Advice From Dr. Posen

THE SIGNS OF STRESS
People often ask "How do I know when I'm having stress?" The question always reminds me of an old song title, "Am I in Love - Or Is This Just Asthma?"

Recognizing stress is important because we can't deal with it if we don't know when it'shappening. Other people are often aware of our stress before we are. We might be brusque or abrupt without realizing it. Often, other people can read stress on our face that we ourselves don't notice.

So, what are the manifestations of stress we should watch for? Stress shows up in four ways: physical, mental, emotional, and behavioural.

Physical symptoms
In a classic stress reaction, (the "fight or flight response") our heart speeds up, muscles tense, breathing gets faster, mouth goes dry, and we may start sweating or feel a knot in the stomach.These are manifestations of acute stress. Chronic stress shows up a bit differently. When I go through my checklist with patients, I start at the head and work down.

I inquire about headaches, dizziness, clenching the jaw or grinding the teeth, tight or sore neck muscles or across the tops of the shoulders, chest pains, palpitations, abdominal symptoms such as indigestion, cramps, constipation or diarrhea. The hands and feet might tremble or feel cold--or moist. Sweating of the palms or soles of the feet is referred to as "emotional sweating". Back pain and tightness are very common.

Fatigue is one of the most common symptoms of stress, but is often overlooked or blamed on something else. Under stress, your appetite may be lost or may increase. Lots of people have trouble sleeping. There are three kinds of insomnia: trouble falling asleep, trouble staying asleep (frequent waking in the night) and early morning awakening (e.g. 4:30 or 5:00 a.m.) Loss of interest in sex (decreased libido) is often reported.

You've probably noticed that virtually all these symptoms can be caused by other factors. For example, fatigue can result from diabetes or anemia; rapid heartbeat may reflect an overactive thyroid gland. You may need a doctor to help you decide if your symptoms are stress-related or not. However, you can learn to look for patterns or groups of symptoms that usually indicate stress as the cause.

Changes in mental function
Do you have difficulty concentrating on mental tasks? That's a common stress symptom. I ask patients about problems with memory. Occasionally they respond: "What was the question again?"

I inquire about trouble making decisions. One patient turned to his wife and said, "I don't know. Do I have trouble making decisions?"

Your mind might race or go blank. A prominent politician was noted to be under a lot of stress and strain when it was observed that he'd lost his usually terrific sense of humour.

Emotional symptoms
It's common for stressed people to feel nervous, anxious, tense, jittery, on-edge, restless or agitated. Or they may feel irritable, frustrated, impatient or short-tempered. On the other hand, individuals may find themselves slowing down, feeling flat, apathetic, depressed, sad, or blue.

Behavioural symptoms
When I was younger, I was a "knee jiggler." It used to drive my twin sister crazy at the dinner table when I'd sit there with my knee rapidly bouncing up and down. Often she'd put her hand firmly on my knee to get me to stop. There were two fascinating parts to this. First, I was totally unaware I was doing it and second, I could never move my knee that fast voluntarily.This habit results from excessive stress energy that the body tries to dissipate through muscular activity. Other people fidget or can't sit still, pacing back and forth. My wife calls this, "feeling like I'm going to jump out of my skin."

Other behaviours include nail-biting, compulsive eating, smoking, drinking, talking loudly, blaming or swearing. Stress can manifest itself in dozens of ways. But for most of us it shows up with five to ten symptoms that are characteristic for us (our own galaxy of symptoms which we can learn to recognize). For example, I get low back pain but rarely get headaches. Other people get headaches, but never chest pains, etc. Your pattern is usually the same each time and you can learn to spot it.

It might be helpful if we had unmistakable signals when we're experiencing stress: smoke coming out of our ears, hands going bright red or hair standing on end. However, if we learn to recognize our individual stress profile, we can become as good at detection as we'd be if there was steam coming out our ears. And identifying stress is the first step to doing something about it.

All material copyrighted, David B. Posen M.D.

