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vii
Foreword
Relaxation is a word that is commonly used across layout of the content is such that specific tech-
many different cultures to describe a range of niques can be readily accessed as stand-alone chap-
feelings, emotions and behaviour. It is associated ters; however, for health care students and health
with feelings of pleasure, control and self-assurance; professionals to benefit fully from the knowledge
emotions of laughter, calmness and tranquillity; carefully and systematically brought together by
activities such as resting, exercise, massage, the author, the text should be read in full.
bathing, listening to music, eating, drinking alco- The book is presented in a logical sequence start-
hol and relaxation training. Health professionals ing with a review of stress as a concept that can be
and lay people alike are regularly informed by explained by various physiological, endocrinologi-
articles in the popular press, texts and scientific cal and psychological theories. The rationale for the
journals of the benefits of relaxation for health; techniques presented in subsequent chapters high-
however, there is often uncertainty about what is lights the theoretical links where these are explicit
meant by relaxation, which technique to choose and identifies where techniques are based on prin-
and how to go about it. ciples that may not fit or may overlap with more
The need for relaxation as a therapeutic interven- than one of these existing theoretical positions. As
tion is evidenced through the links between stress well as the underpinning rationale, a summary of
and illness; when undertaken as part of our every- the research evidence to support each technique is
day activities, relaxation can provide a mechanism discussed. The importance of reviewing the evi-
for lowering stress and thus offer some protection dence to inform decisions in practice is reiterated
against stress-related problems. Health care profes- in Chapter 27, which includes a useful discussion
sionals such as psychologists, nurses, physiother- on issues around current research, on strengths to
apists, occupational therapists, speech and language date and on future directions. This chapter also
therapists, social workers, GPs and professionals contains an interesting discussion around selection
such as coaches and sport and exercise scientists of techniques. Chapter 23, highlighting ‘on-the-
working in the health and leisure industries may all spot’ techniques, is crucial for putting into practice
be involved in teaching relaxation techniques. a shortened version of what has previously been
The third edition of this popular textbook retains learned.
its eclectic and practical approach, presenting a Relaxation Techniques will continue to provide a
number of additional relaxation techniques along useful guide for health professionals, students and
with those previously included, all of which can be lay people who wish to increase their understand-
successfully self-taught or taught by health care ing of stress, its causes and its impact on health. It
personnel. The text is well illustrated and this is also provides a concise and detailed summary of
helpful for gaining an understanding of the various measurement strategies that can be used to evalu-
techniques and putting them into practice. The ate the outcome of interventions designed to
viii FOREWORD
reduce or alleviate the effects of stress. The book is selected for the right situation. For lay people, this
eclectic, with no one method being presented more book raises awareness of relaxation as a strategy to
favourably than another, the author acknowledg- improve physical and psychological health; and
ing that in practice, physical and cognitive methods for readers wishing to teach themselves a method
are often presented together. For students, this sin- of relaxation, there is plenty of choice.
gle volume provides theoretical underpinning, This book provides essential information that
evidence from current research and practical appli- will be useful to those involved in training others
cation of many different techniques of relaxation. in relaxation techniques and to individuals who
In this regard it is a unique and useful text. For wish to teach themselves skills of relaxation, irre-
clinicians, this is a useful bench text with opportu- spective of the level of prior knowledge of the
nity to extend existing practice through the intro- topic or practical experience. This third edition is
duction and application of additional approaches an exciting addition to the current literature, bring-
which are informed by both current research and ing further techniques and greater indepth discus-
current practice. Techniques are presented with an sion and critique to the topic. Read on; you will
explanation of why they are useful, how to use find the direction given by the author to be prac-
them, where they have been evaluated, where they tical, meaningful and stimulating, with new points
can be used interchangeably, and what needs to be of debate emerging.
done to ensure that the best techniques can be Marie Donaghy
ix
Since the preface to the first edition of Relaxation Particular thanks are offered to Marie Donaghy
Techniques was written, developments in the health who has been through the whole manuscript
care scene have created a new emphasis on evi- making useful suggestions and contributing many
dence of effectiveness. This has led to the need for of the ideas which appear in this edition. Her advice
an additional chapter on the results of research. has been invaluable and I am again greatly
New evidence has also been incorporated into the indebted to her. The people who so kindly helped
individual chapters and may be found in their with the first and second editions are also remem-
sections on evaluation. bered for their valued assistance, with a special
The chapter on exercise (Ch. 14) has been appreciation in respect of Margaret Polden and
rewritten to take account of developments in that June Tiley, who have sadly since died. I would
field; it also contains an expanded section on the also like to acknowledge the guidance I have
psychological effects of physical activity. received from the publishers, Elsevier, and to
Chapter 26 now carries a passage relating to thank them for the way they have presented the
audit, in acknowledgement of the importance of work.
this topic, although the contribution made here is This edition focuses on the same techniques
no more than an introduction to what has become as the first one, i.e. techniques which are easily
a major subject. learned and which can be readily applied in the
This third edition contains two new chapters, stressful situation, wherever it arises. It is hoped
one on cognitive behavioural approaches, reflect- that the work in its present form will provide
ing their increasingly dominant position (Ch. 22); the reader with useful additions. In essence, it
the other on techniques which did not appear in remains the same book in an expanded and
earlier editions (Ch. 24). There is also a glossary updated form.
and a table (Appendix 3) suggesting certain tech- Rosemary Payne
niques for specific conditions. Cardiff 2004
xi
A few years ago, when giving a talk on relaxation The book begins with a review of some of the
techniques, I was asked by a social worker if the theory surrounding stress and relaxation. This is
techniques I was describing could all be found in followed by a chapter on general procedure which
one publication. I said I knew of no book which is applicable to all methods. Chapter 3 discusses
contained them all. Since then, other health care stress, beginning with a further passage of theory
professionals have, on different occasions, put sim- and moving on to consider a variety of practical
ilar questions to me. Is there a book which focuses coping skills. The following 19 chapters deal with
on the practical side of relaxation training? Can the specific techniques: 12 chapters are, broadly speak-
detail of the methods be found under one cover? ing, concerned with physical or muscular tech-
Many books mention relaxation techniques but niques and seven deal with mental or psychological
tend not to present them in any depth, unless the methods. There follows a chapter concerning
entire work is devoted to a single method. It seemed ‘on-the-spot’ techniques for dealing with stressful
that there was a gap which needed to be filled. situations, using skills drawn from earlier lessons.
It is estimated that 80% of modern diseases have Relaxation in the antenatal context is the subject of
their beginnings in stress (Powell & Enright 1990) Chapter 25*, and is included because of the promi-
and that stress-related illness accounts for at least nent role that relaxation plays in the field of obstet-
75% of GP consultations (Looker & Gregson 1989). rics. Assessment is addressed in Chapter 26, and
As concern about the safety, efficacy and cost of the final chapter takes a look at a few topics not so
psychotropic drugs grows (Sibbald et al 1993), far discussed: the relation between the approaches
there is increasing interest in non-drug treatments, themselves, some ways in which they can be com-
of which relaxation training is an example. bined, and a brief reference to approaches which
The book is addressed to health care profession- are not included. Physical and psychiatric dis-
als such as nurses, occupational therapists, physio- orders are not within the scope of this work.
therapists, speech and language therapists and Techniques whose main purpose is to promote
social workers; GPs and psychologists also may relaxation are termed primary. The ‘muscular’
find it useful. It can equally be used by lay people methods belong in this category, as does autogenic
since it is written in a jargon-free style. training. Where relaxation is not the main purpose,
Factors of practicality have governed the selec- the technique can be seen as secondary: visualiza-
tion of methods. Thus, techniques which require tion, meditation and the Alexander technique fall
expensive equipment or specialized expertise are
not included, while the methods chosen are those
* To avoid confusion, the chapter numbers have been changed
which lend themselves to presentation in small to match the chapter numbers in the third edition rather than
group settings. the first.
xii PREFACE TO THE FIRST EDITION
into this category. Other approaches which enhance to the trainer as female. The trainee is referred to as
relaxation may be still further removed. These male in Chapters 2–15 and as female in Chapters
include cognitive techniques such as uncovering 16–28.
irrational assumptions and modifying automatic The words ‘trainer’ and ‘instructor’ are both
thoughts. Here, relaxation can be seen as a side- used, the choice being largely determined by the
effect rather than a goal (Fanning 1988). nature of the method: for example, in autogenics,
It is not intended that health care professionals progressive relaxation and behavioural relaxation
should, on the strength of reading this book, con- training the word ‘trainer’ is often used, while in
sider themselves teachers of autogenics and the imagery, meditation, Alexander technique and
Alexander technique. These two methods are Mitchell’s approach, the word ‘instructor’ seems
included to indicate their contribution to the field; more appropriate. The word ‘therapist’ is also
they are described for interest and for the applic- used where it seems fitting.
ability of their central ideas. For example, images A number of people have helped in the making
of warmth and heaviness (autogenics) are relaxing of this book. One important contributor is Keith
in any context, as also is postural advice (Alexander Bellamy, whose photographs have done so much to
technique). Such concepts have universal value. make the book what it is, not forgetting Sarah
Indications of the effectiveness of the techniques McDermott, who acted as the model. With regard
are included but the book does not set out to review to the text, Ian Hughes has given invaluable help in
the evidence from the scientific literature. Other his careful reading and refining of the chapter on
works do that, for example Lichstein (1988). Pitfalls measurement. I would also like to mention those
associated with some methods are listed at the end who have read other chapters and to whom I am
of the relevant chapters. indebted for their helpful suggestions. Alexandra
The word ‘relaxation’ is used in two ways here Hough, Wendy Mair, Margaret Polden and Jim
as it is in other works: first, in a general sense where Robinson have all been kind enough to do this,
it signifies a global state of rest; and second, as a and Christopher Rowland Payne undertook to
technique such as progressive relaxation. It is diffi- read the whole manuscript. Thanks also go to
cult to avoid both meanings in a book of this sort; Michael Adams, Joyce Gibbs, Olga Gregson,
however, efforts are made throughout the work to Andrzej Kokoszka, Brenda MacLachland, Pat
distinguish the meanings wherever ambiguity Miller, Alison Ough, Stuart Skyte, Dinah Thom,
arises. June Tiley and Elizabeth Valentine. Finally, a word
The author is aware of the implications of of appreciation for the members of all the groups
gender-weighted language. She is also aware of the with whom I have worked. Without them, this
cumbersome phrasing that can result from a deter- book would never have been written.
mination to avoid sexist forms of speech. In an
attempt to avoid both traps and for the sake of clar- Rosemary Payne
ity, it has been decided to refer throughout the book Cardiff 1994
3
Chapter 1
Theoretical background
3. As a coping skill, to calm the mind and allow Figure 1.1 The autonomic nervous system.
thinking to become clearer and more effective.
Stress can impair people mentally; relaxation can individual to make a physical response. The
help to restore clarity of thought. It has been found changes are collectively known as the ‘fight–flight
that positive information in memory becomes more response’ which is characterized by an increase in:
accessible when a person is relaxed (Peveler &
● heart rate
Johnston 1986).
● blood pressure
● blood coagulation rate
Mechanisms thought to be responsible for bringing
● blood flow to voluntary muscles
about the state of relaxation have been explored,
● glucose content of the blood
giving rise to a number of theories. Some of these
● respiratory rate
emphasize physiological aspects, such as auto-
● acuity of the senses
nomic activity and muscle tension, while others
● sweat gland activity
focus on psychological elements such as attitudes
towards the self. The major theories are briefly and a decrease of:
described below.
● activity in the digestive tract.
In the absence of challenge or excitement, these
PHYSIOLOGICAL THEORIES
actions are reversed: the sympathetic nervous sys-
tem loses its dominance and the parasympathetic
Body systems associated with the states of stress
assumes control. The actions of these systems are
and relaxation include:
shown in greater detail in Figures 1.2 and 1.3.
● the autonomic nervous system Some of the changes which occur as a result of
● the endocrine system and sympathetic stimulation produce noticeable symp-
● the skeletal musculature. toms, such as an increased respiratory rate, stom-
ach cramps and cold sweat. States such as fear and
The autonomic nervous system
anger illustrate this and underline the association
Physiological arousal is governed by the autonomic between the emotions and the internal organs.
nervous system. This has two branches: the sym- When the changes are pronounced and occur fre-
pathetic, which increases arousal when the organ- quently, the organs concerned can become fatigued
ism is under threat, and the parasympathetic, and this has given rise to the concept of psycho-
which restores the body to a resting state. Their somatic illness (p. 27). The relaxation response
actions are involuntary and designed to enable the method of Benson aims to counteract the effects of
organism to survive (Fig. 1.1). sympathetic activity by promoting the action of the
In a situation of challenge, excitement or danger parasympathetic nervous system (Ch. 21), thereby
the sympathetic nervous system increases the exploiting the reciprocal nature of the two parts of
activity of the heart and redistributes blood from the autonomic nervous system.
the viscera to the voluntary muscles. Blood pres- However, activity of the parasympathetic sys-
sure and respiratory rate are increased; sensory tem is not always benign (Poppen 1988). Asthma is
awareness is heightened, and there is a mechanism exacerbated by bronchial constriction and gastric
for losing excess heat. These factors enable the ulcers by acid secretion. Both bronchial constriction
Theoretical background 5
Pupil dilated
Iris muscle
Slightly relaxed
Superior Blood vessels in head Vasoconstriction
cervical
ganglion Salivary glands Secretion inhibited
Inferior
mesenteric Bladder Smooth muscle wall relaxed
ganglion Sphincter closed
Figure 1.2 The sympathetic outflow, the main structures supplied and the effects of stimulation. Solid lines ———,
preganglionic fibres; broken lines ---, postganglionic fibres. (From Waugh & Grant 2001.)
and acid secretion are associated with parasympa- the action of the internal organs in response to
thetic dominance, yet the conditions of asthma environmental stimuli.
and gastric ulcer are often relieved by relaxation When a situation is perceived to be stressful the
and aggravated by stress. The theory is not consist- brain immediately responds by stimulating the
ent regarding these conditions (Ch. 27, p. 232). adrenal medulla to release the catecholamines
adrenaline and noradrenaline. The function of these
neurotransmitters is to prepare the organs for action
The endocrine system
by, for example, increasing alertness and redistrib-
Closely associated with the autonomic nervous sys- uting the blood. Acting in the longer term, the
tem are the endocrine system and the adrenal glands. pituitary gland releases the adrenocorticotrophic
These are situated above the kidneys (Fig. 1.4) and hormone (ACTH). This stimulates the adrenal cor-
consist of medulla and cortex (Fig. 1.5). Their tex to produce mineralocorticoids and glucocorti-
function is to produce hormones which modify coids, the most important of which is cortisol, which
6 INTRODUCTION
Pupil constricted
Iris muscle Contracted
III Ciliary
Lacrimal gland Tear secretion increased
Figure 1.3 The parasympathetic outflow, the main structures supplied and the effects of stimulation. Solid lines ———,
preganglionic fibres; broken lines ---, postganglionic fibres. (From Waugh & Grant 2001.)
helps to maintain the fuel supply to the muscles. and the stress response is no longer needed, the
In this way it supports the action of the cate- neurotransmitter acetylcholine is released to restore
cholamines (Waugh & Grant 2001) (Fig. 1.6). There a state of balance in the autonomic nervous system.
is also evidence suggesting that the stimulation of The organs which were previously stimulated
normal levels of cortisol enhances the immune sys- now weaken their hold and their actions subside.
tem (Looker & Gregson 1989, Jefferies 1991). High
levels of cortisol, such as those created by prolonged
The skeletal musculature
stress or by pharmacological doses are, however,
associated with a suppressed immune system. Jacobson (1938) proposed that the release of tension
Under challenge, all the above hormones are in the skeletal musculature had the effect of calm-
released. When the situation of challenge passes, ing the mind. The neuromuscular system is thus
Theoretical background 7
Adrenal glands
Medulla
Cortex
R. kidney L. kidney
STRESSOR
(threatening homeostasis)
Hypothalamus
Release of CRH
Sympathetic Anterior
centres pituitary
Secretion of ACTH
Short-term response
Longer-term response
(fight or flight)
Figure 1.6 Responses to stressors that threaten homeostasis. CRH, corticotrophin releasing hormone;
ACTH, adrenocorticotrophic hormone. (From Waugh & Grant 2001.)
8 INTRODUCTION
seen as a mediator in the relief of stress and anxiety. rational alternatives. These ideas form the basis of
Jacobson’s method, progressive relaxation, consists Ellis’s rational emotive therapy.
of tense–release techniques designed to cultivate Beck (1984), a contemporary psychiatrist, also
awareness of muscular sensations. This awareness sees anxiety (and depression) as stemming from
allows the individual to develop the skill of wrong thinking. To Beck, the distress is created by
consciously releasing tension (Ch. 4). faulty thinking patterns which allow the individual
to have a distorted view of events. For example:
by reordering the client’s perceptions, values and the mind, it sees behaviour as conditioned by
attitudes’ (Lichstein 1988). Although their theories environmental events. Such events are seen as
are similar in many ways, their styles of therapy leading the individual to act in predictable ways.
differ; Ellis adopts a confrontational approach In the case of classical conditioning, behaviour is
while Beck is more collaborative (Neimeyer 1985). governed by associations; for example, Pavlov’s
While cognitive theory is referred to several dog learned to salivate at the sound of a bell
times in this book, the theories of Beck and Ellis because the bell was linked with the smell of food.
are particularly relevant to the chapters on stress In the case of operant conditioning, behaviour is
(Ch. 3), goal-directed visualization (Ch. 18) and governed by a system of reinforcement (Skinner
cognitive behavioural therapy (Ch. 22). 1938). Positive reinforcement refers to action
Also influential in this field is Kelly (1955, which increases the likelihood of a certain behav-
1969), whose theory of personal constructs offers iour, for example, giving a dog a biscuit every time
a different approach. To Kelly, interpretations are it brings back a thrown ball. Negative reinforce-
not irrational or illogical, so much as the product ment refers to the withdrawal of certain action, in
of the way each individual construes the world. If order to extinguish a behaviour, for example, no
the individual has problems, Kelly helps him biscuit, no retrieval of ball. Together, these two
work out alternative ways of looking at the world, concepts can be used to shape behaviour.
and he does this by attempting to enter the indi- Since these theories were first propounded,
vidual’s frame of reference (Neimeyer 1985). His behaviour theory has developed in ways which
approach is thus essentially explorative. take it away from its original reductionist models.
While sharing the view that the interpretation However, it still retains its central principle, that
of events can be as important as the events them- observable behaviour is more worthy of investi-
selves, Kelly has rejected the label ‘cognitive theo- gation than behaviour which is only inferred, i.e.
rist’. Such a label has, in the past, implied that mental processes.
cognitions and emotions could be studied sepa- Behavioural approaches include muscular
rately, while to Kelly they are components of a relaxation, distraction, graded exposure and social
single psychological entity. The climate has, how- skills training. Muscular relaxation is described in
ever, changed in recent decades, as cognitive theo- the early chapters of this book; distraction consists
rists in general have come to see emotion and of activity which diverts the attention; graded
cognition as ‘intricately and intimately intertwined’ exposure offers a step-by-step approach towards
(Strongman 1987). mastery over a feared object or situation; and
A further researcher whose work has been social skills training concerns interpersonal com-
influential in the cognitive field is Seligman munication and covers verbal and non-verbal
(1975). He focused on the degree of control which behaviour. Assertiveness techniques, developed
a person perceived himself to have over his envir- in the 1970s by Alberti & Emmons, are a central
onment. People who lacked this kind of control component of social skills training. These writers
were subject to a state he termed ‘learned help- define the concept as behaviour where people are
lessness’ which predisposed them to depression. acting in their best interests without experiencing
Cognitive methods may be seen to include most undue anxiety and without denying the rights of
approaches involving the mind. Thus, self-talk and others (Alberti & Emmons 1982). Topics included
mental diversion are cognitive, as are other tech- in assertiveness training are:
niques which aim to restructure the thoughts. Some
of these, however, are less amenable to scientific ● exercising personal rights
investigation than the structured approach of Beck. ● setting personal priorities
● expressing views
● making requests
Behaviour theory ● refusing requests
Behaviour theory, by contrast, is concerned with ● countering manipulative behaviour in others
observable actions. Discounting what goes on in ● allowing oneself to make mistakes.
10 INTRODUCTION
Behaviour styles can range from aggressive to to be at least as effective as medication in a wide
submissive, but the style of choice in most situ- range of anxiety disorders (Blackburn & Twaddle
ations is the assertive one. Knowing when and 1996, Davis et al 2000).
how to use it is one of the social skills. Cognitive behavioural principles are described
It can be seen from the above items that in Chapter 22. They also underlie some of the
assertiveness training contains a strong cognitive stress-relieving strategies in Chapter 3 and feature
element and that there is a certain overlap in the goal-directed visualizations in Chapter 18.
between cognitive and behavioural methods. This
has led some researchers to combine the two
approaches. THE ‘SPECIFIC EFFECTS’ HYPOTHESIS
AND UNITARY THEORIES
Cognitive behaviour theory Anxiety can express itself in any of three modes:
A belief that behaviourism as a general theory was the somatic (physiological), the cognitive (psycho-
incomplete led to the formal integration of cogni- logical) and the behavioural (observable actions).
tive and behaviourist principles (Reber & Reber It has been proposed that the pattern of changes
2001). Early proponents of this integration were produced by cognitive techniques will be differ-
Meichenbaum & Cameron (1974) whose aim was ent from those produced by physiological tech-
to promote behavioural change through the niques, so that an anxiety which expresses itself
restructuring of conscious thoughts and to weave in a physiological mode will require a different
these into the behaviourist approach. Behaviour approach from one which expresses itself in a cog-
was seen as largely governed by the ‘self-talk’ in nitive mode. This is the ‘specific effects’ hypoth-
which we engage. This is the internal dialogue we esis (Davidson & Schwartz 1976) and it states that
conduct with ourselves in order to interpret the benefit can be derived from matching the treat-
world. If the self-talk is positive, the outcome of a ment to the problem. For example, tension
given task tends to be viewed in positive terms; if headache will be more likely to respond to a
the self-talk is negative, the outcome tends to be somatic approach, such as releasing muscle tension,
viewed in negative terms. Positive self-talk leads than to a cognitive one, such as correcting faulty
to goal achievement and increased confidence; neg- thinking patterns (Lehrer 1996, Yung et al 2001).
ative self-talk to feelings of defeat. The approach Thus training in one mode is inappropriate if anx-
was designed to give the individual a feeling of iety manifests itself in another. Table 1.1 groups
greater control over his life and a protection against relaxation methods according to the presenting
unnecessary stress. mode of anxiety. It is only a rough classification
In this, and in a later publication (Meichenbaum since some approaches, e.g. autogenics, operate
& Cameron 1983), three phases were planned. in more than one mode. Even the pre-eminently
Phase one was educative and aimed at develop- somatic method of progressive relaxation contains
ing awareness of thoughts, feelings, sensations cognitive elements, by virtue of the attention that
and behaviours; the individual identified his self- is focused on muscle sensations (Ch. 4).
talk. In phase two he restructured his self-talk, In contrast, unitary models propose a non-
converting responses from negative to positive, specific relaxation effect resulting from any one
while other coping skills such as problem solving, method. Benson’s ‘relaxation response’ (Benson
relaxation, assertiveness and distraction were et al 1974) is such a one, based on the hypothesis
learned and practised. Finally, in phase three, that all relaxation techniques evoke a common inte-
these new responses and skills were applied to grated response of reduced sympathetic arousal
events through mental rehearsal, role play and (Ch. 21). There is no separation of body and mind.
graded exposure. Jacobson’s (1938) progressive relaxation method is
The approach has been taken up and developed also based on unitary theory, in that the release of
by Beck who has carried it forward in a series of muscle tension is seen as creating a generalized and
publications over the years. Research has shown it non-specific state of relaxation (Ch. 4).
Theoretical background 11
This problem calls for a more elaborate pro- no one standard method. Rather, it is a general
gramme featuring a cognitive approach. Beck’s approach which offers coping skills.
work has much to offer here. He proposes that her However, the varying methods do contain com-
condition stems from faulty patterns of thinking, mon threads, delineated by Lichstein (1988). There
such as believing that the incident is bound to is always some element of each of the following:
happen again or that her apprehension heralds a
● Cognitive restructuring: modifying conscious
heart attack. She is asked whether she thinks such
thought patterns in order to promote more
thoughts are justified and to make a point of test-
successful behaviours.
ing them against reality. For example, it is very
● Relaxation for reducing physiological arousal.
unlikely that she will knock over a second stand,
● Social skills and assertiveness training to
and what does it matter if she does? Or, what evi-
enhance interpersonal communication.
dence is there that she has a weak heart? She is
● Self-monitoring. This consists of recognizing
encouraged to collect her unrealistic, negative
the items which cause stress, recording their
thoughts in a diary and subject them one-by-one
occurrence and noting the level of stress which
to a challenging process. This leads to a cognitive
they generate. Self-monitoring encourages an
restructuring.
individual to take a more objective view of
Behavioural strategies, such as graded expos-
himself as well as charting his progress. It has
ure to the feared situation, can be incorporated
been found that the very fact of monitoring
into the cognitive programme. However, since
increases the likelihood of desired behaviour
real-life exposure initially creates a sense of high
occurring and decreases the likelihood of
threat, visualizations and relaxation training can
undesired behaviour occurring, in a phenom-
provide a useful preliminary (Ch. 18).
enon known as the ‘reactivity of monitoring’
Having experienced success in her visualiza-
(Hiebert & Fox 1981).
tions, the client could then be introduced to the
situation in real life. This is often done in stages,
with intermediate goals. She might on the first
occasion simply step out into the street; on subse- TYPES OF RELAXATION TECHNIQUE
quent occasions she would travel ever nearer to
the supermarket, and eventually go through the Thus, relaxation is only one component of stress
check-out. Whereas in the early stages she is management. The present work focuses on that
accompanied, later stages will see her coping component, setting out a variety of methods and
on her own. Her progress throughout could be techniques. These techniques are drawn from rec-
charted on the Hospital Anxiety and Depression ognized sources and appear in slightly para-
Scale (Ch. 24). phrased versions of the originals. One chapter is
As this case has a strong psychological com- devoted to each method which is described and
ponent, treatment could be linked with the work presented in a step-by-step manner. Rationale is
of the clinical psychologist or the community contained in a short paragraph near the beginning
mental health team. and the chapter ends with a section on evidence
relating to the effectiveness of the method.
However, evidence to support the techniques is
STRESS MANAGEMENT limited and cannot in all cases be used to inform
the rationale. For this reason, the rationale has been
Relaxation training is often viewed as one com- kept separate from the research. In each chapter
ponent of a more comprehensive package, vari- the reader is directed to available research, but it is
ously referred to as stress management, anxiety beyond the scope of this book to provide a system-
management or stress inoculation (Powell & atic review of the literature. In this connection, the
Enright 1990, Keable 1997). What, however, is reader is referred to the critical review of Kerr
stress management? There is no precise definition (2000) whose paper covered progressive relax-
because it is not a specific treatment and there is ation, Mitchell’s method, massage, the Alexander
Theoretical background 13
technique, Benson’s method and Hatha Yoga. ● Everly & Rosenfeld’s passive relaxation (1981)
Appendix 4 contains a table of existing reviews ● Madders’ release-only (1981)
from which it can be seen that not all techniques ● Öst’s applied relaxation (1987)
have been systematically reviewed and this limits ● Poppen’s behavioural relaxation training
the drawing of conclusions in this field. (1988)
The purpose of the book is to provide a com- ● the Mitchell method (1987)
pendium of different relaxation techniques and to ● the Alexander technique (1932)
describe them in relation to their underpinning ● differential relaxation
rationales. The range is not comprehensive: ● stretchings
methods which require specialized training such ● exercise
as hypnosis and advanced autogenics, or elabo- ● breathing methods.
rate apparatus such as biofeedback, are left out. In
The cognitive methods are:
general, choice has been governed by factors of
practicality such as the following, that the method ● self-awareness
should: ● imagery
● goal-directed visualization
● be easily learned and applied
● autogenic training (Schultz & Luthe 1969)
● not require specialized expertise on the part of
● meditation
the trainer
● Benson’s relaxation response (1976)
● not require elaborate equipment
● cognitive behavioural approaches.
● be convenient for use with small groups
● be suitable for all ages. A table summarizing the principles of each method
and suggesting applications for its use may be
found in Appendix 3.
‘DEEP’ AND ‘BRIEF’ RELAXATION
Lichstein (1988) distinguishes between methods
which create ‘deep relaxation’ and those which
create ‘brief relaxation’. Deep relaxation refers to SKILL ACQUISITION AND MOTOR
procedures which induce an effect of large magni- LEARNING THEORY
tude, and which are carried out in a calm environ-
Relaxation training involves the learning of skills.
ment with the trainee lying down, e.g. progressive
As a number of relaxation techniques are somatic
relaxation and autogenic training. Brief relaxation
in nature, i.e. focusing on muscles rather than
refers to techniques (often contracted versions of
thoughts, the principles of motor learning apply.
the above) which produce immediate effects and
Here, learning is defined as having stages, of
can be used when the individual is faced with
which Schmidt (1998) delineates three: a verbal-
stressful events; the object here is the rapid release
cognitive one, a motor one and an autonomous
of excess tension. Thus, whereas deep relaxation
one. In the verbal-cognitive one the individual
refers to a full process of total-body relaxation,
learns how to perform the motor task; he repeat-
brief relaxation applies these procedures in every-
edly talks himself through the action, imagining
day life.
the task without actually performing it. In the motor
stage the individual learns how to perform the
SOMATIC AND COGNITIVE TECHNIQUES physical action as the mentally rehearsed material is
converted into muscular activity. The autonomous
Most methods, whether deep or brief, fall roughly
stage sees a refining of the newly acquired skill, as
into one of the two broad categories: somatic and
execution of the movement becomes automatic.
cognitive. The somatic methods presented in this
Wishart et al (2000) condense the stages into two: a
book are:
cognitive and an automatic one.
● Jacobson’s progressive relaxation (1938) The learning process is aided by a system of
● Bernstein & Borkovec’s modified version (1973) feedback, both intrinsic and extrinsic, which helps
14 INTRODUCTION
the individual to make necessary corrections, and must be carried out daily if mastery of the
while motivation is maintained by record-keeping. skill is to be achieved.
Practice is an essential feature of motor learning
Further reading
Physiological and psychological background Relaxation and stress management
Smith E E, Nolen-Hoeksema S, Fredrickson B 2002 Payne R A 2004 Relaxation techniques. In: Kolt G, Andersen M
Atkinson & Hilgard’s introduction to psychology, (eds) Psychology in the physical and manual therapies.
13th edn. Harcourt Brace, Fort Worth Churchill Livingstone, Edinburgh, Ch 9
Waugh A, Grant A 2001 Ross & Wilson anatomy and physi- Powell T J, Enright S J 1990 Anxiety and stress management.
ology in health and illness, 9th edn. Elsevier Science, Routledge, London
Edinburgh, Ch 9 Reilly C M 2002 Relaxation: a concept analysis. Graduate
Research in Nursing 2(1): 1–12
15
Chapter 2
ESTABLISHING CONFIDENTIALITY
In the case of group work, confidentiality must
be established at the outset and re-established
each time a new member joins. Confidentiality
in this context means that nothing of a self-
disclosing nature made by any member of the
group is referred to outside the session. Topics
can be discussed outside but only in a general
sense.
16 INTRODUCTION
and the second ‘imaginary bubble’. It is not neces- The ‘live’ voice is more effective at inducing
sary to use both. relaxation than the taped voice (Paul & Trimble
1970, Beiman et al 1978, Hillenberg & Collins
Sinking 1982). Tapes are not recommended for teaching
(Lichstein 1988). They may, however, have value;
Make yourself as comfortable as you can … become
for example, a trainee might learn initially from
aware of the surface underneath you … let your
the live voice, then continue at home with a tape
body settle into it … notice how it supports
(preferably one containing the trainer’s voice) until
you … notice the points of contact between you and
he knows the technique (Borkovec & Sides 1979).
the floor: your head … shoulders … spine … ribs …
A disadvantage of tapes is that the individual may
hips … heels … elbows … forearms and hands … feel
become dependent on them and unable to relax
your body sinking into the surface you are lying
without them. Any advantage that tapes have in
on … feel the tension leaving it … your body getting
controlling the verbal aspect of the instruction is
heavier as the tension ebbs away … feel at
more relevant to research than to therapy.
peace … Take one good breath and as you let
it out, feel it carrying all your tensions
away … then let your breathing settle into a gentle TERMINATION
rhythm…
All deep relaxation procedures should be brought
to a gradual end, allowing the participant to
Imaginary bubble make a slow return to the alert state. A variety of
methods are described throughout this book.
As you lie or sit, reflect on the idea that you are
Some practitioners use a counting process; others,
going to give the next half-hour to yourself. No
a simple sentence such as: ‘When you feel ready,
telephone can ring for you; no doorbell disturb you;
please open your eyes and sit up’. Some teachers
no-one will call your name. You may hear sounds
recommend bending and stretching the limbs,
around you: voices, horns, sirens, bangs and
while others advise sitting quietly for a few min-
revs … think of them as being outside your world.
utes. Most of the relaxation approaches men-
With these thoughts in mind, draw an imaginary
tioned in this book carry their own form of
circle around yourself, about three feet from the
termination. The following is a sample procedure:
centre. Create an imaginary bubble … think of the
interior as your space … your own private space. I am going to bring this relaxation session to an
Feel how safe it is … safe to get in touch with end … I’d like you gradually to become aware of
yourself. Turn your thoughts inwards. your surroundings … feel the floor/chair underneath
you … in your own time open your eyes … give your
limbs a few gentle stretches … make a few fists to
DELIVERY stir up the circulation … have the feeling that you
are alert and ready to carry on with your life…
Any relaxation procedure calls for a tone of voice
that is quiet and calm. That does not imply that it Termination is sometimes referred to as ‘arousal’
should be hypnotic. Bernstein & Borkovec suggest or ‘return to everyday activity’. In autogenic train-
that the tone should be conversational to begin ing it is called a cancellation.
with, but that the volume and pace of speech should
be gradually reduced as the session wears on. They
DEBRIEFING
advise a tone which is, ‘smooth and quiet, perhaps
even monotonous, but not purposely hypnotic’ At the end of a relaxation session there is a
(Bernstein & Borkovec 1973). debriefing process, the object being twofold: to
The pauses between instructions should always make the experience more satisfying for the client
be long to give the trainees time to carry out the and to provide the therapist with feedback. The
action or to evoke the image. Dots in the text indi- therapist might open the discussion with ques-
cate these pauses. tions such as: ‘How did you find that experience?’,
18 INTRODUCTION
‘Did it make you feel more relaxed?’, ‘Did you Lichstein (1988), however, advises trainees to
find the technique easy to follow?’, ‘Was anything experiment and find the times that best suit them.
about it confusing?’, ‘Were you able to relate to the When the tuition course has come to an end,
different body parts?’. Plenty of time should be trainees are urged to continue practising, perhaps
allotted to the debriefing section to give the client in some less frequent form, so that the benefits of
opportunity to express his reactions or confide his training are not lost.
experiences, all of which help the therapist to
understand her client better. Information gathered NUMBER OF SESSIONS
in this way helps to increase the success of the
following session. It is possible to learn most methods in about six
sessions, assuming that attention is given to home
practice. Transcendental meditation can be taught
HOMEWORK in six, and progressive relaxation in five to ten ses-
Emphasis is placed on homework in every sions (Lichstein 1988). Many relaxation courses,
method of relaxation training as it leads to greater however, cover several methods, and may do
skill in using the technique. Skill is important more than simply teach relaxation. They may
because stress-related behaviour patterns tend to include group discussion, topics (see p. 27), mutual
be resistant to change. Experienced use of the support and other concerns, thus extending the
technique therefore increases its effectiveness. duration of the course beyond six sessions.
Skill is built up by practice (see Ch. 1, Motor
learning theory). Only by regular and frequent THE TRAINER/INSTRUCTOR/THERAPIST
practice will behavioural change take place. The
On the thorny question of training, Luthe (1970),
need to practise, therefore, is paramount, a point
referring to autogenics, insists that only medically
that needs bringing out as trainees do not always
qualified practitioners are equipped to teach.
appreciate its need. Investigating this topic in
Lichstein (1988) has viewed this position as unten-
1983, Hillenberg & Collins found significant levels
able, believing that health care professionals have
of non-compliance in the home practice compon-
much to offer, provided they use their judgement
ent of their study.
and recognize the limits of their training. He feels
One way of increasing motivation is by intro-
that the interests of society are best served by
ducing the record sheet or diary as a form of
allowing and even encouraging such individuals
self-monitoring (see Ch. 1, Stress management).
to teach relaxation methods.
Regular, time-recorded entries of homework ses-
The requirements for therapists who wish to
sions and their outcomes are made on the sheet
teach relaxation methods include:
by the trainee and these provide feedback and
encourage the trainee to continue. As it is import- 1. basic training as a health care professional
ant that these practice sessions fit in with the 2. professional experience with the type of group
trainee’s daily routine, convenient times can be with whom they are working
discussed at the outset of treatment. Figure 8.3 3. arrangements for supervision on a regular
(p. 71) offers a useful model. basis (see below)
The frequency and duration of homework 4. recognition that relaxation therapy is not a
are conventionally set at two periods a day, panacea, while it can be a powerful tool.
each lasting 15 minutes (Bernstein & Borkovec
A therapist is further advised to carry out three
1973). Whether or not this should be carried out
measures (Lichstein 1988):
soon after meals has been debated, the above
researchers pointing to the benefits of postpran- 1. to study beforehand the method she plans to use
dial low arousal. Others, however, favour avoid- 2. to experience the method herself, as a trainee
ance of that time: Benson (1976) suggests that the 3. to practise the method on friends, relatives
process of digestion interferes with the physiolog- or colleagues in order to build up a skilful
ical changes associated with meditation (Ch. 21). presentation.
General aspects of relaxation training 19
Today, however, there are validated courses on Throughout all procedures he remains self-aware
relaxation techniques which interested therapists and free of control by outside forces. The state of
are strongly advised to attend and, as relaxation relaxation he achieves is of his own making. In
training, in some form or other, has traditionally so doing he assumes ownership of this state
featured in the core training of many health care and responsibility for the progress he makes.
professionals, the therapy clinic becomes an Relaxation training is firmly rooted in this
appropriate setting for such work with clients principle.
(Potter & Grove 1999).
and maintain group bonding, certain points need Whole group activities are particularly useful for
attention. learning people’s names. Remocker & Storch (1992)
suggest a game in which each member wears a
1. Establishing and maintaining confidentiality. name tag. The aim is to collect everyone’s name in
The need for confidentiality was mentioned above. the shortest time.
It is repeated here as it cannot be overstated. 5. Discussion. Exchanging information and
2. Course programme. A knowledge of what to sharing experiences are features of the group
expect enables members to make plans. Dates debriefing period and give the session an extra
should be supplied in advance together with, in the dimension. The therapist now occupies the role of
case of a formal course, a syllabus. facilitator, maintaining the focus of the group and
Some classes offer relaxation alone; others begin seeing that all members who wish to, get a chance
each session with a topic related to the needs of the to express their views. Clients tend to enjoy the dis-
participants (p. 27), before moving into the area of cussion and normally display an eagerness to take
relaxation itself. part. There may, however, be a short period before
clients have learned to trust each other when a nat-
3. Client choice. The sense of belonging to the ural reticence holds them back from disclosing per-
group is enhanced if members are given some sonal information. This can cause the discussion to
choice in the way it is run. How much choice dry up. It can be revived by adopting the strategy
depends on the nature of the group: in the formal of ‘circular questions’ (Powell & Enright 1990). This
led group, less choice may be appropriate than in entails drawing one participant into conversation
the informal self-help group. However, choice can with another, for example: ‘Peter, you’ve been in
still be introduced into the formal group by finding this situation. What would you say to Jenny who is
out from the members at the outset why they joined going through the same experience?’. In most cir-
and what they hope to get out of the meetings. This cumstances, however, the discussion period helps
strategy helps the instructor to meet their needs to hold the group together.
and provides the participants with a more reward- Although the discussion period has value, partic-
ing experience. ipants should not feel under any obligation to take
A system of paper slips can be used to collect part. The voluntary principle, which states that
the written answers. The alternative is to ask pressure should never be exerted on individuals,
members directly. However, many people find it must be upheld (Heron 1977).
threatening to have to voice their private thoughts
6. Handouts. Printed material setting out the
in front of strangers; such an approach may also be
points made in the session acts as an aide-memoire
non-productive if it draws false replies. In the
for participants (Ley & Spelman 1967). Handouts
author’s experience, people prefer not to be asked
should relate to the topic currently being discussed:
such questions in front of a group, but respond
the information loses its relevance if it is produced a
more favourably to the paper slip system (Payne
week later.
1989).
7. Sharing the time. Inevitably, some people talk
4. Ice-breakers. These are strategies for relaxing
more than others. Trainers are glad to have ‘talkers’
the atmosphere. Their essential characteristic is that
in the group: they liven it up. At the same time, it is
the members physically participate. Some are
part of the trainer’s responsibility to see that the
designed for use in pairs while others involve the
quiet ones have an opportunity to speak. Thus, the
whole group. An example of the first is seen when
trainer may feel that she sometimes has to inter-
one member of each pair tells the other about some-
vene. A tactful way of doing it is the following: ‘I
thing pleasant that happened in the previous week;
don’t want to dismiss what you are saying, but I
then they switch over. Another example of working
wonder what X thinks about it?’.
in pairs is when person A talks to person B for two
minutes, telling him who she is and what she does. 8. Friction-dispelling techniques. Occasionally,
Then B talks to A. friction arises; a member may consistently disagree
General aspects of relaxation training 21
with the way the group is run. Calmly facing such ● avoiding the early afternoon for teaching
a person and asking how she would like things sessions.
changed, then putting it to the rest of the group,
Keable (1997) suggests informing participants at
often resolves the matter.
the outset that they will be awakened with a light
tap if they fall asleep. Others suggest that people
FALLING ASLEEP who are inclined to fall asleep should sit in a chair
rather than lie down, since making people less
There is a tendency in group work for some mem-
comfortable reduces their tendency to fall asleep
bers to fall asleep during the session. This is
(Lichstein 1988). Kokoszka (1992) refers to the
discouraged by most therapists. Bernstein &
effectiveness of focusing attention on a repetitive
Borkovec (1973) take the view that it interferes
stimulus, e.g. counting the breaths, for keeping
with the learning of a skill and suggest strategies
people awake.
for preventing or dealing with it:
Thus, falling asleep tends to be seen in negative
● regularly asking for signals in the form of terms. Fanning (1988), however, takes the view
requests such as ‘lift your index finger if you that if people have come purely for respite from
are beginning to feel relaxed’ stress, they should be allowed to sleep.
● directing the voice towards any sleeping
trainee
Further reading
Ernst S, Barnes B, Hyde K 1999 An introduction to group- Payne R A 1986 Health education for small groups.
work. Palgrave, Basingstoke Physiotherapy 72: 56–57
23
Chapter 3
Stress
THEORIES OF STRESS
CHAPTER CONTENTS
Theories of stress 23 The concept of stress in the living organism was
studied by Selye (1956). His work showed that
Symptoms of stress 24 when a body is subjected to a challenging stimu-
Measuring stress 25 lus, a characteristic response occurs. Selye identi-
fied three stages (Fig. 3.1):
Sources of stress 25
Stress in the environment 26 ● alarm
Stress in the individual 26 ● resistance
A classification of sources of stress 27 ● exhaustion.
Time
Figure 3.1 The ‘general adaptation syndrome’. (Adapted
from Cox T. 1978 Stress. Reproduced with kind permission
of the author and Palgrave Macmillan, London.)
24 INTRODUCTION
Performance
takes over. Together these stages make up the
‘general adaptation syndrome’ (Selye 1956).
Selye, whose concern was centred on physio-
logical aspects, viewed stress as the non-specific Distress
response of the body to any demand made on it. experienced
(By non-specific, he meant that the same response
would occur irrespective of the nature of the stim-
Boredom Exhaustion
ulus.) Twenty years later, the psychologists Cox &
Mackay (1976) defined stress as ‘a perceptual Demand
phenomenon arising from a comparison between
Figure 3.2 Human performance curve.
the demand on the person and his ability to cope.
An imbalance … gives rise to the experience of
performance. When demands are perceived as too
stress and to the stress response’. The emphasis
heavy, the overtaxed individual begins to experi-
here is on the individual’s perceptions, on the sub-
ence fatigue; when they are too low, boredom
jective nature of stress and on its psychological
results from understimulation. Distress is experi-
dimension. Selye, in 1956, had ignored the role of
enced in both events (Looker & Gregson 1989).
psychological processes (Cox 1978).
At the top of the curve is the zone of high per-
Cox & Mackay’s model introduces the idea of
formance. Here the individual is operating at levels
perceived coping powers as a factor governing the
of demand which match his coping skills. Daily
resulting stress. If an individual perceives his ability
variation may result in one slightly outweighing
to cope as weak, and sees environmental demands
the other: for example, sometimes he feels that he
as heavy, the level of stress he experiences will be
has more capacity than he is being called upon to
high. If his self-perceived coping powers are strong,
use, which gives him a feeling of confidence and
then those same demands may be readily tolerated
control; other times he may feel that environmental
and the level of stress experienced will be compara-
demands are mildly drawing on untapped inner
tively low. The environmental demands may,
resources, creating the rewarding experience of
however, be too low, so low that stress arises from
being pleasantly stretched. These feelings are col-
boredom. When the individual’s perception of
lectively referred to as ‘eustress’ or ‘good’ stress.
environmental demand is matched by his perceived
Lower down the curve, on either side, the indi-
coping ability, a state of balance can be said to exist.
vidual’s performance gradually declines as the
It is clearly desirable for the individual to oper-
curve runs through transition zones of moderate
ate in situations where demands and coping skills
stress and, ultimately, into zones of deep distress.
are balanced. Establishing and maintaining that
Thus, while distress erodes his quality of life,
balance may involve regulating his exposure to
eustress enhances it. Working at levels of arousal
the stressor. Alternatively he could reduce his
that feel comfortable promotes not only the effi-
anxiety levels and increase his coping ability.
ciency of the individual’s output, but also his
This is a model which allows for variation
mental well-being.
among individuals as well as for changing percep-
tions over time in the same person. The ideas
enshrined in it have led to the concept of the SYMPTOMS OF STRESS
‘human performance curve’ which is based on the
relationship between demands placed on the indi- Stress is associated with physiological symptoms,
vidual and his coping ability (Fig. 3.2). Moderate characteristic of sympathetic nervous system
levels of demand are associated with efficient activity. These symptoms relate to the fight/flight
Stress 25
response (p. 4) and are summarized below, together have been made to measure stress. One which has
with the psychological symptoms of stress, both had particular influence is the Social Re-adjustment
the subjective (how a person feels) and the behav- Rating Scale (SRRS) of Holmes & Rahe (1967).
ioural (how a person acts), although there is con- These researchers compiled a table of life events
siderable overlap in these areas. ranging from minor violations of the law to the
The symptoms vary among individuals because death of a spouse, rating each one in terms of the
of the differing sensitivities of organs to the expe- mental readjustment it demanded. A high score in
rience of stress. one year was associated with a high risk of develop-
ing a stress-related illness. But the SRRS has its
Physiological symptoms critics: whereas Holmes & Rahe had proposed that
As mentioned in Chapter 1, these comprise: any change in a person’s circumstances, positive or
negative, contributed to the risk, other researchers
● raised heart rate (Lazarus et al 1980) argued that positive experi-
● increased blood pressure ences could moderate the effects of negative life
● sweating events, making them less damaging to the immune
● raised blood coagulation rate system. For example, a broken bone is easier to
● increased ventilation tolerate if it coincides with the announcement of
● raised blood glucose level. good exam results.
Another point of discussion raised by the SRRS
Subjective symptoms is whether the stress caused by a series of minor
These include: adverse events is more harmful than one major
adverse event. Lazarus believes it can be, and has
● tiredness and/or difficulty in sleeping devised a tool for measuring small, day-to-day
● muscle tension particularly in neck and shoul- problems, calling it the Hassles Scale (Kanner et al
der muscles 1981).
