The Better Mood Recovery Program, Week 11

STRESS REDUCTION AND PAIN MANAGEMENT

Eleventh Week Overview

In this week you will learn a simple and effective mind/body approach to relieving stress and coping with the pain of depression.

Depression and anxiety do not occur in a vacuum. Although one may be genetically and temperamentally predisposed to depression, it normally takes a triggering stressor such as personal loss, financial setback, illness, etc. to elicit severe symptoms. Although we all experience these kinds of stressors, those of us who are predisposed to depression and anxiety are more vulnerable than the norm to the debilitating effects of stress. This is why stress reduction skills are a critical piece of our recovery program.

The Fight or Flight Response

A good way to understand the effects of stress on the body is to look at the fight or flight response. Lets suppose you are taking a leisurely hike on a wilderness trail, and a bear jumps out of the woods. Once you spot the bear, your body turns on an automatic survival mechanism known as the “fight or flight” response. The brain's hypothalamus and pituitary glands secrete hormones that tell the adrenal gland to release adrenaline. Within seconds, the following changes occur in your body.

When the fight-or-flight response is activated, the body halts its long term projects (digestion, tissue repair, immune functioning, etc.) and focuses on getting you out of danger. Once you make it to safety and perceive that the threat has passed, your systems return to normal.

In modern civilization, we don't have to worry about fending off bears or other predators; instead we experience chronic psychological and social stressors such conflicts at work or home, a child on drugs, an ongoing physical ailment, worries about money, etc. Even though these stressors are not life-threatening—and in some cases may be only imagined (i.e., worrying about the future)—the brain still releases the powerful hormones which activate the fight or flight response. Over time, this unremitting stress wears down the body and causes stress-related illnesses.

Two such stress-related disorders are depression and anxiety. Studies show that 50% of people with clinical depression have abnormally elevated glucocorticoids levels while people who suffer from anxiety disorders have too high levels of adrenaline. (Glucocorticoids are steroids, like the anabolic steroids banned in the Olympics, that work with adrenaline to activate the fight or flight mechanism). Perhaps this is why 80% of people with depression also suffer anxiety—because in both cases the adrenal glands are over secreting hormones that keep the body/mind on continuous red alert.

Noticing the First Signs of Stress

We can think of stress as lying on a continuum. At the low end of the continuum is healthy stress, such as the nervousness you might feel before preparing a dinner party or going on rafting trip. As the stress increases, you cross a line and experience unhealthy stress. Here are some of its symptoms.1

1. Mental symptoms

2. Emotional symptoms

3. Behavioral symptoms

4. Physiological problems

Having read this list, ask yourself the following questions. You will have the opportunity to record your answers in the stress inventory at the end of the chapter:

1) “What is the target symptom that lets me know that I've crossed the line into unhealthy stress? What is the first indication that I am slipping?”

2) “What are the external stressors that most often trigger my stress response?” (Examples may include, hot weather, traffic, difficult people, managed care, financial obligations, etc.) Are the ways I can avoid these triggers?

To further help you evaluate the presence of stressful events in your life, you can also refer to the Holmes Rahe “social readjustment scale” on the opposite page. This scale was developed by two psychiatrists who interviewed hundreds of people of varying ages and backgrounds and asked them to rank the relative amount of readjustment to meet a series of life events. Note that each stressful readjustment is assigned a numerical value from 1 to 100. According to Holmes and Rahe, the higher your score, the greater your risk of developing stress-related symptoms or illnesses. For example, those people who have accumulated a total of 300 or more points over the past year have an 80% chance of getting sick in the near future; those with a score between 200 and 300 have a 50 percent chance of becoming ill. Feel free to evaluate your own score to determine how you are being impacted by environmental changes.

The Relaxation Response

Fortunately, the debilitating condition of chronic stress can be changed. There is a counterbalancing mechanism in the brain known as the relaxation response which produces the opposite effects of the fight or flight response. When your relaxation response is activated, your:

Thus, the key to undoing the chronic stress that can lead to depression and anxiety is to (A) notice when you have crossed the line into unhealthy stress; and (B) elicit the relaxation response, which will counteract the effects of the stress and return the body to a more balanced state.

