determining	how	satisfied	people	are	with	their	work,	with	those	they
work	with,	and	with	those	to	whom	they	are	responsible.
The	Worst	Way	to	Motivate	Someone
The	emotional	vicissitudes	at	work	in	marriage	also	operate	in	the
workplace,	where	they	take	similar	forms.	Criticisms	are	voiced	as
personal	attacks	rather	than	complaints	that	can	be	acted	upon;	there
are	ad	hominem	charges	with	dollops	of	disgust,	sarcasm,	and
contempt;	both	give	rise	to	defensiveness	and	dodging	of
responsibility	and,	finally,	to	stonewalling	or	the	embittered	passive
resistance	that	comes	from	feeling	unfairly	treated.	Indeed,	one	of	the
more	common	forms	of	destructive	criticism	in	the	workplace,	says
one	business	consultant,	is	a	blanket,	generalized	statement	like
“You’re	screwing	up,”	delivered	in	a	harsh,	sarcastic,	angry	tone,
providing	neither	a	chance	to	respond	nor	any	suggestion	of	how	to
do	things	better.	It	leaves	the	person	receiving	it	feeling	helpless	and
angry.	From	the	vantage	point	of	emotional	intelligence,	such
criticism	displays	an	ignorance	of	the	feelings	it	will	trigger	in	those
who	receive	it,	and	the	devastating	effect	those	feelings	will	have	on
their	motivation,	energy,	and	confidence	in	doing	their	work.


their	motivation,	energy,	and	confidence	in	doing	their	work.
This	destructive	dynamic	showed	up	in	a	survey	of	managers	who
were	asked	to	think	back	to	times	they	blew	up	at	employees	and,	in


the	heat	of	the	moment,	made	a	personal	attack.
5
	The	angry	attacks
had	effects	much	like	they	would	in	a	married	couple:	the	employees
who	received	them	reacted	most	often	by	becoming	defensive,	making
excuses,	or	evading	responsibility.	Or	they	stonewalled—that	is,	tried
to	avoid	all	contact	with	the
manager	who	blew	up	at	them.	If	they
had	been	subjected	to	the	same	emotional	microscope	that	John
Gottman	used	with	married	couples,	these	embittered	employees
would	no	doubt	have	been	shown	to	be	thinking	the	thoughts	of
innocent	victimhood	or	righteous	indignation	typical	of	husbands	or
wives	who	feel	unfairly	attacked.	If	their	physiology	were	measured,
they	would	probably	also	display	the	flooding	that	reinforces	such
thoughts.	And	yet	the	managers	were	only	further	annoyed	and
provoked	by	these	responses,	suggesting	the	beginning	of	a	cycle	that,
in	the	business	world,	ends	in	the	employee	quitting	or	being	fired—
the	business	equivalent	of	a	divorce.
Indeed,	in	a	study	of	108	managers	and	white-collar	workers,	inept
criticism	was	ahead	of	mistrust,	personality	struggles,	and	disputes
over	power	and	pay	as	a	reason	for	conflict	on	the	job.
6
	An


6
	An
experiment	done	at	Rensselaer	Polytechnic	Institute	shows	just	how
damaging	to	working	relationships	a	cutting	criticism	can	be.	In	a
simulation,	volunteers	were	given	the	task	of	creating	an	ad	for	a	new
shampoo.	Another	volunteer	(a	confederate)	supposedly	judged	the
proposed	ads;	volunteers	actually	received	one	of	two	prearranged
criticisms.	One	critique	was	considerate	and	specific.	But	the	other
included	threats	and	blamed	the	person’s	innate	deficiencies,	with
remarks	like,	“Didn’t	even	try;	can’t	seem	to	do	anything	right”	and
“Maybe	it’s	just	lack	of	talent.	I’d	try	to	get	someone	else	to	do	it.”
Understandably,	those	who	were	attacked	became	tense	and	angry
and	antagonistic,	saying	they	would	refuse	to	collaborate	or	cooperate
on	future	projects	with	the	person	who	gave	the	criticism.	Many
indicated	they	would	want	to	avoid	contact	altogether—in	other
words,	they	felt	like	stonewalling.	The	harsh	criticism	made	those
who	received	it	so	demoralized	that	they	no	longer	tried	as	hard	at
their	work	and,	perhaps	most	damaging,	said	they	no	longer	felt
capable	of	doing	well.	The	personal	attack	was	devastating	to	their
morale.


morale.
Many	managers	are	too	willing	to	criticize,	but	frugal	with	praise,
leaving	their	employees	feeling	that	they	only	hear	about	how	they’re
doing	when	they	make	a	mistake.	This	propensity	to	criticism	is
compounded	by	managers	who	delay	giving	any	feedback	at	all	for


long	periods.	“Most	problems	in	an	employee’s	performance	are	not
sudden;	they	develop	slowly	over	time,”	J.	R.	Larson,	a	University	of
Illinois	at	Urbana	psychologist,	notes.	“When	the	boss	fails	to	let	his
feelings	be	known	promptly,	it	leads	to	his	frustration	building	up
slowly.	Then,	one	day,	he	blows	up	about	it.	If	the	criticism	had	been
given	earlier	on,	the	employee	would	have	been	able	to	correct	the
problem.	Too	often	people	criticize	only	when	things	boil	over,
when
they	get	too	angry	to	contain	themselves.	And	that’s	when	they	give
the	criticism	in	the	worst	way,	in	a	tone	of	biting	sarcasm,	calling	to
mind	a	long	list	of	grievances	they	had	kept	to	themselves,	or	making
threats.	Such	attacks	backfire.	They	are	received	as	an	affront,	so	the
recipient	becomes	angry	in	return.	It’s	the	worst	way	to	motivate
someone.”
The	Artful	Critique
Consider	the	alternative.
An	artful	critique	can	be	one	of	the	most	helpful	messages	a
manager	can	send.	For	example,	what	the	contemptuous	vice
president	could	have	told	the	software	engineer—but	did	not—was
something	like:	“The	main	difficulty	at	this	stage	is	that	your	plan	will


take	too	long	and	so	escalate	costs.	I’d	like	you	to	think	more	about
your	proposal,	especially	the	design	specifications	for	software
development,	to	see	if	you	can	figure	out	a	way	to	do	the	same	job
more	quickly.”	Such	a	message	has	the	opposite	impact	of	destructive
criticism:	instead	of	creating	helplessness,	anger,	and	rebellion,	it
holds	out	the	hope	of	doing	better	and	suggests	the	beginning	of	a
plan	for	doing	so.
An	artful	critique	focuses	on	what	a	person	has	done	and	can	do
rather	than	reading	a	mark	of	character	into	a	job	poorly	done.	As
Larson	observes,	“A	character	attack—calling	someone	stupid	or
incompetent—misses	the	point.	You	immediately	put	him	on	the
defensive,	so	that	he’s	no	longer	receptive	to	what	you	have	to	tell
him	about	how	to	do	things	better.”	That	advice,	of	course,	is
precisely	the	same	as	for	married	couples	airing	their	grievances.
And,	in	terms	of	motivation,	when	people	believe	that	their	failures
are	due	to	some	unchangeable	deficit	in	themselves,	they	lose	hope
and	stop	trying.	The	basic	belief	that	leads	to	optimism,	remember,	is
that	setbacks	or	failures	are	due	to	circumstances	that	we	can	do
something	about	to	change	them	for	the	better.


Harry	Levinson,	a	psychoanalyst	turned	corporate	consultant,	gives
the	following	advice	on	the	art	of	the	critique,	which	is	intricately
entwined	with	the	art	of	praise:
•
Be	specific
.	Pick	a	significant	incident,	an	event	that	illustrates	a
key	problem	that	needs	changing	or	a	pattern	of	deficiency,	such	as
the	inability	to	do	certain	parts	of	a	job	well.	It	demoralizes	people
just	to	hear	that	they	are	doing	“something”	wrong	without	knowing
what	the	specifics	are	so	they
can	change.	Focus	on	the	specifics,
saying	what	the	person	did	well,	what	was	done	poorly,	and	how	it
could	be	changed.	Don’t	beat	around	the	bush	or	be	oblique	or
evasive;	it	will	muddy	the	real	message.	This,	of	course,	is	akin	to	the
advice	to	couples	about	the	“XYZ”	statement	of	a	grievance:	say
exactly	what	the	problem	is,	what’s	wrong	with	it	or	how	it	makes
you	feel,	and	what	could	be	changed.
“Specificity,”	Levinson	points	out,	“is	just	as	important	for	praise	as
for	criticism.	I	won’t	say	that	vague	praise	has	no	effect	at	all,	but	it
doesn’t	have	much,	and	you	can’t	learn	from	it.”
7
•
Offer	a	solution


7
•
Offer	a	solution
.	The	critique,	like	all	useful	feedback,	should	point
to	a	way	to	fix	the	problem.	Otherwise	it	leaves	the	recipient
frustrated,	demoralized,	or	demotivated.	The	critique	may	open	the
door	to	possibilities	and	alternatives	that	the	person	did	not	realize
were	there,	or	simply	sensitize	her	to	deficiencies	that	need	attention
—but	should	include	suggestions	about	how	to	take	care	of	these
problems.
•
Be	present
.	Critiques,	like	praise,	are	most	effective	face	to	face	and
in	private.	People	who	are	uncomfortable	giving	a	criticism—or
offering	praise—are	likely	to	ease	the	burden	on	themselves	by	doing
it	at	a	distance,	such	as	in	a	memo.	But	this	makes	the	communication
too	impersonal,	and	robs	the	person	receiving	it	of	an	opportunity	for
a	response	or	clarification.
•
Be	sensitive
.	This	is	a	call	for	empathy,	for	being	attuned	to	the
impact	of	what	you	say	and	how	you	say	it	on	the	person	at	the
receiving	end.	Managers	who	have	little	empathy,	Levinson	points
out,	are	most	prone	to	giving	feedback	in	a	hurtful	fashion,	such	as
the	withering	put-down.	The	net	effect	of	such	criticism	is	destructive:
instead	of	opening	the	way	for	a	corrective,	it	creates	an	emotional


instead	of	opening	the	way	for	a	corrective,	it	creates	an	emotional
backlash	of	resentment,	bitterness,	defensiveness,	and	distance.
Levinson	also	offers	some	emotional	counsel	for	those	at	the


receiving	end	of	criticism.	One	is	to	see	the	criticism	as	valuable
information	about	how	to	do	better,	not	as	a	personal	attack.	Another
is	to	watch	for	the	impulse	toward	defensiveness	instead	of	taking
responsibility.	And,	if	it	gets	too	upsetting,	ask	to	resume	the	meeting
later,	after	a	period	to	absorb	the	difficult	message	and	cool	down	a
bit.	Finally,	he	advises	people	to	see	criticism	as	an	opportunity	to
work	together	with	the	critic	to	solve	the	problem,	not	as	an
adversarial	situation.	All	this	sage	advice,	of	course,	directly	echoes
suggestions	for	married	couples	trying	to	handle	their	complaints
without	doing	permanent	damage	to	their	relationship.	As	with
marriage,	so	with	work.
DEALING	WITH	DIVERSITY
Sylvia	Skeeter,	a	former	army	captain	in	her	thirties,	was	a	shift
manager	at	a	Denny’s	restaurant	in	Columbia,	South	Carolina.	One
slow	afternoon	a	group	of	black	customers—a	minister,	an	assistant
pastor,	and	two	visiting	gospel	singers—came	in	for	a	meal,	and	sat
and	sat	while	the	waitresses	ignored	them.	The	waitresses,	recalls
Skeeter,	“would	kind	of	glare,	with	their	hands	on	their	hips,	and	then
they’d	go	back	to	talking	among	themselves,	like	a	black	person


they’d	go	back	to	talking	among	themselves,	like	a	black	person
standing	five	feet	away	didn’t	exist.”
Skeeter,	indignant,	confronted	the	waitresses,	and	complained	to
the	manager,	who	shrugged	off	their	actions,	saying,	“That’s	how	they
were	raised,	and	there’s	nothing	I	can	do	about	it.”	Skeeter	quit	on	the
spot;	she	is	black.
If	that	had	been	an	isolated	incident,	this	moment	of	blatant
prejudice	might	have	passed	unnoted.	But	Sylvia	Skeeter	was	one	of
hundreds	of	people	who	came	forward	to	testify	to	a	widespread
pattern	of	antiblack	prejudice	throughout	the	Denny’s	restaurant
chain,	a	pattern	that	resulted	in	a	$54	million	settlement	of	a	class-
action	suit	on	behalf	of	thousands	of	black	customers	who	had
suffered	such	indignities.
The	plaintiffs	included	a	detail	of	seven	African-American	Secret
Service	agents	who	sat	waiting	for	an	hour	for	their	breakfast	while
their	white	colleagues	at	the	next	table	were	served	promptly—as
they	were	all	on	their	way	to	provide	security	for	a	visit	by	President
Clinton	to	the	United	States	Naval	Academy	at	Annapolis.	They	also
included	a	black	girl	with	paralyzed	legs	in	Tampa,	Florida,	who	sat	in


her	wheelchair	for	two	hours	waiting	for	her	food	late	one	night	after
a	prom.	The	pattern	of	discrimination,	the	class-action	suit	held,	was
due	to	the	widespread	assumption	throughout	the	Denny’s	chain—
particularly	at	the	level	of	district	and	branch	manager—that	black
customers	were	bad	for	business.	Today,	largely	as	a	result	of	the	suit
and	publicity	surrounding	it,	the	Denny’s	chain	is	making	amends	to
the	black	community.	And	every	employee,	especially	managers,	must
attend	sessions	on	the	advantages	of	a	multiracial	clientele.
Such	seminars	have	become	a	staple	of	in-house	training	in
companies	throughout	America,	with	the	growing	realization	by
managers	that	even	if	people	bring	prejudices	to	work	with	them,	they
must	learn	to	act	as	though	they	have	none.	The	reasons,	over	and
above	human	decency,	are	pragmatic.	One	is	the	shifting	face	of	the
workforce,	as	white	males,	who	used	to	be	the	dominant	group,	are
becoming	a	minority.	A	survey	of	several	hundred	American
companies	found	that	more	than	three	quarters	of	new	employees
were	nonwhite—a	demographic	shift	that	is	also	reflected	to	a	large
extent	in
the	changing	pool	of	customers.
8
	Another	reason	is	the
increasing	need	for	international	companies	to	have	employees	who


increasing	need	for	international	companies	to	have	employees	who
not	only	put	any	bias	aside	to	appreciate	people	from	diverse	cultures
(and	markets)	but	also	turn	that	appreciation	to	competitive
advantage.	A	third	motivation	is	the	potential	fruit	of	diversity,	in
terms	of	heightened	collective	creativity	and	entrepreneurial	energy.
All	this	means	the	culture	of	an	organization	must	change	to	foster
tolerance,	even	if	individual	biases	remain.	But	how	can	a	company
do	this?	The	sad	fact	is	that	the	panoply	of	one-day,	one-video,	or
single-weekend	“diversity	training”	courses	do	not	really	seem	to
budge	the	biases	of	those	employees	who	come	to	them	with	deep
prejudice	against	one	or	another	group,	whether	it	be	whites	biased
against	blacks,	blacks	against	Asians,	or	Asians	resenting	Hispanics.
Indeed,	the	net	effect	of	inept	diversity	courses—those	that	raise	false
expectations	by	promising	too	much,	or	simply	create	an	atmosphere
of	confrontation	instead	of	understanding—can	be	to	heighten	the
tensions	that	divide	groups	in	the	workplace,	calling	even	greater
attention	to	these	differences.	To	understand	what
can
	be	done,	it
helps	to	first	understand	the	nature	of	prejudice	itself.
The	Roots	of	Prejudice


The	Roots	of	Prejudice
Dr.	Vamik	Volkan	is	a	psychiatrist	at	the	University	of	Virginia	now,


but	he	remembers	what	it	was	like	growing	up	in	a	Turkish	family	on
the	island	of	Cyprus,	then	bitterly	contested	between	Turks	and
Greeks.	As	a	boy	Volkan	heard	rumors	that	the	local	Greek	priest’s
cincture	had	a	knot	for	each	Turkish	child	he	had	strangled,	and
remembers	the	tone	of	dismay	in	which	he	was	told	how	his	Greek
neighbors	ate	pigs,	whose	meat	was	considered	too	filthy	to	eat	in	his
own	Turkish	culture.	Now,	as	a	student	of	ethnic	conflict,	Volkan
points	to	such	childhood	memories	to	show	how	hatreds	between
groups	are	kept	alive	over	the	years,	as	each	new	generation	is
steeped	in	hostile	biases	like	these.
9
	The	psychological	price	of	loyalty
to	one’s	own	group	can	be	antipathy	toward	another,	especially	when
there	is	a	long	history	of	enmity	between	the	groups.
Prejudices	are	a	kind	of	emotional	learning	that	occurs	early	in	life,
making	these	reactions	especially	hard	to	eradicate	entirely,	even	in
people	who	as	adults	feel	it	is	wrong	to	hold	them.	“The	emotions	of
prejudice	are	formed	in	childhood,	while	the	beliefs	that	are	used	to
justify	it	come	later,”	explained	Thomas	Pettigrew,	a	social


psychologist	at	the	University	of	California	at	Santa	Cruz,	who	has
studied	prejudice	for	decades.	“Later	in	life	you	may
want	to	change
your	prejudice,	but	it	is	far	easier	to	change	your	intellectual	beliefs
than	your	deep	feelings.	Many	Southerners	have	confessed	to	me,	for
instance,	that	even	though	in	their	minds	they	no	longer	feel	prejudice
against	blacks,	they	feel	squeamish	when	they	shake	hands	with	a
black.	The	feelings	are	left	over	from	what	they	learned	in	their
families	as	children.”
10
The	power	of	the	stereotypes	that	buttress	prejudice	comes	in	part
from	a	more	neutral	dynamic	in	the	mind	that	makes	stereotypes	of
all	kinds	self-confirming.
11
	People	remember	more	readily	instances
that	support	the	stereotype	while	tending	to	discount	instances	that
challenge	it.	On	meeting	at	a	party	an	emotionally	open	and	warm
Englishman	who	disconfirms	the	stereotype	of	the	cold,	reserved
Briton,	for	example,	people	can	tell	themselves	that	he’s	just	unusual,
or	“he’s	been	drinking.”
The	tenacity	of	subtle	biases	may	explain	why,	while	over	the	last
forty	years	or	so	racial	attitudes	of	American	whites	toward	blacks
have	become	increasingly	more	tolerant,	more	subtle	forms	of	bias


persist:	people	disavow	racist	attitudes	while	still	acting	with	covert
bias.
12
	When	asked,	such	people	say	they	feel	no	bigotry,	but	in
ambiguous	situations	still	act	in	a	biased	way—though	they	give	a
rationale	other	than	prejudice.	Such	bias	can	take	the	form,	say,	of	a


white	senior	manager—who	believes	he	has	no	prejudices—rejecting
a	black	job	applicant,	ostensibly	not	because	of	his	race	but	because
his	education	and	experience	“are	not	quite	right”	for	the	job,	while
hiring	a	white	applicant	with	about	the	same	background.	Or	it	might
take	the	form	of	giving	a	briefing	and	helpful	tips	to	a	white	salesman
about	to	make	a	call,	but	somehow	neglecting	to	do	the	same	for	a
black	or	Hispanic	salesman.
Zero	Tolerance	for	Intolerance
If	people’s	long-held	biases	cannot	be	so	easily	weeded	out,	what
can
be	changed	is	what	they
do
	about	them.	At	Denny’s,	for	example,
waitresses	or	branch	managers	who	took	it	upon	themselves	to
discriminate	against	blacks	were	seldom,	if	ever,	challenged.	Instead,
some	managers	seem	to	have	encouraged	them,	at	least	tacitly,	to
discriminate,	even	suggesting	policies	such	as	demanding	payment	for
meals	in	advance	from	black	customers	only,	denying	blacks	widely
advertised	free	birthday	meals,	or	locking	the	doors	and	claiming	to
be	closed	if	a	group	of	black	customers	was	coming.	As	John	P.
Relman,	an	attorney	who	sued	Denny’s	on	behalf	of	the	black	Secret


Service	agents,	put	it,	“Denny’s	management	closed	their	eyes	to	what
the
field	staff	was	doing.	There	must	have	been	some
message	…	which	freed	up	the	inhibitions	of	local	managers	to	act	on
their	racist	impulses.”
13
But	everything	we	know	about	the	roots	of	prejudice	and	how	to
fight	it	effectively	suggests	that	precisely	this	attitude—turning	a
blind	eye	to	acts	of	bias—allows	discrimination	to	thrive.	To	do
nothing,	in	this	context,	is	an	act	of	consequence	in	itself,	letting	the
virus	of	prejudice	spread	unopposed.	More	to	the	point	than	diversity
training	courses—or	perhaps	essential	to	their	having	much	effect—is
that	the	norms	of	a	group	be	decisively	changed	by	taking	an	active
stance	against	any	acts	of	discrimination,	from	the	top	echelons	of
management	on	down.	Biases	may	not	budge,	but	acts	of	prejudice
can	be	quashed,	if	the	climate	is	changed.	As	an	IBM	executive	put	it,
“We	don’t	tolerate	slights	or	insults	in	any	way;	respect	for	the
individual	is	central	to	IBM’s	culture.”
14
If	research	on	prejudice	has	any	lesson	for	making	a	corporate
culture	more	tolerant,	it	is	to	encourage	people	to	speak	out	against
even	low-key	acts	of	discrimination	or	harassment—offensive	jokes,


say,	or	the	posting	of	girlie	calendars	demeaning	to	women


coworkers.	One	study	found	that	when	people	in	a	group	heard
someone	make	ethnic	slurs,	it	led	others	to	do	the	same.	The	simple
act	of	naming	bias	as	such	or	objecting	to	it	on	the	spot	establishes	a
social	atmosphere	that	discourages	it;	saying	nothing	serves	to
condone	it.
15
	In	this	endeavor,	those	in	positions	of	authority	play	a
pivotal	role:	their	failure	to	condemn	acts	of	bias	sends	the	tacit
message	that	such	acts	are	okay.	Following	through	with	action	such
as	a	reprimand	sends	a	powerful	message	that	bias	is	not	trivial,	but
has	real—and	negative—consequences.
Here	too	the	skills	of	emotional	intelligence	are	an	advantage,
especially	in	having	the	social	knack	to	know	not	just	when	but
how
to	speak	up	productively	against	bias.	Such	feedback	should	be
couched	with	all	the	finesse	of	an	effective	criticism,	so	it	can	be
heard	without	defensiveness.	If	managers	and	coworkers	do	this
naturally,	or	learn	to	do	so,	bias	incidents	are	more	likely	to	fall	away.
The	more	effective	diversity	training	courses	set	a	new,
organizationwide,	explicit	ground	rule	that	makes	bias	in	any	form
out-of-bounds,	and	so	encourages	people	who	have	been	silent
witnesses	and	bystanders	to	voice	their	discomforts	and	objections.


witnesses	and	bystanders	to	voice	their	discomforts	and	objections.
Another	active	ingredient	in	diversity	courses	is	perspective-taking,	a
stance	that	encourages	empathy	and	tolerance.	To	the	degree	that
people	come	to	understand	the	pain	of	those	who	feel	discriminated
against,	they	are	more	likely	to	speak	out	against	it.
In	short,	it	is	more	practical	to	try	to	suppress	the	expression	of	bias
rather	than	trying	to	eliminate	the	attitude	itself;	stereotypes	change
very	slowly,	if	at
all.	Simply	putting	people	of	different	groups
together	does	little	or	nothing	to	lower	intolerance,	as	witness	cases	of
school	desegregation	in	which	intergroup	hostility	rose	rather	than
decreased.	For	the	plethora	of	diversity	training	programs	that	are
sweeping	through	the	corporate	world,	this	means	a	realistic	goal	is	to
change	the
norms
	of	a	group	for	showing	prejudice	or	harassing;	such
programs	can	do	much	to	raise	into	the	collective	awareness	the	idea
that	bigotry	or	harassment	are	not	acceptable	and	will	not	be
tolerated.	But	to	expect	that	such	a	program	will	uproot	deeply	held
prejudices	is	unrealistic.
Still,	since	prejudices	are	a	variety	of	emotional	learning,	relearning
is
	possible—though	it	takes	time	and	should	not	be	expected	as	the


is
	possible—though	it	takes	time	and	should	not	be	expected	as	the
outcome	of	a	one-time	diversity	training	workshop.	What	can	make	a
difference,	though,	is	sustained	camaraderie	and	daily	efforts	toward	a
common	goal	by	people	of	different	backgrounds.	The	lesson	here	is


from	school	desegregation:	when	groups	fail	to	mix	socially,	instead
forming	hostile	cliques,	the	negative	stereotypes	intensify.	But	when
students	have	worked	together	as	equals	to	attain	a	common	goal,	as
on	sports	teams	or	in	bands,	their	stereotypes	break	down—as	can
happen	naturally	in	the	workplace,	when	people	work	together	as
peers	over	the	years.
16
But	to	stop	at	battling	prejudice	in	the	workplace	is	to	miss	a
greater	opportunity:	taking	advantage	of	the	creative	and
entrepreneurial	possibilities	that	a	diverse	workforce	can	offer.	As	we
shall	see,	a	working	group	of	varied	strengths	and	perspectives,	if	it
can	operate	in	harmony,	is	likely	to	come	to	better,	more	creative,	and
more	effective	solutions	than	those	same	people	working	in	isolation.
ORGANIZATIONAL	SAVVY	AND	THE	GROUP	IQ
By	the	end	of	the	century,	a	third	of	the	American	workforce	will	be
“knowledge	workers,”	people	whose	productivity	is	marked	by	adding
value	to	information—whether	as	market	analysts,	writers,	or
computer	programmers.	Peter	Drucker,	the	eminent	business	maven
who	coined	the	term	“knowledge	worker,”	points	out	that	such
workers’	expertise	is	highly	specialized,	and	that	their	productivity
depends	on	their	efforts	being	coordinated	as	part	of	an	organizational


depends	on	their	efforts	being	coordinated	as	part	of	an	organizational
team:	writers	are	not	publishers;	computer	programmers	are	not
software	distributors.	While	people	have	always	worked	in	tandem,
notes	Drucker,	with	knowledge	work,	“teams	become	the	work	unit
rather	than	the	individual	himself.”
17
	And	that	suggests	why
emotional	intelligence,	the	skills	that	help	people	harmonize,	should
become	increasingly	valued	as	a	workplace	asset	in	the	years	to	come.
Perhaps	the	most	rudimentary	form	of	organizational	teamwork	is
the	meeting,	that	inescapable	part	of	an	executive’s	lot—in	a
boardroom,	on	a	conference	call,	in	someone’s	office.	Meetings—
bodies	in	the	same	room—are	but	the	most	obvious,	and	a	somewhat
antiquated,	example	of	the	sense	in	which	work	is	shared.	Electronic
networks,	e-mail,	teleconferences,	work	teams,	informal	networks,
and	the	like	are	emerging	as	new	functional	entities	in	organizations.
To	the	degree	that	the	explicit	hierarchy	as	mapped	on	an
organizational	chart	is	the	skeleton	of	an	organization,	these	human
touchpoints	are	its	central	nervous	system.
Whenever	people	come	together	to	collaborate,	whether	it	be	in	an


executive	planning	meeting	or	as	a	team	working	toward	a	shared
product,	there	is	a	very	real	sense	in	which	they	have	a	group	IQ,	the
sum	total	of	the	talents	and	skills	of	all	those	involved.	And	how	well
they	accomplish	their	task	will	be	determined	by	how	high	that	IQ	is.
The	single	most	important	element	in	group	intelligence,	it	turns	out,
is	not	the	average	IQ	in	the	academic	sense,	but	rather	in	terms	of
emotional	intelligence.	The	key	to	a	high	group	IQ	is	social	harmony.
It	is	this	ability	to	harmonize	that,	all	other	things	being	equal,	will
make	one	group	especially	talented,	productive,	and	successful,	and
another—with	members	whose	talent	and	skill	are	equal	in	other
regards—do	poorly.
The	idea	that	there	is	a	group	intelligence	at	all	comes	from	Robert
Sternberg,	the	Yale	psychologist,	and	Wendy	Williams,	a	graduate
student,	who	were	seeking	to	understand	why	some	groups	are	far
more	effective	than	others.
18
	After	all,	when	people	come	together	to
work	as	a	group,	each	brings	certain	talents—say,	a	high	verbal
fluency,	creativity,	empathy,	or	technical	expertise.	While	a	group	can
be	no	“smarter”	than	the	sum	total	of	all	these	specific	strengths,	it


