Managing Frustration, a Primary Factor of Health

Iva Lloyd BScH, RPE, ND

Face it, frustration happens, and for many people it is happening more often and more intensely. Not only are the demands and hectic pace of everyday life a constant cause for frustration, but we are also constantly reminded of how toxic our environment is and what we should not do, eat, say, and so forth. For patients who are facing lifestyle changes or the effects of a serious or chronic disease, how they manage frustration can be a primary factor that determines whether or not they achieve health.

Frustration is defined as a state that sets in when a goal-oriented act is delayed or thwarted. It is a feeling of dissatisfaction resulting from unfulfilled needs or unresolved problems. The closer you are to a goal, the greater are the excitement and expectation of the pleasure and the more frustrated you get by being held back. For some, frustrating situations can be motivating and stimulate the need for change; for others. they can result in feelings of powerlessness, depression, and anxiety. Dealing with frustrating situations can be beneficial because it can drive new learning and new skills.¹ Also, how a patient handles frustration is a good predictor of compliance with therapeutic regimens.

Development of Frustration Tolerance
Emotional regulation is defined as “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features to accomplish one’s goals.”² Starting in late infancy, children develop the capacity to self-regulate their emotions, particularly their negative emotions. By adolescence, there are already default reactions to frustrating situations. The primary intrinsic factor is temperament; extrinsic factors include parental style and the influence of other people and situations.¹ Humans, and other mammals, are creatures of routine and habit and show a consistent tendency to stick with their default behaviors.^3,4

There are several theories that attempt to describe the effect of frustration and to predict how a person will respond. Herein, I will discuss a few of them and illustrate how the view of frustration tolerance has emerged over time.
Self-determination Theory
How individuals handle stressful situations is accounted for by their expectations of control and their involvement in finding a solution.⁵ In self-determination theory, the regulation of human behavior is described with respect to intentionality and consists of the following 3 different types of behavior⁶:

• Amotivated Behavior. Amotivated behavior occurs in situations where a person feels incompetent and the outcome is dependent on an external source or is affected by restriction and barriers. If a person is continually faced with situations that are amotivating, a feeling of frustration, fear, and depression will often result.^1,6 Unpleasant or offensive events and the belief that outcomes are uncontrollable often manifest as symptoms of learned helplessness, including deficits in motivation, cognition, and emotion.⁷
• Control-Determined Behavior. Control-determined behavior is initiated or affected by environmental factors or is based on an individual’s behaving simply because he or she has to. This type of behavior is often accompanied by feelings of pressure or anxiety.
• Intrinsically Motivated Behavior. Intrinsically motivated behavior is initiated by choices based on one’s needs and integrated goals. It is the behavior that is most closely self-determined, without feelings of coercion or compulsion. It is also the behavior that is most closely linked to success, feelings of self-worth, and competence.⁶

Responses to Frustration
Research indicates the following 4 responses to frustration: intrapersistent, intrapunitive, extrapersistent, and extrapunitive.⁵

• Intrapersistent. These individuals try to reach a goal through their own forces. They take personal responsibility for the problem and show the greatest facilitation in performance. Failure is attributed to a lack of effort. These individuals demonstrate the highest tolerance of frustration.
• Intrapunitive. These individuals respond to frustration by blaming themselves and attributing failure to a lack of ability. They show the greatest impairment in performance and the lowest tolerance for frustration.
• Extrapersistent. These individuals try to reach a goal by asking for help from external sources and attribute failure to external factors.
• Extrapunitive. These individuals defend their egos by accusing and attacking an external frustrating agent and blame failure on external factors.

The greater the degree to which handling a frustrating situation is deemed to be under internal control, the more heightened a person’s involvement is and the greater the tendency to undertake an activity is. When a situation is deemed to be under external control, decrease motivation and involvement result.⁵

General Causality Orientations Scale
For both children and adults, the ability to handle frustration seems to depend on the balance between the degree of frustration and the motivators to sustain involvement in the task at hand.⁸ The factors at play include autonomy, competence, and relatedness. In 1985, the General Causality Orientations Scale⁶ was promulgated to assess the strength of these 3 different motivational orientations. The strength of a person’s causality orientation explains the variance in his or her behaviors, cognitions, and effects. This scale is a self-report questionnaire composed of 12 vignettes. The questionnaire is available online (www.psych.rochester.edu/SDT/measures/GCOS_12.php).

