Promoting health begins with implementing strategies that prevent illness and enhance wellness. Traditionally, people have thought about their health only when something goes wrong—visiting a physician for diagnosis and treatment. That, say health psychologists, is like ignoring a car’s maintenance and going to a mechanic only when the car breaks down. Health maintenance includes alleviating stress, preventing illness, and promoting well-being.

12-18 In what two ways do people try to alleviate stress?

Stressors are unavoidable. This fact, coupled with the fact that persistent stress correlates with heart disease, depression, and lowered immunity, gives us a clear message. We need to learn to cope with the stress in our lives, alleviating it with emotional, cognitive, or behavioral methods. We address some stressors directly, with problem-focused coping. If our impatience leads to a family fight, we may go directly to that family member to work things out. We tend to use problem-focused strategies when we feel a sense of control over a situation and think we can change the circumstances, or at least change ourselves to deal with the circumstances more capably. We turn to emotion-focused coping when we believe we cannot change a situation. If, despite our best efforts, we cannot get along with that family member, we may relieve stress by reaching out to friends for support and comfort.

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When challenged, some of us tend to respond with cool problem-focused coping, others with emotion-focused coping (Connor-Smith & Flachsbart, 2007). Our feelings of personal control, our explanatory style, and our supportive connections all influence our ability to cope successfully.

12-19 How does a perceived lack of control affect health?

Picture the scene: Two rats receive simultaneous shocks. One can turn a wheel to stop the shocks (as illustrated in FIGURE 12.28). The helpless rat, but not the wheel turner, becomes more susceptible to ulcers and lowered immunity to disease (Laudenslager & Reite, 1984). In humans, too, uncontrollable threats trigger the strongest stress responses (Dickerson & Kemeny, 2004).

At times, we all feel helpless, hopeless, and depressed after experiencing a series of bad events beyond our control. Martin Seligman and his colleagues have shown that for some animals and people, a series of uncontrollable events creates a state of learned helplessness, with feelings of passive resignation (FIGURE 12.29). In one series of experiments, dogs were strapped in a harness and given repeated shocks, with no opportunity to avoid them (Seligman & Maier, 1967). Later, when placed in another situation where they could escape the punishment by simply leaping a hurdle, the dogs cowered as if without hope. Other dogs that had been able to escape the first shocks reacted differently. They had learned they were in control and easily escaped the shocks in the new situation (Seligman & Maier, 1967). In other experiments, people have shown similar patterns of learned helplessness (Abramson et al., 1978, 1989; Seligman, 1975).

Perceiving a loss of control, we become more vulnerable to ill health. A famous study of elderly nursing home residents with little perceived control over their activities found that they declined faster and died sooner than those given more control (Rodin, 1986). Workers able to adjust office furnishings and control interruptions and distractions in their work environment have also experienced less stress (O’Neill, 1993). Such findings help explain why British civil service workers at the executive grades have tended to outlive those at clerical or laboring grades, and why Finnish workers with low job stress have been less than half as likely to die of strokes or heart disease as were those with a demanding job and little control. The more control workers have, the longer they live (Bosma et al., 1997, 1998; Kivimaki et al., 2002; Marmot et al., 1997).

Control also helps explain a link between economic status and longevity (Jokela et al., 2009). In one study of 843 grave markers in an old graveyard in Glasgow, Scotland, those with the costliest, highest pillars (indicating the most affluence) tended to have lived the longest (Carroll et al., 1994). Likewise, those living in Scottish regions with the least overcrowding and unemployment have the greatest longevity. There and elsewhere, high economic status predicts a lower risk of heart and respiratory diseases (Sapolsky, 2005). Wealth predicts better health among children, too (Chen, 2004). With higher economic status come reduced risks of low birth weight, infant mortality, smoking, and violence. Even among other primates, those at the bottom of the social pecking order have been more likely than their higher-status companions to become sick when exposed to a cold-like virus (Cohen et al., 1997). But for those high-status baboons and monkeys who frequently have to physically defend their dominant position, high status also entails stress (Sapolsky, 2005).

