Are you really healthy – or just ‘not ill’?
“What?!?”, many people think when faced with this question: “But what do you mean?!? Healthy and not ill is the same thing, isn’t it….?
No, it is not, and it is crucial to understand why this is the case.
The traditional way of thinking and talking about health is based on the axiom that you are healthy as long as you are not sick. This approach is outdated and wrong. Medical healthcare is not about helping patients acquire good health. Instead its purpose is to diagnose and treat diseases and alleviate unpleasant symptoms. To the extent that healthcare is involved in a health-promoting context, it is for prevention, i.e. early detection of the risk of disease and helping the individual to eliminate the harmful factor and thereby prevent further disease development.
“But”, some people argue, “if you successfully treat or prevent an illness, the patient will get well, right?” – No, not necessarily. Because good health is not something you have until you get sick. Good health is not so much about the absence of disease, but more about whether biological and mental functions are functioning and the needs of the body and mind are adequately met. This means that we need a whole arsenal of health-promoting behaviours that enable our physiological and psychological machinery to function well every day. We need a large number of good habits that expose us to positive influences that match our biochemical, physiological and psychological needs.
Many modern public health problems are lack of health rather than disease
We are seeing a surprisingly high level of ill health in Sweden. More and more people are reporting various types of ill-health and sick leave remains at an alarmingly high level despite attempts in recent years to tighten up payments from the Swedish Social Insurance Agency. Perhaps the cause is new mysterious illnesses that the health service can’t deal with? No, in fact, these are not new diseases at all, but lifestyle, behavioural and psychosocial health problems that can be categorised as a lack of health rather than an illness.
Stress-induced fatigue reactions, psychosomatic disorders, obesity, high blood pressure, high blood lipids, elevated insulin levels and other metabolic disorders are all examples of this. From a practical point of view, we cannot just look at risk factors (what to avoid). We need also think about what to do more, what to expose us to, how to satisfy mental and physical needs. Anyone who wants to change their health situation needs to add more health-promoting behaviours to their daily lives, not just stop doing wrong but start doing more of that which is good for you. It is not the elimination of risks of harm and wrong behaviours that is the biggest challenge of modern health issues, but rather creating models to help people develop new health-promoting behaviours.
Our physical and mental adaptability is not always sufficient to cope with the unnatural conditions we live in nowadays. Many people have not established a sufficiently healthy lifestyle to keep themselves physically and mentally fit. They do not create sufficient counterbalance to the degrading influences of daily life. Our adaptive capacity is exceeded in several ways in modern life: the food we eat is poorly balanced from a nutritional point of view, our physical activities are insufficient and monotonous, and the psychosocial conditions have become so complicated that a growing number of people are walking around with an almost non-stop psychological stress load and a lack of effective mental recovery.
It is perfectly normal and reasonable to feel unwell from time to time, to sense some unpleasant bodily signal. Unfortunately, many people look for the cause of their ill-being in a diagnosis that the doctor is expected to make through pathological examination methods.
Our own ability to create (or at least actively and consciously influence) our own lifestyle – to actively decide how we want to eat, sleep, work, relax, rest, socialise with friends, be stimulated, enjoy culture, walk in the woods, take the kids to school, join a club, etc. – is in fact more crucial to health and happiness than increased access to healthcare.
We all need to learn to consciously and actively add to the positive side of health creation rather than trying to subtract from the negative. This principle applies at the individual level, in the workplace and in society at large.
In the proactive perspective adopted in this book, there is little point in delving into the mystery of disease (pathogenesis). Instead, we should be interested in the mystery of health. How is it possible to feel good and perform well? Good physical and mental functioning is explored in an interdisciplinary research area called salutogenesis.
The mystery of health
Salutogenesis is the study of the origins and functioning of health and well-being (compare with pathogenesis, which is the study of the origins of diseases, which of course forms the basis of health care). The salutogenic approach immediately leads to a development and improvement scenario, since it is concerned with different degrees of health, regardless of the presence of diseases and problems.
Salutogenic research is a young and still neglected medical and psychological discipline. Its principles are attracting more and more attention and have recently moved out of the social-psychological and personality-psychological field where it started to all aspects of our biological and psychosocial existence.
Salutogenic behavioural medicine applications are now present in many aspects of health care. For the individual, it is about doing their best to keep their life situation together, continuously adapting their habits and, if necessary, learning new health-creating behaviours to feel as good as possible within the given internal and external conditions.
Behavioural health model. Anyone who believes that one is either sick or healthy suffers from a significant lack of knowledge. In fact, there is not just one but two interfaces between sick and healthy: the transition between sick and unhealthy and the transition between healthy and unhealthy. This creates a centre zone. There are people who are neither healthy nor ill. They feel unwell because they are insufficiently healthy. In other words, you can be unwell and still have problems. In the middle zone, symptoms are felt through the grinding of body parts that have not had their needs met recently. This is because the body or mind has not been exposed to enough positive influences and is therefore unable to function in a healthy way. The only way to get out of this situation is to do more of what you have previously done too little of. Knowing the centre zone is a prerequisite for understanding why it is not enough to avoid harmful influences and prevent damage. To feel good, you need to expose yourself to enough positive influences.
The branch of research that studies how diseases occur is called pathogenesis. The basic pathogenic principle is: you get sick if you are exposed to more harmful influences than you can tolerate. Pathogenesis research has been extremely intense over the last hundred years and has led to the development of a wide range of tests and samples that we can now use to detect diseases early on. Coupled with amazing new treatments, this has meant that we have now defused many diseases that only 50 years ago were common causes of death and great human suffering.
Most people can easily understand the preventive consequences of the pathogenic principle and can put them into practice by avoiding risks and refraining from harmful and disease-causing behaviours.
But many people miss the salutogenic resilience aspect. Avoiding too much reduces the body’s ability to handle stress. An excessively preventive lifestyle leads to frailty. For example, anyone who avoids all physical stress for fear of breaking a bone will end up with a skeleton so fragile that the slightest stress will lead to a fracture. Anyone who, for fear of infection, exaggerates cleanliness and disinfects themselves everywhere all the time sabotages the natural defence against infection and in the long run becomes an increasingly easy victim of bacteria, fungi and viruses.
Salutogenic equilibrium. The energy taken out must be balanced by the energy put in. Depleted resources need to be restored before you are ready to take on new, tough challenges.
This reasoning brings us to the salutogenic aspect of the health model. It is only by understanding and putting into practice the salutogenic principle that one can stay healthy and feel really good.
The salutogenic principle states: to feel good, you need to expose yourself to enough positive influences.
No matter how good you are at avoiding risks and eliminating harmful influences, you will not get further than the middle zone (=unhealthy) with such a preventive life strategy. To move further towards the healthy end of the scale, you need to actively expose yourself to things that are good for you. This is called promotive competence. A large part of what is health-promoting consists of stresses that may be unpleasant at the time but which, in the long run, strengthen healthy functions in the body and mind.
Another way of expressing the salutogenic principle is: relieved withers, unwilling breaks.
This formulation highlights the two sides of the meaning of positive impact. Stresses strengthen by forcing the recovery system to build up. The right-hand scale in the figure below represents our anabolic system. It is important to realise that it is a reactive system, so it only builds up the resources in the body and mind that are needed. A person who, through their habits, weighs lightly in the left-hand scale will soon shrink on the right-hand side too. And conversely, in a person who is committed, caring and regularly exerts himself, the anabolic system will be activated to a corresponding degree and build up sufficient resources to withstand just such physical and mental stresses. In other words, you cannot rest in shape unless you have first exerted yourself.
The conclusion of the salutogenic behavioural health model is therefore that it is not possible to feel really good unless you regularly expose yourself to stress. It is not comfortable to feel good. This realisation is necessary to understand the strong link between positive stress and good health (to which we will return in later sections).
Many animal studies have shown that the health of animals that are regularly exposed to stress is significantly improved, provided that they are given time to recover properly between bouts. Animals in these activated groups even live much longer than their conspecifics who are kept calm and comfortable all the time.
The ability to manage stress actively, consciously and competently, so as to stay in one’s positive stress zone, is thus an important part of the skills that we humans need to acquire in order to stay fit, healthy and productive. The practical meaning of the expression ‘staying in the positive stress zone’ is thus to regularly expose oneself to all kinds of stresses, both physical and mental, and to ensure that one recovers properly in between.
In order to perform this balancing act at a high level, you need to have a good understanding of both scales so that you get high efficiency in your efforts both in terms of performing and building up and recharging your energy.
What is wellbeing?
The purpose of learning to use the offensive stress management approach described in this book is to maintain high performance while feeling good in body and mind. Wellbeing is not just about quick wellness terms, such as match weight and good breath, but wellbeing in a deeper sense, a sense of quality of life, joy and enthusiasm that is present in much of everyday life. True wellbeing is a prerequisite for being a high performer. The energy with which we perform comes from our wellbeing in a broad sense. Therefore, the ability to maintain a high level of well-being is closely linked to performance and is an important aspect of what we call offensive stress management.
In dictionaries, well-being is defined as a sense of harmony, feeling good, being content, enjoying life, having enough time to engage in what is important to you, and being able to reasonably cope with the challenges you face. A concept closely related to well-being is quality of life.
When life is of high quality, it feels good to exist, what I do is meaningful, I feel that I understand what I am doing and can handle most situations, it feels valuable to be part of life on my part of the planet, and to be part of something much bigger than just me and my own private comfort.
Well-being and quality of life do not mean feeling good all the time and without interruption. Rather, it is the ability to interpret what you are experiencing as meaningful, to often summarise many different experiences and mental states into a positive core feeling: “My life is meaningful.” . .
The elements of well-being are assembled every day into a new sense of self. The proportions vary day by day, and so do the degree and type of well-being. These variations are not so much due to external circumstances as most of us generally seem to believe, but more to what we ourselves do with our experiences, how we focus our attention.
Well-being cannot be triggered by any single, pre-given, external phenomenon, but depends on our own interpretation of everything that happens in and around us.
Components of well-being
- Presence. Intense experiences, continuous engagement in what is happening now.
- Frequently recurring safe and pleasant feelings. The overall richness of emotions seems to be an important ingredient of well-being. The total absence of negative emotions – such as anger, sadness, grief and the like – is not a criterion for well-being, but rather that emotional life is dominated by empowering and uplifting thoughts and experiences that create recurrent joy and compassion.
- Self-confidence as a certainty that “whatever happens, I will come down feet first” and optimism in the sense of believing that life will develop in the desired direction. This self-confidence contributes to courage, i.e. to face new challenges with confidence and thus to devote oneself more intensively to experiencing the present.
- Freedom from fear and anxiety, i.e. not focusing on worries and threats, but on experiencing what is happening now.
- In a complicated and demanding life situation, the ability to accept reasonable challenges, so that one is stimulated and engaged, but not worried about the outcome, can be crucial for well-being.
A prerequisite for well-being is the ability to create a sense of meaningfulness and to see oneself as part of a larger context than just personal gains of prestige and money. This wider context need not be religious beliefs and affiliations in the traditional sense, but can be a highly personal conviction about what is first and foremost valuable in life. Put into practice, this means that one of the most important things we should all be striving for is a self-perceived insight into what lies in and behind the concept of well-being – that is, our own deep meaning of well-being – which we can then carry with us and be constantly inspired and guided by in our daily lives.
About positive and negative stress
The word stress has become a diffuse and ambiguous concept that has acquired so many different meanings that it is almost impossible to use it without adding an adjective to explain what is meant. The NE Dictionary states that the word stress has been used in the Swedish language since 1954: “Stress = strenuous circumstances that induce strain both physically and mentally; agitation; state of tension.”
The word stress is originally English, and has been used there for centuries to denote distress and hardship. In modern English it means rather strain, stress, pressure, but also emphasis, put emphasis on, etc. In English there is also the word strain whose meaning is a shade harsher than stress. Strain means overload, gruelling strain, unpleasant stretching beyond the limit of what one (or a material) can withstand.
Many stress researchers nowadays choose to label such stresses as negative stress. The term negative stress was coined by a Hungarian-Canadian physiologist, often referred to as the father of modern stress research: Hans Selye. He explored the reactions of the body when we are subjected to stresses that the body and brain are ultimately unable to cope with. He called such stress reactions maladaptation. Selye’s discoveries in the 1930s pioneered our understanding of how the stress system first helps us to reorganise a variety of mental and bodily processes to cope with stresses that threaten our well-being, but then gradually devolves into fatiguing and disease-causing reactions if the stress state lasts too long without interruption for recovery. Selye defined negative stress as a prolonged state of imbalance between destructive and constructive processes. Later, his research focussed on why there is such a wide variation between individuals in their ability to tolerate different types of stressful circumstances. Selye’s research gave new meaning to the well-known saying coined by Epictetus 2000 years earlier: “The most important thing is not how you have it, but how you take it.”
The most common way the word stress is used in ‘layman’s terms’ is to denote situations where we feel inadequate and insecure in the face of tough demands or unpleasant risks. Soon afterwards, you can hear the same person using the word stress to refer to the unpleasant reactions, both mental and physical, that arise in us when we face really tough challenges. So we find the word stress on both the cause and effect side, which can be confusing. The confusion increases when we realise that the word is sometimes also used for demanding situations in general, i.e. even short-term and manageable challenges, and the healthy and adequate psychophysiological reactions that then occur.
In the health sector, the word stress is often used to refer to psychogenic and psychosomatic disorders, and is sometimes used as a synonym for worry, anxiety and nervousness.
In the vocabulary of some journalists, the word stress has in recent years become almost synonymous with problems in the workplace, which is unfortunate, because it misleads many stressed-out people into looking for the cause of their problems in the wrong place. Curiously, this is also true for inexperienced doctors who are quick to pull out the sick leave form as soon as a patient shows signs of negative stress reactions. If, in fact, the patient’s stress is due to problems in their personal life, they are deprived of the stimulation and inspiration that work usually provides, and prolonged sick leave can lead to a vicious circle rather than the relief that was the well-intentioned, but misguided, idea behind sick leave.
Finally, it is becoming increasingly common to use the word stress to refer to low quality of life or ill-being. In this sense, stress becomes a vague opposite of happiness and well-being.
So it’s no wonder that some people have recently become wary of the word stress and no longer want to use it, as it can mean almost anything… The context will determine how it is interpreted.
The psychophysiological stress model
Thus, an updated explanation of how modern stress research views the stress system may be appropriate to go through, so that we have a solid platform to start from for future discussions on different types of stress reactions. The explanatory model presented here is called a psychophysiological stress model.
(The numbers in the text refer to the corresponding numbering in the simplified and stylised figure on the next page.)
In it, the body has been reduced to four limbs and a torso (3). The brain has been divided into its two main functional parts, the cerebrum (1) (or more precisely the cortex cerebri) and the brainstem (2) (consisting of the medulla oblongata, pons, mesencephalon, cerebellum, hypothalamus, thalamus, basal ganglia and certain phylogenetically ‘old’ parts of the cerebrum). The basic tasks of the brain are in fact two:
- a) coordinating everything that happens in the body, so that all the body’s functions and organs are always organised according to what is best for the whole organism,
- b) interacting adequately with the environment, interpreting what is happening and ensuring that our actions are meaningful in any given situation.
Each of these tasks is so complex that the brain has been functionally ‘split’ so that each unit can perform its task without interfering with the other. It is the brainstem (2) that monitors and regulates bodily functions. This function is so fundamental that the brainstem shows the same construction in all mammals.
The brainstem regulates everything that happens in the body through hormones and nerve signals. The brainstem is never allowed to sleep, because then the body would ‘stop’. The cerebrum, on the other hand, is allowed to sleep and the brainstem continues to run the physiological machinery all by itself. Even if the cerebrum is damaged and unconscious, the brainstem continues to control all the body’s organs. But only ‘idle’. This is because the brain stem cannot set the body to a higher ‘speed’ on its own. For the brain stem to be able to “accelerate” and activate the body, the cerebrum must give the order.
The main task of the cerebrum is to keep track of what is happening and sort out the most important information from the huge amount of information flowing in from the external senses and the proprioceptive senses that tell us what is going on in our own bodies. Most of the body signals go to the brainstem as feedback to the physiological control systems there, but there is still enough of a bombardment of signals reaching the cerebrum for the cognitive systems to be busy filtering out everything unimportant. The cerebrum performs a miracle several times a second in that it manages to extract the most important things from the enormous amounts of information that come in and establish an interpretation of the whole that is certainly never completely objectively correct but surprisingly often adequate and functional. The meaning of the interpretation the cerebrum has established in the cognitive systems is sent down to the brainstem for translation into hormone and nerve signals. In this way, it is the brainstem that puts the body into the functional state that corresponds to the cerebrum’s interpretation of the situation. You could say that the brainstem ‘translates’ our mental state into bodily functions. And this doesn’t happen every now and then, but several times a second! Every thought we think and every emotion we feel can therefore be read in the body. That is, there are no devices that can read what someone is thinking, but the meaning of each thought is immediately reflected in the way the brainstem tunes the heart, gut, muscles, glands and everything else in the body.
The brainstem is functionally divided into two systems: the stress system and the anabolic system.
The stress system activates the body so that our resources are mobilised for an activity. We become more awake, more alert, faster, stronger, warmer and more. This system reacts at lightning speed to the slightest thought of demand, feeling of insecurity or perceived threat in the cerebrum.
The anabolic system, on the other hand, is sluggish and slow. This is because the anabolic system is responsible for allowing the body to recover between efforts, repair minor injuries and build up new energy stores, and such processes have never needed a jump-start in nature. But it has to be started, most of the time, between resource- and energy-consuming efforts, because it is actually the case that the body cannot rest and rebuild itself if it does not receive “anabolic orders” from the brain stem. The anabolic system remains fairly inactive until the cerebrum sends signals saying “It’s calm and safe to be me now, it’s time to recover and build up”. Only then does the anabolic system kick in and allow the body to properly recharge its batteries. This is why anxious and insecure people are more likely to suffer from fatigue reactions, because if you have trouble relaxing mentally, you won’t be able to rest physically either.
The cerebrum provides us humans with amazing mental resources that no other animal has to the same extent, namely our well-developed linguistic abilities, our ability to analyse and plan, our perception of time, our ability to think abstractly and our self-awareness (= the feeling of having a self at the centre of all experiences). At the same time, it is these mental abilities that can get out of control and create a lot of unnecessary stress that we think about unnecessarily.
Even when these mental processes are healthy and appropriate, they take up so much brain capacity that we wouldn’t stand a chance of survival if it were the cerebrum keeping track of our own body. Or, conversely, we wouldn’t be able to think, talk, or read for more than a few seconds at a time until something in our body started to lag or lag or otherwise get out of sync. This is why the cerebrum and brainstem are autonomous units. That is, they can act on their own, but they can also work together when needed. It is this interaction that is being studied in the field of psychophysiology, which is where the name of this stress explanation model comes from.
Positive stress
The term ‘positive stress’ has been used in recent years to refer to reactions where the activity of the stress system enhances performance and helps us to utilise our resources constructively. Everyone who is committed and wants to achieve something must accept challenges and expose themselves to demanding and pressurising situations. This is when our stress system steps in to help. The stress system is nothing more than a resource mobilisation system that, when needed, makes our brain and body switch on, become alert and ready for action. When this works, we call it sharpening, ignition, vigour and similar positive expressions. This form of stress response is highly desirable and helps us to go the extra mile, overcome challenges, master threats and survive dangers, making us stronger, faster and more focussed.
Different activities require different degrees and types of stress mobilisation within us in order to function at our best. In other words, there is no single optimal stress response, the same for all challenges, but each activity has its specific optimal stress level.
A certain level of activity in the stress system is needed for us to be at our best, both mentally and physically. The figure illustrates that both too little and too much stress causes the wrong or insufficient resources to be mobilised. Depending on the type of activity, different levels of stress are desirable for optimal functioning. For example, it would be devastating to performance if, during a game of tennis, the relatively high stress levels needed to defend oneself in a real fight were to occur. And the moderate stress that a chess player would want to be in to maintain mental acuity and access all his creativity would be completely the wrong stress level if he were in real danger and needed to fight for his life.
The power that an adequate stress response mobilises within us is powerful and can be harnessed if we are physically fit and understand how the underlying mental process works. If we learn to control our stress reactions and direct the energy that is then released, we can do our very best when it matters most. It is at times like these that we tend to see the concept of positive stress used in the literature and in sport and work contexts.
One aspect of stress that needs to be taken into account to determine whether a stress reaction is positive or negative is recovery. If you are unable to ‘switch off’ after a challenging effort, but remain agitated, excited and tense long after you have entered a new situation that does not require stress mobilisation, then it becomes a negative stress reaction anyway. Those who find it difficult to calm down and cannot break a moment of stress and switch to recovery, will leak a lot of energy and sooner or later become exhausted. Consequently, lack of recovery is also a form of negative stress. To determine whether a stressful event is positive or negative, it is therefore necessary to evaluate the outcome, including recovery, some time after the challenge has been completed.
Thus, positive stress is the stimulation and mobilisation of the stress system when we face reasonably difficult challenges. There are two prerequisites for stress to be called positive:
- that we interpret our situation correctly, so that an adequate resource mobilisation response is triggered in both brain and body
- that we can stop the stress and recover before it’s time for the next surge (otherwise the stress system has no resources to mobilise the next time it’s time to surge).
Negative stress
Negative stress in individuals can be said to be of basically two different kinds. The first, most important and most common kind consists of lack of rest. Insufficient rest, if prolonged, leads to a reaction of exhaustion. The second form of negative stress consists of excessive activity of the stress system in relation to what would have been adequate to deal with the objective challenge. This can arise from misinterpreting the situation you are in as more threatening or dangerous than it really is. Such reactions are due to reading into the situation an exaggerated risk of failure or disaster. More moderate variants of this are, for example, excess feelings of demand (‘musts’), uncertainty, anxiety, nervousness, mental tension and similar reactions that are imagined. “imagined” – do not understand this ending.
Sometimes it is impossible to determine whether it is primarily anxiety and internal tension that leads to stress problems in everyday life, or whether the excessive mental tension is triggered by a long period of accumulating external stress.
The key messages here are, firstly, to see disorders triggered by negative stress as a consequence not only of intense stress reactions, but also as a consequence of insufficient recovery. Secondly, many negative stress reactions are not due to external factors but to the way the person concerned thinks and interprets situations. This latter factor is sometimes referred to as ‘internal stress’.
Internal stress
Worrying means creating a state of stress within oneself by focusing attention on unpleasant and frightening future scenarios, the possible loss of something dear, or a risk of some kind that scares more than it challenges. Sometimes in the psychological literature, anxiety is defined as ‘internal stress’, a form of fear that is not due to any present external threat but to something that is thought about.
For anxiety-prone people, everyday life is a battle. Not necessarily against demons, because the vast majority of anxious souls are not mentally ill. But much of their waking hours are spent fighting all kinds of threats to their own and their family’s safety. So it’s not easy to be enthusiastic.
By all accounts, worry is a uniquely human phenomenon. As far as we know, no other animals stress themselves out by exaggerating risks. Even animals that live in predator-dense areas don’t walk around worried or afraid. Not until they sense a predator lurking nearby. Robert Sapolski is an American stress researcher who has written an entire book about this: Why Zebras Don’t Get Ulcers. Many people refrain from tropical travel and envy the wonders of the African savannahs because they can’t bear the discomfort their own fantasies about dangerous animals trigger in them.
Almost everyone has personal experience of the unpleasant state of mind that worry puts you in. Common examples are exaggerated thoughts of disaster in connection with separation, or when you briefly fear that you have lost your wallet, or had your passport stolen while travelling abroad and get caught up in exaggerated negative fantasies about all the trouble it will cause, or when your family is travelling and you cannot get rid of horrible thoughts that they have had an accident, or when you misinterpret your boss’s signals and think that redundancy is the reason you were called into a meeting, or nervousness about the presentation you have to give tomorrow, or the walk in the woods that becomes a torment instead of a pleasure because you can’t help worrying about all the vipers that might be behind the next stone, etc.
If there is a real reason for the stress reaction and the reaction is not exaggerated, but is appropriate to the seriousness of the threat, it is not worry. Worry means that the thought adds dangers, magnifies the risks. A natural and appropriate psychological reaction to an actual concern is not worry. However, if the reaction is disproportionate to the risk or the nature of the danger, because the thought magnifies the threat and distorts the interpretation of the situation into something worse than is justified, then the term worry is appropriate. If the reaction becomes so intense that the person no longer functions, is unable to look after himself or herself, or loses his or her ability to perform, it is called pathological anxiety (sometimes the term anxiety is used as a synonym for worry, but the term anxiety should really be reserved for when the anxiety becomes really intense and reaches a pathological level).
Uncertainty
Worry revolves around two hubs. The first is excessive risk awareness, a tendency to get caught up in thinking about things that could go wrong. It is a kind of mental hypersensitivity to uncertainty and insecurity. Anxiety-prone people check and re-check again and again to prevent horrors. They experience loss of control as something unpleasant, as a harbinger that something bad might happen. The objects of all this checking can vary from person to person, from the behaviour of the children to the contribution of colleagues to the project, the development of the share price, the hob, the iron. The non-worrier may suddenly realise that perhaps he forgot to lock the car, but shrug and leave it until the next day. Not so the worrier, who can’t let go of the thought that the car may soon be looted and if you forgot to lock it, maybe even one of the back windows was left unlocked by the children and if it starts to rain tonight…. All this uncertainty is too much for the worrier, so he gets dressed and goes out to check the car.
Stressed by their own stress
The second hub consists of fear of fear, that is, the sufferer finds it terribly unpleasant to be worried and stressed. When he becomes anxious about something, the fear of becoming even more anxious sneaks in through the back door and creates even more anxiety. The discomfort consists of one’s own tension, both mental, which is fear and anxiety, and physical, which is the stress reaction in one’s own body. However, the anxious person does not realise that this is the case, but projects the cause of the discomfort onto what he is worrying about.
When you are in the middle of your anxiety, it all seems logical, you then find it difficult to recognise how you are thinking yourself into a lot of unnecessary stress. The cause of the anxiety may lie in the future or have a “maybe” stamp on it, but the unpleasant feeling is very real and depends on what you are thinking about, the worried person thinks, which gives him or her a good reason to continue to worry.
If this procedure is repeated often, it becomes like a “negative training” of the stress system, which gradually becomes sensitised and increasingly reactive. The slightest spark ignites a great mental fire in the worrier. Worry takes over more and more in daily life.
When you have experienced really unpleasant anxiety a few times, it is not surprising that you want to avoid it in the future. Various types of ‘just in case’ thoughts and avoidance behaviours emerge. In the long run, it is these avoidance behaviours that reduce the quality of life of the (morbidly) anxious person, who feels obliged to take long detours around various situations that have come to be associated with a risk of the unpleasant.
“To dare is to lose your footing for a little while.
Not to dare is to lose yourself.”
Sören Kierkegaard
A few more complications often (but not always) appear on the worrier’s stage: hypochondria, lack of relaxation and sleep difficulties.
Hypochondria
Hypochondria equals worry about illness. Hypochondria is not a disease of the imagination, because the sufferer has symptoms, real discomfort in the body. The problem with hypochondria, or health anxiety as it is often referred to in the literature lately, is that the sufferer starts feeling the wrong way and misinterprets bodily signals as symptoms of illness. Being ill is no fun, is it? Anyone can get anxious about anything, so of course the hypochondriac gets anxious. This causes stress reactions in the body, which are often unpleasant and can easily be misinterpreted as further symptoms of illness. Consequently, the anxiety escalates to the next level, causing even more unpleasant bodily phenomena and an even stronger negative fixation on the discomfort. Help! If this vicious circle accelerates two more notches, panic is near.
Sabotaged rest periods
People prone to anxiety often find it difficult to calm down. For them, relaxing can feel all wrong, sometimes downright uncomfortable, like losing their footing, losing control. If you find it hard to relax, your rest periods won’t work. In order for the recovery system to be activated and send its rebuilding, renovation and battery-charging signals to the body, you must first put yourself in a state of mental calm. This is precisely what anxiety sufferers find difficult. In practice, this means that they often suffer from a lack of energy, as they forget many of their resting moments.
Difficulty sleeping
Falling asleep is a vulnerable situation. People prone to anxiety often find it difficult to fall asleep not only because of the difficulty in relaxing, but also because of negative expectations. Anyone who has ever laid in bed playing propeller, anxious to get to sleep because tomorrow will be demanding, knows how things can get stuck. Trying too hard to fall asleep is a sure way of not being able to! If you’re also worried about what the lack of sleep will do to you tomorrow, it’s downright impossible. After a few such unpleasant nights, it’s no wonder that a negative anticipatory anxiety creeps in towards the evening: “What if I can’t fall asleep! Oh no, I hope it doesn’t happen again. I must get some sleep tonight!” If you can’t get out of those thoughts, you have effectively sabotaged your sleep once again.
Nervousness is also a form of negative stress
Nervousness is an expectation anxiety that arises from the fear of failing at a task. You could also say that nervousness is an exaggerated stress reaction to a challenge. It is when you are no longer energised and focused on the task at hand, but overexcited and anxious. Some people become resigned and just want to escape the discomfort, others tend to become aggressive.
Mentally, a fatal misalignment occurs whereby the mind dwells on the risks of failure rather than exploring the opportunities for success. Defensive and destructive behaviours are more likely to take precedence at the expense of resilience, precision, speed, subtlety, sensitivity, creativity, humour and other performance-enhancing factors. The body functions less well, arms and legs start to feel heavy, you become stiff and clumsy, your fingers tremble and don’t quite obey, your stomach contracts, your heart beats faster.
Negative feelings follow one another on a conveyor belt. Some regret having taken on the challenge and want to get out quickly. Others barely make it through the situation, far from doing their best and with a bitter aftertaste in the form of the feeling of having let themselves down, of having set themselves up for failure.
Such unpleasant experiences are easily etched in our memories. Sometimes a single time can be enough to disturb us in all similar situations thereafter.
From a biological point of view, it is perfectly logical and adequate that threats and discomforts get stuck in our minds and subsequently influence our reaction to all similar situations in the future. Reacting strongly and quickly to a threat is a primitive learning mechanism of survival value when trudging on foot through the jungle. But this Stone Age talent can sometimes fail us modern humans. After all, we are unlikely to encounter live lions (sadly, there are not many left on the planet). Rather, we are stressed by our own misinterpretation of situations or by unnecessary ruminations, low self-confidence, pursuit of material status, prestige, control-freakery or perfectionism.
The cause of the vast majority of anxiety reactions can be characterised as poor ‘mental hygiene’, which means letting your mind wander, so that you lose focus on what you need to do and start worrying about failure.
And what happens then? Well, the probability of actually failing increases. This is partly because ‘bad’ behaviours become more frequent when you think about something other than doing the right thing. You cannot reduce the risk of mistakes by saying to yourself: “Don’t do the wrong thing!” Such thoughts immediately lead to the unwanted behaviour being processed by the brain, which in turn can lead to that particular behaviour being performed! (Negative thinking is explained in detail in my book “A good life is not comfortable”).
Instead, it is important to focus full attention on the behaviour that can work and that you want to use. In order to have fluency and good feeling when performing something difficult, you need to be fully occupied with doing the right thing. The fear of making mistakes and failing must not come close to your focus once you have started an activity. In advance, while preparing, analysing the risks of failure is a wise step, which can make you change your plan. But it must be done well in advance, and not at the last minute so that it affects the actual execution.
Another mechanism by which nervousness impairs performance is congestion of the mind. Our working memory has a clearly limited capacity and if one starts to analyse the risk of failure or discomfort, mental resources that would have been needed for optimal performance are occupied.
To access your full potential when the chips are down, the crucial skills need to be properly learnt and rehearsed a number of times, so that the brain feels confident in its ability even when the nervous discomfort has set in. When we do something we are really good at, the movements are not guided by conscious control, but by a kind of execution programming in a part of the brain that we can call the ‘autopilot’. “The ‘autopilot’ has a much greater capacity to fine-tune body movements than consciousness does. But it is sensitive to stress. If you have not specifically trained to perform the crucial behaviours under pressure with reasonably good technique, you become insecure when faced with the challenging situation. Then the tense nervous feeling can completely take over and you get “rubber arms”. It is not uncommon to see people who can perform really well in a relaxed state become paralysed under pressure and lose access to their skill. Perception becomes distorted inwards. They increasingly recognise how strange it feels in their own body. Any errors made in movement and speech are magnified and catastrophised. A destructive self-absorption takes over, and they increasingly lose touch with the ‘autopilot’ that controls when they are appropriately excited, fluent and responsive to what is going on around them.
Even if you are good at relaxing and reducing your stress levels slightly, it is rarely possible to remove all stress before a tough challenge, so you must learn to tolerate a certain amount of tension while maintaining your focus on a set tactic. To master this combination, you can build a certain amount of pressure into your training, so that you gradually get used to the feeling of being a little tense and still having access to your full skill set. The principle of gradually increasing the level of difficulty thus applies not only technically but also emotionally.
When the stress system is pushed much further than desired, so that fear or aggression comes into play, the interaction between the brain and the body does not function as usual. “The ‘autopilot’ is disengaged and you may have to ‘drive manually’, that is, consciously steer yourself in the direction of accomplishing what you want to accomplish. This can never work as well as in a relaxed or reasonably tense state, but for some challenges it may be necessary to practice this mode as well, so that you don’t completely lose control (or even panic) if things get really bad. In such situations, it’s not worth trying to do your best, but having a ready-made ‘plan B’, consisting of some simple, reliable, extremely well-rehearsed behaviours that you can fall back on.
Nervousness sabotages our skill and performance in three ways:
- By interfering with the “autopilot” with the wrong instructions so that the feeling in the execution is distorted. You become hesitant and clumsy, tense and slow; the obvious skill you normally possess disappears through some kind of back door, and you have to make an effort to at least do your second best.
- By reducing mental capacity (“working memory” is occupied by fear and anxiety and the desperate attempts to consciously control fingers, arms and legs, tongue and vocal cords, facial muscles, etc.) so that you lose the big picture, find it harder to think tactically, lose your sense of direction, lose touch with your surroundings, misinterpret, get lost.
- By creating an uncomfortable feeling that takes away the desire to engage in the challenge. Motivation wanes, the opportunity you originally sought is drowned out by the fear of failure. Sometimes this feeling becomes so strong that you just want to get out, escape, become dejected or angry with yourself.
It’s easy to see how a vicious circle can emerge when points 1, 2 and 3 exacerbate each other until only a mentally misfocused, nervous, anxious jumble remains.
The medal sometimes has an obverse
At the same time, it should be remembered that some anxiety-prone people can be very stress-resistant in real life situations. Many of them like to work hard and enjoy being busy. This is partly because employment acts as a distraction from potential worries. But it is also because worry-prone people are often resourceful and enterprising, keen to be active, to capitalise on their skills, to take responsibility and to make a difference. However, if anxiety becomes too pronounced, it steals so much energy that people end up not being able to engage and the conditions for enthusiasm to face the challenges of everyday life quickly diminish. Therefore, a good understanding of how internal stress works is useful for anyone who wants to be a sustained high performer.
Pressure mostly positive stress
Having a huge to-do list or a really tough challenge ahead, and perhaps not enough time, can make anyone feel under pressure. Many people use ‘stressed’ to describe their state of mind. As shown above, this is certainly correct, but many people misinterpret it as undesirable, negative stress. But it does not have to be. Rather, it is often a positive stress reaction that helps you to get your head down, tackle tasks effectively and maintain concentration until you finish.
Indeed, many people depend on such pressure to get anything worthwhile done at all. Unless someone else takes the initiative and puts the pressure on, a “stress addict” cannot summon up enough motivation in himself or herself to become mentally energetic, but puts off starting and puts off and puts off until time becomes so short that it can barely be done. Only then does the pressure become intense enough to switch on the stress required to tackle the task. As long as such a behavioural strategy works – that is, the delivery is always on time and of sufficient quality – there is not much to say, but if performance suffers or other people (e.g. colleagues, customers, family members, fellow travellers) are negatively affected by always being at the last minute, the procrastinator must learn to somehow increase the pressure on himself earlier in the process.
The positive-negative stress interface
In conclusion, the difference between negative and positive stress is not absolute but relative. A high level of stress can be positive if the challenge requires intense physical effort and total focus to the exclusion of all else. The same type and level of stress can be devastating when faced with another challenging task that requires relaxation, presence, creativity, judgement, fine motor skills, or sensitivity and attention to the reactions of others. Faced with such challenges, you need the ability to quickly regulate your own stress levels downwards without slipping into a coma or overly deep relaxation.
Sometimes you see people shaking and breaking out in a cold sweat as soon as they are asked to perform. This is usually because their minds go off track, losing focus on what really needs to be done and instead wandering around worrying about everything that could go wrong. Another person, faced with the same challenge, may feel energised and, with no apparent stress, just get on with the task effectively. What matters is not the objective nature of the external situation, but how the individual interprets their situation. As long as one feels confident in one’s abilities and the confidence to take on the challenge, one can stay in a positive stress response and mobilise the right resources internally.
However, it is important to recognise that differences in reactions to demands and challenges are not only interpersonal but can also be intrapersonal over time. Depending on the psychological state of mind, people may react differently to the same stressor from time to time. The fastest change is seen in individuals who have not had any deep sleep for a couple of days. This increases their sensitivity to stress and drastically reduces their ability to handle complex challenges. A milder variation on the same theme is the reduction in mental performance that can be seen in people who eat too few slow carbohydrates and therefore experience dips in blood sugar levels at certain times of the day. Since carbohydrates are the brain’s only fuel, this leads to a decrease in stress management, an increase in irritability and a drop in performance.
Not always easy to read the stress of others
It is necessary to know another person well to be able to read the quality of their stress reactions in different situations. A busy person may appear to others to be unnecessarily stressed, irritable and rude, but this is sometimes a hasty conclusion. Being excited, in a hurry, focussing on the task, disregarding everything else (e.g. being inattentive to others) does not necessarily mean being in a negative state of stress. Ultimately, only the person who is rushing can decide whether he is in an appropriate state of stress or whether it is unnecessary and counterproductive.
It is difficult to provide a universal answer to which behavioural signals indicate positive or negative stress. However, on the next page we have compiled a list of signals that can often be helpful in “diagnosing” what type of stress reaction you or another person is experiencing.
SIGNS OF NEGATIVE STRESS
Psychological effects (cognitive, emotional and behavioural):
Fatigue, reduced stamina, unable to read/listen
Memory disorders, learning disabilities
Concentration difficulties, mental absences (-> “clumsiness”, incidents, accidents)
Bad mood, irritability,
Impatience, restlessness, “queue stress”
Misjudgements, indecisiveness, overestimating problems
Difficulty calming down and relaxing
Sleep disturbances (waking up unslept)
Anxiety, depression, pessimism, negative thoughts
Decreased self-confidence, fear of failure
Bleeding, close to tears
Lowered stress threshold, impaired conflict management
Physiological effects:
Muscle tension and pain (usually in the back, neck, shoulders, chest, hips)
Reduced physical strength and endurance, pain after exercise
Headaches (can be both tension headaches and migraines)
Dizziness, feeling of unsteadiness
Ringing in the ears, blurred vision, eye fatigue, sensitivity to sound and light
Numbness and tingling in arms and legs, loss of sensation
Cold hands and feet
Feeling of not being able to breathe properly, sighing, yawning, chest tightness
Increased blood pressure, palpitations, ‘restless heart’
Difficulty swallowing, lump in throat, dry mouth, tense and squeaky voice
Gastroenteritis, oesophagitis
Restless bladder, frequent urges
Sexual listlessness, sexual dysfunction
Sweating (especially arm and hand sweating)
Skin irritation
Impaired immune system (recurrent infections)
SIGNS OF POSITIVE STRESS
(“Symptoms” of adequate tension and balance between recovery and exertion. This is actually the most important ‘symptom list’ to know. It is better to acknowledge your positive stress state and well-being every day, than to wait until a warning signal appears and only then react).
Psychological effects (cognitive, emotional and behavioural):
Easy to learn new things
Good memory
Present, concentrated, alert
Intensive experiences
Ability to enjoy pleasant events
Patience and perseverance
High stress threshold
Dealing with setbacks and other ‘messes’ without losing focus
Does not get angry or irritated easily
Improved conflict management
Can mobilise their resources to make accurate assessments and decisions
Easy to relax and unwind during holidays
Good sleep (wakes up refreshed)
Healthy self-confidence, self-esteem
Optimism rooted in reality
Emotional stability, often recurring safe and cosy feelings
Physiological effects:
Energetic feeling in the body, you feel energised, resilient, ready to take action if needed
Relaxed and responsive muscles
When you sit down or lie down to rest, your body quickly feels a pleasant calm (*)
Exhalation is relaxed and comfortable, inhalation is with the stomach (not the chest)
Warm hands and feet
During relaxed exhalation, you can feel your heartbeat slow down
*) It is not obvious that relaxing is always comfortable. If a muscle group is really tired, the attachments may swell for a while after the muscle has rested and blood flow has started. It may even be painful, swollen and uncomfortable for a while. If the neck muscles are involved, you may also feel dizzy when you relax them for the first time in a long time.
Positive stress is essential for good health
Positive stress is as strongly linked to good health and performance as negative stress is to ill health and disability.
It is not desirable to be free from all stress. This is partly because adequate stress is needed to adapt performance and partly because we need stress in the form of varying physical and mental loads to force the anabolic system to build up the body and brain to withstand new loads. People who are relieved of stress for long periods of time become fragile and weak and, after a while, are able to withstand less and less stress.
This phenomenon has been studied by several different branches of research, which have unanimously concluded that our body is constantly being broken down and rebuilt. This continuous remodelling process works in such a way that the body that is currently being built up is designed to withstand the stresses it has recently been subjected to. If an arm has been working hard over the last few weeks, it will gradually be remodelled to better and better withstand these loads. This phenomenon is called plasticity, and it is this adaptability that underlies the effects we can see on our own body after a period of regular physical exercise.
When it comes to the musculoskeletal system, it is obvious to everyone that this is how it works, and no one is surprised that the arm in question grows and becomes stronger. Over time, the muscles can handle heavier and heavier weights, and the bones can withstand greater and greater breaking forces. However, the discovery in the 1990s that the brain also exhibits this plasticity caused a stir in the scientific community. It has been shown that the parts of the brain that are used frequently develop and in some cases even grow larger. The reverse is also true: the parts of the brain that are not used for several weeks shrink.
One way in which the principle of plasticity manifests itself in real life is seen every day in orthopaedic clinics where patients with broken arms or legs are cast off after a few weeks of fixation. (The reason why broken bones have to be fixed is that if they move during the weeks of healing, the brainstem interprets this as a joint needing to be formed there and the bones do not grow together.) When patients are cast off, they often flinch in horror when they see their twisted arm. The 4-5 weeks in plaster have meant that the muscles have also been relieved, so that less than half of them remain.
Another example of how plasticity manifests itself in practice is if you put a black patch on one eye and keep it on for a few months. The new eye that is built up during that time will adapt to not being used and when the patch is removed, you are blind in that eye. At the same time, the parts of the cortex that used to process the signals from that eye will also gradually atrophy.
So we need to regularly use and exert all parts of the body to keep us fit, strong and resilient. The anabolic system of the brainstem does not care to invest resources in parts of the body that are under long-term stress.
Over the past 30 years, a myth has crept into our Swedish culture that says the opposite, i.e. that it is harmful to expose oneself to stress and that the best thing is to avoid stress. This is partly because we confuse comfort with genuine well-being, but this is not a uniquely Swedish phenomenon, but one that can be seen in all rich countries. However, it is not as common in other countries to exaggerate the importance of risk minimisation as we do in Sweden. We Swedes are by far the best in the world at prevention, and that’s great in that we have the lowest incidence of injuries and infectious diseases. But the preventive approach has in some respects gone too far and become an obstacle to good health.
Being unwell is not enough to be in good health. To be healthy, you need to be in good shape, have plenty of energy, and have a fit and well-functioning body and brain. The study of how diseases occur is called pathogenesis. We use practical applications of pathogenetic knowledge to avoid harmful influences that cause disease. But we cannot prevent health. Health can only be achieved by exposing oneself to sufficient positive influences. This phenomenon is studied in a completely different branch of research called salutogenesis. The axiom of salutogenesis is: the unburdened wither – the unwilling break. This thesis is illustrated in the figure below.
Both sides must balance each other out for life to be in balance and health to be maintained. The biological laws of nature that our bodies follow mean that we cannot live in a tilted state for very long. Both sides must be respected. It is always the lower side that determines the level of equilibrium. According to the laws of nature, if one side sinks, the other will inevitably soon follow.
The implication of the salutogenic axiom is that if you want to be strong, resilient, energetic, alert, happy, interested and engaged, healthy and fit, you have to make sure you regularly push yourself hard both physically and mentally. In between, you need to recover, restore depleted resources, “go to the depot”, “recharge your batteries”, or whatever you prefer to call the right side of the scale. Those who neglect to rest do not have time to build themselves up between shifts. After a while, you will no longer be able to withstand heavy loads. If you don’t adjust your effort level to what you can actually tolerate, you will sooner or later sustain an injury or become exhausted. In other words: the unwilling become energy-poor and fragile.
Those who exert themselves too little or too rarely will also become fragile and have less and less strength. If the left side shrinks, the right side quickly adapts to maintain equilibrium – but at a lower level. In other words, the unloaded side becomes weaker and may even wither away if the process continues for a long time.
Now let’s look at this from a different angle. How does it happen to feel bad? Well, you can do it in two ways.
One type of ill-health and suffering arises from illness or injury. This is the kind of ill-health that healthcare is designed to address. If the doctor is able to make the right diagnosis, treatment can be started and the illness cured or at least slowed down.
The goal of healthcare is to make patients sick. But not healthy. Healthcare has never made anyone well. Healthcare will never make anyone healthy in the sense of happy, energised, alert, motivated, engaged, resilient, strong, resilient. Healthcare has nothing directly to do with good health, fitness and quality of life. Only with ill health. And not all forms of ill-health, but only those resulting from pathological processes, i.e. diseases and injuries.
Squeaking in the machinery
However, feeling unwell can be caused by reasons other than illness.
Another type of ill health is due to a lack of freshness. This type of health problem is not a disease. Rather, it is the ‘grinding’ of some part of the health machinery that has not been getting what it needs lately. This phenomenon is called ‘functional ill health’. The meaning of this expression is that there is no treatment to be applied because there is no disease to treat. Functional symptoms are due to the fact that the person has been doing too little of something that the squeaky body part would need more of to function in a healthy way (and shown by the dashed arrow from healthy to at-risk-unhealthy in the figure).
Our physical and mental adaptability is not always sufficient in the face of the rapidly changing conditions in which modern people live. Many people have not established a sufficiently healthy lifestyle to keep themselves physically and mentally fit. They do not create sufficient counterbalance to the degrading influences of daily life.
Our ability to adapt is challenged in many ways in modern life. We are bombarded with misleading disinformation from TV, the internet, magazines and camouflaged adverts that can be hard to resist. The food we eat is poorly balanced in terms of nutrition. Our physical activities are insufficient and monotonous. Psychosocial conditions have become so complicated that a growing number of people are walking around with an almost non-stop supply of stress and a lack of effective mental recovery.
So it’s no wonder that so many people feel unwell these days. We just have to realise that it is not due to illness, but to a lifestyle that does not correspond to the way our bodies and minds are wired.
Changing behaviours
The solution to this problem is not to ask a doctor for pills or give some other form of treatment. The solution is to start behaving differently. More specifically, start doing more of what you really need, so that your body’s needs are met and your squeaky body parts can start working normally again.
As can be seen in the behavioural medicine model in the figure, there are not just one but two boundaries between sick and healthy. You are not either healthy or sick. There is a large middle zone where you are neither.
You can also be both at the same time in different parts of your body and mind. Certainly, there are chronically ill and disabled people who are happy anyway and have a good life in all other respects. But far more people are neither, those who are in the unwell-at-risk zone. They feel bad without being sick. They feel bad because they are not healthy enough. Their symptoms can only be alleviated if they themselves start doing more of the healthy things they have been doing too little of lately, so that they get back into the healthy zone.
From a practical point of view, we cannot just look at risk factors (what to avoid) but we need to start thinking pedagogically and pragmatically. People who want to improve their health situation need to add more healthy behaviours to their daily lives, rather than being shouted at and told to stop exposing themselves to risks.
It is not the elimination of risks of harm and wrong behaviours that is the biggest challenge of modern health care. Rather, it is creating models to help people develop new and healthy behaviours.
We all need to learn to consciously and actively add to the positive and health-creating side rather than trying to subtract from the negative. This salutogenic principle applies both at the individual level and in organisations.
Monotony and monotony do not work for us humans. A well-rounded ‘mix’ of many different activities and experiences is required for a person’s body and mind to fulfil all their needs.
Anyone who reduces too many channels to close to zero cannot feel good in the long term. Most often this happens unintentionally, because you try to pull up one channel to the maximum. It can only happen at the expense of other channels. A good level to aim for in most channels is six to eight out of ten possible. No-one can be at the top of their game and do their very best in all respects all the time, so in practice it’s rare that the dial is set at ten out of ten. The price is too high. Such an endeavour would be at the expense of all other aspects of life and is therefore not sustainable in the long run.
Professor Calculus
Another parable that reflects this principle comes to mind for one of us authors: I recall a seminar during one of the last semesters of my medical training in Lund. One of the radiology professors was giving specialised teaching to three of us medical students who had shown an interest in a subject that was outside the regular curriculum. Our teacher that afternoon was a legend at Lund University Hospital, a real “Professor Calculus”. Sometimes he was so wobbly and absent-minded that he would stop in the middle of a sentence, raise his index finger in the air and exclaim “yes, yes”, rush out of the room and leave a hundred stunned students wondering if he would find his way back and remember what he was doing.
On this day, however, he was present and in his element as he explained how the discovery of a new X-ray contrast agent was made and what advantages it offered over older contrast agents.
When it was time for a coffee break, he invited us to the staff coffee room and served us from thermoses on a trolley. While he was pouring, he continued his little mini-lecture. When he got to his own cup, he looked up at us to see if we were listening. We were. So far.
But from that moment on, none of us remember anything more of what he said. All we remember is the coffee spilling all over the carriage, over the edge and into the professor’s left shoe. Then he frowned, relaxed a little in his speech and looked down. There he saw a coffee thermos. Coffee was dripping from it. It flowed and flowed.
“Thank you, that’s enough!” he exclaimed. “Stop pouring, man!” he shouted, looking around desperately as if searching for someone.
His gaze returned to the hand holding the thermos and followed the arm up the shoulder until he realised it was his own right arm.
“Oops,” he said cheekily. “Was it me who poured?”
He then put the thermos down and continued his speech without being bothered.
We three students still agree that the only thing we remember after that is the gasping sound that occurred when he frantically pumped up and down with his left foot to get the coffee out of his shoe. Without stopping himself. He kept talking as if nothing had happened. But we didn’t understand anything he said, because the other things going on were too overwhelming.
Coffee in more than one cup
This image sometimes comes to mind when you meet people who complain about how unpleasant it is to have coffee in their shoes. Even though they are the ones pouring it.
“Hey there! Why don’t you turn your head and see what’s really going on?” you want to say to them. “Don’t pour all your coffee into one cup. If you zoom out a bit, you’ll see that you have twelve coffee cups in front of you. Today’s coffee pot will be a little more than half full in all twelve if you prioritise correctly and plan your pouring.”
This is exactly how our health works. It’s not the full cup that causes us the most problems. It’s the empty cups that give us symptoms and problems.
Make sure to pour some coffee into all your cups every week. Allocate your time so that all your bodily and spiritual needs get at least a splash. Don’t let one cup overflow at the expense of all the others, but ration wisely. Consequently, variety is key to staying healthy and energised.
The courage to challenge your sense of stress
Another key word is courage. The courage to challenge your fears. Sometimes what is good for you is unpleasant. If you chicken out, you miss an opportunity to expose yourself to something that would be good for you. Many times it doesn’t even have to be fear, but just laziness and unwillingness to get uncomfortable.
It takes a kind of courage to challenge yourself in such situations and step out of your comfort zone when you know deep down that it would be good for you. Sometimes when you hear the comment “no, I can’t do it”, it is actually courage that fails. Many people are so addicted to comfort and security that they miss out on the challenges needed to stay fit.
In other situations, it is the courage to challenge others that is needed to feel good. Those who are afraid of conflict and avoid all confrontation with others, who do not stand up for themselves, who do not negotiate, but who give in and comply, run the risk of letting themselves down because it feels more comfortable in the short term.
A common misconception is that we should always trust our feelings and go with what ‘intuition’ tells us. Sometimes it is indeed the right thing to do. The problem is that emotional impulses cannot be trusted. Very often they arise out of convenience or fear and mean that the ego wants to save itself an effort. Following such ‘defensive intuition’ results in avoidance behaviour, where the fear of discomfort causes an opportunity to be missed.
Fortunately, most of us are in a pretty good position to make our way through life even when the wind is blowing against us. With a little training in ‘purposefulness’, things can get even better.
The basic principle behind this is that when we want something, when we desire something, we get ready to step out of our comfort zone and go for it. This mental preparedness for stress and discomfort is precisely what is required for us to take on tough challenges.
For life to be good, we need to pursue it actively and courageously, willingly taking a little risk now and then. Without challenges, endeavours, stresses, strains, it is not possible to be a committed and enthusiastic person who cares and actively contributes to what you think is important. Those who have become addicted to comfort succumb to challenges, even those that bring opportunities to improve quality of life.
“The brave do not live forever – but the overly cautious do not live at all.”
/ Richard Branson
I was at the police college in Sollentuna a while ago to give a lecture to some police officers undergoing further training: when I got a bit further into the area, I was faced with about twenty police dogs sitting in a row across the aisle. I like dogs and am not afraid of them in general, but I was hesitant at the thought of squeezing in between two of those ravenous jaws. I stood there for a while waiting for the handlers to recognise my predicament and create a gap in the line for me to pass through.
Meanwhile, another animal appeared on the scene. A small cat came out of the bushes on one side and walked between me and the dogs across the path to the bushes on the other side. It passed less than ten metres in front of the line of dogs. It felt like Sollentuna was hit by an earthquake. The ground vibrated as all the dogs began to tremble with excitement. Because they were commanded to sit, they exercised their superb impulse control and stayed put. But shake and whine they did – and licked their lips. The cheeky little kitty survived his cat-walk.
I was extremely curious. What had he been aiming for in the bushes on the other side? It must have been something cat-important for him to put his life in such danger, right?
Talk about positive stress and the ability to focus so that obstacles and worries do not take over. That’s impressive. Or was it reckless? Maybe it was a brain-damaged cat who didn’t realise the danger he was putting himself in?
The judgement depends on how well the cat knew the dogs’ training and could make a realistic assessment of the nature of the danger. Presumably, he knew from experience that the police dogs would not chase him. But if not, well, he was just lucky, and that can run out quickly.
Long-term success rarely has much to do with luck. However, it is common for less determined people around you to jealously comment on the success of the stress-resistant person as if he or she is just lucky. This probably feels like a convenient excuse to avoid changing oneself, putting in more effort and practising one’s skills.
The reason why people who harness their positive stress are more likely to succeed than others is that they put in the effort, study, train, prepare, hone in on the crucial details, stubbornly focus on the performance of behaviours that lead to the goal. Other people may want the same thing and answer “oh, sure, I’d love to” when asked if they have the same goal. But what separates them from those with a genuine sense of purpose is their willingness to put themselves under stress – to step out of their comfort zone, to be prepared to work hard and to become mentally and physically tired. People who are not genuinely and wholeheartedly prepared for discomfort outside their comfort zone may act in a reasonably goal-oriented way, but they choose comfortable behaviours in the first place. Their performance does not reach dizzying heights. Compared to a truly goal-oriented colleague, you soon see how they chicken out in the face of tough challenges to avoid the uncomfortable and unpleasant.
This is where the leader’s input can be crucial. Many people need to be guided out of their comfort zone and helped to prioritise the challenges they take on, so that they don’t fall into the negative stress zone, get in over their heads and fail. Many ambitious young, inexperienced, potential high performers give up because they do not receive adequate guidance on the challenge ladder when they enter the labour market. Too many unpleasant experiences associated with challenges can cause stress-sensitive talents to disengage and miss out on promising career development.
Weak, low-performing, development-averse, easily stressed people sometimes have just such an experience of failure. This has created in them a fear of all things challenging and stressful, which has sabotaged their continued personal development. As a leader, you can help them out of this dilemma by giving them tasks and development goals that push them just a little bit outside their comfort zone at a time.
Over the years, we have coached many young managers and specialists who have started to get into trouble because of an unstoppable habit of just going full speed ahead, taking on all responsibilities, accepting all challenges. When that behaviour becomes dysfunctional in adulthood, some are unable to change. For them, it’s all or nothing, and their development stagnates. Of course, this applies not only to managers but to all categories of employees in an organisation, each at their own level. A wise manager therefore guides each employee into their optimal pace by helping them, if necessary, to adjust the goals they set for their own development so that they can stay in the positive stress.
The importance of “recharging your batteries”
In practice, stamina is a very important aspect of positive stress: solving a really difficult problem once is not enough. Doing your very best in the face of a single tough challenge is rarely a major achievement. It is when you can do it again on a regular basis that it becomes a valuable capacity. Therefore, as we saw above, the definition of positive stress reactions includes the rest after the stress. Good recovery, rebuilding of depleted resources in body and mind, good quality ‘depot visits’, is a prerequisite to be ready for new tough, challenging, stimulating, meaningful tasks in a while again. And the next day. And the next week, month, year. . . This is actually so difficult to implement that I have written a separate chapter below, and also an e-book about it. (see shop menu)
Taking on challenges and making an effort
Having a tough time at work, with big challenges, does not automatically mean being exposed to negative stress. In fact, most people thrive on challenges. But we want room to manoeuvre so that we can influence our situation. Job satisfaction does not mean having a good time, but rather being proud of good performance.
Stimulation, healthy arousal, using your resources and feeling useful, learning new things and growing as a person – that’s what it means to be positively stressed.
Positive stress partly overlaps with the concept of enthusiasm, i.e. the willingness to take on challenges and endeavour to achieve something urgent, the eagerness to fight for something important even if it means stepping out of one’s comfort zone and exposing oneself to discomfort. The feeling of caring, being engaged, wanting to make a difference, trying to be part of the game and mobilising one’s resources is part of both the phenomenon of positive stress and genuine job satisfaction.
Let’s summarise what we have covered about the importance of harnessing positive stress:
- Those who avoid stress altogether miss out on positive stress reactions and cannot stay in good shape either physically or mentally.
- Anyone who is stress-free for a long time will stagnate in their development.
- The one that is totally unloaded will wither away.
- Positive stress involves qualitative recovery. Anyone who does not go to the depot every day eventually breaks down.
- Positive stress is necessary to perform at a high level.
Performance capacity
When we perform, we do good, we create something of value, not just as a result of occasional good fortune, but time and time again, even under pressure and adversity. Studies of high achievers who perform at their best over a long period of time have shown that they share a number of common characteristics. At first glance, these research reports appear disparate and only partially consistent, but after a little analysis it becomes clear that the differences are largely apparent. No standardised terminology has been developed, with different researchers using different terms for similar things.
Below, we have provided a somewhat simplified summary of the whole. We have taken the practical, trainable aspects of what determines a person’s ability to utilise their resources and sustainably perform at the top of their game, and divided them into six components:
- Knowledge and skills (technical competence)
- Motivation
- Prioritization
- Focus
- Courage
- Energy access and resilience
Let’s go through them in turn.
Knowledge and skills
The combination of knowledge and practical skills is called competence. A competent person possesses both theoretical knowledge and practical skills developed through long training and solid experience so that he/she really masters his/her task. Being truly competent is not just a matter of being well-read, nor is it just a matter of practical experience; it is precisely this combination that allows you to be truly effective and smart in what you do. Skill only comes from practising and acquiring the skills to perform (work) tasks with precision, speed and good quality, and keeping up to date theoretically so that you always understand what you are doing. Malcolm Gladwell, in his latest book, has compiled data that suggests that after 10,000 hours of effective training, you start to reach your full potential. Of course, you can develop even greater skill even after that, but it’s a matter of honing an already good technique.
Skills are sometimes accompanied by “talents”, i.e. basic personal resources that are difficult to train (e.g. physical fitness, motor skills, intellectual abilities, innate language skills, musical ability, etc.) In general, it can be said that we humans should try to utilise our talents and take advantage of our strengths. Total lack of talent, or rather the opposite of talent, i.e. an innate weakness, should also be respected, and we should not waste too much energy trying to become good at something we can never learn properly. Some people just don’t have what it takes to be a singer, no matter how much they practice in the shower or take expensive singing lessons, right? Some people can never be pianists, helicopter pilots or excavators, they just don’t have the motor skills and can’t train them. It’s that unfair. But the same person can, in return, become skilled in some completely different “branch” where the coordination phenomenon of the helicopter pilot does not stand a chance. Perhaps chess, vegetable gardening, poetry or non-linear arithmetic would be something…?
However, we must emphasise at the outset that even if you have only moderate-normal talent, you can go far with persistent training and become reasonably competent and skilled in your chosen field. In the world of sport, we see it repeated time and time again: the most willing to train often overtake the most talented in the race. A true star is something as rare as a combination of super-talent and unrelenting, stubborn, persistent will to train. Who in FC Barcelona has trained the most hours for their age? -Well, the best of them all: Messi! (According to a calculation made by El Sportivo newspaper a few years ago.)
Most specific skills can be improved through training, just as theoretical studies can provide in-depth knowledge in any field, if you are prepared to put in some work…
Many people inhibit their own development and prevent themselves from becoming truly competent and skilful by being afraid of making mistakes. In training, you have to be allowed to make mistakes, to make lots of little mistakes, and sometimes even to mess up! Not because you learn a lot from your mistakes – that’s a misnomer – but because, while you’re experimenting and trying out different variations, it’s inevitable that you’ll sometimes get it wrong. You have to allow yourself that. (And allow others – let the newbies make the occasional mistake, otherwise they won’t dare to train, and they won’t develop into the competent colleagues and replacements you need).
Motivation
Motivation is the driving force that makes one willing to put in the effort, the determination to try to achieve a goal, what makes one willing to invest time and energy. The degree of motivation is influenced by several factors, the most well-known of which is probably the reward of the goal, but several others are of great importance: for example, enjoying the activity/task, experiencing community and rewarding social interaction, having fun along the way, being proud of the activity, feeling seen and recognised and needed, personal development, learning something new, feeling that you are contributing to something meaningful, etc. In the short term, threats and fear of failure can also be motivating, but such ‘negative motivation’ does not work in the long run and rarely in situations where the task is complex and requires creativity and commitment. When motivation is about more than overcoming lethargy or disinterest, i.e. when genuine engagement is required, only ‘positive’ motivators work.
The ability to set your own clear goals that are in line with your values is a prerequisite for self-motivation. Only when the task feels urgent can you perform really well. Unclear goals, fear or other obscure motivations rarely lead to good performance, because then you are acting entirely or partly on an indirect agenda, and spending too little of your time and energy on behaviours that lead to the real goal.
An Australian research team conducted an international survey a few years ago on how ‘ordinary’ people (= non-athletes) set goals for themselves. They found that only 3% take advantage of the opportunity to reinforce their own drive with clear life goals. What a waste! If this study is correct, it means that 97% of humanity is walking around unnecessarily disengaged in their own lives! Because the fact is that without a clear, urgent, motivating goal, you are just idling. Sometimes we humans should do just that, but not all the time. It is good for us to occasionally engage, care, work hard and struggle to achieve a worthwhile goal.
The goal-setting process is a trickier challenge than you might think. A clear end goal is usually not that difficult to define (although many people fail to do so, as we have just noted, and thus miss out on some of their own potential motivation) but setting realistic and useful intermediate goals, which guide and facilitate, can be even trickier. Overly difficult goals, perceived as unattainable, have a negative impact on performance. The crux of the matter is to often “make goals”, without setting goals that are so easy to achieve that they become uninteresting.
Prioritization
The third prerequisite for high performance is being able to prioritise something in relation to other tasks. Prioritising means choosing. And opting out! Sometimes it is not only the ability to identify what is most important that determines whether you are doing the right things, but in some complex situations, it can be the ability to identify what is not crucial to achieving the desired effect, and then actively sort it out.
Identifying what is most important is sometimes a real challenge. It presupposes that you understand the situation, see the parts from a holistic perspective, understand the order in which the tasks should be tackled, etc. However, it is just as common for prioritisation skills to fail at the other end, where you have to identify what does not need to be done and refrain from wasting energy and time on what is currently less important than the most important.
Strangely, it is rare for people to actively and consciously train their ability to prioritise. Those who have problems with it automatically become stressed, feeling as if they never have enough time, because they don’t actively enough choose the least important things. To be a high performer, you need to have a well-developed ability to eliminate the unnecessary, so that you can devote a sufficient proportion of your energy to what leads to the highest priority goal.
Low performers often look in wonder at the high performer and think to themselves: “How can he get so much done? Where does she get all that time and energy?” But, in reality, we all get just as much done. We all create something in our waking hours, but some people forget to prioritise actively and then there is a great risk that it will be mostly pipe dreams, daydreams, watching TV, partying and non-essentials that end up at the top of the priority list and consequently become the experiences you devote yourself to. Well, no one can say whether that is right or wrong. The value of one’s own behaviour is ultimately up to each individual. Objectively, there is no single answer, but many people who would like to be more high-performing and value-creating, and who wonder why they do not “get it”, could actually change their situation in one go if they transferred some of the time they spend on “low-value behaviours” to “high-value behaviours”, i.e. prioritising the application of their abilities and focusing on what they deeply want to achieve. As you can see, this is linked to the ability to actively establish goals for oneself, and to prioritise these so that they become something more than goal formulations on fine paper…
All performance is relative to a specific objective. It is wise to formulate measurable goals and milestones, so that you can get clear feedback on whether your efforts to reach the goals are effective. Being a high performer does not necessarily mean working hard and long days. It is more important to be highly effective in what you do. Some pseudo-high performers just run around splashing sweat and stirring up dust without achieving anything of value.
So, to summarise, we have established that prioritising means ranking tasks. The less important should be pushed aside so that the most important can be done first. Sometimes, down-prioritising can mean identifying what never actually deserves my time and energy (maybe someone else’s though, and if so, I’ll make sure that someone takes over).
To do this, you need to be able to zoom out, to see the big picture, to see the proportions between the parts. Prioritisation processes are always relativistic, that is, the importance of one thing is determined by the importance of other things. At the end, or rather at the centre, there is only one fact, a background against which everything else can be measured, and that is the basic values. For a group, it’s about why we are a group, what we should achieve that is valued (for ourselves and for others). For an individual, it is about who I want to be, what kind of person I want to be. What do I think is important in life? What do I want to achieve? What gives me a sense of being part of something important and contributing to something that makes a difference? What about having a good life – what do I mean by that?
If you cannot answer these questions, it will be difficult in practice to discern what is most important in each individual situation and to prioritise correctly.
Focus
Once the prioritisation is done, it remains to do something about it and concentrate on what you have prioritised on the top line. This is where the ability to focus comes into play and allows you to direct your mental energy to the performance of one step at a time, to attend to one thing at a time and complete each step, not to be distracted by interruptions, not to jump from one thing to another to the third and back again, but to stay in an activity until it is finished.
One thing that characterises high performers is their ability to use process goals. This means, when it works, using clear pictures of the behaviours to be used, how they are best performed. Through the use of such process goals, one can enjoy being on the way and enjoy being involved in the actual activities leading towards the main goal.
Many gifted and talented potential high performers fall down because, when it really matters, they lose focus on the part of the process they are in the middle of, and instead start to worry that they might not reach the end goal. They become nervous and lose the “presence and good feeling in the middle of the step” that is a prerequisite for enthusiasm and accessing their full potential.
In sports-related mental training, the importance of learning to focus on the execution of each step of the technique with a relaxed approach, without trying to control yourself, and without thinking about the outcome, has long been recognised. A classic in the literature on mental training is the book The Inner Game by Timothy Gallwey. It describes how successful tennis players do not primarily try to win the match on the scoreboard, but the inner game, which is about doing your best. If you do better than your opponent, you will win the outer match, but the important thing is to win the inner match. A player who starts to get annoyed by his own mistakes, and becomes afraid of making more, loses his relaxed focus on his own technique, and can no longer play at the top of his game. Nervousness gets the better of you, and you don’t win even matches.
Ingvar Bengtsson, in his book The Ketchup Effect, gives an excellent account of this aspect of focusing in a reported conversation with Tomas Fogdö about how he used a process goal picture instead of a result goal picture:
“You just have to take one stick at a time.”
“What do you mean by that?”
“Yes, it feels much easier for me to do one thing in the moment. How it will turn out overall (in the competition) remains to be seen. One stick at a time – and how I then go in the other turns is a later question. I can’t influence what happens five gates down now. I’ll be calm if I think that way, it feels so simple.”
“Any other objectives?”
“Yes, to have a positive attitude throughout the course, whether it’s at the beginning or the end, first or second run, so that I don’t change my attitude depending on how I’ve skied in comparison to others. … Yes, so maybe I’ll win the occasional World Cup race too. But I’ll see what happens with that.”
Three weeks later, Thomas Fogdö won the World Cup in slalom.
People with an ingrained developmental attitude (who want to constantly improve and learn something new) find it easiest to commit to process goals and are thus often successful even if their talent and technical skills are not at their best.
You need to learn to focus on what you can influence.
“God, give me the strength to accept what I cannot change,
courage to change the things I can
and wisdom enough to understand the difference between the two.”
St Francis of Assisi (1182-1226) is said to have said these wise words. We all sometimes focus on things that we cannot actually influence. All too often we try to change other people, our colleague, our partner, our children, our wife or husband. But we cannot change other people. We can only change ourselves. An example from the world of sport: hockey players can’t influence how good, or bad, their opponent’s goalkeeper is. But they can influence whether the puck is actually shot at him. If they don’t shoot at goal, it will definitely never be scored. But if they shoot often, sooner or later even the best goalie will let some puck past him. So it’s important to focus on what you can influence, that is, how you behave.
To summarise, then, we can say that a powerful ability to focus is often needed to put priorities into action. In reality, it is not often that we are left undisturbed so that we can calmly devote ourselves to one thing at a time, completing the steps in turn, but we have to fight not to be distracted and get off track. Focusing means directing and keeping your attention on what you should be doing right now.
Focusing also means mustering the mental power and intensity that the task requires. This requirement depends on the situation and the environment; the messier it is, the more mental energy is required. When you are tired, sleepy or absent-minded, this does not work and you become noticeably distracted and disorganised, unfocused and inefficient.
Courage
Maintaining your vigour in the face of a tough challenge often requires being prepared to put up with some discomfort. Knowing in advance that something might be difficult and uncomfortable does not make a high performer back down, but rather grit your teeth and get through the whole thing without worrying that it will be exhausting and sweaty, maybe even uncomfortable. Some people have never practised their ‘resilience’, and they destroy their own enthusiasm as soon as they sense that it is going to be unpleasant, thereby preventing themselves from being high performers.
One branch of psychological research has looked at this and coined the term frustration tolerance. It stands for how resilient one is to discomfort of various kinds, how good a person is at putting up with discomfort without letting it get to them.
Good frustration tolerance means being prepared to push and exert yourself to the point of “burning” if necessary. Sometimes this may mean that the preparation consists of such hard training that it becomes very uncomfortable, but a goal-orientated high performer does not care much about comfort, but does what is necessary anyway.
Those with low frustration tolerance may lose all enthusiasm for a task simply because they get dirty, sweaty, out of breath, bitten by mosquitoes, thirsty, hungry, stressed, or some other short-term unpleasantness that they could learn to deal with. Another time it might be that you have to endure criticism and questioning from others, or maybe even that you have to face a conflict in order to fulfil your task.
High performers dare to opt out of the unnecessary and “go straight for the goal” even when it entails scolding and opposition from people around them who cherish traditional behaviours. The courage to seek one’s own path and question “old truths” consists not only in social courage, but also in the ability to test hypotheses and critically evaluate one’s own experiments without preconceptions. Then it is a matter of daring to trust your own judgement even when it is questioned by others who “know better”.
Another common variant of frustration tolerance is to put up with the fact that a part of the performance is boring. It is also a form of courage to be able to be bored for a while without losing interest or giving in.
Are you an enterprising person? If so, you’ve probably been lucky enough to have people around you who have trusted you to do things on your own and let you try a few times before you got it right.
We can also add to the concept of courage an aspect that we looked at from a different angle earlier in the section on competences, namely the courage to make mistakes, which is the prerequisite for daring to try, test and practice. The courage to give oneself (and if necessary others) encouragement and praise for a good attempt, not for the result itself, is in many contexts crucial for developing and maintaining positive energy in the face of really tough challenges.
As the reader understands from the above, courage is also a trainable mental skill. Part of it is the ability to maintain enthusiasm rather than focus on the unpleasant.
Energy access and resilience
The sixth dimension is about the ability to combine long-term performance with well-being, resilience and endurance. We described the principle of this in the section above “Positive stress is necessary for good health”. In practice, it is about striking a balance in everyday life between effort and recovery. To perform this balancing act at a high level requires a number of skills, which you can read more about in the next two sections below.
Stress tolerance
In order to be able to push themselves and still “last” in the long run, a high performer needs to have a well-developed ability to handle challenging and pressurising situations in a constructive way. In practice, the following seven skills can be practised to strengthen stress resilience:
Perspective ability
Autonomy
Connectedness
Mental self-regulation
Active body awareness
Active rest and recovery
Physical self-regulation
Perspective
The exercise of perspective means actively and consciously using one’s own values when prioritising options in a situation. Recognising the context and proportions makes it easier to choose what is most important and to reject less important options.
Read the following three questions aloud to yourself: “What is important to me? How do I want to spend my short time on earth? What is quality of life for me?”
If you make an honest attempt to answer them, you will immediately gain a better (or at least fresher) perspective on life, which is crucial to avoid unnecessary stress. Actively taking your own perspective on events, big and small, is extremely beneficial. It also works in the midst of everyday life. It’s often called ‘personal planning’ – the art of prioritising, sorting and finishing one thing at a time. Just such a thing as realistic time management can make the difference between an enjoyable day and a stressful one. In today’s fast-paced society, with the vast array of everything between heaven and earth hitting us on a daily basis, it is an important skill to maintain perspective on what is important and consciously refrain from the less important. Don’t waste time on rubbish activities and don’t let unimportant incidents stress you out!
Some people seem to think that life comes later. “I’ll just stress some more and then I’ll start living.” This is nothing but self-deception. You can’t put life on hold, it will rush by, and too late you may realise that your time is limited. Life is short. Make sure you plan for the things you enjoy. Always stay anchored in what is important to you! Choose actively and opt out!
Autonomy
Autonomy means independence. When you act autonomously, you exercise self-respect, recognise your own needs and limitations, and stand up for what you think, feel and believe. An autonomous person is not easily stressed by the demands and expectations of others. When autonomy is well developed, people can assert themselves in a healthy way, stand up for themselves in front of others, avoid taking responsibility for other people’s stress, and tolerate conflict better.
People who lack autonomy, on the other hand, have difficulty with conflict, prefer not to disagree with anyone, have difficulty saying no to others, have difficulty making demands on others, prefer to do it themselves. If you have a lot of contact with other people in your everyday life, you cannot do without a certain minimum level of autonomy, otherwise you will waste a lot of your energy “running after other people’s balls”.
Contrary to what you might think at first, an autonomous person is generous in the long run, because they give from the heart and don’t waste energy when it feels wrong to give. In this way, you can give more in the long run. Autonomous people can keep their promises, but dysautonomous people find it difficult to do so because they cannot say no in time and end up with more commitments than they can handle.
Another consequence of a lack of autonomy is that, in the long run, you do not have time and energy for yourself, for your own time, for taking care of yourself, for rest and recreation, socialising with friends, etc. There is a great risk that you will end up living such a monotonous life under constant pressure that you will end up depressed or constantly irritated and disappointed by the people around you.
If a dysautonomous person also projects the cause onto their surroundings, blames their stress on everyone else making such tough demands or being so in need of help that they have no other option but to be there … well, then they easily get into a vicious circle of blaming behaviours, self-imposed martyrdom and avoidance until their quality of life is significantly affected.
Connectedness
We humans are herd animals. We need to feel anchored in at least some small group where we can feel needed and supported. An important part of our identity and self-esteem is built by our roles in the different groups we are part of. Feeling needed and important in someone else’s life is empowering for most of us. Our brains thrive on good relationships. Touching or exchanging a friendly glance with someone we care about can affect our whole day. Feeling left out and unimportant, not being seen, is a stressor that brings down the quality of life for many people.
Alone is weak – at least in terms of stress. With the support and encouragement of others, we can withstand much higher stresses, more setbacks and more discouragement before we become negatively stressed.
A certain degree of togetherness is a prerequisite for effective and proactive co-operation.
When you practise connectedness (as a skill), you methodically address your social situation and improve your relationships with people you see often enough to have some kind of relationship. Connecting with superficial acquaintances is not worth much, but connecting with work colleagues, family, best friends, in short, those relationships that mean something genuine to you.
Mental self-regulation
The psychological term for the tools in this compartment of the toolbox is cognitive techniques. It is about conscious, thoughtful self-management. What we are looking for here is that you can train your ability to actively choose thoughts, to actively direct and hold your attention on what you choose instead of your thoughts wandering or unnecessarily dwelling on something unpleasant.
A prerequisite for staying positive is to focus on what you want to do and how to do it, so that you don’t get caught up in worrying about what you want to avoid. Negative thinking means, in part, paying undue attention to potential unpleasantness. The danger of this is that the stress level rises above the level that is positive in the situation. It also increases the risk of becoming a self-fulfilling prophecy. It is important to recognise that there is no “not” in the brain. If you think too much about what you want to avoid, it is likely that this is exactly where you end up.
‘Here-and-now’ is also an aspect of mental self-regulation. The ability to be present and experiential from time to time is a prerequisite for mental well-being. It is in an intensely present and experiencing state of mind that we are most alive and harmonious, creative and quick in thought and action. And it is in the present moment that we can meet other people, feel closeness and experience community.
Active body awareness
An overall aim of mastering positive stress is to be able to push yourself hard. This requires active body awareness, otherwise you cannot treat your body well and give it what it needs. When this works, we can cope with an astonishing amount of stress for a long time and feel good at the same time.
For body perception to work well, it is sometimes necessary – especially in pressurised situations – to actively listen to the body for a few seconds every now and then and feel how it is doing in different parts. The difficulty is usually not in feeling and understanding what is happening in the body, but in feeling in advance. Actually, this should be called proactive body awareness, because it is important to have such an approach to the body’s needs that you are early in your behavioural adjustments. Try to stop for a few seconds every hour and ask yourself: “What does my body need right now?” (Notice that the last word in the question is not “soon”!)
As soon as your body doesn’t feel quite right, can’t function in a relaxed way or starts to get tired and worn out, you need to realise this very quickly so that you can take the right measures in good time. But that is precisely when you risk being busy with something else if you are under stress. That’s why it’s often necessary for people with a demanding daily life – and those who already have aches and pains – to train their ability to actively and frequently listen to their body’s need for small adjustments.
Some people tend to over-interpret any unpleasant bodily signals, so that they immediately think something is seriously wrong. This triggers the stress system and makes it even more difficult to listen to the body properly. Body awareness works best if we have a calm and relaxed attitude towards our own body, and listen to it to find out what we need to do to help it feel better in the next minute.
Active recovery capacity
If you feel tired and worn out, it doesn’t necessarily mean you’ve been working too hard. It could just as easily be because you’ve been resting too little or too poorly lately. A really good rest doesn’t happen automatically just because you don’t exert yourself. In fact, we need several different types of rest. The brain and body have a richly equipped rest system, which uses hormones and nerve signals to ensure recovery. The starting engine for this rest system is mental peace and quiet. If you are not mentally relaxed (harmonious, calm, serene, peaceful, safe or whatever word you prefer), the rest system cannot start and the body cannot recover effectively.
Our modern lives are so complex and hectic that most of us need the ability to actively and consciously seize every little opportunity to switch on the ‘battery charger’. When you practise this, it’s called relaxation. There are nowadays a plethora of CDs and web-based programmes for relaxation training that can be wise to try if you find it difficult to unwind and calm down.
Physical energy regulation
This compartment of the toolbox is mainly about maintaining a good chemical environment inside the body so that the brain, muscles and all other organs can function optimally. In practice, this mainly means exercising regularly and eating large amounts of nutritious food. Some also emphasise abstinence from alcohol and tobacco, as these and other drugs/intoxicants have a strong impact on the body’s energy supply and physiological functioning, and thus have a detrimental effect on stress resilience. The whole body, not least the brain, depends on access to energy and nutrition to function well. Good physical fitness makes people better able to withstand stress, both mentally and physically.
The challenge for most of us is to actually do what we know is good for our bodies. Many people would like to exercise more and know what foods are nutritious, but don’t ‘get it’ in their daily lives – desired behaviours don’t happen often enough. Of course, there are also people who don’t know what is good and bad for the body, and have no desire to learn either. Others have misconceptions about how the body works. This, of course, makes it even more difficult to build healthy, beneficial, energising habits. But from a skills point of view, this subject is not about long lectures on nutrition and exercise physiology, but about the ability to maintain the good habits you want, and need to have, to cope with the energy expenditure it takes to have a stimulating, rewarding, value-creating and meaningful life – a life with a lot of positive stress.
RESILIENCE CAN BE TRAINED!
How energetic, intense, enthusiastic, vigorous, persistent, committed and creative you can be depends not only on how motivated you are, but also to a large extent on how well you manage to ‘recharge your batteries’ and recover between shifts. In practice, resilience means regularly doing something other than performing – including thinking about something other than performing, i.e. taking a break, relaxing, enjoying something, having fun, resting, being inspired, nourishing yourself both physically and mentally.
Strangely enough, it is unusual to hear people talk about making deposits in their energy account, investing in their energy and enthusiasm. I always ask this question to my patients and clients that I coach. It’s striking how many are then hesitant and say something about being relieved… Nevertheless, it is obvious that energy access both mentally and physically is a prerequisite for being able to perform over a longer period of time. It is also beyond doubt, thanks to modern research, that both mental and physical performance are enhanced during periods of good recovery, so that you stay fit, well-nourished, well-rested and mentally in tune.
The reason why energy deficiency and fatigue are the downfall of so many high performers is often a lack of knowledge. They have not understood that we cannot take for granted that the supply of new energy will work by itself if you just get rid of all the demands and be relieved for a while. If you want to push yourself hard and push yourself in tough performance sessions, you cannot neglect recovery. To become an enduring high performer, it is important to acquire reliable ‘battery charging competence’, which means knowing how recovery works and, if necessary, strengthening weak parts of the process. In other words, ‘practising recovery’.
This statement surprises many. But it shouldn’t, because it’s really obvious. A central component of good fitness is precisely having a well-trained recovery system capable of quickly and efficiently restoring depleted resources after an effort. A telling example is triathletes and other elite ultra-endurance athletes who can run the marathon distance several times a week without breaking down. The first time I ran a marathon myself, it took me 8 days to recover. I had never run more than 18 kilometres before, which meant that my body was neither functionally nor structurally ready to suddenly increase the load to more than double. The recovery system never builds up any unnecessary resources! Only those parts of the body that have been regularly stressed recently are strengthened to the degree needed to withstand similar stresses again. And then some. But not much more. Even if you inject anabolic steroids, there is no unnecessary build-up. The purpose of this form of doping is to make the recovery system more efficient so that you can withstand more and more intense exercise without breaking down. Thus, the meaning of the term overtraining (called overexertion in other contexts) is actually ‘under-recovery’. This poses a difficult challenge not only for elite athletes but for all high performers whose effort level is at the limit of what their recovery system can handle. For many, it is the mental rather than the physical recovery that is most difficult to master. In fact, if the psychological recovery is not working, the physical recovery will also fail.
An overview
In my nearly 40 years as a psychiatric rehabilitation physician, I have helped identify 10 critical components of human recovery. Within each of them, there are trainable skills that make recovery processes more robust and reliable. These 10 are:
- Pause skills (respecting one’s own needs, knowing when it is time for a break and what ‘batteries’ need to be recharged)
- Relaxation (ability to put yourself in a calm mental state)
- alternation (consciously utilising the body’s capacity for partial recovery, i.e. switching between exerting completely different parts of the brain and body from one moment to the next)
- Presence (letting go of the mind chatter for a moment and allowing the mind to be filled with what is happening here now; not only necessary to relax but also to perform with flow)
- Inspiration and enthusiasm (regularly engaging in activities that generate joy; activities that you find genuinely interesting and energising)
- Value creation for others (caring and generosity have a great impact on one’s mental strength in the long run; enhances self-esteem; engaging in something that is also important to others is the basis for a sense of coherence greater than just satisfying oneself; enhances the quality of the recovery process)
- Nutrition (ability to put healthy food in the mouth, chew and swallow, so that the body gets all the building materials and fuel it needs to keep a healthy physiological machinery going; in practice, it is not only about having knowledge of nutrition but also impulse control and the ability to establish good habits)
- Gratitude (often reminding yourself of what is good in your life and what you actually have reason to be grateful for creates perspective on life; can both dampen leaks and provide a lot of energy)
- Physical exercise, exercise (a crucial factor in staying fit, not least mentally as brain recovery is dependent on having some really tired muscles every night that produce substances that stimulate brain cleansing)
- Sleep (the incidence of sleep disorders is increasing at a dramatic rate, here it is important to have knowledge and respect for your own needs; several important aspects of our recovery can only take place in deep sleep, but on the other hand, not all recovery can take place in sleep so it is not enough to sleep well, the above points are also in play)
Below are some more detailed descriptions of these factors, how to apply them in practice. For those who want to learn more about the subject, we have also produced a self-help book and a 12-week course (‘Recovery school: how to train your recovery skills’) that provide both theoretical depth and more detailed practical guidance for those who want to strengthen the mental skills that determine the effectiveness of one’s recovery ability. Book and course can be ordered via the contact form.
The art of taking a break
When we take a break from work to do something completely different for a while, there is of course an aspect of change in the process, but when we refer to it as a ‘break’, it is not about switching to another task, but a break whose sole purpose is to recharge our batteries and re-energise our minds for resuming work.
Expertise may sound strange in this context. With that in mind, I would like to emphasise that good breaks are not always easy to achieve, and to highlight that they involve a set of trainable skills, namely
– a) remembering to take breaks
– b) doing it often
– c) getting quality in the rest time, i.e. choosing the break activity so that it is not only a break from an effort but also a real energy injection.
A common mistake is to seek distractions that are exciting, fun and stimulating. Then it will not be a good break but only an interruption and not a real rest. It is often better to consciously choose a break activity that is ‘boring’ in the sense of calming you down, helping you to settle down and thereby promoting recovery.
Get into the habit of observing what happens inside you during different activities and identifying different types of effort. ‘What kind of energy am I using now?’ And then try to do the same during rest periods. ‘What battery am I recharging while doing this?’. The insights you gain from this will lead you to develop your break competence, so that you not only remember to take breaks but also choose the right break activity in relation to your need for recovery at that moment. At the end of each break, or immediately after, it is important to do a quick evaluation. ‘How did it go for me? Was it a good break?’ If you neglect this follow-up, you won’t learn nearly as much. Sure, the brain recognises that rest periods vary in quality, but if you don’t actively and curiously observe the effect during and immediately after, you won’t get strong feedback. And this is one of the most important elements of all training, learning and development.
One more important component of rest competence must be mentioned, namely autonomy. Only a few people in your environment, probably only your best friends and closest relatives, care about your rest moments. That’s not to say that everyone else minds your recovery working, but they leave it to you to take care of it yourself. And it is true that it is up to each of us to take a break and fit rest periods into our lives. In practice, this means that sometimes we have to turn down offers that don’t fit into our timeframe, say no to requests and demands. When it comes to work, ‘no’ is often the wrong word to use. Instead, it is about having the courage to negotiate with customers, bosses and colleagues about how much time is needed, the availability of resources, which other tasks must then be deprioritised, which tasks you can delegate and to whom, etc. etc. Not only being agreeable, but sometimes even being a bit difficult and challenging other people does not sound pleasant. No, it can be unpleasant and feel wrong. That’s why you need to have a decent degree of autonomy. We have found that low autonomy is a common cause of negative stress and the factor that causes many people to let themselves down and sabotage their recovery by taking on more than they really have time and energy for. (You can read more about autonomy and how to strengthen the mental strength factor when needed in the book ‘A good life is not comfortable’; printed book is available in bookshops, as an e-book you can order it through the contact form).
Relaxation
Relaxation means putting oneself in a calm mental state, which allows the brain to reduce the activity of the stress system while activating the anabolic regulatory system so that it can put the bodily processes into recovery mode, restoring depleted resources, building and strengthening newly stressed structures, repairing or replacing worn-out body parts and replenishing all energy stores.
The previous section ended with the observation that if the psychological recovery does not work, the physical recovery also fails. Here we are dealing with a clever construct, which from the perspective of our modern way of life may seem like a ‘misconstruction’. However, from an evolutionary and biological perspective, it is a perfectly logical design that works perfectly well for all other animals and, for hundreds of thousands of years, even for our Stone Age ancestors. The construct in question is this: in order for our anabolic regulatory system to be able to ‘throttle up’ above the low baseline activity and trigger intense recovery processes in tired body parts, we need to be in a calm state of mind.
Consider the meaning of the last sentence once more…
The practical consequence of this realisation is extremely important. The unrest, concern, uneasiness, restlessness, agitation or nervousness that causes disruption to recovery does not have to be acute anxiety. It is enough to be ‘un-calm’, to lack calm, to be unable to rest effectively. Even mild forms of internal stress, which only trigger a subtle mental tension, mean that one is not calm and thus cannot initiate effective recovery. Lack of calm is the essence of the mental processes that lead to fatigue. Many doctors and psychologists have also missed this important point and give misleading advice to their patients when they talk about relaxation and prescribe sick leave and anti-anxiety medication and warn about stressful situations, but do not explain that it is the ability to calm down that is the solution to the problem. Not being able to relax is not necessarily caused by clinical anxiety or intense stress. More often it is ‘only’ a lack of mental self regulation skills.
Analogy: if you need to reverse your car, 1st gear is as wrong as 3rd or 5th.
Unrest is a deficiency state, not excess stress.
This knowledge explains why reliable mental relaxation is so crucial to our recovery. If you can’t put yourself in a calm state of mind, even if you lie down and close your eyes and look like you’re resting, there will be no quality of recovery. And it’s even worse for people who don’t even try to rest, but think they’re resting because they’re on sick leave and don’t have to work, or when they distract themselves from worries and demands by playing a game on their computer or mobile phone, watching a film, updating themselves on social media… The relief they feel is pleasant and the experience of relaxation (forgetting their worries for a while) is easily confused with relaxation. The tricky thing is that even if you think you are ‘relaxed’, you may actually be in a slightly tense mental state (= o-ro) and then you have an inhibited recovery system and no quality rest.
There are many indications that relaxation skills are in decline among the population. Despite the fact that we are so well off materially and are relieved by a plethora of modern devices, our mental state does not seem to be going in the right direction. A common myth is that this is because we work too much and are exposed to such high demands. This is not the case. It is (usually) not work or school, but the whole life situation that causes negative stress and exhaustion, not the ‘big bad boss’ or teachers who demand too much. The key to understanding this is precisely the hyphen: o-ro. Exhaustion (‘burnout’) is rarely caused by overwork, but often by ‘under-recovery’.
I often ask people I meet – not just patients, clients, students and trainees, but everyone I meet and talk to – if they can relax. Many people don’t know what it is, have no personal experience of willing themselves into a peaceful state of mind. And this is consistent with what research shows. In our psychophysiological laboratories (where we measure the activity of both the stress system and the recovery system), we see that not only our patients but also many healthy subjects have difficulty relaxing. We even quite often see paradoxical relaxation reactions, i.e. when someone tries to relax, they trigger a stress reaction instead.
How to practice relaxation is not obvious. There is a plethora of different methods and it can be a challenge to find the ones that work for you. But no one else can do it for you. You have to test and try it out yourself.
If you encounter insurmountable difficulties and can’t get it right at all, you can get help from our 8-week basic mental training programme (‘Integrated Relaxation’) focusing on learning effective and reliable relaxation that works in different situations, not just at home in your favourite armchair. Available in 3 versions: the simplest is a self-study compendium, the next level includes 2 hours of personalised coaching and the third, most advanced version also includes recorded short lectures, guided exercises, audio files and personal coaching via Zoom. (to be ordered via the contact form)
But we can’t blame relaxation difficulties and lack of rest for causing all recovery problems. All the other 9 components we are discussing here also have important tasks to fulfil in order for high performers who take on tough challenges and work hard to recover and be ready for the next day.
A change of scenery
In the late 1980s, I took part in a behavioural medicine research project in which we collected data on people’s attitudes towards health-affecting behavioural choices. Among other things, we went out to sports grounds and exercise centres of various kinds. One of my tasks was to go out to exercise tracks in wooded areas outside the city and try to get joggers and skiers to answer a few questions before they got into the shower. I still remember my feeling of sheer amazement at the answer one of the first people gave to the question ‘Why do you do it?’ (The first questions had been about how often he ran, how far, alone or in company, etc.) He answered without the slightest hesitation: ‘Because I rest so well out on the track.’ An image appeared in my mind’s eye of a man in full workout gear walking 10 metres and then lying down in the middle of the jogging track with his hands behind his neck. He noticed my confused expression because he added after a few seconds: ‘Well, I mean resting the brain.’ I had never thought of it in such direct terms, but I immediately understood what he meant and knew he was right. After all, I had made the same observation myself about how mental recovery was favoured by exercise, especially if I could combine it with nature experiences.
– But, many people argue, you can’t rest and exert yourself at the same time, can you?
Yes, you can. It’s called partial recovery, and it’s one of the many clever ‘inventions’ of evolution. Without it, we would have to spend several hours a day resting in a state of wakeful hibernation because total rest is the only alternative to being active. Thanks to the anabolic system’s ability to put some parts in recovery mode while other body parts are working, we can be active and perform many more hours per day. Originally, and for wild animals still, it’s about survival.
Many animals have developed sophisticated forms of partial recovery. Swifts, for example, only land during the breeding season while incubating eggs and feeding young in the nest. The remaining 8-9 months of the year they spend in the air. At night, they fly to higher altitudes and sleep with half their brain at a time, gliding around in wide circles with only one eye open. Similar features are seen in whales and dolphins, which also take turns sleeping. Otherwise they would drown. But the concept of partial recovery is not just about sleep. Most of our waking rest is partial.
That’s why rest is an important component in the arsenal of recovery skills. The tool of ‘active alternation’ involves consciously varying between different activities so that one moment you are stressing certain parts of your body (and brain) and the next moment you are resting these parts while completely different physical and mental functions are working. For switching to work and enable partial recovery, the alternative activities to which you switch must be voluntary and safe expectations, free from fear of failure and not associated with a sense of obligation. However, they should be interesting, meaningful and complex enough to require concentration and presence. Activities that are too simple, that you have mastered so well that you can think about something else while you are doing them, run the risk of making you mentally absent and of the free flow of your thoughts being drawn towards things that annoy, irritate, worry… and suddenly you find yourself unquiet, and even partial recovery loses its quality.
Both at work and in our private lives, we sometimes have unavoidable tasks that are involuntary and boring, perhaps even unpleasant to carry out, or that involve high demands and unpleasant consequences if we fail. In this respect, personal factors are decisive. What one of us perceives as devilishly stressful, someone else finds easy and stress-free. What one person finds boring and pointless, another may find interesting and stimulating. Therefore, there is no universal formula for which activities work well as a change of pace. You have to find out for yourself, experiment and adapt to the nature of your work and your own life situation. Regardless of your profession and the nature of your work, it is wise to think about what you can do in your spare time to add variety to your everyday life. Conversely, it may be that at work you can recover from many of the mental and physical stresses you experience in your free time. Those whose workdays include 6-7 hours of sitting at a computer should be careful not to become sedentary even in their free time, but plan physical activities away from computers and other screens.
So think about it, go through your normal week, identify what the most common situations really mean physically and mentally. Then think of realistic alternatives, activities where you use completely different physical and mental functions. Test them in practice, try them out, take notes on how they go.
Presence
One mental factor is important for all the other components of recovery, namely the ability to be present from time to time. Most of us leak large amounts of mental energy by thinking too much. An unnecessary flow of thoughts goes on within us for many minutes per hour, many hours each day. Of course, it is sometimes necessary and good to think, ponder, analyse, plan, categorise and name things we observe, retrieve knowledge from memory, compare with past experiences, make wise decisions. But a large proportion of our thinking is unnecessary, non-constructive, repeating thoughts that don’t need to be repeated at all, but which spin a few extra revolutions anyway… and make us absent-minded.
It is clear that most animals are able to store information in the form of memories that they can recall at later times and use in some form of thought process. Most mammals also clearly show that they can imagine a future and plan and act purposefully. But only Homo sapiens seem to engage in advanced mental time travel, fantasising about the future, worrying about undesirable scenarios and then wondering why something in the past turned out the way it did, regretting and dwelling on wrongs.
In psychophysiological tests, we can see that most people are unable to be present, i.e. thought-silent, for more than 10-15 seconds. Then the thought carousel starts again.
Mental presence occurs when thoughts become silent and attention is focused on what is happening right now, not somewhere else and not just now or soon, but only here and now. When you do get it right, you find yourself in a state of mind that is peaceful yet extremely alert and open, a kind of raw alertness, free of fears and preconceptions, without irritation, anger or regret. In psychological literature it is called mindfulness or conscious presence. Sometimes the term flow is used, usually in the context of the importance of presence skills for performance.
Presence is a very useful mental skill that can have a major impact on your ability to recover. Not only because you don’t leak as much mental energy, but also because a present mind rests in a way that you can’t access when you are daydreaming and absent. When you begin to master the mental technique, you experience a wonderful sense of freedom compared to those moments when you are swept up in a torrent of thoughts and emotions that you cannot control.
We have developed a course in mental self-regulation that explains in more detail the underlying mental processes and the different present and absent mental states. Theory sessions are interspersed with exercises and practical applications. First, you will learn to recognise which mental state you are in at the moment, and then how to switch, when necessary, to another mental state that is more appropriate at the time. (If you want more information, please send us an email.)
Inspiration and enthusiasm
Inspiration may sound like an obvious component of recovery, but the fact is that it is a misunderstood and for some incomprehensible factor, and then it is naturally neglected.
It is about getting to know yourself and understanding what situations, activities and experiences you get mental (spiritual) energy from. There are some common, natural human needs for experiences that provide mental energy, such as nature experiences and socialising with good friends towards whom one feels deep affinity and mutual care and trust. (Well, maybe not quite common, because there are some individuals who absolutely do not find socialising rewarding, but rather very energy-consuming and tiring. And nowadays there are quite a few people who never spend time in nature and are not able to enjoy it, but on the contrary get stuck in anxiety-provoking thoughts if they are taken out into the woods or lured on a mountain hike).
Despite the fact that, thanks to all the modern technological aids, we are more relieved in an external sense than ever before in human history (drinkable water directly from a tap in the kitchen, our own shower and toilet in every home, lift, car, internet, portable phone that fits in one pocket, etc., etc.), we seem to find it difficult to use all the ‘time gained’ for meaningful, urgent and inspiring leisure activities. Many people engage in ‘rubbish’ activities that are just superficial entertainment, distractions, escapes from boredom. Others fill their time with musts and irrational self-demands. In our messy, disruptive, unnatural modern existence, everyone needs to be ‘filtering’ and actively seeking meaning, realising the importance of finding out what they are really interested in, what are the subjects and practical applications that make them wonder and feel: ‘Wow! This is such a wonderful thing to do!’.
It’s a powerful mental battery charge that can come from spending time in such a genuine interest, a voluntary activity associated with fascination, curiosity, learning and enthusiasm. Simply imitating friends and idols is not enough. For example, listening to music is a completely meaningless activity for some, while for others it is deeply moving and a powerful source of energy. The same is true for other art experiences. Playing with a ball or skiing off-piste, throwing darts or riding a unicycle, reading poetry aloud, making lace, looking at Saturn’s rings through a telescope or studying fungal spores under a microscope, bird watching, scuba diving or learning a new language, are activities that make some of us feel nothing but meaninglessness and others shimmer with joy.
The bottom line is that no one else can do it for us. It’s up to each of us to experiment, to try out different activities, to find our genuine interests and then cultivate them.
Creating value for others
Psychological research has shown that intentionally creating benefits for others can have a positive effect on your own energy and resilience. This is partly because it reduces the risk of walking around with a sense of sacrifice at work or in other contexts where you are expected to create value for others. And because caring and commitment to the well-being of others (provided it is genuine) has been shown to have a significant long-term impact on one’s own mental strength by strengthening a healthy self-esteem.
Research into the origins of quality of life and genuine well-being has identified a key factor called ‘senseof coherence ’: those who are good at it go about their daily lives with a well-founded and justified sense that their lives have meaning and that they are needed, that they are making a difference, that it is worthwhile to make an effort and get involved because there are important things that they can influence with their efforts. This presupposes that they have the resources to deal with the challenges and tasks they face. In fact, it has been shown that the opposite is true: that people actively adapt their lives to make them comprehensible and manageable, and that they seek out contexts that are bigger than just satisfying their own desires, earning more money, being admired by others, protecting their prestige and climbing the hierarchy.
Deliberately creating advantages for others, without immediately benefiting oneself, is completely incomprehensible to some people. This is especially true for those with a dysfunctional identity and self-esteem mechanism (when it’s really bad, it’s called a personality disorder in clinical psychology). For these people, a large part of their lives is about relieving the mental tension they carry around most of the time, and distracting themselves from an uncomfortable emptiness inside, from a constant nagging feeling that something is missing. The purpose of much of their actions is to seek relief from this inner discomfort, often also compensating for it with behaviours that are pseudo-self-enhancing. This leads to self-absorption and selfishness, inability to be genuinely caring, prestige, excessive need for approval, often also boasting, greed, stinginess, envy, jealousy, manipulative exploitation of others. In severe cases, there is also an inability to establish close relationships because they are never openly themselves, always playing a role, hiding behind a nice facade, lying and deceiving and taking advantage of others without caring about the consequences for others. This state is associated with constant internal tension and an inability to calm down, which means they leak energy and find it difficult to recover, because the only time they can relax is with the help of alcohol or some other sedative drug.
The reason I describe this condition in so many words is twofold. Firstly, knowledge of these psychological mechanisms is useful general knowledge because it helps us to deal with people who exhibit these personality traits. Secondly, it is sometimes the case that understanding something you are studying is facilitated by knowledge of its opposite. This is certainly the case here. This compartment of the toolbox is about stress resilience and the ability to strengthen one’s inner harmony and mental strength, one’s grounding in life, one’s preparedness for difficulties and setbacks, by actively choosing to care for others, to be considerate, to be caring, to create benefits for others. In the long run, this leads to an improved quality of all recovery processes.
If you want to learn more about self-esteem mechanisms and how disorders manifest themselves, you can read our small ebook on the most well-known types of personality disorders (narcissism and psychopathy). I explain there how to recognise such people when you encounter them at work or in private. And how you can/should respond and deal with them. Then it is important to understand the difference between empathy and sympathy, which I also explain in one chapter.
Someone reading this may begin to suspect that they themselves have such traits in their own psychological constitution. It’s not all doom and gloom. Although it can be tough and difficult, it is not hopeless. There are therapeutic methods that can help. I am sometimes available for personal consultations. If you are interested, you can send me an enquiry via email.
Nutritional intake
Speaking of energy, we must of course also make physical and chemical deposits in the form of nutritional intake. Nutrition is an important recovery factor. We need to get all the chemical raw materials needed to build and maintain the body. Food must also contain different types of biochemical fuels to keep the organic machinery running. The food industry and the whole food chain are not very thoughtful, it is easier to buy junk food than real food. Making nutrition work in practice requires knowledge and an active commitment to choosing what is healthy. Going into a grocery store and passively buying ingredients for tonight’s dinner and tomorrow’s breakfast at random often results in a basket filled with things that taste good, not things that the body really needs to function healthily.
There is no space to go into this topic in depth here, but for those who are interested, I have written a small book on practical nutrition – ‘Nutrition for sustainable high performers’ – which describes how to develop good eating habits, eat healthy, what myths you need to know and not be fooled by, etc. It will soon be available as an e-book (under construction) and can be ordered by email.
Gratitude
Gratitude is not just a feeling, it is an active behaviour that can change the way we look at our life situation, and it has been shown to have a strong positive impact on our resilience and resistance to burnout.
In an age of technological development, medical advances and rising living standards, we have many reasons to be grateful. Many of us now live in circumstances that just 50 years ago would have been regarded as incredibly luxurious, in some cases as science fiction fantasies that my grandfather would have shaken his head at in disbelief. Living standards have improved enormously in recent decades for many billions of people, not just in Europe and North America but in most countries with a reasonably well-functioning democracy. Despite this, it is easy to take for granted the many tools and features that simplify our lives. Take just one such thing as drinkable water from the tap directly into the kitchen. It is certainly not a self-evident human right, but an enormous privilege for which we should feel grateful every day it works. Our everyday lives rely on a host of infrastructural systems that we rarely think about until they stop working. Clean water, electricity, public transport and waste management are all foundations of a functioning society. The well-organised logistics that enable food supply, mail delivery and public services are the result of centuries of planning and innovation. Not to mention healthcare. Few aspects of modern society are as worthy of our gratitude as the progress of medical science.
By feeling gratitude for these features, we can also develop a greater understanding of the importance of maintaining them. This means supporting political and economic decisions that ensure the infrastructure remains robust and accessible to all.
There is a clear risk associated with seeing these benefits and facilities as a matter of course rather than a privilege. This is partly because it tends to focus on negative elements of life, and partly because gratitude, as a psychological and philosophical attitude, has been shown to be crucial for both individual well-being and societal cohesion. By reflecting from time to time on everything we have access to – from healthcare and education to digital communications and infrastructure – we can cultivate a deeper appreciation for our present and the people who make it possible. Such mental processes influence the psychophysiological mechanisms that promote our recovery. Positive psychology research has shown that gratitude is directly linked to increased wellbeing and the ability to calm down.
Actively practising gratitude can be done through daily reflection, conscious acts of appreciation, or by engaging with society to contribute to its continued development. In an age where it is easy to get caught up in consumption, comparison and the constant search for more, gratitude offers a counterbalance that can empower both the individual and the collective.
A more conscious attitude of gratitude can also counteract the feelings of inadequacy and frustration that often arise in a digitalised world. Viewing technology as a non-obvious possibility rather than an expected default can contribute to a more balanced relationship with our tools, thus reducing the risk of energy leakage and disrupted recovery.
Exercises:
Expressing appreciation for what we have and enjoy leads to a more optimistic outlook on life and stronger social bonds. When we recognise and value the contributions of others – whether it’s technological innovation, healthcare, community service or a personal favour – we create a more empathetic and cohesive world. It can also be applied at home. Do you like your spouse/partner? Do you appreciate his/her initiatives for your good? Tell him/her about it! ‘Thank you for being in my life!’, is an unusual comment, but extremely powerful.
To be as well off as most of us Swedes are, is certainly not for everyone – I have travelled all over the world, studied, worked and lived several years abroad, including in India and Africa, so I know. Even when I think I’m having a really bad day, there are hundreds of millions of other people who would love to swap with me! I remind myself of this from time to time, and have found that it has a profound effect on my state of mind. You should try it too!
Physical exercise
Physical exercise and sport can improve your recovery in several ways. Firstly, it offers both physical and mental variety and stimulation. Secondly, there can be inspirational elements in the form of social interaction (having fun with friends, teammates, training partners) and, if it is an outdoor activity, perhaps also in the form of nature experiences. Thirdly, physical exertion and fatigue lead to a build-up of the stressed body parts and the storage of more energy in the body’s chemical energy stores, which means that you can cope better the next day. Fourth, sporting activities are often so intense and challenging that you can’t think about anything else during them and have to be present. And, as we noted above, being intensely present enables a form of mental recovery that we cannot achieve while thinking, planning, analysing. Everyone understands that this applies to moments when we are brooding and thinking about something worrying, but many people find it difficult to realise that this is also the case when we are just daydreaming, when our thoughts are wandering around and dealing with all sorts of things without any worrying content. That’s why you get a much better mental energy boost during a workout that is so intense, difficult, and challenging that it demands your full attention and thus prevents you from thinking about anything else during the time. I hear many people object to this with arguments like: ‘But it’s so nice to walk with music in my headphones’, ‘I think so well when I jog’, ‘I’ve solved many problems while skiing’, and the like. It’s true that a certain kind of creativity flows during physical exertion, the brain is activated in a different way than when sitting at a desk, and you can find completely new approaches that make you suddenly come up with the solution to a difficult problem while running in the woods. Nothing wrong with that. But that doesn’t exclude the possibility that you might want to get the best possible mental recovery during a training session, and that’s when you should use the presence-creating technique. For example, if you go for a brisk walk or jog in the woods with that intention, you should leave the path. Walking or running on a road or flat path is too easy. It is easy to lose your presence and start thinking about something other than what you are doing. On the other hand, running a few metres beside the trail, where you have to watch your step, zigzag around rocks and protruding roots, jump over puddles and fallen trees, etc., helps you stay present, quiet your mind, and thereby get a moment of mental battery charging that most of us otherwise find so difficult to achieve.
Fifthly, it improves brain recovery in that tired muscles produce chemicals that leak into the bloodstream and, when they reach the brain, they trigger a hormone-like effect on glial cells, intensifying their ‘cleaning’ of nerve cells.
Since an Australian group of dementia researchers accidentally discovered this mechanism a few years ago, they have started looking in a different direction and have now identified more substances that are formed in muscles but can still have neuroprotective and regenerative effects if they manage to reach the brain. Previously, the logical assumption was that such signalling substances are produced by the fatigued neurons themselves as a signal to nearby glial cells. More recent studies have shown that tired muscles leak many other substances with health-promoting effects on metabolism throughout the body. The reason why these mechanisms have not been discovered before is that blood analyses are usually performed on subjects during days of normal (usually equal to low) activity. This mechanism does not occur because large muscle groups need to be severely fatigued for these neurotransmitters to be synthesised in sufficient quantities to make their presence in the blood noticeable and to induce the beneficial effect on recovery.
In practice, this means that every day we should ideally ensure that some large muscle group (leg, gluteal or shoulder muscles) is working hard and getting really tired, so that the brain’s recovery during the night is optimised. Taking the dog for a walk is not enough…
Sleep
If you don’t have trouble sleeping and usually sleep well for 7-8 hours and wake up feeling refreshed, don’t worry about it, because the most common cause of sleep disturbances is worrying about not sleeping.
However, some general advice is worth mentioning.
- Skip the snoozing mornings! The best (probably only) way to stabilise your circadian rhythm and set your biological clock is to wake up and get up at the same time every morning.
- ‘Bedroom hygiene’ is not about disinfecting the bedside table, but about mental hygiene in the form of avoiding looking at screens during the last waking hours of the evening. Watching TV in the bedroom is certainly not a good idea. And never bring mobile phones or tablets (‘toads’) to bed. The blue light from these screens affects the brain more than you might think, interfering with falling asleep, and even if you do fall asleep, it makes it harder for the brain to get into a good deep sleep.
- Many people think that alcohol makes it easier to fall asleep, but unfortunately, alcohol is a potent saboteur of REM sleep, so even if you can be helped to fall asleep, there will be no good deep sleep while you have alcohol in your blood.
- Sleeping pills can be of good use in special situations with severly disturbances of sleeping circumstances. But only if used very sporadically and not on a regular basis. If you are suffering from recurring sleeping problems I strongly recommend that you ask for treatment with a cognitive and behavioral program. It works if applied properly! If you need a personal consultation (via Zoom/Teams) don’t hesitate to contact me! Let’s go through your problem thoroughly and then I can either help you myself or refer you to the right specialist near your home.
Finally, let me offer some general comments and advice on resilience:
- Pay close attention to the ‘bedroom hygiene’ described in the sleep section above. Try to stabilise your circadian rhythm, i.e. wake up and get up at the same time every day, even at the weekend. It is not possible to make up for lost sleep more than 2 days at most. Trying to catch up on sleep at the weekend rarely works. It is better to have a stable circadian rhythm so as not to disturb the biological clock in the brain. Even if you go to bed late one night, it’s best to get up at the usual time the next morning. An irregular circadian rhythm leads to poorer deep sleep.
- Make the most of the first waking hour in the morning. How we start the day has a powerful effect on how we get through the rest of it. So take the time to create a high cosiness factor, meditate for a while, go for a walk, take a bath, enjoy good music, eat in peace and quiet. For many people, this means a total 180 degree change of course, because many people have developed a morning routine that is just the opposite; they try to sleep as long as possible and rush off to work/school. Try an experiment: get up 2 hours earlier than you usually do and try to make the morning the highlight of your day! It can take several weeks for your brain to get into this pattern, so be patient, give it time!
- Cherish the first hour at work. Starting the day with a sense of flow and undisturbed concentration is important for both performance and job satisfaction. Don’t rush through your inbox in your email programme, but focus on your most important long-term tasks. Mark the time as booked and keep away all unnecessary phone calls and meetings.
- Just because you can sit at your desk for 4-5 hours straight without feeling sick doesn’t mean you should . Develop your break skills. Take a break from work 1-2 times per hour, get away from your desk, leave the room, move around, eat a piece of fruit, do a handstand against the wall or a somersault or do something else that is completely different for both your body and your mind than what you were doing before.
- Use active recovery. It gives you twice as much energy as passive recovery, which is where you sometimes end up when you are so mentally tired that you can’t even rest properly, but just lie down in front of the TV and laze around. If you have personal experience of both, you know how little energy it gives compared to a workout, a bike ride or brisk walk in the woods, a moment of deep relaxation, listening to music wholeheartedly (not while doing something else; background music is not good for recovery).
- Try inspiring activities that can help your brain get out of the routine, ruminative state of everyday life and into an intensely experiential and present state of mind that shakes you up mentally and really wakes you up from everyday stress.
- ‘That doesn’t sound very restful…’, you might be thinking now.
- – Well, not restful in the usual sense, but it does promote recovery in other ways and is more energising than lying in your TV chair for a few hours.
- Dare to try new stimulating and inspiring experiences! Do you have a friend who goes winter swimming? Join him or her. Or book half an hour in a float tank. Sign up for a wilderness walk. Or a pilgrimage might appeal to you more – and start training for it with a good friend whose company you enjoy! Go to a concert and listen wholeheartedly, live the music. Sign up for a salsa class and dance like no one is watching you! Overcome a fear, conquer a new arena in life. For example, if you are afraid of water: sign up for a swimming course and then a diving course and then go somewhere where you can swim with dolphins! If you are unfit and have poor body control: book a PT at a nice gym nearby and task him/her with helping you train so that in a few months you can do a handstand, jump from 1 metre and land softly, somersault both forwards and backwards, or something similar at the level of challenge that is reasonable for you.
- Create reminders to help you take more frequent opportunities to apply all the recovery tools you are testing and practising. In the book ‘A good life is not comfortable’ there is a section that develops this concept and explains it in more detail. There is also a long list of different types of reminders you can switch between, such as a post-it note in the middle of your computer screen and on your car’s rear-view mirror, reminder signals on your mobile phone, a piece of double-sided tape on a door handle, a coloured dot on your wristwatch, etc. – the book has many more. The vast majority of reminders stop working after a few days; the signal loses power after it has appeared a few times. After a while, you just switch off the signal and carry on without doing the activity the reminder was intended to trigger. .
Psychophysiological stress measurements and biofeedback
In the psychophysiological laboratory we measure stress functions in the body. Such measurements are used not only for the diagnosis of psychosomatic disorders, but also for treatment by facilitating the learning of better body awareness, reinforcing mental training and motivating decisive behavioural changes.
The incentive for our psychophysiological laboratory is the growing need for effective treatment of stress-related, functional and psychosomatic disorders. Many people with such problems are dissatisfied with pills and sick leave, and instead want help to develop their ability to perceive and understand the body’s signals so that they can take self-care measures instead of symptom relief.
Many people of all ages experience negative stress. It usually manifests itself in both mental and physical symptoms, which can be quite intense without serious illness. The most common mental symptoms are tiredness, anxiety, depression, unhappiness, difficulty concentrating, irritability, loss of self-confidence, etc.
The most common physical symptoms are muscle aches, headaches, stomach or intestinal problems, palpitations, recurrent infections, air hunger (=feeling of not getting enough air), back pain, neck-shoulder pain, etc.
– By learning to expand your behavioural arsenal and using certain forms of mental training, you can strengthen your stress resistance and significantly improve your life. This does not require 5 years of psychoanalysis, but rather simple training programmes that you work on a little every day.
-The keys to our concept are that after testing/diagnosis, we guide our clients/patients through a number of mental and behavioural changes. The whole thing is set up as a step-by-step upgraded training programme which improves the result significantly. Each step is tested and evaluated and the patient/client is involved in seeing what the psychophysiological measurements show. The idea is that you will learn to manage your mental self-regulation on your own for life.
The methods are based on the sciences of psychophysiology and cognitive behavioural therapy, which are combined here in a particularly effective way to help patients with stress-related problems. The PBM clinic is part of a network of nationwide stress clinics.
Biofeedback
A good way to teach people mental self-regulation is supervised mental training with simultaneous feedback of ongoing psychophysiological processes. In our psychophysiological laboratory, we can show what happens in the body when you think in different ways. As a diagnostic tool, this is extremely valuable, because now we can measure the degree of anxiety, mental worry, burnout, etc. But above all, psychophysiology has proven to be a powerful addition to the treatment armoury against stress-related disorders.
When this technique is used for treatment, it is called biofeedback. It involves using special computer programmes to reproduce stress measurements in an educational way. The signals captured on the body are displayed on the screen so that the patient can understand what is going on in his/her brain and body. Not only are there curves and numbers on the screen, but we can also put the signals into simple computer games that the test person can learn to control with their own stress level. When you relax, the player (boat, car, etc.) goes one way, and when you tense up/raise your stress level, the game goes the other way. In this way, we can even help children learn better skills for stress regulation, concentration, relaxation, etc.
For the treatment of anxiety, phobias, depression, burnout and other functional mental disorders, our biofeedback method has proven to be an excellent complement to so-called cognitive behavioural therapy. Many such disorders/diseases that are almost inaccessible to standard psychiatric and psychological treatment can be cured in a few weeks with biofeedback and cognitive behavioural therapy.
In our approach, we de-emphasise the importance of the past and look more at the possibilities for change. We emphasise the present as the cause of how you will feel in the future, rather than (as in classical psychotherapy) seeing the current mental state as a result of the past. Biofeedback immediately reinforces the insight into what and how you can do to feel better now and the next minute and the next 10 minutes and the next hour and so on.
Looks worse than it is…
With a multitude of wires, tubes and electrodes on the body, stress measurement in the psychophysiological laboratory looks worse than it is.
For those who come for treatment or supervised mental training using the biofeedback, the curves on the screen quickly become comprehensible and the body processes represented by the image are soon recognised and influenced. Pretty soon you are training on your own without much help from the test leader. The new, refined body awareness learnt in the lab is then useful in real life; you become like a walking stress meter. This makes it easier to understand what’s happening to you in different situations, which makes it much easier to train.
The measuring device constantly tells you what is happening in your body, visually on a display or via a tone. The intention is to help you realise more quickly what it feels like when you do the right thing. Many people fail in their mental and co-ordination training because they never realise when they start doing the right thing, but just try lots of different ways. After a while, when nothing feels really good, it’s easy to think it’s not working at all. The saying “you learn from your mistakes” is wrong. It is when we succeed, or realise that we are on the right path to success, that we learn!
There are now also small portable stress meters that you can use at home, at work, in the car, in front of the computer, etc. to get a better idea of your stress level or to evaluate whether your mental training is having the desired effect. The box is no bigger than a standard jacket pocket. Some measurement parameters can even be collected in the mobile phone via blue-tooth technology and easily sent to the laboratory for analysis.
Biofeedback is an excellent way to accelerate the progress of beginners in mental training and advanced coordination techniques. The goal is to eventually be able to regulate oneself mentally and physically without the help of measuring instruments.
We keep up to date with developments in the field and can recommend the equipment you need for the type of biofeedback training you would most benefit from. Send your enquiry by email to clas@dcmhk.se
Reinforcement of mental training
Biofeedback is also used as an evaluation tool for mental training, both for athletes and for ‘ordinary’ people. By performing specific relaxation tests, we can see how well the test person benefits from their mental techniques. This allows us to tailor individually adapted mental training programmes.
We use this in our mental training courses, making them unique.
Health checks with a focus on burnout
Psychophysiological measurements deepen the value of medical and mental health checks. In the PF lab, we can see imbalances in the stress and rest systems. We can detect the onset of burnout and other forms of negative stress reactions early.
This has already been recognised by several companies who use us to regularly monitor the stress levels of vulnerable staff groups as a preventive measure. Given the reliability and direct action-orientation of these tests compared to traditional questionnaire-based tests, we can help our clients get much more out of health checks, and save many individuals unnecessary stress-induced suffering.
We also help companies with stress reaction tests when recruiting for demanding jobs, as well as training and personal development programmes.
Psychophysiological explanatory model of stress
Stress is the state that occurs in the body when the mind feels that something needs to be done. The primary task of consciousness is to ask the question “What happens now and what does it mean for me?” and to answer it immediately. If the answer is uncertain, unpleasant or threatening, we react with stress, i.e. heightened readiness to deal with the problem.
Most of the time, a mild form of stress is most appropriate. Positive stress is the tension, or increase in energy, that helps us to be decisive, faster, stronger, better focussed and thus easier to get things done, both mentally and physically. Stress signals are the brain’s way of getting the body ready for action. So the job of the stress system is to help us get going and to adapt all body functions to the type of work needed. For example, digestion shuts down if there is heavy muscular work to be done, concentration increases when making decisions, breathing becomes faster while waiting for something to happen, etc.
But now, what most of us think of first when we hear the word stress is something unpleasant. The word has taken on a negative meaning for us.
Negative stress occurs when one cannot balance the perception of demands on the one hand and the ability to take action on the other. Negative stress also occurs when you cannot escape the feeling that something is wrong or ‘not good’, when life does not feel meaningful, comprehensible and controllable.
Negative stress leads to long-term disruptions in communication between the brain and the body. Resting functions are particularly affected and the “recharging of the batteries” quickly deteriorates; you realise that you don’t really have time to recover between shifts.
The background to the phenomenon of ‘negative stress’ is that we are still equipped with the same stress systems as Stone Age man. Our genetic make-up has not had a chance to keep up with the rapid pace of change that our living conditions have undergone. Our stress system still basically works as if we were living naked on the savannah, but our living situation is clearly quite different. Not only in the sense that we move less and eat completely upside down, but also our psychosocial situation has completely changed. We have more difficult choices to make every day, we work and make a living in a completely different way, and we rely more on our own thoughts and attitudes to create meaning and joy in our lives.
Internal stress
Negative stress is often due to a lack of ability to create within oneself a sense of peace, joy and coherence in one’s own life. This lack is of course always relative to prevailing external circumstances, but we modern Swedes seem to be increasingly “better” at thinking ourselves into unhappiness and dissatisfaction than the other way round, no matter how good we have it!
The stress system is activated as soon as the content of our thoughts becomes threatening or unpleasant. If the thought content does not correspond to any real threat in the environment, we call it ‘internal stress’. Internal stress has become a major stress problem today.
It is our own selection of information and our thoughts’ interpretation of it that determine the activity of the stress system. Any thought such as “something is wrong” or “I don’t feel well”, “something might go wrong soon”, “I wonder if I can cope with this…”, “this is really hard…” or similar, immediately activates the stress system and puts the body on alert to do something….
It’s just that the body can’t do much about internal stress. It’s not worth trying to run away from thoughts. (Or yes, by the way, it can be worthwhile to exercise even if it has nothing to do with the current cause of stress, because physical discharge is also beneficial mentally. But it is not enough as a measure, and besides, most Swedes do not exercise at all….)
Part of the ‘new approach to stress’ is that modern research has taught us much more about how distressing, stress-creating thoughts work, and what you can do to get out of them. We have developed new mental training methods and behaviour change support, which work very well.
Stress-triggered disorders – not always caused by too much stress….
Another aspect of the ‘new view of stress’ is that modern psychophysiological research has shown how burnout can occur even in people who are not particularly stressed. You don’t have to be rushing around and be obviously rushed and under pressure to suffer from stress-induced psychosomatic disorders. A common form of burnout is caused by a lack of rest, rather than too much stress.
This is because resting the body (and brain) requires that the mind is first filled with thoughts of calm and tranquillity, and a sense of inner security and peace is created. Only when the mind is relaxed can the body’s resting systems be activated.
There is a specific ‘calm system’ with its own hormones and nerves, just as there is a stress system with its own specific hormones and neural pathways. In order for there to be activity in the calm & quiet system, the consciousness must send convincing signals to the rest of the brain that it really is calm and quiet that applies now. And this cannot come from outside, but must be created by ourselves.
Here’s the rub: if life doesn’t offer enough beautiful, calming situations, we need to be able to create inner peace anyway!
Life is so incredibly complex and changing these days that it is necessary for each of us to choose and unchoose hundreds of times every day. We are more at the mercy of our own ability to control our thoughts and emotions than ever before in human history. Modern humans are very well placed to influence their own lives, but this requires taking advantage of opportunities to steer themselves as often as possible in the direction that really makes them feel good.
Most of us are not good enough at actively and consciously creating inner peace. This, combined with the increasing complexity of daily life, explains a large part of our modern diseases, which are functional psychosomatic disorders. For such disorders, there are no good treatments in the sense of ‘treating away’ something sick. Instead, something must be added, namely better mental self-regulation and more active choice of behaviour. It is against this background that one can understand why biofeedback is such a valuable addition to the treatment armoury.
Respiratory psychophysiology – Why do we breathe? A brief description of how breathing is regulated and what so-called ‘stress breathing’ is
and how it can cause so many different symptoms
Within modern stress research, one branch has received particular attention recently: respiratory psychophysiology. This field of knowledge has proven to be clinically valuable in two areas of application: 1) for people with lung diseases, and other diseases that interfere with breathing, who can learn to control their breathing better and thereby reduce their disease symptoms, and 2) how different types of stress conditions can lead to changes in the breathing of the affected people, which in turn can lead to a range of disturbances in the body’s functions.
The first area of application (1) mainly concerns asthma. By measuring how the respiratory muscles work, how the oxygenation of the blood varies, and demonstrating this to the patient during the training of calm diaphragmatic breathing, many asthmatics can radically improve their breathing technique, thereby reducing their dependence on medication and improving their general condition. In addition, it appears that many asthmatics suffer from anxiety about their disease and fear of having a severe asthma attack, causing them to take in extra air and stress breathe unnecessarily, exacerbating symptoms. This can be relatively easily remedied with supervised breathing training during oxycapnometric biofeedback.
We will not dwell further on this type of application in this text, but instead concentrate on the second type (2), which has to do with stress analysis and the treatment of stress-related and anxiety-triggered conditions with breathing disorders.
Understanding respiratory psychophysiology requires not only a good understanding of respiratory functions, but also of the body’s acid-base balance, blood oxygen transport capacity and certain other body processes that reflect the functioning of breathing and the stress state of the individual. Measurements are made with blood samples, including BE (alkaline buffers), electrolytes, pH, haemoglobin saturation. With the oxycapnometer we do gas analyses on the exhaled air (ET-CO2 ), analysis of the oxygen saturation in the blood (Sp-O2 ) and with the PF lab we can also record the functions of the respiratory muscles (PNG) in combination with several other physiological measurements that show heart function (HR, RSA), mental stress state (SR/EDG), muscle tension (EMG), blood circulation (FT, BVP), the level of activity in different parts of the brain (EEG, AT), etc.m.
With technological developments leading to the oxycapnometer, an instrument that can measure oxygen saturation and carbon dioxide levels in the blood without the need to insert a needle into the patient’s arteries, respiratory psychophysiology has taken a giant leap forward as a clinical method, both for diagnosis and treatment, as the basic measurements have become possible to perform outside hospitals.
The uses and functions of the oxycapnometer will be described later in the text. First, let us briefly describe the background to why respiratory psychophysiology is so valuable.
Why do we breathe?
It is widely recognised that breathing is important for oxygenating the blood, thereby enabling the body to burn calorie-rich nutrients and extract energy for life processes in the cells. It is also well known that our body uses exhaled air to get rid of excess carbon dioxide produced by burning fat, carbohydrates and protein.
What many people do not realise, however, is that the body regulates breathing primarily on the basis of carbon dioxide levels and the acid-base balance in the blood, and only secondarily on the basis of oxygen levels in the blood. The oxygen-sensing receptors (‘antennae’) in the pulmonary arteries actually form a backup system that only intervenes and activates breathing in the event of oxygen deficiency if the carbon dioxide system has been switched off. This is because it is very important for the body to be able to adjust carbon dioxide levels quickly. The oxygen supply is more stable and less sensitive to rapid changes than carbon dioxide.
Carbon dioxide is constantly produced in all body cells when fat and sugar are burnt.
Carbon dioxide is the gaseous form of carbonic acid. These two substances can freely transform into each other, with bicarbonate as the intermediate form.
CO2. <=> HCO3 <=> H2 CO3
(carbon dioxide) (bicarbonate) (carbonic acid)
Carbon dioxide, as its name suggests, is an acid, and an important one in our metabolism. There can never be too much or too little carbon dioxide in the body, which is why carbon dioxide levels are so closely monitored and fine-tuned. A single extra breath means that we get rid of more carbon dioxide and the level of carbonic acid in the body drops, and vice versa.
Thus, breathing is not only necessary for the uptake of oxygen from the air. It is equally important as an excretory system for carbon dioxide/carbonic acid, and thus a method of maintaining acid-base balance in the body. In fact, the role of breathing in acid-base balance is so important that in order to understand respiratory physiology, we must first understand how acids and bases work in our metabolism.
Therefore, before discussing the stress-induced respiratory disturbances that we work with in our oxycapnometry analyses, let’s briefly discuss the basics of our acid-base balance.
Acid-base balance of the body
Acids are substances that can give off hydrogen ions (protons). Free hydrogen ions react very strongly with most other substances, generally destroying them. Strong acids ‘corrode’ because they emit large amounts of hydrogen ions that ‘jump on’ almost all other substances and destroy them. .
A base (also called lye or alkali) can give off hydroxyl ions, which, like hydrogen ions, react with many other substances and partially or completely destroy them.
It can be said that hydrogen ions (H+ ) and hydroxyl ions (OH– ) are chemically opposites, and when they meet, they are immediately attracted to each other and merge (forming water!).
Acid + Base –> Water + Salt (H+ + OH– –> H2 O)
This means that bases and acids neutralise each other if they are present in equal amounts.
In body fluids, the amount of bases and acids is very carefully regulated, so that the two are always in balance with each other. Chemists can measure acids and bases, and they call the equilibrium state (when acids and bases in a liquid are in balance) ‘neutral pH’. Sometimes you see this expressed as pH=7.
A pH lower than 7 means that the acids are in excess, and higher than 7 means that the liquid is alkaline.
In the normal metabolism of the body, both bases and acids are formed. In addition, both can be supplied from outside with the food or other substances we eat/drink.
The body cannot tolerate an excess of either acids or bases. If the pH is shifted away from the neutral position, and it cannot be equalised immediately, many important bodily functions cease to function. In fact, it is so important for the body to maintain acid-base balance that most other equilibrium reactions take a back seat.
One way the body maintains a neutral pH is through excretion in the urine. The ability of the kidneys to excrete acids is well developed, as these are usually acids produced in excess during normal metabolism. However, these excretion processes are slow in relation to the body’s need for rapid equalisation, should the pH fall far below neutral.
By being able to release carbon dioxide in large quantities through breathing, and thus very effectively regulate carbon dioxide levels, the body has a fast-acting system for excreting excess acid.
Even breathing is not enough, however, despite its great capacity. The body needs an even faster, locally acting system for acid neutralisation in connection with stress, for example during intensive muscle work, when large amounts of acids are quickly formed in the muscle.
Under such conditions, these acids need to be neutralised quickly, otherwise they can cause great harm. The body cannot wait even the minute it takes for the exhalation of carbonic acid to restore the acid-base balance.
The body has developed some very clever ways to solve this problem locally in the tissues.
Firstly, the body produces extra bases and acids, so that the equilibrium is maintained by much larger amounts of both than the amounts that are constantly being metabolised in the normal work of the cells.
At first glance, this may seem like a crazy solution to the problem, but consider the following simple arithmetic example, and the ingenious simplicity of this way of providing cells with quantitative buffers of acids and bases becomes apparent:
Suppose that in a muscle, 10 units of acids are in balance with 10 units of bases. If 3 extra units of acids are now added, the equilibrium quickly tips, as the acidic side becomes 30% heavier than the basic side.
If instead there are 1000 acids balancing 1000 bases, 3 extra acids means only a marginal change that is barely noticeable. The ‘extra’ acids and bases that the body uses in this way are called the ‘buffer system’ because they act as biochemical ‘shock absorbers’. In other words, the buffers divide themselves into equal parts of bases and acids, thereby increasing the amounts of both. The effects of sudden changes in the formation of acids (or bases) in cells are thus relatively small compared to the total amount of acids and bases available.
Secondly, the buffers act as neutralisers also through their peculiar property of being both base and acid. The two can change into each other as long as all other acids and bases are in equilibrium with each other. If the buffers are placed in an acidic environment, i.e. a liquid where the acids are stronger than the bases, the buffers change into their basic form, and in an alkaline environment the buffers take on their acid form. It is this ‘act of transformation’ that characterises the mild acids and bases we call buffers.
In a healthy body, the buffer substances can thus dampen temporary fluctuations in the acid-base balance, by “taking the side of the weaker”.
If, for example, a muscle is working hard and produces lactic acid in such large quantities that the local pH drops below 7, the buffers that are in acid form immediately change to their base form. The amount of base then increases almost as much as the amount of acids has just increased. The imbalance is very short-lived and the buffers quickly restore the overall acid-base balance.
In the minutes that follow, the lactic acid (and other slag acids) seep out of the muscle and are carried away by the blood. This gives the liver and kidneys a respite to excrete the excess acid formed. The body as a whole then regains equilibrium between acids and bases. If the condition that caused the excess acid was temporary and the body is healthy, it takes only a few minutes (up to a few hours if there were large muscle groups that produced large amounts of lactic acid) to restore the basic equilibrium.
One aspect of being healthy, rested and in good physical and mental condition is to have well-filled stores of buffer substances in all organs of the body. If for any reason the buffer stores are depleted, the body’s ability to work and withstand stress decreases. With insufficient buffering capacity, the body is unable to deal with the acids produced during intensive metabolism and a wide range of dysfunctions occur in the most active body organs. This is another argument why qualitative recovery is so important!
Prolonged respiratory distress depletes buffer stores
If breathing (or liver and kidney function) is disturbed, acid-base imbalances may be impossible to fully correct.
Since the body prioritises acid-base balance over most other processes in the body, many life processes are affected if there is a chronic tendency towards an acid-base imbalance. Eventually, metabolism becomes seriously disturbed, and a wide range of unpleasant symptoms develop. (See below)
Recent research (not just our own) has shown that one cause of such chronic imbalances between acids and bases in the body is when respiratory regulation has been disrupted by negative stress, so that it runs too fast.
In fact, it seems that the most common cause of a reduction in the body’s buffering capacity is overwork and burnout resulting from prolonged negative stress and lack of proper rest
This, in turn, is because stress affects breathing, causing it to move higher up the chest and become slightly faster than normal. If the stress is prolonged and not interrupted by adequate rest periods (with effective ‘recharging of the batteries’), the buffer stores become increasingly depleted and eventually muscles, nerves and other organs with intensive metabolism (e.g. intestines, immune system) end up in a very sensitive state where they cannot tolerate any extra effort, and in severe cases not even the normal level of activity.
The resulting symptoms are unpleasant. They may vary slightly from person to person due to individual differences in bodily reactions.
The dominant symptom is usually an unpleasant fatigue, both mental and physical. The sufferer loses all stamina and cannot withstand intense efforts, the stress threshold is lowered
markedly, muscles ache and often there are also headaches and diffuse joint pain, intestinal problems, heart problems, worry and anxiety, sleep disturbances, etc.
Unfortunately, these conditions are not at all uncommon. Until now, the medical community has not had access to clinically useful research on how these conditions arise and work, and therefore diagnosis and treatments have varied from country to country, clinic to clinic and doctor to doctor.
Dear child has many names, they say… Well, this condition is certainly not a favourite one, either for sufferers or for treating physicians (who are often very frustrated in the face of unexplained illnesses). In the modern research literature, this condition is called chronic hyperventilation syndrome. The terms that have been used so far for the disorders included in chronic hyperventilation are numerous and mostly symptomatic in nature. In current clinical practice, a variety of other diagnostic names such as ‘burnout’, ‘chronic fatigue’, ‘somatoform pain syndrome’, ‘neurasthenic depression’, ‘fibromyalgia’, ‘effort syndrome’, ‘chronic stress syndrome’, ‘reactio psychophysiologica’, ‘post-traumatic stress disorder’, ‘functional psychogenic disorders’, etc., etc.
In many cases, hyperventilation also leads to specific cognitive disturbances in brain function (e.g. sudden anxiety attacks known as ‘panic attacks’). Other common symptoms resulting from chronic hyperventilation are migraines and functional enteritis (‘irritable bowel syndrome’). There is even a form of epilepsy that is triggered by hyperventilation.
Chronic hyperventilation syndrome (CHVS)
Hyperventilation due to prolonged stress should be a well-known phenomenon given that it has actually been described in medical, psychological and physiological research literature since the 1920s (burnout in World War I trench soldiers). Yet it is an unknown concept to most doctors and thus a rarely observed phenomenon (we only see what we know is there…)
Chronic hyperventilation is very difficult to detect in a standard physical examination. Even a trained eye actively looking for signs of hyperventilation may have difficulty in detecting chronic, low-grade hyperventilation unless specialised physiological and chemical measurement methods are available. In the first instance, PNG (pneumography = recording of respiratory movements in the chest and abdomen), BVP (= blood volume pulse; shows peripheral circulatory status), oxycapnometry and blood tests (acid-base status on-line analogue reproduction + complete electrolyte status + albumin + lactate, phosphate) are useful.
The modern technology has been in use for some years in intensive care and anaesthesia, but the psychophysiological application methodology for the analysis of chronic functional disorders is completely new and still under investigation. However, it has already been sufficiently evaluated to suggest that it is clinically useful and very promising for the future development of psychosomatic and functional diagnostics. In Sweden, these specially equipped psychophysiological laboratories are currently only available in a few locations.
To understand how and why stress management training and mental training in combination with breathing training can be the best treatment for the disorders described above, one must be reasonably familiar with the physiological disturbances involved in chronic hyperventilation syndrome. In the next 3 pages we will therefore go through this in more detail, after which we will look at therapeutic aspects.
Physiological explanatory model of chronic hyperventilation syndrome
Figure 6 below shows a schematic illustration of how a chronic hyperventilation state works. The following text section follows the different steps of this diagram.
Respiratory functions are affected by stress. In particular, we seem to be dealing here with certain types of prolonged negative stress best described as diffuse anxiety (inability to create inner peace and security, lack of calm, locked in negative thoughts, feelings of helplessness, inhibition of aggression and lack of self-confidence, etc). This condition affects creates an imbalance in the respiratory centre causing dysfunctional breathing in the form of mild thoracic hyperventilation. If prolonged, it can easily become chronic, creating a ‘vicious circle’: hyperventilation leads to respiratory alkalosis, compensated by metabolic acidosis and other secondary physiological disturbances, leading to dyspnoea (feeling of not being able to breathe properly), which fuels breathing. In addition, the stress threshold is lowered and thoughts tend to become anxious and worried, thus locking into the vicious circle.
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Figure 6. The vicious circle of chronic hyperventilation syndrome.
HYPERVENTILATION – even if it is relatively mild – leads to a lowering of the carbon dioxide pressure in the blood (HYPOCAPNI). The body then suffers from a lack of carbon dioxide, which, even if moderate, gives rise to an ALKALOTIC REACTION (= shift of the acid-base balance in the alkaline direction) which in turn gives rise to a COMPENSATORY METABOL ACIDOS (= formation of extra acids in the metabolism, and activation of the buffers which switch to their acid form).
Many body proteins are part of the buffer system. This includes haemoglobin, which can act as a reserve of oxygen (Hb-), thus affecting the function of haemoglobin by increasing its ability to bind oxygen (in much the same way as at high altitude). This may seem positive, but in fact in this situation it makes it more difficult for the blood to deliver oxygen to the body’s organs, by making the release of oxygen from haemoglobin more difficult.
If this change in haemoglobin becomes pronounced enough, a paradoxical situation arises with oxygen supersaturated blood (SpO2 > 97%) travelling around the body lap after lap without giving up enough oxygen.
Low levels of carbon dioxide in the blood cause a contraction of small arteries (VASOCONSTRIction in precapillary arterioles). The combination of vasoconstriction and haemoglobin depletion causes a noticeable and symptomatic, although far from total, lack of oxygen (HYPOXI) in the most intensively working body tissues.
The brain is the most sensitive organ to oxygen deprivation, and symptoms of CEREBRAL INFLUENCE appear quickly in the form of fatigue, cognitive dysfunctions and reduced stress tolerance. In some cases, the brain becomes so disturbed by the reduced oxygen supply that a generalised state of stress sets in, further increasing discomfort. A vicious circle emerges and the whole thing can develop into a full-fledged panic attack.
A common form of migraine occurs when the blood vessels of the head have become exhausted by prolonged contraction and are eventually stretched by blood pressure. There is much evidence that chronic hyperventilation is in fact the cause of stress-related migraine. (Research is ongoing; results so far are very promising. We have already cured several migraine patients using psychophysiological breathing regulation).
Hypoxia leads to disturbances in cellular respiration, oxidative phosphorylation functions only partially, and changes occur in the mitochondria (“ragged mitochondria”). The muscles then switch to incomplete combustion of sugar as the main energy supply method (anaerobic energy extraction = without oxygen) and this eventually leads to the emergence of a primary metabolic acidosis, in addition to the compensatory one we previously talked about above in connection with the respiratory alkalosis. Lactic acid is then formed already at rest, and during exertion the affected person notices a marked reduction in maximum intensity and endurance. The lactic acid threshold is lowered, the energy stores inside the muscle cells are depleted, and the muscles are in a constant energy crisis.
As a result of the metabolic acidosis, magnesium (Mg) leaks into the blood, and some is lost in the urine. A functional magnesium deficiency occurs (not always detectable by blood tests, although blood levels are usually lowered slightly), and organs that are highly dependent on a good supply of magnesium are further disrupted. This is particularly true of the brain and nervous system, muscles, blood vessels, gut and heart.
The metabolic acidosis combined with the ongoing respiratory alkalosis keeps the total acid-base status of the body reasonably in balance, but the buffers are constantly depleted.
BE stands for base excess and is the name of the blood test we can do to get a measure of the amount of available alkaline buffers. Both respiratory alkalosis and metabolic acidosis eventually lead to a decrease in the buffering capacity of the body.
In addition to allowing proteins and basic buffers to switch to their acid forms, the body can counteract the respiratory alkalosis by excreting bases, including basic buffers. Metabolic acidosis also leads to a reduction in the amount of alkaline buffers simply by consuming them as they counteract the lactic and other acids formed in working body parts.
Eventually, a situation of lack of alkaline buffers (low BE level) arises in the most affected organs, which thus find it very difficult to tolerate any additional stress (cf. fig.5 with the situation in fig.2). Any kind of work then leads to a severe exhaustion, as there is no longer any buffer capacity to deal with the acids formed during the work of the cells.
Affected patients describe how the slightest exertion, mental or physical, quickly leads to fatigue out of all proportion to the work done. Some patients who used to be active athletes describe how a stressful day or a kilometre-long light jog can feel like they have run a marathon. It can take a couple of days to recover from a walk, vacuuming the house, etc! Conflicts, extra demands and other stresses have unpleasant physical effects, increasing fatigue and pain.
This physiological burnout condition thus consists of two main components;
on the one hand, peripheral hypoxia and metabolic acidosis with depletion of the cells’ magnesium and alkaline buffers,
and on the other hand the respiratory alkalosis with left shift of the haemoglobin oxygen dissociation curve.
The former component can be detected with blood samples (and even better with tissue fluid samples = microdialysis), and the respiratory component can be measured with oxycapnometry.
Microdialysis
A new method called microdialysis allows us to aspirate small amounts of tissue fluid (interstitial fluid), allowing us to measure changes in the levels of several different substances affected by stress. We are still designing our microdialysis test battery, but so far we can analyse lactic acid, urea, free fatty acids and glucose, giving us a pretty good idea of the level of stress at different times.
A lot of work remains to be done to evaluate the role of microdialysis as a complement to oxycapnometry, but it shows great promise and has already provided important insights into the metabolic transitions associated with negative stress.
What are we analysing with oxycapnometry?
The oxycapnometer measures
– ETCO2 = end-tidal CO2 content in exhaled air. At the end of a real breath, it is alveolar air that comes out, and the gas mixture in this is the same as in arterial blood. ETCO2 is thus an indirect (but reliable, if the measurement method is controlled) measure of PaCO2 . Normally this should be 5.3 – 5.9%. Values above 6% mean that the patient is hypoventilating, probably due to chronic lung disease such as emphysema, but sometimes it may be due to compensation for a primary metabolic alkalosis.
– SpO2 = degree of saturation of oxygen binding to haemoglobin. Optimal value is 95-96%. 98-100% means that the left shift of the Hb-O2 dissociation curve has occurred, i.e. then Hb has assumed a “high-altitude form” and then takes up oxygen more efficiently in the lungs, but in return has more difficulty in releasing oxygen to the tissues.
– RR = number of breaths per minute, measured as the number of gas flow reversals. To interpret this figure, you need to keep an eye on the gas flow curve (see below).
– BVP = the curve at the top left shows how the blood flow in the finger varies. If the tone of the blood vessels is elevated, it can be seen as an abnormal appearance in this curve (amplitude, diastolic notch, base flow).
– gas flow = the curve on the bottom left shows how the gas flow varies. It shows whether incomplete breaths are being taken, diaphragmatic twitches, gasps, etc. This curve must be examined to decide whether the RR value is correct, and whether occasional low CO2 values are correct or due to tracheal air being analysed instead of alveolar air.
We use the oxycapnometer to
- check whether patients/trainees learning breathing techniques are actually doing the right thing. It can be very difficult to assess whether a beginner in mental training who is learning diaphragmatic deep breathing and breathing meditation is doing the right thing in relation to depth of breathing. There can be both hyper- and hypoventilation risk if not measured! We don’t need to do this measurement on everyone, but we should be generous and rather measure once too much than too little.
- Differentiate between different types of anxiety, myalgia, headache, depression, burnout, chronic fatigue, etc. We are then looking to see if signs of chronic hyperventilation are present. We can also see here if primary metabolic acidosis is part of the causal complex and if so, regular breathing training is contraindicated!
(The PFP test is relatively advanced and requires very good knowledge of how the physiology works and training in recognising what any pathological disturbances look like. Often needs to be supplemented with blood tests and physical examination).
- provide biofeedback to patients undergoing treatment that includes deep diaphragmatic breathing and/or other breathing correction.
Interpretation of oxycapnometry data
When interpreting oxycap readings, one must have a good understanding of respiratory physiology and its relationship to various mental and physical states. Basic facts have been presented earlier in this text. Below are some practical examples of common metrics and their most common meanings.
NOTE BENE: Oxygen saturation and carbon dioxide pressure alone cannot provide a definitive diagnosis. These values must be supplemented by other tests and physical examinations. The lists below should only be considered as starting points for the most reasonable preliminary interpretations.
- SpO2 95-96% + ETCO2 5.2 – 5.9 kPa = Healthy normal mode
- SpO2 98-100% + ETCO2 < 4.5 kPa = Hyperventilation, respiratory alkalosis
- SpO2 95-96% + ETCO2 > 5.6 kPa = Hyperventilation due to metabolic acidosis that is compensated respiratorily (may be due to diabetes, kidney disease, poisoning, etc.)
- SpO2 < 94% + ETCO2 > 5.9 kPa = Hypoventilation, usually due to chronic lung disease
- SpO2 97-99% + ETCO2 5.2 – 5.9 = Metabolic alkalosis (may be due to intestinal or liver disease, medication, etc.)