clot. Clearly a pressure-filled life can be damaging to your health.

Something You Can Do To Begin The Process of Change...
As you grow familiar with TheGoodheart MonthlyMessages you may see that the first step toward change is self-awareness. Self-awareness begins with the gathering of personal data. We really need to know how we're behaving in order to learn what the targets for change need to be. In Heart and Mind; The Practice of Cardiac Psychology, Ulmer and Schwartzburd refer to both physical and psychological signs of time urgent behavior. Physical signs include shallow breathing, tics, facial tension, and rapid behaviors, for example, eating or talking fast. The psychological symptoms may show up as impatience, interrupting, irritability when kept waiting, feelings of fatigue, being overburdened and overwhelmed. These are the symptoms and some or all may be indications that your mental and physical health are in a state of distress.

Take Stock...
I would like to ask you to record those times when you notice yourself rushing or feeling "urgent" and pressured. Keep track of how often you function this way (day/date), how long does the behavior last (time frame), and what type of situations or people might be associated with these responses? If you maintain this log for at least two weeks you will probably see your patterns and habits more clearly. This may be an interesting exploration as you learn more about what your assumptions and beliefs about time are and whether or not you're living the way you truly wish to live.

Your Beliefs About Time, The Way You Spend Your Time...
Explore your time assumptions - do you believe that relaxing is "wasting time"? Are you flexible or inflexible with regard to lateness? Are you able to set aside time for yourself - without feelings of guilt? Do you treat time as if it's more important than friends and loved ones? Do you rush because it makes you feel as if what you're doing is more important? Sometimes our need to feel important is seen as we regularly report to others how "busy" we are. Practice: "I don't have to prove my importance to anyone."

Do you have too many possessions? How much time is spent caring for objects? Is it time to remove some of these things from your life? Simplicity may be your new mantra.

Do you spend your days attending to things in life that are truly important to you? Would you be less rushed if you were more discriminating when it comes to choosing how it is you spend your time? Can you say "no"? If you said "no" more often would you feel less rushed?

It might help to be more in charge of your thinking - when you're doing something try to avoid thinking about what you'll do next. "I can give my full attention to what I'm doing at this moment. When I arrive at the next task then, and only then, I'll think about that".

Are you being realistic about how much you plan to do? Those who tend to be time-urgent may be inclined to plan to accomplish too much in any given day. When you make your list, see if you can remove a few scheduled items. When you're traveling or commuting, leave enough time between destinations to allow for the unexpected traffic jam or the train that arrives late. Begin to realize that no matter how much we do, no matter how fast we work, we never get truly "caught up". We're never finished. Think long-range. Things will be done, perhaps not as fast as you had hoped they would. In the meantime, your peace of mind and the health of your heart are most important.

And...You Might Consider...

reducing the amount of caffeine you take in by lowering your intake of cola drinks and coffee

practice meditation, yoga, or tai-chi

practice deep-breathing techniques throughout the day to lower arousal

Follow in the Footsteps Of Someone You Admire...
Finally, it may be helpful to find a role model for the purpose of changing a rushed life. If you know an individual who is successful in life but seems to do it without always being in a big, unhealthy hurry - observe this person - then practice behaving as if you are him or her - this might help to hasten change.

Please let us hear from you about what it is you're doing to live a less pressured, more peaceful life. Your ideas may be so helpful to other Goodheart readers. Have a wonderful, heart healthy month!



---Austen Hayes, PhD

*Schwartz, B (2004). The Paradox of Choice: Why More is Less. New York, Harper-Collins
**Ulmer, D.K. and Schwartzburd, L. (1996). Treatment of Time Pathologies in Heart and Mind: The Practice of Cardiac Psychology. Allan, R. and Scheidt, S. (Eds.) Washington, D.C., American Psychological Society
***Perlmutter, David (2004) The Better Brain Book. New York, Riverhead Books

Topic: Commitment and Self-Regulation

Commitment and Self-Regulation: Regaining and Maintaining Good Health
When you've heard your doctor say, "heart attack" or "heart procedure", many of you may have found that doing all you can to begin living a heart healthy lifestyle was relatively easy. With a potentially life-threatening diagnosis your mind can be changed in a matter of minutes! Suddenly you're paying attention - you're motivated to take excellent care of yourself! Why oh why do we wait until we're ill before we change our behavior and take the all too real possibility of heart disease seriously?

Your Personal Bias and Your Denial...
Perhaps you're the person who thought you wouldn't get heart disease. You're too busy, you're too strong, and you're too "different" from other people you know. You can take it. Some measure of denial may get in the way, preventing you from admitting to yourself that you're tired, that you're eating too much, that you're overweight and unfit, that your work schedule is too demanding, or that you can't possibly take on one more responsibility. You rarely feel pain and when you do you "deny" that it means much of anything.

Denial May Not Always Be A Bad Thing...
Prior to your experience with heart disease, denial might have been the response that allowed you to make unhealthy choices - day-after-day, year-after-year. Surprisingly, denial after a diagnosis of heart disease, may serve you well - for a while. It allows you to jump into action. The person who may have believed that illness comes only to others, may now minimize personal risk and with great confidence, eagerly commit to a prescribed program for recovery. You can do it! You've taken command of your life again! The more involved you are in your exercise routine, better food choices, and (we hope) a program of stress management, feeling healthy and vital may be the reward that helps you to maintain your commitment for the months ahead.

Time Passes - Where is Your Commitment Now?
Now - eight or ten months have gone by. Where is your commitment? Further and further away from an initial diagnosis of heart disease, the (denying) invincible you, may begin the process of making not so healthy lifestyle choices once again. You may give yourself permission to skip exercise, for a day - a week. You may work until you're exhausted, or eat the wrong foods, listening to the "denying" inner voice that tells you "just one day missed", "just one cookie", "just one cigarette" - "I'll be o.k. The doctor told me I was as good as new. I can "slack off".

Support Or Isolation - Which Is It Now?
If you had a system of support immediately after your diagnosis - do you have it now? You may more successfully preserve your commitment to good health with the gentle "prompts" offered in a cardiac support group, through web support, your physician, perhaps a nurse, or your family. As one participant in a support group reports their struggle to stay on track another member may be motivated all over again, even comforted, as they see themselves as "not the only one" experiencing the struggle. For the person who is maintaining good health practices, a supportive setting may mean a renewal and fortification of their goals as they help others in need of encouragement. Support need not come in the form of a group. Keeping abreast of cardiac health "news" may be a form of support. Attending local lectures at a hospital or wellness facility is another useful way to "prompt" you to keep the solid promises you made to yourself early in recovery.

The Cycle Begins...Denial, Unhealthy Choices, Feeling Badly...More Unhealthy Behaviors...More Negative Emotions...and so on, and so on...
Dr. Valentin Fuster, the Director of The Zena and Michael A. Wiener Cardiovascular Institute at Mt. Sinai Hospital in New York, made a provocative comment during a television interview, stating that although the medical field has made extraordinary strides in being able to provide remarkable life-saving procedures, medications, etc., "we can't seem to get people to change their behavior". How true! Approximately 80% of heart disease is related to lifestyle.