• ^· Autonomy Orientation. The autonomy orientation assesses the extent to which a person is oriented toward aspects of the environment that stimulate intrinsic motivation and that provide feedback. These individuals tend to have greater self-initiation, seek activities that are interesting and challenging, and take greater responsibility for their own behavior. They tend to organize their action on the basis of personal goals and interests rather than on controls or constraints. High-autonomy individuals have higher levels of self-esteem, ego development, and self-actualization,⁶ as well as greater integration in personality. For example, cardiac surgery patients who scored high on the autonomy orientation were found to view their surgery more as a challenge and to have more positive postoperative attitudes, whereas those who scored low on the autonomy orientation viewed their surgery more as a threat and had more negative postoperative attitudes.⁶
• ^· Controlled Orientation. The controlled orientation assesses the extent to which a person is oriented toward being controlled by rewards, deadlines, structures, ego involvements, and the directives of others. These individuals are typically more attuned to what others demand than to what they want for themselves. Control-oriented people seek out, select, or interpret events as controlling. They tend to do things because they think they “should.” The controlled orientation has been related to the type A coronary-prone behavioral pattern and to public self-consciousness.⁶
• Impersonal Orientation. The impersonal orientation assesses the extent to which a person believes that attaining desired outcomes is beyond his or her control and that achievement is largely a matter of luck or fate. People high on this orientation are likely to feel incompetent and ineffective. They tend to be amotivated and have no sense of being able to affect outcomes or cope with demands or changes. They are the most likely type to have depressive feelings and to suffer from anxiety.

Rational Emotive Behavior Therapy
Rational emotive behavior therapy proposes that dysfunctional (irrational) beliefs are central to emotional and behavioral problems. These beliefs can be grouped in 2 categories. The first category involves intolerance of frustration; the second category involves evaluation of self-worth based on meeting certain absolute conditions.⁹ Both lack of self-worth and intolerance of frustration are related to procrastination, task aversion, and fear of failure. Beliefs about intolerance of frustration are associated with problems of self-control and were hypothesized as having the most important roles in procrastination and in depression.¹⁰

Frustration-Discomfort Scale
The Frustration-Discomfort Scale was developed in 2003 as a multidimensional measure of frustration intolerance beliefs. Initial analysis of the Frustration-Discomfort Scale yielded a structure involving the following 4 dimensions¹⁰:

• Emotional Intolerance (eg, ‘‘I can’t stand situations where I might feel upset’’). This dimension showed mixed results with regard to procrastination and anxiety, indicating that there are probably other factors at play.
• Discomfort Intolerance (eg, ‘‘I can’t stand doing tasks when I’m not in the mood’’). This relates to the intolerance of difficult tasks and is a strong predicator of both procrastination problems and frequency, even after controlling for self-esteem.
• Entitlement (eg, ‘‘I can’t stand having to give into other people’s demands’’). This dimension was unrelated to procrastination problems or frequency yet showed a strong association with anger.
• Achievement Frustration (eg, ‘‘I can’t stand doing a job if I’m unable to do it well’’). This showed that individuals with high standards and conscientiousness have less procrastination but may have tendencies to overwork and increased levels of stress. There may also be greater correlation with anxiety and anger.

The Frustration-Discomfort Scale provides additional insights in that it indicates that anxiety can be motivating for some people and that irrational beliefs do not always lead to disturbance and in some situations may improve performance. It also suggests that procrastination is common and not always problematic: “In general, there has been a tendency for cognitive approaches to focus on self-worth rather than frustration intolerance beliefs. This may reflect the greater salience and accessibility of beliefs referring to self-worth, or the expectation that these are more meaningful. However, the present study suggests this is mistaken, and that beliefs regarding frustration intolerance are as important as self-worth and should not be overlooked.”¹⁰

Physiological Effect of Frustration
Theories that focus on the underlying physiological components of emotional regulation highlight that maturation of the central and autonomic nervous system provides the foundation for emotional and behavioral regulation. Measurement of the ability to regulate emotions in physiological systems should take into account the baseline pattern, the reactive response, and the attempt to return to baseline.¹¹ A common criticism and explanation for some of the controversy in the literature are single-dimensional measurements and measurements that do not take into account the natural circadian rhythm of the body.¹²

A greater frustration level was typically associated with an increase in salivary measures of the hypothalamic-pituitary-adrenal axis (cortisol) and the autonomic nervous system (α-amylase).^12-14 Total and peak cortisol levels due to stress exposure were increased among highly anxious, reactive aggressive individuals; decreased cortisol levels were observed among individuals who displayed low anxiousness and more of a proactive aggressive behavior. Reactive aggression reflects a hypersensitivity to perceived threats; proactive aggression tends to be goal oriented, often planned and unprovoked. Proactive responses are instrumental in assisting change and in achieving outcomes.¹³ The hypothalamic-pituitary-adrenal axis and sympathetic autonomic functioning represent an indicator of an individual’s frustration tolerance and management.^13,15 For example, it was found that low basal cortisol levels in the morning were associated with high levels of frustration and aggression.¹³

In animal investigations, an increase in β-endorphin, an endogenous opioid peptide implicated in reward processes, was found to correlate with levels of specific stressful and frustrating situations.¹⁶ As an example, it is thought that the removal of a pleasing situation is controlled by reward-associated cues. This is supported by evidence that opioid receptor antagonists decrease the conditioned reinforcing effects of natural and other rewards.¹⁶ Research also shows that when a default behavior is chosen it engages the ventral striatum aspect of the brain, which is the same area that is activated in situations of reward responses, such as winning. When a decision is made to switch away from the default behavior, the anterior insula part of the brain is activated instead.³

Cardiac vagal tone, an index of the functional status of the parasympathetic nervous system, has been viewed as a psychophysiological marker of emotion regulation and arousal.^2,17 Parasympathetic nervous system functioning is measured by the high-frequency variability in heart period (interbeat interval) and is primarily a result of respiratory influences. High vagal tone is associated with lower levels of aggression, greater empathy, social competence, and subjective feelings of sympathy and increased emotion regulation.¹⁸ Adaptive emotional response is believed to require the ability to switch attention from the source of distress and to redeploy it in ways that can reduce distress. Recent research indicates that low vagal tone may be associated with low frustration tolerance and with lack of emotional regulation.²

The mechanisms of human motivational control appear to be similar to those of other mammals.¹ This suggests that progress in understanding neurophysiological mechanisms of hedonic evaluation, frustration, and action regulation will soon enable the development of a comprehensive neuropsychological model.