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Why does perceived loss of control predict health problems? Because losing control provokes an outpouring of stress hormones. When rats cannot control shock or when primates or humans feel unable to control their environment, stress hormone levels rise, blood pressure increases, and immune responses drop (Rodin, 1986; Sapolsky, 2005). One study found these effects among nurses, who reported their workload and their level of personal control on the job. The greater their workload, the higher their cortisol level and blood pressure—but only among nurses who reported little control over their environment (Fox et al., 1993). Another study found that captive animals experienced more stress and were more vulnerable to disease than their wild counterparts (Roberts, 1988). The crowding that occurs in high-density neighborhoods, prisons, and college and university dorms is another source of diminished feelings of control—and of elevated levels of stress hormones and blood pressure (Fleming et al., 1987; Ostfeld et al., 1987). By boosting feelings of control, people often lead happier and healthier lives (Ng et al., 2012).

Increasing control—allowing prisoners to move chairs and to control room lights and the TV; having workers participate in decision making; allowing people to personalize their work space—has noticeably improved health and morale (Humphrey et al., 2007; Krueger & Killham, 2006; Ruback et al., 1986; Warburton et al., 2006).

In the case of nursing home patients, 93 percent of those who were encouraged to exert more control became more alert, active, and happy (Rodin, 1986). As researcher Ellen Langer concluded, “Perceived control is basic to human functioning” (1983, p. 291). “For the young and old alike,” she suggested, environments should enhance people’s sense of control over their world. No wonder mobile devices and DVRs, which enhance our control of the content and timing of our entertainment, are so popular.

Google incorporates these principles effectively. Each week, Google employees can spend 20 percent of their working time on projects they find personally interesting. This Innovation Time Off program increases employees’ personal control over their work environment, and it has paid off. Gmail was developed this way.

People thrive when they live in conditions of personal freedom and empowerment. At the national level, citizens of stable democracies report higher levels of happiness (Inglehart et al., 2008).

So, some freedom and control are better than none. But does ever-increasing choice breed ever-happier lives? Some researchers have suggested that today’s Western cultures offer an “excess of freedom”—too many choices. The result can be decreased life satisfaction, increased depression, or even behavior paralysis (Schwartz, 2000, 2004). In one study, people offered a choice of one of 30 brands of jam or chocolate were less satisfied with their decision than were others who had chosen from only 6 options (Iyengar & Lepper, 2000). This tyranny of choice brings information overload and a greater likelihood that we will feel regret over some of the things we left behind. (Do you, too, ever waste time agonizing over too many choices?)

Internal Versus External Locus of Control If experiencing a loss of control can be stressful and unhealthy, do people who generally feel in control of their lives enjoy better health? Consider your own feelings of control. Do you believe that your life is beyond your control? That the world is run by a few powerful people? That getting a good job depends mainly on being in the right place at the right time? Or do you more strongly believe that you control your own fate? That each of us can influence our government’s decisions? That being a success is a matter of hard work?

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Hundreds of studies have compared people who differ in their perceptions of control. On the one side are those who have what Julian Rotter called an external locus of control, the perception that chance or outside forces control their fate. On the other side are those who perceive an internal locus of control, who believe they control their own destiny. In study after study, the “internals” have achieved more in school and work, acted more independently, enjoyed better health, and felt less depressed than did the “externals” (Lefcourt, 1982; Ng et al., 2006). In one long-term study of more than 7500 people, those who had expressed a more internal locus of control at age 10 exhibited less obesity, lower blood pressure, and less distress at age 30 (Gale et al., 2008).

Another way to say that we believe we are in control of our own life is to say we have free will, or that we can control our own willpower. Studies show that people who believe in their freedom learn better, perform better at work, behave more helpfully, and have a stronger desire to punish rule breakers (Clark et al., 2014; Job et al., 2010; Stillman et al., 2010).

Compared with their parents’ generation, more young Americans now endorse an external locus of control (Twenge et al., 2004). This shift may help explain an associated increase in rates of depression and other psychological disorders in young people (Twenge et al., 2010).

Depleting and Strengthening Self-Control

12-20 How can our self-control be depleted, and why is it important to build this strength?

Self-control is the ability to control impulses and delay short-term gratification for longer-term rewards. In studies, self-control predicts good health, higher income, and better grades (Kuhnle et al., 2012; Moffitt et al., 2011). In one study that followed eighth-graders over a school year, better self-control was more than twice as important as intelligence score in predicting academic success (Duckworth & Seligman, 2005).

