Integrative Stress Management: Part 1

Q: “Can you please tell me some integrative treatments for stress?”

RK, Mumbai

A: By “stress”, I am assuming you mean the emotional effects of stressful conditions.

An integrative approach to stress would have to begin by an exploration of the causes and effects of stress in your life.

Body: What is your lifestyle like? Diet, sleep-wake cycles, use of alcohol, tobacco or other substances, the amount and nature of exercise, or lack of it, posture, and weight – all of these can cause, or be affected by, stress in your life.

Mind: Your thoughts about life and your goals in life. Your assessment of your self, and others. Your world-view. Your temperament. Your ability to understand and modulate your own emotional responses.

Spirit: Your concept of your place in the world and universe. Your feelings about the nature of life and existence. Your concept of meaning and purpose in life.

Therefore, the exploration of the causes of stress in your life will itself be revelatory. Recognition of the causes of stress will help you formulate a plan for stress management.

If you are like most urban dwellers, some useful stress management strategies are:


30 minutes a day 3/week . Plenty of research that has examined the role of aerobic exercise in improving mood. In addition, meditative exercises such as Qi Gong or Tai Chi, and Yoga asanas are useful.


There is a lot of individual variation, but in general I recommend the following diet:

50% of your calories from carbohydrates. However, eat only low glycemic index, unprocessed or minimally processed carbohydrates.

Eat vegetable protein over animal protein. Fish would be ideal but it is becoming harder to find fish that are not overly contaminated by heavy metals such as mercury. Avoid mackerel and tuna, for this reason.

Adequate hydration, with clean room temperature water. No soft drinks. Drink fruit juice if you must but only if it is not full of concentrate. Only 100% juice with no additives. And even then, remember that whole fruits are more nutritious (not to mention cheaper) than juices. Ensure that your total dietary fructose content is not more than 10% of your daily caloric intake at the most.
Remember that in many countries, several products have high fructose corn syrup (HFCS). Stay away from them (The products, not the countries).

Low sodium – not more than 3grams per day (and less than 2 g/day if you have hypertension, or heart disease). The sodium content in pre-packaged food can easily reach dead-sea proportions. This is true even for many organic and otherwise nutritious sounding products – always check the label.

Small frequent meals rather than sporadic large ones.

A daily breakfast. Yes, yes, it’s cliche. But it’s true. Breakfast is the most important meal of the day. Eat wisely and do not miss it. A good breakfast for your mood and your heart – a bowl of oats, bran, or muesli along with a tablespoon of milled flaxseed (for the omega 3 fatty acids).

The judicious use of spice – Spicy food can be good for you. Ensure that the spices are of good quality though. I will write more about spicy food in subsequent posts. Use spicy food more if you are suffering from apathy and decreased energy. Avoid spicy food if you are suffering from anxiety and restlessness.

Yogurt and other dairy products: Eat at least 2 cups of yogurt a day with live cultures. (as in bacteria, not art)

Avoid sugar – avoid sugar. Use honey as a sweetener instead if you have to.

Not more than 2 drinks at a time, and not more than 6 a week. Alcohol does have beneficial effects on the heart and mind in low doses but if you are unable to regulate your use, then abstinence is the best policy.


Ensure adequate micronutrients and vitamins, preferably from dietary sources. But sometimes supplementation with folic acid, Vitamin B complex, zinc, Calcium and Vitamin D might be indicated.
Fish oil supplements (from a manufacturer who tests for mercury and PCBs) – 2 grams per day for most people, except those with bleeding problems is a very important supplement, as well as Ashwagandha (Withania somnifera) 2- 3 grams per day for chronic anxiety (stress that has lasted for more than 1 year).

Regular Circadian Rhythms

Sleep is the most obvious manifestation of your circadian rhythm. Sleep as much as you need to feel refreshed – this is usually between 6-8 hours. Sleep and wake up at the same time everyday, preferably closer to dawn.

Pay attention to your body clock. Some people need a siesta in order to function better. If your work permits that, then by all means ensure an afternoon nap.

