I was on a deserted street in a strange neighborhood in Brooklyn, where I had visited family. The door behind me was locked shut. It was 6:30 am. The temperature was 5°F, and the wind chill made it feel like −15°. Earlier, I had gotten a text from JetBlue: “TSA delays: arrive 2 and a half hours before your scheduled departure.” I rushed out of the house. The Lyft app reported that my driver was 4 minutes away, but after 10 minutes and an unsuccessful call to him, I called an Uber. In no time, my phone reported that he was there. Except he wasn’t. I am from Martha’s Vineyard; what did I know about Uber apps?
Cold, worried that I would miss my my plane home, not quite knowing what to do, I raced down the street to where I thought the car had gone. When I stopped, still not finding the car, I noticed that my heart rate was unnaturally high and I was a short of breath. A bit frantic, I thought about Dr. Diana Dill’s “arousal scale” (see figure 1). On a 1-to-100 scale, if 60 is the beginning of fight or flight, I was at a 70.
According to well-established research and Dr. Dill, a cognitive behavioral therapist, when our arousal measurement goes above 60, our brains lose the ability to experience pleasure, learn new information, reason, navigate challenging situations, or take care of ourselves. Over time, that high-intensity state impairs health. That morning in Brooklyn, I met all of the criteria: bitterly cold (but my coat wasn’t zipped up all the way), struggling to figure out how to correct the address on my Uber app, not thinking about how JetBlue had probably overestimated the delay, and certainly not experiencing any pleasure. Living with this increased level of adrenaline on a daily basis would definitely not be good for my health.
Diana Dill, Ed.D., shared the arousal scale with me about five years ago, when we worked together with some of the same people via video conferencing — two of us on the Vineyard, Dr. Dill in Boston. Since learning about the arousal scale, I have shared it with countless patients. I have also thought about it often from a personal perspective. Five years ago, I would have said that I hit 60 or above at least a couple of times a week. That recent morning in Brooklyn, it felt like a foreign experience. Just the awareness of the arousal scale has changed my life. On that frigid morning when I realized that I had hit 70, I calmed myself with a simple breathing exercise that the yogis call ujjayi breaths. Then my mind reflexively went to Dr. Dill’s “decatastrophizing questions.” What is the worst thing that could happen? I would miss the plane and make the next one. What is the best thing that could happen? The Uber would arrive and I would get to the plane on time. Given the range of possibilities, what is the most likely outcome? I would probably make my plane. How will I cope with the most likely outcome? No sweat. If worse comes to worst, I can spend a night with some good friends in Boston and go home the next day. Having thought it through calmly, I felt some relief.
Still above 50 when I got in the Uber, I closed my eyes, continued the ujjayi breaths and imagined my favorite walks on Martha’s Vineyard. Views of crashing waves and the vast horizon, moss-covered trails, flocks of birds moving in unison, the red-tailed hawk that regularly sits in the same tree near my home, the lush field of ferns that is always changing color and exudes a musty, sweet smell in the summer — all of these images meandered through my mind. In no time I was down to 35.
I got to the gate with an hour to spare, and then the flight was delayed by another hour due to cold weather. All of that worry got me nothing useful except a smile as I think about my unnecessary anxiety, and a good story with which to open this essay.
Take a look at figure 1 again. Think about 0 to 20 as deep relaxation and sleep; 20 to 40 as stress-free calm, 40 to 50 as focused, peak performance, 50 to 60 as performance under some stress. From 60 to 100 represents an increasing level of fight or flight, with 100 being the highest imaginable level of anxiety, fear, and stress.
Dr. Dill gives the following advice: Monitor your “arousal,” or stress level. Set the goal of having a daily average below 40. When you go above 40, even if you get in some good peak-performance time, it’s a good idea to later incorporate some recovery time into your life. Try never to go above 60 in a normal day. Take a look at figure 2. All of us should have the goal of living life on the lighter-shaded line. Over the years, I have shared the arousal scale with countless people. It is amazing how many people live their lives on the darker line. According to Dr. Dill, the longer that life is lived on the dark line in the illustration, or above, the less resilient we are, and the more prone to burnout and emotional as well as physical decline. Many people turn to overuse of drugs, alcohol, and unhealthy food or other quick escapes to provide temporary comfort. It is tiring to our brains and bodies, and it interferes with sleep, making everything snowball.