Self-control is constantly changing—from day to day, hour to hour, and even minute to minute. Like a muscle, self-control weakens after use, recovers after rest, and grows stronger with exercise (Baumeister & Tierney, 2011; Hagger et al., 2010; Vohs & Baumeister, 2011). Exercising willpower temporarily depletes the mental energy needed for self-control on other tasks (Vohs et al., 2012). In one experiment, hungry people who had resisted the temptation to eat chocolate chip cookies abandoned a tedious task sooner than those who had not resisted the cookies. And after expending willpower on laboratory tasks, such as stifling prejudice or ignoring flashing words on a computer screen, people were less restrained in their aggressive responses to provocation and in their sexuality (Finkel et al., 2012; Gaillot & Baumeister, 2007). Similar self-control weakening happens when people flex their self-control muscle outside the laboratory, such as when people try to control their alcohol use (Hofmann et al., 2012).

Exercising willpower decreases neural activation in regions associated with mental control (Wagner et al., 2013). Might sugar provide a sweet solution to self-control fatigue? Sugar not only makes us feel good, it also increases neural activation in mental control regions (Chambers et al., 2009). In several studies, giving sugar (in a naturally rather than an artificially sweetened lemonade) had a sweet effect: It strengthened people’s effortful thinking and reduced their financial impulsiveness (Masicampo & Baumeister, 2008; Wang & Dvorak, 2010). Even dogs can experience self-control depletion and rejuvenation with sugar (Miller et al., 2010).

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Researchers do not encourage candy bar diets to improve self-control. Simply rinsing your mouth with sugary liquid can give you the mental energy you need (Hagger & Chatzisarantis, 2013; Sanders et al., 2012). You will get the boost in self-control without the bulge in your waistline.

Decreased mental energy after exercising self-control is a short-term effect. The long-term effect of exercising self-control is increased self-control, much as a hard physical workout leaves you temporarily tired out, but stronger in the long term. Strengthened self-control improves people’s performance on laboratory tasks and improves their self-management of eating, drinking, anger, and household chores (Denson et al., 2011; Oaten & Cheng, 2006a,b).

The point to remember: Develop self-discipline in one area of your life, and your strengthened self-control may spill over into other areas as well, making for a healthier, happier, and more successful life.

12-21 How does an optimistic outlook affect health and longevity?

In The How of Happiness, psychologist Sonja Lyubomirsky (2008) tells the true story of Randy. By any measure, Randy lived a hard life. His dad and best friend died by suicide. Growing up, his mother’s boyfriend treated him poorly. Randy’s own first marriage was troubled. His wife was unfaithful, and they divorced. Despite these setbacks, Randy is a happy person whose presence can light up a room. He remarried and enjoys his role as stepfather to three boys. He also finds his work life to be rewarding. Randy says he survived his life challenges by seeing the “silver lining in the cloud.”

Randy’s story illustrates how our outlook—what we expect from the world—influences how we cope with stress. Pessimists expect things to go badly (Aspinwall & Tedeschi, 2010; Carver et al., 2010; Rasmussen et al., 2009). When bad things happen, pessimists knew it all along. They attribute their poor performance to a basic lack of ability (“I can’t do this”) or to situations enduringly beyond their control (“There is nothing I can do about it”). Optimists, such as Randy, expect to have more control, to cope better with stressful events, and to enjoy better health (Aspinwall & Tedeschi, 2010; Boehm & Kubzansky, 2012; Carver et al., 2010). During a semester’s last month, students previously identified as optimistic reported less fatigue and fewer coughs, aches, and pains. And during the stressful first few weeks of law school, those who were optimistic (“It’s unlikely that I will fail”) enjoyed better moods and stronger immune systems (Segerstrom et al., 1998). Optimists also respond to stress with smaller increases in blood pressure, and they recover more quickly from heart bypass surgery.

Optimistic students have also tended to get better grades because they often respond to setbacks with the hopeful attitude that effort, good study habits, and self-discipline make a difference (Noel et al., 1987; Peterson & Barrett, 1987). When dating couples wrestle with conflicts, optimists and their partners see each other as engaging constructively, and they then tend to feel more supported and satisfied with the resolution and with their relationship (Srivastava et al., 2006). Optimism also relates to well-being and success in China and Japan (Qin & Piao, 2011). Realistic positive expectations fuel motivation and success (Oettingen & Mayer, 2002).

Consider the consistency and startling magnitude of the optimism and positive emotions factor in several other studies:

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Optimism runs in families, so some people truly are born with a sunny, hopeful outlook. With identical twins, if one is optimistic, the other often will be as well (Mosing et al., 2009). One genetic marker of optimism is a gene that enhances the social-bonding hormone oxytocin (Saphire-Bernstein et al., 2011).

