| Handout - Stress Management Plan |
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Stress is a commonly under-recognized, untreated dimension of recovery, rehabilitation and medical intervention. While all patients seeking medical care experience stress, for individuals with disabilities the dynamics are not the same. Chronic conditions require tremendous mental and physical effort to manage daily tasks, symptoms and ongoing functional challenges; in essence, managing a chronic condition is chronically stressful.
Teaching patients stress management techniques is absolutely critical on several levels:
as tools to protect an individual's emotional resilience,
as interventions to ease the stress caused by the daily demands of staying functional, and
as strategies to assist with the challenges of re-establishing a meaningful life.
Distress vs. Stress
Stress management refers to an individual's abilty to manage both psychological and physiological responses to stimuli. When taught stress management techniques, a patient has a wide range of strategies to cope with, tolerate or alter a stressful situation.
Marsha Linehan, PhD, a cognitive behavioral therapist/researcher, makes an important distinction between stress and distress in her book Skills Training Manual for Treating Borderline Personality Disorder (Guilford Press, 1993). Distress refers to an acute symptom, resulting in emotional and/or physical pain. Helping each patient understand the stress-distress connection is critical for maintaining ongoing wellness. Even when patients work through a distressing episode, there is still stress to return to: going back to work, completing chores and dealing with relationships.
In other words, individuals with chronic disabilities can continuously cycle through chronic pain or acute relapses, but even when a person is not in acute distress, he or she still faces the stress of managing the daily challenges of any medical condition.
This is a very important issue-research has well documented how stress affects the mind and the body. But what is often neglected when working with individuals with disabilities is how stress interrupts the capacity for self care. Patients need both sets of skills in their stress management plans: skills for managing acute distressing episodes and skills for handling the daily stressors of negotiating functionality.
Elizabeth, age 63 and dealing with chronic back pain, shares how she learned to apply this technique:
"The hardest thing is that when I relapse, it is hell to get through it. When I get over it, I usually can't afford to get extra rest. I have to go back to work. I have learned to always keep extra food in the house. I can't handle the stress of going to the grocery store right after I've recovered through an episode. Learning how to handle stress preventatively was really tough, but now I feel I have the skills to know what is going to be stressful ahead of time."
The Ins and Outs
There are a few points to consider when evaluating the stress management needs of each patient. First, identify the sources of stress on two levels. One level is "outside-in" (functional stress management), referring to social supports, living situation and work environment.
Paul, age 79, shares how he was able to pinpoint an unexpected source of stress:
"I realized the boredom I felt being suddenly widowed was causing a lot of stress for me. My wife and I were married for 46 years; she took care of everything. I had to learn to depend on other people. This was stressful at first, but now I have gotten used to it."
"Inside-out" (personal stress management) refers to an individual's specific ability to cope with unexpected emotions or situations. For example, it can be helpful to include questions identifying specific individual triggers that impede a patient's ability to carry out exercises.
Jane, age 49 and dealing with carpal tunnel syndrome in her right hand, talks about how she integrated stress management techniques:
"Having pain in my hand has been such an adjustment for me. You have to use your hand for everything. The exercises are repetitive and boring and time consuming. I want to do it but I found myself putting it off. So now, I plan to do my exercises during my favorite TV show, so I enjoy something and also do what I need to do to take care of my hand."
Next, it is important to help patients identify the right stress management technique for the right need. Patients can be guided by the following questions:
What do I need help with in my daily routine?
What kinds of situations lead to needing to be energized, relaxed or soothed?
If I need to release stress, what is the best way to do it, in what intervals, and how often?
Stress symptoms can take the form of a wide range of emotional or physical sensations. Helping patients distinguish what it is they need is an important detail. Also, each disability has its own condition-specific emotional challenges and stressors. One patient may need more social stimulation as a de-stressor, while another patient may need soothing interventions to alleviate chronic fatigue.
When assisting patients in developing a stress management plan, it is also important to ensure that the strategies are accessible and doable and offer a range of options in terms of the energy required to implement them. I recommend brain-storming with patients about the level of energy, both practical and emotional, required to implement the strategy by categorizing the activity as requiring low, moderate or high levels of energy.
For example, Nancy, a patient struggling with lupus with whom I worked, identified five stress management strategies from the treatment plan list (Sidebar: Developing an Individual Stress Management Plan):
- going out with friends,
- massage therapy,
- calling friends on the phone, and
- watching a favorite TV show.
I instructed her to categorize these strategies by level of exertion, providing her with a range of options to use on low-energy days versus high-energy days.
Nancy offers an interesting account of how shewas able to implement this idea:
"My favorite stress management strategy is going for a massage, but it is expensive and also takes time to get to the place, so I consider that in my high category. Going out with friends and calling friends on the phone is moderate, because it takes planning. Aromatherapy and watching my favorite TV show is low energy because I can do it every day and at home. This plan has helped me a lot. I know I can do something every day, and when I need more, I can plan for it."
Another very helpful stress management strategy is guiding patients to think of their days in terms of behavioral units, using physical place as a marker. For most mobility-impaired patients, the demands of an ordinary day are not ordinary. The daily commute as well as planning goals takes careful forethought. Breaking up the day into units can help alleviate anxiety and stress.
Maribel, 42, shares how she implements this concept: "Having MS and three children has been overwhelming. My kids are only starting to understand what is happening to me. When the kids would arrive home from school, I would just be overwhelmed. Now I break the evening up into units. The kids arrive at 2:30. I am with them for an hour. Then my mother comes at 3:30. She is there to buffer the stress of caring for the kids until 6:30, then my husband arrives by 7:30 and we work together to get the kids settled until they are in bed by 9:30. From 9:30-10:30, it's my time with my husband. Breaking down the evening helps me to manage my stress better. Before I was completely stressed out and could not mentally shift even though I had help."
Two additional stress management strategies are exploring ways for stress reduction and planning for stress-free moments. Even for the most successful person, there are always unexpected situations where one has to delay implementing personality-specific stress-management strategies. In cognitive behavioral therapy, common stress reduction techniques include using distraction when in distress or practicing breathing to bring down stimulation levels.
Planning for stress-free moments can also be helpful. Helping patients find quiet moments or pockets of mental or physical rest in their daily schedules can ease stress and provide them with something to look forward to in the course of a day.
Finally, it is critical that practitioners commit to developing their own stress management capacities. It is important for OTs to experiment with as many strategies as possible, so they have first-hand knowledge of the gains, limits and time demands of each technique. Stress management is an interdependent learning process; patients can be put at ease when we can be good role models of successful stress management. n
Dr. Reji Mathew is a psychotherapist/clinical instructor at the New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at firstname.lastname@example.org. All of Dr. Mathew's articles are available online in the Mental Health Center at www.advanceweb.com/OT.
Resources and References
The following references offer further information on stress management strategies: