Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Chapter 15. Stress and Problem Solving

What is stress?

Stress is one of those things that is hard to define, although we can recognise it in ourselves.

Stress can be thought of as the way we feel. For example, when we feel very tense or worried, or when we feel we are working under pressure.

Stress can also be reflected in the way we behave, such as when we are irritable, having trouble concentrating or smoking/drinking a lot more than usual.

Stress can also be linked to the pressures in our internal and external environment. So, pain is a source of stress, just like having too many bills to pay or too much to do in too short a time.

Sometimes people say that things are stressful when they feel they don’t have any control over them. For example, being late for appointments because the trains don’t arrive on time. Lack of a sense of control is one of the things that people troubled by persisting pain often report as one of the stressful aspects about their pain.

While stress is often seen as bad, it can be useful too.

For example, many of us feel that we perform better under some pressure, rather than no pressure at all – even if we don’t want to admit it. Think about when you would have got something done if there was no time limit. Common examples are things like tidying the house when friends are coming to dinner, or students completing assignments only when the deadline is coming up. Governments are the same – how many useful community projects suddenly get done just before an election?

Similarly, lying on a deserted beach in the tropics will usually be appealing to someone running from the rain on a cold winter’s day in a big city. But, if you lie on that beach too long, you might be nice and relaxed, but apart from being sunburnt you could also find that your muscles have become weaker and your joints stiffer. If we don’t make our muscles and joints do some work every day, after a while they will tend to lose condition and become weak and stiff.

Some stress (or pressure on us to do things) actually helps us to stay alive and our bodies (and minds ) to function properly.

Stress can also be a problem

However, stress can be a problem if we have too much of it. This often happens when we feel the pressure on us is more than we can manage. These are the times when we can get irritable or feel overwhelmed.

The aim of stress management

The aim of stress management is therefore not to eliminate stress, but rather to help you feel you can manage despite all the pressures on you.

Why do we feel stressed?

The amount of stress you feel is likely to be influenced by three types of things:

1. The stressful situation

In general, the bigger, the more unexpected, the more unfamiliar the stressful situation, the more stressful it will be. For example, having your socks stolen is likely to be less stressful than discovering your house has been burgled. Also, knowing in advance that your train will be delayed is likely to be less stressful than when it happens unexpectedly.

With regards to persisting pain,

would it be more or less stressful if you didn’t know why you have pain?

Would it be more or less stressful if you thought it was due to something life-threatening?

Would it be more or less stressful if you thought it meant you could end up in a wheel chair?

2. How you see the problem and your ability to cope

If you see the problem as unimportant, then you are unlikely to feel stressed by it. But if you see it as very important to you then you are more likely to feel stressed or troubled by it. However, if you feel you know how to deal with the problem, then you are less likely to be stressed by it than if you feel you won’t be able to cope.

With regards to persisting pain,

would it be more or less stressful if you thought it wouldn’t interfere with your work or lifestyle?

Would it be more or less stressful if you thought you could cope with it, no matter how bad it got?

3. The level of helpful support available from friends/relatives

If you feel you have helpful and understanding friends or relatives around, you are less likely to feel stressed by a problem than if you feel alone and without support.

With regards to persisting pain,

would it be more or less stressful if you had no one for support? On the other hand, how would you feel if your family took over everything for you and left you feeling completely useless?

Just having family or friends around doesn’t automatically mean they will be helpful. At times, they can add to the burden. The chapter on relationships discusses some of these issues.

Overall,

The amount of stress you feel doesn’t just depend on what has happened to you. For example, if you have a supportive relationship with your family or friends and your pet cat is run over on the road you are likely to suffer much less than a lonely pensioner who is living alone and whose only friend, a pet cat, is run over. You will both suffer to some extent, but you will probably suffer less than the lonely pensioner. The reasons for that are that the cat didn’t mean as much to you as it did to the lonely pensioner and you have friends and family around to provide comfort for you – the lonely pensioner may not.