can	be	much	dumber	if	its	internal	workings	don’t	allow	people	to
share	their	talents.	This	maxim	became	evident	when	Sternberg	and
Williams	recruited	people	to	take	part	in	groups	that	were	given	the
creative	challenge	of	coming	up	with	an	effective	advertising
campaign	for	a	fictitious	sweetener	that	showed	promise	as	a	sugar
substitute.
One	surprise	was	that	people	who	were
too
	eager	to	take	part	were
a	drag	on	the	group,	lowering	its	overall	performance;	these	eager
beavers	were	too	controlling	or	domineering.	Such	people	seemed	to
lack	a	basic	element	of	social	intelligence,	the	ability	to	recognize
what	is	apt	and	what	inappropriate	in	give-and-take.	Another	negative
was	having	deadweight,	members	who	did	not	participate.
The	single	most	important	factor	in	maximizing	the	excellence	of	a
group’s	product	was	the	degree	to	which	the	members	were	able	to
create	a	state	of	internal	harmony,	which	lets	them	take	advantage	of
the	full	talent	of	their	members.	The	overall	performance	of
harmonious	groups	was	helped	by	having	a	member	who	was
particularly	talented;	groups	with	more	friction	were	far	less	able	to
capitalize	on	having	members	of	great	ability.	In	groups	where	there
are	high	levels	of	emotional	and	social	static—whether	it	be	from	fear


are	high	levels	of	emotional	and	social	static—whether	it	be	from	fear
or	anger,	from	rivalries	or	resentments—people	cannot	offer	their
best.	But	harmony	allows	a	group	to	take	maximum	advantage	of	its


most	creative	and	talented	members’	abilities.
While	the	moral	of	this	tale	is	quite	clear	for,	say,	work	teams,	it
has	a	more	general	implication	for	anyone	who	works	within	an
organization.	Many	things	people	do	at	work	depend	on	their	ability
to	call	on	a	loose	network	of	fellow	workers;	different	tasks	can	mean
calling	on	different	members	of	the	network.	In	effect,	this	creates	the
chance	for	ad	hoc	groups,	each	with	a	membership	tailored	to	offer	an
optimal	array	of	talents,	expertise,	and	placement.	Just	how	well
people	can	“work”	a	network—in	effect,	make	it	into	a	temporary,	ad
hoc	team—is	a	crucial	factor	in	on-the-job	success.
Consider,	for	example,	a	study	of	star	performers	at	Bell	Labs,	the
world-famous	scientific	think	tank	near	Princeton.	The	labs	are
peopled	by	engineers	and	scientists	who	are	all	at	the	top	on	academic
IQ	tests.	But	within	this	pool	of	talent,	some	emerge	as	stars,	while
others	are	only	average	in	their	output.	What	makes	the	difference
between	stars	and	the	others	is	not	their	academic	IQ,	but	their
emotional
	IQ.	They	are	better	able	to	motivate	themselves,	and	better
able	to	work	their	informal	networks	into	ad	hoc	teams.


able	to	work	their	informal	networks	into	ad	hoc	teams.
The	“stars”	were	studied	in	one	division	at	the	labs,	a	unit	that
creates	and	designs	the	electronic	switches	that	control	telephone
systems—a	highly	sophisticated	and	demanding	piece	of	electronic
engineering.
19
	Because	the	work	is	beyond	the	capacity	of	any	one
person	to	tackle,	it	is	done	in	teams	that	can	range	from	just	5	or	so
engineers	to	150.	No	single	engineer	knows	enough	to	do	the	job
alone;	getting	things	done	demands	tapping	other	people’s	expertise.
To	find	out	what	made	the	difference	between	those	who	were	highly
productive	and	those	who	were	only	average,	Robert	Kelley	and	Janet
Caplan	had	managers	and	peers	nominate	the	10	to	15	percent	of
engineers	who	stood	out	as	stars.
When	they	compared	the	stars	with	everyone	else,	the	most
dramatic	finding,	at	first,	was	the	paucity	of	differences	between	the
two	groups.	“Based	on	a	wide	range	of	cognitive	and	social	measures,
from	standard	tests
for	IQ	to	personality	inventories,	there’s	little
meaningful	difference	in	innate	abilities,”	Kelley	and	Caplan	wrote	in
the
Harvard	Business	Review
.	“As	it	develops,	academic	talent	was	not


.	“As	it	develops,	academic	talent	was	not
a	good	predictor	of	on-the-job	productivity,”	nor	was	IQ.
But	after	detailed	interviews,	the	critical	differences	emerged	in	the
internal	and	interpersonal	strategies	“stars”	used	to	get	their	work
done.	One	of	the	most	important	turned	out	to	be	a	rapport	with	a
network	of	key	people.	Things	go	more	smoothly	for	the	standouts


because	they	put	time	into	cultivating	good	relationships	with	people
whose	services	might	be	needed	in	a	crunch	as	part	of	an	instant	ad
hoc	team	to	solve	a	problem	or	handle	a	crisis.	“A	middle	performer
at	Bell	Labs	talked	about	being	stumped	by	a	technical	problem,”
Kelley	and	Caplan	observed.	“He	painstakingly	called	various
technical	gurus	and	then	waited,	wasting	valuable	time	while	calls
went	unreturned	and	e-mail	messages	unanswered.	Star	performers,
however,	rarely	face	such	situations	because	they	do	the	work	of
building	reliable	networks	before	they	actually	need	them.	When	they
call	someone	for	advice,	stars	almost	always	get	a	faster	answer.”
Informal	networks	are	especially	critical	for	handling	unanticipated
problems.	“The	formal	organization	is	set	up	to	handle	easily
anticipated	problems,”	one	study	of	these	networks	observes.	“But
when	unexpected	problems	arise,	the	informal	organization	kicks	in.
Its	complex	web	of	social	ties	form	every	time	colleagues
communicate,	and	solidify	over	time	into	surprisingly	stable	networks.
Highly	adaptive,	informal	networks	move	diagonally	and	elliptically,
skipping	entire	functions	to	get	things	done.”
20
The	analysis	of	informal	networks	shows	that	just	because	people
work	together	day	to	day	they	will	not	necessarily	trust	each	other


work	together	day	to	day	they	will	not	necessarily	trust	each	other
with	sensitive	information	(such	as	a	desire	to	change	jobs,	or
resentment	about	how	a	manager	or	peer	behaves),	nor	turn	to	them
in	crisis.	Indeed,	a	more	sophisticated	view	of	informal	networks
shows	that	there	are	at	least	three	varieties:	communications	webs—
who	talks	to	whom;	expertise	networks,	based	on	which	people	are
turned	to	for	advice;	and	trust	networks.	Being	a	main	node	in	the
expertise	network	means	someone	will	have	a	reputation	for	technical
excellence,	which	often	leads	to	a	promotion.	But	there	is	virtually	no
relationship	between	being	an	expert	and	being	seen	as	someone
people	can	trust	with	their	secrets,	doubts,	and	vulnerabilities.	A	petty
office	tyrant	or	micromanager	may	be	high	on	expertise,	but	will	be
so	low	on	trust	that	it	will	undermine	their	ability	to	manage,	and
effectively	exclude	them	from	informal	networks.	The	stars	of	an
organization	are	often	those	who	have	thick	connections	on	all
networks,	whether	communications,	expertise,	or	trust.
Beyond	a	mastery	of	these	essential	networks,	other	forms	of
organizational	savvy	the	Bell	Labs	stars	had	mastered	included


organizational	savvy	the	Bell	Labs	stars	had	mastered	included
effectively	coordinating	their	efforts	in	teamwork;	being	leaders	in
building	consensus;	being	able	to	see	things	from	the	perspective	of
others,	such	as	customers	or	others	on	a	work	team;	persuasiveness;


and	promoting	cooperation	while	avoiding	conflicts.	While	all	of	these
rely	on	social	skills,	the	stars	also	displayed	another	kind	of	knack:
taking	initiative—being	self-motivated	enough	to	take	on
responsibilities	above	and	beyond	their	stated	job—and	self-
management	in	the	sense	of	regulating	their	time	and	work
commitments	well.	All	such	skills,	of	course,	are	aspects	of	emotional
intelligence.
There	are	strong	signs	that	what	is	true	at	Bell	Labs	augurs	for	the
future	of	all	corporate	life,	a	tomorrow	where	the	basic	skills	of
emotional	intelligence	will	be	ever	more	important,	in	teamwork,	in
cooperation,	in	helping	people	learn	together	how	to	work	more
effectively.	As	knowledge-based	services	and	intellectual	capital
become	more	central	to	corporations,	improving	the	way	people	work
together	will	be	a	major	way	to	leverage	intellectual	capital,	making	a
critical	competitive	difference.	To	thrive,	if	not	survive,	corporations
would	do	well	to	boost	their	collective	emotional	intelligence.


11
Mind	and	Medicine
“Who	taught	you	all	this,	Doctor?”
The	reply	came	promptly:
“Suffering.”
—A
LBERT
	C
AMUS
,
The	Plague
A	vague	ache	in	my	groin	sent	me	to	my	doctor.	Nothing	seemed
unusual	until	he	looked	at	the	results	of	a	urine	test.	I	had	traces	of
blood	in	my	urine.
“I	want	you	to	go	to	the	hospital	and	get	some	tests	…	kidney
function,	cytology	…,”	he	said	in	a	businesslike	tone.
I	don’t	know	what	he	said	next.	My	mind	seemed	to	freeze	at	the
word
cytology
.	Cancer.
I	have	a	foggy	memory	of	his	explaining	to	me	when	and	where	to
go	for	diagnostic	tests.	It	was	the	simplest	instruction,	but	I	had	to	ask
him	to	repeat	it	three	or	four	times.
Cytology
—my	mind	would	not
leave	the	word.	That	one	word	made	me	feel	as	though	I	had	just	been
mugged	at	my	own	front	door.
Why	should	I	have	reacted	so	strongly?	My	doctor	was	just	being
thorough	and	competent,	checking	the	limbs	in	a	diagnostic	decision
tree.	There	was	a	tiny	likelihood	that	cancer	was	the	problem.	But	this
rational	analysis	was	irrelevant	at	that	moment.	In	the	land	of	the


sick,	emotions	reign	supreme;	fear	is	a	thought	away.	We	can	be	so
emotionally	fragile	while	we	are	ailing	because	our	mental	well-being
is	based	in	part	on	the	illusion	of	invulnerability.	Sickness—especially
a	severe	illness—bursts	that	illusion,	attacking	the	premise	that	our
private	world	is	safe	and	secure.	Suddenly	we	feel	weak,	helpless,	and
vulnerable.
The	problem	is	when	medical	personnel	ignore	how	patients	are
reacting
emotionally
,	even	while	attending	to	their	physical	condition.
This	inattention	to	the	emotional	reality	of	illness	neglects	a	growing
body	of	evidence	showing	that	people’s	emotional	states	can	play	a
sometimes	significant	role	in	their	vulnerability	to	disease	and	in	the


course	of	their	recovery.	Modern	medical	care	too	often	lacks
emotional	intelligence.
For	the	patient,	any	encounter	with	a	nurse	or	physician	can	be	a
chance	for	reassuring	information,	comfort,	and	solace—or,	if	handled
unfortunately,	an	invitation	to	despair.	But	too	often	medical
caregivers	are	rushed	or	indifferent	to	patients’	distress.	To	be	sure,
there	are	compassionate	nurses	and	physicians	who	take	the	time	to
reassure	and	inform	as	well	as	administer	medically.	But	the	trend	is
toward	a	professional	universe	in	which	institutional	imperatives	can
leave	medical	staff	oblivious	to	the	vulnerabilities	of	patients,	or
feeling	too	pressed	to	do	anything	about	them.	With	the	hard	realities
of	a	medical	system	increasingly	timed	by	accountants,	things	seem	to
be	getting	worse.
Beyond	the	humanitarian	argument	for	physicians	to	offer	care
along	with	cure,	there	are	other	compelling	reasons	to	consider	the
psychological	and	social	reality	of	patients	as	being	within	the
medical	realm	rather	than	separate	from	it.	By	now	a	scientific	case
can	be	made	that	there	is	a	margin	of
medical
	effectiveness,	both	in
prevention	and	treatment,	that	can	be	gained	by	treating	people’s
emotional	state	along	with	their	medical	condition.	Not	in	every	case


emotional	state	along	with	their	medical	condition.	Not	in	every	case
or	every	condition,	of	course.	But	looking	at	data	from	hundreds	and
hundreds	of	cases,	there	is	on	average	enough	increment	of	medical
benefit	to	suggest	that	an
emotional
	intervention	should	be	a	standard
part	of	medical	care	for	the	range	of	serious	disease.
Historically,	medicine	in	modern	society	has	defined	its	mission	in
terms	of	curing
disease
—the	medical	disorder—while	overlooking
illness
—the	patient’s	experience	of	disease.	Patients,	by	going	along
with	this	view	of	their	problem,	join	a	quiet	conspiracy	to	ignore	how
they	are	reacting	emotionally	to	their	medical	problems—or	to
dismiss	those	reactions	as	irrelevant	to	the	course	of	the	problem
itself.	That	attitude	is	reinforced	by	a	medical	model	that	dismisses
entirely	the	idea	that	mind	influences	body	in	any	consequential	way.
Yet	there	is	an	equally	unproductive	ideology	in	the	other	direction:
the	notion	that	people	can	cure	themselves	of	even	the	most
pernicious	disease	simply	by	making	themselves	happy	or	thinking
positive	thoughts,	or	that	they	are	somehow	to	blame	for	having
gotten	sick	in	the	first	place.	The	result	of	this	attitude-will-cure-all
rhetoric	has	been	to	create	widespread	confusion
and