Overcoming Frustration Treatment Considerations
Asking patients how they have previously handled frustrating situations is a good indicator of their default behavior and is a good predictor as to how they will handle current frustrating situations. Teaching patients emotional awareness and self-regulation skills is at the root of improving mental health and of modifying a patient’s ability to deal with stress.¹⁹

Intrinsically motivated behavior has been repeatedly associated with improved frustration tolerance and with the ability to achieve goals. This skill can be facilitated by ensuring that an individual’s basic psychological needs are satisfied, which include the following:

• Autonomy. This is the need to have input in determining one’s own behavior and reflects the degree to which a context provides choice, minimizes pressure to perform in specified ways, and encourages initiation.
• Competence. This is the need to experience productivity and to control outcomes and reflects the degree to which behavior-outcome relationships are understandable, expectations are clear, and feedback is provided.
• Involvement. This is the need to relate to or care for others and reflects the extent to which significant others are interested in and devote time and energy to a relationship.¹⁶

Having a sense of self-control is also an important factor in overcoming obstacles, making changes, and achieving results. The following are the processes involved in self-control:

• Vivid Awareness of Future Consequences. People do not make a decision to change unless there are expected long-term or short-term benefits. Expectations influence the motivation to deal with frustrating situations. Research shows that maintaining self-control and resisting temptation is more effective when the reasons for change are frequently brought to mind. The quality and clarity of the expectations and the reasons for change determine the quality and persistence of the actions taken.
• Ability to Overcome Learned Helplessness. The ability to overcome learned helplessness and to cope with change is related to perceived self-efficacy. Achieving self-efficacy is a skill that can be learned, but it often requires much practice and guidance.
• Ability to Overcome Tunnel Vision. When individuals are frustrated, there is a tendency to have tunnel vision in which the obstacle or frustrating situation becomes overpowering. Tunnel vision results in a narrowing of attention and in an impairment of coping skills. In this situation, it is likely that the default behavior will be chosen. Hence, coping skills learned in tranquility need to be practiced under stress to be effective when dealing with frustrating situations like compulsive behaviors or addictions.
• Development of Commitments. The act of making commitments changes the contingencies. The more that commitments are repeated, such as affirmations or reading of goals, the more influential they become. Commitments that are communicated to others are more likely to result in change.
• Acceptance of Anxiety and Frustration. Accepting and tolerating a fair degree of anxiety and frustration represent one of the most useful coping strategies. Understanding the situations that trigger these feelings and the default behavior is required to start to initiate change.
• Cue Exposure. There is greater likelihood that a person will be able to overcome default behavior when he or she practices coping skills in the face of temptation and not just in times of peace and quiet.²⁰ Repeated provocation of a compulsive urge, while resisting the temptation to carry it out, can result in a dramatic change.⁹ For example, among patients with a history of bulimia, binging and resisting the urge to vomit was successful among 71% of subjects, whereas cognitive restructuring was successful in only 33% of subjects.²⁰

More resources that individuals can use to manage their emotions are becoming available. For example, mobile phone applications have been found to be useful in improving self-awareness and in providing an immediate tool for relaxation and mindful activities.¹⁹ Books that teach skills on mindfulness and that educate patients about frustration are also beneficial. Because much of our increase in frustration is attributed to a society that reinforces immediate gratification, teaching patients or reminding patients about the value of patience is also valuable.

Frustration tolerance is a learned behavior that can be modified and improved with attention, time, and patience. How to become more tolerant of frustration may be one of the most important skills that a practitioner can teach a patient.

Dr Iva Lloyd, BScH, RPE, ND, graduated from the Canadian College of Naturopathic Medicine in 2002. In addition to her ND degree, Iva has a BScH in Life Sciences from Queen’s University, is a Reiki Master, a Registered Polarity Practitioner and Educator, and a Registered Holistic Nutritionist. Dr Lloyd is the founder of Naturopathic Foundations Health Clinic a multi-disciplinary clinic in Markham, Ontario that focuses on the naturopathic and energetic aspects of assessment and treatment. She is part-time professor at the Canadian College of Naturopathic Medicine and past-Chair of the Canadian Association of Naturopathic Doctors (CAND). She is the author of four books, ‘Building a Successful Naturopathic Practice’, ‘Messages From The Body – a guide to the energetics of health’ and “The Energetics of Health, a naturopathic assessment” and “The History of Naturopathic Medicine, a Canadian perspective.” She is also the founder and Editor-in-Chief of www.ndhealthfacts.ca

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