How to manage stress

Using the three points mentioned above you can improve the way you manage (or cope with) stresses in your life. Remember, the aim of stress management is to find ways of dealing with stresses so that they are manageable and not overwhelming. It is unlikely, as well as undesirable, that we can or should get rid of stress completely.

1. Deal with the causes of the stress

If possible, it could help to deal with the cause of the stress. For example, if you find that you are becoming irritated by the volume of your neighbour’s TV, asking them to turn it down would probably solve the problem. Similarly, if you are becoming concerned that the brakes on your car are not working properly, getting them checked by a mechanic should help to sort things out.

However, it is often not possible to deal effectively with the cause of the stress. For example, if you have a car accident you can’t do much about it – it has happened and can’t be undone. Chronic pain is another common cause of stress which often cannot be removed completely.

2. Change the way you are looking at the problem

When you can’t remove the cause of the stress you might be able to change with the way you are looking at it or the way you are reacting to it.

(a) Look at what you are saying to yourself

Sometimes you might realise you are viewing the cause of the stress too negatively. In which case it could help to stop for a moment and think of an alternative, more helpful way of looking at the problem.

For example, if you are running late for an appointment you might find yourself feeling upset and worrying that the person you were going to see would think you were thoughtless or unreliable. Such thoughts are likely to make you feel even more upset. What’s more they may not be accurate and they won’t make you get there faster – unless you become completely unconcerned about whether you get there or not (in that case, the other person would have grounds for thinking you were unreliable).

If you could challenge these thoughts (look at how accurate or how helpful they were) and then try to view the situation in other, more helpful, ways it might help to lower your level of distress. In this example, you could challenge these thoughts by saying (to yourself) things like:

– “He might think I’m thoughtless and unreliable, but it’s unlikely because I’m normally on time, and I always turn up or ring to say I can’t make it”.

– “Even if he does think I’m thoughtless or unreliable, it would be inaccurate and he should understand when I explain the reason for my lateness”.

– “If he doesn’t understand or won’t listen to my apologiesit doesn’t mean his view of me is right (perhaps he is over-stressed)”.

Whenever you are feeling stressed it is worth taking a few moments to stop and consider how you are viewing the problem.

Are your thoughts inaccurate?

Are they unhelpful?

Are they too negative?

Are they too positive?

If your answer to any of these questions is Yes then challenge them, think of another way of viewing the problem. In particular, think of a way of viewing the problem which is more helpful.

The point of this is that if you get a clear idea of what the problem is then you are more likely to be able to deal with it effectively. If you see a problem in too negative a way you could be making things harder than they need to be. But equally, if you see it as too positive (too rosy) you might just be “pulling the wool over your own eyes” (that is, deceiving yourself) and as a result, you may not deal with the problem as effectively as you might. This could lead to more problems later.

(b) Look at how you are trying to cope

Are you using your relaxation technique? Stop for a moment and spend a minute or two relaxing until you feel a bit calmer and more in control of yourself. The clarity of your thinking will probably improve too.

Are you trying to do too much in too short a time? If so, stop and spend a few moments putting things in order of priority. Do what is most important first, then the next most important and so on.

Are you getting stressed by the same (or similar) things repeatedly? If so, take some time out to think about how you are dealing with them. Perhaps, it’s the way you are going about it. What changes could you make? For example, sometimes you might find that you are repeatedly getting stressed because you put things off until the last minute and then run out of time. In this case you could try to prevent the problem recurring by planning to do things sooner rather than later, or spreading it out over a longer time rather than waiting until the last minute.

3. Enlist the help of family or friends

If you already have helpful family or friends then that is fortunate and should prove of great benefit for you at times of stress. Remember, though, they will find it easier to help if you tell them clearly what the problem is and how you would like them to help. [Expecting people who are close to us to read our minds when we have a problem is often the cause of mis-understandings.]