● indigestion, constipation, diarrhoea The meaning that an event has for the individual
● palpitations also needs to be considered: moving house, for
● headache example, can be a pleasant form of stress if you
● difficulty in concentrating and a tendency to choose to move, but a source of deep distress if you
worry are forced to do so. Our interpretation of an event
● impatience; feeling irritable and easily roused thus determines the nature and intensity of our
to anger. response (Lazarus 1991).
In spite of these and other criticisms, the SRRS
Behavioural symptoms
has been highly influential as a tool for measuring
Behavioural symptoms include: the effects of stress. Changing social values have,
however, rendered some of the ratings out-of-date
● increased consumption of alcohol, tobacco,
and created a need for additional items. As a
food, etc.
result, the original scale has been succeeded by a
● loss of appetite or excessive eating
new instrument, the Recent Life Changes Question-
● restlessness
naire (Rahe 1975), which has itself been rescaled
● loss of sexual interest
(Miller & Rahe 1997) (Appendix 5).
● a tendency to experience accidents.
A physiological assessment of stress would Stress can arise from a multitude of sources.
include such measurements as heart rate, blood Broadly speaking, these sources can be catego-
pressure, respiratory rate and skin conductance. rized as those in the environment and those
Psychological as well as physiological attempts within the individual (Powell & Enright 1990).
26 INTRODUCTION
Locus of control
STRESS IN THE INDIVIDUAL
Locus of control is a phrase which refers to the
Personality types individual’s perception of the degree of control he
has over the environment (Rotter 1966). If he feels
Friedman & Rosenman (1974) described a person-
he has influence over most situations in his life, he
ality type particularly associated with coronary
is said to have an internal locus of control. If, on
heart disease. This type was characterized by a
the other hand, he believes that his life is largely
tendency for the individual to:
controlled by factors such as fate or other people,
● drive himself to achieve goals one after another his locus is said to be external.
● have a spirit of fierce competitiveness Locus of control is a feature which has been
● create a programme filled with deadlines studied in various contexts, one of which is stress
● perform activities as fast as possible where low vulnerability to stress seems to be related
Stress 27
to internal locus and high vulnerability to external 4. Physical stressors, in the form of excessive
locus. Thus the more influence an individual load demands experienced in the work environ-
believes he has over his environment, the less ment.
likely he will be to experience stress.
On the whole, a crisis perceived to be solvable and
of short-term duration seems to be less harmful
Other stressors of internal origin than a long-lasting succession of small hassles
Beck (1984) refers to stressors within the individ- which the individual feels he is unable to control
ual, such as the tendency to interpret events in a (Stevens & Price 1996).
consistently negative way. Ellis (1962) points to the
maladaptive effect of holding unrealistic belief STRESS-RELATED TOPICS AS A
systems, for instance believing one has to be right COMPONENT OF RELAXATION
every time in order to be a worthwhile person TRAINING
(p. 8). Other maladaptive styles include:
● Having unclear goals; a lot of effort can be When offering relaxation training sessions to a
wasted if people do not know where they are group of people, the health care professional may
going. wish to include certain topics and a discussion.
The topics will relate to those conditions from
● Failing to make decisions; unmade decisions which group members are suffering and may
can so preoccupy the individual that he cannot include some of the following:
get on with his life. The unresolved matter con-
● anxiety, panic
tinues to claim his attention and eventually
● depression
wears him out.
● substance dependency, e.g. tobacco, alcohol,
● Bottling up emotions; anxiety and anger are tranquillizers
examples of emotions that people often keep to ● life crises, e.g. bereavement
themselves, allowing the feelings to grow out ● life changes, e.g. menopause
of proportion. ● eating disorders, e.g. bulimia, anorexia
● insomnia
● Having low self-esteem; a feeling that one
● hyperventilation
lacks the rights that are accorded to others.
● stress-related physical disorders.
Such a person may allow himself to be over-
ruled on every side. Stress has been associated with a number of med-
ical conditions such as bronchial asthma, essential
hypertension, peptic ulcer, ulcerative colitis, neu-
A CLASSIFICATION OF SOURCES rodermatitis, rheumatoid arthritis and thyrotoxi-
OF STRESS cosis. These conditions have been described as
psychosomatic illnesses. The concept of psycho-
Skelly (2003) presents the sources of stress in four
somatic illness has, however, been extended in
categories:
recent years from the original few illnesses for
1. Social stressors. These relate to the interper- which the term was coined to include many more,
sonal environment of the individual but also as it has come to be realized that psychosocial ele-
include states such as poverty, isolation and dis- ments are present in the aetiology of a wide vari-
ability. Social stressors are considered to be the ety of medical conditions (J. O. Robinson 1994,
dominant causes of mental stress (Goldberg & personal communication).
Huxley 1992). (Relaxation should not be seen as a substitute
2. Psychological stressors, such as certain per- for medical help. However, insofar as stress is an
sonality traits and cultural beliefs. acknowledged component of any particular con-
3. Chemical stressors. These include additives in dition, health care professionals may find them-
food and pollutants in the air and water. selves being asked to help alleviate it.)
28 INTRODUCTION
It is assumed that the instructor has knowledge 4. Being task-oriented and not letting emotions
concerning the problems from which her group take over. Emotions fuddle the mind and interfere
members are suffering, and is in a position to pro- with problem solving. If the emotion is strong, it
vide material about the topic. This can in turn lead can first be acknowledged then separated from the
into a discussion. The relaxation method subse- issue, which can then be judged dispassionately.
quently offered can, where possible, be linked to it: 5. Avoidance of blaming; the latter tends to
for example, slow breathing can be offered in the arouse anger. A more constructive attitude is to see
case of hyperventilation (p. 134), smoking cessa- mistakes as the result of a series of events which
tion imagery for people quitting smoking (p. 166), simply happened.
and eye exercises in cases of insomnia (p. 38). 6. Dealing with anger. Some anger may serve a
In a study investigating the components of useful purpose; much anger, however, is purely
stress management, Powell (1987) reports that destructive. The energy that goes into its arousal
information and group support were rated the could often be more profitably spent in solving the
most helpful components of the treatment package. problem. Ways in which anger can be controlled
The present author, however, found that partici- include:
pants rated relaxation as the most helpful element, – Reinterpreting the stimulus in a more positive
in a small study conducted on self-referred mem- light; many situations contain ambiguities
bers of a led group featuring topic, discussion and which allow reinterpretations to be made.
relaxation (Payne 1989). – Being realistic in one’s expectations of other
The topic can revolve around coping skills as people.
well as causes of stress. – Modifying one’s internal dialogue to include
self-statements such as ‘I am easygoing’ or
‘I keep my cool’.
COPING
– Focusing on the issue rather than the
The word ‘coping’ refers to the efforts made by indi- personality.
viduals to manage the demands placed on them 7. Giving oneself permission to make a mis-
(Lazarus & Folkman 1984). Some coping strategies take. It is part of being human to make mistakes
focus on the problem itself; others on the emotion it occasionally.
arouses. The first kind seek to alter the situation in 8. Distancing oneself. If circumstances seem to
some way to make it less challenging; the second be overwhelming, one can try stepping back men-
kind aim to reduce the emotional response to the tally to get a more objective view (pp 155 and 164).
problem. In most situations, however, people use It is sometimes useful to visualize another person
a combination of problem-focused and emotion- coping with the same problem.
focused approaches (Lazarus & Folkman 1984).
9. Introducing humour at suitable moments.
Listed below are examples of coping skills
When a person smiles and laughs the relaxation
which could feature as topics for discussion in
response takes over (p. 215).
group meetings.
10. Managing time efficiently. Priorities need to
1. Getting as much control over the stressor as be established and time allotted to tasks proportion-
circumstances allow. While accepting the restric- ately. If time is short, inessentials can be cut out and
tions of the situation, there may be areas of free- tasks delegated. It is sometimes possible to say ‘No’
dom which a person can develop. to demands when time is restricted.
2. If control is not possible or expedient, a per- 11. Having someone to confide in.
son can change the way he thinks about the stres- 12. Rewarding himself if one has done a job well.
sor: for example, instead of being irritated by traffic 13. Living in the present. This means savouring
queues, he could see the time as an opportunity to the moment; enjoying the journey as well as the
play music tapes. arrival. It is useful to remember that the future is
3. Training oneself to predict stressful situations to a large extent determined by the way we handle
in order to weaken their impact. the present. A lot of stress arises from dwelling on
Stress 29
Further reading
Gatchel R J 1996 The bio-psycho-social model. In: Gatchel R J, Skelly M 2003 Stress and mental health. In: Everett T,
Turk D C (eds) Psychological approaches to pain manage- Donaghy M, Feaver S (eds) Interventions for mental
ment: a practitioner’s handbook. Guilford Press, New health. Butterworth-Heinemann, Oxford
York, pp 33–52 Smith E E, Nolen-Hoeksema S, Fredrickson B 2002 Atkinson &
Payne R A, Rowland Payne C M E, Marks R 1985 Stress does Hilgard’s introduction to psychology, 13th edn. Harcourt
not worsen psoriasis? A controlled study of 32 patients. Brace, Fort Worth, Ch 14
Clinical and Experimental Dermatology 10: 239–245
33
Chapter 4
Progressive relaxation
This integrated activity between the mind and Jacobson (1938) insisted that his method be
the muscles led him to view the brain centres and regarded as a skill to be learned. Unlike most
the voluntary muscles as working together ‘in one other approaches, the use of suggestion was dis-
effort circuit’ (Jacobson 1970); a neuromuscular couraged. Trainers were urged to avoid planting
circuit, since it was composed of both neural and ideas of the kind: ‘Your limbs are heavy/limp/
muscular tissue. Just as a calm mind would be relaxed’, or even ‘Notice how your limbs are feel-
reflected in a tension-free body, so, Jacobson pro- ing heavy/limp/relaxed’. Jacobson wanted the
posed, a relaxed musculature would be accom- learner to make his own discoveries.
panied by the quietening of thoughts and the
reduction of sympathetic activity, notions that
would have relevance in the treatment of anxiety RATIONALE
and associated conditions. The task facing
Jacobson, therefore, was to find a way of inducing Progressive relaxation (PR) is based on the idea
the skeletal muscles to lose their tension. that people think more clearly when they are
Muscle activity is accompanied by sensations relaxed and this helps them to solve their emo-
so faint that we do not normally notice them. To tional problems (Lehrer 1982). Jacobson proposed
promote awareness of tension, Jacobson empha- that relaxation of the musculature offered a means
sized the need to concentrate on those sensations, to that end, since he further proposed that a
cultivating what he called ‘learned awareness’. relaxed musculature exerted a calming influence
Once tension had been recognized, it would be on the whole organism including the mind. The
easier to release it. If relaxation were then effect was non-specific. Its generalizing nature
achieved, however, how deep would it be? places his method in the category of a unitary
It is traditionally held that, in the waking state, theory (Ch. 1). The approach is a physiologically
healthy muscle, even during rest, is in a state of oriented one since its procedures are concerned
sustained, slight contraction. This is called muscle with physical organs, i.e. muscles and nerves,
tone. Jacobson’s EMG studies (1938) did not, how- although the act of focusing on muscular sen-
ever, support this notion. He found that voluntary sations gives it also a cognitive slant.
muscle could achieve a state of complete relax-
ation during rest. He consequently formed the
view that the aim of relaxation training should be PRESENTING PROGRESSIVE
to eliminate all tension; and relaxation could only RELAXATION
be called complete if it proceeded ‘to the zero
point of tonus for the part or parts involved’ CONDITIONS
(Jacobson 1938). Any tension that remained while
Ideal conditions for presenting progressive relax-
resting a muscle was called ‘residual’, and it was
ation include the following:
this residual tension that Jacobson sought to elim-
inate in deep relaxation. ‘Doing away with residual ● A room that is quiet.
tension is … the essential feature of the present ● Somewhere to lie down. A large room with a
method’ (Jacobson 1976). carpeted floor is suitable for a group. Trainees
Defining relaxation as the cessation of activity may be asked to bring a beach mattress or the
in the skeletal (voluntary) muscles, Jacobson equivalent to lie on, and a small pillow for the
devised a technique which he called progressive head. Lying is the position of choice; however,
relaxation. It consisted of systematically working it is possible to learn progressive relaxation in
through the major skeletal muscle groups, creat- the sitting position.
ing and releasing tension. As a result, the trainee
learned how to recognize muscle tension. Only
INTRODUCING THE METHOD
one muscle action was carried out in each session
and it was repeated twice. The rest of the time was Before starting the training proper, the relaxation
spent releasing tension. method must be introduced. With the trainees
Progressive relaxation 35
Table 4.1 Progressive relaxation: schedule of items (Adapted from Jacobson 1964)
Arms Extend wrist (bend hand back) Eye area Close eyes tightly
Flex wrist (bend hand forward) (contd) Look left with eyes closed
Relax only Relax only
Flex (bend) elbow Look right with eyes closed
Extend elbow (straighten arm) Look up with eyes closed
Relax only Relax only
Stiffen whole arm Look down with eyes closed
Legs Dorsiflex foot (bend foot up at ankle Look forward with eyes closed
joint) Relax only
Plantarflex foot (bend foot down at Visual Imagine a pen moving slowly, then fast
ankle joint) imagination Imagine a train passing, a person walking by
Relax only Relax eyes
Extend (straighten) knee from a bent Imagine a bird flying and stationary
position Imagine a ball rolling, the Houses of
Flex (bend) knee dragging foot along Parliament
floor Relax eyes
Relax only Imagine a horse grazing, a reel of
Flex hip (raise bent knee towards chest) cotton
Extend hip (press thigh down into the Imagine the Prime Minister
supporting surface) Relax eyes
Relax only
Stiffen entire leg Jaw, voice, Close jaws firmly
and auditory Open jaws
Trunk Contract (pull in) abdomen imagination Relax only
Extend spine (arch back slightly) Bare teeth
Relax only Pout
Observe the action of breathing Relax only
Brace shoulders back Press tongue against teeth
Relax only Pull tongue backwards
Flex shoulder joint (bring bent arm Relax only
across chest) Count aloud up to 10
Repeat with other arm Count half as loudly up to 10
Relax only Relax only
Raise (hunch) shoulders Count softly up to 10
Neck Press head back into pillow/headrest Count under your breath up to 10
Raise head off pillow Relax only
Relax only Imagine you are counting
Bend head to right Imagine you are reciting the alphabet
Bend head to left Relax only
Relax only Imagine saying:
your name three times
Eye area Raise eyebrows your address three times
Frown the Prime Minister’s name three times
Relax only (contd on right column)
(Jacobson 1970 p. 45, Lehrer et al 1988). Thus, the Jacobson devised a technique called ‘diminishing
actions require an ever-decreasing intensity of tensions’.
contraction to fulfil their purpose. To help the It is introduced as the learner becomes profi-
trainee become sensitized to low levels of tension, cient in recognizing the sensation of tension.
38 SOMATIC METHODS OF RELAXATION
Returning to the action of wrist bending, the tensing is detrimental to relaxation, and this find-
trainee would be instructed in the following way: ing may have strengthened interest in passive
approaches.
Bend your wrist back, but this time using only half
as much effort as you did the first time. Hold it
EYE MOVEMENTS
back for about a minute, noticing the sensations
you’re getting from the muscle … and at the end of The procedures for the eye and forehead and for
the minute … cease holding it back. Go negative … the area of the speech muscles differ somewhat
feel the tension leaving … allow plenty of time for from those of the trunk and limbs. Consequently
the remaining tension to disappear … allow three they are presented in more detail.
minutes … then bend the wrist back again, this time Although Jacobson (1938) indicated that only
tensing the muscle half as much as last time … hold one or two actions should be carried out in each
it for about a minute, tuning in to the sensations … session, it is customary today to work through all
then release the tension … release it further … and the eye actions in a single session. Plenty of time
further still … allow three minutes … now, raise the should still be allowed for ‘going negative’.
wrist the smallest amount possible … hold it there … Jacobson’s studies had demonstrated the effect-
for one minute … discontinue … allow three minutes … iveness of progressive relaxation in reducing mus-
and finally, make the action just a thought … hold cle tension. He had also been able to show that a
the thought for one minute … go negative … spend relaxed musculature had a calming effect on the
three minutes continuing to go negative… mind (Jacobson 1938). Muscle relaxation could
thus be seen as a mental relaxant. But Jacobson
These progressively diminishing tensions train the went further: he claimed that in deep relaxation,
individual to recognize differing levels, thus increas- thought itself disappeared. In the totally relaxed
ing his control over the voluntary musculature. body, the mind would be a blank.
Jacobson’s assigning of every third session The eye muscles were considered by him to be
exclusively to passive relaxation is evidence of the particularly closely related to thought, since think-
high value he placed on the relaxation phase and ing created mental images which were accom-
the relatively low value he gave to the contraction panied by a sense of tension around the eyes.
phase, using it simply as a means of cultivating Releasing tension from the eyes, Jacobson believed,
sensitivity to the tension sensation. Many of his had the effect of cancelling those images. The fol-
successors have, by contrast, attached great lowing sequences are adapted from Jacobson
importance to the contraction, claiming that it (1970). Time should be allowed between the items
leads to a deepening of the subsequent relaxation. for the trainee to absorb the message:
Jacobson argued that the reverse may be the case,
namely, that tensions which build up during the With your eyes open, raise your eyebrows … feel the
contraction phase would continue to persist for tension … and release it … frown … feel the tension …
some time, thus hindering relaxation. In untrained and discontinue … shut your eyes tightly … feel the
participants he showed that muscle tension con- tension … and let it go … with your eyes still closed,
tinues to remain elevated for up to several min- spend a few minutes releasing tension in this part
utes following a contraction, even when the of your face…
participant is cooperating with appeals to ‘go neg- Moving on to the eyes themselves (they are still
ative’ (Jacobson 1934). Thus, deliberate muscle closed) … without moving your head, turn your eyes
tensing may, in the short term at least, actually upwards as if you were looking at the ceiling. As
obstruct the relaxation process. you do so, notice the sensation you get in the eye
The issue of tense–release versus a release-only region … next, turn your eyes downwards as if you
approach has not been satisfactorily resolved. It were looking at your feet, again taking note of the
has been common in clinical practice to favour feelings around the eyes … repeat that several times,
tense–release. However, the results of a study in until you become familiar with the sensation in the
1991 (Lucic et al) support the view that initial eye muscles … then discontinue, going negative for a
Progressive relaxation 39
minute or so … still with your eyes closed, turn your are relaxed, thinking with the use of words is no
eyes to the left for a few moments … now to the longer possible (Jacobson 1970).
right … repeat this a few times to experience the The following script begins with tensing of the
transient sensations in the muscles … then, cease speech muscles and ends with sequences of count-
the action … do nothing for a few minutes… ing using ‘diminishing tensions’. As with the eye
Would you now, still with your eyes closed, actions, it is customary today to present the whole
imagine you are looking at the ceiling and the floor; group in one session. As a rough guide, 5–10 sec-
do not actively look up and down, but simply think onds can be allowed for each action and 30–40 sec-
of looking up and down … notice the feelings (that onds for ‘going negative’. Each action is repeated
is, the same sensations as when you deliberately once.
turned your eyes up and down, although to a much
lesser degree) … when you have identified the Close the jaws firmly, noticing the sensations you get
feeling, let your eye muscles go negative … notice from the action … hold it … and … discontinue … let
what happens to the images … rest for a few your jaw drop … feel the tension leaving you … and
minutes… continuing to leave you … then repeat the
Now, imagine that you see the wall on your left … sequence…
and the wall on your right … imagine seeing one Next, bare your teeth … feel the tension in the
after the other, noticing that slight tensions accom- cheeks … hold it for a few seconds … and cease the
pany the images … now, let your eyes go … and action…
notice what happens to the images… Make a tight ‘O’ with your lips … hold it, while you
register tension in the lips … and … go negative…
Similar effects can be created by imagining objects
from everyday life:
Press your tongue against your teeth … feel the
pressure … and discontinue…
Imagine a car passing … or a ball bouncing up and Now, pull the tongue back towards the throat.
down … notice the sensation that accompanies the Feel the muscles drawing it back and note the
image … then let the eye muscles go negative and sensations you get from this action … and … let it go
notice what happens to the images… negative…
Multiply 16 by 82 in your head … when you have Tune in to the presence of residual tension in any
got the answer, notice how the eyes felt during the of the muscles associated with speech and let that
task … then, rest the eyes and notice what happens tension recede … and go on receding…
to the figures… (Allow several minutes for the last phase.)
If the eyes are completely relaxed, the image dis-
A counting sequence follows, using diminishing
appears and the thought dies (Jacobson 1964). The
tensions.
individual, however, has made no effort to stop
the thought process. He is asked only to release Count aloud slowly from one to ten, picking up the
tension, ‘letting other effects come as they may’ sensations you get from the muscles in the mouth,
(Jacobson 1976). Whether thought does in fact throat, face and chest. Repeat it a few times … then
disappear in a totally relaxed body has not been stop counting … allow time for the full release of
scientifically established. Jacobson (1938) was, tension…
however, able to produce clinical evidence of Now, count again, half as loudly … noticing the
the success of ocular relaxation in overcoming reduced amount of tension in the speech muscles …
insomnia. discontinue … next time, count softly … notice the
tension … and let it go … and now, under your
SPEECH MOVEMENTS breath … still concentrating on the feelings you get
The speech muscles are also closely related to in the mouth, jaw and throat … rest a moment …
thought. Thinking with the use of words causes and now, simply imagine the counting … here
minute flickers of tension in the muscles of the perhaps you can detect a flickering in the speech
tongue and jaw. Conversely, when these muscles muscles … finally, cease to count altogether…
40 SOMATIC METHODS OF RELAXATION
When the speech muscles ceased to be involved, This method, however, takes as long to learn as
Jacobson (1938, 1964, 1976) claimed that it was no Jacobson’s original technique.
longer possible to think in verbal terms. The
notion that thought disappears in states of deep
muscle relaxation is consistent with a theory EVIDENCE OF EFFECTIVENESS
which sees mental processes being influenced by
the state of the skeletal musculature (Lehrer 1982). Jacobson used EMG, a technique which he
invented, to measure muscle tension. By this
means he showed that progressive relaxation had
a direct effect on the release of tension in the skel-
FURTHER WORK OF JACOBSON
etal musculature. The more practised the trainee,
the greater the effect. He also showed that progres-
DIFFERENTIAL RELAXATION
sive relaxation had an indirect effect on anxiety
Jacobson (1938) also investigated the degree of levels, and that, via brain mediation, it promoted
tension necessary for carrying out a particular parasympathetic dominance (Jacobson 1938).
activity. He drew a distinction between those Jacobson, who was a pioneer in an unexplored
muscles actually performing the activity and area, carried out research which was meticulous
those muscles not involved in it. The first group by the standards of his day. However, despite
needed the minimum level of tension consistent careful attention to method, his work, by present
with performing the task; the second group could day standards, suffers from certain shortcomings.
be totally relaxed or as relaxed as possible. This One of these is the self-selection of participants,
differential in the degree of tension required was i.e. individuals volunteering to take part. Jacobson
studied by Jacobson for the purpose of reducing drew on his close associates and private patients
both the excessive effort often used by the first for subjects, whereas modern standards would
group and the unnecessary effort often used by demand random selection.
the second. Differential relaxation is discussed in A second methodological deficiency is the rela-
more detail in Chapter 12. tive absence of statistical analysis. Jacobson
seldom tested for significance, i.e. conducted
analyses to estimate the probability that the results
SELF-OPERATIONS CONTROL
he obtained did not arise by chance (Lichstein
In addition to progressive relaxation, Jacobson 1988). It was not conventional to use probability
(1964) developed a method of instruction which statistics in his day (Lehrer 1982). In spite of this,
he called ‘self-operations control’. The principles however, his results often reached levels of statis-
of recognizing and eliminating tension are the tical significance (Blanchard & Young 1973).
same as those of progressive relaxation. The In her review of relaxation techniques Kerr
emphasis, however, is placed on self-direction: the (2000) cites studies which have shown reductions
individual controlling his muscle tension through- in both physiological and psychological indicators
out the events of daily life, learning ‘to go on of stress following a course of PR. These results
and off … as different occasions may require’ suggest that PR has the potential to promote relax-
(Jacobson 1964). He learns to monitor all sensa- ation (Kerr 2000). When PR has been compared
tions of tension, simultaneously and automat- with other stress-reducing approaches, PR often
ically, and to release those tensions that are not appears equally effective, as in Salt & Kerr’s (1997)
desired, in a continuing process (McGuigan 1984). study where PR was compared with the Mitchell
The result is a decreased consumption of energy, method in 24 normotensive participants. Whereas
which effect extends to other body systems such significant reductions in heart rate, respiratory
as the autonomic nervous system, where sympa- rate and blood pressure were found in both
thetic activity is reduced. Thought processes are methods, the study did not show any significant
also believed to benefit from the tension-decreasing difference in effectiveness between the two inter-
effect (McGuigan 1981). ventions. Similarly, Crist & Rickard (1993) found
Progressive relaxation 41
no difference in outcome between muscular and between anxiety level and muscle tension. It
imaginal relaxation in 100 healthy students, would seem that any influence exerted by the
although both experimental conditions showed musculature on mental activity is part of an
significant training effects. interactive process as yet not fully understood
Progressive relaxation, in one form or another, (Lichstein 1988, Kerr 2000).
is widely used in the clinical field for reducing The major disadvantage of Jacobson’s original
mental tension. Based on a substantial amount of technique is its length, with accompanying prob-
evidence, it is believed that the mind becomes lems of time and money. These problems have
calmer as a result of relaxing the musculature. inevitably led to a plethora of modifications, one
According to Jacobson (1938) this was best of which is described in the following chapter.
achieved by teaching minimal muscle contrac-
tions, as opposed to repeated strong contractions,
a view which was supported in the findings of
Lehrer (1982) and Lehrer et al (1988). Findings are PITFALLS OF MUSCULAR RELAXATION
not always consistent, however, and there are
studies which show little or no correlation See Chapter 6 (pp 56–57).
Further reading
Jacobson E 1938 Progressive relaxation, 2nd edn. University McGuigan F J 1984 Progressive relaxation: origins, principles
of Chicago Press, Chicago and clinical applications. In: Woolfolk R L, Lehrer P M
Jacobson E 1976 You must relax. Souvenir Press, (eds) Principles and practice of stress management.
London Guilford Press, New York
Progressive relaxation training 43
Chapter 5
Chapter 7 (p. 60). Two additional components are presence of muscle tension. He never intended it
described in later chapters: ‘conditioned relaxation’ as a means of ‘producing’ relaxation (Lehrer et al
in Chapter 8 (p. 71) and ‘differential relaxation’ in 1988).
Chapter 12 (p. 101). The strength of the contraction is not specified
by Jacobson, except in such terms as ‘Do not
stiffen your arm to the point of extreme effort, but
DIFFERENCES BETWEEN PROGRESSIVE only in moderation’ (Jacobson 1964); and the com-
RELAXATION AND PROGRESSIVE mand to ‘tense’, even at greatest magnitude is
RELAXATION TRAINING taken to convey only a comfortable level, since the
object is merely to enable the individual to iden-
Although PRT is founded on Jacobson’s principles tify the sensation of tension. To Jacobson, the
of recognizing and eliminating tension, there are lower the level of the contraction, the more useful
important differences between the two approaches it was. Bernstein & Borkovec, in contrast, use
(Table 5.1). phrases such as ‘tight fist’ and refer to ‘trembling
neck muscles’, suggesting a high level of tension.
The contraction phase
Wolpe & Lazarus (1966), similarly, in their version,
One of these differences is the prominence given urge clients to clench the fist ‘tighter and tighter’.
to the tensing component in the modified version.
Bernstein & Borkovec (1973) describe an effect
Use of suggestion
whereby the strength of the contraction deter-
mines the depth of the relaxation which follows it, Both Jacobson (1938) and Bernstein & Borkovec
in the manner of a pendulum which, when lifted (1973) discuss suggestion. The argument in favour
high on one side, swings back to the same height of using suggestion is that it increases cognitive
on the other side. Thus, the stronger the initial awareness of the affective component which is
contraction, the deeper the subsequent relaxation. believed to enhance the overall effect (Fig. 5.1)
Jacobson (1938, 1970) does not share this view. He (M. E. Donaghy 1999, personal communication).
sees the contraction phase simply as a means Addressing trainees who fear they might be
of cultivating the individual’s sensitivity to the put into a trance state, Bernstein & Borkovec point
Table 5.1 Differences between Jacobson’s progressive relaxation method and Bernstein & Borkovec’s
progressive relaxation training
Relaxation
1. The rationale of the technique is presented
Tense Progressive Tense–release
mind and relaxation of mind and to the trainee, and the items involving the 16 mus-
muscles training procedures muscles cle groups are then described and demonstrated.
Figure 5.1 Diagram to show how the inclusion of (See Introductory remarks section below.)
suggestion might increase the effect of a muscular 2. For the procedure itself the trainee is seated in
procedure. (M. E. Donaghy 1999, personal communication.) a reclining chair. If this is not available, the trainee
can sit in a chair with a high, sloping back and arms.
3. The procedure starts with the trainee being
asked to focus attention on a given muscle group.
out the difference between hypnosis and relaxation. (See Item one section below.)
In hypnosis, maximum use is made of direct 4. A signal, such as the word ‘Now’, indicates
suggestion, such as ‘Now your arm is limp’. Direct that the muscle group is to be tensed.
suggestion, so crucial in hypnosis, is not appropri- 5. The contraction is carried out all at once, not
ate in relaxation. gradually.
PRT does, however, use indirect suggestion, 6. Tension is maintained for 5–7 seconds during
such as ‘Notice how your muscles are feeling more which the instructor asks the trainee to focus on the
and more relaxed’ and ‘Let a feeling of relaxation sensations of muscle contraction.
flow through your limbs’, in order to deepen the 7. On a predetermined cue, such as the word
sense of relaxation. Voice modulations to reinforce ‘Release’, ‘Relax’ or ‘Let go’, the muscle group is
the distinction between tension and relaxation are relaxed (again, all at once).
also encouraged: crisp tones during the tensing 8. As the muscle group relaxes, the trainee is
component and soothing tones during the relax- asked to notice the feelings that accompany the
ation component. relaxation while the trainer maintains a patter
which is indirectly suggestive of relaxation.
To Jacobson, however, even indirect suggestion
9. This continues for the duration of the relax-
is unacceptable. He sees progressive relaxation
ation period which is 30–40 seconds.
exclusively as a muscular skill, the mastery of which
10. All 16 muscle groups are worked in the first
is impeded by any kind of suggestion.
training session.
Relevant to this discussion is the work of Paul
(1969) who has shown relaxation training to be
more effective than hypnosis at reducing muscle Introductory remarks to trainees
tension.
The method you are going to learn is called ‘pro-
gressive relaxation training’ and it consists of tens-
ing and releasing muscle groups throughout the
RATIONALE body. The object is to produce relaxation and this
occurs after the tension is released. A firm contrac-
As with progressive relaxation, it is proposed that tion can lead to a deep relaxation, rather like a
relaxing the musculature exerts a calming effect pendulum swinging high on both sides. You will be
on the whole organism, including the mind. The asked to concentrate on the feelings that accom-
contraction phase in PRT, however, is given pany the tension and the relaxation; feelings that
greater prominence since it is believed that initial up to now, you may have taken for granted. There
tensing actually produces relaxation. are 16 muscle groups to be tensed and released and
46 SOMATIC METHODS OF RELAXATION
16.
}
15. The non-dominant leg is worked separately.
Item two and subsequent items
The trainer continues: Item two involves the muscles of the right upper
arm: the bent elbow is pressed down into the arm
When we begin, I’ll first describe each item but
of the chair (Fig. 5.3). (A wooden arm rest can be
please do not tense the part until I give you the cue
softened with a cushion.)
word ‘Now’. Similarly, let it go only when I give you
the cue word ‘Relax’. Then let it go completely. Let the hand and forearm go on relaxing while you
Would you please close your eyes. transfer your attention to the muscles in the right
upper arm. I’d like you this time to press your elbow
Item one down against the arm of the chair. Do this without
involving the muscles of the hand and forearm …
The first item involves the muscles of the right hand
Now … feel the tension in your upper arm as the
and forearm; the hand is drawn into a fist (Fig. 5.2):
elbow presses down … and … Relax … let it go
We’ll start with the right hand and forearm. I’m completely … focus your attention on the relaxing
going to ask you to tense the muscles in the right muscles … feel the tension flowing out … enjoy
hand and lower arm, by drawing up your hand into the pleasant feelings of the muscles unwinding …
a tight fist … Now … clench the hand … keep it experience the feeling of deep relaxation and of
Progressive relaxation training 47
Figure 5.3 Pressing elbow down into arm of chair. RELAXATION THROUGH RECALL
PRT continues with relaxation through recall. This
comfort … then notice if the upper arm feels as is described in Chapter 7 (p. 60).
relaxed as the lower arm … if it does, then signal
with your little finger.
The above items give an idea of the nature of PRT, EVIDENCE OF EFFECTIVENESS
and in the first session the remaining 14 items are
also worked through. PRT has produced favourable results in many
conditions such as: anxiety (Rasid & Parish
Ending the session 1998), insomnia (Bootzin & Perlis 1992), asthma
(Vazquez & Buceta 1993), hypertension (Yung et al
At the end, the trainer terminates. 2001), epilepsy (Puskarich et al 1992), dyspnoea
I am going to bring the session to an end by count- and anxiety in chronic obstructive pulmonary
ing backwards from four to one … four … start to disease (Gift et al 1992) and rheumatic pain
move your legs and feet … three … bend and stretch (Stenstrom et al 1996). The study of Stenstrom and
your arms and hands … two … move your head colleagues compared the effects of dynamic muscle
slowly … and … one … open your eyes, noticing how training with those of PRT in 54 patients with
peaceful and relaxed you feel … as if you’d just inflammatory rheumatic disease. Participants in
woken from a short sleep. both interventions trained for half an hour, 5 days
a week for 3 months. At the end of that time the
relaxation group exhibited marked improvements
PRACTICE in muscle function which were significantly
Two daily practice sessions of 15–20 minutes each greater than those recorded in the dynamic exer-
are considered essential, the trainee picking cise group. Comparison studies in general often
moments when he is not under any pressure. show equal efficacy as in the study of Crist &
Rickard (1993) where muscular relaxation was
compared with imaginal relaxation in 100 healthy
SUMMARIZED VERSIONS college students.
Carlson & Hoyle (1993) reviewed studies fea-
When the trainee has learned the above procedure,
turing abbreviated progressive relaxation tech-
it can be regrouped in a summarized form,
niques such as PRT. The studies covered a wide
enabling him to cover the process in a shorter time:
range of conditions, but the largest effect sizes
1. Right arm items combined. were found in tension headache. Other conditions
2. Left arm items combined. such as cancer chemotherapy and hypertension
48 SOMATIC METHODS OF RELAXATION
showed smaller effect sizes. Overall, the interven- means of promoting relaxation, others claim that
tion was found to be moderately effective. it obstructs the process, and point to an increased
Shortened and standardized versions of pro- muscle–nerve sympathetic activity resulting from
gressive relaxation such as Bernstein & Borkovec’s the isometric contractions which feature in methods
are, in general, favoured by researchers and clin- such as PRT (Farrell et al 1991).
icians alike, although Lehrer (1982), re-evaluating Because of its various advantages, however,
Jacobson’s work, argued for the superior benefit PRT is widely practised. With regard to the evi-
of the lengthy original. Lichstein (1988), reviewing dence, the picture is far from clear since some of
studies comparing the two approaches, found the the research suffers from methodological prob-
evidence inconclusive. lems. In spite of this, Carlson & Hoyle (1993)
With regard to the ‘pendulum effect’, i.e. the conclude that the evidence is strong enough to
stronger the initial contraction the deeper the support the continued use of such methods in the
relaxation which follows it, Lehrer et al (1988) clinical setting.
found the evidence mixed. To these researchers it
appeared unlikely that an automatic and immedi-
ate decrease in muscle tension to below base-line PITFALLS OF PROGRESSIVE
level would follow a strong muscle contraction. RELAXATION TRAINING
The debate about the value of the initial con-
traction continues. While some authors, such as The pitfalls of muscular approaches are listed in
Bernstein & Borkovec, see the contraction as a Chapter 6 (pp 56–57).
Further reading
Bernstein D A, Borkovec T D 1973 Progressive relaxation Bernstein D A, Given B A 1984 Progressive relaxation:
training: a manual for the helping professions. Research abbreviated methods. In: Woolfolk R L, Lehrer P M (eds)
Press, Champaign, Illinois Principles and practice of stress management. Guilford
Press, New York
49
Chapter 6
A tense–release script
THE EXERCISES
● Breathing (1).
● Arm: spider hand, rod-like arm.
● Leg: plantar and dorsiflexion (foot bending
down and up), toe flexion (bending down)
and extension (bending up).
● Breathing (2).
● Abdominal muscle tensing.
● Shoulder bracing.
● Shoulder hunching.
● Head pressing back.
● Upper face: brow raising, frowning, eye
exercises.
● Lower face: jaw, lips, tongue. Figure 6.1 Spider hand.
Heel raising
Here, the seated participant is asked to raise his
heels off the ground (Fig. 6.5).
Begin by making sure your feet are flat on the floor …
then, keeping your toes firmly in contact with the
floor, raise your heels up in the air … Now … feel the
tension in your calf muscles … hold the action …
then … Relax … drop your heels to the ground …
notice the relief … the comfort … the warm, tingling
sensation in your calves … the enjoyable feeling of
relaxing your feet … go on letting those feelings Figure 6.6 Toe raising.
continue until your feet and calves are completely
relaxed … then, a little bit further…
These two exercises are repeated with diminished
tension.
Toe raising The next exercise is addressed to both lying and
In this exercise, the front part of the foot is raised seated participants.
off the ground (Fig. 6.6).
This time, keep your heels on the ground, and raise
TOE FLEXION AND EXTENSION (Fig. 6.7)
the front part of your feet as if you were about to
tap a rhythm … Now … keep your toes up in the air Let your attention focus on your toes. Whether you
while you take notice of the tension sensation in are lying or sitting, curl your toes down, restricting
the muscles around the shinbones … and … Relax … the action to the toes themselves. Some people can
let the feet fall down … notice the relief in the shin do it more easily than others, but just do what you
area … feel the tension leaving you … draining out can … Now … feel the tension in the sole of the foot
through your feet and toes … and continuing to and the calf of the leg … then … Relax … let it go …
drain out a bit longer… feel the muscles going slack … feel them going
A tense-release script 53
ABDOMINAL MUSCLE TENSING The exercise is repeated once with less tension.
Figure 6.9 Shoulder hunching. Relax … let the tension flow out … feel the furrows
being smoothed … continue until there is no tension
left in your brow … then a little bit further…
The exercise is performed once more using dimin-
ished tension. The repeat is carried out using less tension.
towards your throat (not too strongly) … Now … addition to their psychosis. Discussion with the
hold … and Relax … and then let your tongue attending psychiatrist or psychologist would first
settle in the middle of your mouth, just touching be necessary.
the backs of your front teeth … feel it releasing 3. Variations in the blood pressure may occur in
tension … let it go on relaxing … enjoy the feeling the course of relaxation training: it can rise when
of relaxation … let that feeling spread throughout limbs are being tensed and fall during deep relax-
your mouth and over your face, making them ation. The first can be counteracted by allowing a
feel warm, glowing and relaxed … then, let it spread rest between the tensings, and the second by asking
to cover your neck and shoulders … your arms … trainees, when the session is over, to bend and
back … abdomen … and legs, so that your entire stretch their limbs a few times before resuming
body experiences a feeling of complete active life. The fall in blood pressure which accompa-
relaxation … continue relaxing for several nies deep relaxation is only that which occurs under
minutes… any resting conditions. It is, however, important to
allow time for the individual to adjust to active life
following a session of relaxation. Suddenly jumping
TERMINATION up from a relaxed lying position can induce
And so, I’m going to bring this session to an end … faintness.
gradually I’d like you to return to normal activity, For people whose blood pressure is already high,
but first I’ll count from one to three to help you a release-only method (Ch. 7) is preferable to one
make the adjustment … when I get to three, I’d like which consists of muscle tensings.
you to open your eyes, feeling fresh and alert and 4. Tension-based exercises can induce heart
ready to carry on with your day … one … two … arrhythmias in cardiac patients (McArdle et al 1986)
three … before getting up, give a few gentle and are therefore considered unsuitable for patients
stretches to your arms and legs. following myocardial infarction. An alternative
relaxation method is suggested for people suffering
from heart conditions.
PITFALLS OF MUSCULAR APPROACHES 5. Antenatal and labouring mothers are no
longer given tense–release exercises because of the
It would seem that progressive relaxation is appro- possibility of interference with uterine contractions
priate in any circumstances where rest is pre- (Ch. 25). Release-only forms (i.e. passive relaxation)
scribed (McGuigan 1984). The method is unlikely would, however, be appropriate.
to create negative effects and Jacobson did not 6. Tense–release procedures performed with
refer to any. excessive tightening may lead to cramp. In order to
Some points, however, need to be considered: avoid this, trainees can be advised to stop short of
discomfort. Recurrent cramp would indicate the
1. Training in relaxation should never be unsuitability of the technique for that individual.
viewed as a substitute for medical treatment; Overtensing the spine and the neck should also be
wherever a disorder is present or suspected, med- avoided since it can lead to spinal damage.
ical help should be sought. 7. Some researchers have reported a fear of
2. Relaxation training is not generally recom- relaxing in certain individuals (Lehrer 1979), and
mended for people suffering from hallucinations, others report that relaxation occasionally induces
delusion or other psychotic symptoms, as the exer- anxiety (Borkovec & Heide 1980). This can be rec-
cises can lead to out-of-body sensations. It is trad- ognized by excessive perspiration, trembling,
itionally held that imagery is never appropriate, but rapid breathing or general restlessness. The train-
benefit has been derived from a tense–release and ing (for that individual) should immediately be
physical exercise approach during a non-active stopped. These symptoms may, however, be the
period of psychotic illness (Bloom & Gonzales result of a fear that letting-go might lead to loss of
1981). Keable (1997) has emphasized the value of control. To individuals who harbour such fears,
this finding for individuals who experience stress in the wording can be changed to ‘as relaxed as you
A tense-release script 57
want to be’. It is worth mentioning that the disorder (Davidson & Schwartz 1976). Some
researchers who studied the reaction (Borkovec & individuals, however, find that focusing on the
Heide 1980) were not using Jacobson’s original body intensifies their perception of pain (Snyder
method, but one of its modifications. 1985), and for them, muscular approaches may be
Disturbing feelings may rise to the surface dur- less useful than cognitive ones such as imagery or
ing any kind of relaxation: in the process of releasing meditation.
tension, psychological defences can be weakened 10. Trainees who, because of disability or dis-
(Hough 1991). order, are in doubt as to the suitability of any exer-
8. Abromowitz & Wieselberg (1978) reported cise, should begin by performing it very gently. This
that a few individuals undergoing relaxation train- applies, for example, to individuals with back or
ing became angry when asked to relax. It was neck problems.
unclear what had caused the anger but one reason 11. As attention to breathing is a feature of most
suggested was that they had found difficulty in muscular approaches, the hazards of hyperventila-
mastering the technique. tion should be borne in mind (p. 134).
9. Progressive relaxation training has been 12. Some tense–release scripts make use of
found effective for many people suffering organic imagery. They will therefore, in addition, be sub-
pain. It provides a physical approach to a physical ject to the pitfalls listed in Chapter 18 (p. 170).
59
Chapter 7
The trainer continues in this way for 30–45 seconds. It is suggested that the counting be done at a pace
which corresponds with the trainee’s respirations.
Next, bring your mind to focus on the muscles of Once mastered, this technique can be used by the
your face and neck. Is there any tension there? If so, trainee when faced with challenging situations.
notice where it is and what it feels like … then,
recalling the feeling of letting the tension go, relax
it … feel the tension leaving the muscles … note the PASSIVE NEUROMUSCULAR
pleasant feeling of relaxation … allow the relax- RELAXATION
ation to deepen and go on deepening as you con-
centrate on the peaceful state of those muscles… The technique described here is the work of
Next, concentrate on the muscles of the trunk. Everly & Rosenfeld (1981). This method owes much
Pick up any sensation of tension you may find … to autogenic training (Ch. 19) in its use of sugges-
notice where it is and what it feels like … remember tion and its images of warmth and heaviness. It is,
what it felt like when you previously relaxed tension however, considered by its authors to be a muscular
in those muscles … and relax them now … relax any method and so belongs in this chapter.
tension you find … continue letting the tension go Trainees are introduced to the approach with a
until your muscles feel quite loose. Go on relaxing short explanation on the following lines:
them … feel them getting looser and looser.
Tension in the muscles is associated with tension in
Finally, give your attention to your legs … do you
the mind. If tension is eliminated from the muscles,
notice any tension there? … notice exactly where it
then the subjective feeling of stress is reduced. In
is … notice how it feels … and release it … recalling
this method you will be asked to focus attention on
the sensation of releasing it … remembering that feel-
one muscle group at a time, releasing any tension
ing … letting all the tension dissolve … further … then
that exists. No activity is involved; the method is a
further still … until the muscles feel entirely relaxed…
passive one. It has been found that by concentrat-
By practising relaxation through recall the trainee ing on the muscles in this way, deep levels of relax-
will be able to reduce the time it takes to relax each ation can be achieved. Of course, the more you
muscle group from 45 to perhaps 15 seconds. practise, the more effective it becomes.
The necessary conditions include a warm, quiet
RELAXATION THROUGH RECALL WITH room where interruptions are unlikely to occur, and
COUNTING a comfortable chair to sit in or flat surface to lie on.
The following script is adapted from Everly &
When the trainee feels skilled at relaxing through Rosenfeld (1981).
recall, the procedure can be still further shortened
by introducing counting. Here, recited numbers Settle into the chair you’re in or the surface you are
correspond to the groups in the recall procedure lying on, letting your body weight sink into it. Close
as follows: your eyes. To start with, I’d like you to turn your
attention to your breathing … follow the next
I’m going to count slowly from one to ten. As I breath out … then, let the air in … feel it gently fill-
count, I’d like you to focus on the same muscle ing your lungs … pause for a moment … and
groups as in the recall procedure, relaxing them as breathe out slowly … then allow your breathing to
you did then. follow its natural rhythm: gentle and slow … get-
One … two, focusing on the arms and hands as ting gentler and slower…
they become more relaxed … three … four, relaxing Now bring your attention to the muscles of your
the face and neck muscles … five … six, focusing on head. Begin to feel a slow warm wave of relaxation
the muscles of the chest, back, shoulders and gathering at the top of your head and beginning to
abdomen, feeling them becoming more and more descend towards your forehead … focusing on the
relaxed … seven … eight, allowing relaxation to muscles above your eyes … feel those muscles
flow through the muscles of the legs and feet … becoming heavy and relaxed … concentrate on the
nine … ten, relaxed all over… heavy feeling you are getting from them … now
62 SOMATIC METHODS OF RELAXATION
shift your attention to the muscles of your eyes and Pause for 10 seconds.
cheeks and feel them also becoming heavy and
Then, as you feel all your muscles to be in a state of
relaxed … now, focus on the muscles of your mouth
relaxation, start to recite the phrase, ‘I am relaxed’;
and jaw … allow them to grow heavy and relaxed…
repeat it every time you breathe out.
Pause for 10 seconds.
After a 5-minute pause:
As your head and face continue to relax, let the
wave of relaxation slowly descend into your neck … I’d like you now to bring your attention back to the
focus your attention on the neck muscles and feel room in which you are lying. I am going to count
them becoming slacker and more relaxed with every from one to five, and as I count, begin to feel more
moment that passes… and more awake, more and more refreshed, with a
clear head. When I reach five, I’d like you to open
Pause for 10 seconds. your eyes. One, begin to feel alert … two … three,
The wave of relaxation continues to roll down, this more alert still … four … five … open your eyes and
time spreading warmth over your shoulder muscles … gently stretch your arms and legs…
focus on this area … allow it to become heavy and
relaxed as you concentrate your attention on it.
THE RELAXATION ‘RIPPLE’
Pause for 10 seconds.