 

The Social Readjustment Scale

Life Event Value
Death of a spouse 100
Divorce 73
Marital separation 65
Jail term 63
Death of a close family member 63
Personal injury or illness 53
Marriage 50
Fired from work 47
Marital reconciliation 45
Retirement 45
Change in family member's health 44
Pregnancy 40
Sex difficulties 39
Addition to family 39
Business readjustment 39
Change in financial status 38
Death of a close friend 37
Change to different line of work 36
Change in number of marital arguments 36
Mortgage/loan for large purchase 31
Foreclosure of mortgage or loan 30
Change in work responsibilities 29
Son or daughter leaving home 29
Trouble with in-laws 29
Outsdanding personal achievement 28
Spouse begins or stops work 26
Starting or finishing school 26
Change in living conditions 25
Revision of personal habits 24
Trouble with boss 23
Change in work hours or conditions 20
Change in residence 20
Change in schools 20
Change in recreational habits 19
Change in church activities 19
Change in social activities 18
Mortgage/loan for a lesser purchase 17
Change in sleeping habits 16
Change in number of family gatherings 15
Change in eating habits 15
Vacation 13
Christmas season 12
Minor violation of the law 10

 

The relaxation response has two primary components:

1) Focusing of attention

2) Passively disregarding your thoughts—you assume the position of the “witness” and passively notice your thoughts without trying to change or control them

Guidelines for Practicing the Relaxation Response

With regular practice, you will be able to elicit the relaxation response at will. Here is how Herbert Benson, the doctor who first coined the term “relaxation response,” teaches the process to his patients:2

When: The best time to practice the relaxation response is when you are undisturbed. Doing it in the morning can set the mood for the day. Try to avoid practicing within two hours of a meal, as digestion seems to interfere with the elicitation of the relaxation response.

Where: Find a quiet place where outside noise is minimal. Pick a place that feels safe and protected.

Position: Sit or lie down in any position where you feel comfortable. If you sit in a chair, pick one that has good back support.

Length of Practice: Try to set aside ten to twenty minutes once or twice a day. It is important to practice regularly so that the relaxation response becomes as automatic as the stress response.

Instructions for Focusing the Mind:

1. Sit quietly in a comfortable position and close your eyes.

2. Relax your muscles, beginning at the soles of the feet and slowly work up to the face.

3. Breathe in and out through your nose, becoming aware of the rhythm of your breathing. On the out breath say the word “ONE” silently to yourself. For example, breath IN…OUT, “One;” IN…OUT, “One;” etc. Breathe easily and naturally.

4. Continue for 10 to 20 minutes. You may open your eyes to check the time but do not use an alarm. When you are finished sit quietly for several minutes, first with your eyes closed and then with your eyes opened. Do not stand up for a few minutes.

5. During the process, maintain a passive attitude and permit relaxation to occur at its own pace. When you notice the mind beginning to wander, gently refocus your attention on the word “ONE” (or whatever you are using as your focus word). Remain the neutral witness and watch the mind without becoming its thoughts.

6. Practice this for five weeks. Over time, the relaxation response should come easily and naturally. The more you practice, the more quickly you will enter a state of serenity and peace.

During the relaxation response, your goal is to move your awareness into your right brain so you can observe how your left brain is perceiving events. If you are you are not perceiving the situation correctly, your fight or flight mechanism may be activated when you don't need it. For example, being late on a mortgage payment is a true concern, but it is not a life-threatening emergency. However, if you worry about the mortgage all day long, you will elicit the fight-or-flight response and create unnecessary stress-related symptoms.3

Other Relaxation Techniques

The following techniques have also been also been shown to elicit the relaxation response.

Please refer to the book The Relaxation and Stress Reduction Workbook by Davis, Eshelman and McKay for an in-depth explanation of these techniques and how to use them in your life.

Stress and Other People

Although other people are our main source of support in healing from depression, they can also be our main source of stress. According to researchers, those people with problems at work or with interpersonal conflicts at home are 3-5 times as likely to get a cold as those without such problems. Life abounds with conflicts with the spouse, children, co-workers or the boss—not to mention all of the ethnic hatreds and wars on the planet. “Hell is other people,” noted the philosopher Sartre.

At the height of the Cold War when the United States and the Soviet Union were spending trillions on armaments, one commentator noted, “That's a lot of money to spend on a relationship problem.” While our own squabbles may not compare to a superpower struggle, they can produce significant personal and stress.

Learning to communicate clearly and compassionately is a skill that can be learned. There is a lot of good information out there, both in book and seminar form. (You may want to start with How to Talk So Kids Will Listen and Listen So Kids Will Talk by Faber and Mazlish as well as John Gottman's The Relationship Cure.)

If conflicts with a spouse, child, other family member, boss or co-worker, or anyone else are disturbing your serenity and you can't work them out on your own, locate a professional mediator or family therapist. The dividends you reap in your mental and physical health will be well worth it.