If your family or friends are not very helpful at times of stress then it may be worth your while (and their’s) if you tried to look at why this was the case. When things are calmer, it could be worth sitting down with them to discuss your concerns and how you see things at these stressful times. It may be that they see these situations differently to you, and neither of you have realised that. That doesn’t necessarily mean that one is right and one is wrong, just that you have seen things differently. Perhaps you might now be able to reach some agreement on these situations and how you could handle them better.

In the long-run, putting time and effort into improving and maintaining our close relationships will also help, but won’t, of course, guarrantee a trouble-free life.

Usually improvements in our relationships can only be achieved through the joint efforts of both parties. However, this can be helped by reading a suitable book on assertiveness or communication skills [see the end of this chapter for some useful books on these topics]. In some cases, it can be worthwhile to seek some professional assistance through a suitable counsellor – who would have the advantage of being more objective about the problems in your relationship [in Australia, Relationships Australia have offices throughout the country and are a good place to start looking for professional help for relatively little cost].

Alternatively, if you feel that the chances of being able to improve your existing relationships are low then you could try to build new relationships. There are many ways of going about it. Sometimes you might just be lucky and run into someone at a pub or club, strike up a conversation and, over time, gradually become friends. A more reliable method could be to join a club or organisation connected with one of your interests. In this way at least you would be fairly confident of meeting people with whom you have something in common. Working with others is also a common means of building friendships.

It is important to remember that making and developing friendships is also a skill and needs thought and practice.

In conclusion

Stress or pressure on us to do things is a normal part of life. It is useful if it helps us to keep active and enjoying life. However, it can be a problem if we feel overwhelmed and unable to cope. When someone has chronic pain the normal stresses of daily life can make it even harder to deal with the problems caused by the chronic pain. It is therefore sensible to consider the ways in which you are dealing with the other stresses in your life. While you are probably managing most of these other stresses fairly well, it is possible that you could still make some improvements.

Re-read the points made in this section and see how you can apply them to the stresses in your life.

Problem solving

An important part of Stress Management is Problem Solving. This section provides practical guidance on a general approach to helping people deal with problems, whether they are related to pain or just the normal stresses and strains of daily life. The aims of this approach are:

1. To give you a method for tackling most problems.

2. To teach you a systematic method of dealing with problems, and

3. To improve your sense of confidence that you can cope.

When is problem solving applicable? ANYWHEREANYTIME. Whenever and wherever you have a conflict or demand on you to sort something out. The potential uses of problem solving are wide ranging, and include crisis-management, organisation of daily life, reducing distress and increasing effectiveness.

Naturally, dealing effectively with troubling pain also requires well-developed problem solving skills. In fact, it is our experience that those people who have these skills usually have much less trouble in managing their persisting pain.

If you follow the steps outlined below, you will be more likely to deal with difficult situations, including pain, in a constructive manner. As with all the skills outlined in this book, you will need to adjust them to your own circumstances, but that is a skill which requires practice too.

Steps involved in problem solving

1. Try to accurately describe the problem

Exactly what is it you are not happy with?

Where and when is it occurring?

    What is involved?

        How often is it happening?

Clarifying the problem is the first step towards finding a solution.

For example, if you have been pacing up most of your activities through the day, but by the evening your pain is getting worse. You could say to yourself things like, “well I’ve been doing my pacing but it didn’t work – my pain is worse than ever” “what’s the point of doing all this?” “Maybe I should just give up.”

These statements suggest you feel you’ve been doing everything as recommended, but not getting the results you expected. As a result you are feeling frustrated, disappointed and hopeless.

But is this the only way to look at what’s happened? Is giving up your only or your best option?

Perhaps another way to look at this situation is to look at what you’ve been doing through the day. You might have been pacing most activities, but is the total amount of activity more than you usually do? If it is, then maybe you have really done too much today and that is why your pain is worse. If that’s the case then you might be able to work out another solution besides giving up.

On the other hand, it could be that for some unknown reason your pain is just worse today. This can happen no matter what you do. So, it may not be your fault or the fault of the pacing method. In fact, if you had not paced, you might have been in more pain now.

