Years of research have demonstrated the strong relationship between physical and emotional health, which runs in both directions: Just as the worsening of physical symptoms can diminish your emotional well-being, improving your emotional state can minimize physical symptoms. The experience of having a painful or physically limiting health condition is no exception to this phenomenon. People with chronic, painful conditions report declines in social, recreational, and household activities, and they are at a greater risk for depression. Sometimes the emotional toll of a painful or disabling condition is a greater threat to a person’s well-being than the condition itself.
Arthritis, specifically, is associated with feelings of depression and anxiety. Missing out on activities with friends and family or being unable to tend to your needs because of joint discomfort may lead to feelings of helplessness or a depressed mood. Many aspects of having arthritis, such as pain, swelling, stiffness, stress, or the perceived lack of self-efficacy, can threaten emotional well-being. Self-efficacy is the belief in one’s ability to achieve a specific goal (“I will take a walk today even though I am having pain”) or outcome (“I can live a normal life even though I have arthritis”), and it is very important to self-care.
Sound emotional health is necessary for good self-management of arthritis, just as good self-management is necessary for overall health and well-being. Good self-management usually means taking a broad approach that includes prevention efforts (of pain, for example), following prescribed treatments, managing symptoms, and working toward certain lifestyle and behavioral changes. Sometimes a vicious cycle can develop in which poor emotional well-being makes it more difficult to take care of one’s medical condition. Feelings of hopelessness and despair may reduce motivation and self-efficacy, leaving a person feeling despondent and unwilling (or unable) to manage his condition.
But a variety of emotional self-care strategies can have a dramatic impact on the lives of people with chronic conditions, resulting in improvements in both mood and physical symptoms. The Arthritis Self-Management Program was a large study conducted to see if providing education with self-care strategies in group sessions could improve people’s self-efficacy and self-management, as well as reduce pain and alleviate depression. Participants who received this education did report improvements in these outcomes; remarkably, these improvements were so lasting that even four years after attending the sessions, these participants had better outcomes than others who did not attend the sessions. When it comes to arthritis self-care, identifying strategies that help to cultivate a sense of mastery over pain and physical limitations can be critical to better emotional well-being. This article describes some self-care strategies that have been shown to help many people make the best of living with a chronic medical condition.
Relying on the support of family and friends is an excellent way to reduce stress and improve emotional health. Being able to share burdens and stressful events with people you feel close to has great value, and socializing and enjoying quality time with family and friends can actually trigger physiological changes that decrease feelings of depression and anxiety.
Research has consistently shown that social support is important to achieving and maintaining good emotional and physical health. But not all support is positive. Support is helpful when it meets your individual needs. When friends or relatives act in ways that feel overbearing, intrusive, or controlling, it’s not helpful, even if they mean to be supportive.
In a study that examined how social interactions were related to depression in people with rheumatoid arthritis (RA), positive, or helpful, support from close friends and family was tied to lower rates of depression, while problematic support was associated with higher rates. When seeking support, therefore, look for individuals who can offer what you need, not people who second-guess you, refuse to take your problems seriously, or seem to be trying to take over rather than assisting you.
The positive effects of exercise on physical and emotional well-being have been seen in study after study, both for the general population and for people with a variety of chronic medical conditions. Some research has focused specifically on whether exercise is helpful for people with arthritis, either physically or emotionally (or both). One study of 120 people with either osteoarthritis or RA found that aerobic exercise, such as walking or swimming, was associated with better physical health and greater emotional benefits than range-of-motion exercises alone, and that aerobic exercise was also viewed positively by those who did it. In fact, one year after enrolling in the study, 60% of those who began aerobic exercise were still doing it regularly and maintaining health benefits such as lower blood pressure. Importantly, this study also found that aerobic exercise was associated with decreased feelings of depression and anxiety. In addition, these promising results highlighted that walking and swimming are excellent ways to be physically active. When considering exercise options, these activities may be more feasible for many people with arthritis than more vigorous options, yet still yield meaningful results.
There are many types of relaxation training. Two that have been studied and found effective are breathing exercises and guided imagery. Deep breathing and focused breathing exercises can serve as simple, quick, and effective methods for reducing stress, lowering blood pressure, and even relieving digestive problems. Numerous examples can be readily found online.
Guided imagery uses images and imagination to achieve relaxation and sometimes greater insight or understanding of emotional or physical concerns. One common way to get started is to envision a relaxing, enjoyable setting, then to explore the feelings, sounds, scents, and other aspects of the imaged scene. Guided imagery can also involve imagining things such as the flow of stress and negative energy out of the body, or the lifting of pain from the body.
These techniques can have many benefits on emotional health, including reducing anxiety and pain, especially when more than one technique is used. In a study in which people with RA were taught to use imagery as part of a cognitive-behavioral treatment, participants experienced reductions in depression and stress, coped more effectively with their condition, and reported getting more, and better, sleep.
How often do you really have a chance to stop and smell the roses? Mindfulness exercises teach us how to focus on the present without distractions. Since the 1950’s, many researchers have explored both the physiological and the psychological effects of mindfulness meditation, which has its origins in Buddhist teachings of mindful awareness. For the past two decades, numerous studies have explored the efficacy of various mindfulness techniques in people with chronic illnesses. Among these techniques is a health education and stress-reduction program called Mindfulness-Based Stress Reduction (MBSR). Studies suggest that MBSR can alleviate stress and depression in people with painful conditions. Practicing mindfulness may also help limit the distractions that chronic medical conditions often pose as you try to go about your daily life.