Managing the Pain of Depression and Anxiety

One of the biggest stress of depression and anxiety is dealing with chronic, unrelenting mental/emotional pain. This pain can vary from mild pain (-1 on our mood scale) to the immense agony of a -5. A good way of understanding how to cope with this pain is through he image of a scales as depicted below.

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One side of the scales is pain; on the other side is coping resources. When one's emotional pain exceeds the resources for coping with the pain, the pain becomes unbearable (this, and the belief that there is no hope for change, can lead to suicidal thinking). To get the scales back in balance, you can do one of two things: discover ways to reduce the pain or to increase your coping resources. Here are some tools and strategies that can accomplish both objectives.

1. Monitor the level of your pain. Rate your day to day pain using the -5 to +5 mood scale below and enter the numbers in the daily mood diary on page 172.

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You can also expand the diary to include pain scores during the morning, afternoon and evening. Over time, you may be able to see patterns. For example, many people find that their depression or anxiety is worse in the morning and improves as the day goes on. This was true for me, as nights were the only time I felt any relief.

2. Change your physiology by altering the state of your physical body. There are many ways you can do this.

a) Use progressive muscle relaxation—tense and relax each muscle group, starting with your feet, calves, upper legs, and working your way up to your shoulders, neck and head and then down your arms.

b) Exercise hard—do 100 jumping jacks or run in place, swim until you drop, hit a punching bag, etc.

c) Sit in a warm bath or hot tub.

d) Drink hot milk.

e) Massage your neck and scalp, calves and feet; or have someone else give you a massage.

f) Get in a hot or warm shower and then gradually make the temperature as cold as you can stand it; then make it as hot as you can stand it; then go back to cold. Repeat this as many times as you wish, ending with cold water.

g) Breath deeply.

h) Change your facial expression—try a half smile. Tense and relax your facial muscles.

i) Increase your overall physical activity if you can. Exercise may be the last thing you might want to do when you are severely depressed, but its benefits are more than worth the effort. Exercise makes muscles feel better, improves sleep, eases the symptoms of anxiety and depression, builds fitness, helps manage weight, boosts self-esteem and can increase your sense of empowerment.

3. Monitor your self-talk. While you may not be able to control the level of the pain you feel, you can control what you think and say about it. For example, in Chapter 5 of my personal narrative I relate how I called up my friend Teresa and screamed “This pain is unbearable.” Teresa instructed me to change my statement to, “The pain is barely bearable.” When I took her advice and shifted the wording, I felt less distraught. I had given myself a new message—that although this was really hard, I could handle it.

4. Use distraction techniques to refocus your attention away from the pain. You can distract yourself and take a break from the pain using a variety of methods:

a) Do some activities. Busy yourself with a hobby, go to a movie, take a walk in nature, visit a museum, clean the kitchen, work in the garden.

b) Turn the mind to other thoughts. Count to ten, think of something pleasurable from the past, solve a puzzle, work on a jig-saw puzzle, read a good novel (if you can concentrate), watch a TV show or video.

c) Use intense sensations: hold ice in your hand, squeeze a rubber ball very hard, listen to loud music, yell out loud.

d) Contribute to others: Help someone else in need, do volunteer work. If you can muster the energy to reach out, you will be lifted you out of your own cares as you focus on the welfare of others.

5. Soothe yourself with the five senses.

a) With vision. Purchase a beautiful flower and look at it. Gaze at the stars and moon at night. Watch a beautiful sunset or sunrise. View a pretty photograph or a favorite picture of someone you love.

b) With hearing. Listen to melodious and soothing or inspiring and passionate music. Listen to the sounds of nature or tapes of these sounds—birds singing, leaves falling, the waves of the ocean, the wind rustling through the trees, etc. Sing your favorite song or listen to a tape or CD of a favorite piece of music.

c) With smell. Surround yourself with your favorite scents or fragrances—through perfumes, essential oils, or aromatherapy. Buy some fresh-cut roses or other fragrant flowers and deeply inhale their scents. Take a walk in the woods, smell some freshly mowed grass, or immerse yourself in the aromas of your favorite bakery.

d) With taste. Have a favorite meal. Make yourself a soothing drink such as herbal tea or hot chocolate (avoid alcohol; also avoid caffeine if you are anxious). Taste samples of flavors in an ice cream store. Treat yourself to a meal you've always wanted, or make your favorite meal. Eat slowly, savoring each delicious bite.

e) With touch. Take a bubble bath or sit in a hot tub. Pet your cat or dog (or a friend's) or pet one at the animal shelter. Have someone rub your feet with rich body lotion. Get a therapeutic massage. Give and receive hugs. Walk in the grass with your bare feet. Hug a tree. Sit in a comfortable chair. Let the warm breezes of a summer's night caress your skin.4

6. Soothe yourself using mental imagery. Picture a scene in nature where you feel relaxed and nurtured. Some examples are:

Or you can visualize a man-made sanctuary such as a church, temple, or a special place from childhood where you felt nurtured and safe.