Stop The Cycle - Have a Plan...
To help you meet the challenge of regulating your behaviors, I'd like to refer to the work of cardiologist, Alan Rozanski, M.D. His thoughts on the topic of behavior change and management may help you to formulate a plan for change or learn more about what might interfere with the maintenance of a plan you've already begun but find difficult to sustain...

Dr. Rozanki's Plan...
In a paper published in the journal, Psychosomatic Medicine, in 2005*, Dr. Rozanski points out that although there is sufficient documentation available to accept psychological factors, such as depression, as risks for the development and progression of heart disease, making this understanding a part of a comprehensive plan for treatment for the heart patient has been, more often than not, neglected (the premise underlying the creation of TheGoodheart). Dr. Rozanski outlines a plan for care that considers what it is each patient faces and may need as they attempt change...

1. "Barriers" Interfere With Positive Health Practices

Negative feelings (e.g., depression, sadness, anger) are referred to as "barriers" that may trigger unhealthy behaviors. When you feel down or fearful or worried, you're more likely to want to hibernate than go for a good walk. A quick but temporary fix for a "down mood" might be a cigarette, a box of cookies, or three hours of inactivity in front of a television set. Dr. Rozanski reminds us that behavioral "habits" chosen to "reduce fatigue, tension, or a negative mood, may be particularly difficult to break, because the immediacy of their effects and any resultant positive mood strongly reinforce(s) these habits." Trying to make a better choice is met with what this doctor refers to as "moments of challenge". "Moments of challenge" become a secondary source of "barriers" as they elicit more negative feelings - for example, frustration and anxiety.

2. The Need for External Support

Dr. Rozanski, referring to the process of change as "fragile", states that support is "desirable". Support might include telephone follow-ups, behavioral contracts, web-based programs or possibly the connecting with family members. Although external support may be valuable in the efforts to maintain change, Dr. Rozanski makes a point of the unreliability inherent in this component, for example the fact that it may work for some but not for others, that it may be too costly, and the existing evidence suggesting that no matter how high the quality of support, resistance to change may be too powerful. As an alternative to external support, "Self-Management" is discussed.

3. Patient "Self-Management" Fostered And Encouraged

Drawing upon several studies of behavior change, Dr. Rozanski reports that change might occur more reliably when an individual experiences a state of well-being resulting from basic psychological needs being met. This, Dr. Rozanski outlines, "spawns" a sense of "vitality". One such "psychological need" would be that of feeling "competent in the performance of one's tasks". Another would be the "need" to feel that choices made (e.g., health promoting behaviors like exercise), are chosen because they hold personal meaning or value and they're not followed as a way to please or impress others. Goals we might expect to be more successfully fulfilled are internally, rather than externally, motivated.

How To Make This Work For You...
In psychology, behavior is thought to be "multi-determined". That simply means that we rarely say that something we do or don't do is determined by one single factor. The same applies to behavior change. A change in behavior may be accomplished with many different approaches. With that in mind, following are a small number of many possible points we believe may complement Dr. Rozanski's ideas.

Whatever Your Feelings, Your Thinking Can Direct Your Behavior...
You're making decisions based on your feelings. Cognitive therapy refers to this as reasoning with your emotions. It's considered a "cognitive distortion". Being able to exercise really doesn't require you to feel any particular way - good or bad, negative or positive. Whatever your mood, you can take a walk. What is required is that you are physically capable. "I don't have to feel like walking to walk." When you don't "feel" like doing anything, remember that instead of waiting to feel motivated, motivation may follow action rather than precede it. Movement is a potent antidote to negative mood.

You're choosing particular foods based on particular moods - based on learned assumptions. You may discover that when you're anxious, that's when you're most likely to eat something sweet. Did you learn that sweet foods are meant to "lift" your mood when you're feeling down? Are sweets considered a reward when you've had a bad day? This means that your "opinions" or "assumptions" about sweet (often unhealthful) foods may be biased. These are opinions you're living with as if they were facts - facts that rule your choices. Instead: "I didn't have such a great day today. If I have the piece of pie I may feel great for a few minutes, then I'll feel worse. The more often I tell myself I'll be happy, feel better, have a good day, etc., if I eat the pie, the more I'll follow my own "rule" for choosing. Maybe I need a different rule."

You're living mindlessly. How often are the choices you make done automatically, without much thought, without much awareness? As you make your decision about food or exercise or smoking, say it aloud. That's right. Say out loud, "I am deciding to eat this fatty dinner. This is the choice I'm making in spite of the information I have about my heart and the need for change." Or, "No, at this moment I'm deciding to eat the salad and piece of fish - I'm being good to my heart. I'll feel great about myself when the meal is over". It's much easier to take responsibility and be in charge of our actions when we "hear" our thoughts - outside, rather than inside.

You're trying to change the way you feel. Perhaps when you become aware of the frequency in which you use food or alcohol or cigarettes to change the way you feel, you may realize that you're feeling badly far more often than you should. Please discuss this with your doctor. It may be time for you to seek professional help. Negative emotions really are "barriers" that interfere with the health of your heart.

You're Trying To Go It Alone. Is it possible that you've decided that you don't need help, you don't need support? You don't want to bother anyone. You don't want to tell other people about how scared you are or how much doubt you experience every day. You don't want to appear "weak". You'll just keep it to yourself. In fact, it takes courage and strength to say, "I could use a little help." If you're able to reframe your assumptions about weakness or dependency, and think of cooperation, support, connecting with others, as human strengths - strengths that improve one's chance for survival, maybe you'll reach out with an open mind.

You're Thinking You Just Can't Do It. Sure, you want good health, but can you really stick to it? You've never been able to continue exercising before this, how can you change at this late stage in life? "What about all those people who exercise, those people who are thin and they still get sick?" "Maybe it's not worth it." "Self-efficacy", the belief one holds regarding their ability to accomplish something based on his or her own actions**, will influence physical health. Just about anything you choose to do will benefit from the positive, optimistic assumption..."I can".

You're more motivated when you're trying to please others or prove something to someone else. In an earlier Heart Topics "need for approval" was chosen as a topic for discussion since a large percentage of those who may develop cardiac illness are motivated and driven by this need. It has to do with how we see ourselves and our need for others to like us or admire us. Dr. Rozanski suggests that positive behaviors chosen based on a sincere desire to take care of yourself, rather than a need to impress others about how you're taking care of yourself - are far more sustainable. What motivates you? When it comes to your health, your life, how important is it that you impress others? This is for you, this is not about popularity.

Until Next Month...
As you review this month's Message we hope you'll find one or two points that will guide you in keeping your commitment to good health habits. This is a great time to reevaluate goals. Gather information from you physician and your cardiologist. Where are you now? Where do you want to be? What are your "barriers"? Identify them, name them - figure out a way to be able to measure them in terms of frequency, intensity, duration. Measuring them and seeing change is reinforcing and will further help you to stick to your plan.