HOW WE CREATE STRESS FOR OURSELVES
A man was telling me about his problems at work. Together, we devised a plan of action: he would speak with his boss to discuss his grievances and request changes to improve the situation. It worked. His boss was receptive and supportive, and made changes to address his concerns. Problem solved, right? Well, not exactly. He continued to focus on one issue that wasn't totally resolved. He also ruminated over what had happened in the past and worried about whether the improvements would last. I gently reflected back to him that there was so much good news and so many positive signals to be pleased about. But he continued to struggle and suffer. I then suggested that he was actually making things harder for himself, that the source of his stress was no longer the workplace situation, but the voice in his head that was talking to him.

If you ask folks where their stress comes from, most will identify external sources such as deadlines, noisy neighbours, sitting in traffic and other stressors which I wrote about last week. However, it may surprise you that the most common source of stress is actually inside ourselves.The majority of the stress that most of us have is self-generated. That is, we create most of our own distress. When I share this thought with patients, I usually get one of two reactions. Most of them nod in agreement and say, "Yeah, I know. I'm my own worst enemy." But some take this observation as a blaming statement. It's almost as if they're saying, "Oh, I see, not only am I feeling crummy, but now you're telling me it's all my fault. Thanks for the uplift!" I assure them that my comment is meant in a positive and constructive way.

The good news is that if we create much of our own distress, then we can do something about it. We don't control other people's behaviour, the weather or the economy. But we do have control over ourselves. So addressing our internal stressors is a great starting point for reducing our overall stress.We all have a little voice in our head that talks to us. (You may be relieved to know that you're not the only one hearing voices!) It's the voice that may be saying to you at this moment, "What's he talking about?" or "Oh, yeah, I know what you mean." It's a combination of editorial board,Greek chorus, cheering section and TV commentator. Also called "self-talk" or "internal tapes",the voice comments on everything that goes on. Some of its messages are positive: "This shirt looks really good on me" or "What a beautiful day. I can't wait to get outside." However, a lot of our self-statements have a negative tone. "Well, I blew that sales call!" or "These people are really boring." We react stressfully to certain situations through our internal conversations: "The service in this restaurant stinks" or "Who does he think he is talking to me that way?" But, we also react stressfully to what might happen - called "anticipatory stress" - such as worries about the stock market or who will win the next election.

We even react to things that don't happen - a party invitation that never arrives or an unreturned phone call. We can also get upset just thinking about something that happened long ago, triggering a stress reaction similar to the one that occurred at the time. Sometimes we feel stressed not because what happens is so bad, but because it was less than we expected. For example, a patient felt lousy after giving a speech. She told me, "My presentation went fine, but not nearly as well as I'd hoped. I counted on hitting a home run and only hit a double." These are all examples of the little voice in our heads stirring up trouble and unease.

Add these internal conversations to things like drinking too much caffeine, overloading our schedules and getting into too much debt and you begin to understand how much of our stress is self-created.
If this list seems daunting to you, don't be discouraged. First of all, realize that you're not alone. Secondly, recognize that awareness is the first important step to dealing with these problems. And thirdly, appreciate that, if we're the ones creating the stress, then we're in the best position to do something about it. We have more control than we think.

All material copyrighted, David B. Posen M.D.

HURRIED PARENT, HURRIED CHILD

The Apple doesn’t fall far from the tree.
Have you ever heard a three-year old say to his laid-back parents: “Hurry up. Stop dawdling. We’re going to be late”? Neither have I.

We were all kids once. Who knew about clocks and time? We didn’t dawdle – we explored! We moved according to our natural rhythms, allowing time for distraction, curiosity and playing with our toys. Was that so bad? Apparently. Many of us had that comfortable tempo programmed out of us by hurried parents who were Type A, impatient or had simply become accelerated by the demands of modern life. At first, we dragged our feet and resisted. But, eventually, we learned to imitate their behavior and conform to their expectations.
Hurried parents become role models. They set the pace for their children by the number of activities they try to juggle, and the speed and sense of urgency they bring to their lives. This“volume and velocity” leads to overload. What are we teaching our kids? What signals are we sending? If we’re hard-driving, overloading our schedules and constantly rushing, kids notice. Some of them get stressed out just watching us! (In case you’ve wondered, stress is contagious.)