Body work

A daily massage with warm sesame oil is helpful in reducing stress and anxiety. If you have access to an Ayurvedic facility, Abhyangam and Shirodhara are very useful. (more about shirodhara in a subsequent post)

Also, stress affects postural muscles, resulting in shoulder pain, neck pain, and back pain. In addition a particular posture “locks-in” the mood, anchoring negative emotional energy (to borrow a new-age term) in depressed physical postures. Changing and improving your posture and gait will help your mood. The Alexander’s technique and Feldenkrais are 2 methods that are useful in this regard.


    Stress and the pressures of everyday life prevents many people from really experiencing life around them and within themselves. Through various meditation practices, you will feel a remarkable lessening of your stress.
    For example, a useful stress reduction strategy is to be mindful of, and to fully experience one’s own emotions. I will describe this and other meditations related to stress reduction in a subsequent podcast/post.

    Understanding and Changing Your Thoughts

Psychiatrists refer to this as cognitive therapy. But the basic tenets of cognitive therapy are intuitively practiced by most people. When you try and change a negative thought into a more balanced one, you are practicing cognitive therapy.

Practicing the Golden 3

    Forgiveness of yourself and others
    Acceptance of yourself and others
    Gratitude for the good in your life and for the good in everyone’s life.


    Part 2: Spirit – Transcendence of the Negative 3: Existential Fear, Guilt and Shame; The Experience of Meaning, Purpose, and Optimism

The Moment

This story is intended to be a sort of Rorschach, if you will. Read it and interpret it and your interpretation might help you understand your unconscious. Or not.

They stood out in the open, looking up at the battle in the sky.

“You afraid of dying?” she asked him.

“No,” he said, although he was lying. She knew that he was lying, and he knew that she knew that he was lying.

Then she said, “I’m scared.”

The easy manner in which she said it and snuggled into his arms belied her words and he knew that she was lying too. Her lie made him feel even more fearful but he could not reveal that to her, and so he held her in his arms for a while as they listened to the sounds of distant explosions.

Then a bomb exploded ahead of them, close enough that they fell back into ground, rolling on the grass, until they came to a stop. They were lying in a dale, and neither of them said a word. After a while, the sounds of battle stopped.

“So we are alive,” she said and stood up first, giving him a hand.

He held it but instead of standing up, he pulled her down, seized by an urge to assert his greater physical strength.

She fell down and began laughing and he looked up at her, his eyes squinting because of the sun.

“What’s so funny?” he asked.

“Everything,” she said. “We are alive, the bombing has stopped, the sun is shining, the sky is blue, and look at those birds!”

She pointed to a flock of birds that turned and swooped high above them. He suddenly felt dizzy as he watched them and had to look down. She was now looking in the direction of the lake.

“You are not thinking of…”

“No,” she said. And then she added, “But won’t it be nice to get into that cool water?”

She wasn’t asking him of course, as much as waiting for her words to work their magic. He knew already that he and she would jump into the lake soon, but he wanted to postpone it for a while longer, for as long as he possibly could.

The Emptiness of the Soul

If I had my way, I would prevent all my patients from reading Kierkegaard.

Justin (not his real name) is my age, 37, and has contemplated suicide for most of his life. Then a week ago, he says he climbed onto a bridge and was going to jump onto the oncoming traffic, but then decided to come to the hospital instead. One last try, he said.

“When I was 10, my mother told me, ‘Justin, you missed your true calling in life. You were meant to be an abortion.”

He was born an only child to parents who were depressed and preoccupied, and probably had a loveless marriage.

He recalls, “I would sit at the dinner table and my mother would pass the dishes around, my father would eat silently, and their conversation seemed scripted, polite but without any love. I wanted to slit my wrists, because I knew that I was not wanted. They tolerated me but did not love me.”

He says, “I don’t have anything, Doctor. I don’t have a wife, no kids, my job sucks and everything is meaningless. I am not going to be a Jonas Salk, or write the great American novel. People like Henry Ford, or Da Vinci, they had a purpose, they added to the world, their presence made a difference. I am insignificant, my life has no meaning, and death is inevitable.”

