There are only two ways to handle tense situations; you can change them or you can change the way you look at them.(Wilson)1

This chapter looks at the link between pain, tension and stress. I will look at how to reduce pain by relaxation and give a taster of some relaxation exercises.

Although a lot of research has been done to try to find out if stress is a trigger for the onset of chronic diseases, or if stress causes flare-ups for existing conditions, it is still not clear if indeed there is a link. Research appears to indicate different conclusions. The reason that these results are inconclusive may be because it is not only the amount of stress that you have to deal with that is important, but also the way that the stress is dealt with.

We all have some stress in our lives and in fact we all need a certain level of stress to function at our optimum level. Stress is often considered to be about having lots to do and having deadlines to complete tasks, but although this can be stressful it is also this stress that gives us the urgency to get started. We all know that if you have too much time you tend to continually procrastinate and leave things for another day. It is always said that if you need something done quickly then ask a busy person! Yet we all vary in the amount of stress that we can manage and therefore we all have to learn how much we can cope with successfully. To do this we need to learn to notice the symptoms of stress that occur when we have too much to manage.

Sometimes it is easier for other people to notice the signs of stress than it is for us to realise ourselves that we are under too much stress. We need to become better at noticing the symptoms and taking action. The signs that indicate that we are not coping are unique to each individual, but there are lots of common features and we are all likely to exhibit some of them. The signs of stress can be divided into different categories:

• physical
• cognitive; and
• behavioural symptoms.

SYMPTOMS OF STRESS

1 Physical Symptoms

These are the ones that we can feel:

• headaches;
• tense stomach or feeling sick;
• sweating;
• raised heartbeat;
• sleeplessness.

2 Cognitive symptoms

These affect our thinking:

• difficulties in concentrating;
• negative thoughts;
• mental blocks;
• finding difficulty in making a decision;
• feeling guilty when you are not doing anything.

3 Behavioural symptoms

These are the ones that change our behaviour:

• impatience;
• short temper;
• aggression;
• eating too much or too little;
• irritability;
• frustration;
• smoking and drinking to excess;
• tearfulness.

A DEFINITION OF STRESS

These are the most common symptoms of stress but what exactly is stress? It is a word that is used very frequently and in many different ways. The word was originally used in engineering terms to mean a force that could be applied to a structure until it would collapse. In human terms it has a similar meaning – in other words there is only so much stress that we can stand before we suffer a breakdown. If there is too much pressure in our situation for us to deal with then we can no longer perform at our optimum level. The point at which this is reached will be different for everyone although the situations that cause us to be stressed will be similar.

WHY STRESS OCCURS

Stress normally builds up when there is too much uncertainty in our lives and not necessarily because we have a lot to do. It could be because there are important decisions to be made in connection with work or family issues, and these decisions are difficult and we are putting them off. It could be because there is too much to do and not enough time to do it in and it is difficult to know what to do first. Sometimes we feel burdened by conflicting roles and we feel as though we cannot manage them all.

Another reason for stress could be that we feel inadequate because we cannot do anything as well as we would like and we feel that we are failing others or ourselves. Once there is too much pressure things will inevitably start going wrong and more crises will happen. At this point the correct balance for our own body needs to be restored or we become in danger of a complete breakdown of health (see Figure 16).

It can be seen from this diagram of the human function curve that performance gets better with some stress, but eventually there is too much arousal. At this point we need to restore the balance. It can also be seen that it is possible to have too little arousal because of too little stimulation and then performance is also poor. Whatever the situation we need to maintain a balance. This is important for everyone, but especially for those of us with rheumatoid arthritis because the stress may well be making our condition worse.

RESTORING THE BALANCE

Often if we are unable to cope it is because we have taken on too much. We have done this either because we have underestimated how long things will take or because we were unable to say no. It is crucial to decide what is important for us to do and what we can let go of. At college I worked through a very useful exercise that can be used to help people to decide which activities and roles they would like to carry on with and which are dispensable. It is called the juggling act. You imagine yourself as a juggler and at the start of the exercise you will be holding too many balls to manage. You will need to decide which balls you will hold onto and which you will let go of. You may need a friend or relative to help you with this because the more stressed you are the more difficult it is to make decisions. Having made the decision you must then carry it through. To do this you may need to be assertive.