Another way parents transmit messages is through belief systems. Beliefs are premises and assumptions, mostly held subconsciously, about how the world works, how people should behave and thoughts about ourselves. These are the messages that run our lives. Examples
include: Success comes from hard work; You should always be busy; I can’t sit still. We hold these messages as “The Truth” so they become the truth for us. Sometimes we teach these lessons overtly – (“It has to be perfect” or “You can’t play until you clean up your room”). Other times, the messages are subtle and implied – such as a sigh of impatience when children move slowly.We also convey messages by over-programming children; keeping them constantly busy; enrolling them in lessons, leagues and activities; filling their days with soccer, ballet, piano,tutoring, homework and chores.

How can we reverse this trend? One step is for us to slow down and balance our own lives. That will set a better example – and reduce our stress. Another is to stop pushing and pressuring our kids. It’s important to expose children to different activities but not to push them too much –especially when it’s clear they’re not picking up on it. We need to open doors, let youngsters experiment and, then, let them decide which doors to walk through. The only activity my wife and I required our children to master was swimming. This was mostly for safety reasons but also to prepare them for water sports in the future. Other than that, we allowed them to pick and choose from the variety of things they were exposed to.

Timing is another issue. There’s a concept called maturational readiness. Infants usually start walking at about one year but, sometimes, it’s 15 or 18 months. Eventually they all catch up. It’s the same with learning to talk, read or use numbers. But many parents want to accelerate the process, getting their kids off to a fast start. Child psychologist David Elkind notes in his excellent book, “The Hurried Child”, that children who start to read early may not achieve as much as their parents think. “Although the children who started earlier had an initial advantage on the reading tests used to assess pupil progress, this advantage disappeared by the time the children were in grade 4.” In addition, they found that, by the teen years, “the adolescents who were introduced to reading late were more enthusiastic, spontaneous readers than were those who were introduced to reading early”. We’re raising kids, not training prodigies. Conscientious parenting has a place but, as one book titled noted, “Einstein Didn’t Use Flash Cards”. They’re only young once – let them enjoy it!

Kids often find their way back to things when we don’t push. We have a son who started playing piano at age six. When he was eight, he became frustrated and unhappy and wanted to quit. Realizing there was no benefit in pushing, we agreed. A year later, when his younger brother started lessons, my wife encouraged him to give it another try. This time it clicked and, over time, his progress soared. He’s now in university, plays the piano beautifully and practises at every opportunity. I doubt that would have happened if we’d pressured him when he wasn’t ready.

There’s a neat irony here: when parents stop over-programming and hyper-parenting their children, the adults benefit too. Their own lives slow down. There’s less chauffeuring from one activity to another, freeing up time for both parents and kids. It also allows for more family time and a less hurried home atmosphere. People often talk about “quality time” with children. But it’s hard to have quality time without quantity of time. You can’t turn moods and receptiveness on and off like a switch, especially as kids get older. (Try walking up to your teenager and saying “It’s 8 o’clock – let’s talk”). But if we’re available, they may wander into the room and start talking or say “Wanna play ping pong?” That’s when they’re ready to have “quality” time. Just as adults need breaks, children need unstructured time too. This is not frivolous or wasted time. It’s a time for them to play, to use their imagination, to learn to problem-solve, to develop social and language skills and to increase their ability to learn. This unstructured time needs to be spent with siblings, peers and even alone, without parents hovering.

Hurried Parent, Hurried Child. Whether unconsciously or with good intentions, we created this problem. And we can solve it. We can step back and slow things down. And when we do, everyone wins.

All material copyrighted, David B. Posen M.D.

WORK-LIFE BALANCE: SETTING BOUNDARIES AND LIMITS
Do you feel you have a good balance between work and life?

Pinball machines have a terrific way of demanding respect. If players push them around toomuch, they go "TILT" and shut down. No second chances. That's a pretty impressive way of setting limits on the amount of abuse they're willing to take. When it comes to work-life balance we also need to set limits to protect ourselves. We could use the word, "TILT," but I have another suggestion.