The good news is that all of us, even the most pessimistic, can learn to become more optimistic. Compared with pessimists who simply kept diaries of their daily activities, those who became skilled at seeing the bright side of difficult situations and viewing their goals as achievable reported lower levels of depression (Sergeant & Mongrain, 2014). Optimism is the light bulb that can brighten anyone’s mood.

12-22 How does social support promote good health?

Social support—feeling liked and encouraged by intimate friends and family—promotes both happiness and health. In massive investigations, some following thousands of people for several years, close relationships have predicted health. People are less likely to die early if supported by close relationships (Uchino, 2009). When Brigham Young University researchers combined data from 148 studies totaling more than 300,000 people worldwide, they confirmed a striking effect of social support (Holt-Lunstad et al., 2010). Those with ample social connections had survival rates about 50 percent greater than those with meager connections. The impact of meager connections appeared roughly equal to the effect of smoking 15 cigarettes a day or having an alcohol use disorder, and double the effect of not exercising or being obese. A small taste of acceptance, such as through small talk, can lengthen life expectancy (Steptoe et al., 2013). People aren’t the only creatures to benefit from friends. Among baboons, strong social bonds with relatives and friends similarly predict longevity (Silk et al., 2010).

People need people. Some fill this need by connecting with friends, family, co-workers, members of a faith community, or other support groups. The need to belong is so strong that people will sometimes risk their health to gain social acceptance (Rawn & Vohs, 2011). Others connect in positive, happy, supportive marriages. In one analysis of more than 72,000 individuals, people in low-conflict marriages lived longer, healthier lives than the unmarried (Robles et al., 2014). One seven-decade-long study found that at age 50, healthy aging was better predicted by a good marriage than by a low cholesterol level (Vaillant, 2002). On the flip side, divorce predicts poor health. In one analysis of 32 studies involving more than 6.5 million people, divorced people were 23 percent more likely to die early (Sbarra et al., 2011).

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What explains the link between social support and health? Are middle-aged and older adults who live alone more likely to smoke, be obese, and have high cholesterol—and therefore to have a doubled risk of heart attacks (Nielsen et al., 2006)? Or are healthy people more supportive and marriage-prone? Possibly. But research indicates some other possibilities.

Social support calms us and reduces blood pressure and stress hormones. Numerous studies support this finding (Hostinar et al., 2014; Uchino et al., 1996, 1999). To see if social support might calm people’s response to threats, one research team subjected happily married women, while lying in an fMRI machine, to the threat of electric shock to an ankle (Coan et al., 2006). During the experiment, some women held their husband’s hand. Others held the hand of an unknown person or no hand at all. While awaiting the occasional shocks, women holding their husband’s hand showed less activity in threat-responsive areas. This soothing benefit was greatest for those reporting the highest-quality marriages. Supportive family and friends—human and nonhuman—help buffer threats. After stressful events, Medicare patients who have a dog or other companionable pet are less likely to visit their doctor (Siegel, 1990).

Social support fosters stronger immune functioning. Volunteers in studies of resistance to cold viruses showed this effect (Cohen et al., 1997, 2004). Healthy volunteers inhaled nasal drops laden with a cold virus and were quarantined and observed for five days. (In these experiments, more than 600 volunteers received $800 each to endure this experience.) Age, race, sex, smoking, and other health habits being equal, those with the most social ties were least likely to catch a cold. If they did catch one, they produced less mucus. More sociability meant less susceptibility. The cold fact is that the effect of social ties is nothing to sneeze at!

Close relationships give us an opportunity for “open heart therapy,” a chance to confide painful feelings (Frattaroli, 2006). Talking about a stressful event can temporarily arouse us, but in the long run it calms us, by calming limbic system activity (Lieberman et al., 2007; Mendolia & Kleck, 1993). In one study, 33 Holocaust survivors spent two hours recalling their experiences, many in intimate detail never before disclosed (Pennebaker et al., 1989). In the weeks following, most watched a tape of their recollections and showed it to family and friends. Those who were most self-disclosing had the most improved health 14 months later. Confiding is good for the body and the soul. In another study of surviving spouses of people who had committed suicide or died in car accidents, those who bore their grief alone had more health problems than those who could express it openly (Pennebaker & O’Heeron, 1984).