Closely related to the above method is the relax-
The head, neck and shoulders remain relaxed while
ation ‘ripple’. Adapted from Priest & Schott
you focus on your arms … letting the wave of relax-
(1991), the technique consists of one continuous
ation bring heaviness and warmth to them … con-
wave of relaxation which begins at the crown of
centrate on the feelings in the arms…
the head and progresses down through the body
Pause for 10 seconds. to the toes. As the wave descends, the individual
Now feel the wave of relaxation descending into briefly scans the muscle groups, releasing tension.
your hands as you focus on them … feel the muscles If he is lying down, all tension can be released; if
of your palms and fingers relaxing … feel warmth he is standing, excess tension can be released. The
flowing into them as they become more relaxed… effectiveness of the exercise is increased if it is
timed to coincide with the outbreath. However,
Pause for 10 seconds. the participant should be discouraged from
Now, as the upper part of your body remains in extending the outbreath too long.
deep relaxation, switch your attention to your The exercise can be better understood if the first
abdomen and the wall of muscle covering your relaxation ripple is preceded by a tensing of the
internal organs … let those muscles loosen and whole body (Schott & Priest 2002). Thereafter, it
spread … then feel the wave of relaxation beginn- can be performed in a passive manner.
ing to descend into your thigh muscles … and
as you concentrate on them, feel your thighs
becoming heavy … heavy as lead… A PASSIVE RELAXATION APPROACH
Pause for 10 seconds.
The script presented here is adapted from
The wave of relaxation continues to descend into Madders (1981). It is addressed to trainees who
your lower legs … focus on your calf muscles … feel are lying down. A supplementary section enables
the sense of heaviness and relaxation in your calves… the instructor to adapt it for the seated participant.
Pause for 10 seconds.
INTRODUCTORY REMARKS TO TRAINEES
Now, as the rest of your body remains relaxed, turn
your attention to your feet … feel the warm wave This is a method which helps to relax your
of relaxation descending into your foot muscles … muscles and your thoughts. It consists of focusing
feel them becoming warm, heavy and relaxed… on different parts of the body in turn and releasing
Passive muscular relaxation 63
any tension you find. There are no physical actions away … let it go on relaxing a bit further than you
involved; relaxation occurs by virtue of a thought thought possible.
process. In spite of its length, the method is one Settle your spine into the rug or mattress …
which you can easily use to induce relaxation on become aware of how it is resting on the floor. Let
your own. it sink down, making contact wherever it wants to …
all tension draining out of it.
Let your abdominal muscles lose their tension.
PROCEDURE FOR TRAINEES WHO Let them go soft and loose. Feel them spreading as
ARE LYING DOWN they give up their last vestige of tension … notice
how your relaxed abdomen rises and falls with your
A firm support with a soft surface is needed, e.g. a
breathing … rises as the air is drawn in and falls as
length of foam spread out on the floor. The script
the air is expelled … abdominal breathing is relaxed
could begin with the passage called ‘Sinking’ in
breathing.
Chapter 2 (p. 17), and continue as follows:
Moving up to your shoulders, to muscles which
With your eyes closed, notice how slow and regular are prone to carry tension … feel them letting go …
your breathing is becoming … easy, calm and even … feel them spreading … feel them easing into the
leaving you more relaxed than you were before… floor, limp and heavy … feel them dropping down
I’m going to ask you to take a trip round the towards your feet … imagine them shedding their
body, checking that all the muscle groups are as burdens … and as the space between your shoulders
relaxed as possible and letting go any tension that and your neck opens out, imagine your neck a bit
might still remain. If outside thoughts creep in, hold longer than it was before.
them in a bubble and let them float away. I’ll begin Now, direct your thoughts to the muscles of your
with the feet. left arm. Check that it lies limply on the ground.
Bring your attention to your toes … are they Notice the feeling of relaxation and allow this feel-
lying still? If they are curled or stretched out or in ing to sweep down to your wrist and hand. Think of
some way not entirely comfortable, waggle them the fingers, are they curved and still? … neither
gently. As they come to rest, feel the tension ebbing drawn up nor stretched out … in a hand that is
away … feel the tension leaving them as they lie neither open nor closed, but gently resting … totally
motionless… relaxed. As you breathe out, let the arm relax a little
Let your feet roll out at the ankles. This is the bit more … let it lie heavy and loose … so heavy and
most relaxed position for them. Let all the tension loose that if someone were to pick it up, then let go,
flow out of them … enjoy the sensation of just it would flop down again like the arm of a rag doll.
letting them go.
Repeat the last paragraph with the muscles of the
Moving on to the lower legs: feel the tension
right arm.
leaving the calf muscles and the shins. As the
tension goes, so they feel heavier … so they feel Your neck muscles have no need to work with your
warm and pleasantly tingling. head supported, so let them go … enjoy the feeling
The thighs next: to be fully relaxed they need to of ‘letting go’ in muscles which work so hard the
be slightly rolling outwards … feel the relaxing rest of the time to keep your head upright. If you
effect of this position … make sure you have find any tension in the neck, release it and let this
released all tension, and feel your thighs resting process of releasing continue, even below the
heavily on the floor. surface … feel how pleasant it is when you let go
Focus for a moment on the sensation of sagging the tension in these muscles.
heaviness throughout your legs … let the muscles Bring your attention now to your face, to the
shed their last remaining hint of tension and settle many small muscles whose job it is to manage your
into a deep relaxation. expressions. At the moment there’s no need to have
And now, think of your hips. Let them settle into any expression at all on your face, so allow your
the surface you are lying on … recognize any ten- muscles to feel relaxed … imagine how your face is
sion that lingers in the muscles … then relax it when you are asleep … calm and motionless…
64 SOMATIC METHODS OF RELAXATION
Now, think about the jaw … and as you do, allow Before the meeting breaks up, the value of prac-
it to drop slightly so that your teeth are separated … tice should be emphasized. If carried out on a
feel it relaxing with your lips gently touching. daily basis, the technique will help the trainee to
Check that your tongue is still, and lying in the relax himself more effectively.
middle of your mouth, soft and shapeless. Relax
your throat so that all tension leaves it and the
muscles feel smooth and resting. ADAPTED PROCEDURE FOR SEATED
With no expression on your face, your cheeks are TRAINEES
relaxed and soft. If you think of your nose, let it be
The trainee picks the chair he finds most comfort-
just to register the passage of cool air travelling up
able, although in a public building the choice may
your nostrils while warmer air passes down …
be limited. For deep relaxation the body needs to
breathe tension out with the warm air … breathe
be well supported. The procedure begins in the
stillness in with the cool air.
following way:
Check that your forehead is smooth … not fur-
rowed in any direction … and as you release its Settle into your chair, sitting well back into the
remaining tension, imagine it being a little higher seat, your feet flat on the floor and your hands in
and a little wider that it was before … let this feel- your lap. Close your eyes. Become aware of the
ing of relaxation extend through your scalp muscles, parts of your body that touch the chair and the
over the crown of your head and down behind your floor. Feel the weight of your body passing through
ears … feel a sense of calm as you do this. those points: hips, thighs, feet, back and arms, some
Let your attention focus on your eyes as they lie of them carrying more weight than others. If the
behind gently closed lids. Think of them resting in back of the chair is high enough, use it to support
their sockets, floating rather than fixed … and as your head. If not, your head may be dropping for-
they come to rest, so do your thoughts also. wards which is all right if you find it comfortable,
Spend a few minutes continuing to relax, deep- but it tends to put a strain on the neck muscles if
ening the effect of the above sequences… held for a long time. Try raising your head and see-
You have now relaxed all the major muscle ing it as a weight supported by a pole. If you can
groups in your body. Think about them now as a balance it in this way, on your spine, you will be
whole … a totally relaxed whole … soothed by your giving your neck muscles a rest.
gentle breathing rhythm, feel the peacefulness of
this idea… The same script as for the lying position may be
Images may drift in and out of your mind … see used, substituting the word ‘sitting’ for ‘lying’,
them as thoughts passing through. Feel yourself and ‘chair’ for ‘floor’. The paragraph about the
letting go of them. Say to yourself: ‘I am feeling neck muscles can be deleted, and also the one
calm, I am feeling peaceful’. Let your mind conjure referring to the feet.
up a scene of contentment.
Trainees can relax quietly for a few minutes, before
KERMANI’S SCANNING TECHNIQUE
the session is brought to an end.
To ‘scan’ in this sense, is to run the attention over
all the voluntary muscles.
TERMINATION
Scanning may be used for at least two pur-
I am going to ask you to bring yourself slowly back poses: on the one hand, as a means of checking to
to the room you are lying in. Gradually become see if tension exists, and on the other, as a device
aware of it. Gently move your arms and legs … to enable the individual to feel in touch with his
wriggle your spine, and in your own time, allow body as a whole. Both purposes are relevant in the
your eyes to open. Slowly sit up and take in your context of relaxation, and the method forms a
surroundings. Give your body plenty of time to quick and simple version of the passive relaxation
adjust from the relaxed to the alert state. approach.
Passive muscular relaxation 65
Here is an example adapted from Kermani descend to the forehead … ending with the jaw …
(1990). feel that every part of your body is relaxed…
You might like to think of a giant paint brush
I’ll ask you to spend a moment getting in touch
sweeping over your body, following the same route.
with the different parts of your body, acknowledg-
ing them as part of you and checking that they feel
relaxed and comfortable. Begin by bringing your RELEASE-ONLY
attention to your feet. First the toes … working up
through the ankles … to the calves and shins … over A release-only method is described in Chapter 8
the knees … along the thighs … the abdomen … (p. 70) as one component of Öst’s applied relaxation.
then the chest. Think now of your shoulders … of
travelling down to the elbows … through the fore-
arms … and into the wrists … hands and fingers. PITFALLS OF PASSIVE RELAXATION
Become aware even of your fingertips.
Next, move across to the lower spine and the Passive relaxation is subject to the pitfalls of other
pelvis. Give your attention to the lumbar region … muscular approaches (Ch. 6, p. 56). Because pas-
rising to the back of the chest and the blade sive methods often include imagery and sugges-
bones … continuing up into the neck and scalp … tion, the pitfalls relating to visualizations should
to the crown of the head … then slowly begin to also be taken into account (Ch. 18, p. 170).
Further reading
Bernstein D A, Borkovec T D 1973 Progressive relaxation Kermani K S 1990 Autogenic training. Souvenir Press,
training: a manual for the helping professions. Research London
Press, Champaign, Illinois Madders J 1981 Stress and relaxation: self-help ways to cope
Everly G S, Rosenfeld R 1981 The nature and treatment of with stress and relieve nervous tension, ulcers, insomnia,
the stress response. Plenum Press, New York migraine and high blood pressure, 3rd edn. Martin
Jacobson E 1976 You must relax. Souvenir Press, London Dunitz, London
67
Chapter 8
Applied relaxation
HISTORY
CHAPTER CONTENTS
History 67 The methods described in previous chapters have,
on the whole, been concerned with the induction of
Description 67 deep relaxation. Their purpose is to equip the indi-
Rationale 68 vidual with routines to be performed in the privacy
of his own home. As such, these methods are useful
Procedure 69 for unwinding after a stressful day, but may not,
Introductory remarks to participants 69 however, provide strategies for coping with stress
Tense–release 70 as it occurs. For this, some kind of shortened ver-
Release-only 70 sion that can be linked into life activities is required.
Cue-controlled or conditioned relaxation 71 Jacobson’s (1938) differential relaxation (p. 40) and
Differential relaxation 72 Wolpe’s (1958) systematic desensitization represent
Rapid relaxation 73 early attempts at applied formats. However, it was
Application training 73 Goldfried (1971) who, recognizing the extent of the
Maintenance programme 73 gulf between relaxation in the therapeutic environ-
Evidence of effectiveness 73 ment and relaxation in the stressful situation,
focused expressly on the issue of the application of
Pitfalls of applied relaxation 74 the skills. He emphasized the need for a portable
and shortened form of progressive relaxation; a
form which could be used to defuse anxiety as it
occurred, and one which the individual could use
as a general coping skill in everyday life. In so
doing, he gave the individual a new role, defining
him as an active agent in his treatment rather than
a passive client. The approach was called ‘training
in self-control’ because it implied active mastery
of anxiety by the individual himself.
DESCRIPTION
Date Situation Reaction, i.e. anxiety signals Intensity (0 –10) Action taken
Figure 8.2 A form for recording self-observed early anxiety signals. (Adapted from Öst 1987.)
thus be seen as a cognitive behavioural method When people experience anxiety they tend to
(Heimberg 2002). react in three different ways: a physiological way in
Because anxiety is easier to relieve when it is which their blood pressure rises and they become
mild, it should be addressed before it reaches a breathless with a pounding heart and a cold sweat;
peak. Early signals or signs of rising anxiety levels a psychological way in which distressing thoughts
such as a pounding heart, sweating, fast breathing go through their head; and a behavioural way
or tense muscles can be used as cues to employ the whereby they find themselves trying to escape.
technique. Experiences of anxiety-provoking events If the physiological symptoms are viewed as
can be recorded by means of ‘self-monitoring’, threatening, the body will respond by intensifying
where the individual notes on a printed form the situ- those symptoms, which in turn will make the
ations, the intensity of his anxiety and the remedial thoughts more negative. This is the way a panic
action taken by him (Fig. 8.2). This form, over time, attack develops.
reflects his progress in coping with such events. However, this vicious circle can be broken and
one way of doing this is by learning not to react so
strongly. This will reduce your feeling of distress
PROCEDURE and your symptoms will tend to subside.
I am going to lead you through a well-tested
It is suggested that participants sit for the exercises method which will help you to achieve this. You’ll
since daily stress frequently occurs in this posture be learning a skill, so it’s important to practise it,
rather than in a lying one. The chair should be but once you’ve mastered it, you’ll find it useful in
comfortable and have arm rests. nearly all situations.
The approach starts by introducing you to
INTRODUCTORY REMARKS TO progressive relaxation which consists of tensing
PARTICIPANTS and releasing the muscles throughout the body.
When that is learned and practised daily, the
Before beginning the programme of relaxation,
tensing part of the exercise is dropped.
the rationale of the treatment is presented to
Next, you’ll be asked to repeat the word ‘relax’
participants:
to yourself when you are in a state of relaxation.
As its name suggests, this method will show you Attaching the word to the state has the effect of
how to apply relaxation skills in everyday life. This turning the word into a cue; a cue to invoke a state
means the techniques have to be quick-acting of relaxation. This only happens, of course, after
and unobtrusive. The ultimate aim is to be able to repeated associations.
relax in 20–30 seconds and to transfer this skill to Learning how to use reduced amounts of muscle
situations of stress. tension when carrying out specific tasks is the next
70 SOMATIC METHODS OF RELAXATION
procedure, followed by a rapid-acting technique for ● pressing the head against the back of the chair
maintaining low levels of stress throughout the ● pressing the chin down on to the chest
day. Finally, these skills are applied to particular ● hunching the shoulders up to the ears
situations of stress. ● bracing the shoulders back to bring the blades
These exercises enable you to achieve relaxation together.
in progressively shorter periods of time. Success Termination. When the above exercises have
depends on practice. been worked through, the session is brought to
an end.
The relaxation session is over now, and to help you
TENSE–RELEASE
return to activity, I’m going to count from one to
Two sessions of tuition are devoted to learning five, and when I get to five, I want you to open
this version of progressive relaxation. The proce- your eyes, feeling calm and relaxed … one, feeling
dures are first demonstrated by the trainer and calm … two, feeling relaxed … three, very
carried out by the trainee to ensure that they have calm … four, very relaxed … five … open your eyes,
been understood. The trainee then closes his eyes feeling ready to carry on with your everyday life.
while the instructor runs through the programme.
A debriefing session follows. Participants are
At the end, the trainee rates the degree of relax-
instructed to practise for 15 minutes twice daily.
ation gained on a 0–100 scale.
They are asked to record the level of relaxation
achieved, using a 0–100 scale where 0 ⫽ total
First session relaxation, 100 ⫽ maximum tension, and 50 repre-
This is spent working on the hands, arms, face, sents normal. They are also asked to keep a note
neck and shoulders. Each muscle group is taken of the length of practice time taken to reach the
through one tense–release cycle in which 5 seconds level achieved. The form shown in Figure 8.3
are allotted for the tension and 10–15 seconds for serves to motivate the individual to practise as well
the release, as follows: as to record the details of the homework session.
0 = totally relaxed
100 = maximum tension
Degree of relaxation (0–100)
Date Time Component Time taken to
Before After achieve it
Figure 8.3 Form for recording relaxation training homework. (Adapted from Öst 1987.)
part. As a result, the relaxed state can be achieved breathing continue at its own pace, expanding the
in less time than when working with the full stomach region in particular … Now, relax your
sequence; 5–7 minutes are suggested instead of back … now, the lower part of your body … hips …
the 15 of the tense–release session. thighs … knees … calves … shins … feet… toes … still
The training session begins with breathing breathing gently and noticing the relaxing effect of
instructions, followed by a scanning of all the vol- each breath … feel yourself relaxing more and
untary muscles starting with the head and working more…
down to the toes. The following instructions are
The sequence is terminated in the same way as for
adapted from Öst (1987):
the first component.
In a moment I’m going to ask you to focus your Again, the homework assignment is a twice-
attention on your breathing and, in particular, on daily practice, the trainee being asked to record
the movement of your upper abdomen … notice afterwards the level of relaxation achieved and
how it swells slightly as you breathe in, and sinks how long it took to reach it.
back as you breathe out … do not change it in any
way … just tune in to its rhythmic pattern … feel
CUE-CONTROLLED OR CONDITIONED
yourself relaxing more with each breath … feel
RELAXATION
your muscles letting go from the top of your
head … your forehead … eyebrows … eyelids … This component of the training focuses on the
cheeks… temples … jaws … throat … tongue … lips … breathing. It begins by asking the trainee to relax
feel your entire face relaxed … now … your himself by employing the release-only method of
neck … shoulders … arms … and down to the tips of progressive relaxation. Once relaxed, he is asked
your fingers … and while you are doing this, let your to begin silently to recite the word ‘relax’; he
72 SOMATIC METHODS OF RELAXATION
recites it once each time he breathes out. Following some tension is needed in order to carry out the
many repetitions, an association is built up between task, the level is often greater than is necessary
the word and the relaxed state whereby the word and may need to be reduced. Also there may be
alone becomes capable of inducing a measure of unnecessary tension in the muscles not directly
relaxation. The word has thus become a cue. The engaged in the task. Different levels of tension (or
stronger the association, the greater the power of relaxation) are required for each.
the cue word. Expressed in other terms, a condition- Since an ability to recognize muscle tension at
ing process has been set up, as a result of which its varying levels is essential for developing this
the trainee feels himself relaxed whenever he skill, differential relaxation is presented after
thinks the word ‘relax’. the individual has been trained in progressive
The trainer introduces the exercise in the follow- relaxation.
ing manner: Two sessions of tuition are indicated, one dealing
with sitting and the other with standing activities.
Spend a few moments with your eyes closed … relax Both sessions begin with a revision of cue-
yourself by running through the release-only controlled relaxation.
routine … signal to me by raising your right index
finger when you feel fully relaxed … if you are ready, The first session: sitting
turn your attention now to your breathing … tune In the first, the trainee, seated in an armchair,
in to its rhythm … let it adopt its own pace … do is instructed to make certain movements while
not be tempted to alter it … and just before you maintaining a relaxed state in the rest of the body.
breathe in, think the word ‘inhale’ … just before
you breathe out, think the word ‘relax’… Please make yourself as comfortable as possible.
Settle into the chair with your feet flat on the
Leading with the instructions of ‘inhale’ and floor. With your eyes closed relax yourself using
‘relax’ for five breaths, the trainer then asks the your cue word with breathing … when you are
participant to continue on his own for a further ready, would you raise your right index finger … I’d
five breaths. After a few minutes’ rest, the full like you now to open your eyes and look around the
sequence is repeated. room without moving your head … notice the tension
If there is more than one participant, the trainer in the eye muscles but keep the body relaxed…
will not attempt to synchronize their respirations Next, look around the room allowing your head
but will let them conduct their own exercise. to move in order to increase your range of vision.
As proficiency increases, the command ‘inhale’ can Keep a minimum of tension in the neck muscles
be dropped, and the word ‘relax’ used on its own. while you do this, and check that the rest of your
Homework consists of 20 pairings a day of the body is free from tension…
word ‘relax’ with the state of relaxation. Participants Would you now lift one arm, and as you do,
should be warned against overbreathing, i.e. allow- remember to keep the other parts of your body
ing the breathing to become deeper or more rapid relaxed … and, lower the arm. Continue to scan
(p. 134). The trainee keeps a record of the level of your body for signs of unnecessary tension.
relaxation achieved and the time taken to reach it. Now, lift one leg off the ground, keeping the
Once learned, it takes only 2 or 3 minutes to get rest of your body as relaxed as possible … and, let
fully relaxed by this method. it down.
If you had any difficulty with this exercise,
DIFFERENTIAL RELAXATION perhaps we could discuss it before moving on.
So far, the sessions have been concerned with The routine is then carried out on the other arm and
teaching basic techniques. The application of those leg, after which the trainee is moved from his arm-
skills now begins. Differential relaxation focuses chair to an upright chair. He relaxes himself in this
on controlling the levels of muscle tension while new sitting position before being led through the
the individual is engaged in some activity. Although same procedure of eye, head and limb movements.
Applied relaxation 73
Next, he is seated at a table and asked to write Regular practice of this short sequence (15–20
something short such as his name and address, times a day) makes the technique more effective
using the minimum of muscle tension needed to and results in the trainee being able to relax in a
accomplish the task. As an alternative, in practice still shorter space of time. It has been found that
sessions, he could make a short telephone call, after 1 or 2 weeks’ practice, he can relax himself by
adopting the same relaxed state. this method in as little as 20–30 seconds.
this has advantages in a condition, such as anxiety, feedback, a combination of both and a waiting list
where changes occur in different modes. control. After treatment twice weekly for 4 weeks
Applied relaxation has been tested in the treat- significant reductions in pain, depression, distress
ment of a large number of conditions including and anxiety were found in all the relaxation groups,
phobia, panic disorder, headache, epilepsy and while minimal change occurred in the waiting list
tinnitus. In a review of 18 controlled studies, it control. The greatest benefit, in the short term at
was found to be significantly more effective than least, was reported in the group who received
no treatment or placebo conditions. Follow-up, at applied relaxation.
varying times from 5 to 19 months, showed that Studies comparing applied relaxation with other
the effects were maintained and in some cases psychological methods often find very little differ-
augmented (Öst 1987). ence in effectiveness. For example, in a study com-
A study which compared applied relaxation with paring the method with cognitive therapy on a
progressive relaxation training showed applied population of 33 people experiencing generalized
relaxation to be more effective on most measures anxiety, it was not possible to declare one method
immediately following treatment. At follow-up superior to the other. Both however, were found
19 months later, however, applied relaxation was to be effective (Öst & Breitholtz 2000).
shown to be more effective on all measures (Öst
1988). Thus the method seems to provide long-term
benefit.
More recently, Spence and colleagues (1995) PITFALLS OF APPLIED RELAXATION
tested the effect of applied relaxation on chronic
upper extremity pain caused by cumulative trauma. Since applied relaxation is based on progressive
Forty-eight patients were randomly allocated to relaxation, it is subject to the same pitfalls. They
four groups: applied relaxation, electromyographic may be found in Chapter 6 (p. 56).
Further reading
Hawton K, Salkovskis P M, Kirk J, Clark D M 1996 Öst L-G 1987 Applied relaxation: description of a coping
Cognitive behaviour therapy for psychiatric problems. technique and review of controlled studies. Behaviour
Oxford University Press, Oxford Research and Therapy 25: 397–407
75
Chapter 9
Based on these ideas, Schilling & Poppen (1983) knees, forearms and head, as required. Women
set up a method of relaxation which they called will find it convenient to wear trousers.
behavioural relaxation training (BRT). Liberal
comment from the trainer provided reinforcement
or corrective adjustment. The method is thus INTRODUCTION OF METHOD TO
underpinned by behaviourist principles. PARTICIPANTS
Participants are introduced to the method in the
following way:
DESCRIPTION
We can all recognize signs of tension: tightly drawn
BRT is a method in which tense postures are face muscles, clenching of teeth and fingers. These
replaced by relaxed ones. The trainee is required are typical postures that people adopt when under
to take up specified relaxed postures based on the stress. When people are relaxed, muscle tensions
way people look when they are relaxed. He then are released and a new posture results. The central
registers the feeling of adopting that posture. idea of behavioural relaxation training is that by
adopting the posture of a relaxed person, we can
make ourselves feel more relaxed.
PROTOCOL FOR BEHAVIOURAL In this method you will be asked to make differ-
RELAXATION TRAINING ent parts of your body look as relaxed as possible
and then to notice the effect the new position has
SETTING on you; to notice how the new position feels. I’ll
describe and demonstrate each item before we
The ideal setting is a warm, quiet room with
begin. Please try out the items on yourself.
dimmed lighting. A padded recliner is the chair of
choice but, since this may not be available, any flat The postures, as described in Table 9.1, are then
surface will serve. Pillows may be used under the demonstrated and the trainee asked to copy them.
Table 9.1 Relaxed and unrelaxed behaviours (Adapted from Lichstein © 1988 Clinical relaxation strategies,
p. 137, with permission from John Wiley and Sons Inc, New York)
Mini-relaxation can be practised throughout The scale is based on the assumption that a per-
the day and reminders to do so provided by placing son who feels relaxed also looks relaxed. As a
coloured dots on the telephone, watch, steering result, some kind of judgement of the degree to
wheel, typewriter, kettle-handle or any other which a person is relaxed can be made by an
frequently used appliance. onlooker. Using the same items that feature in
BRT, the scale allows an objective assessment to
be made, without the need for expensive equip-
PITFALLS OF BEHAVIOURAL
ment such as electromyographic instruments.
RELAXATION TRAINING
Each posture is checked for its degree of relaxation
with reference to the table of relaxed and unre-
As with any relaxation approach, possible pitfalls
laxed postures (see Table 9.1). The order of the
should be considered before taking it up. Chapter
items in Table 9.1 is seen by Poppen (1988)
6 (p. 56) contains a discussion of hazards relating
as being the most convenient for assessment
to muscular approaches.
purposes.
+ relaxed
Breathing baseline – unrelaxed
INTERVALS
1 2 3 4 5 Total
Breathing – + – + – + – + – +
Quiet – + – + – + – + – +
Body – + – + – + – + – +
Head – + – + – + – + – +
Eyes – + – + – + – + – +
Mouth – + – + – + – + – +
Throat – + – + – + – + – +
Shoulders – + – + – + – + – +
Hands – + – + – + – + – +
Feet – + – + – + – + – +
Self-ratings 1 2 3 4 5 6 7 Score
Figure 9.1 Behavioural Relaxation Scale score sheet. (Adapted from Poppen R. Behavioral relaxation training and
assessment, p. 123, © 1988 by Pergamon Press. Reprinted by permission of Sage Publications, Inc., Thousand Oaks,
CA, USA.)
80 SOMATIC METHODS OF RELAXATION
Behavioural Relaxation Self-rating Scale is easily learned and readily applied. These attri-
butes make it a convenient technique for reducing
1. Feeling extremely tense and upset throughout anxiety in people with learning disabilities. In this
my body. context, Lindsay and colleagues have carried out
2. Feeling generally tense throughout my body. a series of studies charting its effect on cognitive
3. Feeling some tension in some parts of my body. performance. Results showed that where the dis-
4. Feeling relaxed as in my normal resting state. ability was severe, short-term memory and learn-
5. Feeling more relaxed than usual. ing significantly improved following 12 sessions
6. Feeling completely relaxed throughout my of BRT, compared with quiet reading where no
entire body. significant differences were reported (Lindsay &
7. Feeling more deeply and completely relaxed Morrison 1996).
than I ever have. In a later study, Lindsay et al (1997) tested con-
centration and responsiveness in eight partici-
Discrepancy between self-report and pants, this time with profound learning disabilities.
objective testing Several different procedures were compared:
There are often wide discrepancies between self- snoezelen, aromatherapy massage, BRT and active
reports and objective measurements. One of the therapy. Following each therapy participants were
reasons is that self-report may be coloured by fac- set simple concentration tasks. The treatments
tors of social desirability, for instance where the which led to the most successful outcomes were
trainee gives the answer he thinks is expected snoezelen and BRT, where significant effects were
of him. These matters are discussed further in recorded. There was no improvement in the
Chapter 26 (p. 225). aromatherapy group and the active group even
showed a deterioration.
Brain injury is another area where the approach
EVIDENCE OF EFFECTIVENESS has been applied. Guercio et al (2001) taught BRT
skills to one adult with an ataxic tremor resulting
Behavioural relaxation training offers both therapy from an acquired brain injury. Having learned the
and a scale of assessment. As a therapy it provides a skills, the participant was then connected to a
form of body scanning in which relaxed postures are biofeedback facility. Results demonstrated a sig-
adopted and feelings of relaxation experienced. As nificant reduction in the severity of the tremor.
an assessment tool it provides a numerical measure The benefits of BRT can be seen after very little
of the level of relaxation present in the musculature. teaching: Schilling & Poppen (1983) observed ben-
The approach does not ask participants to recog- efit within as few as two training sessions. They
nize subtle degrees of arousal or to be conscious of also reported that effects were retained at follow-
different levels of relaxation; moreover, the method up 4–6 weeks later.
Further reading
Poppen R 1988 Behavioural relaxation training and assess- Schilling D J, Poppen R 1983 Behavioural relaxation training
ment. Pergamon Press, Oxford and assessment. Journal of Behaviour Therapy and
Experimental Psychiatry 14: 99–107
83
Chapter 10
the working muscle groups are identified, and then 2. Forward-lean sitting, i.e. leaning forwards with
relaxed by activating the opposing groups. The head and arms resting on a table (Fig. 10.2).
resulting changes of position of the joints, and 3. Sitting in a high-backed chair with arm rests
the accompanying skin sensations, are then men- on which the hands are supported, palms
tally registered as the part settles into the posture downwards (Fig. 10.3).
of ease. Thus, her approach consists in moving the
Varying the starting position is useful in order to
body out of the posture of defence or stress, and
extend the range of application of the method. The
training the mind to recognize the posture of ease
eyes may be open or closed.
or relaxation.
The aim of the procedure is to reduce stress and
relax the mind. Mitchell proposes that the relax- INSTRUCTIONS
ation induced by her method spreads throughout The instructor begins by giving an order to direct
the organism to include the mind. a part of the body away from its posture of ten-
sion. The order is followed by the word ‘Stop’.
This means that the part is no longer being
DESCRIPTION actively moved; it also means that the muscles
responsible for the movement are no longer con-
Mitchell’s method is composed of 13 items, tracting. The part then falls naturally into the posi-
referred to as joint changes (although they do not tion of ease. This position is then mentally
all involve joint activity). These changes reverse registered. Below is a list of the items to be worked:
different aspects of the punching position, which
is described below:
ITEMS OF THE MITCHELL METHOD OF
● shoulders hunched RELAXATION
● arms held close to sides
1. Pull your shoulders towards your feet.
● fingers curled into the palms
2. Slide your elbows away from your body.
● legs crossed
3. Stretch your fingers and thumbs.
● feet dorsiflexed (drawn up towards face)
4. Turn your hips outwards.
● torso bent forwards
5. Move your knees until they are comfortable.
● head held forwards
6. Push your feet away from your face.
● breathing rapid with noticeable movement in
7. Breathing.
the upper chest
8. Push your body into the support.
● jaw clenched
9. Push your head into the support.
● lips pursed
10. Drag your jaw downwards.
● tongue pressed into upper palate
11. Press your tongue downwards in your
● brow furrowed into a frown.
mouth.
Mitchell does not suggest that the punching pos- 12. Close your eyes.
ition is actually adopted under stress; rather, that 13. Think of a smoothing action which begins
the muscles responsible for it are contracting to a above your eyebrows, rises into your
slight extent. hairline, continues over the top of your head
and down into the back of your neck.
Each item is modelled by the instructor who asks
PROCEDURE the trainee to copy it.
STARTING POSITIONS
INTRODUCTORY REMARKS TO
Three starting positions are described: PARTICIPANTS
1. Supine lying with a pillow under the head (Fig. Trainees are introduced to the method by a short
10.1). A pillow under the thighs is optional. description of the rationale and procedure.
The Mitchell method 85
Figure 10.2 Starting position: forward-lean sitting. Figure 10.3 Starting position: sitting.
I just want to say something about the Mitchell The method itself consists of a succession of
method before we begin. When people are under changes of position. Each change moves a body
stress, there is a position which they tend to adopt. part out of its position of defence and into its pos-
We could call this ‘the punching position’. Although ition of ease. As the part settles into the position
people don’t actually present themselves in a of ease, you’ll be asked to notice how it feels. The
punching posture, the muscles which create it are aim is to learn to recognize the relaxed position so
tensing to a minute degree. This happens instinc- that you can reproduce it more easily. I’ll first
tively and helps to promote a feeling of being ready demonstrate the items.
for anything.
If we move the body into the opposite of the
punching position, we will be taking it into a posi- WORKING THROUGH THE SCHEDULE
tion of ease or relaxation.
The schedule is then worked through in its entirety.
You might ask: ‘How do we get the punching
It is presented here with the orders expressed in
muscles to relax?’. This is where the physiological
inverted commas:
principle comes in: when one group of muscles
acting on a joint is tensed, the opposing group
1. Shoulders
automatically relaxes.
‘Pull your shoulders towards your feet.’ Do this gen-
The trainer demonstrates.
tly, but go on until you can’t pull them down any
When I bend my wrist forwards, the bending-back more. Feel the space between your shoulders and
muscles relax, and vice versa. It’s a reciprocal your ears getting greater. ‘Stop pulling.’ Notice the
mechanism without which smooth action could not feel of the new position. Take plenty of time to
take place. register the sensations you are getting from it.
86 SOMATIC METHODS OF RELAXATION
2. Elbows (Figs 10.4, 10.5 and 10.6) and notice how it feels to have a space between
‘Elbows out and open.’ For participants lying supine your arms and your body. Feel this position.
or sitting in a high-backed chair: slide your elbows
sideways, carrying your arms away from your body
3. Hands (Figs 10.7 and 10.8)
until you reach a comfortable point (Figs 10.4,
10.6). For participants in forward-lean sitting: slide ‘Fingers and thumbs long.’ Stretch and separate
your arms away from your body, opening your arms your fingers and thumbs while the heels of both
at the elbow joint (Fig. 10.5). ‘Stop moving.’ Check hands remain in contact with the floor, the table or
that your arms are resting on the supporting surface the arm of the chair. While the fingers and thumbs
The Mitchell method 87
4. Hips (Fig. 10.9) 6. Feet and ankles (Figs 10.10 and 10.11)
‘Turn your hips outwards.’ If you are lying, this ‘Push your feet away from your face.’ If you are
means rolling your thighs outwards (Fig. 10.9). If lying, point your feet and toes down, being careful
you are sitting, it means swinging your knees apart. not to induce cramp. If you are sitting with your
‘Stop.’ Let your legs settle comfortably, noting how feet on the floor, keep your toes in contact with it
they feel in this position. and raise your heels. You are working the calf
muscles and reciprocally relaxing the muscles
around the shin. ‘Stop.’ As you stop, your calf
5. Knees muscles stop working too. (If you are sitting, your
‘Move your knees until they are comfortable.’ This heels drop down.) Take note of the feelings you are
simply means adjusting their position in whatever now getting from your feet and ankles. Spend a
way enhances their comfort. ‘Stop’ and register that few minutes enjoying the sensation of ease in
sense of ease. your legs.
88 SOMATIC METHODS OF RELAXATION
7. Breathing down. Let your eyes be as still as they can be. Feel
the peace of the darkness.
There are no orders for this item because people have
their own breathing rates. I’ll describe the action 13. Forehead and scalp
first, then you can perform it in your own time.
I’d like you to think of the soft triangle between ‘Think of a smoothing action which begins above
the front edge of your ribs and your waist. As you your eyebrows, rises up into your hairline, continues
breathe in you can feel it swelling slightly; at the over the crown of your head, and down to the back
same time you can feel your ribs spreading out- of your neck.’ Savour the effect.
wards. As you breathe out, that soft area sinks The above 13 items may be repeated.
back and your ribs recoil.
Allow your breathing to take place slowly and Mind
comfortably, without putting any effort into it and
without attempting to alter its rhythm. Mitchell ends with a sequence for the thoughts.
identified by asking the individual how he tends Mitchell’s insistence that breathing should be
to react when experiencing anger, pain, anxiety or slow and easy and never include breath-holding,
conflict. If he tends to make fists, his key change is another reason for the method being favoured
will be finger-lengthening; if he tends to clench his by those working in the obstetric field (Mantle
teeth, it will be jaw-dropping. Key changes, by et al 2004). For the same reasons the method is
their generalizing effects, can promote a sense of often adopted by those who work in the field of
ease throughout the whole body. respiratory medicine (Hough 2001).
Mitchell applies her technique to everyday
activities, using the concept of ‘triggers of ten-
COMPARISON WITH OTHER APPROACHES
sion’, i.e. events which tend to provoke feelings of
stress, such as waiting at traffic lights or being Both Jacobson (Ch. 4) and Mitchell see their
interrupted by bells and alarms. She suggests approach as a skill to be learned. Neither favours
sticking coloured tabs on potentially stressful the use of tone of voice to influence the message.
appliances, such as the steering wheel and the Instead, the participant is required simply to
telephone, as reminders to adopt the key change. respond to the basic order. Again, like Jacobson,
Thus, to become more relaxed in daily life, there is Mitchell avoids using the order ‘Relax’. Her rea-
first a need to recognize the triggers, and second, son is that she finds it ‘vague, generalized and
a need to diminish their effect by using the key ambiguous’. Jacobson avoided using it because he
change to move the body into the ease position. felt it provoked the trainee into making an effort
Benefit can also be gained from a partial use of which was superfluous, when ‘going negative’
the schedule. Mitchell suggests that selected joint was the effect he wanted. On other points they are,
changes be used during specific activities; for of course, fundamentally opposed: Mitchell placing
example, the face items can be carried out while the highest value on joint and skin sensations and
driving, or the leg items while reading. The idea rejecting the idea of information coming from the
is not far removed from the concept of differential muscles, while Jacobson is only interested in muscle
relaxation (Ch. 12). feelings, dismissing any value that joint sensa-
tions might have.
Greater resemblance may be found between
THE ‘THREE-POINT PULL’ Mitchell and Alexander (Ch. 11) in the value they
both place on proprioceptive stimuli and awareness
This is a variation of the shoulder item where, in
of posture. There is little difference between the
addition to pulling the shoulders down, the head
three-point pull of Mitchell and the ‘neck lengthen’
gently reaches upwards. (It should be done with-
injunction of Alexander.
out tilting the head backwards.) The action is use-
ful for stretching the joints in the neck, and may
be practised in public situations without attract-
EVIDENCE OF EFFECTIVENESS
ing attention.
Mitchell’s method promotes awareness of relaxed
postures. The method is simple and quick and
APPLICATION OF THE METHOD TO
many of the ‘changes’ can be carried out unobtru-
SPECIFIC CONDITIONS
sively. It is widely practised as a stress-relieving
The Mitchell method lends itself to a range of con- strategy, and clinical findings testify to its effect-
ditions including insomnia, psychiatric disorders, iveness. Scientific evaluation of the method, how-
dyspnoea, osteoarthritis and cardiac rehabilitation, ever, has only just begun. Jackson (1991) studied
as well as to everyday stress. It is widely used in four rheumatoid arthritis sufferers trained in the
the field of obstetrics where its advantage lies in Mitchell method, comparing them with controls
its avoidance of tensing procedures (Ch. 25). The who simply rested. Using electromyography to
required relaxation is achieved by simply moving measure activity in the frontalis muscle (a sensi-
the body part. tive indicator of general muscle state), she found a
90 SOMATIC METHODS OF RELAXATION
marked reduction of tension in the study group of systolic blood pressure. On a subjective level,
and very little change in the control group. No stat- there was some evidence of participants finding the
istical analysis was reported. Mitchell method easier to follow and less demand-
An interesting comparison between the methods ing in concentration than progressive relaxation.
of Mitchell and Jacobson was made by Salt & Kerr Thus, while each approach demonstrated
(1997). With a sample of 14 men and 10 women, greater effectiveness than supine lying on certain
these authors measured the effects of both counts, the study has been unable to demonstrate
approaches on the cardiovascular and respiratory a substantial difference in the separate capacities
systems. The study was designed with a control of the two approaches to induce physiological
condition of supine lying. Participants were ran- relaxation. This is the first study to investigate the
domly assigned to three groups in which they Mitchell method using statistically analysed data.
received the two trainings and the control condi- A later study compared the Mitchell method with
tion, presented in different sequences to avoid diaphragmatic breathing (Bell & Saltikov 2000)
order effects. Heart rate, systolic blood pressure, and also found a lack of significant difference
diastolic blood pressure and respiratory rate were between the two. The study is reported in greater
recorded before and after every treatment. detail in Chapter 15, page 134.
Results showed significant reductions after
treatment on all measures for both methods, with
no significant differences between them. The con-
trol condition itself showed significant reductions PITFALLS OF MITCHELL’S METHOD
in heart rate and respiratory rate; however, when
compared to the control, both treatment methods These are similar to the pitfalls of other muscular
were found to be significantly superior on measures approaches (Ch. 6, p. 56).
Further reading
Mitchell L 1987 Simple relaxation: the Mitchell method for
easing tension, 2nd edn. John Murray, London
Acknowledgement
The author acknowledges the permission granted by the
publisher, John Murray Publishers, to reproduce the
phrases from Simple Relaxation 1987 by L. Mitchell.
91
Chapter 11
● primary control
● use and misuse
● faulty sensory perception
● inhibition
● ‘end-gaining’ and the ‘means whereby’
● integration of mind and body.
PRIMARY CONTROL
Alexander believed that the primary control of
human posture lay in the relationships of the head
to the neck and of the neck to the rest of the spine.
So convinced was he of their crucial nature, that
an almost magical significance was attached to Figure 11.1 Head held forward and up.
these relationships in his day. This status has,
however, been modified over the years, and the
Alexander teacher of today sees primary control
less as an inviolable principle than as a useful
starting point.
Primary control has three components:
RECOGNIZING AND CORRECTING MISUSE this action will tend to bring the lumbar vertebrae
Test for body alignment into contact with the wall (lumbar curve flattened).
As mentioned in the section on faulty sensory per- Figure 11.11 demonstrates this effect.
ception, an habitual posture, whether balanced or If you can hold this position with relative comfort,
not, will feel ‘right’ to its owner. This makes it dif- then your body is not in a misused state. If you find
ficult for him to recognize misuse in himself. A it unduly tiring, then practice will make it easier
procedure to solve this matter has been worked and help to restore alignment.
out by Barlow (2001):
Stand with your heels 5 centimetres (2 inches) from a
wall, with your feet 46 centimetres (18 inches) apart. Changing posture
Let your body sway back until it touches the wall. Alexander sees misuse as resulting, largely, from
Figure 11.10 shows this position. stress and the demands of contemporary life; in its
turn, misuse can be the cause of physical stress
If your shoulders and hips touch simultaneously leading to muscle and joint problems.
with each side level, your alignment is correct. A person wishing to change his posture needs
However, you may find that one side touches the to consider three points. He should:
wall before the other or that your shoulders touch
before your hips. Do what you can to realign your- ● be aware of the particular habit-governed
self. Next, bend your knees slightly and notice that movement that he wants to alter
98 SOMATIC METHODS OF RELAXATION
whereas the control group registered no such which impose physical stress on the lumbar spine.
changes. He has found that a moderate degree of flexion
In her critical review of relaxation techniques, (i.e. flattening of the lumbar curve) is mechanic-
Kerr (2000) finds that the available research ally advantageous, which supports Alexander’s
suggests that the Alexander technique may offer views about the action of sitting down and the
benefit in states of stress; it may also have posi- value of the monkey stance.
tive effects in conditions such as anxiety and There is, however, a need for more research,
depression. both psychological and physiological, into the
The work of the anatomist Adams (Adams & effectiveness of the Alexander technique. Until
Hutton 1985, Adams et al 1994) is relevant with that has been carried out and conclusions drawn,
regard to some of the postural claims made by the technique must, in Barlow’s words, continue
Alexander. Adams has studied the effect of actions to be regarded as a hypothesis (Barlow 2001).
Further reading
Alexander F M 1932 The use of the self. Dutton, New York Park G 2002 The art of changing: exploring the Alexander
Barlow W 2001 The Alexander principle. Orion, London technique and its relationship to the human energy body.
MacDonald G 2002 The Alexander technique: a practical Ashgrove, London
programme for health, poise and fitness. Element,
London
101
Chapter 12
Differential relaxation
too much effort into tasks of this nature. Relax your are, of course, artificial ways of walking; however,
face muscles while you carry out the digging. by exploring different styles, you may find it easier
to distinguish between unnatural and natural
forms, and be helped to find your own natural
STRESSFUL SITUATIONS way of walking. This will be the one that gives you
Differential relaxation is relatively easy to achieve most comfort and ease. Practise it, enjoy it. Feel
in activities which do not pose any threat, but is your whole body relaxing into the rhythm of your
more difficult in situations of stress, e.g. deliver- walking. Feel that the muscles responsible for
ing a speech. In such cases additional strategies carrying you along are no more tense than they
may need to be employed, such as mental rehearsal need to be … and that your face and shoulder
of the event and positive self-talk, to help reduce muscles are relaxed.
excessive tension (see Ch. 18, p. 163).
PREREQUISITES
STANDING AND WALKING
The principles of differential relaxation can also be Differential relaxation is thus concerned with min-
applied to the postures of standing and walking, imum tension levels during activity and task per-
where certain muscle groups, such as those of the formance. There are two prerequisites: knowing
back and the legs, hold the body vertical and pro- which muscle groups are needed for each activity
pel it along while uninvolved groups, such as those and which are not; and possessing the skill of
of the face, can be relaxed. muscle relaxation.
The following two examples illustrate these
ideas.
COMPARISON WITH OTHER METHODS
Standing
The Alexander technique, with its concept of
Have your eyes open. Stand with shoes off, feet
‘balanced use’ (p. 92), is grounded in the principle
parallel and 5–7.5 centimetres (two or three inches)
of differential relaxation. Here, the crucial elements
apart. Release excess tension with cue-controlled
are the relationships of head, neck and spine which,
breathing. Unlock your knees, slightly bending and
when correct, allow the body to adopt balanced
stretching them a few times to feel the weight
and relaxed postures while engaged in activity.
falling evenly down through them to your feet.
Alexander’s procedures for the actions of sitting
Rock forwards and backwards over them until you
down and rising are essentially techniques of dif-
find a comfortable position for your hips. Feel your
ferential relaxation.
spine rising above your hips … feel it supporting
Mitchell (1987) is advocating differential relax-
your head, and let your head reach up as high as it
ation when she urges the partial use of her schedule
wants to go. Nod it gently to find its best position.
during task performance; for example, practising
Relax your face muscles. Let your arms hang down
‘joint changes’ for the shoulders and the jaw while
by your sides with your shoulders dropped. Feel
driving or typing. Her ‘key changes’ can also be
your body relaxed and resilient. Enjoy being inside
seen as a differential technique, in that they are
it. There should be no effort involved. When the
directed at switching off unnecessary global ten-
posture feels as comfortable as possible, notice
sion while allowing specific movements to take
what makes it feel like that.
place (p. 88).
Poppen’s (1988) mini-relaxation is another dif-
Walking
ferential form. Here, relaxed-looking postures
One way of finding your own energy-economical are adopted in the muscle groups not engaged in
way of walking is to experiment with different the task; for example, the legs can be relaxed while
kinds of walking. Marching, sailor’s roll and tiptoeing writing a letter (p. 78).