When I was in general practice and reached a critical mass of patients to see, phone calls to return, and paperwork to deal with, the word that flashed through my mind was, "ENOUGH" -- like a big neon sign. I'd pause, sit down with my nurse and start delegating like crazy--finally making decisions I had been putting off for days. The pile of charts on my desk would fade within minutes, leaving me a manageable workload again, and a great sense of relief.

ENOUGH is another word we should add to our work-life balance vocabulary. The work day is getting longer and faster and more open-ended. To get control of this situation we need to start asking, "How much is enough?" How much is enough time spent at work? How much is enough achievement and success? How much is enough money?

Let me share three stories. A friend of mine was lamenting his overload of work. A self-employed professional, he was inundated with clients, paper, phone calls and faxes, and plagued by constant deadlines. His work often spilled over into his evenings and weekends. He said he had no choice because there was all this stuff to do. I asked: "What do you mean you have no choice? Why did you take on so many clients in the first place?" He said, "Hmm, I see what you mean. I guess I did have a choice."

In the second case, a patient recounted a whirlwind trip to Chicago to finalize a business deal. He put in several 18-20 hour days with a large team of lawyers, accountants, and business people before finally dragging himself home, utterly exhausted. I asked him what was the compelling urgency that had all these people working around the clock to complete this transaction? He said, "That's just the way they do business there." And then he said, "If you want to know the worst of it, after I left, they were already revving up for another marathon session to close the next deal. For them, it never stops."

The next story involves a person who only got home for dinner a couple of nights a week. In addition to his full-time job, he volunteered his time to five community organizations. A nicer guy you couldn't find, but he was pulling himself in so many directions that he barely had time for his family. To all of these people I asked two questions: "Why are you doing this?" and "How much is enough?" Too many of us are on overload. I think that people who work long hours are fooling themselves. Very few people can put in more than 10 hours a day (or 50 hours a week) and still be productive. After that, not only does everything take longer, but we become tired and inefficient.

This is illustrated by the classic Yerkes Dodson Curve which shows the relationship between performance and stress. In the first part of the curve, stress actually improves our efficiency. But past a certain point, the reverse occurs: ongoing stress impairs our effectiveness. In fact, working longer or harder beyond that point is not only unproductive, it's counter-productive. We might even call this the law of diminishing returns. Our bodies and minds need recovery time to restore us to full function. Instead of peddling harder and faster, the best approach is to avoid the down side of the curve altogether. This is where setting boundaries and limits is most useful.

Here are some parameters I use to maintain efficiency in my work, and balance in my life:
1. I usually work from 8:00 a.m. to 6:00 p.m. with time for lunch and an exercise break in the
afternoon.
2. I work only a few evenings a month.
3. I rarely work on weekends.
4. I almost never do business travel on Saturday or Sunday.
5. I rarely go out more than two evenings in a row, even socially or to play sports.
These are boundaries I've established over the years. They're not hard and fast, but I don't violate
them very often. What works for one person may not work for another, but these are examples of
guidelines that you can set in your own life depending on your circumstances.

You can also establish boundaries by location. For example:
1. Don't do work at home.
2. If you do work at home, limit yourself to only one room or place in the house.

Whatever the specifics you decide on, the important thing is to fix some kind of limits. Ask yourself "How much is enough?" (work, income, success) and set boundaries accordingly. You need to know what your limits are regarding energy and productivity. Then you need to say,
"ENOUGH" before your body goes "TILT."

All material copyrighted, David B. Posen M.D.

GOOD HEALTH - IT'S YOUR CHOICE

Let me begin with a premise: that most of our behaviour and activities are actually strategies designed to reduce stress. Before you think I don't get out much or that I've been doing stress counselling for too long, let me explain.

What happens when we experience stress or feel upset? Some of us grab our favourite comfort food or light up a cigarette. Several people tell me the first thing they do when they get home at night is pour themselves a good, stiff drink to help them unwind from the day. Others withdraw and isolate themselves. Still others "dump their bucket" on arriving home, ventilating at length about the upsetting day they've just had. Some go out for a run to release built-up tensions. Then there are folks who veg out in front of the TV every evening.
All of these (and this is only a partial list) are ways that patients tell me they cope with stress. And while some are healthier or more constructive than others, all of them work to some extent or people wouldn't keep doing them.