Suppressing emotions can be detrimental to physical health. When health psychologist James Pennebaker (1985) surveyed more than 700 undergraduate women, about 1 in 12 of them reported a traumatic sexual experience in childhood. The sexually abused women—especially those who had kept their secret to themselves—reported more headaches and stomach ailments than did other women who had experienced nonsexual traumas, such as parental death or divorce. Another study, of 437 Australian ambulance drivers, confirmed the ill effects of suppressing one’s emotions after witnessing traumas (Wastell, 2002).

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Even writing about personal traumas in a diary can help (Burton & King, 2008; Hemenover, 2003; Lyubomirsky et al., 2006). In an analysis of 633 trauma victims, writing therapy was as effective as psychotherapy in reducing psychological trauma (van Emmerik et al., 2013). In another experiment, volunteers who wrote trauma diaries had fewer health problems during the ensuing four to six months (Pennebaker, 1990). As one participant explained, “Although I have not talked with anyone about what I wrote, I was finally able to deal with it, work through the pain instead of trying to block it out. Now it doesn’t hurt to think about it.”

If we are aiming to exercise more, drink less, quit smoking, or be a healthy weight, our social ties can tug us away from or toward our goal. If you are trying to achieve some goal, think about whether your social network can help or hinder you. That social net covers not only the people you know but friends of your friends, and friends of their friends. That’s three degrees of separation between you and the most remote people. Within that network, others can influence your thoughts, feelings, and actions without your awareness (Christakis & Fowler, 2009). Obesity, for example, spreads within networks in ways that seem not merely to reflect people’s seeking out similar others.

Having a sense of control, developing more optimistic thinking, and building social support can help us experience less stress and thus improve our health. Moreover, these factors interrelate: People who have been upbeat about themselves and their future have tended also to enjoy health-promoting social ties (Stinson et al., 2008). But sometimes we cannot alleviate stress and simply need to manage our stress. Aerobic exercise, relaxation, meditation, and spiritual communities may help us gather inner strength and lessen stress effects.

12-23 How effective is aerobic exercise as a way to manage stress and improve well-being?

Aerobic exercise is sustained, oxygen-consuming, exercise—such as jogging, swimming, or biking—that increases heart and lung fitness. It’s hard to find bad things to say about exercise. By one estimate, moderate exercise adds not only to your quantity of life—two additional years, on average—but also to your quality of life, with more energy and better mood (Seligman, 1994; Wang et al., 2011).

Exercise helps fight heart disease by strengthening the heart, increasing bloodflow, keeping blood vessels open, and lowering both blood pressure and the blood pressure reaction to stress (Ford, 2002; Manson, 2002). Compared with inactive adults, people who exercise suffer half as many heart attacks (Powell et al., 1987; Visich & Fletcher, 2009). Exercise makes the muscles hungry for the fats that, if not used by the muscles, contribute to clogged arteries (Barinaga, 1997). In one study of over 650,000 American adults, walking 150 minutes per week predicted living seven more years (Moore et al., 2012). People who avoid sedentary activities, such as watching television, also tend to live longer lives (Veerman et al., 2012; Wilmot et al., 2012).

The genes passed down to us from our distant ancestors were those that enabled the physical activity essential to hunting, foraging, and farming (Raichlen & Polk, 2013). In muscle cells, those genes, when activated by exercise, respond by producing proteins. In the modern inactive person, these genes produce lower quantities of proteins and leave us susceptible to more than 20 chronic diseases, such as type 2 diabetes, coronary heart disease, stroke, Alzheimer’s disease, and cancer (Booth & Neufer, 2005). Inactivity is thus potentially toxic. But physical activity can weaken the influence of some genetic risk factors. In one analysis of 45 studies, the risk of obesity fell by 27 percent (Kilpeläinen et al., 2012).

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Does exercise also boost the spirit? Many studies reveal that aerobic exercise can reduce stress, depression, and anxiety. Americans, Canadians, and Britons who do aerobic exercise at least three times a week manage stress better, exhibit more self-confidence, feel more vigor, and feel less depressed and fatigued than their inactive peers (McMurray, 2004; Mead et al., 2010; Puetz et al., 2006; Smits et al., 2011). Going from active exerciser to couch potato can increase the likelihood of depression—by 51 percent in two years for the women in one study (Wang et al., 2011). And in a 21-country survey of university students, physical exercise was a “strong” and consistent predictor of life satisfaction (Grant et al., 2009).

