I spoke this week to Dietetics students about to head out on their final year of work placements. The focus of the presentation was looking after themselves.
It is common for someone like me (psychologist) or one of my Health, Counselling and Disability Service colleagues to speak to students heading out on placement, because of the known stress of these final years.
One of the things we talked about was the distinction between stress and anxiety and why it can be important to make the distinction.
These terms are often used interchangeably to communicate that a student doesn’t feel like they are coping with their placement – ‘I’m feeling stressed’, ‘I’m feeling anxious’.
This makes sense because experientially they can be quite similar. They can affect our physical body, how we think, our behaviour, our emotions and how we interact with others.
Physiological (experienced in the body) – low energy/fatigue, headaches, upset stomach, aches/pains/tense muscles, chest pain/discomfort, shallow quick breathing, more regular colds/infections, shaking, dry mouth, clenched jaw/teeth grinding
Psychological/thinking (experienced in the mind) – trouble concentrating, forgetful, indecisiveness, apathy, hopelessness, negative self-evaluation, worry, racing thoughts, disorganisation, inability to focus, poor judgement, pessimistic
Behavioural (how we act when stressed) – increased drinking or smoking, poor sleep, distracting activities (gaming/ internet), nervousness, avoiding other people, changes in appetite, procrastination, nail biting
Emotional (how we feel when stressed) – feeling anxious, out of control, overwhelmed, stressed out, unhappy, angry, irritable, tense, agitated, having difficulty relaxing
Interpersonal (how we act around other people) – short-tempered with people, clingy, aggressive, loss of trust
Both can result in episodes of extreme distress. In anxiety we might call these panic attacks. In stress we might call them breakdowns.
Whilst there are many similarities in how stress and anxiety present themselves, there is value in exploring how they are different, because this has implications for how we address them.
Stress
A good way to think about stress is as a response to an imbalance between the challenges/ demands of life, versus the resources you have to manage those challenges and demands.
When you have the necessary resources (time, money, social support, energy, health, knowledge, skills, coping strategies) to cope with the challenges and demands you are facing, then stress levels are low.
When the challenges you are facing you exceed your resources, then stress levels increase.
In this understanding, stress is the function of overload. Too much on your plate.
Someone who is feeling stressed has a few options. First, they can try to manage the symptoms of stress by using relaxation strategies or making lifestyle modifications (exercise, sleep, nutrition). This can work sometimes by providing just enough of a health/energy boost to tip the scales in favour of ‘resources’.
However stress is usually better managed by making medium to long-term changes that either significantly increase one’s resources or reduce the challenges. This might mean prioritising projects/activities and dropping or shelving some of them. It might mean reducing work hours. It might mean actively problem-solving particularly difficult stressors/challenges to see if they can be meaningfully shifted. This can mean tackling problems that you’ve been avoiding, even though you know they’ve been causing problems for a long time.
On the resources front, it might mean bringing new people into your support network (including professionals), asking for help, increasing your financial resources or building up your psychological coping toolkit (e.g. problem solving ability, emotional self-regulation).
For students on placement, this translates into:
- Asking supervisors for assistance
- Reducing the number of other things they are trying to do at the same time as their placement (e.g. work, volunteering)
- Focusing on practising the skills necessary to do the most difficult placement tasks
- Calling on friends and family for financial support during placement periods
- Eating well and getting plenty of sleep
Thus when you are feeling stressed, the solution is problem-solving the discrepancy between your resources and the challenges/ demands you are facing.
Anxiety
A useful way to think about anxiety is as the result of unrelenting and typically irrational and self-defeating fears/ beliefs.
‘I will always fail, no-one likes me
I can’t do anything
I can never be perfect
I’ll make a fool of myself
I’ll never find love again
I will always be alone’
These beliefs, which can operate in both the foreground and background of our minds shape how we see the world, how we react to situations and provide the fuel for a constant state of fear and worry.
Notice how these fears/beliefs are absolutist – always, anything, never. They’re gross distortions of reality and can be self-defeating, because to believe them is to feel hopeless and out of control and see no point in trying. They lead us to avoid people or situations or contexts in which we worry they’ll be affirmed. They end up shrinking our world.
Irrational beliefs need to be confronted directly.
At the emotional and cognitive level this might include meditation/ mindfulness where we become more familiar with these beliefs but less reactive to them (learn to sit with them, whilst still pushing forward in our lives). It might also involve learning to identify and challenge these beliefs through models of therapy like CBT.
At the behavioural level, it means identifying those situations or contexts that we most fear, and deliberately pushing ourselves to be in those situations. For example, if a student fears most talking to a room of other health professionals (for fear of being negatively evaluated), this is the situation they need to put themselves in more regularly, in order to develop a more accurate sense of what that situation actually involves. We call it ‘exposure’.
It is possible to be stressed and anxious
We definitely see students who are experiencing both overload and irrational fears – stress and anxiety. Those students have the somewhat unenviable task of both exploring how to scale back the demands on them and also confront the fears that are holding them back.
We also see situations where long-standing stressful situations start to create irrational fears. An example might be a student who has been trying to juggle work, study and a complex family situation for a long time who starts to seriously doubt their capacity to work in their profession (irrational because they are not considering the load they’ve been carrying).
It is because of the ease at which any of us can end up in one of these stress/anxiety spirals that we try to talk to students before they head out on placement and give them the heads-up on what to look for and what to do if they notice the emergence of these kinds of problems. It doesn’t change the fact that clinical placements can be stressful, but we hope it gives students some useful filters through which to view placement stress.
Final words
Certain words like anxious and depressed have made it into common parlance, joining words like stressed, overloaded, exhausted.
We sometimes use them interchangeably but this can hide subtle distinctions that are informative about how to manage them.
Distinguishing between stress and anxiety is useful because one involves a reassessment of one’s resources and challenges. The other involves an assessment of one’s beliefs and fears.
Hope you found this helpful.
Dr Gareth Furber 