“So why postpone the inevitable?” I ask. Probe the wound, release the pain in a safe environment.

He looks up. “Yes, what’s the point? I have no meaning, my life has no meaning.”

“But isn’t that true for most people?” I ask.

“Well, you are a doctor, you help people, you are probably married, have kids, someone loves you.”

“We are both going to the same place,” I reply. “Death is inevitable for all of us and in the backdrop of eternity, my life has no meaning either.”

He shrugs. “I just know that I didn’t ask to be born. Nobody will care when I am gone. When I leave here, Doc, I will go home and find out what the drop should be, calculate the length of the rope and then hang myself.”

He has been in the hospital for a week. He is on antidepressants but they are not working. His problems go back to his childhood, to his genes, his biology, and his upbringing.

From what he says, his mother was depressed. Maybe his father was too. And so Justin was born into a world that was oppressive and humorless, without meaning.

“Half my life is over. I might as well end it all,” he says, and waits to see how I might deal with his anguish. And then adds, “If you discharge me from here, I will kill myself.”

He is here because he wants help. And yet, he is sure that nothing can change his perspective that life is meaningless and not worth living.

His ambivalence, his plea for help combined with his fatalism and his barely repressed anger at the world, have alienated him from the staff. He evokes anger and frustration from the staff. I feel it too. He wants help. He says he wants to kill himself, and so he has to stay in the hospital. But at the same time he says that nothing can help him short of answers to life’s ultimate questions – What is the meaning of life? What is our purpose? Why are we born?

How can I answer his questions? He is a victim of prosperity, in a sense. If he had to toil just to keep food on his table, he would not have wanted to kill himself – his natural drive for self preservation would not allow him to think of suicide. I have never seen a poor man suffering an existential crisis – his angst is different, the object of his worries more tangible.

When your belly is empty, you know what will bring you contentment. But what will fill the emptiness of your soul?

I take a few moments to process my frustration, to remind myself that I am feeling a negative “countertransference” – the feeling that can be evoked in a psychiatrist by a patient, and is often a reflection of what the patient is feeling himself. If I feel frustrated with a patient, then it’s likely that the patient is feeling that frustration. Like mirrors facing each other, emotions are reflected from patient to therapist and back.

When in doubt, reflect his feelings. If they are accurate, he may not feel so alone.

“On the one hand you want to live,” I say, cautiously. “Otherwise you would not be telling me that you wanted to kill yourself. On the other hand you don’t see the purpose of living and you want to die. You are angry. You feel that the world owes you an explanation for your existence and that if the world cannot provide it to you, you want to die. You see the world as uncaring and unfeeling, meaningless and desolate.”

“Yes, that’s right.”

I take a deep breath. “By your logic, the world is meaningless, Justin. But in that sense, it is meaningless to everyone.” I point to the stack of books by the side of his bed. “That is what the existentialists were grappling with, that we are born into this world alone, and we will leave alone. That there is no meaning, other than the meaning that we create. Meaning is not something that awaits us, but something that arises as a result of our life.”

“So, what’s the point then?”

“The world is not rejecting or unfeeling. It’s just neutral, a blank canvas on which we create our meaning and our purpose with each moment of our lives. Accepting that it’s equally meaningless for everyone can be difficult like it is for you right now.”

He is listening intently and I continue. “Or it can be liberating, because everything is equally meaningful if you can only allow yourself to experience it. You are free, if you can experience life, immerse yourself in life and when you look back at your life someday, you will see that it has meaning.”

I feel like a used car salesman, except I am selling a philosophical perspective rather than a car.
I can sense his ambivalence weakening.

But he adds, “I question everything. I question why I am here, what is the point of this or that, what is the point of anything?”

“Everything you do is part of a larger picture, like millions of pixels that come together to create a painting. And since only you can live your life, only you can create your meaning.”

“I will think about it,” he says.

And for today, that will have to be enough.

Ultimately, man should not ask what the meaning of his life is, but rather he must recognize that it is he who is asked.
Viktor Frankl

Assumptions and Denial

Denial and Assumption - 2 Common Defense Mechanisms

Denial and Assumption