rhetoric	has	been	to	create	widespread	confusion
and
misunderstanding	about	the	extent	to	which	illness	can	be	affected	by
the	mind,	and,	perhaps	worse,	sometimes	to	make	people	feel	guilty


for	having	a	disease,	as	though	it	were	a	sign	of	some	moral	lapse	or
spiritual	unworthiness.
The	truth	lies	somewhere	between	these	extremes.	By	sorting
through	the	scientific	data,	my	aim	is	to	clarify	the	contradictions	and
replace	the	nonsense	with	a	clearer	understanding	of	the	degree	to
which	our	emotions—and	emotional	intelligence—play	a	part	in
health	and	disease.
THE	BODY’S	MIND:	HOW	EMOTIONS	MATTER
	FOR	HEALTH
In	1974	a	finding	in	a	laboratory	at	the	School	of	Medicine	and
Dentistry,	University	of	Rochester,	rewrote	biology’s	map	of	the	body:
Robert	Ader,	a	psychologist,	discovered	that	the	immune	system,	like
the	brain,	could	learn.	His	result	was	a	shock;	the	prevailing	wisdom
in	medicine	had	been	that	only	the	brain	and	central	nervous	system
could	respond	to	experience	by	changing	how	they	behaved.	Ader’s
finding	led	to	the	investigation	of	what	are	turning	out	to	be	myriad
ways	the	central	nervous	system	and	the	immune	system
communicate—biological	pathways	that	make	the	mind,	the
emotions,	and	the	body	not	separate,	but	intimately	entwined.
In	his	experiment	white	rats	had	been	given	a	medication	that
artificially	suppressed	the	quantity	of	disease-fighting	T	cells
circulating	in	their	blood.	Each	time	they	received	the	medication,


they	ate	it	along	with	saccharin-laced	water.	But	Ader	discovered	that
giving	the	rats	the	saccharin-flavored	water	alone,	without	the
suppressive	medication,	still	resulted	in	a	lowering	of	the	T-cell	count
—to	the	point	that	some	of	the	rats	were	getting	sick	and	dying.	Their
immune	system	had	learned	to	suppress	T	cells	in	response	to	the
flavored	water.	That	just	should	not	have	happened,	according	to	the
best	scientific	understanding	at	the	time.
The	immune	system	is	the	“body’s	brain,”	as	neuroscientist
Francisco	Varela,	at	Paris’s	Ecole	Polytechnique,	puts	it,	defining	the
body’s	own	sense	of	self—of	what	belongs	within	it	and	what	does
not.
1
	Immune	cells	travel	in	the	bloodstream	throughout	the	entire
body,	contacting	virtually	every	other	cell.	Those	cells	they	recognize,
they	leave	alone;	those	they	fail	to	recognize,	they	attack.	The	attack
either	defends	us	against	viruses,	bacteria,	and	cancer	or,	if	the
immune	cells	misidentify	some	of	the	body’s	own	cells,	creates	an
autoimmune	disease	such	as	allergy	or	lupus.	Until	the	day	Ader	made


his	serendipitous	discovery,	every	anatomist,	every	physician,	and
every	biologist
believed	that	the	brain	(along	with	its	extensions
throughout	the	body	via	the	central	nervous	system)	and	the	immune
system	were	separate	entities,	neither	able	to	influence	the	operation
of	the	other.	There	was	no	pathway	that	could	connect	the	brain
centers	monitoring	what	the	rat	tasted	with	the	areas	of	bone	marrow
that	manufacture	T	cells.	Or	so	it	had	been	thought	for	a	century.
Over	the	years	since	then,	Ader’s	modest	discovery	has	forced	a	new
look	at	the	links	between	the	immune	system	and	the	central	nervous
system.	The	field	that	studies	this,	psychoneuroimmunology,	or	PNI,	is
now	a	leading-edge	medical	science.	Its	very	name	acknowledges	the
links:
psycho
,	or	“mind”;
neuro
,	for	the	neuroendocrine	system	(which
subsumes	the	nervous	system	and	hormone	systems);	and
immunology
,
for	the	immune	system.
A	network	of	researchers	is	finding	that	the	chemical	messengers
that	operate	most	extensively	in	both	brain	and	immune	system	are
those	that	are	most	dense	in	neural	areas	that	regulate	emotion.
2
Some	of	the	strongest	evidence	for	a	direct	physical	pathway	allowing
emotions	to	impact	the	immune	system	has	come	from	David	Felten,	a


colleague	of	Ader’s.	Felten	began	by	noting	that	emotions	have	a
powerful	effect	on	the	autonomic	nervous	system,	which	regulates
everything	from	how	much	insulin	is	secreted	to	blood-pressure	levels.
Felten,	working	with	his	wife,	Suzanne,	and	other	colleagues,	then
detected	a	meeting	point	where	the	autonomic	nervous	system
directly	talks	to	lymphocytes	and	macrophages,	cells	of	the	immune
system.
3
In	electron-microscope	studies,	they	found	synapselike	contacts
where	the	nerve	terminals	of	the	autonomic	system	have	endings	that
directly	abut	these	immune	cells.	This	physical	contact	point	allows
the	nerve	cells	to	release	neurotransmitters	to	regulate	the	immune
cells;	indeed,	they	signal	back	and	forth.	The	finding	is	revolutionary.
No	one	had	suspected	that	immune	cells	could	be	targets	of	messages
from	the	nerves.
To	test	how	important	these	nerve	endings	were	in	the	workings	of
the	immune	system,	Felten	went	a	step	further.	In	experiments	with
animals	he	removed	some	nerves	from	lymph	nodes	and	spleen—
where	immune	cells	are	stored	or	made—and	then	used	viruses	to
challenge	the	immune	system.	The	result:	a	huge	drop	in	immune
response	to	the	virus.	His	conclusion	is	that	without	those	nerve


response	to	the	virus.	His	conclusion	is	that	without	those	nerve
endings	the	immune	system	simply	does	not	respond	as	it	should	to


the	challenge	of	an	invading	virus	or	bacterium.	In	short,	the	nervous
system	not	only	connects	to	the	immune	system,	but	is	essential	for
proper	immune	function.
Another	key	pathway	linking	emotions	and	the	immune	system	is
via	the
influence	of	the	hormones	released	under	stress.	The
catecholamines	(epinephrine	and	norepinephrine—otherwise	known
as	adrenaline	and	noradrenaline),	cortisol	and	prolactin,	and	the
natural	opiates	beta-endorphin	and	enkephalin	are	all	released	during
stress	arousal.	Each	has	a	strong	impact	on	immune	cells.	While	the
relationships	are	complex,	the	main	influence	is	that	while	these
hormones	surge	through	the	body,	the	immune	cells	are	hampered	in
their	function:	stress	suppresses	immune	resistance,	at	least
temporarily,	presumably	in	a	conservation	of	energy	that	puts	a
priority	on	the	more	immediate	emergency,	which	is	more	pressing
for	survival.	But	if	stress	is	constant	and	intense,	that	suppression	may
become	long-lasting.
4
Microbiologists	and	other	scientists	are	finding	more	and	more	such
connections	between	the	brain	and	the	cardiovascular	and	immune
systems—having	first	had	to	accept	the	once-radical	notion	that	they
exist	at	all.
5
TOXIC	EMOTIONS:	THE	CLINICAL	DATA
Despite	such	evidence,	many	or	most	physicians	are	still	skeptical	that


emotions	matter	clinically.	One	reason	is	that	while	many	studies
have	found	stress	and	negative	emotions	to	weaken	the	effectiveness
of	various	immune	cells,	it	is	not	always	clear	that	the	range	of	these
changes	is	great	enough	to	make	a
medical
	difference.
Even	so,	an	increasing	number	of	physicians	acknowledge	the	place
of	emotions	in	medicine.	For	instance,	Dr.	Camran	Nezhat,	an	eminent
gynecological	laparoscopic	surgeon	at	Stanford	University,	says,	“If
someone	scheduled	for	surgery	tells	me	she’s	panicked	that	day	and
does	not	want	to	go	through	with	it,	I	cancel	the	surgery.”	Nezhat
explains,	“Every	surgeon	knows	that	people	who	are	extremely	scared
do	terribly	in	surgery.	They	bleed	too	much,	they	have	more
infections	and	complications.	They	have	a	harder	time	recovering.	It’s
much	better	if	they	are	calm.”
The	reason	is	straightforward:	panic	and	anxiety	hike	blood
pressure,	and	veins	distended	by	pressure	bleed	more	profusely	when


cut	by	the	surgeon’s	knife.	Excess	bleeding	is	one	of	the	most
troublesome	surgical	complications,	one	that	can	sometimes	lead	to
death.
Beyond	such	medical	anecdotes,	evidence	for	the
clinical
	importance
of	emotions	has	been	mounting	steadily.	Perhaps	the	most	compelling
data	on	the	medical	significance	of	emotion	come	from	a	mass
analysis	combining	results	from	101	smaller	studies	into	a	single
larger	one	of	several	thousand	men	and	women.	The	study	confirms
that	perturbing	emotions	are	bad	for
health—to	a	degree.
6
	People
who	experienced	chronic	anxiety,	long	periods	of	sadness	and
pessimism,	unremitting	tension	or	incessant	hostility,	relentless
cynicism	or	suspiciousness,	were	found	to	have
double
	the	risk	of
disease—including	asthma,	arthritis,	headaches,	peptic	ulcers,	and
heart	disease	(each	representative	of	major,	broad	categories	of
disease).	This	order	of	magnitude	makes	distressing	emotions	as	toxic
a	risk	factor	as,	say,	smoking	or	high	cholesterol	are	for	heart	disease
—in	other	words,	a	major	threat	to	health.
To	be	sure,	this	is	a	broad	statistical	link,	and	by	no	means	indicates
that	everyone	who	has	such	chronic	feelings	will	thus	more	easily	fall


prey	to	a	disease.	But	the	evidence	for	a	potent	role	for	emotion	in
disease	is	far	more	extensive	than	this	one	study	of	studies	indicates.
Taking	a	more	detailed	look	at	the	data	for	specific	emotions,
especially	the	big	three—anger,	anxiety,	and	depression—makes
clearer	some	specific	ways	that	feelings	have	medical	significance,
even	if	the	biological	mechanisms	by	which	such	emotions	have	their
effect	are	yet	to	be	fully	understood.
7
When	Anger	Is	Suicidal
A	while	back,	the	man	said,	a	bump	on	the	side	of	his	car	led	to	a	fruitless	and
frustrating	journey.	After	endless	insurance	company	red	tape	and	auto	body	shops
that	did	more	damage,	he	still	owed	$800.	And	it	wasn’t	even	his	fault.	He	was	so	fed
up	that	whenever	he	got	into	the	car	he	was	overcome	with	disgust.	He	finally	sold	the
car	in	frustration.	Years	later	the	memories	still	made	the	man	livid	with	outrage.
This	bitter	memory	was	brought	to	mind	purposely,	as	part	of	a
study	of	anger	in	heart	patients	at	Stanford	University	Medical	School.
All	the	patients	in	the	study	had,	like	this	embittered	man,	suffered	a
first	heart	attack,	and	the	question	was	whether	anger	might	have	a


significant	impact	of	some	kind	on	their	heart	function.	The	effect	was


striking:	while	the	patients	recounted	incidents	that	made	them	mad,
the	pumping	efficiency	of	their	hearts	dropped	by	five	percentage
points.
8
	Some	of	the	patients	showed	a	drop	in	pumping	efficiency	of
7	percent	or	greater—a	range	that	cardiologists	regard	as	a	sign	of	a
myocardial	ischemia,	a	dangerous	drop	in	blood	flow	to	the	heart
itself.
The	drop	in	pumping	efficiency	was	not	seen	with	other	distressing
feelings,	such	as	anxiety,	nor	during	physical	exertion;	anger	seems	to
be	the	one	emotion	that	does	most	harm	to	the	heart.	While	recalling
the	upsetting	incident,	the	patients	said	they	were	only	about	half	as
mad	as	they	had	been
while	it	was	happening,	suggesting	that	their
hearts	would	have	been	even	more	greatly	hampered	during	an	actual
angry	encounter.
This	finding	is	part	of	a	larger	network	of	evidence	emerging	from
dozens	of	studies	pointing	to	the	power	of	anger	to	damage	the	heart.
9
The	old	idea	has	not	held	up	that	a	hurried,	high-pressure	Type-A
personality	is	at	great	risk	from	heart	disease,	but	from	that	failed
theory	has	emerged	a	new	finding:	it	is	hostility	that	puts	people	at
risk.
Much	of	the	data	on	hostility	has	come	from	research	by	Dr.
Redford	Williams	at	Duke	University.
10