But we could state this observation another way: Stressed and depressed people exercise less. These findings are correlations, and cause and effect are unclear. To sort out cause and effect, researchers experiment. They randomly assign stressed, depressed, or anxious people either to an aerobic exercise group or to a control group. Next, they measure whether aerobic exercise (compared with a control activity) produces a change in stress, depression, anxiety, or some other health-related outcome. One classic experiment randomly assigned mildly depressed female college students to three groups. One-third participated in a program of aerobic exercise. Another third took part in a program of relaxation exercises. The remaining third (the control group) formed a no-treatment group (McCann & Holmes, 1984). As FIGURE 12.30 shows, 10 weeks later, the women in the aerobic exercise program reported the greatest decrease in depression. Many had, quite literally, run away from their troubles.

Dozens of other experiments confirm that exercise prevents or reduces depression and anxiety (Conn, 2010; Rethorst et al., 2009; Windle et al., 2010). Moreover, exercise is not only as effective as drugs, it may better prevent symptom recurrence (Babyak et al., 2000; Salmon, 2001). When experimenters randomly assigned depressed people to an exercise group, an antidepressant group, or a placebo pill group, exercise diminished depression levels as effectively as antidepressants—and with longer-lasting effects (Hoffman et al., 2011).

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Vigorous exercise provides a substantial and immediate mood boost (Watson, 2000). Even a 10-minute walk stimulates 2 hours of increased well-being by raising energy levels and lowering tension (Thayer, 1987, 1993). How does exercise work its magic? In some ways, exercise works like an antidepressant drug. It increases arousal, thus counteracting depression’s low arousal state. It often leads to muscle relaxation and sounder sleep. It also orders up mood-boosting chemicals from our body’s internal pharmacy—neurotransmitters such as norepinephrine, serotonin, and the endorphins (Jacobs, 1994; Salmon, 2001). And it may foster neurogenesis. In mice, exercise causes the brain to produce a molecule that stimulates the production of new, stress-resistant neurons (Hunsberger et al., 2007; Reynolds, 2009; van Praag, 2009).

On a simpler level, the sense of accomplishment and improved physique and body image that often accompany a successful exercise routine may enhance one’s self-image, leading to a better emotional state. Exercise (at least a half-hour on five or more days of the week) is like a drug that prevents and treats disease, increases energy, calms anxiety, and boosts mood—a drug we would all take, if available. Yet few people (only 1 in 4 in the United States) take advantage of it (Mendes, 2010).

12-24 In what ways might relaxation and meditation influence stress and health?

Knowing the damaging effects of stress, could we learn to counteract our stress responses by altering our thinking and lifestyle? In the late 1960s, some respected psychologists began experimenting with biofeedback, a system of recording, amplifying, and feeding back information about subtle physiological responses, many controlled by the autonomic nervous system. Biofeedback instruments mirror the results of a person’s own efforts, enabling the person to learn which techniques do (or do not) control a particular physiological response. After a decade of study, however, the initial claims for biofeedback seemed overblown and oversold (Miller, 1985). In 1995, a National Institutes of Health panel declared that biofeedback works best on tension headaches.

Simple methods of relaxation, which require no expensive equipment, produce many of the results biofeedback once promised. Figure 12.30 pointed out that aerobic exercise reduces depression. But did you notice in that figure that depression also decreased among women in the relaxation treatment group? More than 60 studies have found that relaxation procedures can also help alleviate headaches, hypertension, anxiety, and insomnia (Nestoriuc et al., 2008; Stetter & Kupper, 2002).

Such findings would not surprise Meyer Friedman and his colleagues. They tested relaxation in a program designed to help Type A heart attack survivors (who are more prone to heart attacks than their Type B peers) reduce their risk of future attacks. They randomly assigned hundreds of middle-aged men to one of two groups. The first group received standard advice from cardiologists about medications, diet, and exercise habits. The second group received similar advice, but they also were taught ways of modifying their lifestyles. They learned to slow down and relax by walking, talking, and eating more slowly. They learned to smile at others and laugh at themselves. They learned to admit their mistakes; to take time to enjoy life; and to renew their religious faith. The training paid off (FIGURE 12.31). During the next three years, those who learned to modify their lifestyle had half as many repeat heart attacks as did the first group. This, wrote the exuberant Friedman, was an unprecedented, spectacular reduction in heart attack recurrence. A smaller-scale British study similarly divided heart-attack–prone people into control and lifestyle modification groups (Eysenck & Grossarth-Maticek, 1991). During the next 13 years, that study also showed a 50 percent reduction in death rate among people trained to alter their thinking and lifestyle. After suffering a heart attack at age 55, Friedman started taking his own behavioral medicine—and lived to age 90 (Wargo, 2007).

