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Consultant Psychiatrist, Alfred Hospital
From the address to The IN Group at its meeting on 13th February 1996 at 4 Alandale Ave, Balwyn.
My talk tonight is about the general issues of STRESS and how we cope with it and how we deal with it.
Stress is something that basically causes us to change, often something that interrupts our routine unexpected-ly as, of course, illness often does. In physics it is defined as a force or group of forces that deform a body. In psychological terms it is something that is disquieting or distressing.
What we tend to do is to develop routines. We get into the habit of doing things that are familiar and known to us. So that anything that comes along unexpectedly or something that is not familiar to us is a stressor.
A stressor is a useful thing to a degree. It enhances performance, it encourages us to strive, to cope with difficult things more than perhaps we would do otherwise. But there may come a point when it becomes difficult, when we can no longer cope. Obviously long standing illness comes under this category or any severe illness for that matter.
When we are very stressed we have a stress reaction. This can be an au-tonomic nervous system response - things that we can't control within our own body directly such as blood press-ure, heart rate, sweating and those kinds of physiological responses that go on inside all of us. But there are also psychological sequelae that aren't necessarily quite so easy to deal with. The kinds of things we may feel when we are stressed include depression, frustration, (one of the biggest things that anyone with a long term illness has to deal with).
We express these things by imagin-itus, we embellish things, our fantasies run wild, we can start feeling things that aren't there, we get anxious, we start worrying about what might occur. We get angry, we get absolutely furious. How often are we encouraged to be angry? Very rarely, when people are angry we want to keep away, it is a bit scary, it's rude, impolite etc.
Every time you feel anger that you don't express, you are being rude, impolite, and unfair to yourself. Just try and jog your memory as to some of the things you experience when you feel stressed. This is looking at symptoms of anxiety which go hand in hand with feeling depressed and unusually frustrated.
They can be purely psychological or purely somatic, ie physical. It can be attacks of nervousness or persisting nervousness, poor concentration, fear of nervous breakdown, fear of death and dying. On the other end of the spectrum there can be palpitations, headaches, muscle aches, blushing, tensions, sweating, chilly sensations, dizziness, vertigo, numbness, shakes, nausea, vomiting, tinnitus (ringing in the ears), dry mouth, loss of weight, urinary frequency, blurred vision. These are all normal physiological responses that are accentuated when we are stressed. Shortness of breath is very common as is overbreathing (hyperventilation).
In the upbringing of the past (and many other generations), keeping a stiff upper lip and hoping to cope was the right and proper thing to do. One was not to be a burden to others. Unfortunately, that is not necessarily the best thing because stress comes out in other ways. Do you remember the old fashioned pressure cooker? What happened if you close the vent off and left the heat on? Steam would start coming out of the seams, after a while the inevitable would occur, a blow-up. If we adopt the stiff upper lip approach at a time of stress and the heat gets turned up, sometimes very high, and often out of the blue, then we are left in a position whereby if we don't make some adjustments to our vent the pressures are going to build up inside. So if we keep our stiff upper lip, which is very noble and nice, it is not always appropriate. Our feelings and frustrations start to spill over, our families tell us how terrible we are to live with and so on. The trouble is that we cannot always stand six paces back and look at ourselves.
We should only really worry about things we can do something about but this very hard to put in to practice. Imagine you aren't feeling well and you go along to see a GP. He says don't worry about it, everything is fine - just a virus! This goes on and on for a while and you don't feel too good at all and keep getting this information. Then you go along one day and the locum is on and he says oh no you haven't got a virus you've got this and this. One could say, why worry about it, it's happened, it's history. So what, the GP I've been seeing for so long had got it wrong. In theory it should be relatively easy to say what's the point of worrying about it but in practice it is not easy not to feel angry and a little bit peeved, it's not quite good enough. It is not quite so easy to just accept. So it is a matter of dealing with such issues as chronic illness.
How we cope with this kind of experience depends on many factors: our particular coping style, what kind of stress you were under in the first place, how severe. Obviously things that are more severe and more traumatic are more difficult to cope with for most of us. What the time span is, is this an acute or very sudden thing that has happened to us or is it something that was spread out over a period of time that we may have more opportunity to adjust to and get accustomed to. There is personality, perhaps a genetic loading in there somewhere, some of us are better copers than others. There is prior experience, what has it been like dealing with these kind of issues before? The availability of support is important. How much is based on our fantasies about what is going on. How much control do we ourselves have, is important.
By the last I mean how many of you with chronic illness are prepared to hand over the control of your wellbeing to others, how much you are prepared to hand it all over to the doctors. Of course there is a great range of degree of caring and of competence in the medical profession as in other professions. It depends on how comfortable you are with handing over your body and your well-being to someone in this regard. There is no trust that is inherent so we have to have some kind of reasonable feeling about whom one sees as far as one's health is concerned. Some of us are prepared to hand it all over. Whatever the doctor says, goes, no matter what. It is the old style when you could really trust the family GP. It's not the same now with the 24 hour clinics, difficulties in health funding, etc.