104 SOMATIC METHODS OF RELAXATION
Further reading
Bernstein D A, Borkovec T D 1973 Progressive relaxation Öst L-G 1987 Applied relaxation: description of a coping
training: a manual for the helping professions. Research technique and review of controlled studies. Behaviour
Press, Champaign, Illinois Research and Therapy 25: 397–407
Jacobson E 1976 You must relax. Souvenir Press, London
105
Chapter 13
Stretchings
1987). Stretchings will not guarantee protection progressive relaxation training, i.e. the tensing
from injury, but they may make it less likely to routines in the abbreviated version of Bernstein &
occur. (See the sections on Back arching and Borkovec’s protocol are replaced by stretch-based
Crouching/squatting.) actions. Each stretch lasts 10 seconds and is
Many jobs require work postures which throw followed by a relaxation period of 60 seconds
strain on body structures. Stretches help to relieve (Carlson et al 1990). The purpose is to induce an
this strain. The stretch exercise is designed to overall sense of relaxation.
carry the body or body part in the opposite direc- Stretchings presented here consist of a range of
tion from the posture determined by the work; for large body movements and are similar to those in
example, a seated worker could stand and stretch Carlson’s schedule. Each stretch is carried out
upwards, whereas a standing operator might arch slowly, held for 5–10 seconds, then released
himself backwards or crouch down on his haunches. quickly. An interval of approximately 30 seconds
Activities which involve precision movements can be allowed between each stretch (Heptinstall
with flexed arms and fingers would call for wide 1995). Participants are asked to notice the feelings
arm stretches. in the relevant body part and to compare the sen-
Stretching is something we do unconsciously sations during and after the action.
after being in one position for a long time. The
body seems to ask for it. We stretch after sleeping,
after working at a desk, after bending down to
INTRODUCTORY TALK TO
weed a flower bed. All three trigger the need or
PARTICIPANTS
the desire to stretch the body. Subjectively, stretches
result in a feeling of comfort, pleasure and relief.
The method you are about to learn consists of a
Stretching is essentially a physical action. The
series of stretches. It is believed that stretching a
process of stretching links in with physiological
muscle helps to relax it and there is evidence to
principles in that the stretched group is responding
support this idea. The exercises are arranged
in a reciprocal way to the action of the prime mover.
so that each stretch lasts about 5 seconds after
Charles Carlson, a psychologist at the University
which there is a rest period of 30 seconds. Please
of Kentucky, has looked at the effects of stretching
don’t overdo the actions – they should be
and suggests mechanisms by which it might help
comfortable, even pleasant. Let the stretch
to promote relaxation (Carlson et al 1990):
build up slowly and take note of the sensations
1. It has been found that a greater contrast can that accompany it. Then, when you release it,
be obtained between stretching and releasing than register the feelings of relaxation and notice how
between tensing and releasing, because more they contrast with the feelings of the stretch. I’d
length-sensitive receptors in the muscle are acti- like you to settle into a comfortable position
vated during stretching than during tensing before we start.
(Anderson 1983). This more pronounced contrast
effect might make it easier for individuals to
release body tensions.
PROCEDURE
2. Stretch-based exercises have been found to
lower the excitability of the motorneurone pool
The exercises are arranged according to their start-
(Scholz & Campbell 1980), a finding which suggests
ing positions:
a resulting decrease in levels of muscle tension, pain
and ischaemia.
LYING
DESCRIPTION The floor or ground provides the best surface,
softened by a mat or a carpet. Grass or firm sand
Carlson and colleagues have devised a procedure also give the degree of hardness required. A bed is
consisting of muscle stretchings on the lines of too soft.
Stretchings 107
Hip joint stretches (Fig. 13.3) Figure 13.3 Hip joint stretches.
Sit on the ground (cushion optional) and draw your
legs into a bent position with your knees pointing pressure to your thighs, gently and slowly. You
sideways. Have the soles of your feet facing each should feel a comfortable stretching in the hip area.
other and in contact. Place your hands around your However, the range of movement in hip joints varies
ankles and rest your elbows on your thighs. Apply greatly, so do not compare yourself with other
108 SOMATIC METHODS OF RELAXATION
people. Perform the exercise just to the point overstretch or bounce. Then return to the starting
where you feel it is giving you a comfortable position. Repeat in the other direction.
stretching sensation and no further. Then take a
rest. Reapply the pressure. Shoulder circling (Fig. 13.5)
Bend your elbows and place your fingertips on your
shoulders. With your elbows, draw slow circles in
SITTING the air. After two or three circles, break off and
An upright chair or stool is used for this group of repeat in the opposite direction.
stretchings. For the first item, a long stick such as
a broom handle is needed, in an exercise which Arms stretching above head (Fig. 13.6)
stretches the trunk and shoulder muscles. Other Bend your elbows and lift your arms above
exercises in this group stretch the shoulder area in your head. Feel yourself pushing the air above you
different ways. with your open hands. When your elbows are
straight, spread your arms sideways and lower
Body turning (Fig. 13.4) them to your sides. Let them rest limply. Repeat
once or twice.
Sit with your feet flat on the ground. Grasp the
broom handle with your hands 90 cm (3 ft) apart
and raise your arms so that the stick just clears
Head pressing backwards (Fig. 13.7)
your head (your elbows are bent). Turn the upper Clasp your hands behind your head and, resting
part of your body to the left. This moves the stick your head in them, arch backwards. Take care
through about 90°. Just go as far as you need to in not to lean back too far if you are in a lightweight
order to get a comfortable stretch. Do not chair. Return your body to a vertical position.
Stretchings 109
STANDING
Trunk bending sideways (Fig. 13.8)
Stand with your feet apart and your hands by your
sides. Bend your body sideways, giving it a good
stretch. Return to the upright position and repeat
on the other side.
Chapter 14
Physical exercise
in the first five years following the menopause, as day; the exercise consisted of 45-minute sessions of
a result of diminishing oestrogens, and the decline weight-bearing exercise (activity which applies
continues, although less sharply, into old age. This longitudinal pressure to the long bones) three times a
can result in osteoporosis (Box 14.3). week. After 2 years a modest significant increase in
The mineral density of bone is determined by bone mineral content occurred in the calcium-plus-
the concentration of calcium salts per unit volume exercise group, compared with the calcium-only
(Law et al 1991). It is subject to two influences: the group where there was a decline. The only two
peak mineral content achieved during early life, fractures reported were in the calcium-only group.
and the rate of loss sustained during middle and A number of the participants had falls but these
old age. Recent data suggest that environmental occurred more in the calcium-only group than in
influences are responsible for as much as half the the calcium-plus-exercise group, and as the study
variation in peak bone mass among women (Krall moved into its second year the difference became
& Dawson-Hughes 1993). This implies that factors significant. Such findings question the value of
such as exercise and nutrition play a role in estab- calcium supplementation and highlight the value
lishing bone mass in the female child and young of exercise.
adult (Snow-Harter et al 1992). It has been sug- Thus, a policy which addresses bone mineral
gested that these factors are also important in content alone might not be focusing on the most
controlling the loss in later years (Box 14.4). productive area. Instead, it is suggested that since
fractures occur as a result of falls, attention be given
to exercises designed to reduce the possibility of
PREVENTIVE MEASURES
falls, i.e. exercises which improve balance, flexibil-
Recent guidelines have advised post-menopausal ity and strength (McMurdo et al 1997). Current
women to take 1 g of calcium a day in the belief that advice to women looking for ways of protecting
it helps to reduce bone loss (Cooper & Dennison themselves from osteoporotic fractures is to adopt
1997). Testing this assumption, McMurdo et al a combined policy of exercise with a dietary sup-
(1997) compared the effects of a calcium-only plementation of calcium and vitamin D (Collier
regimen with a calcium-plus-exercise regimen on 2002).
bone mineral content in 118 volunteers aged These approaches are non-pharmacological. It is
between 60 and 73 who were not taking hormone widely held, however, that hormone replacement
replacement therapy. The calcium dose was 1 g a therapy is the most effective way of controlling
Physical exercise 119
bone loss in the later life of women. This is difficult is also found useful, however, and a meta-analysis
to refute, although some authors report that appro- of six trials, which included both forms, demon-
priate weight-bearing activity can provide a com- strated that the incidence of fracture at this site
parable level of benefit. Mutrie (1997) cites trials may be reduced by 50% following activity pro-
in which exercise had resulted in a bone density grammes (O’Brien 1996).
gain of 4%. Although results of research on this topic are
Exercise at an intensity of 60–70% of HRmax not consistent, a pattern does emerge which indi-
(maximum heart rate) has been shown to enhance cates the benefits of regular, moderate, dynamic,
the psychological as well as the physical health of weight-bearing exercise. It must, of course, be
osteopenic women. In a programme of mixed activ- appropriate to the age group and take account of
ity (brisk walking, stepping on and off benches, the presence of other restricting factors.
aerobic dancing and flexibility exercises) for 1 hour
three times a week over 12 months, the women
experienced an increase in well-being and self- PSYCHOLOGICAL WELL-BEING
perceived health. This was in addition to the physi-
cal benefit gained whereby bone mineral density in RATIONALE
the spine was found to stabilize (Bravo et al 1996).
Exercise seems to be closely linked to mental
Exercise offers some degree of protection against
health. There is evidence of the link in healthy pop-
bone loss throughout life: the bone density of
ulations, but in clinical populations it is even
women who exercise at least three times a week is
stronger (North et al 1990, Scully et al 1998).
higher than the bone density of sedentary women
Psychological assessment suggests that a sense of
in their age group, whether they are 20 or 80 years
well-being is derived from regular exercise, with
of age (Talmage et al 1986).
participants reporting less tension, fatigue, aggres-
sion, depression and insomnia (Royal College of
TYPES OF EXERCISE Physicians 1991). The psychological benefits of
exercise include distraction from worries, release
Weight-bearing (often referred to as load-bearing)
of frustrations, a sense of achievement, a feeling of
activity is considered necessary for maintaining
improved physical appearance and enjoyment in
bone density. No bone response occurs unless the
the company of other individuals in the pleasant
area is stressed, which means the load must be spe-
surroundings of the exercise activity. In addition
cific to the site targeted (Smith 1995). For improv-
to the above benefits, exercise is inexpensive,
ing the bone mineral density of the spine, for
non-invasive and has few side effects.
example, aerobic weight-bearing exercise seems to
As a therapy, exercise is not underpinned by any
be the most effective activity; this means that
particular theory. However, rather than being con-
swimming and cycling are less effective than walk-
ceptualized as an atheoretical approach, Mutrie &
ing, jogging and dancing. For improving the bone
Faulkner (2003) suggest it should be viewed as a
density of the forearm and wrist, resisted localized
process through which therapeutic goals can be
strengthening work has been found the most effec-
reached.
tive exercise. This is illustrated in the finding that
the dominant arm of tennis players shows a
What is the mechanism?
greater density of bone than the non-dominant
arm (Smith 1995). Many hypotheses are put forward in an attempt to
A few studies have suggested that high impact explain the mechanism underlying the association
exercise, e.g. jogging, may be more effective than between exercise and mental well-being. Some of
low impact exercise, e.g. walking, for gaining bone these are physiological, such as an increase in brain
response. When the former is performed three times oxygenation which might result from aerobic exer-
a week for 18 months it can lead to significant cise (Donaghy & Mutrie 1999). Others pose ques-
increases in bone mineral density of the femoral tions about biochemical changes. For example, to
neck (Heinonen et al 1996). Lower impact exercise what extent are the catecholamines involved? It has
120 SOMATIC METHODS OF RELAXATION
been suggested that exercise can help to maintain contribute to cardiovascular fitness (Doyne et al
a healthy balance in the neurochemistry of the 1987, Martinsen et al 1989, Donaghy et al 1991).
body (Chaouloff 1989). Or again, how do the beta- Thus, it is the engagement in physical activity rather
endorphins fit into the picture? We know that exer- than the enhancement of aerobic fitness which is
cise is accompanied by raised levels of endogenous associated with the positive mood shift. However, it
morphines, but not how those raised levels might must be said that the outcome of research on this
influence the mental state. De Coverley Veale topic is not consistent, and Scully and colleagues
(1987) has indicated that for a few hours following (1998) in their review do not feel the evidence is
a period of activity, the mood of a person who regu- strong enough to declare the matter resolved.
larly takes exercise can become altered: a depressed There are no satisfactory answers to these ques-
person becomes less depressed, an anxious person tions, nor to the much debated topic of whether
less anxious and an angry person less angry; and exercise actually causes improvements in psycho-
Sher (1996) reports that intravenous administration logical well-being. At present all that can be said
of beta-endorphin reduces both anxiety and is that an association exists between physical
depression. This creates a persuasive picture but activity and psychological health (Mutrie 1997).
leaves open the question of how such changes are Ruuskanen and Ruoppila (1995), in their survey
brought about. of 1244 elders in Finland, suggest that exercise
Moving away from biochemical concerns to psy- may promote a subjective sense of well-being, but
chosocial ones, we can ask other questions in an go on to raise the question of the extent to which a
attempt to discover the mechanism. For example, sense of well-being might lead to continued phys-
does the sense of physical well-being transfer to the ical activity. Such comments introduce a further
psychological sphere, making the thoughts more dimension to the argument in the form of direction
positive? Does the active coping strategy engender of causality.
a feeling of mastery? Mutrie (1997) refers to the Clearly, more work needs to be done to deepen
association of regular exercise with raised self- our understanding of this issue.
esteem, but it is not known whether this is brought
about by virtue of weight reduction, improved
DEPRESSION
physical health, or sense of achievement.
Then again, is there some connection with peo- The evidence associating exercise with relief from
ple’s expectations? Do people feel positive mood depression has been gathering strength over the
changes following a bout of exercise because they last two decades and this association has been
expect to? Does distraction play a part? demonstrated in both cross-sectional and large-
La Forge (1995) has reviewed all the possible scale epidemiological studies (Mutrie 2001). The
mechanisms. He sees them as integrated mecha- role played by physical activity and exercise in the
nisms rather than separate ones. His model shows management of mild-to-moderate depression may
the mechanisms to overlap, sharing the same neu- be an important one (Donaghy & Durward 2000,
ral pathways. In this light, an approach which Paluska & Schwenk 2000) while positive effects
addresses them as linked processes would seem may also extend to the more severe forms of the
more productive than one which studies them in condition (Craft & Landers 1998). Lawler & Hopker
isolation. (2001), however, are reluctant to conclude in favour
Much has been made of the role of fitness and its of exercise (apart from short-term relief) on account
association with psychological health; for example, of the poor quality of some of the research. In spite
Moses et al (1989) found that although fitness often of such drawbacks, Mutrie & Faulkner (2003) find
accompanies the sense of well-being, it is not a pre- compelling evidence of a positive relationship
requisite. Being physically active is seen as more between physical activity and mental health.
important. This point is brought out in studies Exercise as a treatment for depression has not
which show non-aerobic exercise to be as effective only been found effective but its results compare
for psychological well-being as aerobic exercise, well with those of psychotherapy (Biddle & Mutrie
since only the aerobic component can be said to 2001). Furthermore, when psychotherapy and
Physical exercise 121
drug intervention were added to exercise there reduce the risk of depression and that physically
was only a slightly larger, non-significant effect inactive individuals ran a significantly higher risk
than with exercise on its own (Craft & Landers of depression than regular exercisers. Fox (2000a)
1998). supported this view.
Patients themselves have reported favourably Not all studies concur with this result, however.
on exercise: Scully and colleagues (1998) noted Cooper-Patrick et al (1997) undertook a prospective
that some patients with depression rated exercise study on 973 middle-aged physicians to explore the
the most valuable component of the total treat- preventive capacity of exercise, but results did not
ment programme. indicate that exercise reduced the risk of develop-
The effects of exercise on depression have ing depression. It seems that no confident judge-
been investigated among different population ments can be made on the predictive value of
groups, one of which is the elderly. In the above- physical exercise, although a trend suggesting a
mentioned survey of Finnish elders, Ruuskanen protective effect does exist (Donaghy & Durward
and Ruoppila (1995) found a significant correla- 2000).
tion between absence of physical exercise and
attacks of depression. At the other end of the age Depressive psychosis
range, Steptoe and Butler (1996), in their study
among adolescents, demonstrated an association More severe forms of depression are apparently
between vigorous exercise and antidepressant not helped by exercise. There is no convincing evi-
changes. dence of effectiveness in this area (Smeaton 1995).
Although most studies have in the past indi-
cated the superiority of aerobic over strengthening
ANXIETY
exercise, there have been increasing reports of the
value of strengthening exercise as an antidepres- Anxiety can refer either to an emotional state or to
sant (Doyne et al 1987, Martinsen et al 1989, a personality disposition. The first is called ‘state’
Donaghy et al 1991). Doyne et al compared the anxiety, the second is ‘trait’ anxiety. State anxiety
effects of aerobic and strengthening exercise pro- occurs as a temporary reaction to an event per-
grammes on women suffering from depressive ceived as threatening; it refers to the experience of
disorders. After 8 weeks, depression symptoms apprehension in a precise moment. Trait anxiety,
were significantly reduced in both exercise groups, by contrast, is characterized by the individual’s
with no significant difference between them. More tendency to view all neutral events as potentially
recently Singh et al (1997), in their study of 32 stressful and to experience state anxiety as a
depressed elders, demonstrated that the depres- response to them (Spielberger 1980). State anxiety
sion scores of participants decreased significantly tends to accompany most disorders and is a natu-
following a programme of resistance exercises. ral concomitant of adverse conditions. Some find-
Both aerobic and strengthening exercise were ings suggest that exercise training can help to
found to be useful for relieving depression in relieve both forms (Donaghy & Durward 2000).
North et al’s meta-analytic review (1990), as they For example, Taylor (2000) found that a small-to-
were in the work of Biddle & Mutrie (2001). moderate effect on state anxiety could be achieved
by single sessions of exercise; reductions in trait
anxiety, on the other hand, would require a longer
Exercise as a preventive measure
period of exercise.
Since exercise has been shown to confer substan- It is perhaps easier to accept that exercise (a high
tial benefit as a treatment for depression, it has arousal activity) could relieve depression (a low
been hypothesized that it might also have some arousal state) than that it could relieve anxiety, itself
protective value in psychologically healthy mem- a high arousal state. Nevertheless, exercise has been
bers of the community. Weyerer and Kupfer (1994), fairly consistently associated with decreased levels
reviewing work on physical activity and mental of state anxiety (Scully et al 1998). The link is, how-
health, found evidence that exercise did help to ever, a modest one. Donaghy & Durward (2000) rate
122 SOMATIC METHODS OF RELAXATION
weak one. However, exercise seems to help most examined a wide range of outcome measures,
people view themselves more positively (Carless & among which were changes in psychological well-
Fox 2003). being. Results showed that both aerobic and
Exercise programmes need to run for a mini- strengthening exercises significantly lowered
mum of 12 weeks before any change in self-esteem depression scores and also reduced anxiety scores,
becomes measurable. Greatest benefit has been while the autogenic group showed no differences.
found to occur in those whose self-esteem was Thus, it is suggested that aerobic and strengthen-
low to start with (Carless & Fox 2003). ing forms of exercise are effective in alleviating
It is not clear what mechanism is involved. mood disorders in problem drinkers. This finding
Carless & Fox (2003) suggest that participation in supports the view that exercise which promotes
physical activity might favourably influence phys- cardiovascular fitness is not essential for creating
ical self-perceptions which, in their turn, might psychological benefit.
lead to positive changes in global self-esteem. In However, since alcohol misusers tend also to
this model the physical self is seen to play a medi- have low fitness levels, regimens which focus on
ating role between exercise participation and aerobic aspects of exercise would seem to offer
self-esteem. particular advantage (Donaghy & Mutrie 1999).
Using the Physical Self-perception Profile, a Reviewing studies which investigate the effects
scale devised by Fox (1997), Donaghy (1997) inves- of exercise in the treatment and rehabilitation of
tigated different aspects of the physical self, such the problem drinker, the conclusion has been
as perceived physical skills and physical appear- drawn that physical exercise is indeed linked to
ance, in 158 problem drinkers. After a 3-week improved fitness and strength and that this find-
course of exercise, both aerobic and strengthening, ing can be stated with some confidence. Regarding
participants showed an improved perception of the psychological benefits of exercise with this
their physical self-worth. Self-perceptions of their clinical group, the evidence is, however, less strong
fitness and strength also showed an improvement (Donaghy 2003, Donaghy & Mutrie 1999).
which was maintained at follow-up 2 months later.
There was a positive association between objective
SLEEP
levels of fitness and strength, and participants’
perceptions of these parameters. Without sleep we can hardly be said to enjoy psy-
It is not known, however, what effect such chological well-being. Insomnia, however, has been
changes in physical self-perceptions may have on found to respond favourably to exercise. In their
the global self-esteem of this population group or sample of 29 healthy, sedentary men and women in
on their decisions to adopt a healthier lifestyle. late middle-age, King and colleagues (1997) demon-
Donaghy suggests that the sense of self-efficacy strated a significant improvement in global sleep
may be favourably influenced by the experience score following a training programme consisting of
of exercise leading to a change in the perception of four half-hourly sessions a week of brisk walking at
self-worth and creating the confidence to continue an intensity of 60–75% HRmax for 16 weeks.
with physical exercise.
WOMEN’S HEALTH
PROBLEM DRINKING
Physical activity appears to be psychologically
A condition which is often accompanied by high useful for young women who experience pre-
levels of depression and anxiety is problem drink- menstrual syndrome (Scully et al 1998). Its bene-
ing, where exercise is shown to have more to offer fits, however, extend to women at all stages of life.
than relaxation. Exploring the benefits of different This includes the elderly. A recent study in a large
types of exercise, Donaghy and colleagues (1991) cohort of Australian women in their 70s across a
compared aerobic with resistance forms in 45 prob- 3-year period demonstrated an association between
lem drinkers, using a control group who received physical activity and emotional well-being (Lee &
a form of autogenic relaxation. The authors Russell 2003).
124 SOMATIC METHODS OF RELAXATION
DOSAGE OF EXERCISE this kind of exercise. Low intensity exercise has also
been associated with reductions in muscle tension
A general principle of exercise prescription is that
as recorded in electromyographic readings (Sime
it should be introduced gradually and progress by
1990).
small stages covering a period of several weeks.
Amid conflicting reports therefore, it cannot be
This is to ensure that the activity designed to ben-
said with confidence that any one intensity level
efit the body is matched by the body’s capacity to
appears superior to the others. Because of this,
tolerate the exercise.
Scully and colleagues (1998) take the view that the
situation calls for a compromise whereby the indi-
Dimensions of exercise vidual is asked, on the basis of health and inclina-
tion and in consultation with professional advisors,
It is conventional to describe exercise in terms of to select his own goals. Such a strategy has the
its three dimensions: added advantage of increasing the participant’s
● intensity sense of commitment.
● duration Duration. Regarding the duration of exercise
● frequency. sessions, literature reviews tend to indicate the
benefit of 20–40 minutes (Gauvin & Spence 1996).
Intensity. Intensity, which can be high, medium This duration can be split into 10-minute segments
or low, has received particular attention from and still provide benefit (Blair et al 1992), while in
researchers. Although results have not been con- the case of anxiety, short 5-minute bouts can also
sistent, there seems to be a consensus that moder- have value (Scully et al 1998). One advantage of
ate intensity activity produces the greatest benefit. short exercise periods is that they can be fitted into
‘Moderate’, in the context of exercise, means that break times, which makes them ideally suited for
the exercise should be vigorous enough to create a people suffering from work stress. In setting the
physical effect but not so strenuous that the person duration much depends first on the nature of the
feels unduly challenged. Extremely high intensi- exercise, in that lighter activities are easier to sus-
ties can have negative effects by inducing a degree tain for longer periods, and second on the physical
of stress (Gauvin & Spence 1996). health and age of the individual, which will affect
The suggested superiority of moderate over his exercise tolerance.
high intensity exercise is illustrated in the work of Frequency. On the matter of frequency there
Moses and colleagues (1989) who investigated the are no fixed recommendations: programmes vary
mood changes following exercise in 109 sedentary in their specifications from 3 to 7 times a week.
non-clinical volunteers. After 10 weeks of training, Certainly a high frequency of practice is advo-
reductions in psychological tension were signifi- cated, but whether 7 times a week confers more
cantly greater in the moderate intensity exercisers benefit than 5 times a week has not been estab-
than in the high intensity exercisers. lished. Most researchers suggest that daily exer-
Although there have been studies which indi- cising has merit.
cate the value of high intensity exercise (Tate &
Petruzzello 1995), and studies in which no differ-
Optimum length of programme
ence between moderate and high intensity
exercise is found (King et al 1993), most investiga- The benefit derived from exercise programmes
tions conclude in favour of moderate intensity builds up over the weeks until it reaches a peak.
exercise. In their review of the effects of exercise on depres-
Low intensity exercise has also been shown to sion, North and colleagues (1990) found that max-
confer benefit, as Aganoff and Boyle (1994) demon- imum psychological benefit peaked at 17 weeks,
strated in their study of symptom reporting in although some gain could be expected after just
middle-aged women. Significant improvements in 4 weeks. Similar results have been found for
the mood scores of the participants resulted from anxiety.
Physical exercise 125
When exercising for psychological health the The strongest evidence of benefit lies in the field
programme chosen should be enjoyable, non- of mild-to-moderate depression where symptoms
competitive and carried out in pleasant surround- are significantly reduced by exercise (Donaghy &
ings (Shephard 1997). There are, however, no Durward 2000). Moreover, benefits can be gained
official guidelines specific to exercise in this field. in as short a time as 1 or 2 months and can last for
Published guidelines refer to physical health up to a year (Donaghy & Durward 2000). Findings
and come from institutions such as the Health in other areas tend to be less robust (Mutrie 1997,
Education Authority (HEA 1995) and the American p. 306). In drawing conclusions, however, writers
College of Sports Medicine (Pate et al 1995). These indicate the paucity of good quality data. Many of
are: 30 minutes of moderate intensity activity on the studies contain methodological flaws which
most days of the week. Fox (2000a) suggests that a reduce their validity and, because studies use a
similar programme is appropriate in the field of variety of populations, a wide range of exercise
mental health, adding that any exercise programme modes and different measuring systems, it is diffi-
should match the needs of the individual. cult to make comparisons. Scully and colleagues
(1998) point to such issues and emphasize the need
Adherence to exercise programmes for for large-scale multidimensional experimental pro-
psychological health grammes, while Smeaton (1995) urges replication
of existing work.
All exercise programmes are dependent on the
willingness of the participants to carry out the pro-
cedure. Without their cooperation, the results will TOOLS FOR MEASURING EXERCISE
not have any meaning. In the field of therapeutic INTENSITY
exercise, however, the adherence rate is not high.
Reviewing estimations, Glenister (1996) finds it A standard measure of exercise intensity is. the per-
varies between 50% and 80% for short-term centage of maximum oxygen uptake (VO2max).
programmes. For long-term programmes it is This requires skills and apparatus which may not
lower still. Moreover, adherence to vigorous exer- always be available. Simpler to measure is the
cise programmes is lower than it is to moderate percentage of maximum heart rate (HRmax) and
intensity programmes (Glenister 1996). There since the two scales bear a linear relationship to
seems to be a generally low willingness on the part each other, the HRmax is the method commonly
of people to carry out regular exercise, with only employed (Smeaton 1995).
10% of the population committed to it (Scully et al HRmax is estimated by subtracting the person’s
1998). age from the figure 220. In the case of a 40-year old
individual this would be 180, representing his
hypothetical maximum. If the programme requires
CONCLUSION
a 60–65% HRmax level of intensity, then the pulse
Evidence mounts in support of the idea that physi- rate for this individual should be kept within the
cal activity is associated with psychological well- range of 108–117 during exercise.
being (Biddle 2000). As the argument in favour This figure is appropriate for healthy individu-
of exercise gains strength, so the areas in which als. People who are less fit, however, can take the
improvements take place become identified, such figure of 200 instead of 220 as their starting point,
as mood, self-concept and work behaviour (Folkins and those under medical supervision should seek
& Sime 1981), self-esteem and cognitive function the advice of their doctor.
(Mutrie 1997) as well as depression, anxiety and Criticisms of this method include the possibility
stress (Gauvin & Spence 1996, Glenister 1996, of error within the age categories and difficulty in
Scully et al 1998). However, not all authors reach palpating the pulse for those unfamiliar with the
the same conclusions and this lack of consensus practice (Birk & Birk 1987). An alternative method
gives a guarded tone to the reviews. for determining exercise intensity has been
126 SOMATIC METHODS OF RELAXATION
this intervention reduces the risk of injury and Task Force 1989), although hard evidence of any
muscle soreness (Herbert & Gabriel 2002). association between running and the risk of
5. Cooling down is also important. During vig- osteoarthritis in weight-bearing joints is slight (Blair
orous or moderate exercise a higher than normal et al 1992). However, if there is a family history of
proportion of the total blood volume circulates joint problems, it may be advisable to consider an
through the voluntary muscles. This state contin- alternative form of aerobic exercise such as cycling
ues for some time after the exercise has come to an or swimming.
end, and causes a lowering of the blood pressure. 11. Bone mineral density in athletes has been
It is potentially hazardous in the elderly, but found to be higher than it is among people who take
should be guarded against even in the very fit. As no exercise. However, exercise can be excessive and,
a remedy, the exercise can be slowly reduced in in the case of young women in endurance sports
intensity or, alternatively, some lighter activity such as long-distance running or ballet dancing,
such as slow walking can be performed to bring there can be a temporary reduction in the level of
about a gradual return of normal blood distribu- oestrogen, with resulting amenorrhoea (cessation of
tion (Hough 2001). menstruation). If prolonged, this can lead to loss of
6. Exercise should not be too strenuous. To be bone. As soon as the excessively strenuous exercise
safe, exercise should be well within the capacity of stops or is lowered in intensity, however, the oestro-
the individual and performed regularly. The indi- gen level rises, menstruation returns and bone loss
vidual should never feel he is exercising to the limit is halted.
of his strength. He should also know how to recog- 12. ‘Fatigue fracture’ is a condition which some-
nize signs of fatigue. Warnings of overwork in the times afflicts rowers and long-distance runners. It
form of chest pain or faintness, for example, should is inclined to occur where the level of exertion
never be ignored (Allied Dunbar National Fitness markedly exceeds what is customary for the
Survey 1992). individual.
7. While team sports and marathons can be fun, 13. Exercise is contraindicated during any kind
they involve a spirit of competition which may be of fever and should be avoided during viral infec-
stressful. Non-competitive activities, on the other tions such as influenza.
hand, impose less pressure on the individual, who 14. It is possible to become addicted to exer-
can pace himself in a way that takes account of his cise. Trainers and trainees need to be aware of
reactions. this phenomenon and to control any trend in its
8. In the case of older people, the exercise should direction.
be light and regular. Demands should be kept low
since ageing organs do not have the reserves of
The gradient of risk
strength or the resilience of younger organs. Aerobic
work should not be too arduous, while resisted Blair and colleagues (1992) refer to a gradient of
work for muscle strengthening should be seen as risk across activity levels: the more intense and
potentially hazardous because of the rise in blood longer-lasting the exercise, the greater the risk it
pressure which accompanies it. In most other imposes. They emphasize the benefits of lower
respects, older people derive the same benefit from levels of activity since these are associated with
exercise as younger people. They simply need to reduced risk while yet conferring significant fit-
know when to stop. ness benefit. Blair et al recommend a public health
9. The capacity of the individual to carry out message which reads: ‘A little exercise is better
exercise may be compromised by the drugs he is than none at all’, rather than one which insists on
taking. It is advisable to check that these do not con- minimum levels of exercise intensity.
flict with the effects of exercise. This applies particu- While the advantages of exercise must be set
larly where high doses have been prescribed. against its potential hazards, most people derive
10. The cardiovascular benefit of jogging has to benefit from it. It should, however, be carried out
be balanced against the possible stress it imposes on in a sensible manner (Royal College of Physicians
the weight-bearing joints (US Preventive Services 1991).
128 SOMATIC METHODS OF RELAXATION
Further reading
Biddle S J H, Fox K R, Boutcher S H (eds) 2000 Physical Everett T, Donaghy M, Feaver S 2003 Interventions in mental
activity and psychological well-being. Routledge, health: an evidence-based approach for physiotherapists
London and occupational therapists. Butterworth-Heinemann,
Biddle S J H, Mutrie N 2001 Psychology of physical activity: Oxford
determinants, well-being and interventions. Routledge, Mutrie N 1997 The therapeutic effects of exercise on the self.
London In: Fox K R (ed) The physical self: from motivation to
Donaghy M, Durward B 2000 A report on the clinical effec- well-being. Human Kinetics, Leeds
tiveness of physiotherapy in mental health. Chartered
Society of Physiotherapy, London
129
Chapter 15
Breathing
INTRODUCTION
CHAPTER CONTENTS
Introduction 129 A wide variety of breathing routines have been
proposed to induce relaxation, such as slow breath-
The process of breathing 129 ing, deep breathing, breathing meditation and
Rationale of breathing control 131 abdominal breathing. Using the breathing system
as a means of gaining relaxation is clearly an
Breathing awareness 131 accepted approach. Moreover, the techniques are
Exploring respiratory movements 131 easy to learn and can be carried out anywhere – a
Slow breathing 131 fact which makes them available in the stressful
General points regarding breathing as a situation itself.
relaxation technique 132 In this chapter the respiratory mechanism is
Breathing routines for relaxation 132 first described; exercises which induce relaxed
Abdominal or diaphragmatic breathing 132 breathing patterns are presented; there is a section
Breathing pouch 133 on hyperventilation, and also one on the pitfalls of
‘Out tension, in peace’ 133 breathing exercises.
Breathing meditation (1) 133
Breathing meditation (2) 133
THE PROCESS OF BREATHING
Breathing with cue words 133
A yoga exercise 133
Breathing is an automatic process governed by
Breathing ‘chi’ 133
centres in the brain stem (pons and medulla).
Sighing 134
These activate the diaphragm and costal muscles
Evidence of effectiveness 134 to open the rib cage which expands in three direc-
tions: vertically, laterally and anteroposteriorly.
Hyperventilation 134
Negative pressure in the pleural cavity pulls the
Treatment 135
lungs out, causing air to be sucked in. Relaxation
Discussion 137
of the same muscles results in the recoil of the thor-
Pitfalls of breathing exercises 138 acic structures and the expulsion of air. The respira-
tory organs are illustrated in Figure 15.1.
Oxygenated blood leaves the lungs bound for
the heart which pumps it round the body where its
oxygen is exchanged for waste products, amongst
them carbon dioxide. These are carried back to the
130 SOMATIC METHODS OF RELAXATION
Nose
Pharynx
Epiglottis
Hyoid bone
Thyroid cartilage Larynx
Cricoid cartilage
Right clavicle
Trachea
Apex Apex
Heart space
Pleural cavity
Inferior vena cava Aorta
Vertebral column
Figure 15.1 The organs of respiration. (From Waugh & Grant 2001.)
a raised arterial PCO2 (hypercapnia). A small rise this for themselves by carrying out the following
(mild hypercapnia) is associated with lethargy and exercises for which plenty of time should be
symptoms resembling those of parasympathetic allowed.
dominance, i.e. relaxation (Slonim & Hamilton
1976). 1. Lying or sitting
Place your hands on the lower edge of your ribs,
RATIONALE OF BREATHING CONTROL fingertips a few centimetres apart. Feel your hands
rise and separate as the air flows in, and recoil as it
Most relaxation methods like imagery and muscle flows out.
routines influence the autonomic nervous system by
indirect routes. Breathing is different. It is directly
2. Sitting with head and arms resting
linked to the system which controls physiological
on a table
arousal. This adds to its potential as a means of With movement in the front of the chest now
inducing physiological relaxation (Lichstein 1988). restricted, you can feel the chest expanding
The kind of breathing which accompanies sym- backwards.
pathetic arousal is quite different from the kind of
breathing characteristic of parasympathetic arousal: 3. Lying or sitting
the first tends to be fast and staccato-like, while
Place your right hand over the solar plexus (the
the second tends to be slow and gentle. This connec-
soft part between the ribs and the navel) and your
tion between slow breathing and parasympathetic
left hand over the front of your chest below the
dominance has created a perception that slow
clavicles (collar bones). Notice what happens under
breathing has stress-relieving properties and has
your hands when you breathe. As the air enters,
led to its adoption as a relaxation technique
feel the expansion growing, first under your right
(Sudsuang et al 1991). The approach is thus under-
hand, then rising through the chest to reach the
pinned by physiological theory, but it also has
area under your left hand. Explore that idea for a
cognitive elements in the form of the imagery
minute or two.
which features in some of the exercises.
Its mechanism, however, is unclear. Lum (1981) The emotional state
proposed that slow breathing had a corrective
effect on an abnormal pattern of breathing, while Breathing is also subject to a person’s emotional
Garssen et al (1992) suggested that it may reduce state:
stress for other reasons such as distraction. Imagine for a few moments a situation that makes
you feel uneasy … Next, imagine one in which you
BREATHING AWARENESS feel at ease … Did you notice any change in your
breathing pattern from one to the other?
This is a phrase which refers to the focusing of Breathing in a calm individual is associated with
attention on the breathing pattern. It puts the indi- relaxed abdominal muscles and is characterized
vidual in touch with the respiratory process and by visible movement of the upper abdomen; breath-
helps him to feel he has some control over it. As ing in a stressed individual is associated with a
such it forms a useful introduction to the topic. predominantly upper costal movement and often
Breathing awareness begins with an exploration involves contraction of the shoulder girdle muscles.
of the movements of the chest and abdomen which Calm breathing tends to have a slow rate; stressful
accompany respiration. breathing, a more rapid one.
attention on this area. Start the exercise with a the air is drawn back in … notice the feel of the
breath out … a naturally occurring breath out. air … warm as it leaves, and cool as it
Notice a slight sinking of the area under your hand. enters … continue on your own with this idea for a
Next, allow air to flow into the lungs, noticing the few minutes.
slight swelling which takes place under your hand.
Then as the air is expelled, notice the area under
BREATHING MEDITATION (2)
the hand sinking back again. Allow the breathing
to take place naturally. This script illustrating ‘breath mindfulness’ is
adapted from Lichstein (1988). It is particularly
Some writers teach abdominal breathing by urging
addressed to people with high blood pressure.
pupils to ‘think in and down’ (Innocenti 2002).
This helps to create a natural abdominal movement. With your eyes closed, settle into your chair, couch
or wherever you have chosen to be … let your body
lose its tension and let your mind gradually become
BREATHING POUCH calm by using some pleasant imagery … allow
A variation of abdominal breathing, this exercise your mind’s eye to rest on the upper part of your
incorporates imagery. It is adapted from Everly & abdomen … be aware of it swelling and sinking as
Rosenfeld (1981). you breathe … notice these breathing movements
without trying to change them … just observe
Concentrate on your breathing rhythm without them in the knowledge that your body takes full
trying to change it. Become aware of your upper care of your breathing … allow your breathing to
abdomen swelling as you inhale and sinking as you continue on its own … flowing gently and
exhale. Picture an imaginary, hollow pouch lying smoothly … perhaps you can feel the rate getting
inside your abdomen … as you breathe in, air slower … this is because your resting body doesn’t
travels down to fill the pouch, making the need so much oxygen as when you are active …
abdomen swell … breathing out empties the pouch, your heart rate also is lowered and your blood
causing the abdomen to sink back … if you place pressure falls, as a state of quiet settles on you …
your hand over your abdomen, you can feel gentle allow yourself to enjoy this feeling of tranquillity …
swelling and sinking taking place. let your mind continue to focus on your breathing
for a few minutes longer.
‘OUT TENSION, IN PEACE’
Listen to your breathing without altering its BREATHING WITH CUE WORDS
pattern … imagine your tensions being breathed This exercise is described under the name of cue-
out … imagine them being carried away, a little at controlled relaxation in Chapter 8 (p. 71).
a time with each breath out … and now, imagine
that every time you inhale, you are breathing in
peace, a little at a time with each breath … breathe A YOGA EXERCISE (Quoted by Hough
out tension … breathe in peace … gently 1991)
breathing … feeling peace flowing through your Sit with your feet flat on the floor, and as you
body … always keeping your breathing natural… inhale, imagine the air being drawn in through the
top of your head, travelling down through your
body and passing out through your feet.
BREATHING MEDITATION (1)
Let your mind follow the path of the breath, taking
BREATHING ‘CHI’
care not to change its pace or its rhythm. Think of
the air flowing in through your nostrils, along your Breathe in the energy force, ‘chi’, and let it flow
nasal passages, down your windpipe and into your into the solar plexus … then … on the breath
lungs … then, gently and smoothly turning, it is out … let it flow to an area of your body that needs
carried out along the same route … turning again as healing or soothing…
134 SOMATIC METHODS OF RELAXATION
0 1 2 3 4
Never Rarely Sometimes Often Very often
Chest pain
Feeling tense
Blurred vision
Dizzy spells
Feeling confused
Faster or deeper breathing
Short of breath
Tight feelings in chest
Bloated feelings in stomach
Tingling fingers
Unable to breathe deeply
Stiff fingers or arms
Tight feelings around mouth
Cold hands or feet
Palpitations
Feelings of anxiety
Figure 15.4 The Nijmegen questionnaire (Van Doorn et al 1982). (From Hough A. 1996 Physiotherapy in respiratory
care, 2nd edn, p. 209. With kind permission from Stanley Thornes.)
This can be achieved by modifying the breathing out. Counting strategies can be incorporated,
pattern in different ways: for example, counting ‘one … two …’ on the
breath in and ‘one … two … three … four …’ on the
1. altering the rate and depth, making the
breath out.
breaths slower and/or shallower
For reducing the volume of air that passes
2. holding the breath for a few seconds
through the lungs, short breath holds can be used.
3. changing the composition of inhaled air by
Innocenti suggests using them in an intermittent
rebreathing exhaled air.
manner throughout the day. Apart from this, a
Altering rate and depth. When people are asked regularity of breathing pattern is aimed at through-
to reduce their rate of breathing they tend to take out the treatment and an abdominal form of
deeper breaths. This will not change the arterial breathing encouraged (Innocenti 2002).
PCO2 level. If it is to be changed, the interaction of In the early stages of re-education, controlled
rate and depth needs to be considered. When breathing may create air hunger because the brain
reducing one, the other has to be held constant if continues to maintain a high respiratory drive.
the PCO2 is to be raised. The individual can be Later however, following daily practice, the respira-
reminded that slowing the rate means that the tory centre will begin to make the necessary adapta-
same volume of air is passing through, only travel- tion (Rowbottom 1992).
ling more slowly. A rate of 10–12 breaths a minute Breath holding. If, during re-education, this
is a useful first target (Hough 1996). This can be feeling of air hunger becomes too great, the individ-
reduced as the condition improves. ual may sometimes find himself taking an exces-
Breathing cycles which address rate and volume sively deep breath. This, of course, further lowers
are introduced (Innocenti 2002). For instance, a his PCO2 and temporarily worsens his condition.
cycle for slowing the breath might consist of a As a corrective measure, one breath hold is recom-
gentle breath in followed by a slowed breath mended lasting 5 or 6 counts (2 or 3 seconds),
Breathing 137
Further reading
Hough A 2001 Physiotherapy in respiratory care: an Innocenti D M 2002 Hyperventilation. In: Pryor J A,
evidence-based approach to respiratory and Prasad S A (eds) Physiotherapy for respiratory and
cardiac management, 3rd edn. Nelson Thornes, cardiac problems: adults and paediatrics, 3rd edn.
Cheltenham Churchill Livingstone, Edinburgh
141
Chapter 16
Self-awareness
The notion of self-awareness is fundamentally includes muscle tension and bodily relaxation.
linked to the notion of living in the present, The external part refers to what other people see:
responding in the here-and-now, and being aware our verbal and non-verbal behaviour together with
of the present moment, since that is where we other aspects of the way we present ourselves.
express ourselves and make our impact on life. Of To Tschudin (1991), the inner world consists of
course, we need to take into account lessons learned thoughts and emotions and the outer world of peo-
from the past and goals set for the future, but it is ple and environments with a ‘go-between’ world
all too easy to dwell on these and let the present relating to the senses. A composite view is pre-
take care of itself. This can lead to our losing what- sented here (Fig. 16.1). The inner aspect includes
ever control we had of it. Being aware of the self thinking, intuition, emotions and bodily sensa-
helps us perform in the present. tions which include those of muscle tension; the
Greater control of our lives, enhanced relation- outer aspect refers to the way we relate to other
ships and improved self-knowledge all contribute people; and the intermediate area is concerned
to our peace of mind. Self-awareness exercises can with the five senses.
thus be seen as relaxation techniques. Self-awareness exercises are essentially of the
Authors have structured self-awareness in differ- mind, being concerned with the thoughts in the
ent ways. Stevens (1971) divided it into three parts: head. The approach is thus underpinned by cogni-
an outer world of sensory information; one inner tive theory. Exercises presented here are adapted
world of feelings (visceral and emotional); and a from Stevens (1971), Burnard (1992) and Bond
second inner world of mental activity (thoughts (1986).
and images). Burnard (1992) sees the internal part
as corresponding with Jung’s four functions of the
mind (thinking, feeling, sensing and intuiting),
EXERCISES IN SELF-AWARENESS
to which he adds a visceral component which
AWARENESS OF THINKING STYLE
We have different ways of thinking: sometimes we
Inner world
think in a vertical or focused way as when doing
arithmetic. At other times our thinking may be
more inclined to a lateral style, as, for instance,
Thinking
when we are engaged in creative work. We also
Intuition
Feelings
have our own personal styles of thinking: some
Bodily people tend towards a cause–effect style, others to
sensations a broader canvas style.
Other modes of thinking relate to the self-concept
Intermediate world of the senses and self-esteem (Ch. 14, p. 122). For example, think-
ing strategies which direct the individual into areas
likely to lead to successful outcomes are associated
with high self-esteem, while those which direct
Seeing
Hearing
her into areas with a low probability of success
Smelling tend to be associated with low self-esteem (Fox
Tasting 1997, p. 116). Self-esteem can also be promoted by
Touching attributing successful outcomes to one’s own
efforts and poor outcomes to external factors over
which one had no control (Blaine & Crocker 1993).
Outer world Or again, thinking can be influenced by the indi-
vidual’s locus of control (Ch. 3, p. 26): an internal
Relating to other people locus with its accompanying sense of self-reliance
Figure 16.1 Aspects of the self. seems to be related to high self-esteem, whereas
Self-awareness 143
an external locus seems to be related to lower Sit quietly and allow yourself to become relaxed.
levels of self-esteem (Fox 1997, p. 118). Although Follow your breathing, and next time you breathe out,
our self-esteem owes much to value systems set up release all your tension in a long sigh. Scan your body,
by the culture and society we belong to, it is also checking that all your muscles are relaxed. Imagine
governed by our use of self-serving strategies, such yourself in a place of beauty and peace. Allow your
as the way we present ourselves (Carless & Fox thoughts to drift in and out. Focus on a matter that
2003). To Fox, low self-esteem is more a defect in has been claiming your attention recently … keep it
the use of self-enhancement strategies than a light … there’s no compulsion to resolve it at this
reflection of any deep sense of disregard. moment … just listen to yourself … tune into your-
The individual can review her own style in the self … be receptive to any ideas that float into your
following manner: head … listen to your gut feeling; you can judge its
merits later … just be open to yourself … When you
Take a few moments off to make a list of the
are ready, bring your visualization to an end.
thoughts that are going through your mind and the
dialogue that accompanies them. Write them down.
Repeat this twice later in the day. Compare the AWARENESS OF FEELINGS (EMOTIONS)
items on your three lists and notice if a pattern
The capacity to use our mental abilities is strongly
emerges. Is some particular thought claiming your
influenced by the emotional state of the indivi-
attention? If so, how do you approach it? Do you
dual, whose thinking brain can be overwhelmed,
see it as a problem to be solved or do you let it
even paralysed by the emotional brain (Goleman
dominate you? If you are trying to solve it, are you
1996). Goleman emphasizes the importance of
using a focused method or are you keeping your
self-awareness in this area.
mind open and receptive to fresh ideas? Both
To focus on emotions need not be seen as self-
approaches are useful. Do you have a tendency to
indulgence. Rather, it is a form of self-examination
favour one more than the other?
which can provide us with insights and perhaps
Do you tend to think in ways which enhance your
indicate useful paths of change. While our emo-
self-esteem such as steering the self in directions
tions may be said to enrich our lives on the one
likely to lead to success? Or do you tend to cling to
hand, they give us trouble on the other; some feel-
areas where success is less likely to occur? Do you
ings can be so strong they cloud our judgement
make a point of interpreting outcomes in ways
and others may be so uncomfortable we repress
which show yourself in the best possible light, or do
the thought that gives rise to them.
you let negative interpretations assert themselves?