Redford	Williams	at	Duke	University.
10
	For	example,	Williams	found
that	those	physicians	who	had	had	the	highest	scores	on	a	test	of
hostility	while	still	in	medical	school	were	seven	times	as	likely	to
have	died	by	the	age	of	fifty	as	were	those	with	low	hostility	scores—
being	prone	to	anger	was	a	stronger	predictor	of	dying	young	than
were	other	risk	factors	such	as	smoking,	high	blood	pressure,	and	high
cholesterol.	And	findings	by	a	colleague,	Dr.	John	Barefoot	at	the
University	of	North	Carolina,	show	that	in	heart	patients	undergoing
angiography,	in	which	a	tube	is	inserted	into	the	coronary	artery	to
measure	lesions,	scores	on	a	test	of	hostility	correlate	with	the	extent
and	severity	of	coronary	artery	disease.
Of	course,	no	one	is	saying	that	anger	alone	causes	coronary	artery
disease;	it	is	one	of	several	interacting	factors.	As	Peter	Kaufman,
acting	chief	of	the	Behavioral	Medicine	Branch	of	the	National	Heart,
Lung,	and	Blood	Institute,	explained	to	me,	“We	can’t	yet	sort	out
whether	anger	and	hostility	play	a	causal	role	in	the	early
development	of	coronary	artery	disease,	or	whether	it	intensifies	the
problem	once	heart	disease	has	begun,	or	both.	But	take	a	twenty-


year-old	who	repeatedly	gets	angry.	Each	episode	of	anger	adds	an
additional	stress	to	the	heart	by	increasing	his	heart	rate	and	blood


pressure.	When	that	is	repeated	over	and	over	again,	it	can	do
damage,”	especially	because	the	turbulence	of	blood	flowing	through
the	coronary	artery	with	each	heartbeat	“can	cause	microtears	in	the
vessel,	where	plaque	develops.	If	your	heart	rate	is	faster	and	blood
pressure	is	higher	because	you’re	habitually	angry,	then	over	thirty
years	that	may	lead	to	a	faster	buildup	of	plaque,	and	so	lead	to
coronary	artery	disease.”
11
Once	heart	disease	develops,	the	mechanisms	triggered	by	anger
affect	the	very	efficiency	of	the	heart	as	a	pump,	as	was	shown	in	the
study	of	angry	memories	in	heart	patients.	The	net	effect	is	to	make
anger	particularly	lethal	in	those	who	already	have	heart	disease.	For
instance,	a	Stanford	University	Medical	School	study	of	1,012	men
and	women	who	suffered	from	a	first	heart	attack	and	then	were
followed	for	up	to	eight	years	showed	that	those	men	who	were	most
aggressive	and	hostile	at	the	outset	suffered	the	highest
rate	of	second
heart	attacks.
12
	There	were	similar	results	in	a	Yale	School	of
Medicine	study	of	929	men	who	had	survived	heart	attacks	and	were
tracked	for	up	to	ten	years.
13
	Those	who	had	been	rated	as	easily


13
	Those	who	had	been	rated	as	easily
roused	to	anger	were	three	times	more	likely	to	die	of	cardiac	arrest
than	those	who	were	more	even-tempered.	If	they	also	had	high
cholesterol	levels,	the	added	risk	from	anger	was	five	times	higher.
The	Yale	researchers	point	out	that	it	may	not	be	anger	alone	that
heightens	the	risk	of	death	from	heart	disease,	but	rather	intense
negative	emotionality	of	any	kind	that	regularly	sends	surges	of	stress
hormones	through	the	body.	But	overall,	the	strongest	scientific	links
between	emotions	and	heart	disease	are	to	anger:	a	Harvard	Medical
School	study	asked	more	than	fifteen	hundred	men	and	women	who
had	suffered	heart	attacks	to	describe	their	emotional	state	in	the
hours	before	the	attack.	Being	angry	more	than	doubled	the	risk	of
cardiac	arrest	in	people	who	already	had	heart	disease;	the	heightened
risk	lasted	for	about	two	hours	after	the	anger	was	aroused.
14
These	findings	do	not	mean	that	people	should	try	to	suppress	anger
when	it	is	appropriate.	Indeed,	there	is	evidence	that	trying	to
completely	suppress	such	feelings	in	the	heat	of	the	moment	actually
results	in	magnifying	the	body’s	agitation	and	may	raise	blood
pressure.
15


pressure.
15
	On	the	other	hand,	as	we	saw	in
Chapter	5
,	the	net	effect
of	ventilating	anger	every	time	it	is	felt	is	simply	to	feed	it,	making	it
a	more	likely	response	to	any	annoying	situation.	Williams	resolves
this	paradox	by	concluding	that	whether	anger	is	expressed	or	not	is
less	important	than	whether	it	is	chronic.	An	occasional	display	of


hostility	is	not	dangerous	to	health;	the	problem	arises	when	hostility
becomes	so	constant	as	to	define	an	antagonistic	personal	style—one
marked	by	repeated	feelings	of	mistrust	and	cynicism	and	the
propensity	to	snide	comments	and	put-downs,	as	well	as	more	obvious
bouts	of	temper	and	rage.
16
The	hopeful	news	is	that	chronic	anger	need	not	be	a	death
sentence:	hostility	is	a	habit	that	can	change.	One	group	of	heart-
attack	patients	at	Stanford	University	Medical	School	was	enrolled	in
a	program	designed	to	help	them	soften	the	attitudes	that	gave	them	a
short	temper.	This	anger-control	training	resulted	in	a	second-heart-
attack	rate	44	percent	lower	than	for	those	who	had	not	tried	to
change	their	hostility.
17
	A	program	designed	by	Williams	has	had
similar	beneficial	results.
18
	Like	the	Stanford	program,	it	teaches	basic
elements	of	emotional	intelligence,	particularly	mindfulness	of	anger
as	it	begins	to	stir,	the	ability	to	regulate	it	once	it	has	begun,	and
empathy.	Patients	are	asked	to	jot	down	cynical	or	hostile	thoughts	as
they
notice	them.	If	the	thoughts	persist,	they	try	to	short-circuit	them
by	saying	(or	thinking),	“Stop!”	And	they	are	encouraged	to	purposely


substitute	reasonable	thoughts	for	cynical,	mistrustful	ones	during
trying	situations—for	instance,	if	an	elevator	is	delayed,	to	search	for
a	benign	reason	rather	than	harbor	anger	against	some	imagined
thoughtless	person	who	may	be	responsible	for	the	delay.	For
frustrating	encounters,	they	learn	the	ability	to	see	things	from	the
other	person’s	perspective—empathy	is	a	balm	for	anger.
As	Williams	told	me,	“The	antidote	to	hostility	is	to	develop	a	more
trusting	heart.	All	it	takes	is	the	right	motivation.	When	people	see
that	their	hostility	can	lead	to	an	early	grave,	they	are	ready	to	try.”
Stress:	Anxiety	Out	of	Proportion	and	Out	of	Place
I	just	feel	anxious	and	tense	all	the	time.	It	all	started	in	high	school.	I	was	a	straight-A
student,	and	I	worried	constantly	about	my	grades,	whether	the	other	kids	and	the
teachers	liked	me,	being	prompt	for	classes—things	like	that.	There	was	a	lot	of
pressure	from	my	parents	to	do	well	in	school	and	to	be	a	good	role	model.…	I	guess	I
just	caved	in	to	all	that	pressure,	because	my	stomach	problems	began	in	my
sophomore	year	of	high	school.	Since	that	time,	I’ve	had	to	be	really	careful	about


drinking	caffeine	and	eating	spicy	meals.	I	notice	that	when	I’m	feeling	worried	or
tense	my	stomach	will	flare	up,	and	since	I’m	usually	worried	about	something,	I’m
always	nauseous.
19


Anxiety—the	distress	evoked	by	life’s	pressures—is	perhaps	the
emotion	with	the	greatest	weight	of	scientific	evidence	connecting	it
to	the	onset	of	sickness	and	course	of	recovery.	When	anxiety	helps	us
prepare	to	deal	with	some	danger	(a	presumed	utility	in	evolution),
then	it	has	served	us	well.	But	in	modern	life	anxiety	is	more	often	out
of	proportion	and	out	of	place—distress	comes	in	the	face	of	situations
that	we	must	live	with	or	that	are	conjured	by	the	mind,	not	real
dangers	we	need	to	confront.	Repeated	bouts	of	anxiety	signal	high
levels	of	stress.	The	woman	whose	constant	worrying	primes	her
gastrointestinal	trouble	is	a	textbook	example	of	how	anxiety	and
stress	exacerbate	medical	problems.
In	a	1993	review	in	the
Archives	of	Internal	Medicine
	of	extensive
research	on	the	stress-disease	link,	Yale	psychologist	Bruce	McEwen
noted	a	broad	spectrum	of	effects:	compromising	immune	function	to
the	point	that	it	can	speed	the	metastasis	of	cancer;	increasing
vulnerability	to	viral	infections;	exacerbating	plaque	formation
leading	to	atherosclerosis	and	blood	clotting
leading	to	myocardial
infarction;	accelerating	the	onset	of	Type	I	diabetes	and	the	course	of
Type	II	diabetes;	and	worsening	or	triggering	an	asthma	attack.
20


20
Stress	can	also	lead	to	ulceration	of	the	gastrointestinal	tract,
triggering	symptoms	in	ulcerative	colitis	and	in	inflammatory	bowel
disease.	The	brain	itself	is	susceptible	to	the	long-term	effects	of
sustained	stress,	including	damage	to	the	hippocampus,	and	so	to
memory.	In	general,	says	McEwen,	“evidence	is	mounting	that	the
nervous	system	is	subject	to	‘wear	and	tear’	as	a	result	of	stressful
experiences.”
21
Particularly	compelling	evidence	for	the	medical	impact	from
distress	has	come	from	studies	with	infectious	diseases	such	as	colds,
the	flu,	and	herpes.	We	are	continually	exposed	to	such	viruses,	but
ordinarily	our	immune	system	fights	them	off—except	that	under
emotional	stress	those	defenses	more	often	fail.	In	experiments	in
which	the	robustness	of	the	immune	system	has	been	assayed	directly,
stress	and	anxiety	have	been	found	to	weaken	it,	but	in	most	such
results	it	is	unclear	whether	the	range	of	immune	weakening	is	of
clinical	significance—that	is,	great	enough	to	open	the	way	to
disease.
22
	For	that	reason	stronger	scientific	links	of	stress	and	anxiety
to	medical	vulnerability	come	from	prospective	studies:	those	that
start	with	healthy	people	and	monitor	first	a	heightening	of	distress


start	with	healthy	people	and	monitor	first	a	heightening	of	distress
followed	by	a	weakening	of	the	immune	system	and	the	onset	of
illness.


In	one	of	the	most	scientifically	compelling	studies,	Sheldon	Cohen,
a	psychologist	at	Carnegie-Mellon	University,	working	with	scientists
at	a	specialized	colds	research	unit	in	Sheffield,	England,	carefully
assessed	how	much	stress	people	were	feeling	in	their	lives,	and	then
systematically	exposed	them	to	a	cold	virus.	Not	everyone	so	exposed
actually	comes	down	with	a	cold;	a	robust	immune	system	can—and
constantly	does—resist	the	cold	virus.	Cohen	found	that	the	more
stress	in	their	lives,	the	more	likely	people	were	to	catch	cold.	Among
those	with	little	stress,	27	percent	came	down	with	a	cold	after	being
exposed	to	the	virus;	among	those	with	the	most	stressful	lives,	47
percent	got	the	cold—direct	evidence	that	stress	itself	weakens	the
immune	system.
23
	(While	this	may	be	one	of	those	scientific	results
that	confirms	what	everyone	has	observed	or	suspected	all	along,	it	is
considered	a	landmark	finding	because	of	its	scientific	rigor.)
Likewise,	married	couples	who	for	three	months	kept	daily
checklists	of	hassles	and	upsetting	events	such	as	marital	fights
showed	a	strong	pattern:	three	or	four	days	after	an	especially	intense
batch	of	upsets,	they	came	down	with	a	cold	or	upper-respiratory


infection.	That	lag	period	is	precisely	the	incubation	time	for	many
common	cold	viruses,	suggesting	that	being	exposed	while	they	were
most	worried	and	upset	made	them	especially	vulnerable.
24
The	same	stress-infection	pattern	holds	for	the	herpes	virus—both
the	type	that	causes	cold	sores	on	the	lip	and	the	type	that	causes
genital	lesions.	Once	people	have	been	exposed	to	the	herpes	virus,	it
stays	latent	in	the	body,	flaring	up	from	time	to	time.	The	activity	of
the	herpes	virus	can	be	tracked	by	levels	of	antibodies	to	it	in	the
blood.	Using	this	measure,	reactivation	of	the	herpes	virus	has	been
found	in	medical	students	undergoing	year-end	exams,	in	recently
separated	women,	and	among	people	under	constant	pressure	from
caring	for	a	family	member	with	Alzheimer’s	disease.
25
The	toll	of	anxiety	is	not	just	that	it	lowers	the	immune	response;
other	research	is	showing	adverse	effects	on	the	cardiovascular
system.	While	chronic	hostility	and	repeated	episodes	of	anger	seem
to	put	men	at	greatest	risk	for	heart	disease,	the	more	deadly	emotion
in	women	may	be	anxiety	and	fear.	In	research	at	Stanford	University
School	of	Medicine	with	more	than	a	thousand	men	and	women	who