There are four main coping styles that can be used when presented with stress or crises - denial, regression, inertia and mature problem solving techniques .
Denial is when we don't want to know about it. We are told, but we put our fingers in our ears. There have been lots of studies looking at the amount of information that has been retained by someone who has just been informed about some significant illness like cancer. There is a large percentage of people who when questioned about the interview 24 hours later say that this illness was never mentioned. We don't want to know about things that are traumatic or painful to us - it is our protective mechanism. Most of the time it is a great help and gets us through the day - we might not even get out of bed and even that would probably be dangerous. You can be immobilised by your anxiety. When the protective factor to a large degree gets in the way it is no longer constructive but is self-defeating or destructive. This can include a doctor saying this kind of medication or therapy would be of use and our response is, we don't have a problem, there is nothing wrong, we will not go along to therapy, we will not take our medication.
This is where men are at a great disadvantage. We have this Super Man mentality, we are bullet proof, it is our job to be strong. Again this an area where following this attitude to the letter of the law doesn't actually help.
Women have an advantage over men in dealing with stress in this regard because they usually are much more able to express their feelings, being able to cry, to be angry, to talk with their peers.
Regression. When we are stressed, one way for us to deal with the many things that we are involved in, is to use what's tried and true in the past. We become younger, we lose some of our adult, we tend to be child-like. We may be accustomed to being very competent but when in hospital and told we are very crook we can deteriorate to being not far from crying little babies. What has worked in the past we will revert to again even if it doesn't fit the situation - even if it is self-defeating.
Inertia is just give up, it's all too hard, what's the point, this is it, the number's up, there's no point in go-ing on, I'm a burden to my family, I've had enough difficulty dealing with these types of issues in the last ten years anyway. This can develop into depression. Inertia is not likely to get you very far. It might get you to a nursing home - the family may give up too, it's infectious. Inertia is obviously not a constructive way of coping.
Mature Problem Solving Techniques is a mixture of things - its about expressing one's feelings about what is happening, trying to realistically appraise the situation as best one can, about finding some acceptance within oneself about what is going on, about not giving up, not losing all fight but accepting that I've got this situation - I'm in intensive care. The ball is now in my hands, I have to decide what I'm going to do. I might even drop it and just leave it in the lap of the gods or the doctors. Or, find a way to fight my way through this as best I can, taking into account I am not superman or wonderwoman and that I might need some help along the way. If we have been used to looking after ourselves we might not really like having to need help from others. Often independence can be forgotten by the carers and it is important that it is retained. Sometimes the patient is treated like a baby. Often we feel so overwhelmed that we can become depressed, giving up. That is indeed when we are best served by allowing those around us, those who care for and love us, to help.
How can one optimise one's position when dealing with stress? I am not going to talk about exercise, diet and the like. What helps one to cope is - talking about it, sharing it with the friends around you, not keeping it inside, recognising that there is a need to have the support and love of others.
Especially what is helpful about such groups as yourselves is that most of you have felt or know what it is like, you are able to share your experiences whether it be in great detail or whether it be just sharing things in the same room. There is a sense of reassurance, peace, something that makes us feel okay - we can find our way over the next hurdle that presents, the next obstacle that is in our path.
I will finish off by encouraging you to keep talking amongst yourselves. Don't keep silent. If you feel like crying, cry. If you feel angry, be angry. And don't keep quiet as far as the doctors are concerned. Keep sticking up for yourselves and remind yourselves frequently that it's your body, it's your life, and you have a say in it. If you are prepared to hand over for example all your life's savings to a financial adviser then it is a nice thought that it will always be handled as if it is that person's own money - but unfortunately, it sometimes becomes their own money! I am not encouraging you to do that but to retain some sen-se of control of what is yours but at the same time accepting that there are some limitations, especially when you get older. There are things that we can't do as we used to be able to do. That is just how it is. There is the popular slogan "Get a life". This is what it is about, making it happen for yourself regardless of the circumstances we may find ourselves in and the limitations this may impose on us at times emotionally as well as physically.
(Dr Lowenstern began his February talk with this story)
Two eminent psychiatrists were musing after dinner over brandies late one night, talking about life and many philosophical issues. Then one said "How about making a pact. Whichever one moves off into the afterlife first will come back and present in a dream what it's like." They both agreed and some six months later unfortunately one of them died. Lo and behold three or four weeks later the other one had a dream. There he was, talking to him, plain as day, saying how fantastic it was. But there is good and bad news. The good news is that a select group meets each week, there is Freud and Jung and Adler and we have just the most stimulating discussion. Each week we take it in turn to present some topic or case. The bad news is that you are presenting next week.