Heron (1977) reminds us that society urges us
Again, do you see most problems as being sur-
to control rather than express emotion, and this,
mountable and, to some extent, within your control?
he claims, blocks our development as full human
Or do you, generally speaking, feel yourself to be a
beings. Anger and grief are two examples where
pawn in the hands of fate and a victim of events?
this occurs. He sees the handling of emotions as a
This is an opportunity to examine your attitude
skill and has developed a model which identifies
towards yourself and to ask if it is serving you well.
four aspects of this skill. They consist of the
degree to which we:
AWARENESS OF INTUITIVE POWERS 1. are aware of our emotional patterns
2. express ourselves in controlled or
Our glorification of the rational has all but eclipsed
spontaneous ways
the imagination in everyday affairs. We distrust
3. share our feelings
intuition or, at best, give it short shrift. Our belief
4. use catharsis to move forward.
in the undeniable value of logical thinking does
not, however, mean we must stifle the imagina-
1. Awareness of emotional patterns
tion, and those who underestimate its power may
do so at their peril for it communicates with the We need to recognize our feeling patterns and ten-
inner self. dencies to react in certain ways. Only when we are
144 COGNITIVE APPROACHES TO RELAXATION
aware of them can we see how they may be influ- the individual’s understanding of the situation and
encing our behaviour. of herself.
3. Decision making. If emotional release has
2. Control or spontaneity cleared her mind of its burden, and newly found
Many situations require us to hide our feelings, but insights have enriched her perceptions, the indi-
there are other occasions when a more spontaneous vidual is better able to plan and carry out con-
response is called for. Whether we express our emo- structive changes to her life and solve the
tion or hold it back is governed not only by the cir- problems which stand in the way.
cumstances but also by our general inclination. A self-awareness script based on Heron’s model is
Some individuals have a tendency to respond in one presented below.
way rather than another. If so, are they aware of it?
Spend a few minutes considering your feeling pat-
3. Sharing our feelings terns … do you tend to react in characteristic ways?
Self-disclosure is part of the process of deepening a … what are these? … for example, do you tend to
relationship, and this applies whether the individ- hold back your feelings or do you make sponta-
ual is making the disclosure or listening to another neous responses? … can you think of occasions
making hers. Although the sharing of feelings when you have used one or the other? … and to
involves taking a risk, the relationship is unlikely to what effect? … (pause)…
develop without it. Most relationships are enriched Do you tend to share your feelings or are you
by some degree of self-disclosure; the extent to reluctant to trust people? … have you been let down
which it occurs depends partly on the nature of in the past by sharing your feelings? … if so, has it
the relationship and partly on the inclination of affected your readiness to trust others? … (pause)…
the individual. Is she inclined to share her feelings? How do you deal with situations which make you
angry? … do you answer back (as the occasion per-
4. Releasing emotions in a process of mits), or do you tend to bottle up your feelings? …
catharsis having bottled them up, are you able to find ways
of releasing that pent-up anger? … if so, do you feel
This aspect of emotional skills provides a safe-
more content afterwards? … think of occasions
guard against the bottling-up of emotions. If emo-
when you have used catharsis…
tions are not expressed or dealt with at the time
they are aroused, they may get repressed. In this
latter case, a subsequent environmental trigger
may stir them up and lead to inappropriate behav- AWARENESS OF THE BODY
iour of two kinds: first, we may over-react if we From time to time, the body needs attention. In
see the issue as a safe channel in which to let off between, we spend periods of varying length with-
the pressure of our repressed emotions, or second, out giving it a thought. Breathing, digestion, skin
we may under-react, having trained ourselves to sensations can all be ignored; muscle tension also
keep a tight rein on our feelings at all times. Either passes unnoticed. If we are interested in reducing
way our response is a maladaptive one. The muscle tension, it can be useful to make a point of
process of catharsis helps to free the individual listening to the body occasionally.
from the tyranny of unresolved emotions. Heron
Allow your thoughts to focus on your body. Notice
lists three elements of cathartic release:
any sensations, such as stomach rumblings, joint
1. Letting-go of feelings. This can take place in discomfort, itches or the tendency to sigh … things
a controlled way such as going for a jog or doing a you normally disregard as you concentrate on your
workout; it can also be achieved in less restrained work. Perhaps you are also ignoring feelings of ten-
ways such as shouting into a pillow or kicking a sion in your muscles, in your back, your shoulders,
cushion. your face or your writing arm … try focusing on
2. Gaining insights. The release of emotions may those areas and releasing the tension … realize that
be accompanied by intuitive insights which deepen you could just as easily increase it … try for a
Self-awareness 145
moment deliberately exaggerating the tension in speech, such as tone of voice, timing, emphasis,
the muscles … notice that you have the power to accent (paralinguistic features), as well as facial
switch it on or off … simply by making a conscious expression, eye contact, gesture, posture, physical
effort you can increase or decrease those feelings proximity, clothes and appearance (Argyle 1978).
of tension. Explore that idea for a few moments. The way we respond within the interaction pro-
vides a further level of behaviour: how we prompt,
AWARENESS OF THE ENVIRONMENT cut in, and listen.
Less stress in
Stress the
the long
long run
run
Non-assertive Assertive
approach approach
Figure 16.2 Breaking out of the stress/low confidence trap. (From Bond 1986.)
complement one another: self-awareness protect- while distraction protects her from too much
ing the individual from the hazards of denial, introspection.
Further reading
Fox K R (ed) 1997 The physical self: from motivation to well- Goleman D 1996 Emotional intelligence. Bloomsbury,
being. Human Kinetics, Leeds London
Freshwater D (ed) 2002 Therapeutic nursing: improving
patient care through self-awareness and reflection. Sage,
London
149
Chapter 17
Imagery
effect; and Melzack & Wall (1983) put forward relaxation is one such state. Others include dream-
their theory whereby pain messages are blocked ing, drug-induced states, hypnosis, meditation,
from consciousness by a ‘gate’ mechanism which daydreaming and guided imagery. During these
shuts them off when the sensory channels are states, the influence of the left brain is reduced,
loaded with other information (which may include which allows material from the right hemisphere,
imagery). normally hidden, to become accessible. Thus, the
Although the precise mechanism of imagery is altered state is seen as providing a path to the
unknown, it is believed to involve the right cere- interior of the self.
bral hemisphere. This chapter contains a short Lyman et al (1980) claim to have found a con-
discussion on the concept of laterality which is nection between images and emotions, having
followed by a section on the unconscious mind. shown experimentally that emotionally charged
Examples of different kinds of imagery will be situations are more likely than neutral ones to be
found in a later part of the chapter. accompanied by imagery. They posit a direct rela-
tionship between the right hemisphere (which is
associated with imagery) and the autonomic sys-
LATERALITY
tem (which governs the physiological responses
The cerebral cortex is divided into two hemi- associated with emotion).
spheres, each of which has four lobes: frontal, The link between imagery and physiological
parietal, temporal and occipital. Research indi- processes can be demonstrated by imagining a
cates that the hemispheres have specialized roles lemon (Barber et al 1964):
(Fig. 17.1). One side, usually the left, is believed to
Visualize its exterior shape, colour, scent and tex-
process logical thought and language. It is involved
ture; then slice it across the middle, look at the
in linear, analytic and rational thinking, reading,
pale, glistening flesh, squeeze it gently and watch
writing and mathematical activity and is normally
the juice dripping from it; take the cut end to your
the dominant hemisphere. The right hemisphere
mouth and lick it. Notice your mouth watering.
is seen as dealing with information of a non-
rational nature, being concerned with creative Electromyographic recordings also demonstrate
thinking, fantasy, metaphor, imagery, dreams, associations between visualization and physio-
analogies, intuition and emotion, including feel- logical activity: positive imagery has been shown
ings of stress and is normally the non-dominant to lower muscle tension levels and negative imagery
hemisphere. However, it is believed to acquire to raise them (Jacobson 1938, McGuigan 1971).
dominance during altered states of consciousness, In applying these findings it is suggested that a
i.e. states of mental functioning which seem dif- useful approach to stress relief and relaxation is
ferent to the individual from the ordinary pattern through methods which involve the right hemi-
experienced by her (Atkinson et al 1999). Deep sphere (Davis et al 2000).
Reason
Imagery THE UNCONSCIOUS
Creativity
Logic
Lateral thinking Freud (1973) viewed the unconscious as a reposi-
Vertical thinking
Recognition tory of repressed fears and unresolved emotions.
Language
Rhythm
Reading It thus represented aspects of ourselves which we
Emotions
Writing LEFT RIGHT wished to forget. Its contents were only available
Dreams
Mathematics
Analysis
Symbols in certain states such as dreaming, when the con-
Synthesis scious mind was less dominant. A Jungian view of
Ego
Id
Relating to the the unconscious, however, saw it as also contain-
Relating to the
conscious ing the seed of infinite new possibilities deriving
unconscious
mind
mind from insight, intuition and inspiration (Jung 1963,
Figure 17.1 Left and right hemisphere activities. Fordham 1966). Thus, while Freud viewed it in
(Adapted from Shone 1982.) negative terms, Jung’s view was primarily positive.
Imagery 151
Whatever their theoretical position, writers in blindly accepted. Although the guide is an aspect
general agree that the unconscious operates not of the inner self, it may not be working in the indi-
with the language of logic, but through pictures, vidual’s best interests. On the other hand, too
emotions, senses, symbols and imagery, i.e. the sceptical an attitude will tend to generate fewer
concerns of the right hemisphere. Hidden and elu- ideas than a trusting one.
sive, the unconscious does not lend itself to direct The individual need not feel restricted to one
investigation, either from the scientist or from the guide, and may find it useful to have one male
self-analysing individual. It is this quality of and one female, each supplying complementary
elusiveness that moves Jung to speak of the diffi- wisdom. A hazard of working with a number
culty in penetrating one’s own being. His arche- of inner guides, however, is that the personality
typal figures (earth mother, wise man, persona, may come to be seen as a collection of separate
shadow, anima and animus) are the expression of entities when the aim of the exercise is to achieve
attempts to find new ways of gaining access to the integration.
unconscious. Any meeting with an inner guide should be
rounded off with words of gratitude, respect and
The inner guide appreciation as this helps to strengthen the indi-
vidual’s respect for her inner self. Continuity also
Arising out of these ideas is the concept of the is important and may be established by a contract
‘inner guide’: a mental construct that links the to meet on another occasion.
individual with her inner self. In its role as chan-
neller of information from the unconscious, the
inner guide may be seen as the personification of
the intuitive self. It can take forms other than THERAPEUTIC EFFECTS OF IMAGERY
those of archetypal figures and may appear as any
person or animal whose attributes have appealed Imagery can be used in a therapeutic sense to pro-
to the individual’s imagination. mote the following:
Typically the inner guide evolves in the mind
1. Self-development and psychological change.
during a session of deep relaxation, using an
These effects are expanded in Chapter 18.
imagined setting of rich sensory quality. Oyle (1976)
2. Relaxation. Zahourek (1988), working in a
suggests a place of peace and beauty such as a
nursing context, sees imagery as a therapeutic
mountain lake or a natural grotto, while Ferrucci
tool which can reinforce the message to
(1982) prefers an Alpine peak reached after an
relax.
arduous climb. A figure is conjured up; it advances
3. Healing. This is an area not covered in the
slowly. The visualizer welcomes the approaching
present work.
figure, noticing everything about it: what it looks
like, how it is dressed, who if anyone, it resembles.
A dialogue ensues. Ferrucci warns against the
possibility of the guide being no more than a self- PROCEDURE OF A THERAPEUTIC
deceiving fantasy and suggests criteria for testing IMAGERY SESSION
its authenticity:
RELAXATION
● does it bring answers which come from the self?
● does it bring understanding? For the imagery to be effective, the individual
● does it carry a sense of rightness? should first be in a state of relaxation. Fanning
● does its message make sense in the light of (1988) regards relaxation as ‘an absolute prerequis-
reason and morality? ite’ of effective imagery. The individual may use
● will its advice stand up in real life situations? any method she finds helpful, but passive
approaches are seen as being the most appropri-
Even after acceptance of the guide as authentic, its ate (Achterberg 1985). Thus relaxation is a precon-
advice should always be scrutinized and not dition as well as a result of therapeutic imagery.
152 COGNITIVE APPROACHES TO RELAXATION
INTRODUCTORY REMARKS TO also differ in their ability to control the image once
PARTICIPANTS formed (Finke 1989). Image-making is thus a skill
with more than one facet.
As with other approaches, a short passage of
There is some evidence to suggest that image-
explanation is necessary.
forming can be improved with practice, although
Imagery is about building pictures in the mind. The the extent of any such improvement has not been
pictures can be pleasant or unpleasant. The first determined (Kosslyn 1983, Lichstein 1988). Never-
kind induce a feeling of calm, the second, of theless, exercises are often used in the belief that
unease. they help to develop innate potential. A difficulty
The relaxing effect of pleasant imagery is partly in imaging should not, however, be seen as a
due to the distraction it creates from stressful deficit but rather as a manifestation of the many
thoughts. Daydreaming is an example of this kind ways in which human beings differ from one
of imagery. However, the imagination can also bring another. People who report difficulty in forming
us nearer to our inner selves, and this aspect of it images may also describe a sensation which fulfils
is used to help people discover new possibilities the same function in their thought processes.
within themselves, thereby enriching their lives. For those who wish to explore their capacity to
This kind of imagery is more structured than create images, however, the following exercises
daydreaming. are presented. They use the modalities of sight,
You’ll find it helpful to make yourself relaxed sound, smell, taste, touch, temperature and kinaes-
before you begin. thetic sense. A total of 15–20 seconds can be spent
on each item.
Imagine a jelly not quite set. It has been turned The above are simply examples. The most effect-
out of its mould and stands, holding itself together ive imagery is that which the individual creates
but not yet firm. Every time the plate is moved, it for herself, choosing the context to which she can
wobbles. best relate.
Now, think of yourself as that jelly. You are
standing on a dish, and every time someone knocks
DISTANCING
the table, a ripple runs through you. You yourself
are not able to initiate the movement; only others The distress caused by unpleasant events can be
can do that by bumping into your table or moving overwhelming. Moreover, the intensity of the
your dish … and, every time this happens, you emotion aroused by them may cloud the individ-
wobble. One bump, and you wobble several ual’s judgement. In order to gain a more objective
times … imagine you are about to be bumped view, she may find it useful to draw back from the
into … feel your body limp … let all the tension go scene mentally: in effect, to distance herself.
out of it … let yourself become a wobbly jelly… Certain images promote the feeling of being able
to put a distance between herself and the situation:
TRANSFORMATIONS ● a leaf floating downstream
● clouds moving across the sky
Images can also undergo transformations: harsh
● helium-filled balloons rising
images can give way to smooth ones. Fanning
● bubbles being blown away
(1988) shows how negative emotions, represented
● a train receding along a straight track.
by harsh images, can be influenced to move in a
more positive direction, when the harsh images
are transformed into smooth ones.
COLOUR
Imagine the sound of discordant music … listen to
its harsh tones … and as you do, let your painful People say they have favourite colours. Is this
thought express itself in terms of the dissonant because certain colours make them feel good?
notes … feel the mood of your difficulty resonating And is this governed by the association that those
with the sound. Then gradually allow the image to colours have with pleasant events in their lives? It
undergo a transformation … follow the music as it is generally believed that red is a stimulating
slowly resolves into harmonies … and, as the har- colour and blue a soothing one but to what extent
monies fill the air, experience the beginnings of a is the preference for one over the other tied up
change in your feelings… with the mood of the moment? Such notions
Other examples of negative imagery resolving might help to explain why a person does not
into pleasanter forms are: always choose the same colour. Or does she sim-
ply become sated with one colour and feel the
● sour lemon juice into sweet lemon sorbet need to replace it with another (as in decorations,
● sandpaper into silky fabric. clothes, etc.)? These are psychological consider-
Both come from Fanning (1988). The next two are ations, although the aesthetic aspects of colour
drawn from Davis et al (1988): give the topic a further dimension.
However, in the present context we are con-
● a screaming siren into a woodwind melody cerned with psychological aspects. Certainly
● the glare of a searchlight into the soft glow colours can create strong effects. Some of these can
of a lamp. be explored through exercises in colour imagery.
Four of the sense modalities (taste, touch, sound The following example is adapted from the work
and sight) are represented in these examples. The of an autogenic therapist, Kai Kermani (1990).
fifth, smell, is illustrated below in the transform-
With your eyes closed let the word ‘colour’ float
ation from:
into your mind. The word may first evoke one par-
● burning rubber into smouldering pine logs. ticular colour although others will quickly follow.
156 COGNITIVE APPROACHES TO RELAXATION
Take the one that first appears. Stay with it. Let it already closed. Let your mind be as still as possible.
develop in any way it wants to: flooding your field Pick a colour that feels right for you. Pick it spontan-
of vision, appearing in patches, little flecks or any eously and see it before your eyes. You can picture
other arrangement. Concentrate on the colour in a it as brushstrokes of paint, coloured cloth, tinted
passive way, letting it speak to you. Does it remind smoke or coloured atmosphere. Let it extend all
you of anything? Does it trigger any special feelings round you. Notice its quality, its tone and be aware
or memories? If it has no effect on you, try ‘step- of any associations it has for you. Feel yourself
ping into’ it and allowing it to surround relating to this colour, harmonizing with it, becom-
you … notice any effect it now has on you… ing infused with it. Imagine yourself absorbing the
After a few minutes, or when you are ready, colour through every pore of your skin until your
allow the colour to draw itself away from you. In body is filled with it…
your mind’s eye, watch it resuming the form it had Now … let the colour begin to radiate from
in the beginning. you … feel yourself releasing it … making it expand
all round you until it gradually comes to fill the
If colour can indeed influence our mood, then
room you are in. As you continue to generate more
colour visualization could have particular value.
colour, see if you can fill the building you are
We could mentally surround ourselves with sin-
in … pause for a moment … then slowly begin to draw
gle colours to gain specific effects, soothing our
the colour back, first from the building … then from
feelings when we are anxious and raising our
the room … watching it get more condensed … until it
mood when we are depressed. Single colours are
gathers in a cloud around you … feel yourself bathed
again explored in the following two exercises.
in this colour … now … absorb it back into your
Imagine finding yourself in a room decorated exclu- being … into the very organs of your body … pause
sively in a colour of your choice. See the entire again … then watch it drawing itself away from all
room in this one colour, the walls, ceiling, paint- parts of you … feel yourself being emptied of the
work, carpet, upholstery. If you have difficulty, try colour. Convert it back to the paint, cloth or smoke
going through the motions of painting the walls in which it started. Be aware of how you
and hanging the curtains. Totally immerse yourself feel after doing the exercise. Notice any effect it
in this colour and notice the effect it has on had on you.
you … does it relax you or give you a lift? … why did
you pick it? … what associations does it have for
you? … stay with it long enough to absorb its full CHAKRAS
effect … then let it fade. In Hatha Yoga vital energy is seen as being
Now picture yourself in a room decorated in a focused in specified areas of the body known as
colour you don’t like … Surround yourself with this ‘chakras’. These are situated at:
colour, let it permeate your consciousness (so long
as it doesn’t disturb you, in which case stop the ● the base of the spine
exercise) … Ask yourself why you dislike this colour ● the lower abdomen
and what effect it is having on you … When you are ● the navel
ready, let the colour fade and be replaced by the ● the heart
colour of your choice before ending the visualization. ● the throat
● the brow
(It is preferable to end colour imagery sessions with
● the crown of the head.
a colour that the visualizer feels comfortable with,
in order to carry away a rewarding sensation.)
Each chakra is associated with one of the colours
Ernst & Goodison (1981) present a sequence in
of the spectrum: the base of the spine with red, the
which colour flows to and from the visualizer. It is
lower abdomen with orange, the navel with yel-
reproduced here in modified form:
low, the heart with green, the throat with blue, the
First relax yourself using any method you find brow with indigo and the crown of the head with
works for you. Close your eyes if they are not violet.
Imagery 157
sensation of moving through the scene … feel the the scents around you … is it honeysuckle? … or is it
tension leaving your body … feel it being carried thyme? … or perhaps it’s newly mown grass … you
away each time you breathe out … and enjoy the may decide to walk through the garden, along a
peace and calm of the scene you’ve created… path which perhaps carries you under some
trees … notice how cool it is in their shade … and
For those who are looking for more specific
how warm when you step out into the sunlight
scenes, three examples follow: a sunny beach; a
again … notice also the trees which line the
country meadow; and a scented garden. (If the
path … and the texture of their bark … in your
trainee suffers from hay fever, the first item is the
mind’s eye reach out to touch one of them … was it
best choice.)
smooth or deeply incised?…
A sunny beach
Imagine a stretch of shoreline … make it rocky or EVIDENCE FROM RESEARCH
smooth as you like … notice the ground underfoot,
is the sand wet and hard or is it dry and soft? … if Imagery is a safe and non-invasive technique
the sun is shining perhaps you can feel its warmth which does not require elaborate equipment. As a
on your skin … and see the light dancing on the coping tool for reducing anxiety and stress, it has
water … perhaps you can smell the sea air as it fills been found useful (Donovan 1980, Hamm &
your nostrils … what sounds can you hear? … the O’Flynn 1984, King 1988) and Dossey (1988) finds
gulls calling? … the waves breaking? … a motor it can reduce psychological stress in a healthy
chugging? … you may decide to take a walk along working population. With hospital patients guided
the beach and, as you travel, notice how the imagery has been used to enhance patient experi-
scenery changes … perhaps rocks begin to break up ence, resulting in significant decreases in anxiety,
the surface of the beach, with pools beneath pain, narcotic consumption, side effects, financial
them … you might feel you want to dip your hand costs, care and length of stay (Tusek & Cwynar
into one of them … and are surprised to find how 2000). However, imagery alone has rarely been
warm this shallow water is… studied as a treatment (Luskin et al 2000). It is
often combined with muscle relaxation techniques
A country meadow in the treatment of clinical conditions. For
example, Cupal & Brewer (2001) found signifi-
Picture yourself in the country … perhaps you are in
cantly less pain and re-injury anxiety following a
a field in early summer … notice how long the grass
course of relaxation and imagery among individ-
is … notice also how green it is … are there wild
uals undergoing rehabilitation after anterior cru-
flowers growing in it? … which ones? … can you
ciate reconstruction; and Johnson (2000) showed
smell their scent rising up? … and is there a gentle
that the mood levels of competitive adults with
breeze? … enough to rustle the leaves on the
long-term injuries could be significantly raised
trees? … you may decide to wander along a narrow
by relaxation and guided imagery.
sheeptrack … and as you cross the ground, perhaps
Cancer pain is another area where the combina-
you can hear the sound of water … if it’s a stream,
tion of these two techniques has been studied. In
notice how it runs … whether smoothly or bubbling
the conclusion of her review article, Wallace (1997)
over rocks … and how soon does it swing out of
found that relaxation and imagery appeared to
sight?…
reduce the sensory experience of pain. The evi-
dence in their favour is not strong but it is sug-
A scented garden
gested that the combined techniques have a place
Let your mind conjure up the scene of a beautiful as an adjunct to other forms of treatment.
garden … notice the way it is laid out … the trees, The use of imagery as a tool for promoting
shrubs and flower beds … perhaps it has just relaxation is supported by the work of Haas &
rained … a gentle summer rain … can you smell the Axen (1991) who showed that the behaviour of
air, warm and moist? … in your imagination notice alpha waves becomes altered during sessions of
Imagery 159
Further reading
Zahourek R P 1997 Relaxation and imagery: tools for thera-
peutic communication and intervention. Alternative
Health Practitioner 3(2): 89–109
161
Chapter 18
Goal-directed visualization
DEFINITION
CHAPTER CONTENTS
Definition 161 In their book Seeing with the Mind’s Eye, Samuels &
Samuels (1975) describe a technique using imagery
Rationale 162
which has two phases, receptive and programmed.
The method 162 In the receptive phase, the individual passively
Position 162 listens to her inner self, drawing on her own wis-
Preparatory relaxation 162 dom. In the programmed phase, she engages in
Special place 162 an active and deliberate thought process for the
Receptive visualization 163 purpose of improving a situation or resolving a
Positive self-statements or affirmations 163 problem in her life. It is based on the assumption
Programmed visualization 164 that, by repeatedly experiencing an outcome in
Termination 164 the imagination, we increase the likelihood of it
Additional technique 164 taking place in real life.
The Samuels’ work has been developed by
Relaxation and goal-directed
Achterberg (1985), Simonton et al (1986) and
visualization 164
others in areas of medicine and healing; and by
Applying the method of goal-directed Shone (1984) and Fanning (1988) among others in
visualization 165 areas of self-development and relaxation. Since in
Visualizations for people who want to give up this book we are concerned with the latter area,
smoking 166 the definitions of Fanning and Shone are appro-
Evidence of effectiveness of imagery in priate. Fanning describes this kind of imagery as
changing smoking behaviour 168 ‘the conscious, volitional creation of mental sense
impressions for the purpose of changing oneself’;
Other applications of goal-directed
Shone refers to it as a mental experience which
visualization 168
helps to bring about desired outcomes. Implicit in
Comment 170
both definitions is the notion of a goal.
Pitfalls of imagery and goal-directed How does this form of imagery differ from
visualization 170 other forms? One answer is that it is more explicit
than techniques which rely on metaphor and sym-
bolism; it is also more purposeful than reverie
states such as daydreaming. How is it different
from talking to yourself, reflecting, and giving
162 COGNITIVE APPROACHES TO RELAXATION
setting the scene so that it can easily be recreated Feel at home there. Let your attention gently focus
in subsequent visualizations. Since imagery is a on the item that preoccupies you … just keep an
right hemisphere activity, the constraints of logic open mind … quietly listen to the thoughts that
do not apply. Thus, the special place may contain flow through it … if you are stuck, call on your
any figment of the imagination which the visual- inner guide … listen to the wisdom your inner guide
izer finds useful, as for example, a permanent sun- brings … realize that it is your own wisdom, coming
set in the background, a viewing screen in a forest from your deeper self … spend a few minutes
clearing or a crystal ball in a mountain spring. It is listening to yourself…
in such a scene that the inner guide could appear When you are ready, end your visualization and
(Ch. 17, p. 151), and so there should be a clearly gently bring your attention back to the room.
defined way in. Write down any ideas that came to you.
Some people prefer an indoor special place Consider them. Have you gained any insights? Do
such as an attic room or a garden shed; others like you want to change your way of handling this
to have both, using them on different occasions. situation? Are there more positive ways of dealing
There is no right or wrong way: whatever works with it?
for the individual is right.
Receptive visualizations can be repeated as often
as they continue to provide insights.
RECEPTIVE VISUALIZATION
The visualizer imagines herself in her special POSITIVE SELF-STATEMENTS OR
place. This is where she can feel in tune with her- AFFIRMATIONS
self and where she will be likely to gain insights. The positive self-statement, often referred to as
She is in a state of mind that allows her to listen to an affirmation, helps the visualizer to see herself
the part of herself which is normally beyond con- as being capable of realizing her aspiration and
scious awareness. It is a passive state of mind achieving her goal. Inherent in the affirmation is
which in some ways resembles daydreaming, but the suspension of self-doubt. Examples include
differs from the latter in that the visualizer is ask- the following:
ing specific questions of herself (Samuels &
● I believe in myself.
Samuels 1975). Whether she is making a choice,
● I am in control of my life.
sorting out a conflict, uncovering motivations or
● I can achieve my aim.
exposing automatic thoughts, the receptive visu-
alization is a way of allowing intuitive insights to While the above statements are of a general nature,
be released and inner wisdom to be revealed. additional affirmations relevant to the matter in
The visualizer should be advised that if uncon- question can also be composed. Thus, for a person
trollable or unpleasant feelings which she is not wishing to become more relaxed, the following
ready to deal with arise, she can walk away or dis- statements may be included:
tance herself in some other manner. She can also
end the visualization. Otherwise she quietly tunes ● I feel calm.
in to her unconscious. If ideas do not flow, the ● I am at peace.
inner guide can be called and asked for advice ● I can cope in stressful situations.
(Ch. 17, p. 151).
Positive self-statements need to be short, in the
An example of a receptive visualization script
first person and in the present tense; the best ones
is given below. (Allow 10 or 15 minutes for it.)
are those composed by the individual herself
Lie down. Get yourself comfortable and close (Fanning 1988). When repeated, they act like self-
your eyes. Run through a relaxing procedure until hypnotic suggestions, influencing the individual’s
you feel very calm. Visualize yourself lying in your view of herself in a positive direction, and adding
special place. Evoke its atmosphere by mentally force to the positive images of the programmed
experiencing its sights, sounds, smells and textures. visualization (described below).
164 COGNITIVE APPROACHES TO RELAXATION
Before the individual begins her visualization, stages is another useful strategy, since they act as
she should first become relaxed. stepping stones along the way. This has the effect
● It may be experienced as a secondary effect of making the ultimate goal seem easier to reach,
following mental rehearsal in which the as well as providing rewards at intervals. Smoking
individual sees herself successfully coping one less cigarette a day can constitute a subgoal;
with an activity which has hitherto been so can taking one more step to a person recover-
associated with stress. ing from leg injury. Difficulties can be considered
● A need for relaxation may be created while the in advance and ways of solving them worked out
goal is being achieved, such as during the strug- (Fig. 18.1).
gle to withdraw from cigarettes or tranquillizers. Samuels & Samuels (1975) advise the individ-
ual not to confide her visualization to anyone who
Goal-directed visualization is thus not a primary
may not share her faith in the wisdom of the goal
method of inducing relaxation, but it does have
and in her capacity to reach it. Unshaken belief is
close links with it.
vital for her success.
Of course, participants in some groups may be
too demoralized to begin; they may feel they have
APPLYING THE METHOD OF little future; they may be angry or depressed.
GOAL-DIRECTED VISUALIZATION These are valid reactions which call for modifica-
tion of the method and perhaps referral to a spe-
Unlike most other methods described in this cialist agency. In general, however, the approach
book, goal-directed visualization addresses the can be a useful one.
specific problems of a person. This feature is seen Although it is difficult to construct a model
in both the receptive and the programmed com- script without specific knowledge of the problem
ponents. Thus it is not possible to present a model concerned, an attempt is made here to provide an
script without a clear understanding of the example.
background. The reader is reminded of the principal items in
A key factor in the success of any plan is the the method.
motivation of the visualizer. While for some indi- Receptive visualization. The individual tunes in
viduals this is not a problem, others may need to her own wisdom.
encouragement. One way of fostering motivation Self-statements. She reaffirms herself through
is to make the goals specific. For example, having positive internal dialogue.
a timescale for a smoking abstinence plan defines Programmed visualization. She works on a plan for
it more clearly. Creating subgoals or intermediate the future in which she sees herself surmounting
Where you are now Consider realistic Difficulties encountered Ways of solving them
expectations
obstacles, realizing possibilities and achieving smoke? Perhaps you hadn’t thought about it before,
goals. The keynote of this stage is seeing the self as just taken it for granted. In your mind’s eye, take
succeeding. out a cigarette and light up … what does it do for
you?…
Run through different situations during the day
VISUALIZATIONS FOR PEOPLE WHO when you feel the need of a cigarette … start with
WANT TO GIVE UP SMOKING breakfast time … what prompts you to reach for
It could be argued that smoking has more to do the first cigarette? … then follow yourself to
with relaxation than smoking abstinence has, and work … smoking on the journey … at work in your
many people become smokers because they per- coffee break … after the midday meal … again in the
ceive cigarettes as being a source of mental calm. afternoon … on the way home … to round off the
However, many such people may then wish to evening meal … last thing at night … do you notice if
quit smoking. Quitting is associated with stress, you smoke for different reasons? … do you get dif-
which means that the same people may be seek- ferent rewards from smoking? … when do you find
ing an alternative means of obtaining relaxation. you particularly want a cigarette?…
Health care professionals increasingly find them- Bring your visualization to an end when you are
selves faced with groups of people who are strug- ready…
gling to give up cigarettes and for whom relaxation The visualizer may feel she smokes for different
training has been prescribed. Although any of the reasons at different times. Some of the reasons why
methods in this book might help, a method which people smoke are:
directly addresses the problem would seem to have
particular advantages. ● to feel reassured
Within a single group of people who wish to ● to relieve boredom
reduce their smoking habits, there may be a wide ● to feel soothed
variety of aspirations: one person may want to cut ● to feel relaxed
down from 40 cigarettes a day to 20, another may ● to give her hands something to do
want to give up altogether. They may also have ● to give herself a lift
different ideas as to how to go about it: one may ● to reward herself
want to reduce by one cigarette a day, another may ● to keep her weight down.
want to make a more abrupt change. Or again, the She decides which of these apply to her and is
group may consist of people who are looking for then urged to think of alternative ways of meeting
ways of avoiding relapse after having successfully these needs:
given up smoking. The following visualization
(adapted from Fanning 1988) is designed for ● For reassurance, she tells herself she does not
people who have decided to give up altogether. need a crutch.
● To relieve boredom, she gets out a crossword
puzzle.
Receptive visualization ● To feel soothed, she reminds herself of the love
Lie or sit in a position which you find comfortable. of her partner.
Close your eyes. Allow yourself to unwind. (The ● To feel relaxed, she runs through a relaxation
instructor presents either passive relaxation or slow sequence.
breathing.) As your body and mind become calm, let ● To give her hands something to do, she carries
your special place take shape in your imagination. a small, rounded pebble which she rolls in her
Notice the sights, sounds and smell of the place. hand.
Put out your hand and feel the textures: the grass, ● To give herself a lift, she remembers the prize
the rug, the pine needles, etc. … feel that you are she won for cookery/essay-writing/athletics
there … lying peacefully … tuned in to yourself. last year.
Gently bring your mind to focus on your smoking ● To reward herself, she buys the salmon roll
habit. Explore your feelings about it. Why do you instead of the cheese roll.
Goal-directed visualization 167
● To keep her weight down, she eats an orange vividly as you can … employing alternative strategies
instead of a second helping of potatoes, or goes and encouraging yourself with positive self-state-
for a walk/workout, etc. ments … remind yourself of the benefits of giving up
smoking: clear lungs, no cough, extra change in your
Positive self-statements or affirmations pocket … and if you feel your resolution weakening,
The individual cultivates a view of herself as remind yourself why you made it in the first place.
a healthy non-smoker by composing a few posi- Continue through the day, appreciating the
tive self-statements which she recites regularly to experiences that not smoking opens up to you: the
herself: taste of your food … the garden scents … the fresh
smell of your clothes … and the easy way you climb
● I am healthy the hill. See yourself as someone who doesn’t smoke…
● I am a non-smoker At some point, feel your stress levels rising as
● I have the strength to control my habits something goes wrong at work … you weaken and
● I value the time when I am not smoking take out a cigarette … but after a couple of puffs
Additionally, she is gentle with herself for occa- you stub it out … allow yourself to feel pleased that
sionally breaking her resolve: you could have a slight relapse but not let it inter-
fere with your determination to conquer your
● I can forgive myself for occasionally breaking habit … see yourself continuing to carry out your
my resolution. resolution and succeeding … see yourself as some-
Some people find it helpful to have one strong one who can cope without resorting to cigarettes…
reason for changing their behaviour and to focus When you are ready, bring your visualization to
on this one idea whenever they feel in danger of an end with a count of one … two … three … open
weakening. your eyes … look around you … stretch your arms
and legs … and in your own time prepare to resume
Programmed visualization normal activity.
This takes the form of a mental rehearsal of cop- Some visualization therapists include an aversion
ing activities which may focus on the goal itself component as a further incentive to give up smok-
(the end result) or on the means of achieving it ing. This could take the form of images of dirty
(the process) (Ryman 1995). The example below is ash trays, blackened lungs, stained fingers or
mainly concerned with the process. smoky atmospheres. Aversive measures work for
At the start of the session the instructor can offer some people; other people simply switch off if the
passive relaxation or relaxation through abdominal image becomes too unpleasant.
breathing. The benefits of programmed visualization come
from daily practice: the constant repetition of a
Lie down and spend a few minutes relaxing quietly.
routine in which the individual sees herself as suc-
Imagine yourself at the beginning of a normal day.
cessful in the task she has set herself. The above
Run through every moment when you think you
example is offered as a guideline or starting point
might want to light up. Have an alternative way of
from which the health care professional may wish
dealing with every urge to smoke. Start with the
to develop her own script. Alternatively, partici-
moment when you would have the first cigarette of
pants can be encouraged to compose their own
the day … evoke the scene using sensory detail to
visualizations, since the most effective ones are
bring it to life … really live the moment in your
those designed by individuals for their own use
imagination … feel yourself craving a cigarette, then
(Fanning 1988).
promptly use your alternative strategy … and as you
Where motivation needs strengthening, the fol-
do so, encourage yourself with your positive self-
lowing additional visualization may be found
statements…
useful:
Move on to the next moment when you would
want to light up … and the next and so on … making Find a quiet moment. Relax yourself and close your
each moment come alive by recreating the scene as eyes. Imagine the house in which you expect to be
168 COGNITIVE APPROACHES TO RELAXATION
living 10/5/2 years from now. Go inside … explore health care professionals trained in smoking ces-
it … what does it tell you about the occupant: sation interventions was measured against that of
yourself? … who else lives there? … try identifying an untrained control group. Results showed a
with your older self … notice how it might feel to modest but significant increase in the number of
be that older self … at work … at her hobby … with quitters attending the trained participants com-
her family … then, try looking back at yourself as pared with those attending the untrained controls.
you are now … do you have anything to say to Thus, training is seen to increase the skills of those
yourself?… who provide smoking cessation programmes,
When you are ready, allow your visualization to leading to a higher level of success. The authors
fade … slowly, bring yourself back to the present … consider that further improvement in client out-
counting one … two … three … as you open your come would require changes in health service pol-
eyes… icy which gave greater prominence to prevention.
Some recent work has focused on the experi-
ence of craving and how this can be influenced by
EVIDENCE OF EFFECTIVENESS OF
different kinds of imagery; for example, whether
IMAGERY IN CHANGING SMOKING
standard images evoke urges to smoke of more or
BEHAVIOUR
less intensity than self-created images (Conklin &
Many formal smoking cessation programmes have Tiffany 2001). The answer would help to deter-
been shown to have high success rates which have mine the degree to which craving is dependent on
typically reached levels of 70% or over (Feldmann environmental factors, such as seeing other
& Richard 1986, Schwartz 1987, Wynd 1989). This people smoking. Research has produced conflict-
success has been attributed to different compon- ing outcomes and the issue has not been resolved.
ents of the programmes: education, stress reduc- This is partly owing to the different ways individ-
tion, cognitive-behavioural strategies and relaxation uals react to smoking cues (Niaura et al 1998) and
imagery. the various ways in which these cues can be pre-
The relapse rate, however, also tends to be high. sented (Conklin & Tiffany 2001).
Shiffman (1985) believes that relapse occurs when
individuals lack the coping skills to continue their
abstinence. Such coping skills include: OTHER APPLICATIONS OF
●
GOAL-DIRECTED VISUALIZATION
behavioural strategies:
– removing oneself from a scene in which
Goal-directed visualization can be used in a wide
others are smoking
range of situations and conditions associated with
– using distraction techniques
stress, for example:
– practising relaxation
● cognitive strategies: 1. performance fear
– using pleasant imagery to divert oneself 2. sport and athletics
from the thought of smoking 3. anger
– creating images of improved health. 4. problem solving and decision making
5. eating disorders
Because relaxation imagery has been successfully
6. phobia and panic disorder
used for smoking cessation, Wynd (1992) employed
7. alcohol and substance misuse
it in the prevention of relapse. Her controlled
8. cancer
study of 84 quitters covered a post-cessation period
9. pain.
of 3 months. At the end of that period, 72% of par-
ticipants were still abstaining from smoking. From insights gained during the receptive phase,
The effectiveness of training people to provide a realistic solution can be worked out. This solu-
smoking cessation programmes was investigated tion can then be mentally rehearsed during the
by Silagy et al (1994). They reviewed eight random- programmed visualization, and a successful out-
ized controlled trials in which the performance of come experienced in the imagination.
Goal-directed visualization 169
2. Imagery and visualization methods may not those emotions they feel comfortable with. This is
be suitable for people suffering from severe mental not to disclaim ownership of their feelings, but
disorders. Imagery is particularly inadvisable for rather to allow time for them to be accepted.
people who have difficulty in separating fantasy Mildly disturbing thoughts can be reduced in
from reality and for those who experience hallucin- intensity by blurring the image, letting it recede or
ations. Ackerman (2000) refers to the inadvisability dissolving it in white light. For severely disturb-
of using imagery when taking medication for a ing thoughts, the image should be cancelled and
thought disorder. the visualization terminated.
3. People differ in their ability to form images for In a study that rated the occurrence of different
reasons which have yet to be established (Kosslyn negative reactions, it was found that intrusive
et al 2001). For those who find it difficult, a muscu- thoughts had the highest frequency, followed by
lar approach might be more useful. On the other disturbing sensory experiences and the fear of los-
hand, since visualization is thought by some to be a ing control. The frequency of such effects bore no
learnable skill, practice may increase proficiency relation to the therapist’s experience (Edinger &
(Dalloway 1992). Jacobsen 1982).
4. Goals, which should be set by the individual 6. By contrast, intruding images can be so
herself, need to be attainable. To set goals that are attractive that the visualizer is lured in their
out of the individual’s reach will only create addi- direction, away from the original goal. This is
tional stress. daydreaming; it differs from therapeutic forms
Goals may also be set too low to be construc- of imagery in that it is unstructured and tends to
tive, as occurs in individuals whose self-esteem be remote from reality. (This is not to say that
has crumbled. Exceptionally low self-esteem can daydreaming is without psychological benefit,
make a person feel she does not deserve success since it is essentially a self-affirming strategy
and joy. A first step would be to help her to value (Singer 1975). Some people, however, daydream to
herself. the extent of having difficulty in relating to the
Working towards a goal often entails the need real world.)
to change. The individual, however, may not want 7. A participant may be so depressed that he or
to change, and although she would like to reach she is harbouring thoughts of suicide. Any mention
the goal, she may place obstacles in its path. of taking his or her life must be viewed seriously
5. Since imagery tends to put people in touch and the person urged to seek professional help.
with deeper parts of themselves, strong emotional 8. Occasionally, an individual may experience
reactions such as anger, resentment, guilt and frus- feelings of unreality. These can be dealt with by a
tration may be experienced. Weeping is fairly com- grounding technique such as feeling the floor
mon. If it occurs, the instructor can reassure the underneath her (Ch. 20, p. 184). If, however, the
distressed participant on the following lines: feeling is strong, the image should be allowed to
fade, and the visualization brought to an end.
It’s all right to weep here … it often happens … it
9. It is not the object of the exercise to create a
shows how deeply relaxed you are … and how truly
hypnotic trance. Neither is it likely that one will
in touch with yourself.
occur. However, since some individuals are more
Insofar as the participant is working through pre- susceptible than others, the possibility exists that
viously repressed material, weeping may have the instructor may inadvertently create one. When a
positive value for her. The instructor, on the other person is in a hypnotic trance, the power of sugges-
hand, may find the reaction difficult to handle. tion becomes greater. That being so, the instructor
Such an incident would be a matter for discussion needs to be aware of the phenomenon of post-
with the supervisor (Ch. 2, p. 19). hypnotic suggestion.
Zahourek (1988) likes to warn participants at Post-hypnotic suggestion results in the individ-
the outset that deep-seated emotions may be ual blindly carrying out injunctions outside the
released during imagery. Larkin (1988) suggests to trance situation. For example, a statement such as:
participants that they need acknowledge only ‘When you go home you will assert yourself’
172 COGNITIVE APPROACHES TO RELAXATION
would be indiscriminately applied. This would 10. As part of the visualization procedure, the
leave no room for reassessment of the situation individual constructs new self-statements. One of
which might, in changing circumstances, call for a these may be ill-conceived. The visualizer needs to
modified approach. be alerted to this possibility and to the importance
Any suggestion which could be applied of cutting out any such self-statement.
inappropriately outside the relaxation session 11. Certain colours can have a powerful and
should be avoided. Generally speaking, however, unexpected effect on a person. The antidote for such
post-hypnotic suggestion is not a problem since an experience is to substitute white light for the
the individual tends to resist any exhortation that offending colour, while at the same time attaching a
runs counter to her personal goals and moral prin- message of calmness to the white light. If, however,
ciples (Lynn & Rhue 1977). the effect of the colour is very strong, the visualiza-
Larkin (1988) has useful advice for the health tion should be brought to an end.
care professional who is offering imagery and is 12. Jung felt that too much emphasis on the
concerned to avoid hypnotizing the client: sugges- inner world could take a person away from every-
tion should be indirect, incorporating words like day happenings, and that it was important to
‘can’, ‘may’, ‘might’ and ‘perhaps’. Larkin empha- ground oneself in something solid such as work
sizes the importance of presenting the client with or family.
options, so that the suggestion finally adopted 13. Occasionally, a participant has difficulty
comes from the client herself. returning from his visualization. Repeating the ter-
However, if the instructor is in doubt as to the mination procedure usually resolves the problem.
effect of her words, she can terminate the session Another device is to include in the termination
with a cancelling statement (Shone 1982) on the procedure some reference to feeling alert and
lines of: refreshed.
Before you bring your visualization to an end, can-
When techniques are being learned and applied,
cel any suggestion you do not wish to take effect
one cannot count on instant success. As with any
in your waking life.
new skill, the most that can be expected is a trend
As mentioned earlier, it is unlikely that uninten- in the desired direction. Frequent practice, however,
tional hypnosis will occur. strengthens this trend.
Further reading
Gawain S 1995 Creative visualization: use the power of your Ryman L 1994 Relaxation and visualization. In: Wells R J,
imagination to create what you want in your life. New Tschudin V (eds) Wells’ supportive therapies in health
World Library, California care. Baillière Tindall, London
173
Chapter 19
Autogenic training
self as subject (the ‘I’) and the self as object (the question by pointing out that hypnosis purpose-
‘me’) (Mead 1934). fully aims at producing a trance; hypnosis also
Incomplete understanding of the mechanism of emphasizes therapeutic suggestion. In relaxation,
trance makes it difficult to draw further distinc- by contrast, there is no striving for a state of trance,
tions between trance states of differing depth. and any suggestion made is under the control of
Some writers see altered states of consciousness as the individual herself who, as a human being, is
separate entities, different in kind from each other, constantly making suggestions to herself anyway.
while others view them as lying on a continuum Certainly, some of the devices used in relaxation,
between sleep at one end, and wakefulness at the i.e. passive concentration, self-suggestion and
other. The latter view suggests that the altered imagery, are closely related to hypnosis, but they
states represent varying grades of trance, different are not confined to that practice; and their effective
only in degree and all part of the same entity use does not require the full knowledge of a formal
(Barber 1969, 1970). hypnosis training (Zahourek 1985).
Imagery and autosuggestion form part of most
relaxation approaches (Larkin 1988); indeed,
HISTORY AND INTRODUCTION OF many would say there are elements of suggestion
AUTOGENIC TRAINING in all stress reduction methods (Barber 1984). To
ensure that they are used responsibly, however, it
Autogenic training (AT) is an approach derived is necessary for the health care professional to
from self-hypnosis. It dates from the 1930s, when have clear goals, to use techniques designed to
Johannes Schultz, a psychiatrist working at the promote those goals and to be aware of the
Berlin Neurobiological Institute, discovered that hazards involved.
some patients had learned to put themselves into Davis et al (2000), addressing their book particu-
a light trance by concentrating on images of heavi- larly to those who ‘work with people who are in
ness and warmth. Even more interesting was stress’ (itemizing doctors, nurses, therapists,
the fact that they had seemed to benefit in terms teachers and supervisors), present step-by-step
of their mental health. Schultz called this self- directions for mastery of different approaches, one
generated trance state ‘autogenic’, and proceeded of which is self-hypnosis. They claim that no cases
to develop a therapy based on it. have been reported, even among the most inex-
The goal of the procedure was attainment of perienced practitioners, of harm resulting from
this autogenic state, achieved by means of given self-hypnosis (Davis et al 2000). This is an impor-
phrases recited by the pupil. These phrases, by tant point because, although self-hypnosis is not
their imagery and autosuggestion, created what one of the methods contained in this book, there is
was called the ‘autogenic shift’; a shift in the par- no strict demarcation between self-hypnosis and
ticipant away from a stressed state towards the relaxation. Pitfall number 9 in Chapter 18 (p. 171)
state known as autogenic. Exactly what, however, is relevant to this discussion.
was the autogenic state?
A prominent exponent of the method, Luthe
(1965), has described the autogenic state as being RATIONALE
linked to drowsiness. In this work Luthe considers
the nature of this ‘drowsiness’ and its relation to AT is not underpinned by any theory; rather, it is
hypnosis, but without reaching any conclusion. based on principles of suggestion. It is claimed that
These matters have still to be resolved. Today AT the recited phrases, following many repetitions,
is an established approach, but since the trainee create a light trance which increases the suggestibil-
is active in her own treatment, it is generally ity of the participant and helps to promote a nat-
regarded as a relaxation technique rather than a ural healing process. Possible explanations include
form of hypnosis. the Freudian notion of lowered mental defences
What, however, is the difference between hyp- allowing communication with the interior. The
nosis and relaxation? Zahourek (1985) answers the method also has cognitive and physiological
Autogenic training 175
elements: cognitive ones in its attention-focusing those of warmth can be deepened by images of
phrases, and physiological in the induced sensa- sunshine or warm water (Rosa 1976). The first two
tions of warmth which associate it with the themes are frequently presented on their own (by
parasympathetic branch of the autonomic nervous clinicians and researchers alike), although it is not
system, and a reduction of physiological arousal. known at what cost to the overall relaxation effect
The sensations of warmth are also associated with (Lichstein 1988).
an improved blood flow which brings with it an 4. Mental contact with the body part to which
augmented supply of oxygen. This can benefit a the phrase refers.
variety of conditions including rehabilitation fol-
Central to AT is the principle of client control: the
lowing injury and recovery from surgery as well
trainer describes the method, but it is the trainee
as providing relief from stress and anxiety.
who carries it out. To reinforce this notion, the
In their search for an underlying mechanism,
phrases are styled in the first person. The instruc-
Henry et al (1993) suggest that AT may be
tor reads the relevant phrase using a slow and
re-establishing a balance between the sympathetic
soothing tone and the trainee repeats it mentally or
and parasympathetic systems.
vocally three times. About 30 seconds are assigned
to each phrase and a further 35–40 seconds for con-
DESCRIPTION tinued focusing of attention by the trainee. After
working through the allotted phrases a cancella-
Autogenic training teaches the body and the mind tion procedure is carried out as a safeguard against
to relax. It is based on four requirements. any deep-trance state. The whole routine is then
repeated three times. This marks the end of the
1. Reduced external stimulation, i.e. a quiet
lesson and leads into a discussion and debriefing
environment with dim lighting.
session for which the trainees are seated (see Ch. 2,
2. An attitude of passive concentration,
p. 17).
described in the booklet advertising the autogenic
Schultz & Luthe (1969) worked slowly through
training course as a state of mind which is relaxed,
the schedule, taking 6 months to complete the
non-striving and unconcerned with the end prod-
instruction. The need to save time and money has,
uct. This means not forcing any change, rather, just
however, led to reductions in length, and now the
letting the exercise work (Achterberg 1985); an
full programme is presented in a few weeks.
‘allowing’ rather than a ‘doing’ (Rosa 1976). If, while
The phrases themselves may be interspersed
engaged in passive concentration, distracting
with relevant messages, for example, ‘I feel at
thoughts enter the mind, they can be ignored or
peace’ or ‘I am relaxed’, as in the following ver-
gently dismissed. Thoughts which carry insightful
sion which is adapted from the works of Kermani
images, however, can be seen as a valuable product
(1990) and Lichstein (1988).
of the exercise. Passive concentration may be said to
exist in other approaches such as meditation and
some forms of progressive relaxation. PROCEDURE
3. The repetition of relaxation-inducing phrases
based on six main themes: INTRODUCTORY TALK TO TRAINEES
a. heaviness in the arms and legs
A short description prepares the trainees who
b. warmth in the arms and legs
should be seated:
c. calm and regular heartbeat
d. calm breathing Autogenic training has been shown to help people
e. warm solar plexus overcome feelings of anxiety. It creates a state of
f. cool forehead. extreme calmness which helps people to be in
These phrases are repeated to emphasize their touch with deeper parts of their mind. The mind
effect and to draw the client’s attention away from becomes more receptive than normally. Individuals
the external environment. Suggestions of heavi- can suggest changes to themselves which they feel
ness can be intensified by images of lead, while may enhance their lives.
176 COGNITIVE APPROACHES TO RELAXATION
● Smoking is an unhealthy habit (for people who supportive group therapy with which it was com-
wish to quit smoking). pared (Henry et al 1993).
● My mind is quiet and serene (for anxious Kanji (2000) studied the effectiveness of AT as a
individuals). pain-reliever in conditions such as headaches,
migraines, childbirth, back pain, heart pain and
Certain physiological problems can be addressed
cancer pain, and found the approach to be useful.
through ‘organ-specific formulae’ such as:
This researcher proposed that AT be introduced
● My throat is cool (for a troublesome cough). into the treatment of a wide range of pain-allied
● My feet are warm (for a tendency to blush). disorders where it could help to reduce the need
The trainee will incorporate particular phrases for analgesic drugs.
according to her personal requirements. AT In the field of anxiety disorders AT has been
should not, however, be viewed as a substitute for compared with progressive relaxation and found
medical attention. to be significantly superior in terms of EMG
decreases and effects on symptoms (Takaishi
2000). A further finding from this study indicated
OTHER AT EXERCISES that the patients judged AT easier to carry out
AT also includes meditative exercises which than progressive relaxation. This suggests that an
involve colours, objects, concepts and personalities. approach which involves passive listening, i.e. AT,
Other exercises known as ‘advanced’ belong to may be a more effective route to relaxation than
an area described as therapy rather than training, one which demands active concentration, i.e.
and are beyond the scope of this book. progressive relaxation, for people experiencing
anxiety-related disorders.
Not all results, however, are positive and many
EVIDENCE OF EFFECTIVENESS are equivocal. Weighing the evidence comparing
the effectiveness of AT with that of other approaches,
Kanji & Ernst (2000) have reviewed the evidence Stetter & Kupper (2002) find AT to be about equal.
and in their findings they suggest that AT does This accords with Lichstein’s view that AT phrases
reduce stress and anxiety. Medium to large clin- seem to carry no more power as relaxants than
ical effects have been found after treatment with phrases employed in other relaxation approaches
AT and these tend to be stable at follow-up and to (Lichstein 1988).
exceed placebo effects (Stetter & Kupper 2002). Results should be viewed with caution since
The meta-analysis of Stetter & Kupper shows that the methodological quality of the individual stud-
benefit has been found in psychological disorders ies varies widely (Stetter & Kupper 2002). Despite
such as anxiety, mild to medium depression and such drawbacks, however, it can be said that AT is
functional sleep disorders. Positive effects have an effective relaxation technique in most condi-
also been observed in psychosomatic disorders tions associated with stress, either as a preventive
such as tension headache, migraine, essential measure or as an adjunct to conventional treat-
hypertension, coronary heart disease, asthma, ment (Broms 1999).
Raynaud’s disease and certain kinds of pain. AT also has the advantage of being available to
In the case of tension headache, Spinhoven et al individuals experiencing conditions where move-
(1992) demonstrated a significant reduction in its ment is painful, such as arthritis, and conditions
incidence among people receiving AT and self- where movement is not possible, such as paralysis.
hypnosis, compared with people on a waiting list.
This result could not have been due to any greater
effectiveness of self-hypnosis, since the same PITFALLS OF AUTOGENIC TRAINING
researchers also compared AT with self-hypnosis
and found them to be of equal efficacy. In the case 1. The phrase inducing abdominal warmth should
of asthma sufferers, significantly greater bene- be deleted for people suffering from abdominal
fit was found in a group practising AT than in inflammation (Rosa 1976).
Autogenic training 179
2. AT is not suitable for children under 5 years of can be reversed, i.e. the limbs can be made to feel
age nor for people lacking motivation. light and cool; alternatively, the procedure can be
3. Trainees should be advised to keep their per- stopped.
sonal formulae realistic. Creating unattainable
goals will only lead to disappointment. The pitfalls of visualization (Ch. 18) are also rele-
4. In the unlikely event of the phrases causing vant (p. 170); points 1, 2 and 9 particularly, should
distress, the messages of heaviness and warmth be noted.
Further reading
Bird J, Pinch C 2002 Autogenic therapy: self-help for mind Lichstein K L 1988 Clinical relaxation strategies. John Wiley,
and body. Newleaf, Ireland New York
Kermani K S 1996 Autogenic training. Souvenir Press, Rosa K R 1976 Autogenic training. Victor Gollancz, London
London
181
Chapter 20
Meditation
INTRODUCTION
CHAPTER CONTENTS
Introduction 181 The word ‘meditation’ is used to describe varied
states of inner stillness. It is also used to describe dif-
Rationale 182 ferent methods of attaining those states. Again, the
Benefits of meditation 182 many schools of meditation all have their own inter-
A procedure for meditation 183 pretation. Thus, with no universally agreed mean-
Introductory remarks to the novice ing, attempts to define the word founder. Common
meditator 183 to all interpretations, however, is the concept of
A meditation session 183 emptying the mind of thought, that is, letting go the
preoccupations that make up the mind’s chatter.
Focal points for meditation 184 If there is a general aim in meditation, it might
The breath 184 be described as non-attachment, although some
Visual object 185 writers such as Fontana (1991) feel that to have an
Parts of the body 187 aim at all tends to destroy the result since any
Mantras 188 kind of goal-setting calls on rational powers and
Evidence of effectiveness 189 left-brain activity (Ch. 17, p. 150).
Meditation could perhaps, therefore, be seen as
Pitfalls of meditation 189 an opening of the self to reveal its inner world,
while at the same time conveying no hint of deter-
mination since that would be alien to the medita-
tive state.
People come to meditation for many reasons:
● to find peace
● to achieve awareness
● to gain enlightenment
● to find themselves
● to empty the mind
● to experience true reality.
Originating in the East, meditation is an inte- thinking process does not imply that meditators
gral part of the Hindu, Taoist and Buddhist reli- consider left-brain activity to be of lesser value:
gions. In the West versions have been created analytical thinking is an essential human function.
which are simpler, and these have, for the most But its tendency generally to dominate mental
part, evolved from Zen and Yoga. The material activity has the effect of devaluing its counterpart,
presented here is of a non-religious form and the imagination. Meditation enables the individ-
comes from a variety of modern sources, notably ual to redress the balance.
the work of Fontana (1991, 1992).
It has been pointed out that meditation is both
a state and a method. As a state, it is one in which RATIONALE
the mind is stilled and listening to itself. The med-
itator is relaxed but at the same time alert. It is claimed that meditation helps to quieten the
As a method, it consists of focusing attention on mind and reduce the effect of stressful thoughts. It
a chosen stimulus. This concentration is sustained can thus contribute to a state of relaxation.
but effortless and has the effect of detaching the A number of theories have been put forward to
meditator from external life events on the one hand account for the effect of meditation on the individ-
and from her own mental activity on the other. ual. Of these, Banquet’s (1973) shift in hemispheric
Thoughts may enter her head, but instead of exam- dominance is widely accepted. His research sug-
ining their content, she allows them to drift away. gests that during meditation the left cerebral
This attitude has been described as one of passive hemisphere loses its dominance, resulting in a
concentration, and it implies that the meditator has more influential right hemisphere than occurs in
a relaxed attitude while, at the same time, giving everyday life. As a result, linear, verbal thinking
attention of the kind that is without criticism or plays a less prominent part, allowing intuitive,
judgement. Mental functions, such as thinking wordless thinking to express itself. By this means
and evaluating, are inappropriate since they are the individual may come to know and understand
processed by the left brain; rather, the meditator herself better and acquire a new peace of mind.
should cultivate what in Zen is called a ‘don’t know
mind’, that is, a mind which is open and receptive BENEFITS OF MEDITATION
to new, undreamed-of possibilities. Past and
Devotees of meditation claim that they benefit
future associations are shed. The mind is emptied
greatly from its practice. These are some of the
of all thought save awareness of the stimulus.
advantages:
In common with hypnosis and daydreaming,
meditation is an altered state of consciousness. ● A better understanding of the self is achieved
Fontana (1991) distinguishes it from other altered through meditation. That is, through medita-
states, seeing it rather as a rediscovery of normal tion the individual becomes more aware of
consciousness since it takes the individual to the herself and more receptive to the insights that
core of the self. arise from her deeper being.
The meditator does not fall into a trance, ● A new sense of relaxation and inner peace can
become drowsy or surrender control; on the con- be derived from meditation.
trary, she is in a state of heightened awareness, ● The process itself promotes a clearer mind and
alert, aware of her surroundings and securely improved powers of concentration. These
focused on the present moment. extend outside the meditation session.
Passive concentration, referred to above, is also ● The individual, by discovering her inner self, is
a feature of autogenic training and receptive visu- able to live more in harmony with herself.
alization, although not of programmed visualiza- ● By developing a sense of detachment, the indi-
tion which, as it is involved with the achievement vidual comes to accept that many of her
of goals, is essentially a left brain thinking activity unpleasant emotional reactions are no more
and therefore remote from meditation. However, than short-lived bodily sensations created by
to say that meditation excludes the analytical her thoughts.
Meditation 183
● The emphasis on self-awareness helps the indi- should be held in a relaxed position directly above
vidual to live in the present and to value the the spinal column to release the neck muscles from
here-and-now. When the mind is concentrated strain while the eyes may be closed or slightly open.
in the moment, it becomes keenly alert.
Winding-down procedure
A PROCEDURE FOR MEDITATION Participants are asked to direct their thoughts
inwards.
INTRODUCTORY REMARKS TO THE The meditation session is preceded by a check
NOVICE MEDITATOR for muscle tension, i.e. each participant checks all
her muscle groups to make sure they are as
A few words describing the procedure are relaxed as possible. It is often referred to as scan-
required before starting the first session. ning and may be introduced in the following way:
Meditation is an ancient method of quietening the I am going to ask you to check that your muscles
mind. The method you are about to experience is a are as relaxed as possible. Starting with your feet,
non-religious form. It is concerned with focusing the notice any tension … then move up to your ankles,
attention on different phenomena such as the breath, shifting them slightly if they are not relaxed … now
a visual object or a repeated phrase. The effect of the your legs … and your hips … settle them into the
meditation will be to make you feel very peaceful. At chair or the floor. Continue up through your body to
no time will you lose consciousness or be controlled your shoulders, letting them drop down. Allow your
by any outside force. The state you reach will be arms to fall comfortably, with your fingers free of
entirely created by you. It is best to come to medita- tension. And now your head: relax your jaw and let
tion without expectations; rather, to have an attitude your tongue rest in your mouth … Iet all the
which makes you content to be in tune with yourself. muscles in your face feel smoothed out. Allow your-
self to unwind, and as you unwind, feel in tune with
yourself … listening to yourself … just being
A MEDITATION SESSION
you … experiencing what it is to be you … being
A session may be seen to have four components: aware how it feels, without delving into reasons,
explanations or even words…
1. attention to position
2. a winding-down procedure Irritating sounds or bodily discomfort may inter-
3. concentration on a chosen stimulus rupt the meditation. Davis et al (2000) suggest
4. return to everyday activity. ‘softening’ them by purposely giving them atten-
tion for a few moments instead of pretending that
Attention to position they do not exist.
In an environment that is quiet and warm, the
Concentrating on a chosen stimulus
meditator takes up a sitting or a lying position.
Sitting is preferred since some people tend to fall ‘All meditations are built upon … concentration and
asleep when lying down. The individual may sit tranquillity’ (Fontana 1992). The individual quietly
in a straight-backed chair, sit cross-legged on a focuses attention on the chosen stimulus which may
cushion on the floor, or take up the lotus position take the form of breath watching, gazing at a visual
(cross-legged with each foot resting on the oppo- object or chanting a mantra. The purpose of the
site thigh). This position can be very uncomfort- stimulus is to hold the attention of the participant.
able for people who are not used to it; even in the This may be difficult at first since the mind is
East it has never been obligatory if the novice used to being engaged in a constant stream of
found it unbearable. images, memories and associations, all competing
Whichever sitting position is chosen, the hands with one another. It will not help the individual to
rest on the thighs, with the fingers gently curled or fight these distractions, but if she can accept their
arranged in traditional symbolic postures. The head presence and continue her concentration on the
184 COGNITIVE APPROACHES TO RELAXATION
Figure 20.1 A mandala. Reproduced from The Stream of Consciousness by Pope & Singer (1978) with permission from
Plenum Publications.
Both enclose symbolic motifs arranged in con- the following meditation on a candle burning in a
centric rings around a clearly defined central point. darkened room:
This point symbolizes the inner self on the one
Let the lighted candle hold your attention … settle
hand and divine consciousness on the other, while
your eyes on the upper part of the wax column
the enclosing circles represent the cycle of life
rather than the flame itself … sit without moving
and the notion of Nature forever renewing herself.
while you gaze at it … focus on it in a relaxed but
Thus the mandala/yantra stands for the personal
constant way, letting the image fill your mind …
as well as the transpersonal, for change within per-
continue for at least a minute … Now close your
manence, for life both in the present and in eternity,
eyes. Notice that the image of the candle prints
while affirming the fundamental unity of all things.
itself in the darkness … hold the shape in your
mind’s eye, accepting any change of colour … if it
The candle slips to one side, gently bring it back … continue to
focus on it until it fades … then open your eyes and
As mentioned above, the visual image can be used
resume your gaze on the candle … continue, repeat-
in different ways to clear the mind of thought. For
ing the sequence in silence for several minutes.
instance, while the individual is gazing at the
object, she can intermittently close her eyes and The image that appears behind the closed eyes is
allow the image to recreate itself in her mind, as in known as the ‘after-image’ (see Box 20.1).
Meditation 187
Figure 20.2 A yantra. Reproduced from The Elements of Meditation by Fontana (1991) with permission from
Element Books.
base of the spine, the lower abdomen, the navel, The big toe
the heart, the throat, the space between the eye-
brows and the crown of the head. After meditating With your eyes closed, your legs uncrossed and your
on the sites in this order, the physical energies are muscles relaxed, draw your attention to your right
said to be transformed into spiritual energies. big toe. See it in your mind’s eye … move it gently to
Yoga is a separate subject, and no attempt is make its presence felt … notice how it feels when
made here to present it. However, the symbolic you move it … focus on the sensations you get from
nature of the chakras makes them suitable sites bending and stretching it … be aware of the feel
for meditations outside yoga. Two examples are of the sock or stocking over it, or of the shoe
given here: the space between the eyebrows and restricting it … think of it carrying the full weight
the crown of the head. of the body … think of its strength as well as its
mobility … if unwanted thoughts intrude, gently
bring your attention back to the toe … focusing
The space between the eyebrows on the toe…
Behind closed lids, let your eyes turn upwards and
settle on the space between your eyebrows … relate
MANTRAS
to it … recognize its closeness to your brain … feel
its central position … imagine viewing it from the A mantra is a verbal stimulus which can be used to
outside … then, imagine viewing it from the concentrate the attention. Traditionally it embod-
inside … continue to focus on that one spot … feel ies an ancient, sacred truth whose meaning may
drawn to it … and consider that, as the space reveal itself to the meditator during the process of
between your eyebrows is part of you, so you are concentration. A well-known example is the
part of that space. Sanskrit word ‘om’ which is said to represent the
primal sound. Pronounced like ‘home’ without
(Pause)
the ‘h’ (Smith & Wilks 1988), the sound can be
If outside thoughts drift into your mind, mentally intensified by stretching the syllable to form a …
blow them away and return to your point of oo … mmmm (Fontana 1991). It is the sound of the
focus … to the space between your eyebrows. mantra that has particular value for the novice
meditator, although its meaning may also be con-
templated at a later stage. The following piece is
The crown of the head adapted from a passage in Fontana (1991):
With your eyes closed, focus your attention on the
crown of your head, concentrating on it in a passive Breathe in gently and as you let the air out, recite
way … let your inner eye be drawn to it and held the word om: a … oo … mmmm. Feel the sounds
there … see it from the outside, noticing how it vibrating within your body: feel the ‘a’ ringing in your
appears … then imagine it from the inside, from belly, feel the ‘oo’ resonating in your chest and the
under the dome of your head… ‘mmmm’ resounding in the bones of your skull … let
these sounds provide a focus for your attention … link
(Pause) them into your natural breathing rhythm … keep the
Symbolically as well as literally, it represents the breathing calm and slow and avoid any inclination to
highest part of you … if thoughts intrude, let them deepen it … after 10 breaths, gradually reduce the
be carried away … Iet them drift away from you as volume of the sound until the word is spoken under
you gently return your attention to the crown of your breath … lower it further … keep your attention
your head … feel yourself identifying with it … expe- focused on the mantra … eventually, you will come
riencing it … feel yourself uniting with all that is to a point where your lips cease to move and the
highest within you. syllables lose their form so that you are left with
just an idea … feel it clinging to your mind … united
On a simpler level, any part of the body can with it … if thoughts intrude, turn them into puffs
serve as the stimulus, for example, the big toe. of smoke and let them be blown away.
Meditation 189
Many other sounds or words can act as mantras, cerebral cortex. This supports the view that mental
e.g. ‘peace’, ‘harmony’, ‘calmness’, or phrases activity is reduced (Fenwick 1987). Certainly, medi-
such as ‘God is love’ and ‘here-and-now’. It does tation has been found effective in reducing tension,
not matter if the word has a meaning, since con- and as Lichstein (1988) points out, can often lead to
stantly reciting it will tend to divest it of that deep states of physiological and phenomenological
meaning, although the word may still retain its relaxation. However, it is unclear how much more
aura. It is advisable, however, to choose a word effective it is than any other relaxation practice.
that has no emotional associations for the user, Research findings are inconsistent; some point to
and one that is unlikely to stir up her thoughts. the superior benefit of meditation, while others,
While the main purpose of the mantra is to hold such as that of Holmes et al (1983), are unable to
the meditator’s attention, its rhythmic repetition show that meditation is any more effective at low-
also has a soothing effect. ering physiological arousal than ordinary rest.
On the other hand, a mantra may be picked There is no Cochrane review on meditation at
expressly for its meaning. In this kind of medita- the present time (Cantor 2003). Existing research
tion the mantra is not reflected on philosophically revolves mainly around TM which has been stud-
so much as experienced. It is identified with, ied extensively and in a variety of populations,
rather than analysed. often comparing the approach with progressive
Lichstein (1988) compares mantra chanting relaxation (Cantor 2003). A series of trials has been
with dwelling on the muscles in progressive relax- conducted in the area of hypertension showing
ation (Ch. 4) and to the silent recitation of phrases positive effects from TM. One of these, a study of
in autogenic training (Ch. 19) and points out that older African Americans, compared TM with pro-
in addition to their inherent relaxation properties, gressive relaxation and a control group who were
they all share the capacity to divert the attention given education. Reductions of both systolic and
from stressful thoughts. diastolic blood pressures in the meditation group
were found to be significantly greater than those
Transcendental meditation in the progressive relaxation group (Schneider
An approach which sets great store by the mantra et al 1995). Similarly, Barnes et al (2001) demon-
is transcendental meditation (TM). Its central fea- strated significant decreases in systolic blood
ture is the contemplation and repetition of a pressure following a 2-month daily course of TM
Sanskrit mantra bestowed by Maharishi Mahesh in a randomized controlled trial of 35 American
Yogi who brought the movement to the West in adolescents. These results are in line with those of
1959. As well as gathering many disciples, TM a review conducted earlier, which suggested that
attracted a great deal of research: from several several cardiovascular risk factors could be
hundred studies it emerged that TM created sig- reduced by TM (Sharma & Alexander 1996).
nificant physiological changes associated with Although many of the trials investigating the
relaxation. However, lack of controls and the use therapeutic effectiveness of meditation have
of self-selected (volunteer) participants weakened produced positive results, a high proportion of
the validity of some of these findings. them are flawed. In the absence of more rigorous
Proponents of TM insist on the mantra being testing, Cantor (2003) does not, therefore, find
chosen with ceremony and in secrecy by a master the evidence in favour of meditation to be strong.
teacher, although this practice has not been shown The proposition that meditation produces
to be any more effective than one which uses a unique state of consciousness has been put
simple words (Benson 1976). forward, but there is no evidence to support it.
Electroencephalographic changes during medita- These can be found at the end of the following
tion suggest a state of decreased arousal in the chapter.
190 COGNITIVE APPROACHES TO RELAXATION
Further reading
Fontana D 1991 The elements of meditation. Element, Ozaniec N 2003 Teach yourself meditation. Hodder
Shaftesbury Educational, London
Fontana D 1992 The meditator’s handbook: a comprehensive Sivananda Yoga Vedanta Centre 2003 The Sivananda
guide to eastern and western meditation techniques. companion to meditation. Gaia Books, London
Element, Shaftesbury
191
Chapter 21
Benson’s method
had already applied to join a transcendental medi- individual herself. He refuted the idea that the
tation course to reduce their blood pressure. This mantra’s meaning added to its effect.
would suggest that their motivation was high. Passive attitude. Passive acceptance is an
Extensive study of other meditation practices essential feature of the approach. A ‘let it happen’
led Benson to the belief that the above effects were attitude should be adopted. Benson regards the
not confined to the practice of TM, but were the passive attitude as ‘perhaps the most important
result of certain key elements common to all medi- element in eliciting the relaxation response’. Dis-
tation practices. He set out to identify these elem- tracting thoughts may intervene but they should
ents, seeing them as responsible for eliciting what be ignored and the meditator’s attention returned
he called ‘the relaxation response’, or a state of to the recited mantra.
decreased psychophysiological arousal. To Benson
(1976), this was ‘a natural and innate protective
RATIONALE
mechanism’ that opposed the effects of the stress
response. Viewed in these terms, the relaxation
By focusing the attention on a particular object,
response appeared synonymous with parasympa-
word or concept in a sustained and effortless way,
thetic nervous activity.
meditators are able to detach themselves from
The key elements that Benson (1976) identified
daily events and induce a mental stillness. This
were:
stillness is reflected in reduced physiological
● a quiet environment responses, that is, diminished activity in the sym-
● a comfortable position pathetic nervous system (Benson 1976). Both cog-
● a mental device such as a word to focus on nitive and physical elements are present: the first
● a passive attitude. relating to the focusing of attention on the mantra,
and the second to the role of the breath. The theory
THE KEY ELEMENTS underpinning the method is a unitary one in that
the meditation creates a general, integrated calm-
Quiet environment. In the ideal setting there is an
ing effect. Although the participant is engaged in
absence of any background stimulus, pleasant or
the cognitive activity of focusing on the mantra,
unpleasant.
the effect on the system is global. This led Benson
Comfortable position. Benson does not insist on
to coin the phrase ‘relaxation response’.
any particular position since he feels that discom-
fort might draw the attention away from the men-
tal device. The meditator should be allowed to PROCEDURE
choose her own position. She can, however, be too
comfortable and tend to fall asleep; the orthodox INTRODUCTORY REMARKS TO
lotus position (Ch. 20, p. 183) is thought to have PARTICIPANTS
been introduced partly to prevent that happening.
A few words explaining the method are addressed
For the same reason Benson does not recommend
to novices who should be seated.
a lying position.
Mental device. Since his studies had shown The relaxation method you are about to learn is a
that TM was not unique in its ability to lower non-religious version of meditation. It has a very
physiological arousal, Benson concluded that any simple form, requiring that you sit comfortably in a
repetitive, monotonous stimulus capable of hold- quiet place; that you focus your attention on the
ing the attention, could fulfil the function of the word ‘one’ and that you adopt an attitude which is
Sanskrit mantra, i.e. that any emotionally neutral accepting and unconcerned.
object, sound or other phenomenon could be These conditions will help you to experience
used as a focal point of attention. Benson chose what is called the relaxation response; a state
the word ‘one’, which has similar qualities of which research shows is associated with reduced
resonance to the primal sound ‘om’, but he felt physiological activity. That means the heart rate
the choice of word or words was best made by the will become slower and the blood pressure will fall.
Benson’s method 193
You’ll notice that you feel calmer than usual and Apart from that, his method is very similar to
the whole sensation will be a pleasant one. transcendental meditation except that the word
At no time will you lose consciousness or be ‘one’ replaces the Sanskrit mantra and the process
controlled by an outside force. The state you is entirely secularized (Lichstein 1988).
reach is one which you will have induced in The emphasis placed on ‘passive attitude’
yourself. recalls the ‘passive concentration’ of autogenic
training (Ch. 19). It is also not far removed from the
quiet observation that characterizes progressive
INDUCTION relaxation (Ch. 4). It would seem that, underneath
When participants are ready, the induction their varying procedures, the approaches are saying
sequence itself is carried out. The following version much the same thing (Lichstein 1988), and that in
is adapted from Benson (1976). The ‘10 minutes’ their psychophysiological effects, they are all
indicated can be extended to 20 as the meditator evoking the relaxation response.
becomes more experienced. In common with the authors of other methods,
Benson stressed the importance of regular practice,
Settle comfortably in whatever position you have to be carried out once or twice a day. When practis-
chosen, and close your eyes. Relax all your muscles, ing at home, people are urged not to use an
starting with your feet and ending with your face. alarm, but to guess when it is time to end the
Feel yourself deeply relaxed. meditation.
Notice the rhythm of your breathing. Let the air
in through your nose, allowing the breaths to take
place quite naturally. Each time you exhale, recite EVIDENCE OF EFFECTIVENESS
the word ‘one’ under your breath. Repeat the word
slowly every time you breathe out. If thoughts Since 1974 Benson and colleagues have carried out
intrude, try to ignore them, and continue repeating a series of experiments to test the effectiveness of
the word ‘one’. his method, but it has not so far been possible to
Avoid any inclination to judge how successful replicate the marked physiological effects produced
you are being. Keep your attitude passive, and allow in the early studies (Eisenberg et al 1991). However,
relaxation to occur in its own time. Please continue compared to transcendental meditation, little
for 10 minutes… research has been carried out on Benson’s method.
When you are ready to end your meditation, What results are available are inconsistent.
continue to sit quietly for a few minutes with your Kerr (2000) has critically reviewed the literature
eyes closed, then for a few minutes longer with and finds that reductions in both psychological
them open. and physiological responses to stress have been
shown following a course of relaxation response
meditation, although greater consistency has been
FEATURES OF BENSON’S METHOD found in the psychological responses. These
responses are marked enough to give meditation
As shown above, the induction is short and a role to play, particularly in the field of coronary
simple. Benson writes that his method carries heart disease and hypertension, where the approach
little embellishment. Perhaps he made it too increasingly features in both prevention and treat-
simple; in excluding all but the essentials, he may ment (King et al 2002). Among other psycho-
have overlooked the value of ceremony and ritual, somatic conditions where benefit has been
which are important factors for some individuals demonstrated is irritable bowel syndrome. Keefer &
(Carrington 1984, Lichstein 1988). Blanchard (2000) found Benson’s method
In identifying what he considered to be key fac- moderately effective in a group of 21 men and
tors, Benson’s purpose was not to create a rival women with the disorder.
approach, but to devise a standardized technique Lichstein (1988) is persuaded that, in his con-
which could be used in scientific investigation. cept of key elements, Benson did in fact discover
194 COGNITIVE APPROACHES TO RELAXATION
a truth, but one whose mechanism is far from rate or rhythm. However, the mere request to
being understood. become aware of the breathing can result in a slight
alteration of its rhythm. It is therefore suggested
that, before attempting breathing meditations,
PITFALLS OF MEDITATION the reader become familiar with the section on
hyperventilation in Chapter 15 (p. 134).
1. Meditation is not suitable for people in acute 6. Benson (1976) believed that it was better to
psychotic states. Nor is it advised in seriously dis- practise meditation before a meal than directly after
turbed individuals as it might trigger psychotic it. He considered that the process of digestion, by
episodes. Such people may, however, benefit from drawing the blood to the viscera, interfered with the
other efforts to relax them as they tend to experience physiological changes associated with meditation,
high levels of stress (Faulkner & Biddle 1999, Cantor and advised waiting for at least 2 hours after eating.
2003). People suffering from milder forms of mental More recent research, investigating the distribution
illness, who wish to practise meditation, should first of blood during meditation, supports Benson’s
discuss it with their doctor or psychologist. view: Bricklin (1990) found that the blood flow to
2. Meditation should not be used as a substitute the brain during meditation increased dramatically,
for medical treatment. Individuals who may be rising on average by 65% of its normal volume. It
already receiving medication should inform their would not, therefore, be constructive to practise
doctor of their wish to study meditation since the meditation at a time when other demands were
effects of one may influence the other (McCormack being made on the vascular system.
1992). 7. The lotus position has been referred to as the
3. Although the central idea of meditation is to posture traditionally adopted in the East. This pos-
keep the mind focused and aware, it does occasion- ture, however, was never obligatory even in its
ally happen that an individual loses the sense of country of origin. In the West it may be inadvisable
who and where she is, or develops the feeling of for novices even to attempt it because of the exces-
being ‘outside her body’. These are trance-like states sive stretching of the joint structures which accom-
of disorientation and depersonalization. In this panies it. Sitting cross-legged on a cushion is no less
event, a grounding strategy similar to the one conducive to meditation, and many people practise
referred to in Chapter 20 (p. 184) may provide a meditation sitting in a chair.
remedy. Altered states associated with a sound 8. Some meditation may be disturbing if the
stimulus, e.g. a mantra, are more likely to lead to stimulus object has unpleasant associations. A
trance than those associated with other stimuli such change of stimulus is therefore indicated.
as breathing. The instructor can safeguard against 9. The outcome should not be judged in terms
disorientation and depersonalization by regularly of success or usefulness because these are rational
reminding participants to keep their attention dimensions. Progress is seen in terms of self-
focused on the stimulus (Fontana 1991). discovery rather than achievement (Fontana 1991).
4. Meditation creates an altered state of con- 10. Those who expect meditation to be a ready
sciousness. The novice will not know in advance remedy for life’s problems may become disillu-
how she will respond. It is therefore recommended sioned. Meditation should be seen as a way of life,
that, to begin with, sessions be kept short, that is, 5 not as a panacea.
minutes in length. This can be increased to 15 or 20 11. It is possible for an individual to experience
minutes for those with experience but not exceeded, euphoric states in which she believes she has made
as it is possible to meditate too much and run the a profound spiritual discovery. Fontana (1992)
risk of getting out of touch with day-to-day life. advises a cautious approach to the interpretation of
Benson (1976) reports that none of the participants material from the inner self.
in his studies displayed ill effects after meditating 12. For those who have undergone psycho-
for 20 minutes twice a day. analysis, the idea of ignoring their flow of thoughts
5. The breathing meditations in Chapter 20 do may not come easily. Benson (1976) reminds us
not seek to interfere with the natural breathing that psychoanalysis trains people to regard their
Benson’s method 195
thoughts as a vital link with the inner self. People Guidance should be sought from an experienced
who have experienced this form of therapy may teacher by those wishing to pursue more advanced
have some initial difficulty in learning meditation. forms of meditation since they are beyond the
13. Because of individual variation, there will scope of this book.
always be some people who gain very little from
meditation.
Further reading
Benson H 1976 The relaxation response. Collins, London
197
Chapter 22
INTRODUCTION
CHAPTER CONTENTS
Introduction 197 Cognitive behaviour therapy (CBT) is an approach
which uses a variety of modes of treatment. It
Description and rationale 197 seeks to address the client’s difficulties from the
Evidence of effectiveness 198 client’s point of view and to equip her with the
information and confidence to become an active
participant in the management of her condition
(Marshall & Turnbull 1996). It thus lends itself to
conditions such as anxiety, depression, psychotic
disorders, eating disorders, chronic fatigue syn-
drome and chronic pain and is relevant in many
other illnesses and dysfunctions.
available to the individual who can challenge will help to draw out the client’s fears and heighten
them directly and if necessary, modify them (Roth the effectiveness of the partnership.
& Fonagy 1996, Donaghy 2003). Cognitive therapy CBT covers a range of therapeutic interventions
addresses problems in the context of the here-and- and so, may be viewed as an approach rather than
now, unlike psychodynamic therapies where life a treatment. Depending on the nature of the prob-
is seen as predetermined by past events which can lem and the relevance of the technique, it may
only be accessed through some kind of analysis. provide any of the following:
Cognitive theory views the individual as a self-
determining agent in her own life, which means ● education, i.e. advice on diet and exercise as
that, when receiving treatment, she needs to feel a well as information about the disorder and its
degree of control in the management of her condi- treatment
tion. This aspect makes the approach particularly ● cognitive restructuring, i.e. identifying and
applicable in the field of chronic disorder. challenging maladaptive thought patterns and
Behaviour theory, on the other hand, views making negative self-talk more positive
human behaviour as a result of environmental ● goal-setting and pacing of activities
conditioning, and when this behaviour is mal- ● motivational techniques such as diary-keeping
adaptive, employs methods such as reinforcement, ● reinforcing certain behaviours and discourag-
distraction and exposure to modify it. Positive ing others
reinforcement is a method for increasing the like- ● skills training to include social skills such as
lihood of a desired behaviour; negative reinforce- assertiveness
ment, of extinguishing it. Distraction, i.e. holding ● problem-solving and other coping techniques
the attention elsewhere, can be a useful strategy ● relaxation training and imagery
particularly for people in chronic pain. Exposure, ● rehearsal of feared events and feedback
i.e. facing the anxiety-provoking situation itself, ● graded exposure to feared events
can be a useful tool for helping people who expe- ● fitness training such as exercise or other phys-
rience panic attacks or various forms of social ical activity
anxiety. ● strategies for maintenance of improvement
The cognitive behavioural approach combines and protection against relapse.
both theories. It sees thought processes as learned
and maintained through reinforcement (Donaghy An example of the way in which selected items
2003); and by addressing the interrelationship could form a treatment programme may be found
of thoughts, feelings and behaviour, it creates a in an article on pain relief (Harding & Watson
unifying philosophy with a strong psychosocial 2000). The items selected were: education, goal-
emphasis (Marshall & Turnbull 1996). In the ther- setting and pacing, fitness, relaxation, reducing
apy arising out of it, there is an attempt to foster pain behaviour, sleep management and relapse
more adaptive thoughts and emotions which, in self-management.
turn, will influence the individual’s behaviour to
become more rewarding to that individual and so,
help to promote a feeling of well-being. EVIDENCE OF EFFECTIVENESS
A contract is drawn up between client and ther-
apist at the outset whereby a limit is set on the CBT is now the most widely endorsed form of
duration of treatment and this is respected by both psychological therapy (Rachman 2003) and has
parties. Throughout therapy the relationship wide application in both physical and mental
between therapist and client is one of collabora- health. Duncan (2003) points out that although
tion with the client closely involved in drawing up cognitive behavioural approaches have featured
the treatment programme and in the decision- in both occupational and physiotherapy treatment
making process. Thus the client is empowered to programmes, relatively few studies so far have
play a major role. Qualities of warmth, empathy been carried out. The research base is, however,
and genuineness in the therapist (Rogers 1961) growing. Donaghy & Durward (2000) report that
Cognitive behavioural approaches 199
systematic reviews have found these approaches with musculoskeletal injuries were prevented
to be an effective treatment for mild-to-moderate from talking about their pain.
depression. CBT has been compared with other approaches:
Other areas where the effectiveness of CBT has Hassenbring et al (1999) found CBT more effective
been investigated include social anxiety (Heimberg than electromyographic feedback in reducing pain
2002), chronic fatigue syndrome (Prins et al 2001), and disability. Donaghy & Durward (2000) in their
psychotic disturbance (Chartered Society of report found CBT more effective than psycho-
Physiotherapy 1999), low back pain (Johnstone et al analysis or counselling in generalized anxiety dis-
2002) and chronic pain management (Harding & order; and Gould et al (1995) found that CBT with
Watson 2000). Pain is an area which has attracted exposure provided more benefit than drugs treat-
considerable interest: Sinclair et al (1998) demon- ment in panic disorder. Öst & Breitholtz (2000),
strated a significant improvement in terms of on the other hand, comparing CBT with applied
psychological well-being and personal coping relaxation in a study of 36 outpatients with gener-
resources in people experiencing chronic pain alized anxiety disorder found no significant dif-
following a course of CBT, and Turner and Jensen ferences between the two methods, although both
(1993) found that pain intensity could be reduced demonstrated large improvements.
by cognitive strategies. Relaxation techniques Who should be using these techniques? Although
themselves were also shown to be effective but, as CBT is a psychological specialty, many of its tech-
shown by Harkapaa (1991), best when combined niques are highly accessible to the health care pro-
with other cognitive behavioural strategies. fessional, and since health care professionals have
The perception of pain and its experience been asked to broaden their approach by taking
can be mediated by the feelings and beliefs that account of psychosocial aspects of assessment and
people hold; social and cultural factors will often treatment, they will find in cognitive behavioural
determine how much pain an individual will feel techniques a means of achieving this (Everett 2003,
or is prepared to tolerate (Bendelow & Williams Johnstone et al 2002).
1995, Jones & Martin 2003). Research into the per- In summary, CBT helps people to challenge
ception of pain suggests that too much sympathy their beliefs and thoughts and to develop positive
can act as a reinforcer, intensifying the pain as coping strategies. Insofar as the therapy con-
experienced by the individual (Keefe 2003); and tributes to a feeling of well-being, it can itself be
Tulkin et al (1996) found that perception of pain seen as a relaxation technique: its effect, however,
was reduced and mobility increased when people goes far beyond the strict bounds of relaxation.
Further reading
Duncan E A S 2003 Cognitive behavioural therapy in physio- Gregoris S 2002 Cognitive behaviour therapy. Brunner-
therapy and occupational therapy. In: Everett T, Routledge, East Sussex
Donaghy M, Feaver S (eds) Interventions for mental Hawton K, Salkovskis P, Kirk J, Clark D M (eds) 1996
health. Butterworth-Heinemann, Oxford, Ch 10 Cognitive behaviour therapy for psychiatric problems: a
Greenberger D, Padesky C A 1995 Mind over mood. practical guide. Oxford University Press, Oxford
Guilford Press, New York
203
Chapter 23
‘On-the-spot’ techniques
INTRODUCTION
CHAPTER CONTENTS
Introduction 203 The goal of most methods described in previous
Characteristics of on-the-spot chapters has been the induction of deep relax-
techniques 204 ation: a slowly induced state which allows the
Factors affecting the success of on-the-spot individual to lose all tension. In order to achieve
techniques 204 this, she must detach herself from environmental
stimuli and focus all her attention on the method.
The exercises 204 This approach is appropriate where total relax-
Physical actions 204 ation is required and where the environment is
Scanning 205 making no current demands on her.
Breathing 206 The individual may, however, be looking for a
Cognitive strategies 207 shorter technique which works fast: a strategy to
lighten the effect of a stressor suddenly imposed
upon her. The aim here is not to release all tension
but to lose superfluous tension. Far from being
detached from the environment, the individual
wants to be fully alert to deal with its challenges.
Instead of eliminating stressors, she wants to
increase her tolerance of them. What she needs is
a technique which can be implemented at a
moment’s notice, and still allow her to carry on
with the task, whatever it might be.
Such an approach goes under a variety of names:
instant, emergency, immediate, rapid, quick, all of
which carry an appropriate hint of urgency.
‘Brief’, which sounds more neutral, is used by
some practitioners. In the present work, the
phrase ‘on-the-spot’ has been chosen, since, while
acknowledging the need of the moment, it also
conveys a sense of being equal to the occasion.
Shortened forms of techniques have already been
referred to. The rapid relaxation of Öst (1987) is
one example (Ch. 8, p. 73), where the individual
204 MISCELLANEOUS TOPICS
recites a cue word on exhalation while scanning the and psychological cues is important. As stress
body for tension. Mitchell’s (1987) ‘key movements’, levels rise, the cues become more pronounced.
which are capable of unlocking the body from tense The earlier she is able to pick them up, the more
postures (Ch. 10, p. 88), are another example. effective will be the relaxation device that she
Although the aim of on-the-spot techniques is applies.
to lose excess tension, retaining only what is neces- 3. Level of skill attained by previous practice.
sary for the task, these techniques are not the The capacity to ‘switch on’ relaxation whenever
same as differential relaxation. Differential relax- the individual feels under stress depends to a
ation is a principle to be applied throughout the great extent on the level of skill attained in
day, regardless of activity. By contrast, on-the-spot any one technique. This in turn depends on
techniques are designed to exert a momentary the amount of home practice that has been
effect in the face of sudden threat. carried out.
A variety of methods for inducing relaxation at 4. Personal preference in choice of technique.
short notice are presented in this chapter. They are Individuals have preferences for some methods
derived from methods already described, being, over others (Woolfolk & Lehrer 1984, Payne 1989).
for the most part, abbreviated versions of them. The method in which a person feels most at ease
They work best in individuals who have given the will be likely to induce greater relaxation than a
parent method many hours of practice. It is prac- method which feels alien to her.
tice that enables the individual to switch on 5. Diversionary content of the technique.
the full effect at short notice. Thus, on-the-spot Diversion, such as the reciting of a mantra, is said
techniques are shorthand versions of lengthier to contribute to the effect of a relaxation device.
methods previously learned. The stronger the diversionary element, the greater
the power of the technique (Lichstein 1988). It is a
useful feature where all that is required is a reduc-
CHARACTERISTICS OF ON-THE-SPOT tion in stress levels, as in the condition of panic.
TECHNIQUES Where successful coping relies on intellectual and
Lichstein (1988) lists the essentials of such tech- verbal skills, distraction is less useful, and a tech-
niques. They need to be: nique which leaves the mind free to focus on the
issue is more appropriate.
● portable: short enough and convenient enough
to be used in most situations
● unobtrusive: not attracting attention or inter-
rupting ongoing work THE EXERCISES
● capable of inducing moderate levels of relax-
ation. The object is not to induce deep relax- A technique may be picked from any of the fol-
ation but to enable the individual to carry on lowing approaches:
with the task, in as relaxed a state as possible.
● physical actions
● scanning
FACTORS AFFECTING THE SUCCESS OF ● breathing
ON-THE-SPOT TECHNIQUES ● cognitive strategies.
Not every strategy is going to succeed every
time. A number of factors may influence the
PHYSICAL ACTIONS
outcome.
1. Situation. The degree of inherent threat in a When under stress the individual tends to close up
situation may vary. Situations of high threat tend physically. It is an unconscious reaction to any
to reduce the effectiveness of the technique. kind of threat and has the effect of making her feel
2. Sensitivity to internal cues. A person’s less exposed. Although the action may not be
ability to recognize her own physiological observable, the muscles involved may nevertheless
‘On-the-spot’ techniques 205
Thinking of a smile eyes from a distance of 45 cm (18 in). Let it blot out
all images.
Facial expression has been found to influence
emotions. A positive expression tends to induce a
positive feeling in that individual (Ch. 9, p. 75, Telephone number
Ch. 24, p. 215). Thus, if a person smiles, her feel-
ings of stress will tend to be diminished. However, Invent a telephone number. Make it a long one, so
as it is not always appropriate to smile, it is that you will have to concentrate hard. Hold it in
enough to stay with the thought of it and simply your head for 1 to 3 minutes, depending on the
to imagine the smile (L. H. Capel 1986, personal situation.
communication).
Chapter 24
Other techniques
MASSAGE
in the form of improved venous and lymphatic relaxation and acupuncture, but less effective than
drainage are gained from these procedures shiatsu, transcutaneous electrical stimulation and
together with a decrease in pain, muscular tension manipulation, while it was found equal to exercise
and psychological stress (Kerr 2000, Ernst 2003). and therapeutic corsets (Furlan et al 2000, Ernst
Early attempts to measure its effectiveness 2003).
tended to suffer from methodological flaw but Normal healthy adults have also been studied,
some of this stems from research difficulties such where it was shown that massage can provide
as finding an acceptable placebo. It is, however, relaxation, thus lending itself to the treatment of
interesting to look at some of the research that has workplace stress (Cady & Jones 1997). Massage
been carried out and subsequently reviewed by also offers immunological benefits. Lovas et al
Kerr (2000). Several studies have investigated the (2002) demonstrated a significant increase in the
effects of massage on elderly people. For example, proliferative response of T and B lymphocytes,
Fraser & Kerr (1993) studied the effects of 5 minutes and also in the levels of serum IgG during full-
of slow rhythmical back massage on 21 residents body Swedish massage on healthy females.
of a care institution and found that electromyo- What is the mechanism behind these effects? Is
graphic and anxiety scores in the groups receiving it the pressure of the massage? Or the rhythm of
massage were significantly lower than in the the stroking? It has been suggested that massa-
control group 10 minutes following intervention. ging particular segments of skin can have specific
Other studies have demonstrated considerable effects (Kurosawa et al 1995) and this notion might
effects on physiological parameters following mas- help to explain why results are not always consis-
sage. For example, Fakouri & Jones (1987) measured tent (Kerr 2000).
heart rate, blood pressure and skin temperature in Most people seem to find massage a pleasant
18 elderly clients after 3 minutes of slow stroke experience. Research shows that when performed
back massage. Following treatment, heart rate and slowly it increases feelings of relaxation (Kerr
systolic blood pressure were significantly lower 2000). It does this at relatively little financial cost
than before treatment while skin temperature was and without side effects or negative interactions.
significantly higher, indicating an overall benefit.
