What to do when feeling low, grumpy or fatigued…

Yesterday I wrote about emotion regulation and how this is seen as an essential part of achieving good mental health.  Emotion regulation is about being able to monitor, judge, and work with emotional responses in order to achieve goals.
People with chronic pain often experience a range of negative emotions – pain itself is characterised as being a negative emotional and sensory experience. At the same time we know there is an interaction between feeling low and experiencing pain that makes both experiences feel worse.

Three of the more troublesome emotions that people experience when they have chronic pain is low mood (not always depression, often ‘demoralisation’ or simply feeling sad and down); frustration and anger; and fatigue. Fatigue you say? Is that an emotion? Well – sort of. In this context, it’s the emotional aspects of feeling fatigued, and the judgements or automatic thoughts about these feelings that I’m referring to.

What can we offer people who struggle with these emotions?
Yesterday I mentioned acceptance and being mindful or open to experiencing them without judging them or trying to change them. I think this is but one part of coping with negative emotions. At other times, it might be useful to know how to modify emotions in order to achieve specific goals.

Low mood, or feeling sad and flat
Have you ever felt down in the dumps? Yes? Good, you’re normal! Have you ever used that feeling as a reason NOT to do something you’d usually enjoy? Like not visiting a friend, or going out, or doing exercise? Yes? Does avoiding those activities help change your mood? No? Then you’ll understand one of the principles of behavioural activation. It’s an old occupational therapy approach – doing things is good for mental health. In the 1970’s it was found that people with depression who were simply encouraged to follow a structured daily routine with or without pleasurable activities, actually started to feel better in themselves. Somehow in the rush to integrate cognitive therapy into mental health treatment, this behavioural approach got forgotten until recently when there has been a sudden increase in interest in this approach by psychologists.

Behavioural activation involves developing a structured daily programme of activities that include energising ones – like going for a walk – soothing activities like taking a bath, and pleasurable activities like being with others or doing a hobby. It’s a little more complex than that of course, but in essence it does involve using the effects of activities as the medium of change.

For people with low mood, the last thing they want to do is go and be active! It’s no easy job to ‘get motivated’ to get out of the house, and for many people it seems quite paradoxical that a therapist might suggest doing something energetic before motivation increases. But if you think of yourself for a moment – remember those times you’ve been asked out to a friend’s place and you don’t really feel like it? But you’ve gone anyway? How do you feel once you’re there? Yes, for most of us, the positive emotion actually occurs once we’re doing what we’ve chosen to do. Not before.

So, we can help people generate a list of energising and positive activities to draw upon (or schedule) when they’re feeling low or flat.  I think it’s probably more helpful to schedule these activities rather than just having a list, because it will help to anchor them in to certain times of the day (forming a framework for the day), as well as disengaging the ‘doing’ from being associated with ‘feeling’ – a bit like quota-based activity where pain is not used as a guide, rather time or quantity is used.

Frustration and anger
These emotions are common when people who have pain feel they are being blocked from achieving what they either want to do, or think they ‘have’ to do. Both emotions increase physiological arousal, so one of the strategies to use is diaphragmatic breathing. It could be why the old ‘count to 10’ trick works! As well as delaying a response, counting to 10 gives space and time to breathe out!

Activities that can help modulate these emotions can vary from energising ones – like furiously dusting or going for a walk or tidying up – to calming and soothing ones like sitting quietly for a period of time, perhaps in nature, or using relaxation.

When people are feeling frustrated or angry, it is usually related to underlying core beliefs.  Maybe ‘shoulds’ or rules about what the person ‘should’ be like, or able to achieve (or what the person thinks other people should do!)  Challenging these assumptions and beliefs can be an important part of helping moderate the emotional response, but in this post today I just want to look at behavioural approaches that can be used.

As for behavioural activation for , a list of suitable activities can be drawn up, ready to be used as needed when a person feels frustrated and angry.  At the same time it’s helpful to include activities that the person can do regularly to (a) feel like they are achieving things that are important to them (especially if frustration is a feature) and (b) blow off some steam in a helpful way!

As I mentioned above, fatigue can be thought of as a physiological response – but it has a healthy dollop of emotional content too. I’m not talking about fatigue associated with mTBI or brain injury or even poor sleep – that type of fatigue can be expressed as yawning, actually nodding off, difficulty concentrating or attending to things and so on. The fatigue I’m referring to here is more than subjective sense of ‘I can’t be bothered to…’

This type of fatigue responds well to energising activities – a brisk walk, a hot shower, dancing, doing some enjoyable activity that involves some whole body movement or all the senses.

As for both low mood and frustration, to manage feelings of fatigue it’s really useful to have a daily plan or schedule so that a structure of planned activities becomes the framework for the day or week. This reduces the tendency to allow emotions to dictate behaviour. It also allows for good planning so that people have a balance of restful and energising activities, and ensures activities are spaced throughout the day, minimising the ‘boom and bust’ or sawtooth pattern of activity. Good scheduling will also form a basis for things like sleep hygiene so that sleep patterns become more consistent.

There are certain times of the day when fatigue is more noticeable – that ‘after lunch’ flat spot is a good example! And while it’s entirely possible for people to plan to have a regular siesta at that time, for many of us that isn’t feasible – so it may be more helpful to put an energising activity in place around that time, or just before. A brisk walk, some stretches, a housework task like hanging out the washing or dusting – activities that get the heart rate up a little, use the whole body and don’t require an awful lot of brain power.

Berking, Wupperman et al (2008) briefly discuss a five step problem solving process that can be used to generate a range of ways to modify ‘quantity and quality’ of emotional reactions.  The basic problem solving process is nothing new – what may be new to the people we work with is the idea that they can modify their own feelings, and act independently of the way they feel.  I think it’s something that especially occupational therapists and psychologists can explicitly use, but anyone who is involved in helping people with pain change their daily activity routine will probably find it helpful to consider.

BERKING, M., WUPPERMAN, P., REICHARDT, A., PEJIC, T., DIPPEL, A., & ZNOJ, H. (2008). Emotion-regulation skills as a treatment target in psychotherapy☆ Behaviour Research and Therapy DOI: 10.1016/j.brat.2008.08.005



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