Have a successful month! Good health, positive thinking, and always hope!

---Austen Hayes, PhD

*Rozanski, A. Integrating psychologic approaches into the behavioral management of cardiac patients. Psychosomatic Medicine 2005;67: S67-S73

**Maddux, J.E. (2002) Self-efficacy: The power of believing you can. In Snyder, C.R. & Lopez, S.J. (Eds.) Handbook of positive psychology (pp.277-287) Oxford University Press.

Topic: Depression

Depression and the Health of Your Heart

Our Message this month is about depression. Those who study emotion and cardiac disease are beginning to consider depression a most serious negative emotional state when it comes to the health of your heart. If you're living with undiagnosed cardiovascular problems or if you've already received a diagnosis of heart disease, depression may be the factor that would predict health complications and possibly a cardiac event, such as a heart attack. Would it surprise you to learn that a recurrence of some form of heart-related illness is more closely linked to depression than to high cholesterol, smoking, hypertension, or diabetes? Another important factor -- depression does not have to reach the level of moderate or severe to pose a risk -- even mild, or "sub-syndromal," depression may be related to unhealthy behaviors and debilitating physical reactions.

Feeling "Down" Can Start to Feel Normal

Because feeling "low" or "down" may persist for such a long time, it may seem "normal." You grow accustomed to feeling less than good. You explain your feelings away. "I should be down. I'm getting older." Or, "Of course I feel sad. I'm not as strong as I used to be." Or, "What do you expect? Anyone with my problems would feel pretty unhappy." Yes, we do react with sadness and despair when we experience loss, or bad news, or any of life's many challenges that seem too great to bear, too painful to understand or accept. However, if you believe that you haven't felt "like yourself" for weeks or months, if your sadness persists or if you've noticed a loss of interest in things that usually give you pleasure, we urge you to:

• discuss the way you're feeling with your primary care physician
• discuss the way you're feeling with your cardiologist
• talk to a therapist
• find a cardiac support group in your area through a nearby hospital or by contacting your local chapter of the American Heart Association

When You're Depressed, Your Behavior Will Change

Depressed individuals are less inclined to exercise, more likely to make poor food choices, and less inclined to follow a recommended regimen of life-saving heart medications. The depressed person is more likely to smoke and may find it more difficult to stop than someone who is not depressed. Struggling with the symptoms of depression usually means that you'll spend less time on self-care and, in general, pay less attention to behavior that promotes good health.

And...When You're Depressed, Your Body Will Respond

Depression may trigger a chronic activation of the nervous system ("fight or flight response") and this may lead to:

• increased levels of inflammation
• suppression of the immune system
• blood cells that may more easily "clump" together
• blood vessels that are less flexible
• an increase in resting heart rate

Because these behavioral and physiological responses can be damaging, and more so the longer the depression persists, it's extremely important that you seek help as early as possible. In a study that included treatment for depression following a heart attack, investigators speculated that the less-than-satisfying results of the treatment (no real reduction in incidence of future heart attacks) were probably due to the fact that the depression may not have been caught quickly enough -- the damage was done.

TheGoodheart.com Cannot Treat Your Depression

The Heart Topics is not meant to "treat" depression. We make every effort to educate our readers about the way negative feelings may interfere with the health of your heart and positive thinking and positive feelings may act as buffers between you and the stress in your world. If you see yourself engaging in any or all of the negative habits of thinking that we've outlined below, it may be helpful to consider making some changes. If not addressing all three "habits" of thinking, even one small change may make a considerable difference for the health of your heart. Do you see yourself here?

When You Process Through the "Filter of Negativity"

When a person experiences depression it becomes difficult to see the good, the positive, the "up" side of life. The brain begins to work differently and information is viewed through the filter of negativity. Something that had been pleasing suddenly looks less attractive, less appealing, less interesting. When you're depressed you avoid rather than approach life. You "reason" with your feelings ("I don't "feel" like doing any exercise, therefore, I can't do any exercise"). If depression lasts for an extended period of time or returns more than once during the course of a lifetime, there's the possibility of developing chronic patterns of negativity. An individual may be more self-critical and critical of others. Most communication will be an opportunity to complain about something -- anything! Complaining and being critical become familiar like an old shoe -- comfortable and barely noticed by the wearer. With a loss of motivation, curiosity, and enthusiasm, life grows more narrow and limiting. What is your first impression of what you see? Is it usually negative? What if you were to make the effort to find the good, find the benefit, find something positive in whatever comes your way? Would it help?

How Do You Explain Negative Events to Yourself?

In psychology there's a term used to describe the way we process negative events in our lives -- it is our "explanatory style." If, when things go badly, you generally consider the situation to be your fault, always going to be this way, and entirely bad, this pessimistic explanatory style may leave you feeling helpless. You may assume there's nothing you can do to make a difference, nothing you can do to make things better. An optimistic explanatory style would mean thinking that things may be related to external circumstances (i.e., not entirely your fault), not going to last forever, and specific to this troublesome situation. All is not bad. All is not lost. How do you explain your cardiac difficulties to yourself?

What You Expect in Life Makes a Big Difference -- What You Expect for Your Health Makes a Big Difference!

When you think about your health, do you know what it is that you expect? Are you expecting a positive, strong recovery or a less than favorable outcome? Are you expecting that you'll cope well and heal quickly? Do you expect excessive discomfort or do you expect that this is manageable and all for your ultimate good? Your expectations matter. Your expectations may have a great influence on whether or not you go forward with confidence or self-doubt regarding your health and self-care. Finding it difficult to see a future or seeing a future filled with strife and struggle is often a sign of depression. Expecting the worst may lead to giving up, not trying, believing that whatever you do won't make a difference. Can you think of five positive things you might expect? You might grow stronger; you may have more stamina than before; you may begin to exercise regularly for the first time in many years. Anything else?

May I Encourage You To:

• Find something beneficial or positive in each and every experience you have this month -- it may mean really tugging on your mind to find the positive but it's worth a try…it's not what is, it's the way you perceive what is.
• Be aware of how it is you explain each and every experience you have this month -- is it truly all bad and will it really last forever, or is it not as bad as it seems, other aspects of your life are good, and this may be temporary.
• Pay attention to what it is you've been expecting in life -- practice expecting a future with improved health and greater vitality…practice expecting that good things will come your way.

We sincerely hope that this month's Message has been helpful. We always welcome your comments -- your feedback helps to shape our voice. See you next month! Thank you for joining us!