Is it really accurate to say that your pain “is worse than ever”? But even if it is, does it really mean that there’s no point in trying to achieve your goals? And does it mean you should give up? What could you do instead? What would you do if you “gave up”? Would that be any better?

Perhaps a more accurate assessment of things would be to say something like, “well my pain is worse tonight than usual. Maybe I’ve overdone things today. On the other hand, it could be just one of those days when my pain flares up for no good reason. This has happened lots of times before. I know it will settle soon, perhaps even by tomorrow.”

2. Generate as many alternative options as possible.

What can you do about it? Try to come up with as many options as possible, regardless of how unlikely they may seem at first. It’s a bit like having a menu to select from at a restaurant.

In the example given above, you could think back over the day and see if you really had over-done things. If that’s the likely cause of your increased pain, at least you can work out how to avoid it happening again.

A good example of this was provided by one of our patients (we’ll call him George) who really wanted to take his boat out to do some fishing. George hadn’t been able to do this for a couple of years because of his back pain. After attending our programme he tried it again. Unfortunately, when he returned home from fishing the first time his pain was much worse. His wife said it looked like he would have to sell his boat. But George thought about why his pain had been stirred up and worked out that it could have been due to his sitting down while the boat bumped across the waves. As a result, he thought he might have been absorbing all the bumps through his body, especially his back, and that was why his pain was worse. A few days later George went out in the boat again. But this time instead of sitting down all the time, he stood up most of the time, and absorbed the bumps through his legs. This time when he got home his pain was no worse than usual and much better then it had been after the first trip. And he had managed to go fishing!

George could have said after the first attempt at going fishing that it was no use, his pain was worse, that doing our pain management programme hadn’t helped. Instead, he used problem solving to think his way around a problem so he could achieve his goal of going fishing again.

In this example, some of George’s options were:

1. Give up and sell the boat

2. Take more pain killers and still try to go fishing

3. Stand up when travelling in the boat rather than sitting down

4. Leave it a few weeks or months and try again

5. Wait for a calm day

George looked at each of these options and weighed up the pro’s and con’s of each. Then he tried option 3 and it worked.

3. Evaluate the alternatives.

Once you have made up your list of options for dealing with the problem you should then assess them – their advantages and disadvantages. Until you find one which seems the best. It may not be perfect, but it may be the best option available at present.

Try to be objective and realistic. Try taking into account both long and short term consequences.

In the example of George going fishing, if he had given up going fishing and sold his boat it would have meant giving up on his favorite leisure activity and he would have felt quite depressed at the loss. On the other hand if he had taken more pain killers and just gone fishing regardless, he would have had more pain after the trip, when the drugs had worn off and he would have ended up taking even more, which he wanted to avoid. Also, he was concerned about being out at sea full of strong pain killers. If they’d run into trouble he couldn’t be sure that he would have managed. The other options of waiting, would only have meant putting it off without any guarantee that things would be any better in a few weeks or that a calm day would stay calm. In the end George felt that trying to go fishing but doing it differently offered him the best option and he was right.

4. Choose the best alternative.

What is the most appropriate, reasonable and practical option for you to take, in your present circumstances?

5. Make a plan

What are you aiming to do? How can you do it? What may make it difficult (and how could you get around these difficulties)? What resources do you have to implement your plan? Do you need help? What do you think you will need, (eg., money, tools, skills)?

6. DO IT.

Put your plan into action (as best you can). Use relaxation and challenge unhelpful thoughts if you are anxious and remember to pace yourself.

7. Assess the outcome.

Did your plan of action work? Did it have the effect you wanted? If yes, then do you want to do it again? If no, could you try one of the other alternatives, or generate some more?

Remember, many problems do not have perfect solutions. In many instances you can only try to do your best. At the end of the day, it can be more useful to learn from your mistakes than not to try at all. Always think about what you could do differently next time. Give yourself credit for what you did well and for trying.