Being assertive

This is another word that tends to be used a lot these days and it is often confused with being aggressive. Being assertive means being responsible for making your own decision and carrying it out. It means stating your intentions without getting angry or upset. It involves making clear statements about the way you feel or what you intend to do, but always respecting other people’s feelings and rights. It means recognising your own needs and wants and doing something about them.

If you are not assertive you will tend to let others make decisions for you or you will give up easily. You will be very bad at saying no and therefore will end up doing things that you really do not want to do. This can then make you feel angry, frustrated or worn out from doing too much.

If you feel that you are not assertive enough then it would definitely be beneficial for you to go on an assertiveness course. These may be offered to you in your work environment but otherwise you can contact the local education authority or college. I was not very assertive in my teens and twenties but I attended a course when I was in my late thirties and I found it extremely useful. It helped me to say no and to act to resolve problems and express my feelings more clearly to others. This is very important if you have rheumatoid arthritis because you will need to be able to let others know about any help that you require. You may need to negotiate changes at work (see Chapter 8) and you will definitely need to make decisions in relation to your medical condition. It is also a good idea to do as much as you can to reduce stress because it may be aggravating your medical condition.

Decision-making

Failing to make a decision is another reason that makes us suffer stress. This happens either because we are putting off making a decision that needs to be made or because there is too much uncertainty surrounding the issue for a decision to be made. If it is the latter then you either need to look at all the different scenarios and make a number of alternative plans, or you need to learn to switch this problem off for the time being until it is possible to make the decision. It is no use worrying about things before they happen. The decisions can be made when the time comes.

Alternatively take action to obtain the information you need so that you will be able to make the decision. If a decision needs to be made and you have all the information to do this, and the situation is unlikely to change, then do it straight away. Write down the pros and cons and choose. Get someone to assist if you like. You will feel a whole lot better when the decision is made and carried out. Sometimes a decision can be made intuitively. You just know what to do and in this case you can go ahead, there is no need to wait. The longer the indecision goes on the worse you will feel. After you have made the decision remind yourself about all the good reasons that led you to making the decision and all the benefits that the decision has given you. Once decisions have been made and plans carried out then the symptoms of stress will gradually reduce, although it may take your body a few days or weeks to get back to normal.

THE FIGHT OR FLIGHT RESPONSE

You can begin to reduce the physical symptoms of stress by relaxation techniques. Physical symptoms of stress arise because the body reacts to stress in the same way that it would react to being chased by a tiger. It prepares for flight or fight. This means that if you were in a situation where you had to fight or run away your body would prepare for action. In order to have increased energy, and so that your muscles would be ready to begin running, your body would prepare in the following way. There would be an increase in heart rate and blood pressure, extra production of adrenalin, your metabolic rate would increase and so would the blood flow to the muscles. More sweat would be produced and your muscles would become tense. At the same time the digestive system and the immune system would be subdued so that the body could put all its energy into the flight or fight.

The body reacts in exactly the same way in order to combat stress. If the body continually acts in this state of preparation because of stress, then it never gets a chance to recover. It is always in a state of alert and it is never resting. The immune system and the digestive system will become less efficient so it is essential to relax.

LEARNING TO RELAX

We need to learn to relax so that the body can recharge itself, energy levels are restored and there is a feeling of well being. Having your body wound up into a state of tension uses a lot of energy. During relaxation there is a reduction of breathing rate, heart rate, blood flow and muscle action and a lowering in the hormones that cause these actions. The body is therefore able to restore itself. During relaxation the brain produces alpha rhythms instead of beta rhythms: alpha rhythms have a therapeutic effect in the restoration of bodily health.

Relaxation is a skill that has to be learnt and it takes time and practice. It is probably better to go to a course or have individual lessons when you begin learning. There now many more complementary health centres and these usually offer relaxation courses. Alternatively speak to your GP or visit the type of shop that specialises in gems, crystals and rocks as these often have this type of course available. These shops also sell relaxation tapes or CDs of relaxing music and sound compilations. If you are self disciplined and determined you may be able to learn by using tapes or CDs or by recording your own script.