---Austen Hayes, PhD

Topic: First Year of Recovery

The First Year Following a Diagnosis of Heart Disease --
The Challenges, the Unexpected, and the Hope

The year following a heart attack, surgery for coronary arteries, diagnosis of angina (chest pain related to cardiovascular function), angioplasty, or other cardiovascular problems, is a most important year. It's a year of hope and opportunity for new life. It's a year during which you may learn so much about who you are, what matters to you most, how you wish to live your life, and what choices you want to make. It's a year of change as you alter patterns of exercise, food intake, smoking, and social ties. It's also a year filled with questions, unexpected happenings, difficult feelings -- both physical and mental, ups and downs, and, sometimes, confusion and doubt. As you approach this year, please know that you don't have to meet it head-on, full speed ahead, perfectly. You can't. There are too many unknowns. However, you can improve your understanding of what to expect during this first year, and this can make the difference between a really good year, moving towards optimal recovery, or a fair-to-poor year, filled with struggle and an increased risk of unwanted cardiovascular complications.

Let Your Doctors Be Your Partners

In the immediate period following a diagnosis of heart disease, your cardiologist and primary care physician are your most important partners. Getting you well is a team effort. You need to be clear about what your doctors are asking of you, and they, in return, must know how you're feeling, both physically and emotionally. It's important that your caregivers know what reactions you might be having to prescribed medications and how you're responding physically to day-to-day activities and exercise. You help your physician to treat you more effectively when you report any troubling or unusual sleep patterns, moods, or physical discomfort. Please don't expect them to read your mind. No matter how many patients a doctor sees, each person is different. Your doctors may have a complete record of your medical history, but your social, psychological, and economic history combine with that medical record to make you unique. You're a total picture, a full story, not merely numbers on pages and pages of medical reports and diagnostic test results. If your cardiologist knows that your blood pressure is under control, your cholesterol has greatly improved, and your weight is down, but he or she doesn't know that you've recently lost a loved one, you may not be receiving all the care you need. What your doctor knows about you can help him treat you in the best way possible. What he doesn't know puts both of you at a disadvantage.

"If I ask my doctor questions, am I imposing? I really don't want to be a bother."

• If you find it difficult to ask your doctors questions or bring up topics that they're not asking you about, consider listing your concerns and questions on a piece of paper so that you feel more confident referring to them at your next visit. You may also inquire as to whether you can forward your concerns directly to the doctor's office by e-mail.
• If you're having difficulty with the regimen your doctor has asked you to follow, please let him or her know. What your doctor has prescribed has a purpose. If it isn't clear to you or you can't see the value in a particular suggestion, ask questions rather than make decisions on your own about changing or not following what has been suggested.
• If you're experiencing pain or fatigue, it's important that you tell your doctor. She may tell you that the feelings are perfectly "normal," not at all unusual, or she may make adjustments in your treatment regimen. Worry and anxiety may complicate your recovery following a cardiac event. As you get more information from your doctor you may experience a great sense of relief. Relief means calm -- and calm means better heart function.
• Take action. Collaborate with your caregivers. Ask questions. As your questions are answered you may feel a return of confidence and control. Your heart will thank you for taking the chance.

Depression As a Risk Factor

A common problem with cardiac patients is depression. Compared to the general population, individuals with heart disease may be as much as eight times more likely to experience some form of depression. This statistic includes mild forms, as simple as feeling sad, as well as more severe forms, and in all cases may increase the likelihood of complications during the first year following your diagnosis. For example, depression has been linked to inflammation, platelet "stickiness," immune abnormalities, and increased resting heart rate. Depression may interfere with your willingness and ability to exercise, stop smoking, and eat well. People who are depressed are less likely to take their prescribed medications. In the presence of cardiovascular disease, depression may be more predictive of a cardiac event than risk factors such as cholesterol, hypertension, or smoking. If you think you may be depressed, if you tend to cry more easily than usual, or you've lost interest in things that previously brought you pleasure, please report this to your physicians. You may benefit from a support group, a mild, cardiac-safe form of an antidepressant, or psychotherapy. Though depression is such a strong risk factor for cardiovascular functioning, it responds so well to treatment. Please don't let it interfere with your health and your quality of life.

Cardiac Rehabilitation -- Yes or No?

Some of you may be unsure about whether or not to attend a Phase II program of Cardiac Rehabilitation. Generally, after a cardiac procedure or heart attack, you'll receive a form of rehabilitation referred to as "Phase I" before returning home from the hospital. "Phase II" refers to a cardiac rehabilitation program that's generally attended on an out-patient basis, 3 times weekly, for a period of approximately 12 weeks. This period of physical rehabilitation would most often be recommended to you by your doctor. For those of you who have access to such a program, we heartily recommend that you participate. One of the most important benefits provided through your participation is the self-confidence you build as you learn about your physical limitations -- what you can and cannot do. You have an opportunity to experience first-hand how your body responds to the challenge of physical exercise. Heart patients feel encouraged and inspired as they see their energy levels and muscle strength increase week after week. Furthermore, you'll be working side by side with others who've experienced a similar life event, thereby reducing feelings of isolation. If you're not able to attend a cardiac health program, please ask your physicians for recommendations for a program of exercise appropriate to your needs and appropriate to your environment. For example, if you live in a climate where winters are long and cold, walking in a long hallway in your apartment building or local indoor mall may be safer than venturing outside on icy terrain. If you reside in a tropical climate, excessive heat may prevent you from going for a walk. Again, an indoor program may be best. If your climate is fine but your motivation is lacking, see if you might find a friend or neighbor who'll walk with you or share a ride to the gym with you. Making an "appointment" with another for an exercise date might help keep you moving. Your physicians will guide you as to what form and intensity of activity is best.

"This 'twinge,' this unusual feeling, this fatigue worries me."

A common problem in the first year following a diagnosis of heart disease is the experience of feeling unfamiliar or unusual symptoms. Some report feeling fatigued either chronically or perhaps at particular times of the day. Others will refer to "twinges" they feel in their chest area or other parts of the upper body that are immediately thought to signal trouble. Some of you will report "setbacks," for example, having an adverse reaction to a medication, a return to the hospital for monitoring, or learning news about the state of your health that may have nothing to do with your heart. You may feel discouraged. You may worry or feel frightened. You may think, "I'm doing all that I'm supposed to be doing -- why am I feeling this way? Why am I having more problems?" In most cases, "setbacks" are not at all unusual and can be addressed successfully. As you move forward, the line to recovery is rarely straight. It can be unpredictable and dismaying. Knowing this, expecting this, may help you cope with the unexpected before you jump to conclusions. Please, do not ignore symptoms. Avoid trying to guess what your problem might be. As you reacquaint yourself with the new workings of your body, communicate whatever it is you're feeling to your doctors. Let them help you decide what needs to be done. The important point we want to make is that the first year of recovery is a year of tweaking, refining, stabilizing, and finding your "new normal."

Changing behaviors is not easy to do and difficult to maintain, but you can do it!