A colleague of mine once told me that anxiety is what occurs when we overestimate risk and underestimate our ability to cope with it. Ultimately, the cornerstone of overcoming anxiety or fear is found in some form of exposure therapy — repeatedly exposing oneself to a frightening thought or event in such a way that it doesn’t send the body and brain into a high-anxiety state (over 60). Just reimagining that morning in Brooklyn, replaying it in my mind with calm, allows me to feel empowered and able to address future challenges with more of a sense of mastery. This thinking is the essence of cognitive behavioral therapy.
One of my favorite CBT tools is the mnemonic “A-W-A-R-E.” The first A stands for Accept. The essence of this step is to acknowledge and understand the anxiety. Rather than fighting it, I like to speak to it: “Hello, anxiousness, I see you are here again. We’ve been around the block together before, and I know that you will be leaving in time.” (This poem by Rumi helps: bit.ly/OMMRumi.) The W in “A-W-A-R-E” stands for “Watch it”: “Oh, I see that I am becoming a little short of breath, my heart rate is going up, and my hands are growing clammy.” The second A stands for “Act as if everything is normal.” There are other expressions related to this that may have originated in the 12-step rooms: “Act as if becomes as if.” “Fake it until you make it.” By pretending that everything is normal, the part of the brain that experiences normality becomes activated. R — repeat the first three steps above. And E — Expect that it will get better because, in fact, it always does.
Dr. Dill suggests that the most effective strategy is to get professional coaching to set up a stress-management plan. But she also points out that there are four steps that anyone can take. “1) Monitor yourself. 2) Set a target daily arousal level. 3) Plan interventions. 4) Implement and assess the impact.” Finding a coach or therapist can help fine-tune a plan that includes details of all of the above.
Here are some of Dr. Dill’s tips that I have seen have an enormous impact: Change your circumstances. Nothing works as well as getting away from things that trigger stress. I certainly felt better when I got into the Uber and the driver turned up the heat. Mini-vacations, like going for a walk, closing your eyes and imagining nature, or taking a mental health day can make all the difference. If you are an emergency worker or ER doctor, of course you are going to go above 60 often, and perhaps go on automatic pilot so that you don’t need to use the planning part of your brain. But taking time afterward to relax is essential to your health.
Change your perceptions. You can do this by “decatastrophizing.” I love these questions: What is the worst thing that can happen? Can I cope with that? High stress gets in the way of using the parts of our brain that have good judgment. Dr. Dill gives the example, “Two people with the same investment portfolio see a change in the stock market. One thinks, ‘I’ve lost everything,’ and feels panicked (arousal >60). This person is thinking catastrophically. The second person thinks, ‘This is an investment strategy for the long term; there are bound to be fluctuations over the course of years.’”
Change your response. High levels of stress hormones adversely effect just about every organ in the body. Emotions go haywire. Reason goes out the window. And some of our behaviors are nuts. Why didn’t I take a few seconds to zip up my coat all the way? Breathing exercises, physical exercise, and mindful meditation, or just the act of observing ourselves, often offer immediate relief.
But maybe the most important strategy is just to take some time to do nothing. As author Amy Krouse Rosenthal said, “As kids, our stock answer to most every question was nothing. What did you do at school today? Nothing. What’s new? Nothing. Then, somewhere on the way to adulthood, we each took a 180-degree turn. We cashed in our nothing for busy. I’m starting to think that, like youth, the word nothing is wasted on the young. Maybe we should try reintroducing it into our grownup vernacular. Nothing. I say it a few times and I can feel myself becoming more quiet, decaffeinated. Nothing. Now I’m picturing emptiness, a white blanket, a couple ducks gliding on a still pond. Nothing. Nothing. Nothing. How did we get so far from it?”