School	of	Medicine	with	more	than	a	thousand	men	and	women	who
had	suffered	a	first	heart	attack,	those	women	who	went	on	to	suffer	a
second	heart	attack	were	marked	by	high	levels	of	fearfulness	and
anxiety.	In	many	cases	the	fearfulness	took	the	form	of	crippling
phobias:	after	their	first	heart	attack	the	patients	stopped	driving,	quit


their	jobs,	or	avoided	going	out.
26
The	insidious	physical	effects	of	mental	stress	and	anxiety—the	kind
produced	by	high-pressure	jobs,	or	high-pressure	lives	such	as	that	of
a	single	mother	juggling	day	care	and	a	job—are	being	pinpointed	at
an	anatomically	fine-grained	level.	For	example,	Stephen	Manuck,	a
University	of	Pittsburgh	psychologist,	put	thirty	volunteers	through	a
rigorous,	anxiety-riddled	ordeal	in	a	laboratory	while	he	monitored
the	men’s	blood,	assaying	a	substance	secreted	by	blood	platelets
called	adenosine	triphosphate,	or	ATP,	which	can	trigger	blood-vessel
changes	that	may	lead	to	heart	attacks	and	strokes.	While	the
volunteers	were	under	the	intense	stress,	their	ATP	levels	rose	sharply,
as	did	their	heart	rate	and	blood	pressure.
Understandably,	health	risks	seem	greatest	for	those	whose	jobs	are
high	in	“strain”:	having	high-pressure	performance	demands	while
having	little	or	no	control	over	how	to	get	the	job	done	(a
predicament	that	gives	bus	drivers,	for	instance,	a	high	rate	of
hypertension).	For	example,	in	a	study	of	569	patients	with	colorectal
cancer	and	a	matched	comparison	group,	those	who	said	that	in	the
previous	ten	years	they	had	experienced	severe	on-the-job	aggravation


were	five	and	a	half	times	more	likely	to	have	developed	the	cancer
compared	to	those	with	no	such	stress	in	their	lives.
27
Because	the	medical	toll	of	distress	is	so	broad,	relaxation
techniques—which	directly	counter	the	physiological	arousal	of	stress
—are	being	used
clinically	to	ease	the	symptoms	of	a	wide	variety	of
chronic	illnesses.	These	include	cardiovascular	disease,	some	types	of
diabetes,	arthritis,	asthma,	gastrointestinal	disorders,	and	chronic
pain,	to	name	a	few.	To	the	degree	any	symptoms	are	worsened	by
stress	and	emotional	distress,	helping	patients	become	more	relaxed
and	able	to	handle	their	turbulent	feelings	can	often	offer	some
reprieve.
28
The	Medical	Costs	of	Depression
She	had	been	diagnosed	with	metastatic	breast	cancer,	a	return	and	spread	of	the
malignancy	several	years	after	what	she	had	thought	was	successful	surgery	for	the
disease.	Her	doctor	could	no	longer	talk	of	a	cure,	and	the	chemotherapy,	at	best,
might	offer	just	a	few	more	months	of	life.	Understandably,	she	was	depressed—so
much	so	that	whenever	she	went	to	her	oncologist,	she	found	herself	at	some	point


bursting	out	into	tears.	Her	oncologist’s	response	each	time:	asking	her	to	leave	the


office	immediately.
Apart	from	the	hurtfulness	of	the	oncologist’s	coldness,	did	it	matter
medically	that	he	would	not	deal	with	his	patient’s	constant	sadness?
By	the	time	a	disease	has	become	so	virulent,	it	would	be	unlikely
that	any	emotion	would	have	an	appreciable	effect	on	its	progress.
While	the	woman’s	depression	most	certainly	dimmed	the	quality	of
her	final	months,	the	medical	evidence	that	melancholy	might	affect
the	course	of	cancer	is	as	yet	mixed.
29
	But	cancer	aside,	a	smattering
of	studies	suggest	a	role	for	depression	in	many	other	medical
conditions,	especially	in	worsening	a	sickness	once	it	has	begun.	The
evidence	is	mounting	that	for	patients	with	serious	disease	who	are
depressed,	it	would	pay	medically	to	treat	their	depression	too.
One	complication	in	treating	depression	in	medical	patients	is	that
its	symptoms,	including	loss	of	appetite	and	lethargy,	are	easily
mistaken	for	signs	of	other	diseases,	particularly	by	physicians	with
little	training	in	psychiatric	diagnosis.	That	inability	to	diagnose
depression	may	itself	add	to	the	problem,	since	it	means	that	a
patient’s	depression—like	that	of	the	weepy	breast-cancer	patient—
goes	unnoticed	and	untreated.	And	that	failure	to	diagnose	and	treat


may	add	to	the	risk	of	death	in	severe	disease.
For	instance,	of	100	patients	who	received	bone	marrow
transplants,	12	of	the	13	who	had	been	depressed	died	within	the	first
year	of	the	transplant,	while	34	of	the	remaining	87	were	still	alive
two	years	later.
30
	And	in	patients	with	chronic	kidney	failure	who
were	receiving	dialysis,	those	who	were
diagnosed	with	major
depression	were	most	likely	to	die	within	the	following	two	years;
depression	was	a	stronger	predictor	of	death	than	any	medical	sign.
31
Here	the	route	connecting	emotion	to	medical	status	was	not
biological	but	attitudinal:	The	depressed	patients	were	much	worse
about	complying	with	their	medical	regimens—cheating	on	their
diets,	for	example,	which	put	them	at	higher	risk.
Heart	disease	too	seems	to	be	exacerbated	by	depression.	In	a	study
of	2,832	middle-aged	men	and	women	tracked	for	twelve	years,	those
who	felt	a	sense	of	nagging	despair	and	hopelessness	had	a	heightened
rate	of	death	from	heart	disease.
32
	And	for	the	3	percent	or	so	who
were	most	severely	depressed,	the	death	rate	from	heart	disease,
compared	to	the	rate	for	those	with	no	feelings	of	depression,	was
four	times	greater.


four	times	greater.
Depression	seems	to	pose	a	particularly	grave	medical	risk	for	heart


attack	survivors.
33
	In	a	study	of	patients	in	a	Montreal	hospital	who
were	discharged	after	being	treated	for	a	first	heart	attack,	depressed
patients	had	a	sharply	higher	risk	of	dying	within	the	following	six
months.	Among	the	one	in	eight	patients	who	were	seriously
depressed,	the	death	rate	was	five	times	higher	than	for	others	with
comparable	disease—an	effect	as	great	as	that	of	major	medical	risks
for	cardiac	death,	such	as	left	ventricular	dysfunction	or	a	history	of
previous	heart	attacks.	Among	the	possible	mechanisms	that	might
explain	why	depression	so	greatly	increases	the	odds	of	a	later	heart
attack	are	its	effects	on	heart	rate	variability,	increasing	the	risk	of
fatal	arrhythmias.
Depression	has	also	been	found	to	complicate	recovery	from	hip
fracture.	In	a	study	of	elderly	women	with	hip	fracture,	several
thousand	were	given	psychiatric	evaluations	on	their	admission	to	the
hospital.	Those	who	were	depressed	on	admission	stayed	an	average
of	eight	days	longer	than	those	with	comparable	injury	but	no
depression,	and	were	only	a	third	as	likely	ever	to	walk	again.	But
depressed	women	who	had	psychiatric	help	for	their	depression	along
with	other	medical	care	needed	less	physical	therapy	to	walk	again


and	had	fewer	rehospitalizations	over	the	three	months	after	their
return	home	from	the	hospital.
Likewise,	in	a	study	of	patients	whose	condition	was	so	dire	that
they	were	among	the	top	10	percent	of	those	using	medical	services—
often	because	of	having	multiple	illnesses,	such	as	both	heart	disease
and	diabetes—about	one	in	six	had	serious	depression.	When	these
patients	were	treated	for	the	problem,	the	number	of	days	per	year
that	they	were	disabled	dropped	from	79	to	51	for	those	who	had
major	depression,	and	from	62	days	per	year	to	just	18	in	those	who
had	been	treated	for	mild	depression.
34
THE	MEDICAL	BENEFITS	OF

POSITIVE	FEELINGS
The	cumulative	evidence	for	adverse	medical	effects	from	anger,
anxiety,	and	depression,	then,	is	compelling.	Both	anger	and	anxiety,
when	chronic,	can	make	people	more	susceptible	to	a	range	of
disease.	And	while	depression	may	not	make	people	more	vulnerable
to	becoming	ill,	it	does	seem	to	impede	medical	recovery	and
heighten	the	risk	of	death,	especially	with	more	frail	patients	with
severe	conditions.


But	if	chronic	emotional	distress	in	its	many	forms	is	toxic,	the
opposite	range	of	emotion	can	be	tonic—to	a	degree.	This	by	no
means	says	that	positive	emotion	is	curative,	or	that	laughter	or
happiness	alone	will	turn	the	course	of	a	serious	disease.	The	edge
positive	emotions	offer	seems	subtle,	but,	by	using	studies	with	large
numbers	of	people,	can	be	teased	out	of	the	mass	of	complex	variables
that	affect	the	course	of	disease.
The	Price	of	Pessimism—and	Advantages	of	Optimism
As	with	depression,	there	are	medical	costs	to	pessimism—and
corresponding	benefits	from	optimism.	For	example,	122	men	who
had	their	first	heart	attack	were	evaluated	on	their	degree	of	optimism
or	pessimism.	Eight	years	later,	of	the	25	most	pessimistic	men,	21
had	died;	of	the	25	most	optimistic,	just	6	had	died.	Their	mental
outlook	proved	a	better	predictor	of	survival	than	any	medical	risk
factor,	including	the	amount	of	damage	to	the	heart	in	the	first	attack,
artery	blockage,	cholesterol	level,	or	blood	pressure.	And	in	other
research,	patients	going	into	artery	bypass	surgery	who	were	more
optimistic	had	a	much	faster	recovery	and	fewer	medical
complications	during	and	after	surgery	than	did	more	pessimistic


complications	during	and	after	surgery	than	did	more	pessimistic
patients.
35
Like	its	near	cousin	optimism,	hope	has	healing	power.	People	who
have	a	great	deal	of	hopefulness	are,	understandably,	better	able	to
bear	up	under	trying	circumstances,	including	medical	difficulties.	In
a	study	of	people	paralyzed	from	spinal	injuries,	those	who	had	more
hope	were	able	to	gain	greater	levels	of	physical	mobility	compared	to
other	patients	with	similar	degrees	of	injury,	but	who	felt	less	hopeful.
Hope	is	especially	telling	in	paralysis	from	spinal	injury,	since	this
medical	tragedy	typically	involves	a	man	who	is	paralyzed	in	his
twenties	by	an	accident	and	will	remain	so	for	the	rest	of	his	life.	How
he	reacts	emotionally	will	have	broad	consequences	for	the	degree	to
which	he	will	make	the	efforts	that	might	bring	him	greater	physical
and	social	functioning.
36
Just	why	an	optimistic	or	pessimistic	outlook	should	have	health
consequences	is	open	to	any	of	several	explanations.	One	theory
proposes	that	pessimism	leads	to	depression,	which	in	turn	interferes
with	the	resistance	of	the	immune	system	to	tumors	and	infection—an
unproven	speculation	at	present.	Or	it	may	be	that	pessimists	neglect


themselves—some	studies	have	found	that	pessimists	smoke	and	drink


more,	and	exercise	less,	than	optimists,	and	are	generally	much	more
careless	about	their	health	habits.	Or	it	may	one	day	turn	out	that	the
physiology	of	hopefulness	is	itself	somehow	helpful	biologically	to	the
body’s	fight	against	disease.
With	a	Little	Help	From	My	Friends:
The	Medical	Value	of	Relationships
Add	the	sounds	of	silence	to	the	list	of	emotional	risks	to	health—and
close	emotional	ties	to	the	list	of	protective	factors.	Studies	done	over
two	decades	involving	more	than	thirty-seven	thousand	people	show
that	social	isolation—the	sense	that	you	have	nobody	with	whom	you
can	share	your	private	feelings	or	have	close	contact—doubles	the
chances	of	sickness	or	death.
37
	Isolation	itself,	a	1987	report	in
Science
concluded,	“is	as	significant	to	mortality	rates	as	smoking,	high	blood
pressure,	high	cholesterol,	obesity,	and	lack	of	physical	exercise.”
Indeed,	smoking	increases	mortality	risk	by	a	factor	of	just	1.6,	while
social	isolation	does	so	by	a	factor	of	2.0,	making	it	a	greater	health
risk.
38
Isolation	is	harder	on	men	than	on	women.	Isolated	men	were	two
to	three	times	more	likely	to	die	as	were	men	with	close	social	ties;


for	isolated	women,	the	risk	was	one	and	a	half	times	greater	than	for
more	socially	connected	women.	The	difference	between	men	and
women	in	the	impact	of	isolation	may	be	because	women’s
relationships	tend	to	be	emotionally	closer	than	men’s;	a	few	strands
of	such	social	ties	for	a	woman	may	be	more	comforting	than	the
same	small	number	of	friendships	for	a	man.
Of	course,	solitude	is	not	the	same	as	isolation;	many	people	who
live	on	their	own	or	see	few	friends	are	content	and	healthy.	Rather,	it
is	the	subjective	sense	of	being	cut	off	from	people	and	having	no	one
to	turn	to	that	is	the	medical	risk.	This	finding	is	ominous	in	light	of
the	increasing	isolation	bred	by	solitary	TV-watching	and	the	falling
away	of	social	habits	such	as	clubs	and	visits	in	modern	urban
societies,	and	suggests	an	added	value	to	self-help	groups	such	as
Alcoholics	Anonymous	as	surrogate	communities.
The	power	of	isolation	as	a	mortality	risk	factor—and	the	healing
power	of	close	ties—can	be	seen	in	the	study	of	one	hundred	bone
marrow	transplant	patients.
39
	Among	patients	who	felt	they	had
strong	emotional	support	from	their	spouse,	family,	or	friends,	54
percent	survived	the	transplants	after	two	years,	versus	just	20


percent	among	those	who	reported	little	such	support.	Similarly,
elderly	people	who	suffer	heart	attacks,	but	have	two	or	more	people
in	their	lives	they	can	rely	on	for	emotional	support,	are	more	than
twice	as	likely	to	survive	longer	than	a	year	after	an	attack	than	are
those	people	with	no	such	support.
40
Perhaps	the	most	telling	testimony	to	the	healing	potency	of
emotional	ties	is	a	Swedish	study	published	in	1993.
41
	All	the	men
living	in	the	Swedish	city	of	Göteborg	who	were	born	in	1933	were
offered	a	free	medical	exam;	seven	years	later	the	752	men	who	had
come	for	the	exam	were	contacted	again.	Of	these,	41	had	died	in	the
intervening	years.
Men	who	had	originally	reported	being	under	intense	emotional
stress	had	a	death	rate	three	times	greater	than	those	who	said	their
lives	were	calm	and	placid.	The	emotional	distress	was	due	to	events
such	as	serious	financial	trouble,	feeling	insecure	at	work	or	being
forced	out	of	a	job,	being	the	object	of	a	legal	action,	or	going	through
a	divorce.	Having	had	three	or	more	of	these	troubles	within	the	year
before	the	exam	was	a	stronger	predictor	of	dying	within	the	ensuing


seven	years	than	were	medical	indicators	such	as	high	blood	pressure,
high	concentrations	of	blood	triglycerides,	or	high	serum	cholesterol
levels.
Yet	among	men	who	said	they	had	a	dependable	web	of	intimacy—
a	wife,	close	friends,	and	the	like—
there	was	no	relationship	whatever
between	high	stress	levels	and	death	rate.	Having	people	to	turn	to
and	talk	with,	people	who	could	offer	solace,	help,	and	suggestions,
protected	them	from	the	deadly	impact	of	life’s	rigors	and	trauma.
The	quality	of	relationships	as	well	as	their	sheer	number	seems	key
to	buffering	stress.	Negative	relationships	take	their	own	toll.	Marital
arguments,	for	example,	have	a	negative	impact	on	the	immune
system.
42
	One	study	of	college	roommates	found	that	the	more	they
disliked	each	other,	the	more	susceptible	they	were	to	colds	and	the
flu,	and	the	more	frequently	they	went	to	doctors.	John	Cacioppo,	the
Ohio	State	University	psychologist	who	did	the	roommate	study,	told
me,	“It’s	the	most	important	relationships	in	your	life,	the	people	you
see	day	in	and	day	out,	that	seem	to	be	crucial	for	your	health.	And
the	more	significant	the	relationship	is	in	your	life,	the	more	it
matters	for	your	health.”
43