• We're often able to change lifestyle practices when priorities change. For some, having cardiac surgery or having a heart attack will influence priorities in a dramatic way. As an example, the individual who is sedentary, eats poorly, and experiences a great deal of stress on the job may suddenly shift his dedication from career to family when faced with serious illness. With a renewed commitment to family, the state of this person's health may become more important than ever. Commitment to a new lifestyle will persist when the rewards are found to outweigh any perceived sacrifice. Are you thinking about what matters most to you? What you think is most important will guide and direct your behavior.
• Changes in behavior are more likely to persist when you have social contact and support. Being connected to others stimulates courage as you experiment with new ways of living. More often for women than men, personal healthcare suffers due to the guilt women feel when not attending to the needs of their family. With support during the very important first year of recovery, women are more inclined to spend the right amount of time exercising, resting when needed, and completing cardiac rehabilitation when prescribed -- all with less guilt. In addition, those who are the beneficiaries of support are more likely to support others. In general, those who show concern for others are both mentally and physically healthier. Support saves hearts.
• Behavior change takes time. While you're able to learn a lot about positive health practices in a short period of time, truly changing your opinion about exercise, eating well, or giving up cigarettes may take a year or two. Knowing that you should exercise may be in direct conflict with your belief that "exercise is boring." This knowledge will be undermined quickly if the belief is not modified. Modification of a belief follows lots of repetition of the newly acquired behavior over an extended period of time.

Of course, there's so much more...

We realize that you may have many more concerns regarding your first year following a diagnosis of heart disease -- whether or not to retire or change careers; possibly thinking that you're a burden to your family; how to create more simplicity and balance in your life; how to get along better with others; or how to adjust to new ways of seeing yourself -- your changed "identity," pre- and post-heart disease. There are so many things to think about at this time. As we move forward from month to month at TheGoodheart, we will attempt to address all of your concerns. Please feel free to forward your questions and suggestions to The Message Board and read our responses to the questions we've already received. You may find answers to your questions. Thank you for joining us. See you next month!

---Austen Hayes, PhD

Topic: Hostility/Cynicism

Are You A Skeptic or A Cynic? Your Heart May Have a Preference...

During the past several years there have been a number of studies conducted in which investigators searched for a relationship between hostility and the development of cardiovascular disease. Results have been mixed. Nevertheless, it's generally thought that any conflict in outcomes is likely due to differences in measures used to determine hostility, rather than a weak or absent relationship between the two variables. Indeed this relationship has been widely reviewed and most practicing clinicians seem to agree that a hostile nature may very well be associated with the development of heart disease. Perhaps less commonly talked about, the "attitude" linked to a hostile nature, referred to as "cynical mistrust", carries its own weight when it comes to the emotional elements of heart disease. Understanding this "attitude" may make an important difference as you focus your efforts toward prevention and recovery.

We Feel the Anger, We See the Aggression - What About Cynicism?
Rather than "anti-cynicism" or "cynicism management" seminars or classes, in most towns and cities across the country you'll more easily find information on "Anger Management". The numbers of books written about anger and how to deal with it more effectively, are extensive (please see TheGoodheart "Resources and Readings" page). Rather than a collective national interest in cynical mistrust and how it affects us day-to-day, we've shown our desire for greater understanding and control of aggression as we study whether or not television makes our children more physically combative, why drivers have "road rage", and why ongoing events such as the war in Iraq may increase acts of aggression here and abroad. Cynicism is a close but less noticed relative of these negative responses, with anger and aggression often the result of the cynical attitude itself. What's this all about?

Ancient Roots...
The Cynics were an ancient Greek school of philosophy known for their bold disrespect of conventional life practices of the day. They embraced poverty, self-sufficiency, and self-restraint. Their leader, Antisthenes, Socrates' pupil, apparently single-minded and narrow in his thinking, contemptuously rejected pleasure, human connection, wealth and power as corrupting forces. In these teachings, the most important form of knowledge a man could explore would be "self-knowledge"" - (or perhaps "self-absorption"?).

...and Current Understanding
Like the Cynics of old, there are those today who believe that being cynical is the only hope for a truthful life. Holding a "realistic" view of life and the world we live in is the only intelligent way to survive. This means being a disbeliever, a doubter, a pessimist - the general attitude is one of contempt, rejecting, negating - a "nay-sayer". The cynic believes that others are motivated by self-interest, out to "use" them, take advantage of them in some way. Feelings of scorn might be revealed as they agree with statements such as:

• "I don't try to cover up my poor opinion or pity of another person."
• "Most people lie to get ahead."
• "People seek friends who are likely to be useful to them."

Is the Cynic More "Realistic"?...
For the cynic, "realistic" means seeing the world as it - "really is" - rather than through some pretense that portrays the world and the people in it as basically trustworthy and good. Unfortunately, this "realistic" view is largely negative, critical, and defeatist. The person experiencing the cynical view looks, sounds, and often feels unhappy. The mistrusting cynic is inclined to be less healthy. Since the thoughts are about others posing a possible threat ("people will somehow get you"), feelings associated with perceived threat will bring about a vigilant, sometimes disdainful response - possibly a "chip on the shoulder". The "fight or flight response" is triggered the moment we perceive threat, or more chronically as we carry our negative thoughts around with us day after day. This sets the stage for the release of stress hormones which may, over time, contribute to poor health and that includes damage to the cardiovascular system. In one study, women with high hostility and high cynicism scores had greater body mass index, higher levels of triglycerides, lower levels of good cholesterol (HDL), and reported a reduced experience of good general health. In another investigation, young men scoring high on measures of hostility and cynical mistrust were found to have significant levels of calcification in their coronary arteries - the calcification an early indicator of progressive coronary disease. These represent a small sample of outcome studies supporting the relationship between negative outlook, specifically cynicism, and heart disease.

Then...What is "Realistic" Thinking -- Really?
In fact, "realistic" thinking includes many possibilities. It means considering the good and the not so good, the positive and the negative. It uses evidence "for" and "against", it incorporates "gray". Realistic thinking means more reasoning, being more careful about what one will conclude, being more present-minded, considering information newly as it comes rather than thinking only through the mental filter of past experience, past knowledge. It means the opposite of jumping to conclusions. It means being a better listener - waiting for the person you're speaking with to finish before you decide the outcome. It means stretching your mind to think of new ways of looking at old problems. It means being "broad" rather than "narrow" minded.

We see again and again that negative emotions are related to rigid, inflexible patterns of thinking, while positive feelings are not only related but help to facilitate and develop open-minded, adaptable thinking, creativity, personal growth, and curiosity. Our goal at TheGoodheart is to help you to replace habits of dissatisfaction, unhappiness, and negativity, with responses and emotions that promote well-being. Greater well-being is related to improved self-care, fuller and faster recovery after a cardiac event, better health overall, and ultimately, a longer, healthier life. Let's take a step...

Skepticism - A Healthier Choice?
Perhaps you don't have to give up your doubting ways entirely! If a cynical individual is thought to be largely pessimistic, it's unlikely that he or she will suddenly become an optimist. Perhaps there is a healthier alternative - not quite optimist all the way but moving in the direction of a thoughtful, reasoning person, lessening some of the strong negative emotions associated with the hostility of the cynic. Perhaps cynicism could be exchanged for skepticism. In a very real sense they both may be linked to pessimism - but there can be a difference - a very beneficial difference. A skeptical person might have a questioning attitude and feeling uncertain about what he's heard, want more information before deciding what it is he'll conclude. Open-minded (non-judgmental) listening lessens the likelihood of vigilance and the heightened state of arousal that it triggers (increased blood pressure, heart rate, vessel constriction), encouraging more relaxed responding - more relaxed blood vessels - less demand on your heart.