But let's go further. Why do people leave early to get to meetings or appointments if not to avoid the stress of rushing and/or arriving late? Angry outbursts are a way that many people vent frustration. Crying and laughing are also tension relievers. For a lot of people, worrying is a subconscious strategy that they use to deal with difficult situations. In fact, some individuals use worry as a conscious strategy to ward off trouble ("If I worry about it, then it won't happen.") Often people use procrastination to put off unpleasant activities or situations. Most of what we do can be looked upon as a coping strategy, conscious or unconscious. If this premise is true, then we should ask ourselves two questions:
1. Do our strategies work?
2. Are they causing any other problems?

Let's compare "bad coping strategies" and "good coping” strategies. Bad Coping Strategies can be things like smoking, alcohol, over-eating, drugs, withdrawing, self-pity and blaming. Good Coping Strategies include nutrition, exercise, relaxation, recreation, assertiveness, time-outs and humour.

Stress is one of the leading causes of ill health in our society. But, as if that's not bad enough, many of our coping strategies are, in themselves, unhealthy. So we're hit with a double whammy. Conversely, by shifting from "bad" coping strategies to "good" ones, we can achieve two benefits.
1. They're better stress-reducers.
2. They improve our health.

If we think of our bad habits as not just self-destructive lifestyle choices, but actually misguided attempts to relieve stress, then we can start to look for better strategies that are effective stress relievers and healthier for us overall.
So the next time you have a glass of wine to help you relax in a social situation, or compulsively chomp on potato chips to reduce anxiety, stop and consider that you're actually trying to deal with stress. Then think of alternative ways to achieve the same result - without the negative side effects.

All material copyrighted, David B. Posen M.D.

ATTITUDE IS EVERYTHING

In a baseball tournament I played in, we went into the bottom of the 9th inning trailing 17-7. We scored three runs before someone flied out to end the game at 17-10.

As we walked off the field, our shortstop said, "You know what guys, we didn't lose. We just ran out of time!" This was an example of Reframing - looking at something from a different perspective to reduce stress.His comment didn't change the score. We still lost. But he gave us a bit of a lift, finding something positive to comment on. He also gave us a feeling of momentum for our next game. And he gave us a laugh - Reframing can be playful. People who see the world this way are more resilient and handle setbacks better than people who haven't yet learned the skill.

If you study "stress-hardy" people, one of their shining characteristics is the ability to think differently about situations. A famous example is the story of Tom Sawyer. Mark Twain's hero was given the job of whitewashing a picket fence, which he wanted no part of. To avoid this task, he enticed his friends to do it for him. His strategy was to reframe the activity as being fun rather than a chore. He got them so keen to participate that they actually paid him for the privilege. And while they worked, Tom relaxed under a tree. In this case the reframing was for others - but it cleverly demonstrated that we can look at the same things from different points of view.

There are certain questions that can help us to reframe situations:
"How else can I look at this?"
"How can I put this in a different perspective?"
"Are there any positives or benefits to this situation?"
"Is there anything I can learn from this?"

Sometimes it's easier to reframe things for other people. So a helpful question would be, "What would I tell a friend in a similar situation?"

When my children were small, we planned a Thanksgiving weekend with my sister and her family in Minneapolis. We were all looking forward to the trip when, at the last minute, one of the kids developed an ear infection and couldn't fly. We had to cancel and stay home. A mood of disappointment prevailed. My wife then said, "All right, there's nothing we can do about this. How can we reframe it?" My immediate thought was "That's easy - we just saved $1,000." But we came up with other benefits, including taking in a play we would otherwise have missed. This story illustrates an important point: often we can't choose what happens, but we can always choose how we think about what happens. This is the essence of reframing.

In 1978 I developed pneumonia. When the diagnosis was made (complete with a chest x-ray that looked like a snowstorm) I was put on antibiotics and sent home for 10 days. I wasn't thrilled with the situation - but I quickly noticed an upside. There was a pile of books on my night table that I'd been itching to get at for months. This was the perfect opportunity - 10 days with nothing else to do but sleep and read. I decided the situation wasn't so bad after all. It had at least one redeeming feature - and that's what I chose to focus on.

Here's another example of reframing. A patient of mine had been working like a drayhorse for years at a very demanding job and finally reached a point of burnout. He had to be off work and go on medication. He said his leave-of-absence made him feel weak, that he couldn't handle the pressure. I said, "It's interesting that you say that, because I had exactly the opposite thought. What struck me was how strong you must have been to put up with that grueling schedule and pressure for as long as you did. Most people would have wilted long ago. I think this demonstrates your strength, not weakness. There's only so much any of us can put up with before
our bodies say, 'I don't want to do this anymore.' Your body is only now saying 'that's enough'." This made him feel much more comfortable. He replied with a phrase that told me the reframe was both credible and helpful: "Gee, I never thought of it that way."

So again we see that how you look at things influences how you feel. Negative thoughts drain you. Positive thoughts energize you. And you have a choice. So in any difficult situation, look for the positives and focus on the benefits.

All material copyrighted, David B. Posen M.D.

THE ART OF REFRAMING

I was presenting a workshop at a conference, one of several concurrent sessions in the morning to be followed by a gala luncheon. There were about 100 people in my group and things seemed to be going well for the first 20 minutes. Then a woman at the back of the room gathered up her purse and writing materials and quietly walked out. My immediate thought was, "Gee, I must have been a big hit with her." The moment passed, I regained my confidence and carried on. An hour later the same woman reappeared, sat at the back of the room, opened her workbook and started to participate in the session. After 15 minutes she again picked up her things and left. This time I thought: "Well, there's strike two! She gave me a second chance and I blew it." Again Iwas taken aback, but quickly put it out of my mind. At lunch, all the speakers were seated at one table. And guess who was sitting with us? She came over to me and said, "Your session was terrific. I'm sorry I couldn't stay." ("Yeah, right!" I thought.) She continued: "I'm one of the (conference) organizers and it was my job to slip in and out of the sessions to make sure things were under control. I could see your participants were really enjoying themselves. I wish I could have heard more." I was pleasantly surprised and relieved.

That incident became a touchstone for me, a reminder not to jump to conclusions. It also illustrates that most of our stress comes not from events and situations, but how we interpret them. Things aren't always what they seem.

In addition, it raises an exciting possibility. If stress usually results from the way we think about things, then we can reduce our stress by changing the way we think. The technique for doing this is called Reframing. It's one of the most powerful skills in our stress management repertoire.

We all use reframing at times, spontaneously and by instinct. For example, I made a housecall on a teen-aged boy who was very sick. He had a high fever, raw red sore throat, swollen lymph nodes, and an enlarged liver and spleen. After examining him, I said to his mother, "I'm pretty sure he has infectious mononucleosis. I just want to confirm it with a blood test." She immediately became alarmed and said, "He's got Mono?" Just then I noticed, out of the corner of my eye, that the kid was smiling. A moment ago he looked really sick, but now he looked pretty happy. I asked, "What are you smiling about?" He replied: "I have two exams next week. And I'm not prepared for either of them. Now I'm off the hook." He was right about that. He was too sick to go anywhere. But what he had done in that moment was a classic example of reframing. He had seen an upside to a down situation. We all do this on occasion, but we can learn to do it more consistently and by intention.

When I was writing my first book, it took me four years to find a publisher. When the first rejection letters came in, I got a little discouraged. So I developed other ways of looking at the situation.
1. I did a reality check and admitted that it would be pretty unlikely for an unknown author to find a publisher on the first try. Obviously, the process takes time.
2. "The longer I wait for an acceptance, the more exciting it will be when it finally happens." (which certainly proved true)
3. "It'll make a much better story to tell later on than if I'd found a publisher quickly." ('The saga of how I overcame adversity') Success is more interesting when it involves struggle.
4. "This is a test of my determination and persistence," (plus patience and optimism).
5. "This gives me a chance to keep re-working my manuscript, to make it better." As Tom Peters observed: "Feedback is the breakfast of champions." In retrospect, I'm grateful the manuscript wasn't accepted in its early drafts. I think it's a much better book because of
the time-consuming process that was required.

Reframing helped me to manage the feelings of frustration and disappointment. By holding the rejections in a different way in my mind's eye, those letters started to look like rungs on a ladder rather than rebukes from the universe. By changing my thoughts I changed my feelings. Incidentally, if I'd discovered that the woman left my seminar because she thought I was doing a lousy job, I would have reframed that too -- perhaps by saying, "Well, I guess you can't please everybody all the time."

All material copyrighted, David B. Posen M.D.

DEALING WITH DIFFICULT PEOPLE

Early in my training I encountered a doctor who triggered a tremendous amount of stress in me. I found him extremely arrogant, smug, and full of himself. He also seemed to have a very condescending and patronizing manner that I found very offensive. It was bad enough that I had to periodically encounter him in some of my training rotations, but the capper came when I was assigned to his service for two months. I couldn't imagine how I'd get through the ordeal.

As we started to work together, I found him less abrasive and irritating than I'd expected. Then something amazing happened. He asked me to work with him on a long case and I found myself feeling flattered by the request. During our several hours together I found myself lightening up and kibitzing a bit. He responded and by the end of the afternoon we had made a real breakthrough. That was a turning point, but it got even better. As I got to know him I enjoyed him more and more. Most importantly, I realized that he wasn't arrogant or smug at all. In fact, he was extremely shy and soft-spoken and what I had taken to be arrogance was a combination of shyness and the way he compensated for his social unease. His behaviour and mannerisms didn't change, but my view of them changed totally. In the final ironic twist, he actually became one of my favourite people and we became real friends. It was a lesson in how easy it is for us to misinterpret other people and to react not to who they are, but to our interpretations and judgements of them.

This experience taught me something very important about dealing with difficult people: that the more you learn about them, the better you understand them. Even if you don't end up liking a person, getting to know him or her can lessen the feelings of tension. Appraisal of where they're coming from and what makes them tick is an excellent way of dealing with difficult people, but not the only one.

Let's look at some others.
Avoidance:
An obvious way of dealing with stressful people is to just stay away from them. And where this is feasible, it usually works. However, there are four problems with this approach. One is that it's not always possible to avoid people, particularly if you work or live with them. Second, if you avoid people who are still in your orbit you may find yourself looking over your shoulder to make sure they're not nearby. This can be stressful in itself. The third problem is that you don't learn how to deal with the person if you simply skirt around the problem. It won't help you to develop better coping strategies. And fourth, you could actually end up magnifying your stress when you do see them. I learned this lesson years ago when I ran into someone I'd been studiously and stubbornly ignoring. He was sullen, abrasive and generally disliked and I wanted nothing to do with him. One day I found myself walking towards this person with not another soul around. It would have been too obvious if I'd turned around and gone the other way. So I kept walking, determined not to make eye contact with him. I was going to show him what a jerk I thought he was! Well, guess whose stress level went up with every step? As I passed him, Inoted with dismay (and, frankly, some amusement) what a lousy strategy I'd concocted. I felt more stress when I couldn't avoid him. After that, I realized avoidance was a "losing game" - and I gave it up.

Appeasement:
This is where you concede to the other person and give them what they want in order to avoid conflict. This is the "line of least resistance" often employed by "pleasers." One of my patients used this approach with an aggressive friend of hers, saying that "being a pleaser is easier." However, she started to realize that appeasement wasn't really easier at all. It perpetuated her upset and gave her friend the impression that her behaviour was acceptable. In effect, she gave tacit permission to the other person to continue to be controlling, domineering, and bossy. Appeasement may be necessary at times (to avoid a scene, for example), but isn't a great strategyon an ongoing basis. It keeps you feeling powerless and victimized.

All material copyrighted, David B. Posen M.D.

RELAXATION TECHNIQUES

The human body is beautifully designed and balanced. Just as we have the ability to trigger a stress reaction when we feel threatened, we also have, hard-wired into our nervous system, an opposite physiological state of total relaxation. Harvard's Dr. Herbert Benson calls this "The Relaxation Response." It's not only a pleasant state to be in, but is an important natural antidote to the stress reaction, allowing our bodies to recover from and reverse the effects of sustained stress.

The "relaxation response" is the mirror image opposite of the "fight-or-flight reaction." When we feel threatened our heart rates speed up, blood pressure rises, breathing gets faster, muscles tense,etc. In a relaxation state, the heart rate slows down, blood pressure decreases, breathing gets slower and deeper, muscles relax and so on. However, unlike the stress reaction, which is involuntary and triggers automatically, the relaxation response has to be brought forth voluntarily and by intention. This means that we have to choose to become relaxed in order for it to happen. Fortunately, there are many ways to do this that are easy to learn: meditation, yoga, hypnosis, visualization and others.

In the "relaxation response," unlike sleep, the body is fully relaxed but the mind is awake and under conscious control. The goal is to "empty the mind" of thoughts and concerns and to let it simply exist in a relaxed state. To prevent distracting thoughts, concentrate on a mantra, or your breathing or other calming, repetitive images.

Relaxation exercises should be done in a quiet, comfortable environment. You can sit or lie down. Loosen tight clothing, remove shoes and glasses, and get fully comfortable. For maximum benefit, you should practice regularly (15-20 minutes/day) but you can also use the skills on an"as needed" basis (e.g. before a job interview or giving a presentation).

Relaxation (abdominal) breathing
Relaxation breathing can be used on its own, but is often combined with other techniques. It gets its name from the fact that we breathe differently when we're stressed than when we're relaxed.Under stress, the chest expands, shoulders rise, and we breathe rapidly in order to take in air quickly. During relaxation, the movement is in the abdomen, which expands with each breath in.This is the way we all breathed when we were infants and how we still breathe when we're asleep. As Eli Bay of "The Relaxation Response" in Toronto puts it, "When you breathe as if you are relaxed, you become relaxed."

Five principles of relaxation breathing:
1. Breathe in through your nose and out through your nose or mouth (opened slightly).
2. Breathe into your abdomen and feel your tummy rise as you inhale and fall as you exhale.
3. Breathe slowly, otherwise you'll hyperventilate.
4. Start by breathing out, to empty your lungs in preparation for the first deep breath.
5. Focus on and observe your breathing (like a form of self-hypnosis).

If you're having trouble coordinating this, put one hand on your tummy and the other hand on your chest. As you breathe, focus on the abdominal hand moving, but the chest hand staying still. Practice this for five minutes to start, then slowly increase to 15 or 20 minutes.

Progressive muscle relaxation
Edmund Jacobson was a Chicago physician who published a 1929 book called, Progressive Relaxation. In it he described a technique of deep muscle relaxation which reverses the muscle tension of a stress reaction. This is another way of accessing the relaxation response. It involves focusing on different muscle groups and consciously letting them relax. Start from your toes and work up, going slowly and with conscious awareness. Focus your attention on the muscles of your toes and allow them to relax. Then move your attention to the muscles of your feet and then let them relax. Then your ankles, shins, calves, knees, etc. As you let go of tension in each muscle group, continue to relax the muscles that you've already relaxed so that you can feel the wave of relaxation rising in your body.

The best books for learning a variety of relaxation techniques are: The Relaxation and Stress Reduction Workbook, by Davis, Eshelman, and McKay (New Harbinger Publications) and The Wellness Book by Dr. Herbert Benson and Eileen Stuart (Birch Lane Press, 1992).

While these techniques can be learned from books or even tapes, I think the best way of acquiring these skills is to take a course. It gives you hands-on teaching and practice, along with structure and support if you have problems with self-discipline. I recommend that couples take the course together, to increase the commitment and to be able to give support to each other. Relaxation techniques are safe, portable, natural, and have no negative side effects. They are easy to learn, pleasant to do, and there are multitudes of different techniques to choose from. And they work!

All material copyrighted, David B. Posen M.D.