To practise you will need to find a comfortable place with no disturbance in order to achieve relaxation, but as you get better you will learn to relax yourself anywhere at any time. You will become aware of your body and you will recognise symptoms of anxiety and stress and you will be able to control them.

THE POSTURES OF STRESS

Learn to become aware of certain postures which indicate that you are tense or under stress.

Head

Forwards or downwards with the chin tucked in. If this position is held for long it can lead to neck and head pain.

Arms

Shoulders are hunched up. Elbows bent and arms held into the body.

Hands

Fingers are closed into a fist or objects are gripped tightly. There could be continual fiddling with an object such as a pen or ring.

Legs

If seated, legs will be crossed or wound around each other and if the person is sitting on a seat they will sit on the edge of it.

If standing the person moves around a lot, or changes legs, or crosses and uncrosses the legs continually.

Body

Stooped forward or held rigidly. A continual posture of stress can cause back pain.

Face

Jaw clamped shut, lips tightly closed, the teeth may grind. Brows and eyes are screwed up.

Any of these positions can lead to pain.

GETTING STARTED

This section is a brief look at breathing, and relaxing the body and mind. It is beneficial to learn in a class or obtain a tape, CD or book for more details.

At the beginning of a relaxation session always take a couple of relaxing breaths first to ease tension. You also need to ensure that you are comfortable, so have a fidget around first before settling down.

The following extract from a progressive passive relaxation exercise is one that I have often used and found helpful. It was given to me by a hypnotherapist. I feel that this type of exercise is better for people with painful joints as it does not involve any tensing up of muscles. You just focus on your breathing and the different parts of the body in turn and let go of tension. I have a selection of different relaxation exercises that I learnt on my OT training course. I have listened to them all and found my own way of relaxing. You will need to find a method that you are happy with yourself. The voice on tapes can be very relaxing for you or it might be very irritating – find one that works to relax you.

Passive progressive relaxation

‘Make yourself as comfortable as you can by stretching and getting into a good position. Notice if you are clenching or tightening your muscles. Let your arms, legs and whole body go floppy. Gently close your eyes. Use a few long, deep breaths to breathe out all the tension. Hold a deep breath in for a few seconds and breathe out. Repeat this a few times, relaxing your body with each out breath. If you hear sounds around you use them to help you to relax. Let them recede into the distance as you relax into your breathing. Notice the rise and fall of your chest. Breathe easily and freely relaxing more and more as you breathe out.’

After this the next stage is to go through all the parts of the body, either starting at the feet and going up, or at the head and working down. You need to become aware of each part of the body and release the tension in each part. You should begin to feel warm and comfortable and relaxed. I always start at the head because I can imagine the feeling of relaxation flowing through me from the top to the bottom.

Here is another extract.

‘Bring your attention to your scalp, become aware of the top of your head. Feel a nice warm, relaxing sensation all over the top of your head. Now feel it slowly moving down your entire body, relaxing each part of you. Feel your forehead becoming smooth and softened. Let the relaxation spread more and more over the forehead. This pleasant feeling slowly flows all over your head, making you feel comfortable and relaxed. Now feel your eyelids, eyebrows and the muscles around your eyes: let them become heavy and sleepy and comfortable. Now become aware of all the many muscles in your face. Allow all these muscles to relax, so that your face becomes expressionless and you look as if you’re sound asleep. Even your lips part slightly and so does your tongue inside your mouth. Make sure your jaw is relaxed. If the jaw muscles are held tightly the tension radiates into the rest of our body, especially the head and scalp. Tension drains energy from us, and by simply giving our attention to each part of the body we can relax deeply. By being aware of the body, part by part and muscle by muscle, the entire body is completely freed of tension and stress. You feel loose, relaxed, soft and comfortable.’

The exercise continues in this way, going through all the body so that you can release all the tension. At the end of the exercise you should feel warm and deeply relaxed, sinking into the chair or bed. In fact you feel so comfortable that it is very hard to do anything at all afterwards!