Rewriting the Assumptions of the Cynic...
The statements taken from the hostility scale might be quite different for the skeptic. They might be something like this:

• "Some will lie to get ahead, others will be truthful and succeed through hard work and dedication - let me wait before I judge this particular person."
• "Although I see times when people's friendships seem to be based on what a friend can do for them, I see other friendships where mutual generosity is the rule."
• "I have to be cautious about the medical care I receive and the information I'm given. Still, I feel hopeful about my health and my future."

Your Emotions, Your Health..
The important point is that hostility and its underlying variables, cynicism, anger, and aggression, seem to hasten the development of atherosclerosis. Anger alone has been found to trigger a sudden heart attack. If you think of yourself as meeting the description of the cynic of old, or the cynical person of today, it's likely that your levels of hostility or anger are higher than they should be. With the onset of these emotions comes stress hormones that so quickly constrict blood vessels, increase the rate of your heartbeat, and change the composition of your blood. Inflammation may result worsening your illness and possibly leading to a cardiac event of some type.

Angry, cynical individuals, tend to eat more poorly than their more relaxed, optimistic counterparts. They smoke more, eat more fat, are more sedentary, and generally fail to take as good care of themselves as they might. If your cynicism creates distance between yourself and others, you may feel alone, isolated - disconnected or "not-belonging". This too, is an added risk for the development heart disease.

Your Next Step - Start With You...
Find the definition of cynical in the dictionary. Is this you? If you think it is, then for the next two weeks record the times when you observe yourself thinking through the filter of cynicism. How often and when do you harbor negative thoughts about others and their lack of trustworthiness? How often do you judge something as negative or unworkable before you've heard everything you need to know? How frequently are you pessimistic or judgmental if someone shares news with you? Record each and every situation that may reveal this aspect of your personality.

Practice Being a Skeptic
When you've gathered all the information over the two-week period return to the description of the skeptic - would the role of skeptic allow you to still have doubts as you weigh everything in a more relaxed, less defensive manner? You can avoid jumping to conclusions and "overgeneralizing". You might practice being less certain. Reducing the frequency of critical thoughts might mean making room for positive assumptions and positive emotional responses. Reducing the amount of vigilance, seeing others as less threatening, may mean more freedom to relax and enjoy the company of others more easily. Observe yourself as you practice responding differently. A wise man realizes how little he really knows. You owe it to your heart to be wise.

---Austen Hayes, PhD

Topic: Impatience

Are You (un)Willing to Wait?

For years there has been regular discussion concerning anger, aggression, cynicism, and the affect these responses have on heart function. More recently, IMPATIENCE has been added to the list of negative responses that may contribute to the triggering of a potentially damaging level of arousal in the cardiovascular system. Perhaps these responses are very much a part of one theme. In fact, a thesaurus suggests that the words, "impatience", "anger", "annoyance", "irritability", are synonymous.

Often when I work with a group of heart patients, most in the group will be achievers, individuals with high standards…responsible, goal directed…desirous of a certain order and predictability in their lives. These are positive characteristics requiring persistence, follow-through, resilience, vision, good planning, and efficiency. These characteristics are believed to have been passed on by our ancestors and are likely related to survival. Clearly, with an abundance of these traits one is more likely to acquire needed resources and adapt in times of adversity. If chances for survival are enhanced through the expression of this style of responding, how is it that these same responses may turn out to be harmful - threatening health, ultimately threatening life?

Persistence in moderation can be valuable. Persistence, when it might be wiser to relax one's effort, may lead to frustration, irritability, IMPATIENCE. High standards in moderation may guide us in doing our job well. High standards coupled with intolerance and a resulting IMPATIENCE with the less than perfect standards of others, may lead to potentially harmful physiological responses, for example, constriction of blood vessels with a rise in blood pressure. So --- positive traits and strengths, overdone, may turn against us. Again, there may be times when IMPATIENCE would lead to a greater chance for survival - for example, the moment the person putting the life raft into the water is taking far too long to do the job - when the boat is sinking - your IMPATIENCE may signal to you that it's time to take over. Your response may save everyone's lives, including your own. However, if you experience this response too frequently, too intensely, and for long periods of time when it's about something that is NOT truly threatening, your body will still live through the physiological results of frustration and irritability. In a matter of minutes you may experience a heart that is working too hard, thicker, "stickier" blood, higher levels of fats being deposited into the blood stream, the possibility of damage to artery walls, excessive immune system activity, followed by an inflammatory response.

For the individual who does have high standards, who believes that things should be done in a particular way, who thinks that time should never be wasted, who experiences others' "slower" actions as obstacles getting in the way of personal goals - all those moments in life when things may not go as you would wish them to, IMPATIENCE may be a routine, highly automatic, response. Someone in the way of your goal, even if it's to get to work on time, may feel like a threat. You may assume that you're entitled to go faster - after all, YOU have very important things to do! The need to reestablish dominance comes into play, hence the "get out of my way as fast as you can" thinking. Clearly, this commonly observed, frequently experienced feeling of IMPATIENCE can be powerful with respect to health - and for our purposes, at TheGoodheart, particularly heart health.

Here are a few suggestions - all with the goal of giving your heart a chance to function well, without the too frequent, often wasteful, demands that may cause harm. If you're a person who is chronically late, you may notice that IMPATIENCE follows your lateness. Is it possible for you to give yourself more time to do each thing? Is your sense of time planning realistic? Do you simply schedule more than you can do in any given day? Are you racing to do as much as you possibly can each and every day? If you're racing, I'm certain there will be others in your way. Before, you leave the house in the morning remind yourself that today you're going to practice PATIENCE. You'll listen to others more PATIENTLY when they speak, you'll avoid pushing your way through traffic, you may read a book while waiting on a long, slow line. At moments when you notice that you're feeling IMPATIENT, you might say to yourself, "My health, my heart is more important than rushing everything and everyone. If I breathe more slowly, my heart rate will slow, I'll feel less pressure. There will be plenty of time - years - to do all that I want to do, if I can help my heart to be healthier. I'm taking a long-range view of life - not the "everything has to be done right now and as fast as I can do it", view of life.