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Time may heal all wounds, but relaxation can help speed that process. In one study, surgery patients were randomly assigned to two groups. Both groups received standard treatment, but the second group also experienced a 45-minute relaxation exercise and received relaxation recordings to use before and after surgery. A week after surgery, patients in the relaxation group reported lower stress and showed better wound healing (Broadbent el al., 2012).

Meditation is a modern practice with a long history. In many of the world’s great religions, meditation has been used to reduce suffering and improve awareness, insight, and compassion. Numerous studies have confirmed the psychological benefits of meditation (Goyal et al., 2014; Sedlmeier et al., 2012). Today, it has found a new home in stress management programs, such as mindfulness meditation. If you were taught this practice, you would relax and silently attend to your inner state, without judging it (Kabat-Zinn, 2001). You would sit down, close your eyes, and mentally scan your body from head to toe. Zooming your focus on certain body parts and responses, you would remain aware and accepting. You would also pay attention to your breathing, attending to each breath as if it were a material object.

Practicing mindfulness may improve many health measures. In one study of 1140 people, some received mindfulness-based therapy for several weeks. Others did not. Levels of anxiety and depression were lower among those who received the therapy (Hofmann et al., 2010). In another study, mindfulness training improved immune system functioning and coping in a group of women newly diagnosed with early-stage breast cancer (Witek-Janusek et al., 2008). Mindfulness practices have also been linked with reductions in sleep problems, cigarette use, binge eating, and alcohol and other substance use disorders (Bowen et al., 2006; Brewer et al., 2011; Cincotta et al., 2011; de Dios et al., 2012; Kristeller et al., 2006). Just 15 minutes of daily mindfulness meditation is enough to improve decision-making performance (Hafenbrack et al., 2014).

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So, what’s going on in the brain as we practice mindfulness? Correlational and experimental studies offer three explanations. Mindfulness

Exercise and meditation are not the only routes to healthy relaxation. Massage helps relax both premature infants and those suffering pain. An analysis of 17 experiments revealed another benefit: Massage therapy relaxes muscles and helps reduce depression (Hou et al., 2010).

12-25 What is the faith factor, and what are some possible explanations for the link between faith and health?

A wealth of studies—some 1800 of them in the twenty-first century’s first decade alone— has revealed another curious correlation, called the faith factor (Koenig et al., 2011). Religiously active people tend to live longer than those who are not religiously active. One such study compared the death rates for 3900 people living in two Israeli communities. The first community contained 11 religiously orthodox collective settlements; the second contained 11 matched, nonreligious collective settlements (Kark et al., 1996). Over a 16-year period, “belonging to a religious collective was associated with a strong protective effect” not explained by age or economic differences. In every age group, religious community members were about half as likely to have died as were their nonreligious counterparts. This difference is roughly comparable to the gender difference in mortality.

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How should we interpret such findings? Correlations are not cause-effect statements, and they leave many factors uncontrolled (Sloan et al., 1999, 2000, 2002, 2005). Here is another possible interpretation: Women are more religiously active than men, and women outlive men. Might religious involvement merely reflect this gender-longevity link? Apparently not. One 8-year National Institutes of Health study followed 92,395 women, ages 50 to 79. After controlling for many factors, researchers found that women attending religious services weekly (or more) experienced an approximately 20 percent reduced risk of death during the study period (Schnall et al., 2010). Moreover, the association between religious involvement and life expectancy is also found among men (Benjamins et al., 2010; McCullough et al., 2000, 2005, 2009). A 28-year study that followed 5286 Californians found that, after controlling for age, gender, ethnicity, and education, frequent religious attenders were 36 percent less likely to have died in any year (FIGURE 12.32). In another 8-year controlled study of more than 20,000 people (Hummer et al., 1999), this effect translated into a life expectancy at age 20 of 83 years for frequent attenders at religious services and 75 years for nonattendees.

These correlational findings do not indicate that nonattenders can suddenly add 8 years to their life if they start attending services and change nothing. Nevertheless, the findings do indicate that religious involvement, like nonsmoking and exercise, is a predictor of health and longevity. Can you imagine what intervening variables might account for the correlation? Research points to three possible sets of influences (FIGURE 12.33):

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