matters	for	your	health.”
43
The	Healing	Power	of	Emotional	Support


In
The	Merry	Adventures	of	Robin	Hood
,	Robin	advises	a	young
follower:	“Tell	us	thy	troubles	and	speak	freely.	A	flow	of	words	doth
ever	ease	the	heart	of	sorrows;	it	is	like	opening	the	waste	where	the
mill	dam	is	overfull.”	This	bit	of	folk	wisdom	has	great	merit;
unburdening	a	troubled	heart	appears	to	be	good	medicine.	The
scientific	corroboration	of	Robin’s	advice	comes	from	James
Pennebaker,	a	Southern	Methodist	University	psychologist,	who	has
shown	in	a	series	of	experiments	that	getting	people	to	talk	about	the
thoughts	that	trouble	them	most	has	a	beneficial	medical	effect.
44
	His
method	is	remarkably	simple:	he	asks	people	to	write,	for	fifteen	to
twenty	minutes	a	day	over	five	or	so	days,	about,	for	example,	“the
most	traumatic	experience	of	your	entire	life,”	or	some	pressing	worry
of	the	moment.	What	people	write	can	be	kept	entirely	to	themselves
if	they	like.
The	net	effect	of	this	confessional	is	striking:	enhanced	immune
function,	significant	drops	in	health-center	visits	in	the	following	six
months,	fewer	days	missed	from	work,	and	even	improved	liver
enzyme	function.	Moreover,	those	whose	writing	showed	most


enzyme	function.	Moreover,	those	whose	writing	showed	most
evidence	of	turbulent	feelings	had	the	greatest	improvements	in	their
immune	function.	A	specific	pattern	emerged	as	the	“healthiest”	way
to	ventilate	troubling	feelings:	at	first	expressing	a	high	level	of
sadness,	anxiety,	anger—whatever	troubling	feelings	the	topic
brought	up;	then,	over	the	course	of	the	next	several	days	weaving	a
narrative,	finding	some	meaning	in	the	trauma	or	travail.
That	process,	of	course,	seems	akin	to	what	happens	when	people
explore	such	troubles	in	psychotherapy.	Indeed,	Pennebaker’s	findings
suggest	one	reason	why	other	studies	show	medical	patients	given
psychotherapy	in	addition	to	surgery	or	medical	treatment	often	fare
better
medically
	than	do	those	who	receive	medical	treatment	alone.
45
Perhaps	the	most	powerful	demonstration	of	the	clinical	power	of
emotional	support	was	in	groups	at	Stanford	University	Medical
School	for	women	with	advanced	metastatic	breast	cancer.	After	an
initial	treatment,	often	including	surgery,	these	women’s	cancer	had
returned	and	was	spreading	through	their	bodies.	It	was	only	a	matter
of	time,	clinically	speaking,	until	the	spreading	cancer	killed	them.	Dr.


David	Spiegel,	who	conducted	the	study,	was	himself	stunned	by	the
findings,	as	was	the	medical	community:	women	with	advanced	breast
cancer	who	went	to	weekly	meetings	with	others	survived
twice	as
long
	as	did	women	with	the	same	disease	who	faced	it	on	their	own.
46
All	the	women	received	standard	medical	care;	the	only	difference


was	that
some	also	went	to	the	groups,	where	they	were	able	to
unburden	themselves	with	others	who	understood	what	they	faced
and	were	willing	to	listen	to	their	fears,	their	pain,	and	their	anger.
Often	this	was	the	only	place	where	the	women	could	be	open	about
these	emotions,	because	other	people	in	their	lives	dreaded	talking
with	them	about	the	cancer	and	their	imminent	death.	Women	who
attended	the	groups	lived	for	thirty-seven	additional	months,	on
average,	while	those	with	the	disease	who	did	not	go	to	the	groups
died,	on	average,	in	nineteen	months—a	gain	in	life	expectancy	for
such	patients	beyond	the	reach	of	any	medication	or	other	medical
treatment.	As	Dr.	Jimmie	Holland,	the	chief	psychiatric	oncologist	at
Sloan-Kettering	Memorial	Hospital,	a	cancer	treatment	center	in	New
York	City,	put	it	to	me,	“Every	cancer	patient	should	be	in	a	group
like	this.”	Indeed,	if	it	had	been	a	new	drug	that	produced	the
extended	life	expectancy,	pharmaceutical	companies	would	be
battling	to	produce	it.
BRINGING	EMOTIONAL	INTELLIGENCE	TO	MEDICAL	CARE
The	day	a	routine	checkup	spotted	some	blood	in	my	urine,	my	doctor
sent	me	for	a	diagnostic	test	in	which	I	was	injected	with	a	radioactive


dye.	I	lay	on	a	table	while	an	overhead	X-ray	machine	took	successive
images	of	the	dye’s	progression	through	my	kidneys	and	bladder.	I
had	company	for	the	test:	a	close	friend,	a	physician	himself,
happened	to	be	visiting	for	a	few	days	and	offered	to	come	to	the
hospital	with	me.	He	sat	in	the	room	while	the	X-ray	machine,	on	an
automated	track,	rotated	for	new	camera	angles,	whirred	and	clicked;
rotated,	whirred,	clicked.
The	test	took	an	hour	and	a	half.	At	the	very	end	a	kidney	specialist
hurried	into	the	room,	quickly	introduced	himself,	and	disappeared	to
scan	the	X-rays.	He	didn’t	return	to	tell	me	what	they	showed.
As	we	were	leaving	the	exam	room	my	friend	and	I	passed	the
nephrologist.	Feeling	shaken	and	somewhat	dazed	by	the	test,	I	did
not	have	the	presence	of	mind	to	ask	the	one	question	that	had	been
on	my	mind	all	morning.	But	my	companion,	the	physician,	did:
“Doctor,”	he	said,	“my	friend’s	father	died	of	bladder	cancer.	He’s
anxious	to	know	if	you	saw	any	signs	of	cancer	in	the	X-rays.”
“No	abnormalities,”	was	the	curt	reply	as	the	nephrologist	hurried
on	to	his	next	appointment.


My	inability	to	ask	the	single	question	I	cared	about	most	is
repeated	a	thousand	times	each	day	in	hospitals	and	clinics
everywhere.	A	study	of
patients	in	physicians’	waiting	rooms	found
that	each	had	an	average	of	three	or	more	questions	in	mind	to	ask
the	physician	they	were	about	to	see.	But	when	the	patients	left	the
physician’s	office,	an	average	of	only	one	and	a	half	of	those	questions
had	been	answered.
47
	This	finding	speaks	to	one	of	the	many	ways
patients’	emotional	needs	are	unmet	by	today’s	medicine.	Unanswered
questions	feed	uncertainty,	fear,	catastrophizing.	And	they	lead
patients	to	balk	at	going	along	with	treatment	regimes	they	don’t	fully
understand.
There	are	many	ways	medicine	can	expand	its	view	of	health	to
include	the	emotional	realities	of	illness.	For	one,	patients	could
routinely	be	offered	fuller	information	essential	to	the	decisions	they
must	make	about	their	own	medical	care;	some	services	now	offer	any
caller	a	state-of-the-art	computer	search	of	the	medical	literature	on
what	ails	them,	so	that	patients	can	be	more	equal	partners	with	their
physicians	in	making	informed	decisions.
48
	Another	approach	is
programs	that,	in	a	few	minutes’	time,	teach	patients	to	be	effective


questioners	with	their	physicians,	so	that	when	they	have	three
questions	in	mind	as	they	wait	for	the	doctor,	they	will	come	out	of
the	office	with	three	answers.
49
Moments	when	patients	face	surgery	or	invasive	and	painful	tests
are	fraught	with	anxiety—and	are	a	prime	opportunity	to	deal	with
the	emotional	dimension.	Some	hospitals	have	developed	presurgery
instruction	for	patients	that	help	them	assuage	their	fears	and	handle
their	discomforts—for	example,	by	teaching	patients	relaxation
techniques,	answering	their	questions	well	in	advance	of	surgery,	and
telling	them	several	days	ahead	of	surgery	precisely	what	they	are
likely	to	experience	during	their	recovery.	The	result:	patients	recover
from	surgery	an	average	of	two	to	three	days	sooner.
50
Being	a	hospital	patient	can	be	a	tremendously	lonely,	helpless
experience.	But	some	hospitals	have	begun	to	design	rooms	so	that
family	members	can	stay	with	patients,	cooking	and	caring	for	them
as	they	would	at	home—a	progressive	step	that,	ironically,	is	routine
throughout	the	Third	World.
51
Relaxation	training	can	help	patients	deal	with	some	of	the	distress
their	symptoms	bring,	as	well	as	with	the	emotions	that	may	be
triggering	or	exacerbating	their	symptoms.	An	exemplary	model	is	Jon


Kabat-Zinn’s	Stress	Reduction	Clinic	at	the	University	of


Massachusetts	Medical	Center,	which	offers	a	ten-week	course	in
mindfulness	and	yoga	to	patients;	the	emphasis	is	on	being	mindful	of
emotional	episodes	as	they	are	happening,	and	on	cultivating	a	daily
practice	that	offers	deep	relaxation.	Hospitals
have	made	instructional
tapes	from	the	course	available	over	patients’	television	sets—a	far
better	emotional	diet	for	the	bedridden	than	the	usual	fare,	soap
operas.
52
Relaxation	and	yoga	are	also	at	the	core	of	the	innovative	program
for	treating	heart	disease	developed	by	Dr.	Dean	Ornish.
53
	After	a
year	of	this	program,	which	included	a	low-fat	diet,	patients	whose
heart	disease	was	severe	enough	to	warrant	a	coronary	bypass
actually	reversed	the	buildup	of	artery-clogging	plaque.	Ornish	tells
me	that	relaxation	training	is	one	of	the	most	important	parts	of	the
program.	Like	Kabat-Zinn’s,	it	takes	advantage	of	what	Dr.	Herbert
Benson	calls	the	“relaxation	response,”	the	physiological	opposite	of
the	stress	arousal	that	contributes	to	such	a	wide	spectrum	of	medical
problems.
Finally,	there	is	the	added	medical	value	of	an	empathic	physician
or	nurse,	attuned	to	patients,	able	to	listen	and	be	heard.	This	means


fostering	“relationship-centered	care,”	recognizing	that	the
relationship	between	physician	and	patient	is	itself	a	factor	of
significance.	Such	relationships	would	be	fostered	more	readily	if
medical	education	included	some	basic	tools	of	emotional	intelligence,
especially	self-awareness	and	the	arts	of	empathy	and	listening.
54
TOWARD	A	MEDICINE	THAT	CARES
Such	steps	are	a	beginning.	But	for	medicine	to	enlarge	its	vision	to
embrace	the	impact	of	emotions,	two	large	implications	of	the
scientific	findings	must	be	taken	to	heart:
1.
Helping	people	better	manage	their	upsetting	feelings—anger,	anxiety,
depression,	pessimism,	and	loneliness—is	a	form	of	disease	prevention
.
Since	the	data	show	that	the	toxicity	of	these	emotions,	when	chronic,
is	on	a	par	with	smoking	cigarettes,	helping	people	handle	them
better	could	potentially	have	a	medical	payoff	as	great	as	getting
heavy	smokers	to	quit.	One	way	to	do	this	that	could	have	broad
public-health	effects	would	be	to	impart	most	basic	emotional
intelligence	skills	to	children,	so	that	they	become	lifelong	habits.


Another	high-payoff	preventive	strategy	would	be	to	teach	emotion
management	to	people	reaching	retirement	age,	since	emotional	well-
being	is	one	factor	that	determines	whether	an	older	person	declines
rapidly	or	thrives.	A	third	target	group	might	be	so-called	at-risk
populations—the	very	poor,	single	working	mothers,	residents	of
high-crime
neighborhoods,	and	the	like—who	live	under
extraordinary	pressure	day	in	and	day	out,	and	so	might	do	better
medically	with	help	in	handling	the	emotional	toll	of	these	stresses.
2.
Many	patients	can	benefit	measurably	when	their	psychological	needs
are	attended	to	along	with	their	purely	medical	ones
.	While	it	is	a	step
toward	more	humane	care	when	a	physician	or	nurse	offers	a
distressed	patient	comfort	and	consolation,	more	can	be	done.	But
emotional	care	is	an	opportunity	too	often	lost	in	the	way	medicine	is
practiced	today;	it	is	a	blind	spot	for	medicine.	Despite	mounting	data
on	the	medical	usefulness	of	attending	to	emotional	needs,	as	well	as
supporting	evidence	for	connections	between	the	brain’s	emotional
center	and	the	immune	system,	many	physicians	remain	skeptical	that
their	patients’	emotions	matter	clinically,	dismissing	the	evidence	for
this	as	trivial	and	anecdotal,	as	“fringe,”	or,	worse,	as	the


exaggerations	of	a	self-promoting	few.
Though	more	and	more	patients	seek	a	more	humane	medicine,	it	is
becoming	endangered.	Of	course,	there	remain	dedicated	nurses	and
physicians	who	give	their	patients	tender,	sensitive	care.	But	the
changing	culture	of	medicine	itself,	as	it	becomes	more	responsive	to
the	imperatives	of	business,	is	making	such	care	increasingly	difficult
to	find.
On	the	other	hand,	there	may	be	a	business	advantage	to	humane
medicine:	treating	emotional	distress	in	patients,	early	evidence
suggests,	can	save	money—especially	to	the	extent	that	it	prevents	or
delays	the	onset	of	sickness,	or	helps	patients	heal	more	quickly.	In	a
study	of	elderly	patients	with	hip	fracture	at	Mt.	Sinai	School	of
Medicine	in	New	York	City	and	at	Northwestern	University,	patients
who	received	therapy	for	depression	in	addition	to	normal	orthopedic
care	left	the	hospital	an	average	of	two	days	earlier;	total	savings	for
the	hundred	or	so	patients	was	$97,361	in	medical	costs.
55
Such	care	also	makes	patients	more	satisfied	with	their	physicians
and	medical	treatment.	In	the	emerging	medical	marketplace,	where
patients	often	have	the	option	to	choose	between	competing	health


plans,	satisfaction	levels	will	no	doubt	enter	the	equation	of	these	very
personal	decisions—souring	experiences	can	lead	patients	to	go
elsewhere	for	care,	while	pleasing	ones	translate	into	loyalty.
Finally,	medical	ethics	may	demand	such	an	approach.	An	editorial
in	the
Journal	of	the	American	Medical	Association
,	commenting	on	a
report	that	depression	increases	fivefold	the	likelihood	of	dying	after
being	treated	for	a	heart	attack,	notes:	“[T]he	clear	demonstration
that	psychological	factors	like
depression	and	social	isolation
distinguish	the	coronary	heart	disease	patients	at	highest	risk	means	it
would	be	unethical	not	to	start	trying	to	treat	these	factors.”
56
If	the	findings	on	emotions	and	health	mean	anything,	it	is	that
medical	care	that	neglects	how	people
feel	as
	they	battle	a	chronic	or
severe	disease	is	no	longer	adequate.	It	is	time	for	medicine	to	take
more	methodical	advantage	of	the	link	between	emotion	and	health.
What	is	now	the	exception	could—and	should—be	part	of	the
mainstream,	so	that	a	more	caring	medicine	is	available	to	us	all.	At
the	least	it	would	make	medicine	more	humane.	And,	for	some,	it
could	speed	the	course	of	recovery.	“Compassion,”	as	one	patient	put


it	in	an	open	letter	to	his	surgeon,	“is	not	mere	hand	holding.	It	is
good	medicine.”
57