Research your life. What are you doing that you no longer need to be involved with? Are the things you're attending to taking up time that's in short supply in a busy life? Ask yourself what your MOTIVE is in each activity or commitment. This may help you decide whether or not to continue. Try to avoid EXPECTING that others will follow your rules about how to live, how to think, what to do and how to do it. ACCEPT others with greater compassion. When you look at someone with scorn because they're not doing their job as you might - perhaps they really are doing the best they can. If they're not, is it really your job to change everyone? - is your IMPATIENCE making the situation better? Think about how you might be more accepting of the DIFFERENCES between people - as opposed to unrealistically wishing for more and more similarity. Acceptance fosters PATIENCE. You may not agree with the things others do, or the way they do them - agreement isn't necessarily needed - UNDERSTANDING is sufficient to foster PATIENCE. Why, when you're in a long line, do you begin watching the behavior of others in the line - looking for actions to criticize - "They'll slow things up even more", "Why is that woman writing a check for such a small order?" "This line is marked "5 items or less", and THAT woman has more than five in her cart!" Use your time in a line to read your favorite magazine or book - moments waiting will turn into a "gift" of time to do something you enjoy…rather than a moment of frustration, leading to IMPATIENCE.

---Austen Hayes, PhD

Topic: Loss and Heart Disease

Post-Traumatic Stress or Post-Traumatic Growth?!
"Post-Traumatic Stress" is a term used to describe a collection of negative responses someone may experience following a major or unusual trauma. Symptoms might include, intrusive "flashbacks" of the traumatic event, sleep disturbances, chronic feelings of vulnerability, and avoidance of anything that even remotely reminds the individual of the experience. Life grows more restrictive, less rewarding, more "narrow". Distress may be present for months or years. This fairly well known diagnosis of lingering emotional injury following trauma may lead us to believe that negative experience equals negative aftermath. This is not necessarily so. Human beings are amazingly resilient, resourceful, and remarkably capable of not only surviving but flourishing through the most difficult experiences. When faced with heart disease, with all its potential for good or bad, maybe good is where it will go - maybe Post-Traumatic Growth is what you will find.

The Difficult Road to Growth...
For those "prone" to developing cardiac disease, "successful" living may be attached to autonomy (independence, freedom), seeing oneself as competent, purposeful, always meeting personal, professional, and social responsibilities - head on. A heart attack or cardiac surgery may mean a sudden turning point - a dramatic shift in direction imposed upon one's life. A diagnosis of heart disease may be experienced as an interruption that demands rather than gently facilitates change. Thoughts about autonomy, purpose and competence may be replaced by thoughts of loss - loss of vigor, loss of control, loss of identity.

In The Beginning... Who Am I Now?

Physical	Unable to do what you once did More easily fatigued Less vigorous Loss of confidence
Employment	Work limited to part time Unexpected, unplanned retirement No longer "contributing" Loss of self-worth Fearful of letting your workmates know you have heart disease
Life Role	No longer the provider Less of a partner/helper than you once were See self as a "burden" rather than an asset Dependent on others
Financial	Unexpected medical expenses Loss of earnings Loss in status Uncertain future
Emotional	Loss of control Sadness, fear

The Struggle May Be the Path - Growth May be the Reward...
If the time since your diagnosis of heart disease has been relatively short, concerns in any or all of these areas might be viewed as normal. As weeks and months go by, thoughts and feelings related to loss and vulnerability may be far less potent. You may begin to see yourself in more positive ways - relationships and personal values may strengthen. Lawrence Calhoun and Richard Tedeschi* report that when we're faced with loss, personal growth is apt to follow. It may not be the loss itself that helps us to grow but rather how we manage the struggle associated with loss that facilitates change. These investigators suggest that for those with psychological "room to grow" and some capacity to adapt to loss, greater meaning or purpose and enthusiasm for life may be found.

"No Big Deal"...Not Coping Very Well or...Somewhere in Between...
When there's an appearance of "sailing" right through illness with barely any disruption in life, the experience may be reported as "no big deal" - very little was changed and very little is learned. On the other hand, for those who fail to cope successfully, psychological stress may foster the development of medical complications. For those in the middle, not exactly "sailing through" but making every effort, somehow able to cope, adversity may be the prompt needed for fresh thinking - fresh thinking about what matters most in life, about who matters most, and about lifestyle changes that offer the promise of greater health and vitality. These "middle" people, facing the struggle of recovery will take advantage of this "room to grow". Threatened with a sense of loss as to who or what they once were might encourage the inner search that reveals new views of the self or new ways of doing things - now equally or more rewarding than the old. An example of growth offered by Calhoun and Tedeschi* would be an, "increased sense that life is fragile and hence very precious", indicating greater levels of gratitude for life - ultimately a positive effect and one we often see in those diagnosed with heart disease. Since the onset of your illness, is there a way that you might be thinking differently than you had before - a way that might encourage you to live life more fully?

In a study of life-changing experiences reviewed by Elaine Wethington problems with health and health habits ranked highest in impact for both men and women. The negative effect of being given troubling health information was associated with (in rank order); (1) Learned what was important in life; (2) Depression/Life out of control; (3) Learned new things about the self, others. Fortunately, the negative situations also had positive effects. For example, both men and women felt greater self-mastery after "learning something upsetting about themselves". Many experienced greater self-confidence. It was concluded that successful coping with a stressful life event, seeing one's self as having overcome or face the health challenge, was what led to a valuable and ultimately positive "psychological turning point".

Behavioral Scientists Speak - These are Positive Outcomes You May Find as a Result of Loss...

• Feel more connected to others
• Greater empathy
• Quality of relationships improved
• Greater self-esteem
• Find greater meaning in life
• Greater self-acceptance
• Greater sense of personal mastery
• More easily able to express emotions
• Self-confidence
• Appreciation for what matters most
• Values strengthened
• Emphasis on simplicity, balance
• Self-knowledge

Ways of Thinking...
Developing more flexible ways of thinking - including the views you've held about yourself - may be one way to aid the process of growth. Teachings in Cognitive Therapy often refer to and quote the philosopher, Epictetus, who said, "What disturbs human beings is not the things themselves, but their conceptions of things." Perception, and subsequently the way you feel, will be tied to the words you use to describe yourself and your illness. Perhaps, for example, rather than thinking about what you may have lost, you may ask yourself, "What has been gained?" Perhaps vulnerability that in the past would have been viewed as "weakness" might now be seen as courage - after all, it takes courage to admit vulnerability. Perhaps before your diagnosis self-worth was attached to the work you do. Now you may see yourself as having worth measured far beyond what it is you've done for a living. You may see that your need for approval was directing your life. Life now is so much more than what others think of you. Perhaps you see value in living more simply, more balanced. Perhaps seeing yourself as fragile allows you to have greater compassion for the fragility in others. Is it possible with some of the new ways of perceiving yourself and others that you have an opportunity to live more successfully, more freely, more satisfied than at any time before?

Ways of Behaving...

The way you behave and the way you perceive your behavior during recovery may also contribute to growth. Are you focusing on what you cannot do or what you can do? Can you allow yourself to go slowly? Perhaps you might spend time doing things that provide you with a sense of peace. A daily walk or time in a cardiac rehabilitation program (if either has been prescribed by your physician) is likely to renew and bolster self-confidence. Feeling discouraged or fearful but still tackling the day may enhance your sense of personal mastery. Offering and receiving support in a cardiac support group may hasten recovery as you see others going through a similar challenge - even if "independent" and autonomous was the only person you knew yourself to be. Behaving differently = perceiving differently = feeling differently.

