iCBT Program for Chronic Pain

Module 5. Stress

Scenario: You have been in pain for 2 weeks following a motor vehicle accident and are unable to go back to work for now. This is causing you very bad anxiety. Because of this, you are unable to sleep properly at night. Insomnia begins to stress you out. Your pain begins to worsen. A vicious cycle begins.

What is causing the excess anxiety, followed by insomnia? Is it preventable?

Stress is our reaction to a situation. It is not the actual situation that is causing the stress, but the emotional reaction.

As you can see from the scenario on the previous page, stress can increase our suffering in a “bad” situation.

If we learn to decrease stress and control our emotions we will, in turn, suffer less anxiety and depression.

stressed woman

Stress Model of Chronic Pain

Repeated prolonged episodes of pain provoke a sustained stress response, contributing to the pain experienced by the patient, which further maintains the stress response.

Think of it as a cycle…

pain cycle

Stress Management

The S.T.R.E.S.S Technique
S: Self Awareness
T: Time Management
R: Relaxation
E: Exercise
S: Share
S: Self Talk

S: Self Awareness

Know your body and how it reacts to stress.

See the symptoms that you develop, and take steps to relieve the stress before it gets too high.

Look for heart rate increases, muscle tension, headaches, jittery behaviour, lack of focus, changes in breathing, and excessive (or lack) of energy.

T: Time Management

Create a schedule for your daily plans.

This will ensure you have time to do every activity you wish to do, including finding time for relaxation, exercise and activities you enjoy.

Staying organized is key to stress reduction.

Time Management – Activity Planning

To help combat stress, use an agenda so that you can visualize your schedule. This will help you ensure that you are never too busy to schedule in time to do the things you enjoy.

Two times a week, schedule an activity that you enjoy doing to relieve some of the stress.

Click here to download the Activity Selection sheet.

Using the Activity Selection sheet, rate the list of activities as enjoyable, neutral, or not enjoyable.

From this list, or any additions you have made, choose the activities you rate enjoyable to incorporate into your schedule.

R: Relaxation

Relaxation will help with all physical reactions to stress including: laboured breathing, heart rate increases, muscle tension, and more.

You will be taught relaxation techniques in the next few modules, which you can learn and use to control your physical reaction to stress.

E: Exercise

Exercise is a great way to remove some of the energy built up by stress and can help you feel more relaxed.

Try going for a walk around the block when you feel stressed.

You will be taught exercise techniques in the coming modules to help reduce stress and maintain mobility – this is crucial for someone in chronic pain.

S: Share

A helpful way to deal with stress is to choose a person, or a group of people in your life that you can talk to about problems or stressful situations.

You can utilize each other to get another perspective on your stressful situations, or even just to talk out the problem with someone instead of keeping all of your emotions internalized.

It is very beneficial to have at least one person in your life that you can confide in.

S: Self Talk

The use of positive self-talk is instrumental in lowering stress.

When you feel stressed, close your eyes and repeat to yourself that you can do this. Give yourself 5 minutes of only words of encouragement.

Write a list of some positive affirmations so you can always be reminded to use positive self-talk. Examples: I am strong, I will get better, I love myself, life is beautiful.

Homework for Module 5

Using the S.T.R.E.S.S technique, complete the following components for 7 days.

Now that you have learned about each “letter” of STRESS, put your pen to paper and get to work. Writing things down on paper helps to create change.


Click here to download the Physical Reactions sheet.

Make note in the Physical Reactions sheet of how your body reacts to stress. As new stressful events occur, refer back to this list and add to it.

Use this list as a way to be self-aware of when you are stressed, based on how your body is reacting.

List the physical reactions you experience over the next week.

Time Management:

Using the list of activities discussed earlier in the module, take the ones you have selected as “enjoyable” and include them in a daily agenda right now.

Select 1 or 2 activities a day, for 7 days, and see how incorporating enjoyable activities into your routine will affect your mood, your pain levels, and your enjoyment of everyday life.


Select 7 exercises that you are able to do with your current levels of pain, and complete one each day to the best of your abilities. You will learn more about the importance of exercising in the coming modules.

Examples of Exercises: take yoga classes, walk around the block with your dog, do tai chi in the park, take aquafit classes at the community centre.


Grab a pen, and blank sheet(s) of paper. Put a timer on for anytime between 5-20 minutes (if this is your first time, try starting at 5 minutes). You can play music in the background during this time, but non-lyric music is best.

When you hit start on the timer begin writing. You can write about anything that comes to mind, but never move your pen off the page. Continuously write for the full time.

What you write does not have to make sense; it is every thought that pops in your head during that time. When you are done, read everything you wrote.

If you do this exercise daily, you will find that a lot less disruptive thoughts will repeat constantly in your head. (Your hand may be sore the first few times from the continuous writing).


EACH DAY write 5 things to motivate yourself.
Examples: I can do it, I am a priority, I have done/will do my best, challenges are made to overcome.

Some tips on writing positive affirmations:
  • Always use the first person: “I” or “My” or “Me”.
  • Use the present tense.
  • Don’t use negative terms. Example: when you are afraid to fail, instead of “I will not fail” use “I will succeed”.
  • Only use phrases relatable to you. For example, don’t say “I will get 100%” but say “I will put in 100% effort” or “I will do my best”.

Exercises for Different Areas of Pain from Wilderman Medical Clinic

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