12
The	Family	Crucible
It’s	a	low-key	family	tragedy.	Carl	and	Ann	are	showing	their	daughter	Leslie,	just	five,
how	to	play	a	brand-new	video	game.	But	as	Leslie	starts	to	play,	her	parents’	overly
eager	attempts	to	“help”	her	just	seem	to	get	in	the	way.	Contradictory	orders	fly	in
every	direction.
“To	the	right,	to	the	right—stop.	Stop.	Stop!”	Ann,	the	mother,	urges,	her	voice
growing	more	intent	and	anxious	as	Leslie,	sucking	on	her	lip	and	staring	wide-eyed	at
the	video	screen,	struggles	to	follow	these	directives.
“See,	you’re	not	lined	up	…	put	it	to	the	left!	To	the	left!”	Carl,	the	girl’s	father,
brusquely	orders.
Meanwhile	Ann,	her	eyes	rolling	upward	in	frustration,	yells	over	his	advice,	“Stop!
Stop!”
Leslie,	unable	to	please	either	her	father	or	her	mother,	contorts	her	jaw	in	tension
and	blinks	as	her	eyes	fill	with	tears.
Her	parents	start	bickering,	ignoring	Leslie’s	tears.	“She’s	not	moving	the	stick
that
much!”	Ann	tells	Carl,	exasperated.
As	the	tears	start	rolling	down	Leslie’s	cheeks,	neither	parent	makes	any	move	that


indicates	they	notice	or	care.	As	Leslie	raises	her	hand	to	wipe	her	eyes,	her	father
snaps,	“Okay,	put	your	hand	back	on	the	stick	…	you	wanna	get	ready	to	shoot.	Okay,
put	it	over!”	And	her	mother	barks,	“Okay,	move	it	just	a	teeny	bit!”
But	by	now	Leslie	is	sobbing	softly,	alone	with	her	anguish.
At	such	moments	children	learn	deep	lessons.	For	Leslie	one
conclusion	from	this	painful	exchange	might	well	be	that	neither	her
parents,	nor	anyone	else,	for	that	matter,	cares	about	her	feelings.
1
When	similar	moments	are	repeated	countless	times	over	the	course	of
childhood	they	impart	some	of	the	most	fundamental	emotional
messages	of	a	lifetime—lessons	that	can	determine	a	life	course.
Family	life	is	our	first	school	for	emotional	learning;	in	this	intimate
cauldron	we	learn	how	to	feel	about	ourselves	and	how
others	will
react	to	our	feelings;	how	to	think	about	these	feelings	and	what


choices	we	have	in	reacting;	how	to	read	and	express	hopes	and	fears.
This	emotional	schooling	operates	not	just	through	the	things	that
parents	say	and	do	directly	to	children,	but	also	in	the	models	they
offer	for	handling	their	own	feelings	and	those	that	pass	between
husband	and	wife.	Some	parents	are	gifted	emotional	teachers,	others
atrocious.
There	are	hundreds	of	studies	showing	that	how	parents	treat	their
children—whether	with	harsh	discipline	or	empathic	understanding,
with	indifference	or	warmth,	and	so	on—has	deep	and	lasting
consequences	for	the	child’s	emotional	life.	Only	recently,	though,
have	there	been	hard	data	showing	that	having	emotionally	intelligent
parents	is	itself	of	enormous	benefit	to	a	child.	The	ways	a	couple
handles	the	feelings	between	them—in	addition	to	their	direct
dealings	with	a	child—impart	powerful	lessons	to	their	children,	who
are	astute	learners,	attuned	to	the	subtlest	emotional	exchanges	in	the
family.	When	research	teams	led	by	Carole	Hooven	and	John	Gottman
at	the	University	of	Washington	did	a	microanalysis	of	interactions	in
couples	on	how	the	partners	handled	their	children,	they	found	that
those	couples	who	were	more	emotionally	competent	in	the	marriage
were	also	the	most	effective	in	helping	their	children	with	their


were	also	the	most	effective	in	helping	their	children	with	their
emotional	ups	and	downs.
2
The	families	were	first	seen	when	one	of	their	children	was	just	five
years	old,	and	again	when	the	child	had	reached	nine.	In	addition	to
observing	the	parents	talk	with	each	other,	the	research	team	also
watched	families	(including	Leslie’s)	as	the	father	or	mother	tried	to
show	their	young	child	how	to	operate	a	new	video	game—a
seemingly	innocuous	interaction,	but	quite	telling	about	the	emotional
currents	that	run	between	parent	and	child.
Some	mothers	and	fathers	were	like	Ann	and	Carl:	overbearing,
losing	patience	with	their	child’s	ineptness,	raising	their	voices	in
disgust	or	exasperation,	some	even	putting	their	child	down	as
“stupid”—in	short,	falling	prey	to	the	same	tendencies	toward
contempt	and	disgust	that	eat	away	at	a	marriage.	Others,	however,
were	patient	with	their	child’s	errors,	helping	the	child	figure	the
game	out	in	his	or	her	own	way	rather	than	imposing	the	parents’
will.	The	video	game	session	was	a	surprisingly	powerful	barometer	of
the	parents’	emotional	style.
The	three	most	common	emotionally	inept	parenting	styles	proved
to	be:


•	Ignoring	feelings	altogether
.	Such	parents	treat	a	child’s	emotional
upset	as	trivial	or	a	bother,	something	they	should	wait	to	blow	over.
They	fail	to	use	emotional	moments	as	a	chance	to	get	closer	to	the
child	or	to	help	the	child	learn	lessons	in	emotional	competence.
•
Being	too	laissez-faire
.	These	parents	notice	how	a	child	feels,	but
hold	that	however	a	child	handles	the	emotional	storm	is	fine—even,
say,	hitting.	Like	those	who	ignore	a	child’s	feelings,	these	parents
rarely	step	in	to	try	to	show	their	child	an	alternative	emotional
response.	They	try	to	soothe	all	upsets,	and	will,	for	instance,	use
bargaining	and	bribes	to	get	their	child	to	stop	being	sad	or	angry.
•
Being	contemptuous,	showing	no	respect	for	how	the	child	feels
.	Such
parents	are	typically	disapproving,	harsh	in	both	their	criticisms	and
their	punishments.	They	might,	for	instance,	forbid	any	display	of	the
child’s	anger	at	all,	and	become	punitive	at	the	least	sign	of
irritability.	These	are	the	parents	who	angrily	yell	at	a	child	who	is
trying	to	tell	his	side	of	the	story,	“Don’t	you	talk	back	to	me!”
Finally,	there	are	parents	who	seize	the	opportunity	of	a	child’s


Finally,	there	are	parents	who	seize	the	opportunity	of	a	child’s
upset	to	act	as	what	amounts	to	an	emotional	coach	or	mentor.	They
take	their	child’s	feelings	seriously	enough	to	try	to	understand
exactly	what	is	upsetting	them	(“Are	you	angry	because	Tommy	hurt
your	feelings?”)	and	to	help	the	child	find	positive	ways	to	soothe
their	feelings	(“Instead	of	hitting	him,	why	don’t	you	find	a	toy	to
play	with	on	your	own	until	you	feel	like	playing	with	him	again?”).
In	order	for	parents	to	be	effective	coaches	in	this	way,	they	must
have	a	fairly	good	grasp	of	the	rudiments	of	emotional	intelligence
themselves.	One	of	the	basic	emotional	lessons	for	a	child,	for
example,	is	how	to	distinguish	among	feelings;	a	father	who	is	too
tuned	out	of,	say,	his	own	sadness	cannot	help	his	son	understand	the
difference	between	grieving	over	a	loss,	feeling	sad	in	a	sad	movie,
and	the	sadness	that	arises	when	something	bad	happens	to	someone
the	child	cares	about.	Beyond	this	distinction,	there	are	more
sophisticated	insights,	such	as	that	anger	is	so	often	prompted	by	first
feeling	hurt.
As	children	grow	the	specific	emotional	lessons	they	are	ready	for—


As	children	grow	the	specific	emotional	lessons	they	are	ready	for—
and	in	need	of—shift.	As	we	saw	in
Chapter	7
	the	lessons	in	empathy
begin	in	infancy,	with	parents	who	attune	to	their	baby’s	feelings.
Though	some	emotional	skills	are	honed	with	friends	through	the
years,	emotionally	adept	parents	can	do	much	to	help	their	children


with	each	of	the	basics	of	emotional	intelligence:	learning	how	to
recognize,	manage,	and	harness	their	feelings;	empathizing;	and
handling	the	feelings	that	arise	in	their	relationships.
The	impact	on	children	of	such	parenting	is	extraordinarily
sweeping.
3
	The	University	of	Washington	team	found	that	when
parents	are	emotionally
adept,	compared	to	those	who	handle	feelings
poorly,	their	children—understandably—get	along	better	with,	show
more	affection	toward,	and	have	less	tension	around	their	parents.	But
beyond	that,	these	children	also	are	better	at	handling	their	own
emotions,	are	more	effective	at	soothing	themselves	when	upset,	and
get	upset	less	often.	The	children	are	also	more	relaxed
biologically
,
with	lower	levels	of	stress	hormones	and	other	physiological
indicators	of	emotional	arousal	(a	pattern	that,	if	sustained	through
life,	might	well	augur	better	physical	health,	as	we	saw	in
Chapter
11
).	Other	advantages	are	social:	these	children	are	more	popular
with	and	are	better-liked	by	their	peers,	and	are	seen	by	their	teachers
as	more	socially	skilled.	Their	parents	and	teachers	alike	rate	these
children	as	having	fewer	behavioral	problems	such	as	rudeness	or


children	as	having	fewer	behavioral	problems	such	as	rudeness	or
aggressiveness.	Finally,	the	benefits	are	cognitive;	these	children	can
pay	attention	better,	and	so	are	more	effective	learners.	Holding	IQ
constant,	the	five-year-olds	whose	parents	were	good	coaches	had
higher	achievement	scores	in	math	and	reading	when	they	reached
third	grade	(a	powerful	argument	for	teaching	emotional	skills	to	help
prepare	children	for	learning	as	well	as	life).	Thus	the	payoff	for
children	whose	parents	are	emotionally	adept	is	a	surprising—almost
astounding—range	of	advantages	across,	and	beyond,	the	spectrum	of
emotional	intelligence.
HEART	START
The	impact	of	parenting	on	emotional	competence	starts	in	the	cradle.
Dr.	T.	Berry	Brazelton,	the	eminent	Harvard	pediatrician,	has	a	simple
diagnostic	test	of	a	baby’s	basic	outlook	toward	life.	He	offers	two
blocks	to	an	eight-month-old,	and	then	shows	the	baby	how	he	wants
her	to	put	the	two	blocks	together.	A	baby	who	is	hopeful	about	life,
who	has	confidence	in	her	own	abilities,	says	Brazelton,
will	pick	up	one	block,	mouth	it,	rub	it	in	her	hair,	drop	it	over	the	side	of	the	table,
watching	to	see	whether	you	will	retrieve	it	for	her.	When	you	do,	she	finally


completes	the	requested	task—place	the	two	blocks	together.	Then	she	looks	up	at	you
with	a	bright-eyed	look	of	expectancy	that	says,	“Tell	me	how	great	I	am!”
4
Babies	like	these	have	gotten	a	goodly	dose	of	approval	and
encouragement	from	the	adults	in	their	lives;	they	expect	to	succeed
in	life’s	little	challenges.	By	contrast,	babies	who	come	from	homes
too	bleak,	chaotic,	or
neglectful	go	about	the	same	small	task	in	a	way
that	signals	they	already	expect	to	fail.	It	is	not	that	these	babies	fail
to	bring	the	blocks	together;	they	understand	the	instruction	and	have
the	coordination	to	comply.	But	even	when	they	do,	reports	Brazelton,
their	demeanor	is	“hangdog,”	a	look	that	says,	“I’m	no	good.	See,	I’ve
failed.”	Such	children	are	likely	to	go	through	life	with	a	defeatist
outlook,	expecting	no	encouragement	or	interest	from	teachers,
finding	school	joyless,	perhaps	eventually	dropping	out.
The	difference	between	the	two	outlooks—children	who	are
confident	and	optimistic	versus	those	who	expect	to	fail—starts	to
take	shape	in	the	first	few	years	of	life.	Parents,	says	Brazelton,	“need
to	understand	how	their	actions	can	help	generate	the	confidence,	the