The Greatest Test Yet...
We may go through life thinking of ourselves as hardy - we can "take it". We get up each day and do our best. We see ourselves cope well with what life sends our way. We manage to get the job done. We're willing, cooperative, and energetic. We're determined and persistent. But then there may be a time - there may be a time when you see for the first time - that you really have to step up to the plate - it may not be so easy. This is a time when your natural strength may not be enough. This time you have to try harder, you have to reach way down inside to find the strength you need to meet this test - to recover - to get through this difficult time. This may be the time. This may be the test. This takes effort. You can do it. One day - one doctor's visit, one medication, one step, one walk, one ray of hope at a time.

Please let us hear from you.



---Austen Hayes, PhD

*Calhoun, L.G. & Tedeschi, R.G. (2001) Posttraumatic Growth: The Positive Lessons of Loss. In R.A. Neimeyer (ed.), Meaning and reconstruction & the experience of loss (pp157 - 172). Washington, D.C.: American Psychological Association

Topic: Maintaining Perspective

How Do You Apply Your Mind?
What Are You Making Important?

Taking charge of the way you respond mentally to the challenges you're faced with every day gives you an opportunity to create a more physiologically balanced environment for your heart. The way you look at life, the way you perceive experiences moment to moment, can have a major influence on the functioning of your cardiovascular system.

Maintaining balance in thinking, achieving "physiological coherence", is not always easy. It requires self-awareness as you begin to take a good LOOK at what it is that you find difficult, observe the way you RESPOND to the difficulty, and then PERSIST in your practice of responding with greater competence and calm. Life is filled with imbalance! Things don't go as you had hoped, others don't do things as you had expected, efforts are thwarted, and goals are delayed. This is life and life is what we're fighting for here!

If Your Standards in Life Are High...

...you may expect that things should be done "well" if they're done at all. People should follow a protocol of good manners, consideration for others, honesty ……people should pick up their trash, take better care of themselves, they should "know better". People should never fail to do something they say they will do. They should take greater pride in their work, they should never promise a phone call if they don't follow through - these are the "rules" of living - why can't people just follow the "rules!?"

If You Always Do Your Best in Whatever it Is You Do...

...you may expect things to go as planned - for example, you "plan" to get to a meeting on time but a flat tire holds you up and you arrive late. You're intolerant of anyone who's late, including yourself - you feel, annoyed, frustrated, the day starts badly. You hire someone to do a job for you and they fail to show up on the expected day and you can't "believe" that someone could behave this way. The expert computer technician "fixes" your computer. You set aside an entire day to catch up on work that must be done - when you attempt to turn on the computer - nothing happens - it's worse than it was before it was "fixed"! How can people be so "incompetent"? What do you do? How do you react?

If It's Important to You That You Make a Good Impression on Others...

...how do you respond when you're criticized or rejected? Perhaps you receive negative comments regarding a project you're working on, or someone you ask to have dinner with you turns you down with a complete lack of interest, or a "higher up" you've been trying to impress in your company passes you by at the club then fails to recognize you when you say, "hello". Someone you know comments on the weight you've gained, or the outfit you've chosen to wear - you feel wounded, hurt, or resentful. For hours you find it difficult to think of anything else other than the "insult".

Is a Wise Heart a Healthy Heart?

If you think of yourself as the type who handles life's "big" challenges well, but you respond intensely and negatively to the "little" things, if you're easily offended, if things people do just seem to "annoy" you a lot of the time - your emotions are far from "balanced" and your physical reactions are likely to be turbulent. Perhaps what you've learned to treat as VERY important is not REALLY that important at all. Perhaps you spend too much time ATTENDING (applying your mind) to things that ultimately mean little in your life one way or the other. Keeping things in PERSPECTIVE and choosing to ATTEND to what truly matters are signs of strength of character. PERSPECTIVE is akin to WISDOM. When we're wise we choose carefully, we discriminate, we think before we leap. In their "Classification of Strengths", Christopher Peterson and Nansook Park,* offer a list of cognitive and behavioral practices forming the underpinnings of wisdom: thinking CREATIVELY using, "novel and productive ways to do things"; being CURIOUS as one "explores and discovers" experience in life; making use of JUDGMENT and CRITICAL THINKING as one "thinks things through", avoids, "jumping to conclusions"; embraces opportunity for LEARNING, "mastering new skills and bodies of knowledge"; and finally, practices PERSPECTIVE, as "ways of looking at the world that make sense". With a commitment to good health, deciding that you want to change the way you live to save your heart, priorities may shift. You may find yourself in "transition" from the person you were to the person you would prefer to be. Fostering new ways of thinking and behaving - approaching life with curiosity, developing fresh assumptions about the self and others, becoming a more deliberate thinker, less "automatic", deciding what's best to pay ATTENTION to and what can be ignored, and mastering PERSPECTIVE as you more "correctly" regard the importance of things, can be important steps towards change.

If you think about the way you feel physically when you see yourself losing PERSPECTIVE, you know instinctively this can't be good for you. In those moments when you react to the driver who cuts in front of you, with anger, "steaming", "blood boiling", "seething", because you've been treated in a way that suggests you're not important, your needs don't matter - what you've done is make your place in traffic and the way the other driver is "disrespecting" you, more important than anything - more important than peace of mind, more important than your heart. Conversely, if you're able to respond to this challenge with calm and self-assurance, you may be protecting your body from exposure to the action of potentially damaging stress hormones, - adrenaline and cortisol. Your calm response acts as a buffer helping to maintain good health and good heart function. Your calm response builds on itself as in that moment you feel a sense of mastery, a sense of control over your life - you've taken charge, made a CHOICE about how it is you WANT to react. Your independent of the trigger - it hasn't ruled you.

"How do I do things differently?" ...Solutions for Change

How do you get to the "calm" response? In the example of others' poor driving habits, if you recognize that they're a trigger for you - you're ahead of the game. You can plan, you can "rehearse" the way you want to respond the moment you get into your car. You can think of a different way to look at bad drivers. First, what are your expectations? If you seem angry and "amazed" when you see an example of bad driving, then your expectations may be unrealistic. You've probably encountered many, many examples of poor driving behavior - why would you find it, "unbelievable" when you see it again? If when you start your auto, you remind yourself that it's highly likely that you may encounter some form of driving behavior that isn't courteous or safe you'll be more prepared for what you see and you're likely to react more calmly. If you further remind yourself that getting angry at the other driver does nothing to change his or her behavior and that the most responsible thing YOU can do is remain calm behind the wheel, you'll feel more confident and relaxed. Avoid "looking" for mistakes. Looking for others' to behave badly puts you in a state of vigilance that may raise blood pressure, constrict vessels, and create turbulence within your arterial system. Ask yourself, "What IS most important to me"? If you tell yourself today that on the trip to the office you're going to pay ATTEN