After deep relaxation you need to gradually rouse yourself with gentle movements and some stretching out. After 20 minutes’ relaxation it will take another five to ten minutes to be fully alert again.

Relaxing the mind: visualisation

As an alternative to this sort of relaxation exercise, or in addition to it, you could try a visualisation exercise. The relaxation exercise should be done first, followed by the visualisation or some relaxing music. Visualisation is aimed at relaxing the mind and this is probably more important than relaxing the body. We have all had occasions when it has been impossible to sleep because of the thoughts going round in our heads. If you are able to calm the mind then this will enable you to sleep and it will also help you to free your mind from anxiety and to reduce the build-up of stress.

Ideally you should try to achieve both types of relaxation, and use them as and when they are needed. You will still need to take the deep breaths and quieten your breathing at the beginning, as in the previous exercise. Try to concentrate on the breathing and let thoughts drift in and out of your mind, but do not concentrate on any one thing for long. You could focus on something in the room if this makes it easier for you to concentrate and quieten your mind.

After your breathing is quieter imagine a place that you like to visit. It could be somewhere outside, like a garden or somewhere in the country, or it could be a room or an inside situation that makes you feel relaxed. Imagine the details, the colours or even the smells of this place. Alternatively you could imagine yourself to be on a magic carpet that can fly you to wherever you want. You can then look down onto a beach or a lake or a village and imagine what you see below. If you find this hard to do you can buy recordings of jungle or sea sounds to assist you until practice has improved your skills.

Here is an extract of a visualisation that I have used. I obtained this script when I was working at a community mental health trust running a relaxation course.

‘You are lying on a beach in a safe, quiet cove. Settle into the soft, warm sand beneath you. It is warm and sunny, just the perfect temperature for you. You are feeling relaxed and calm as you look out at the calm blue sea. Just little ripples of waves coming in. Through the clear water you can see seaweed and pebbles and shells. Further out a boat is slowly moving along the line of the horizon and the sea is reflecting the clear blue sky with just the odd wispy cloud. You see a few birds flying overhead, and hear a few seagulls. You feel peaceful and relaxed, you are in the perfect place for you.

‘Take a look around. What do you see? Perhaps you notice a cliff with a path running along the top. There may be people walking along this path enjoying the scenery, or other people on the beach quietly enjoying themselves too. As you look at the cliff face you may see birds nesting, flying to and from their nests. If you like, take time to explore rock pools full of sea life, filled with sea anemones, crabs and shrimps.

‘Watch the gentle waves lapping over the soft, smooth sand. Can you smell the salty, refreshing air? The whole scene is peaceful. You are at peace, warm, comfortable and relaxed. You can stay on the beach and relax for a little while longer...’

You can record this type of visualisation onto a tape or CD by using an extract from a book or devising your own scenario, or you can just imagine any place that is special for you. (You would obviously not use this scenario if water makes you anxious or you are worried about heights.) The idea is to look all around the scene and imagine the details. Focusing on this will help you to relax and will block out other thoughts and give you a chance to be peaceful and quiet.

Activity as relaxation

Another way of relaxing is to do an activity that you really enjoy. This will not achieve complete relaxation but it will help reduce symptoms of stress because it will take your mind off whatever is causing you stress. If the activity involves exercise this is even better as it will give you extra benefits. The next chapter explores the subject of work and leisure and the benefits they bring and also gives some ideas to help you achieve your goals.

A PERSONAL SCENARIO

I first learnt meditation at a yoga class and this helped me to know how to relax. During each of my pregnancies I always had a period of deep relaxation in the middle of the day, just for 20 minutes. It really helped to recharge me. During my third pregnancy I learnt self-hypnosis, which is really just deep relaxation, and it certainly gave me a very easy pregnancy and birth. My third daughter was born in a few minutes. I had been so relaxed I had hardly noticed the contractions! I had a bath, went to bed and when I awoke at 5am rushed off to hospital and only just made it into the delivery room before she made her appearance!

I use relaxation if I need to recharge my energy, or if I am tense before an interview or a meeting. Once you have learnt relaxation it is always easier to notice when your muscles are tense and then you can relax them. You will learn to be aware of the postures of stress.