7. Call on your spiritual reserves. Open your heart in prayer to God or your Higher Power. Ask for the soul strength to bear the pain in this moment until it repatterns (see my dark night of the soul prayer on page 64).

Find or create some purpose, meaning, or value in the pain. Ask that your suffering be redemptive (i.e., that out of your pain some good may arise).

8. Set up support systems. The pain of depression is made worse by isolation and loneliness; on the other hand love and intimacy, connection and community produce pain-killing endorphins in the brain. Maximizing your social support will help you on the road to recovery. Having support also means that you are receiving proper medical treatment for your condition by seeing a counselor and/or a prescriber for medication.

9. Practice mindfulness. Focus your attention on what you are doing right now. Put your entire attention on the physical sensations that accompany ordinary tasks (e.g., doing the dishes, walking, doing the laundry, weeding the garden). If you start to feel the sensation of pain, let it wash over you like a wave. Breathe into the pain instead of fighting it.

10. Live one day at a time. Remember the saying, “Yard by yard life is hard. Inch by inch, it's a cinch.” Break your pain down into manageable parts. Practice getting through each day. If a day seems too much, try to make it through each hour; if an hour seems too long, set your sights on getting through each minute or second.

11. Practice acceptance. There is a psychological truth which states, “Whatever you resist persists (i.e., resistance to pain creates more pain). Instead of fighting your pain or telling yourself that you shouldn't be feeling this way, try to accept where you are right now. Practicing acceptance does not mean being passive. Do whatever it takes to improve your situation, while at the same time recognizing that “this is my life for the moment,” and I am going to make the best of it.

Using these strategies will not make all of the pain go away overnight. But it should tip the scales in favor of the coping resources so that you can bear the pain until it repatterns. Of course, if you are severely depressed or anxious, it may feel too hard to practice these strategies. If this is the case, ask your coach/buddy or other support person to give you the encouragement and help you need to work with these tools. In the meantime, remember Robert Schuller's maxim—tough times never last but, tough people (i.e. those who don't give up) do.

This Week's Goals/Assignments

These are you assignments for the coming work:

Fill out the “Stress Management Inventory.” Make it a goal of the week to pick two or more days and practice the relaxation response. Keep your Better Mood Journal by your side and write down any thoughts or feelings that come up. Share them with your coach/buddy or your counselor.

Ongoing Self-Care Activities

 

My Stress Management Inventory

1. What is the target symptom that lets me know that I've crossed the line into unhealthy stress? What is the first indication that I am slipping?”

2. What are the external stressors that most often trigger my stress response?” (Examples may include, hot weather, traffic, difficult people, managed care, financial obligations, etc.) Are the ways to avoid these triggers?

3. What is the quality of my interpersonal relationships? How am I handling any interpersonal conflicts that may be arising?

4. How am I handling the pain of depression and/or anxiety. What coping resources am I using? Does my pain exceed my coping resources? If so, what am I doing to get the scales back in balance.

 

 

My Goal Sheet for Week 11

This week's starting date_____________My coach/buddy ____________________

Date/time we will connect _____________________________

Goal or Goals _______________________________________________________

___________________________________________________________________

___________________________________________________________________

Benefits of attaining this goal____________________________________________

___________________________________________________________________

___________________________________________________________________

Action plan _________________________________________________________

___________________________________________________________________

___________________________________________________________________

Ongoing goals (check off the ones as you accomplish them)

______ Read my vision statement daily (upon awakening or before bed)

______ Chart my moods in the Monthy Mood Diary

______ This was my average mood on the better mood scale.

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How was my mood this week?

Record your moods below for each day of the week.

  Day Mood       Comments
 Mon    
 Tue     
 Wed    
 Thu    
 Fri     
 Sat    
 Sun    

1 Many of these symptoms of stress are identical to those of anxiety and depression.

2 See Benson, Herbert, The Relaxation Response, New York, HarperCollins, 2000.

3 The cognitive restructuring techniques you learned during weeks five and six are well suited for countering the stressful effects of worry.

4 Many of the distraction and soothing strategies were adapted from the Skills Training Manual for Treating Borderline Personality Disorder, by Marsha Linehan, The Guilford Press, 1993.