Where people have been diagnosed with hyper-
tension, researchers find that massage may be AROMATHERAPY
effective in reducing diastolic blood pressure and
in ameliorating the symptoms associated with Loosely connected with massage is aromatherapy.
hypertension (Hernandez-Reif et al 2000). Here, concentrated essential oils from aromatic
Massage has been found effective in the context plant extracts are applied to the body. These oils
of cancer. Meek (1993) studied the physiological are generally conveyed through massage or some-
effects of 3 minutes of slow stroke back massage times by steam infusion, while the massage itself
in 30 terminally ill hospice patients and obtained may cover the whole body or focus on a part of it,
significant findings for heart rate, blood pressure for example, the foot. Of the very few published
and skin temperature. Ferrell-Torry & Glink (1993), trials that exist, Cooke & Ernst (2000) have reviewed
investigating the psychological effects of massage six. They all had similar designs in that massage
in nine male inpatients suffering cancer pain, found with essential oil was compared to massage with-
significant reductions in both pain and anxiety. out essential oil and the participants were all suf-
Such results persuaded the Oncology Department fering from anxiety. Results showed that, on the
of the Hammersmith Hospital to introduce mas- whole, aromatherapy massage was slightly more
sage as a standard component of treatment, seeing effective than massage on its own, although the
it as offering benefit in terms of quality of life benefits were short-lived. The reviewers concluded
without the negative consequences of other forms that aromatherapy has a mild and transient anxio-
of treatment (Burke et al 1994). lytic effect.
In the area of back pain, massage has been shown Regarding the mechanisms of action, Cooke &
to be more effective than placebo, muscular Ernst find they are unclear and propose that future
Other techniques 211
investigations should attempt to separate the Patient populations have also benefited, particu-
effects of transdermal absorption from the effects larly those suffering from psychosomatic dis-
of smell. orders. Duckro & Cantwell-Simmons (1989)
The popularity of aromatherapy as a relaxation reviewed studies investigating biofeedback-assisted
technique is undeniable and has led to a growing relaxation in the management of paediatric
use of it in the fields of midwifery and cancer care. headache and found good support for its use as a
stress-reducing technique.
Research comparing BFB with other relaxation
BIOFEEDBACK-ASSISTED RELAXATION techniques has so far been unable to show that
THERAPY BFB is more effective than other methods of indu-
cing relaxation (Brannon & Feist 1992).
Biofeedback (BFB) is ‘a descriptive term for the
process of providing an organism with informa-
tion about its biological functions’ (Reber & Reber BODY AWARENESS THERAPY
2001). In one sense, such information is relayed to
us every day by the sensory systems in the body. Body awareness therapy is based on the notion
It is illustrated by, for example, the way joint pro- that human movement has a psychological
prioceptors inform the individual about the pos- dimension, i.e. that it means something in emo-
ition of her hands when she cannot see them, i.e. tional terms (Piret & Beziers 1979). For example,
when they are clasped behind her back. The bene- each movement has a purpose; each movement
fit of the information is that adjustments can be creates a subjective experience; each movement
made to the movements in her arms. expresses some aspect of the individual’s life
In the case of the workings of the internal body (Roxendal 1990). Movements carried out by the
organs this information is normally unavailable. body are recognized as part of the self and are
However, it can become available with the help of therefore part of a person’s identity. The aim of
an instrument capable of converting the inner treatment is to integrate the body in the total
workings of the body into visual or auditory experience of identity and by way of achieving
signals. It is claimed that an individual who is this, emphasis is placed on sensory awareness at a
provided with signals from a particular organ can conscious level (Roxendal 1990).
modify the functioning of that organ. The instru- Gjertrud Roxendal, a Swedish physiotherapist,
ment picks up stress responses such as muscle ten- presents two aspects of the approach: basic and
sion, high blood pressure, raised heart rate or expressive. Basic refers to general movement func-
sweat gland activity. The client then reads the sig- tions, such as posture and gait, and it consists of
nal. If the stress indicator is high she practises a structured exercises covering concepts such as the
relaxation technique and observes the result. This body’s relation with the ground, its contact with the
tells her how effective her attempts have been. supporting surface, posture, balance, free breath-
Such feedback gives her clear evidence of the result ing and muscle relaxation. Boundaries of the body
of her efforts and any success she achieves serves in different contexts are discussed; for example,
to increase her motivation (Stoyva & Anderson the experience of holding hands in formal dances.
1982). In this way she learns how to reduce the The expressive aspect refers to a person’s
effects of stress on her internal organs. experience of the movements she makes and to
There is a substantial body of evidence relating her uniqueness as an individual. The exercises
to biofeedback-assisted relaxation therapy. Not all are related to personal style as expressed in gait,
of it is favourable. However, a proportion of stud- voice, degree of eye contact, way of interacting
ies have found the method effective in reducing the with other people and how comfortable she is
stress response and promoting a state of mental with her mirror image and the sound of her name.
tranquillity. Chandler et al (2001) found the tech- Partner exercises form a context for exploring the
nique successful with counsellor trainees as did need for human contact and the sense of security
Fehmi (1974) with middle management executives. or insecurity attaching to it.
212 MISCELLANEOUS TOPICS
Progress is measured on the Body Awareness techniques, such as touch and manipulation,
Scale which contains an assessment of movement, tailored to the individual’s need. Treatment is inten-
together with a structured interview on body sive and one-to-one and designed to ‘communicate
image and attitudes to movement. The Scale has new possibilities of body organization’ (Kerr et al
been tested for validity by Gyllesten et al (1999). 2002).
Clients seem to find the approach helpful. Feldenkrais relaxation (FeldR) has been com-
Irritable bowel syndrome is one area where it has pared to the Alexander technique by Fulden
been found effective (Eriksson et al 2002). Another (1989) who points out that whereas FeldR pro-
is sexual abuse where Mattsson et al (1998) stud- motes awareness of the body while it is in motion,
ied seven women over 20 months. An improve- the Alexander technique concentrates on the body
ment in body image and self-image occurred in in space. In general, however, Fulden sees FeldR
the majority of the women and their symptoms as a fusion of the Alexander technique and
were reduced by half. Anorexia, schizophrenia, Oriental body training.
and chronic pain are other conditions which have Malmgren-Olssen et al (2001) compared FeldR
benefited from it. with body awareness therapy and conventional
Body awareness therapy is not primarily a physiotherapy in patients suffering from muscu-
relaxation technique but in promoting a sense of loskeletal disorders. There were few differences in
well-being, it induces a feeling of serenity. outcome among the groups, but significant posi-
tive changes occurred before and after treatment
with respect to distress, pain and negative self-
FELDENKRAIS RELAXATION image in all three groups. This led the researchers
to suggest that psychological aspects be addressed
Moshe Feldenkrais was a physicist who began to in the management of all musculoskeletal injuries.
study human movement following an injury to his Evidence of the efficacy of awareness-through-
knee. He developed an approach whose aim was movement in reducing anxiety was demonstrated
to improve function by teaching the individual to by Kolt & McConville (2000). Of the 35 female and
move with greater ease and efficiency (Kolt & 19 male undergraduate participants in their study,
McConville 2000). His method consists of training the female ones reported significantly lower
the client to be more aware of the body in order to anxiety scores following treatment.
enhance sensitivity to existing movement pat- FeldR is steadily gaining in popularity and is
terns. These can then be replaced by more efficient used in the management of a range of disorders,
new ones. In addition to improving neuromuscu- such as cerebral palsy and multiple sclerosis,
lar function, the method also claims to influence where its holistic approach is found particularly
the way an individual thinks and feels. Thus it has helpful.
psychological benefit and can be said to promote
a sense of well-being.
The Feldenkrais method covers two training FUNCTIONAL RELAXATION
systems: awareness-through-movement and func-
tional integration. The first consists of verbally Devised by a German physiotherapist, Marianne
directed movements designed to increase sensori- Fuchs, functional relaxation (FunctR) consists of
motor awareness and leading to improved coord- small movements of the jaw, neck, spine and
ination (Malmgren-Olssen et al 2001). Treatment shoulders. These are performed smoothly in a
starts with a simple exercise; it is repeated, then snake-like fashion while breathing out. The par-
developed into a more complex movement with a ticipant focuses her attention on the movements
coordinated pattern which involves the whole themselves and on the body feelings elicited by
body. The emphasis throughout is on awareness the movements, thus intensifying her perception
of the movement. of them and enhancing body awareness. It is said
The second, functional integration, focuses on that, as a result, a spontaneous physical relaxation
individual functional problems and uses guiding occurs.
Other techniques 213
This is a relaxation technique which can be Kerr (2000) has found evidence of its effective-
readily integrated into the lives of people suffering ness in her review of relaxation techniques. In one
from disorders, such as tension headache and study, 40 male physical education teachers attend-
asthma, where its effectiveness has been tested by ing a residential camp were trained in yogic pro-
Loew and colleagues (2000). These researchers cedures. After 3 months significant reductions in
showed significant differences between measure- autonomic arousal and increased psychophysio-
ments before and after treatment with FunctR in logical relaxation were demonstrated (Telles et al
total headache hours and intensity of pain. These 1993). In 2000 these researchers turned their atten-
results support the view that FunctR may have a tion to a notion referred to in ancient yoga texts,
use in the relief of tension headache, both as an i.e. the effect of combining stimulating and calm-
adjunct to pharmacological treatment and as a ing yogic procedures in the same session. Their
prophylactic. results supported the notion that a greater reduc-
Loew et al (2001) have also explored the effect tion in autonomic arousal followed the combined
of FunctR in the context of asthma. Twenty-one procedures than that which followed the relaxing
asthma sufferers were randomly assigned to three procedures on their own (Telles et al 2000).
groups: FunctR, the drug terbutaline and placebo. Yoga has been shown to provide benefit in a
Results showed that FunctR was significantly variety of medical conditions, one of which is
more effective in decreasing airway resistance asthma. Khanam et al (1996) demonstrated a sig-
than the placebo, although FunctR was not as nificant decrease in sympathetic activity in nine
effective as terbutaline. In their conclusion the participants following a 7-day course.
researchers suggested that FunctR had potential Psychological benefit has been demonstrated in
as a supplementary therapy in cases of asthma. the work of Schell et al (1994). Twenty-five young,
FunctR is easy to learn and, on account of its healthy females were instructed in yogic pro-
unobtrusive nature, can be practised in any situ- cedures in the form of spinal stretches, breathing
ation. Although 20 1-hour sessions are needed to and meditation and tested along a variety of dimen-
acquire full proficiency, small benefits can be sions including life satisfaction, mood and coping
gained in considerably less time. with stress. Results were compared with those of
a control situation consisting of quiet reading. A
significant difference was demonstrated in favour
YOGA of the yoga-practising group.
Despite its popularity, yoga should not be seen
Yoga is a discipline with a long history in Hindu as an easy remedy. On the contrary, it requires infin-
philosophy. As a method, it integrates physical, ite patience. Neither should it be seen as a test of
psychological and spiritual aspects of life. pain endurance (some of the postures can be uncom-
Physical postures and breathing-control prepare fortable for the novice); rather, it may be seen as a
the body and mind for the rigours of meditation test of self-discipline where progress is viewed in
which, in turn, lead to a state of harmony in terms of process, not end-result (Gilbert 1999).
which the soul is able to reach a higher level, com-
municating with the Universal Spirit (Gilbert
1999). EASTERN TECHNIQUES
Within this general concept there are different
schools, each with its own emphasis. Hatha yoga These are based on the Taoist principles of yin and
or ‘the yoga of health’ is the one most frequently yang, which are themselves a product of the
practised in the West. Its focal elements are pos- Ultimate Source of Being. Yin and yang are oppos-
tures, breath control and simple meditation in the ing principles in Chinese philosophy but they are
form of chantings or candle-gazing. It attracts not in conflict; rather, they complement one
people for a variety of reasons, such as relief another, and when they are balanced, a state of
from stress, healing after body injury, or simply, harmony is said to exist. Yin and yang, which are
the wish to increase one’s joint flexibility. present in all living things, interact with each
214 MISCELLANEOUS TOPICS
REFLEX THERAPY
Reflex therapy owes its name to the belief that the
sole of the foot carries a representation of the
Figure 24.1 The reflex zones of the feet. With
entire body. It is claimed that treatment of these acknowledgement to the Association of Chartered
reflected areas can influence healing in related Physiotherapists in Reflex Therapy (ACPIRT).
parts of the body. The approach has a long history
in the East where its practice is linked to the prin-
ciples of Chinese medicine, i.e. locating imbalances
in the body and restoring harmony of body and benefits have been measured are cancer, sinusitis,
mind. Today its use is growing in the West where menopause, childbirth and mental health. With
many people are looking for the kind of holistic regard to cancer, substantial reductions in pain,
approach it offers with its acknowledgement of nausea and anxiety have occurred after reflex
the anxiety that accompanies physical disease. therapy, leading some researchers to suggest that
Reflex therapy is a gentle manual technique the approach should feature in all cancer units
consisting of pressure massage of the foot. This (Grealish et al 2000, Stephenson et al 2000).
massage covers the whole foot but focuses on points In the mental health field, significant improve-
relating to organs where symptoms of trauma have ment in general emotional state has occurred in
been detected. In addition to regulating imbal- individuals receiving reflex therapy in a drop-in
ances, one of the aims is to stimulate self-healing and day centre in Worthing. The data were quali-
powers (Association of Chartered Physiotherapists tative but indicated a marked increase in confi-
in Reflex Therapy (ACPIRT) 2001). dence and self-esteem levels (Trousdale et al 1997).
The rationale in Chinese terms concerns the This service was reassessed in 2000 when it was
free flow of chi which is promoted by the mas- found that 74% of respondents reported improve-
sage. In scientific terms its rationale is not known, ment in their physical health in addition to the
but one possible explanation is that stimulation psychological benefits. Chronic sinusitis also
or sedation of certain points in the foot releases appears to benefit from reflexology as Heatley
endorphins which relieve pain. This induces et al (2000) demonstrated when they found its effect
relaxation. The relaxation may, in its turn, result in equalled that of nasal irrigation.
a freer-flowing circulation and improved nourish- These results suggest that reflex therapy has
ment, both of which promote healing. much to offer. However, some studies have com-
Diagnosis may lie outside the therapist’s domain pared the approach with standard foot massage
and acute pain and fever should always receive and found no discernible difference in effective-
medical attention. However, once the diagnosis is ness. Cornbleet (2001) has reported this in the field
established, reflex therapy may help in a wide of palliative care, and Williamson et al (2002) in
range of disorders. Some of the areas in which its the field of menopause where, following treatment,
Other techniques 215
scores for negative mood fell in equal measure, harmony and inner calm (Mack 1980, Fasko &
whether the group were receiving reflex therapy Grueninger 2001). The gentle character of the exer-
or non-specific foot massage. cises makes the approach particularly suitable for
This might suggest that the benefits of reflex older age groups where, as the muscles become
therapy are mainly a function of manual contact; stronger and the balance improves, the tendency
and yet, many other studies have shown the for falls to occur is reduced (Luskin et al 2000).
approach to be effective in a variety of settings. Practice periods last about 15 minutes and are
Like massage, it is also non-invasive and, since it carried out twice a day, singly or in groups. During
does not rely on special equipment, is relatively the movements the practitioner focuses her atten-
low-cost. As with other complementary approaches, tion on them and on her breathing which should
however, scientific measurement of its effective- be slow and even. The emphasis placed on con-
ness has only recently begun, so that no estab- centration has earned the method the name of
lished body of research yet exists. ‘meditation-in-motion’.
Fasko & Grueninger (2001) have reviewed
studies investigating the effectiveness of t’ai chi;
SHIATSU
these researchers conclude that benefit is to be
As a branch of Oriental medicine, shiatsu looks at gained from the practice of t’ai chi along all
the whole person, checking the meridians, diag- dimensions of health: physical, physiological,
nosing weak points and applying a range of man- cognitive and emotional.
ual techniques, such as palpations, stretchings and
pressure. The pressure is applied inwards, which
distinguishes it from most other massage tech- SMILING AND LAUGHTER THERAPY
niques where strokes and circular movements pre-
dominate. The therapist generally uses her fingers William James (1890/1950) remarked over a cen-
to apply the pressures but her thumbs, palms, tury ago that the way to cheerfulness is to act and
elbows and even knees and feet may play a part. speak as if cheerfulness were already there. In
Psychosomatic and musculoskeletal disorders other words, smiling makes us feel happy (Ch. 23,
particularly respond to this approach but, since a p. 208). This idea has given rise to the facial and
shiatsu treatment covers the whole body, it can be postural feedback hypotheses (Ch. 9, p. 75) which
applied in a wide range of conditions (Beresford- state that feedback from facial expression and
Cooke 1996). posture induces the emotion associated with that
Stevenson (1995) investigated the effects of expression and posture (Izard 1977, Duclos et al
shiatsu as a palliative procedure in a single case 1989, Hatfield et al 1992).
study of a patient diagnosed with lymphoma of Humour and laughter are related to positive
the lung. Results were favourable as registered by moods, and few would deny that laughter
the patient’s self-report and the physician’s obser- releases tension. Ekman (1984) has posited the
vation. No statistical analysis was reported. existence of neural connections between the facial
muscles and the autonomic system; an idea which
has been supported by research (Berk et al 1988).
T’AI CHI CH’UAN
It has been shown that levels of hormones related
A non-aggressive form of the martial arts, t’ai chi to sympathetic activity are reduced by humour
ch’uan consists of a series of slow, circular and and mirthful laughter, thus suggesting an associ-
deliberate movements which flow from one into ation between laughter and parasympathetic activ-
another. Their slowness tends to be reflected ity. In this light, laughter can be seen as a natural
throughout the body organs, including the respira- tranquillizer (Hodgkinson 1987).
tory system where the breathing rate falls. T’ai chi Smiling and laughter have been referred to as
ch’uan thus appears to induce the relaxation overlapping but distinct domains, the one of
response and, as this influences the mind also, the friendliness, the other of amusement (Van Hooff
method helps to promote a sense of personal 1972). Both can be effective stress-relievers.
216 MISCELLANEOUS TOPICS
Further reading
Massage Reflexology
Holey E A, Cook E M 2003 Evidence-based therapeutic Gillanders A 1995 Reflexology: a step-by-step guide. Gaia
massage, 2nd edn. Churchill Livingstone, Edinburgh Books, London
Rosser M 2004 Body massage: therapy basics. Hodder &
Stoughton, Abingdon
Yoga
Meaux K 2002 Dynamic yoga. Dorling Kindersley, London
217
Chapter 25
Relaxation in pregnancy
and childbirth
RATIONALE
CHAPTER CONTENTS
Rationale 217 This chapter differs from the rest of this book in
that it focuses on a condition for which relaxation
Breathing and antenatal training 217 training is offered, rather than the description of a
Awareness of breathing 218 particular technique. It has been included because
Other forms of relaxation 219 of the widespread use of relaxation in the field of
Muscle relaxation 219 obstetrics, where the aim has been to achieve an
Massage 219 altered response to physical pain through acquired
Visualization 219 skills (Culverwell & McKenna 1988).
For relaxing during discomfort 220 Relaxation has been taught antenatally since
the 1930s when Grantly Dick-Read saw it as
Home practice 220 a means of breaking the cycle of pain–fear–
Evidence of effectiveness 220 tension–pain in childbirth. His particular concern
was to reduce the fear many women have of
labour (Dick-Read 1942). Others followed, teach-
ing a variety of methods, most of which were con-
cerned in different ways with the control of
breathing. The purpose of these methods was to
provide a distraction from the discomfort of strong
uterine contractions (Noble 1988), and also to
ensure that the fetus received an adequate supply
of oxygen.
dioxide levels than to gain from increased levels route … make sure the rate is a natural one and
of oxygen (Buxton 1973). Buxton’s study included that you don’t overbreathe. Let your body tell you
a group who had been taught controlled breath- when to breathe in and out … Move your hands down
ing. It was found that this group, compared with a bit lower and feel the whole abdomen gently
participants who had been given other forms of rising and falling in synchrony with your breaths.
antenatal training, exhibited marked hyperventi- Take a little rest, then lean forwards with your
lation with resulting adverse effects (Ch. 15, arms resting on a table. This position gives full play
p. 134). Stradling (1983) has since re-emphasized to chest movement in the back. Perhaps you have
the dangers of overbreathing during labour. the sensation of your ribs expanding backwards.
Some hyperventilation may occur physiologic- Don’t be in a hurry. It’s important to keep the
ally in labour without affecting the normal fetus breathing natural…
(Polden & Mantle 1990). It is not, however, in Finally, sit back and lay one hand over your
the interests of the fetus to increase the degree upper abdomen and the other over your chest
of hyperventilation, because the resulting low just below your collar bones. Take plenty of time.
carbon dioxide levels could theoretically lead to Notice movement taking place under both hands.
both vasoconstriction of uterine blood vessels, and Perhaps you also notice that the more relaxed
interference in the transfer of oxygen to the tissues you feel, the more movement there is under
and fetus (Ch. 15, p. 135). Moreover, hyperventila- your lower hand. Conversely, a slow, abdominal
tion can be followed by apnoea (temporary cessa- breathing rhythm helps to induce relaxation. It is
tion of breathing) which could also reduce the useful to remember this in moments of emotional
availability of oxygen. A fetus which was already unease, since slowing the breathing can help to
compromised would be more vulnerable to these calm the feelings. Otherwise, your body takes
effects than a normal one (Mantle et al 2004). care of your respirations, giving you more air
In the light of such findings, antenatal teachers when you need it and reducing the supply when
no longer use controlled breathing exercises but you don’t.
instead encourage women to breathe freely, nat-
The connection between respiration and the experi-
urally and easily, seeing the interests of the fetus
ences of exertion, pain and emotion can be made
best served by breathing rates and rhythms deter-
by asking the women to consider what happens to
mined by the mother’s own physiology (Stradling
their breathing when they run for a bus, bang their
1983, Noble 1988). Breathing exercises, in their
shin or get angry. The women will understand how
original sense, are no longer a feature. Awareness
effort, discomfort and emotion can temporarily dis-
of breathing, however, is widely taught. It is seen
rupt the breathing pattern (Schott & Priest 2002).
as a means of helping the mother to understand
Since disrupted breathing can take the form of
her body.
increased ventilation, this is an opportunity for
discussing hyperventilation: its causes, how to
recognize it, and how to relieve its symptoms
AWARENESS OF BREATHING
(Ch. 15).
While emphasizing that breathing should be
effortless, mothers are invited to explore the dif-
Breathing awareness exercises for inducing
ferent aspects of the expanding chest (Schott &
relaxation
Priest 2002). (Plenty of time should be allowed for
this exercise.) Many women find breathing awareness exercises
have a relaxing effect. Two examples follow.
Sit quietly. Allow your breathing to settle to a rest-
ing rhythm. Place your hands over your lower ribs 1. Sit, lie or stand comfortably. Turn your thoughts
(fingers almost touching), and become aware of the towards your breathing and watch it settling
movements that occur underneath them. Think of down to a resting pattern. Become aware of the
the air gently flowing in and down towards your movement occurring in your upper abdomen and
hands … and then flowing out along the same lower chest. Without doing anything to change the
Relaxation in pregnancy and childbirth 219
they also get closer together. You find you continue try out different ones to find the one that suits
to ride them. Still higher and closer together … the her best.
waves seem almost to overwhelm you, but as they
dip, you notice they are carrying you nearer to the
shore … nearer to the shore where your baby will EVIDENCE OF EFFECTIVENESS
be born.
A number of studies have been carried out in
the area of childbirth and relaxation, for example
FOR RELAXING DURING DISCOMFORT the controlled investigation of Rees (1995). This
author examined the effect of relaxation training
Some teachers prepare women for the birth by
on levels of anxiety, depression and self-esteem in
simulating the discomfort of a contraction. They
primiparas. Sixty participants were randomly
do this by getting the woman’s partner or another
assigned to experimental and control groups. The
member of the group to apply an uncomfortable
experimental group received 15 minutes of taped
pinch or squeeze to her arm or thigh. The woman
relaxation which included muscle routines, breath-
is asked to relax towards the pressure in an effort
ing awareness, meditation and imagery, while the
to reduce the sensation. The aim is to help the
control group listened to tape-recorded music for
woman feel she can raise her pain threshold. The
the same length of time. Results showed the experi-
pinch or squeeze should last about a minute.
mental group to have significantly lower scores on
It starts with a light touch and gradually builds
anxiety and depression than the control, and sig-
up in intensity over the first 30 seconds; in the sec-
nificantly higher scores on self-esteem than the
ond half-minute it is gradually released. Slow,
control. Thus, it is suggested that relaxation tech-
gentle breathing should accompany the exercise
niques can contribute to the psychological well-
(Polden & Mantle 1990).
being of women giving birth to their first child.
Before using the techniques contained in this
chapter, the pitfalls relating to each should be read
HOME PRACTICE in the corresponding sections of the book. The
chapters on breathing (Ch. 15) and visualization
Relaxation is a skill, and like any skill it requires (Ch. 18) both contain lists of relevant pitfalls
practice for proficiency. This practice can be done (p. 138 and p. 170 respectively).
in any position which the mother chooses: lying, This chapter does not cover all the relaxation
sitting, kneeling on all fours, kneeling with arms strategies for helping women through labour. For
supported on a chair seat, standing with raised further information in this highly specialized
arms resting on the wall or any other position field, readers are referred to the Further reading
which the woman finds comfortable. She can section below.
Further reading
Mantle J, Haslam J, Polden M 2004 Physiotherapy in obstet- Schott J, Priest J 2002 Leading antenatal classes: a practical
rics and gynaecology, 2nd edn. Butterworth-Heinemann, guide, 2nd edn. Books for Midwives, Oxford
Oxford
221
Chapter 26
particular aspect of mental distress. The following which may change over the period in which
are examples. relaxation is practised. Any resulting change should
The Hospital Anxiety and Depression Scale not, however, be totally attributed to relaxation,
(HAD) (Zigmond & Snaith 1983). This contains since other factors such as changing environmental
14 items, seven relating to anxiety and seven to circumstances may be contributing to alterations
depression. The score gives an indication of the in scores.
degree to which the individual is suffering from Tests show that the HAD possesses a consider-
either condition. The scale is also able to pick up able degree of validity and reliability although, as
alterations over time. with most scales, further testing is required before
The General Health Questionnaire (Goldberg confident judgements on its performance can be
& Williams 1988). This consists of 12 items and is made. Its ability to detect minor degrees of psy-
designed to detect feelings of distress in the indi- chiatric disorder has been shown and it has been
vidual. As a simple screening device it is used for found responsive to changes in individuals with
much the same purposes as the HAD. neurotic disorders. The scale is also easy to under-
The Beck Depression Inventory (Beck et al stand and has been found acceptable to patients,
1961, Beck 1988). Measures of the level of depression taking only 5 minutes to complete (Bowling 1997).
can be obtained from this questionnaire which can A fuller list of self-administered questionnaires
be used at different stages of illness and recovery. appears in Appendix 2. It relates particularly to
The Cognitive Anxiety Questionnaire the condition of depression.
(Lindsay & Hood 1982). This contains 12 items
and reflects some of the commonest thoughts
Specific questions for participants
associated with anxiety. The scale measures the
tendency of the individual to engage in such To make the assessment information more specific
thoughts. to the group whose problems are being measured,
additional questions could be put to the partici-
These are all simple screening devices for use with pants, for example:
individuals. The results, when obtained at the ● In the case of a smoking cessation group, ‘How
beginning and at the end of a training course, give
many cigarettes are you now smoking a day?’.
an indication of change over time in the individ- ● In the case of a person suffering from
ual concerned.
agoraphobia, ‘How many times have you been
The results can also be used to assess the effect-
out of the house in the past week?’.
iveness of relaxation training on groups of people.
In this case, means and standard deviation are cal- Each person could select two or three personally
culated so that the data can be used for statistical meaningful targets like these and keep a record of
purposes and employed, for instance, in building their progress in relation to them. Precise targets,
a case for funding. such as the above examples, are measurable and
The Hospital Anxiety and Depression Scale is therefore preferable to vague aspirations such as
shown in Figure 26.1. It has been picked as an ‘I’d like to feel better’.
example because of its widespread use and general
applicability. Questions 1, 4, 5, 8, 9, 12 and 13
SELF-RATING
relate to anxiety, and questions 2, 3, 6, 7, 10, 11 and
14 relate to depression. Scoring instructions are Related to the questionnaire is the self-rating
attached to the assessment sheet but not included scale, i.e. the rating an individual gives herself. It
here. A score of 8–10 in either section indicates a often takes the form of a visual analogue. Though
mild degree of the condition, while a score of 11 or it is a highly subjective assessment, it nevertheless
above suggests the advisability of referral to a has value since relaxation is an internal state with
specialist agency. Although the scale is seen as a a strong subjective component. The self-rating
screening tool, it is, in the present context, used scale is particularly useful for recording levels of
primarily to measure tendencies to mental distress pain and anxiety.
224 MISCELLANEOUS TOPICS
SECTION 1
(3) I still enjoy the things I used to enjoy: (4) I get a sort of frightened feeling like
Definitely as much ‘butterflies’ in the stomach:
Not quite so much Not at all
Only a little Occasionally
Hardly at all Quite often
Very often
(5) I get a sort of frightened feeling as if
something awful is about to happen: (6) I have lost interest in my appearance:
Very definitely and quite badly Definitely
Yes, but not too badly I don’t take so much care as I should
A little, but it doesn’t worry me I may not take quite as much care
Not at all I take just as much as ever
(9) Worrying thoughts go through my mind: (10) I look forward with enjoyment to things:
A great deal of the time As much as ever I did
A lot of the time Rather less than I used to
From time to time but not too often Definitely less than I used to
Only occasionally Hardly at all
(13) I can sit at ease and feel relaxed: (14) I can enjoy a good book or radio or TV programme:
Definitely Often
Usually Sometimes
Not often Not often
Not at all Very seldom
Figure 26.1 The Hospital Anxiety and Depression Scale. (Adapted from Zigmond & Snaith 1983 Acta Psychiatrica
Scandinavica 67: 361–370 with permission from Munksgaard, Copenhagen, and reproduced from Anxiety and Stress
Management by Powell & Enright 1990 with permission from Routledge, London.)
Assessment and audit 225
Self-rating may take different forms: answered differently, depending on who is asking
the question: whether, for instance, it is a friend, a
● A rating scale in the form of a line calibrated
newspaper reporter or a doctor. This highlights the
from 0 to 10 where 0 represents total relaxation,
fact that there are many ways in which a question
and 10 maximum tension. The intervening
may be answered. The participant can then be
numbers refer to intermediate states. The
asked to distinguish between the answer she feels
trainee rings the appropriate number.
is expected of her and the answer that reflects
● A rating scale which consists of numbered
what she really feels. The second interpretation is,
descriptors signifying different degrees of
of course, the one that is required.
relaxation and tension, as in Poppen’s (1988)
Self-rating can only provide a rough guide as to
self-rating scale (Ch. 9, pp 80–81). Again, the
the effects of training. Its value lies particularly on
trainee rings the appropriate number.
an intrapersonal level, that is, where measure-
These may be used before and after the relaxation ments are taken in the same individual before and
session. Marking scales in this way gives a measure after training sessions. Interpersonally, i.e. when
of the effect of the treatment. comparing one individual with another, self-rating
During the homework periods a form such as is less useful because of the varying standards of
the one illustrated in Figure 8.3 (p. 71) may be the reporters (Lichstein 1988).
completed. This helps to ensure that practice is A range of self-report measures can be found in
carried out as well as providing an indication of Johnstone et al (1995).
the degree of benefit obtained. A diary, when used
to record instances of high stress, is another form PHYSIOLOGICAL MEASUREMENT
of self-report; so is the record sheet (Fig. 8.2, p. 69)
in which the occurrence and intensity of anxious Assessing the effect of relaxation training on body
feelings are recorded on a numbered scale together systems provides an objective measurement. A
with details of the particular coping strategy variety of indicators are in current use, including
adopted. pulse rate, blood pressure, respiratory rate, muscle
The advantages of the self-report method are tension, peripheral blood flow, palmar sweating,
that it is quick, easy, cheap and non-threatening to and electrical activity in the brain. Most of these
the trainee. It does, however, have limitations: can easily be measured, and machines are avail-
able for the purpose. The results indicate the level of
1. Responses may be influenced by social physiological arousal in an individual, and the test
concerns which enter into the individual’s or tests are carried out before and after relaxation
judgement, for example: sessions. The baseline is established before training
a. people tend to say what they feel is begins and, in common with all pre-treatment
expected of them measures, should be recorded after a short period
b. they may say what they think the trainer of rest (see above).
wants to hear It might be supposed that this approach offered
c. they may present a view which shows the perfect solution. The field of physiological
them in a favourable light. assessment, however, is not as straightforward as
2. A placebo effect may be operating, whereby it appears. Keable (1997) discusses certain points:
belief in the approach leads some people to
● Physiological measures can be distorted by
report more benefit than has in fact occurred
circumstances. The individual may, prior to a
(see below, p. 226).
relaxation session, have eaten, which would
These factors result in a tendency for the result in artificially low arousal scores; she may
responses to be unduly positive. have taken exercise immediately before, which
In his discussion of the verbal aspects of would raise her scores; emotional distress
multimodal assessment, Poppen (1988) suggests would also raise them and drugs could distort
remedies for this tendency. The participant can be them. Tests therefore need to be conducted
reminded that questions of any sort tend to be under controlled conditions.
226 MISCELLANEOUS TOPICS
● Since the physiological response of individuals clinicians may resort to counting the sessions
is to some extent idiosyncratic, a single measure attended on the assumption that a fixed number of
may not include relevant information. To gain sessions will create a predictable level of relaxation
an accurate picture, therefore, a system which skill. This method can never be more than a rough
provides multiple measurements is needed. guide of progress, since there is known to be a
mismatch between the amount of teaching and the
Poppen (1988) adds the following point.
amount of learning that occurs in any lesson
● Even in the case of specific symptoms, it is not (Poppen 1988).
always clear how their measurement should be
approached. In tension headache, for example, it
might be thought that electromyography of the A PRACTICAL APPROACH TO ASSESSMENT
surrounding muscles would be appropriate; Because none of the above measures alone offers
however, exactly which muscles should be the perfect solution, and because relaxation is a
measured is less clear. Or again, instead of meas- multimodal state, assessment ideally includes a
uring the electrical activity, it might be more variety of measures, each reflecting a different
constructive to measure the bloodflow through dimension of relaxation. Time-consuming as it is,
the surrounding muscles (Olton & Noonberg careful assessment is important. Its value cannot
1980). Researchers hold different views. be overemphasized if clinical methods are to have
Furthermore, while measurement of the pulse and credibility.
breathing rate are simple procedures, most other However, it is acknowledged that overworked
physiological measures require equipment and health care professionals may find it difficult to
expertise, neither of which may be available. meet the above requirements, particularly if their
In spite of these difficulties, however, physio- groups are large. In this event, the following pro-
logical measurement is an important aspect of cedure could be set up:
general assessment. ● Participants are asked to state (verbally or in
writing) what they hope to gain from the
OBSERVATION course. They can be asked to list three targets
as described above.
Informal unstructured observation is practised by
most trainers and used to corroborate information While the course is in progress:
collected from other sources. A structured form ● Some kind of self-rating is carried out regularly.
of observation, such as role play, may also be ● Some kind of physiological assessment is carried
employed. However, since the presence of the out regularly (pulse or breathing rate).
observer tends to affect the outcome, it is some- ● The attendance rate is noted.
times carried out in her physical absence but with ● Home practice is monitored (Fig. 8.3).
the use of videos, tape recorders and two-way
mirrors. (Ethical considerations demand that the At the end of the course:
individual’s consent must first be obtained.) ● Participants are asked if the course satisfied the
It was in an attempt to structure the observation three targets they listed in the beginning.
process that Schilling & Poppen (1983) devised the
Behavioural Relaxation Scale as an assessment tool It should be noted that this kind of assessment is
(Ch. 9, p. 79). As mentioned in Chapter 9, the scale minimal. A system which provides fuller informa-
provides a quantified measure of the motor com- tion is desirable for clinical purposes, and essential
ponent of relaxation (Poppen 1988). for research purposes.
This is the benefit derived by the individual as a of a process which can be attributed to the
result of her belief in the efficacy of the procedure, process’ (Long et al 1993). In the context of health
and it is separate from the procedure’s intrinsic care, outcome can be seen as change in the health
value. Simply believing in the treatment creates of an individual which is likely to be due to the
benefit, and this contributes to the total effect. The therapeutic intervention.
placebo response, however, is not the same as Outcome is measured by an instrument which
spontaneous improvement. It may produce the might be a questionnaire or other measuring tool
same result, but whereas spontaneous improvement and the results then undergo analysis in order to
is unrelated to treatment, the placebo response determine the degree to which the intervention
is an intrinsic feature of treatment. The placebo was responsible for any change in the health status
effect should be borne in mind in clinical work, of the individual.
while in research it must be controlled for. Outcome measures can be objective or subjec-
tive. Objective measures include quantifiable fac-
tors such as arterial blood gas levels; subjective
CLINICAL AUDIT measures include on the one hand, the level of
pain experienced by the patient, and on the other,
Clinical audit consists of the systematic analysis of observational judgements made by the therapist
procedures used for diagnosis, care and treatment (Barnard & Hartigan 1998).
(Department of Health 1994). It poses questions Tools for measuring outcome are designed for
such as: different purposes, such as goal attainment, func-
●
tional status, pain levels or patient satisfaction
To what extent do these procedures benefit the
(Romain 1995). They may also vary in their range
patient?
●
of concern, i.e. be multidimensional or condition-
Do these procedures make the best use of
specific. An example of a multidimensional
resources?
●
outcome measure is the Short Form 36 (Ware &
Can this service be improved?
Sherbourne 1992) which assesses physical and
Audit assesses the effectiveness of a particular mental components of health, giving an indication
intervention in a particular context or location and of quality of life; an example of a condition-specific
acts as a guide in the planning of services. As well outcome measure is the Self-esteem Inventory
as measuring the effects of clinical practice, it is (Rosenberg 1965) which focuses on one particular
concerned with issues such as resource allocation area of mental health. Since a treatment outcome
and may be used to highlight a need for depart- can have several aspects, the question can be
mental funding. This distinguishes it from research answered more fully if a variety of measures are
whose aim is to generate new knowledge or to test used. Some examples of standardized devices for
old knowledge and methods of treatment, seeking measuring therapeutic outcome may be found in
to identify the most effective intervention. Put Appendix 2.
another way, audit examines existing practice It can be seen that the same devices may be used
while research defines best practice (Sealey 1999). for assessing the patient’s progress as for auditing
However, there is an interaction between audit and the service or conducting research. For example,
research in that the standards by which clinical an instrument such as the Beck Depression
practice is measured are established mainly from Inventory can be useful in all contexts. To make
the research literature (Barnard & Hartigan 1998, outcome measurement as accurate as possible,
Bury & Mead 1998). This relationship underlies the certain criteria must be fulfilled (Donaghy 2001).
principles of evidence-based practice. The measuring device should be:
Further reading
For assessment and research Bury T J, Mead J M (eds) 1998 Evidence-based health care: a
Barnard S, Hartigan G 1998 Clinical audit in physiotherapy: practical guide for therapists. Butterworth-Heinemann,
from theory into practice. Butterworth-Heinemann, Oxford
Oxford Tansella M, Thornicroft G (eds) 2001 Mental health outcome
Bowling A 1997 Measuring health: a review of quality of life measures. Gaskell, London
measurement scales. Open University Press, Buckingham
Bowling A 2001 Measuring disease: a review of disease-
specific quality of life measurement scales, 2nd edn.
Open University Press, Buckingham
Acknowledgement
The author is indebted to Ian Hughes for his advice on this
chapter.
229
Chapter 27
INTRODUCTION
CHAPTER CONTENTS
Introduction 229 There is a pressing need for therapists to demon-
strate the effectiveness of their treatments, not only
What is the evidence? 230 to serve the client in the best way but also to val-
Anxiety 230 idate their work. Carefully designed and rigor-
Panic disorder 231 ously executed studies, repeated many times, help
Depression 231 to build a robust foundation of effective treatments
Headache and migraine 231 which contribute to the current best practice.
Asthma 232 Much work has been done to measure the effect
Insomnia 232 of different methods or to weigh up relaxation
Hypertension and cardiac rehabilitation 233 training against other approaches such as cogni-
Pain 233 tive treatment, exercise or pharmacology. The
Cancer 234 results are, however, beset by methodological
Pre- and post-surgery 235 shortcomings; moreover, the diversity of method-
Alcohol misuse 235 ologies makes it difficult to compare one study
Menopause 235 with another (Donaghy & Morss 2000). Kerr (2000)
Epilepsy 236 reports that all techniques have the potential to
Learning disabilities 236 reduce indicators of stress, whether physiological
Athletic injury 236 or psychological, thereby suggesting benefit; how-
Chronic fatigue syndrome and ever, regarding the superiority of one technique
fibromyalgia 236 over another, no clear picture emerges. In her
HIV/AIDS 237 review, Kerr (2000) lists some of the reasons
Occupational stress 237 for this: variations in sample size, varied dur-
Different forms of research 237 ations of the intervention and different outcome
measures. Only further research can resolve these
Some pitfalls of research in this field 238 matters.
While assessment measures the relaxation
achieved in the individual, research tests the gen-
eral value of the relaxation method. Among the
questions asked by the researcher are:
● Is method X useful in condition A?
● Is it more effective than method Y?
230 MISCELLANEOUS TOPICS
Since this review, Sartory and colleagues (1998) pharmacological treatment. Thus, a stress-relieving
have published a study involving 43 children, technique was shown to be effective in this sub-
aged 8–16 years, with migraine, in which three group, leading the authors to conclude that pro-
different strategies for reducing the frequency, gressive relaxation training could be a useful
intensity and duration of children’s headaches intervention for people whose asthma was associ-
were tested. Of the three strategies, the most suc- ated with stress. They further suggested that,
cessful one was found to be relaxation training, before treatment programmes were drawn up, it
followed by cephalic vasomotor feedback, with might be useful to identify those asthma sufferers
beta-blockers taking third place. whose attacks were triggered by emotional
factors.
Evidence regarding the effectiveness of relax-
ASTHMA
ation training in adult asthma is presented in a
A number of non-pharmacological treatments paper by Ritz (2001, p. 659) in which he discusses
are offered to asthma sufferers. These include relax- possible mechanisms. In the case of progressive
ation therapy, biofeedback, educational self- relaxation training, he suggests that it might be
management and family therapy. In their review of the tensing component rather than the release
scientific work in the area, Lehrer and colleagues component which is useful in relieving asthma
(1992) found that relaxation therapy occasionally since tensing is associated with excitation of the
produced some significant effects, in particular sympathetic nervous system, one of whose func-
with the use of progressive relaxation. While not all tions is to open the airways. By contrast, the
results reached levels of statistical significance, they release component is associated with parasympa-
did consistently lie in that direction, which led the thetic influence and a restriction of airflow.
reviewers to suggest that relaxation therapy be
seen as a useful adjunct to medical management of
INSOMNIA
the condition. A recent systematic review (Huntley
et al 2002) drew similar conclusions and singled out Interventions for the relief of insomnia have typ-
muscular relaxation as conferring more benefit ically been pharmacological. However, a wide
than other forms of relaxation training. In general, range of non-pharmacological treatments exist in
however, the evidence in favour of relaxation train- the form of sleep hygiene techniques, stimulus
ing in the management of asthma was not strong. control instruction, sleep restriction, chronother-
Reviewers point to the poor quality of many of the apy, relaxation therapy, biofeedback, paradoxical
studies and the problems inherent in this field of intention and cognitive therapy. These approaches
study – factors which make it difficult to draw firm are popular with people who fear the possibility
conclusions. of drug side effects and dependency, which can
It is possible that some asthma sufferers are occur with many pharmacological remedies.
more responsive to relaxation training than In their review of the relevant literature,
others. This might suggest that stress plays a part Bootzin & Perlis (1992) indicated the particular
of varying importance as a trigger of attacks. To benefit of stimulus control, an approach which
test this hypothesis, Vazquez & Buceta (1993) is concerned with the setting up of sleep/wake
highlighted a sub-group of people whose attacks patterns such as using the bedroom exclusively
were triggered by emotional factors. Focusing on for sleep, rising at the same time every day and
children with light to moderate degrees of asthma, avoiding a daytime nap. Relaxation training was
these researchers found that participants who dis- also shown to have value, and the same reviewers
played emotionally triggered attacks, and who referred to one of the better designed studies in
were treated with progressive relaxation training, which the effectiveness of progressive relaxation
experienced significantly shorter durations of training as a sleep-inducing technique was
attack and significantly greater increases in demonstrated.
peak expiratory flow rate than those who dis- Other reviewers (Richmond et al 1996) weigh-
played emotionally triggered attacks and received ing the evidence in respect of insomnia report
Evidence from research 233
that, although relaxation training can be effective, (Yucha 2001). These reviewers concluded by
its benefits seem to be confined to certain aspects urging health care professionals to offer relaxation
of sleep. In their opinion, meditation produces techniques as a treatment adjunct to their hyper-
good results, which are sometimes better than tensive clients.
those produced by muscular methods. Overall, In the management of essential hypertension
however, they agree with Bootzin & Perlis (1992) it has been shown that the risk factor with the
that stimulus control is a highly effective non- strongest and most consistent correlation (apart
pharmacological treatment for insomnia. from age) with blood pressure is weight (Anand
1999). A cognitive behavioural approach with
relaxation component would seem an appropriate
HYPERTENSION AND CARDIAC
way to address this problem.
REHABILITATION
Relaxation training has also been studied with
Relaxation training has been extensively studied regard to its usefulness following myocardial
with respect to its effectiveness in reducing blood infarction. In a study involving 156 patients, post-
pressure. This literature was reviewed by infarction hospitalizations were shown to be
Eisenberg and colleagues in 1993. From a pool of reduced by 31% following a relaxation programme
800 published works, 26 met the strict criteria of (Van Dixhoorn 1997). The authors suggest that the
the authors, and these 26 covered such approaches addition of such procedures to cardiac rehabilita-
as meditation, muscle relaxation and biofeedback. tion might favourably influence the course of the
Meta-analysis revealed that these interventions underlying disease.
were more effective than no therapy, but not more King et al (2002) reviewed the research on tran-
effective than credible sham techniques. This sug- scendental meditation in the treatment and
gested that the effect of relaxation training was prevention of coronary heart disease. In their con-
primarily that of placebo. Thus it seemed that the clusions they found a measurable association
benefits of relaxation training for reducing blood between transcendental meditation and decreased
pressure were, at best, modest, and the authors hypertension together with indications that the
concluded that anti-hypertensive pharmacother- approach had potential as a preventive strategy
apy had more to offer. for coronary heart disease.
By contrast, the findings of a large study con- People with cardiovascular problems can
ducted in Taiwan were more supportive of the benefit from interventions which modify their
claims made for relaxation training. In a trial con- autonomic changes. Studying ways of reducing
sisting of 590 hypertensive people, Yen and col- the intensity of sympathetic responses to environ-
leagues (1996) found progressive relaxation and mental stimuli, Lucini and colleagues (1997) com-
meditation to be more effective than either regular pared a combination of muscle relaxation and
blood pressure monitoring or self-learning pack- breathing awareness with beta-adrenergic block-
ages, although all interventions significantly ade and found them equally effective, and signifi-
reduced systolic blood pressure. Further support cantly more effective than sham training. This
has come from the findings of a study which set apparent capacity of relaxation techniques to
out to explore the relative effectiveness of two blunt excitatory autonomic responses has implica-
relaxation techniques. Salt & Kerr (1997) found tions for behaviour in all situations which the
that both progressive relaxation and the Mitchell individual finds challenging.
method were significantly more effective than
supine lying at reducing systolic blood pressure
PAIN
(Ch. 10, p. 90).