There are many types of mindfulness exercises to choose from. Examples include focusing on your breathing for a set amount of time; paying close attention and trying to understand others before making any judgments or inferences; observing a familiar object more carefully, seeing if you notice anything new; and the “raisin exercise,” which promotes an awakening of your senses. In this exercise, a person prepares to eat, and then eats, a raisin while considering every detail of the experience (color, texture, feel in the hand, odor, etc.).
The work of Dr. James Pennebaker and others has shown the value of expressive writing, or writing therapy. Initial studies of this approach asked college students to write about an important emotional issue for about 20 minutes a day over three consecutive days. Results showed improvements in both emotional and physical well-being, such as improved mood and reduced use of health-care services. Given these findings, it made sense to try this approach with people with a variety of medical conditions. A study that examined the impact of expressive writing on the well-being of people with RA (and asthma) found that participants’ health improved as a result, as determined by rheumatologists’ ratings. It may be the case that keeping a journal, if done regularly and used to examine difficult issues, is an excellent form of self-care.
Personal narratives, or the act of narrating one’s life story (orally or in writing), have also become a popular coping strategy for people with physically limiting conditions. Research on this technique has often focused on the need to make meaning out of the disruption that a chronic illness presents. Depending on a person’s age at diagnosis, a chronic illness can disrupt his very identity, leading to feelings of being defined by sickliness or a lack of control over the body. Personal narratives let people tell their life story in a way that injects meaning and order into these disruptive, unforeseen life events. Research suggests that narrative techniques focused on building one’s identity and finding meaning can lead to positive self-transformation in people who have experienced negative life events.
Expressive therapy does not necessarily need to involve writing; it can also take the form of artwork, photography, film, or other media. It also does not need to focus entirely on the experience of living with illness to be helpful; in fact, examining the positive along with the negative aspects of one’s life can be very helpful for some people. Personal narratives require the individual to act as the storyteller, and to narrate his life and experiences in a way that is coherent and examines the past, the present, and perhaps also the future. For example, you might organize your life into chapters with key scenes or events. The life story that people construct as part of this therapy tends to be internalized, giving them a greater sense of meaning and purpose.
Sometimes the demands of a painful or physically limiting condition lead to chronic depression or anxiety that cannot be effectively treated with social support and self-care strategies alone. In these cases, psychotherapy may be a good option. Research has shown that many people with arthritis may not be receiving the mental health services they need to help alleviate their depression or anxiety. In one study, only about half of people with arthritis who reported having chronic depression had received treatment for it.
The benefits of psychotherapy are far-reaching and may include learning coping skills, developing strategies for consistent self-management, and achieving better overall emotional well-being. These gains may even lead to better physical well-being. The list of resources on page 8 includes some useful Web sites for finding a psychotherapist in your area. Ideally, you should seek mental health care from a psychologist or clinical social worker who is licensed to practice in your state (not a “counselor” with little or no formal training).
Putting it together
Here is a real-life example of someone using a few of the strategies described above. At age 23, Mary began experiencing pain in her knees that at times was so severe she had difficulty walking. Now 25, she has been unable to work consistently since the pain started. Eventually, Mary was diagnosed with polyarthralgia. However, for a long time, Mary felt that her expressions of pain were not being taken seriously, perhaps due to her young age. Mary found herself frequently experiencing feelings of sadness. Sometimes she found that feeling sad and lethargic made it more difficult to follow her medical regimen. She decided to speak with a psychologist, Dr. Cordova, affiliated with the hospital where she came for her rheumatology appointments.
Dr. Cordova recognized that Mary was a bright young woman struggling to live a “normal” life. She began their work together by helping Mary implement some of her medical team’s suggestions, such as engaging in more physical activity. Specifically, they problem-solved barriers to exercise and set goals for Mary. At the same time, Dr. Cordova taught Mary mindfulness exercises, which Mary found to be helpful. Mary also noticed that walking usually made her feel better, not worse, and more energetic.
Dr. Cordova saw that Mary was fairly isolated. Her substantial pain and medical needs had resulted in her withdrawing from friends and even family. Together, they discussed the importance of social support for overall well-being. Mary agreed to spend more time with her friends and family. She described feeling less depressed as she became more active and socially engaged. Finally, Mary mentioned her love of writing, and Dr. Cordova suggested that she write about herself. Mary embraced the idea of constructing a personal narrative, and she also began keeping a regular journal. After just a few sessions, Mary felt that she had gained some very helpful coping skills. She began to see Dr. Cordova less frequently as she felt more able to care for herself emotionally.
Chronic painful or limiting conditions can test even the strongest of wills, leading to feelings of despair that you may not even be fully aware of. Regardless of how severe your arthritis is, or how much pain or inconvenience you experience, chances are good that you can benefit from one or more of the techniques described in this article. Whatever you do, remember that your emotional well-being is important and may require your attention, and that it can affect (and be affected by) your physical condition. Once you accept that your emotions are as much a part of you as your joints, you may find that you treat yourself with the kindness and consideration you deserve.
The following resources can help you put into practice a few of the many possibilities for improved emotional health.
Full Catastrophe Living
New York, 1990
Mindfulness Meditation for Pain Relief: Guided Practices for Reclaiming Your Body and Your Life (Audio CD)
Sounds True, Inc.
Louisville, CO, 2009
Opening Up: The Healing Power of Expressing Emotion
James W. Pennebaker
New York, 1997
“The Life Story Interview” (Web page)
Foley Center for the Study of Lives, Northwestern University
National Association of Cognitive-Behavioral Therapists
Association for Behavioral and Cognitive Therapies