Biofeedback-assisted relaxation training is A widely adopted view sees the perception of pain
another approach which has resulted in signifi- as governed by a neural ‘gate’ in the spinal cord
cant reductions of systolic and diastolic blood (Melzack & Wall 1965). When this gate is open it
pressure as was demonstrated in a meta-analysis allows signals from the pain receptors on the skin
of randomized controlled clinical trials on adults to pass to the brain, exposing the individual to the
234 MISCELLANEOUS TOPICS
full experience of the pain; however, signals sent colitis where as many as six out of seven pain out-
down from the cortex can close the gate, thereby come measures showed relaxation training to be
reducing the perceived intensity of the pain. For significantly more effective than being in a waiting-
example, if you are enjoying a film, you will be list control group. (In this study, progressive relax-
less inclined to notice bodily irritations that might ation was the technique used.) One cancer pain
otherwise claim your attention. Most non- study showed a significant reduction in pain sen-
pharmacological pain relief can be explained by sation scores where relaxation was taught by the
the gate theory. nurses on the ward.
Seers & Carroll (1998) singled out the effects of Carroll & Seers conclude that there is not
relaxation training in a review of the literature in enough evidence to state that relaxation can, by
the context of acute pain, i.e. pain experienced fol- itself, reduce chronic pain; however, it does seem
lowing surgery or during procedures. They exam- to be a useful component of treatment when used
ined seven randomized controlled trials where in combination with other cognitive behavioural
relaxation was the only intervention and found strategies (Carroll & Seers 1998, Johnstone et al
that three of them showed a significant reduction 2002).
of pain sensation and pain distress while the other Chronic pain featured as a topic of discussion
four demonstrated no difference. The reviewers among the 12 members of a panel set up to con-
concluded that while there is some evidence to sider the merits of behavioural and relaxation
support the use of relaxation techniques in acute approaches (Richmond et al 1996) (see section on
pain, that evidence is not strong and, in the pres- insomnia). The members represented different
ent state of knowledge, relaxation training should fields of medicine. In their conclusion relating to
therefore be seen as an adjunct rather than a prin- chronic pain, the panel indicated the clear benefit
cipal form of treatment in the management of of relaxation training over a wide spectrum of
acute pain. However, many patients are reluctant medical conditions where, in many instances, the
to rely too heavily on analgesics, and for them it evidence was judged to be quite strong. They also
could be a useful alternative. found relaxation approaches to be more effective
It was not possible to compare the various tech- than other cognitive behavioural methods and
niques for effectiveness because in most of the biofeedback. Regarding the choice of technique,
studies they were used in combinations. there was no indication that any one method was
A second review was conducted by the same more successful than another for reducing pain in
two researchers, with the focus of interest this a given condition.
time on chronic pain (Carroll & Seers 1998). The Thus, it would seem that relaxation techniques
studies covered a range of conditions but all used in general have a place, if a modest one, in the
relaxation training (in different forms) as the sole management of chronic pain.
intervention. Nine randomized controlled trials
met the inclusion criteria. Chronic pain levels,
CANCER
which in most cases were measured on the McGill
Pain Questionnaire (Melzack 1975), were lowered There is a large body of research focusing on the
following training and, in four of the studies, pain and distress associated with different forms of
showed a significant difference between pre- and cancer. Wallace (1997) examined the effect of relax-
post-test scores. Three studies comparing relax- ation and imagery within this context. In her
ation with other treatments reported significant review of studies, which included a variety of tech-
findings in favour of relaxation training. niques and combinations, she could find few that
Some studies showed relaxation training to be were without methodological flaw. However,
particularly effective in certain conditions, for in spite of such weaknesses, a trend of benefit
instance in rheumatoid arthritis where subjective emerged in the sense that relaxation and imagery
ratings of pain were significantly lower following seemed to reduce the sensory experience of pain.
training in the relaxation group than in the More recently, Ernst et al (2001) referred to the com-
routine-treatment control group; and in ulcerative plementary therapies as having some potential for
Evidence from research 235
benefit in palliative cancer care and Sloman (2002) intervention groups but very little difference
found significantly positive changes in quality between them.
of life resulting from such therapies. In the field of cardiac surgery, Halpin et al
Some authors have explored ways of relieving (2002) showed that patients treated with guided
the distress following chemotherapy. One such imagery before and after surgery had a shorter
study (Vasterling et al 1993) examined the relative length of stay in hospital and a reduced level of
values of cognitive distraction (video games) and pain medication, while high overall patient satis-
relaxation training (progressive relaxation and faction was maintained.
guided imagery) in this context. Both interven-
tions resulted in less nausea and showed lower
systolic blood pressures than the control (no inter- ALCOHOL MISUSE
vention), while the relaxation group exhibited
Problem drinking is a condition that seems to
reduced diastolic blood pressures in addition.
respond better to exercise than to relaxation train-
Although significance was not always achieved,
ing (Donaghy et al 1991). However, relaxation
the authors suggest that relaxation may have a
training may have a place in helping to alter the
useful adjunctive role to play in the relief of dis-
individual’s locus of control. This refers to the
tress caused by chemotherapy.
degree to which events are viewed as being within
Relaxation training with imagery has been the individual’s control: an internal locus implies
associated with increases in survival duration. a strong sense of personal control; an external
Spiegel & Moore (1997) followed up 86 women locus implies a tendency to believe that events are
from a previous randomized trial and found that controlled by factors outside the individual. The
group therapy over the period of a year was not alcohol misuser is inclined to be more external in
only supportive, as described by the participants, her locus of control than others; therefore, a treat-
but was related to significant increases in length ment which could increase her sense of personal
of survival time. The groups, which met at weekly control might be helpful to her.
intervals, received various forms of relaxation This topic interested Sharp and colleagues
training together with healing imagery. (1997) while they were working with young resi-
dents in North American treatment centres. Using
PRE- AND POST-SURGERY autogenic training with biofeedback, these authors
showed that relaxation techniques could increase
Relaxation training can help people manage the
the individual’s sense of internal locus. They con-
distress they experience before and after surgery.
cluded that autogenic therapy might be a useful
Petry (2000), in her review of complementary
component of the total treatment package for
therapies, indicates the benefit of such strategies
young misusers of alcohol.
for the well-being of the client. She also points to
Relaxation training has also been shown to help
the advantage of such interventions in reducing
alcohol misusers through periods of insomnia. In
the need for pain-relieving medication. It is further
their study of 22 adults, Greeff & Conradie (1998)
suggested that immune function, stress hormone
demonstrated significant improvements in sleeping
levels and wound healing may also benefit from
patterns and in the quality of sleep following a pro-
the effects of relaxation strategies. Among the tech-
gramme of progressive relaxation training.
niques considered in Petry’s article are muscular
routines and imagery.
Some researchers have suggested that music
MENOPAUSE
might help provide pain relief. Good et al (2001)
tested this hypothesis during the first 2 days The efficacy of relaxation training has also been
following surgery. Four hundred and sixty-eight investigated in conditions relating to women’s
participants were divided into four groups: relax- health. One of these is the menopause. Irvin and
ation, music, their combination and a control. colleagues (1996) studied the effects of instruction
Results showed significant effects in all three in Benson’s method on a volunteer sample of
236 MISCELLANEOUS TOPICS
women aged 44–66 years who were not using hor- Long-term injuries are known to lower the
mone replacement therapy. mood of injured athletes. In an attempt to find a
Results showed a significant reduction in hot way of raising that mood level, Johnson (2000)
flush intensity, tension–anxiety and depression in studied the effect of different short-term inter-
the group receiving relaxation training, while a con- ventions such as stress management, goal-setting
trol group with whom they were compared showed skills and relaxation training with guided
no reduction. In their conclusion, the authors sug- imagery. Of the three interventions, the only one
gested that daily practice of Benson’s method might to show statistical differences was relaxation train-
help to reduce symptoms of the menopause and ing with guided imagery.
could be particularly useful for women who do not Imagery is widely used in sport, and particu-
wish to use hormone replacement or whose health larly by athletes in training and competition. Both
status precludes its administration. cognitive and motivational forms of imagery are
practised (Ch. 18, p. 169). When athletes are
injured they also use healing imagery which has
EPILEPSY been found to be associated with reduced pain,
Seizure reduction has been associated with regu- anxiety and distress, with accelerated healing and
lar practice of relaxation techniques, as in the con- improved immune responses (Sordoni et al 2002).
trolled study of Puskarich et al (1992). Progressive
relaxation training was the method employed. Of CHRONIC FATIGUE SYNDROME AND
the 13 participants who received the intervention, FIBROMYALGIA
11 experienced a reduction in seizure frequency,
while only 7 out of 11 in the control group of quiet Chronic fatigue syndrome (otherwise known as
sitting showed a decreased frequency. This sug- myalgic encephalomyelitis) is a condition in
gests that the technique might be a useful adjunct- which the predominating symptom is tiredness in
ive procedure for some people with epilepsy. the absence of previous exertion. Price & Couper
Moreover, it is non-invasive, inexpensive and (2000) conducted a systematic review of studies
gives the client a sense of being in control. with adults which provided evidence of the bene-
In discussing the mechanism by which seizure fit of cognitive behaviour therapy in this condi-
frequency is reduced in this study, the authors tion. In three of the trials greater benefit was
propose that relaxation acts as a mediating factor, demonstrated from this method of treatment than
diminishing the impact of the stressor. from orthodox medical management or from
relaxation. Other researchers, for example Fulcher
& White (1998), report that graded exercise and
LEARNING DISABILITIES physical activity are effective approaches. The
conclusion reached by Everett (2003, p. 257) is that
(See Ch. 9, p. 81)
both cognitive behaviour therapy and graded
exercise can be useful approaches in the treatment
of chronic fatigue syndrome.
ATHLETIC INJURY
Fibromyalgia is a chronic disorder characterized
Athletic injury carries with it a number of stresses. by a variety of symptoms which include aching
In addition to the fear of pain and the fear of non- muscles, general fatigue, sleep disturbances, anxi-
recovery there is the fear of re-injury when play ety and bowel problems. Many of these symptoms
is resumed. Cupal & Brewer (2001) studied the resemble those of chronic fatigue syndrome with
effects of relaxation and guided imagery in 30 par- which the condition is sometimes confused.
ticipants undergoing rehabilitation following Research into fibromyalgia syndrome has been
anterior cruciate ligament reconstruction. Among systematically reviewed by Sim (2002). It indicates
the positive effects demonstrated at 6-month an absence of strong evidence for any single non-
follow-up was a significantly reduced level of pharmacological intervention in the treatment
re-injury anxiety and pain. of this condition, although there was some
Evidence from research 237
preliminary support for aerobic exercise. A system- Tsai & Swanson-Crockett (1993) studied the effects
atic review in the preceding year (Oliver et al 2001) of breathing, imagery and meditation on 68
found cognitive behaviour therapy effective. Chinese nurses in Taiwan who practised these
methods regularly for 5 weeks. At the end of this
time, the stress scores of the participants were
HIV/AIDS
found to be significantly lower than those of the
It has been shown that cognitive behavioural pro- control group members who attended lectures on
grammes which include relaxation techniques can the theory of nursing. Thus, it seems that relax-
have favourable results, both psychological and ation training may have a part to play in the con-
physical, in HIV disease. Such outcomes represent trol of occupational stress.
an improved quality of survival time in individ- However, research is not marked by consistent
uals found to be HIV-positive. Several randomized findings. The overview of Van der Hek & Plomp
controlled trials have shown significant reductions (1997) was conducted in the hope of clarifying the
in anxiety and distress, while at the same time picture and singling out the most successful
improving mood and self-esteem (Taylor 1995, approach. In the event, this proved an impossible
Lutgendorf et al 1997). A decrease in the severity task since the different studies had varying tar-
of physical symptoms was also reported by these gets; for example, it was difficult to compare the
authors, who demonstrated significantly lowered effects of a procedure which addressed the indi-
herpes simplex virus type 2 antibody titres vidual and her subjective experience of stress with
(Lutgendorf et al 1997) and significantly raised those of a different procedure where the central
T-cell counts (Taylor 1995) resulting from such concern was with attendance rates and productiv-
programmes. ity levels. Conclusive evidence, therefore, awaits
In the case of Lutgendorf et al’s participants, further work.
the more consistently they practised the relaxation
technique, the more their distress was relieved.
The study ran for 10 weeks. Taylor’s participants, DIFFERENT FORMS OF RESEARCH
who had trained for 20 weeks using progressive
relaxation, meditation, biofeedback and hypnosis, While research is not the only source of evidence
demonstrated significant improvement which for the value of relaxation training, it is the princi-
was maintained at follow-up 1 month later. pal one, enabling the health care professional to
These researchers suggest that relaxation is a provide the best treatment. Other sources include
useful component of treatment for people diag- clinical experience, expert consensus, reflective
nosed as HIV-positive. practice, patient assessment and patient prefer-
ences (Bury & Mead 1998).
Evidence of effectiveness is most valued in the
OCCUPATIONAL STRESS form of the review, which collects and scrutinizes
The Health and Safety Executive report that half a relevant studies. Reviews may vary in terms of sci-
million people every year suffer from the effects entific rigour, the most respected one being the sys-
of stress at work (Frontline 1999). From a large tematic review. Here, strict criteria are laid down,
number of published studies on the subject of i.e. the databases employed are to be cited, the
occupational health, the most successful pro- years which relate to the search stated, the number
grammes seem to be those which not only involve of papers involved recorded, the basis on which
the entire organization and have the full support the selection was made stated and the key words
of management, but also engage the cooperation listed. A critical review is also a useful document. It
of the workforce during the planning stage is often described as a narrative review and tends
(Van der Hek & Plomp 1997). to express the opinion of the researcher. Critical
Several studies have been designed with reviews can vary in quality. Another type of review
a strong relaxation component which typically is the overview which is a description of key find-
consists of varying combinations of techniques. ings (M. Donaghy 2004, personal communication).
238 MISCELLANEOUS TOPICS
Appendix 4 contains a list of the reviews referred more effective than another. Lichstein (1988),
to in the text and includes all three kinds. reviewing studies on progressive relaxation, auto-
Individual studies can also be classified in genic training and meditation, points out that this
terms of scientific rigour. Here, the most highly conclusion may not, for several reasons, reflect
respected form is the randomized controlled trial the true picture. Research in this area is compli-
(RCT). A hypothesis is first formulated and tested, cated by a number of factors related to procedural
then the data are analysed for statistical signifi- variability (Hillenberg & Collins 1982, Lichstein
cance. A well-designed RCT will fulfil the follow- 1988):
ing criteria. It will:
1. different methods of delivery: ‘live’ or taped
● contain a control group which does not receive 2. different number of training sessions
the intervention and acts as a baseline 3. variations in amount of home practice
● adopt a randomized process both for the selec- 4. variations in interpretation of the procedure.
tion of participants and their assignment to
particular groups
●
1. Different methods of delivery
be designed so that the results can be statis-
tically analysed The procedure may be ‘live’ or taped. Early
● consist of a sample large enough to have a research supported the view that a ‘live’ delivery
chance of reaching statistical significance was more effective than a taped one for reducing
● carry a precise description of the intervention tension levels (Paul & Trimble 1970). A more
so that the study can be replicated recent study (Sloman et al 1994), however, has
● be free of bias and order effects which may demonstrated equal benefit from both ‘live’ and
confound the results. taped delivery in a hospital oncology ward. The
taped delivery has the advantage of standardizing
When these criteria are not met the study is said
the procedure and, by this means, promoting
to be methodologically flawed, which means that
reliability.
the results lose some of their credibility. However,
it is not always ethical or appropriate to use the
randomized controlled trial as a design, and in 2. Different number of training sessions
these situations other forms of trial may be adopted
Studies offer varying amounts of training. The
such as non-randomized controlled studies and
more lessons a participant receives, the more
single system studies. The experiment, however,
skilled she is likely to become in the technique
is not the only way to answer a question in research:
under investigation, where results will be influ-
a qualitative approach, in which descriptive data
enced accordingly.
are collected, can also provide useful information
and may be the method of choice where the func-
tion of research is one of exploration (Sim 1999). 3. Variations in amount of home
Interviews can be employed here. practice
Wherever subtleties in the therapeutic situa- It is believed that home practice is given inad-
tion are being studied, the qualitative approach equate attention (Hillenberg & Collins 1983).
has much to offer. It reflects the lived experience Reasons which may account for this phenomenon
of clients (Gibson & Martin 2003). Qualitative include failure of the therapist or researcher to
methods can also be used to complement the convey its importance, misunderstanding by the
findings of experimental work, thereby building participant of the nature of the technique or disin-
up a more complete picture. clination to carry it out. If, however, the technique
is practised more frequently, the effect it creates
SOME PITFALLS OF RESEARCH IN is increased (Borkovec & Mathews 1988). Most
THIS FIELD writers recommend two practice periods a day, each
lasting 15–20 minutes, accompanied by some kind
With regard to the different relaxation approaches, of self-monitoring system to ensure that they are
research does not show one method to be any carried out and to record their effect.
Evidence from research 239
Further reading
Bowling A 1997 Research methods in health: investigating physiotherapists and occupational therapists.
health and health services. OUP, Buckingham Butterworth-Heinemann, Oxford
Bury T J, Mead J M (eds) 1998 Evidence-based health care: French S, Reynolds F, Swain J 2001 Practical research: a
a practical guide for therapists. Butterworth-Heinemann, guide for therapists. Butterworth-Heinemann, Oxford
Oxford Hammell K W, Carpenter C M, Dyke I 2000 Using qualita-
Crombie I K 2000 The pocket guide to critical appraisal. tive research: a practical introduction for occupational
BMJ Publishing Group, London and physical therapists. Churchill Livingstone,
Donaghy M, Durward B 2000 A report on the clinical Edinburgh
effectiveness of physiotherapy in mental health. Polgar S, Thomas S A 2000 Introduction to research in the
Chartered Society of Physiotherapy, London health sciences, 4th edn. Churchill Livingstone,
Everett T, Donaghy M, Feaver S (eds) 2003 Interventions Edinburgh
for mental health: an evidence-based approach for
241
Chapter 28
combinations are drawn. The first is for mental EXAMPLE OF A SCRIPT CONTAINING
stress, the second is for physical tension. A VARIETY OF APPROACHES
1. ‘Changing channels’: As well as grouping different techniques together,
a. attention-switching (Appendix 1), several techniques can be worked into a single
b. guided imagery (Ch. 17, p. 157) and passage as shown here.
c. coping mantra, e.g. ‘I am at peace’ (Ch. 20, Please lie down. Get yourself comfortable. Allow
p. 188). your eyelids to grow heavy and eventually to close.
2. ‘Stretch and relax’: Feel the rest of your body also growing
a. stretchings (Ch. 13), heavy … feel it sinking into the rug or the uphol-
b. abdominal breathing (Ch. 15, p. 132) and stery … compressing the fibres … sinking down so
c. Mitchell’s method (Ch. 10). that more body area comes in contact with it … let
your weight flow out … feel your body totally freed
For groups of people with varied kinds of stress, from its responsibility to hold you up…
more general combined programmes can be built. Turn your attention to your breathing … without
A few examples are given below: attempting to alter its rhythm, become aware of the
1. Abdominal breathing (Ch. 15, p. 132), movement of your chest and abdomen … notice the
tense–release (Ch. 6) and guided imagery passage of the air … the coolness of the air entering
(Ch. 17, p. 157). your nostrils … travelling through your nose and down
2. Passive relaxation (Ch. 7), goal-directed visu- the back of your throat … notice also, the warm,
alizations using receptive and programmed moist air being exhaled … next time you breathe
components (Ch. 18) and self-statements out, think the word ‘relax’ … continue slowly…
(Ch. 18, p. 163). Now, I’d like you to scan your muscle groups one
3. Abdominal breathing (Ch. 15, p. 132), warmth by one, checking them for tension … adjust your
and heaviness phrases (Ch. 19) and differen- position if you are uncomfortable … starting with
tial relaxation (Ch. 12). the feet, notice how they rest heavily on the floor …
4. Passive relaxation (Ch. 7), Benson’s meditation heavy as lead … now your legs, imagine them too
(Ch. 21) and self-awareness exercises (Ch. 16). heavy to lift … your hips too are lying heavily … and
5. Behavioural relaxation training (Ch. 9, p. 77), your shoulders, feel how they are dropped down …
breathing meditation (Ch. 15, p. 133) and with your arms resting heavily by your sides…
guided imagery (Ch. 17, p. 157). Now, your head, let it sink back, giving its
6. Breathing pouch (Ch. 15, p. 133), eye and weight to the pillow, making a dent in it … feel your
tongue muscle work (Ch. 4, p. 38) and brow smoothed and your jaw relaxed … feel your
meditation on a visual object (Ch. 20, p. 185). whole body heavy, warm and relaxed … if tension
returns, just let it go … let it flow out through your
Set patterns will not suit everyone since the needs fingertips and toes…
and preferences of each person are different. Davis Transfer yourself in your mind’s eye to a sandy
et al (2000) urge people to construct their own beach … see yourself lying in the soft sand … run
combination of techniques. your fingers through the dry grains … smell the sea
Although client preferences cannot be predicted, air … feel the hot sun on your skin … listen to the
it is clear that they exist (Fanning 1988, Kutner & waves breaking on the shore … enjoy the peace … if
Zahourek 1988, Lichstein 1988, Payne 1989). In the disturbing thoughts intrude, accept that they
author’s experience it is useful to ask the client exist … then let them drift away like clouds passing
which techniques best suit her. Involving the across the sky … you’ll attend to them later…
client in the choice of technique, as in other When you are ready, let the scene fade … gradu-
aspects of therapy, enriches the treatment. All this, ally bring your attention back to the room in which
of course, means that therapists may need to learn you are lying … count one … two … three … and
several methods in order to respond to the client’s slowly open your eyes … then give your arms and
needs. legs a gentle stretch…
244 MISCELLANEOUS TOPICS
Further reading
For combinations of techniques For other methods of achieving relaxation
Davis M, Eshelman E, McKay M 2000 The relaxation and Sutcliffe J 1991 The complete book of relaxation techniques.
stress reduction workbook, 5th edn. New Harbinger, Headline, London
Oakland, California
247
Appendix 1
Among the many devices for distracting the atten- excluded. It helps if the item is made as vivid as
tion away from disturbing thoughts are the cogni- possible, and this is done by bringing out its sensory
tive techniques of attention switching and thought detail (the sights, sounds, smells, textures, etc.).
stopping. Work through the list every day for a week.
When you feel you have built up the skill, try
deliberately introducing the disturbing thought;
ATTENTION SWITCHING give it a moment to take shape, then abruptly
replace it with the next item on your list.
This technique consists of giving attention to par- In this way you cultivate the ability to control
ticular items for specified lengths of time. The your thoughts. You may not be able to stop
individual spends 15–20 seconds exclusively uncomfortable thoughts entering your head,
thinking about a prearranged item, then abruptly but you can decide how much attention you
switches to another prearranged item for the same give them.
length of time. If a stopwatch is not available, she
The ability to control the thoughts is present in
guesses the times. The items range from pleasant
every person. Attention switching simply helps to
to neutral. The next stage is to deliberately intro-
strengthen it. Widely used as a technique, it offers
duce the disturbing thought, let it take shape, and
most benefit to people who have a facility for
as soon as it does, to replace it with a pleasant or
creating visual imagery.
neutral thought. The method may be described to
the participant as follows:
Make a list of topics that are pleasant (such as THOUGHT STOPPING
hobbies, holidays, happy experiences) or neutral
(such as the weather, telephone numbers, geometric Thought stopping (Quick & Quick 1984) intercepts
shapes); say, 10 examples of each. Take the first one stress-inducing thoughts and substitutes stress-
on the list and focus attention on it for 20 seconds. relieving ones. The technique involves the word
At the end of that time abruptly switch your atten- ‘STOP’, spoken or imagined, but in such a way that
tion to the next item. Concentrate on this for 20 it momentarily blots out the disturbing thought.
seconds, then switch to the next item, working your This is immediately replaced with an idea or activ-
way through the list. The object is to concentrate so ity which diverts and holds the attention, such as
firmly on the item that all other thoughts are counting games, puzzles or physical exercise.
248
Appendix 2
The Profile of Mood State (McNair et al 1992) Rosenberg Self-Esteem Inventory (Rosenberg 1965)
Multiple Affect Adjective Check List (Herron 1969) Physical Self-Perception Profile (Fox &
Corbin 1989)
Appendix 3
Appendix 4
Appendix 5
Glossary
Bio-psycho-social this approach gives weight to Beck Depression Inventory, where the severity
psychosocial aspects as well as biological ones. of the condition can be classified into mild,
medium and severe.
Blinding this is a condition built into the study
design whereby participants are kept in igno- Cognitive behavioural therapy is an approach
rance of the group they are in: experimental or which teaches cognitive and behavioural skills
control. When the researchers are also in igno- to enable individuals to function adaptively.
rance of this fact the situation is called double- Patient and therapist are engaged in a collabo-
blind. Single- and double-blinding are techniques rative effort to address and solve or alleviate
for reducing the risk of bias in the results. the patient’s problem. The therapy is of pre-
Catecholamines these include adrenaline, nora- determined and short duration and is focused
drenaline and dopamine. They play an impor- on the patient’s current circumstances.
tant role as neurotransmitters in the functioning Cognitive restructuring this involves a re-
of the autonomic and central nervous systems. evaluation of a person’s perception of danger or
Catharsis in psychoanalytic theory, this refers vulnerability and a questioning of the beliefs
to the release of tension which occurs when which underlie it. The technique consists of
repressed thoughts are brought into cons- three stages: identifying negative thoughts,
ciousness. challenging their accuracy and replacing them
with constructive alternatives based upon new
Centring refers to the focusing of attention on the judgements about the degree of risk.
interior of the self. To achieve this state all exter-
nal stimuli must be disregarded. The purpose is Confidence interval is the distance between an
to find and make contact with the essence of the upper and a lower point between which the
self. true result lies with a probability of 95%.
Presented in this way the result assumes a
Clinical depression is depression that requires
range of possibilities. A narrow range will indi-
clinical intervention. The question is, at what
cate a more precise result than a wide one.
level of severity should this be introduced?
Some clinicians define clinical depression as Control group a basic scientific study will con-
persistent low mood, low enough to interfere sist of two groups, resembling each other in as
with daily life and lasting more than two many ways as possible. One of these is the
weeks. Others, including researchers, look for experimental group. This group receives the
numerical ratings which are obtained through intervention; the other group is the control
standardized screening devices, such as the which does not receive the intervention. The
258 GLOSSARY
control thus provides a baseline against which Meta-analysis is a statistical technique which
to measure the effects of the intervention. collates and analyses the findings of many dif-
Epidemiology is the study of diseases in popula- ferent studies and identifies trends in outcome.
tions and is concerned with the cause of the dis- Mindfulness this refers to the experience of
ease and the way the disease is distributed being in the here-and-now.
within a given population.
Motor skill refers to a skill which involves phys-
Evidence-based practice is practice informed by ical movement.
research findings. It consists of procedures which
Number needed to treat (NNT) this represents
current evidence shows to be the most effective.
the number of people who would be needed in
Thus, it may be referred to as best practice.
an intervention group before one specific out-
Exposure techniques these are introduced to help come occurred. For example, in an experimental
individuals face situations which they find group of elderly women wearing hip protectors,
anxiety-inducing such as occur in panic and pho- the NNT is an estimate of how many partici-
bia. Exposure generally involves a hierarchy of pants would be necessary before one hip frac-
low-to-high-threat versions of this event. The ture was avoided. The NNT is one way of
individual is first presented with the item of low- presenting the effectiveness of a treatment.
est threat. With the help of a relaxation technique,
Outcome measuring devices are tools used for
she works to overcome her fear at that level.
measuring the results of interventions.
When she succeeds, she moves on to the next
level of threat, dealing with it in the same way. Pacing refers to the way a learning programme is
structured to allow for the varying level of skill
Fear-avoidance this is behaviour which the
in the performer. New material is introduced in
individual adopts to avoid situations which
a gradual and controlled way.
give rise to fear. However, by avoiding the situ-
ation, the fear attached to it mounts. Avoidance Pre-experimental studies here, a single system
may lead to an immediate sense of relief but such as a cohort is studied to explore an idea.
creates an increase in anxiety levels on the next The exercise helps in formulating a hypothesis
occasion of threat. The solution is to face the which may later be tested.
feared situation.
Quasi-experimental studies these bear some
Generalized anxiety disorder is characterized characteristics of a true experiment but lack the
by excessive worry, overtense muscles and full requirements of a randomized controlled
impairment of function, all of which have per- trial. They feature, for example, in research
sisted for at least 6 months and are not confined where randomization is not possible.
to any specific circumstances.
Randomization is similar to pulling names out of
Homeostasis the process whereby a balanced a hat except that it is done by a computer. In
state is maintained in body systems throughout psychosocial terms, it means that every member
varying external conditions. An example can be of the parent population has an equal chance of
found in the regulation of body temperature being selected for the sample. The same method
during extreme heat and cold. is then used to allocate participants to experi-
mental and control groups. Randomization
Hypothesis this is a statement which acts as a pro-
helps to ensure that the participants are repre-
visional explanation. In science a hypothesis
sentative of the population being studied.
must undergo a test, the findings of which will
tell the researcher whether the hypothesis has Randomized controlled trials these are studies
been supported or whether it should be rejected. which carry the full rigour of a scientific experi-
The conclusion reached, however, will only ment. Participants are selected by a random
apply within the context of the particular piece process and divided into two or more groups,
of research. one of which receives the intervention. The
Glossary 259
presence of a control is essential but it can take Skill this enables a person to achieve a goal with
different forms. a high level of certainty and an economy of
time and energy.
Reflective practice refers to the knowledge
gained from one’s experience in the past Somatization this is said to occur when an indi-
and the creative application of it in unfamiliar vidual complains of symptoms, such as pain,
situations. which cannot be explained in terms of organic
disease. It differs from hypochondriasis where
Reinforcement positive reinforcement is action the individual is constantly in fear of develop-
which increases the likelihood of a certain behav- ing a disease.
iour, for example, giving a dog a biscuit every
time it brings back a ball makes it more likely Standard deviation (SD) is a measure of the way
the dog will bring back the ball next time it is the scores are spread about the average score.
thrown. Range is also a measure of spread but it does not
reflect the way the scores are distributed, i.e.
Reliability refers to the consistency of results whether bunched close to the mean or more
when the test is repeated, either by the same spread out. The standard deviation expresses this
researcher on different occasions or by different feature in a single unit.
researchers on the same occasion.
States of altered consciousness these are states
Repression is a psychoanalytical concept in of mental functioning which are different from
which anxiety-inducing thoughts are prevented the ordinary pattern. Examples are: dreaming,
from reaching conscious awareness. drug-induced states, hypnotism, meditation,
daydreaming, deep relaxation, guided imagery.
Reviews scientific reviews collate the results of
all studies in a particular field. They are the Statistical significance means that there is a 95%
result of extensive literature searches and pro- likelihood that the result of the experiment is
vide the health care professional with the kind due to the manipulations of the experimenter
of information needed to form a view of the and not to chance factors. Expressed another
best treatment. way: the result achieved in the experiment could
only have occurred by chance in fewer than 5
Schizophrenia this condition is characterized by out of 100 cases.
symptoms such as hallucinations and thought
disturbances. It may also be accompanied by
Validity a test is valid when it measures what it
claims to measure. It has internal validity when
social withdrawal, low self-esteem, reduced
it is devoid of bias, and external validity when
motivation, emotional and attentional deficits
its results can be generalized to other situations.
and other symptoms of depression.
It has content validity when its components are
Self-efficacy is the feeling of having the ability representative of the item to be measured and
to deal with whatever one is faced with in life. face validity when it seems valid after superficial
In short, feeling competent. appraisal.
261
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279
Index
Applied relaxation (Öst’s method) breathing control 131, 137–138, 206 Benson’s relaxation response
contd. laughter therapy 215 191–192, 193
major principles 249 progressive relaxation 40 biofeedback-assisted relaxation
pitfalls 74 self-operations control 40 211, 233
rapid relaxation 68, 73 yoga 213 massage 210
rationale 68–69 Autonomy of individuals 19 measurement 225
release-only 68, 70–71 Autosuggestion 174 meditation 189, 191–192, 193, 233
settings for 70 muscular relaxation 40–41, 47–48,
tense–release 68, 70 56, 90
Aromatherapy 210–211 physical exercise 116, 117
Arousal after sessions see B stress 25, 27
Termination of sessions Body awareness 144–145
Arthritis 234 Back pain, massage 210 Feldenkrais relaxation 212
autogenic training 178 Beck, A T functional relaxation 212–213
Mitchell method 89–90 cognitive behaviour theory 10 meditation 184
PRT 47 cognitive theory 8–9, 12 Body awareness therapy 211–212
stress component 27 Beck Depression Inventory 223 Body–mind integration 93, 98, 157
suggested techniques 249 Behaviour theory/approaches 9–10, Body parts, meditation on 187–188
Assertiveness 9–10, 12, 145–146, 146 198 Body positions for relaxation 16
Assessment of patients see Patient distraction 9, 146–147 meditation 183, 192, 194
assessment muscular relaxation 68–69, 75–81 Body posture see Posture
Asthma 232 ‘specific effects’ hypothesis 10–11, Body scanning 64–65, 81, 183,
autogenic training 178 11, 12 205–206
functional relaxation 213 unitary models 10–11 Bone mineral density 117–118, 127
muscular relaxation 47, 232 see also Cognitive behaviour Bones, physical exercise 115,
parasympathetic activity 4–5 therapy 117–119, 127
stress component 27, 232 Behavioural Relaxation Scale (BRS) Borkovec, T D
suggested techniques 249, 250 79–80, 79, 226 differential relaxation 102
yoga 213 Behavioural relaxation training (BRT) PRT 43–48, 56–57, 74
Ataxic tremor 81, 249 75–81 relaxation through recall 60–61,
Athletics anxiety 80, 81, 230 205
goal-directed visualization 168, 169 assessing 79–81, 226 Brain injured people 81
injuries 236, 249, 250 checklist 76, 206 Brain laterality 150, 150, 182, 242
pitfalls 127 combined relaxation methods 243 Breathing 129–138
suggested techniques 249, 250 effectiveness 81, 230 abdominal 90, 132–133, 134, 137,
Attention switching 243, 247 indicated conditions 249 138, 206, 243
Attentional Behavioural Cognitive introductory remarks 76–77, 76 antenatal training 217–218
relaxation model 11 major principles 249 applied relaxation 71–72, 206
Audio-taped delivery 17, 238 ‘mini-relaxation’ 78–79, 103 baseline rate 79–80
Audit 227–228 on-the-spot use 206 ‘chi’ 133
Autogenic training (AT) 10, 11, pitfalls 79 combined relaxation methods 243
173–179 procedures 77–79 cue-controlled 71–72, 206
consciousness 173–174, 242 rationale 75–76 diaphragmatic see Breathing,
effectiveness 178, 235 settings for 76 abdominal
home practice 177–178 termination 78 effectiveness of routines 134, 231,
indicated conditions 250 Behavioural symptoms of stress 25 237
introductory remarks 175–176 Benson, H, relaxation response 4, 10, exploring respiratory movements
major principles 250 191–194, 235–236, 242, 243, 251 131
on-the-spot use 207 Bernstein, D A hyperventilation 27, 130–131, 132,
pitfalls 178–179 differential relaxation 102 134–138, 218
procedure 175–178 PRT 43–48, 56–57, 74 hyperventilation syndrome 135,
rationale 174–175 relaxation through recall 60–61, 137–138
similar approaches 241 205 indicated conditions 250
Automatic thoughts 8 Biofeedback-assisted relaxation major principles 250
Autonomic nervous system 4–5, therapy (BFB) 211, 231, 232, meditation 132, 133, 184–185, 194,
4–6, 233 233 243
autogenic training 175 Blame, avoidance of 28 Mitchell method 88, 89, 134
Benson’s relaxation response 191, Blood pressure 230, 233 on-the-spot techniques 206–207
192 autogenic training 178 Öst’s applied relaxation 71–72, 206
Index 281
out tension, in peace 132, 133 Chronic fatigue syndrome 199, 236, meditation 182, 189, 194
overbreathing see Hyperventilation 250, 251 self-consciousness 141
pitfalls of exercises 138 Chronic obstructive pulmonary see also Unconscious, the
in pregnancy 217–219, 220 disease 47, 249 Control
rationale for control of 131 Cigarette smoking 165, 166–168 of emotions 143, 144
rebreathing 137 Circle, meditation on 185 locus of 26–27, 142–143, 235
re-education 135–137 Client choice, establishing 20 Cooling down 127
relaxation principles 132 Clinical audit 227–228 Coping skills 4, 24, 28–29
relaxation routines 132–134, 138 Cognitive Anxiety Questionnaire 223 Coronary heart disease see Heart
respiratory mechanism 129–131, Cognitive behaviour therapy (CBT) disorders
130 10, 197–199 Cortisol 5–6
slow 131–132 effectiveness 198–199, 230, 231, Counting, relaxation through recall
t’ai chi ch’uan 215 233, 234, 236, 237 61, 205
tense–release exercises 50, 53 indicated conditions 251 Course programmes 20
underbreathing 130–131 major principles 251 Cramp 56
yoga 133, 213 Öst’s applied relaxation 68–69 Creep 105
Breathing awareness 131–132, Cognitive theory/approaches 8–9, Critical reviews 237, 252–253
218–219, 220 10, 197–198 Crying 171
Breathing cycle 207 attention switching 243, 247 Cue-controlled (conditioned)
Breathing meditations 132, 133, autogenic training 173–179, 207, relaxation 68, 71–72, 206
184–185, 194, 243 235, 241, 242
Breathing pouch 132, 133, 243 Benson’s method 191–194,
Brief relaxation, definition 13 235–236, 242, 243
see also On-the-spot techniques cognitive restructuring 8–9, 12 D
Burn-out, therapists’ 19 in combination 243
imagery see Goal-directed Daydreaming 171
visualization; Imagery Debriefing 17–18
indicated conditions 250–251 Decision making
C major principles 250–251 goal-directed visualization 168,
meditation see Meditation 169
Calcium, bone mineral density 118 on-the-spot use 207–208 self-awareness 141, 143
Cameron, R, cognitive behaviour Öst’s applied relaxation 68–69 stress 27
theory 10 in pregnancy 219–220 Deep relaxation, definition 13
Cancer 234–235 relaxation response 191–194, Delivery of sessions 17, 238
autogenic training 178 235–236, 242, 243 Depersonalization 194
goal-directed visualization 168, self-awareness 141–147 Depression 231
170 ‘specific effects’ hypothesis 10–11, Alexander technique 99–100
imagery 158, 168, 170, 235 11, 12 assessment 223, 224, 248
massage 210 in stress management 12 autogenic training 178
PRT 47–48 thought stopping 247 cognitive behaviour therapy 197,
reflex therapy 214 transactional model 11 199, 231
shiatsu 215 unitary models 10–11 cognitive theories 8, 9
Candles, meditation 186 see also Cognitive behaviour goal-directed visualization 171
Cardiac disorders see Heart therapy outcome measuring tools 248
disorders Colour imagery 155–157, 172 physical exercise 120–121, 122,
Cardiovascular system Coloured markers 73, 89, 208 124, 125
exercise effects 115, 116–117, 120 Combined relaxation approaches pregnant women 220
meditation 189 242–243 stress component 27
suggested techniques 250, 251 Conditioned (cue-controlled) suggested techniques 250,
see also Blood pressure; Heart relaxation 68, 71–72, 206 251
disorders Conditioning 9 Desensitization 170
Catecholamines 5, 6, 7 Confidentiality 15, 20 Diaphragmatic breathing see
Cathartic release 144 Conflict within groups 20–21 Abdominal breathing
Cerebral cortex, laterality 150, 150, Consciousness Diaries, home practice 18, 225
182, 242 altered states of 150, 173–174, 182, Differential relaxation 40, 68, 72–73,
Cerebral palsy 212 194, 242 78, 101–103, 243
Chakras 156–157, 187–188 brain laterality 150, 182, 242 ‘Diminishing tensions’ 36–38
Chi (ki) 133, 214 Kokoszka’s general theory 242, Discussions, group work 20, 28
Childbirth 56, 178, 217–220, 249 242 Distancing 28, 155, 164
282 INDEX
Hobbies 244 guided 157–158, 231, 235, 236, 243 PRT compared 44–45, 44
Home practice 18, 238 indicated conditions 250 self-operations control 40
applied relaxation 70, 71 the inner guide 151, 163 suggestion 44–45, 89
autogenic training 177–178 introductory remarks 152 Joints
meditation 184, 193 major principles 250 biofeedback 211
pregnant women 220 metaphor in 154–155 Mitchell method 83–90, 103, 219
self-reports 18, 71, 225 on-the-spot use 207 on-the-spot techniques 205
Hormonal system 5–6, 7, 215 passive relaxation 60, 65, 162 physical exercise 127
Hormone replacement therapy pitfalls 170–172 stretchings 105, 205
118–119, 122 in pregnancy 219, 220 Jung, C G
Hospital Anxiety and Depression procedures 151–158, 162–164 grounding 172
Scale 223, 224 for relaxation 151, 158–159, 165 the unconscious 150–151, 153
Human performance curve 24, 24 relaxation for 151, 162, 164–165
Humour 28, 215 in self-awareness 143
Hypertension 230, 233 symbolic 153–154
autogenic training 178 tense–release relaxation 56, 57, 162 K
Benson’s relaxation response 193 termination of sessions 152, 164,
massage 210 172 Kelly, G A, personal constructs 9
meditation 189, 193, 233 therapeutic effects 151, 158–159, Kermani, K S
muscular relaxation 56, 57–58, 233 165, 170 colour imagery 155–156, 157
physical exercise 117 transformations 155, 170, 207 scanning technique 60, 64–65, 206
stress component 27 the unconscious 150–151, 153 Key changes, Mitchell method
suggested techniques 249, 250, 251 using each sense for 152–153, 155 88–89, 103, 205, 219
Hyperventilation (overbreathing) 27, white light 157, 172 Ki (chi) 133, 214
130–131, 132, 134–138, 218 ‘Imaginary bubble’ technique 17 Kinaesthetic sense, imagery 153
Hyperventilation syndrome 135, Imagination, intuitive powers 143 Kokoszka’s general theory 242, 242
137–138 Immediate relaxation see On-the-spot
Hypnosis techniques
autogenic training 174 Immune system 6, 210
consciousness in 173–174 Inhibition L
fear of 16, 44–45 Alexander technique 93
goal-directed visualization 171–172 reciprocal 83 Labour, women in 56, 178, 217–220
relaxation compared 174 Inner guide 151, 163 Laterality 150, 150, 182, 242
Insomnia 230, 232–233 Laughter therapy 28, 215
meditation 233 Learned helplessness 9
Mitchell method 89 Learning disabled people 81, 249
I physical exercise 123 Learning of skills 13–14
PRT 47, 235 Led groups 19
Ice-breakers 20 stress 25, 27 Life events 25, 27, 254–255
Imagery 149–159 suggested techniques 249, 250, 251 Living in the present 28–29
in Alexander technique 94 Instant relaxation see On-the-spot Load-bearing exercise 119
anxiety 157, 158, 230–231 techniques Locus of control 26–27, 142–143, 235
applications of goal-directed Instructors 18–19 Lotus position 183, 192, 194
165–170 Interview schedules 222
attention switching 247 Introductory remarks 16–17
autogenic training 174, 177 see also specific methods
brain laterality 150, 150 Intuition 142, 143, 163, 182 M
in breathing exercises 132–133 Irritable bowel syndrome 193, 211, 251
chakras 156–157 Madders’ passive relaxation 60,
in childbirth 219–220 62–64
colour 155–157, 172 Mandalas 185–186, 186
combined relaxation methods 243 J Mantras 188–189, 192, 194, 243
definitions 149, 161–162 Massage 99–100, 209–210
distancing 28, 155, 164 Jacobson, E, progressive relaxation in pregnancy and labour 219
effectiveness 158–159, 168, 10, 33–41, 43 reflex therapy 214–215
230–231, 235, 236, 237 differential relaxation 40, 101, 102 shiatsu 215
exercises 152–158 Mitchell method compared 90 Meals
goal-directed visualization passive relaxation in 36, 38, 60 home practice after 18
161–172, 243, 250 pitfalls 41, 56 and meditation 194
284 INDEX
Self-disclosure 144 Social anxiety disorder 230 physical exercise 123, 235
Self-esteem Social Re-adjustment Rating Scale stress component 27
assertiveness 145 (SRRS) 25 suggested techniques 250, 251
goal-directed visualization 171 Social skills 9–10, 12, 145–146, 146 Suggestion
outcome measuring tools 248 Social support 26 autogenic training 174–177, 178,
physical exercise 120, 122–123, 125 Sound, imagery 152, 153, 155 179
pregnant women 220 ‘Specific effects’ hypothesis 10–11 hypnotic trance 173, 174
stress 27 Speech movements 39–40, 243 in muscular relaxation 34, 44–45,
suggested techniques 250 Sports 45, 61–62, 89
thinking style 142–143 goal-directed visualization 168, post-hypnotic 171–172
Self-help groups 19 169 Suicide 171
Self-hypnosis 174, 178 injuries 236 Supervisory back-up 19
Self-monitoring suggested techniques 250 Surgery 235, 249, 250
anxiety signals 69, 69 see also Physical exercise Sweeping technique 206
home practice 18, 71 State anxiety Symbolic imagery 153–154
in stress management 12 applied relaxation 68–69 Symbolic objects, meditation
see also Self-rating measures physical exercise 121–122 185–186, 187–188
Self-operations control 40 research-based evidence 230–231 Sympathetic nervous system 4, 4–5,
Self-rating measures 80–81, 223, 225, Strengthening exercise 116, 121, 122, 233
248 123 autogenic training 175
see also Self-monitoring Stress Benson’s relaxation response 191
Self-statements 10 asthma 27, 232 breathing control 131, 137–138, 206
autogenic training 177–178, 207 autogenic training 178 laughter therapy 215
goal-directed visualization 163, Benson’s relaxation response 192, self-operations control 40
165, 167, 172 193 yoga 213
on-the-spot use 207 biofeedback-assisted relaxation
Self-talk see Self-statements 211
Seligman, M E P, cognitive theory 9 coping skills 4, 24, 28–29
Senses of giving up smoking 166 T
biofeedback-assisted relaxation hyperventilation 27, 134–137
211 imagery 149–150, 158 T’ai chi ch’uan 215
faulty perceptions 93 management 12 Taped delivery 17, 238
imagery 149, 152–153, 155, massage 210 Taste, imagery 153, 155
157–158 measurement 25, 254–255 Temperature, imagery 153
self-awareness through 144–145 Mitchell method 89 Tense–release relaxation 49–57
Settings for relaxation 15, 16 occupational 26, 210, 237, 250 applied relaxation 68, 70
Sexual abuse 212 on-the-spot techniques 203–208 asthma 232
Shiatsu 215 physical exercise 125 combined relaxation methods
Sight, imagery 152, 153, 155 relaxation aims 4 243
‘Sinking’ technique 16–17 relaxation training components differential relaxation 40
Sinusitis, reflex therapy 214 27–28 exercises 50–56, 50–55
Skeletal musculature 6, 8 sources 25–27 imagery 56, 57, 162
see also Muscular relaxation symptoms 24–25 introductory remarks 49
Skill acquisition 13–14 theories 4–8, 23–24, 149–150 Jacobson’s PR 33–36, 38–40, 44
Sleep 232–233 thought stopping 247 pitfalls 56–57
autogenic training 178 Stretchings 105–113 PRT 43–48, 232
during sessions 21, 192 before exercise 126–127 self-operations control 40
Kokoszka’s general theory 242 combined relaxation methods 243 stretchings compared 113
meditation 233 effectiveness 112–113 termination of session 56
Mitchell method 89 indicated conditions 250 Tension headaches 11, 178, 213, 226,
and physical exercise 123 introductory remarks 106 249, 250
PRT 47, 235 major principles 250 Termination of sessions 17
stress 25, 27 on-the-spot techniques 205 behavioural relaxation training 78
suggested techniques 249, 250, 251 pitfalls 113 imagery 152, 164, 172
Slow breathing 131–132 procedure 106–112, 107–113 meditation 184
Smell, imagery 153, 155 rationale 105–106 tense–release relaxation 56
Smiling therapy 28, 208, 215 Substance misuse 235 Therapists 18–19, 198
Smith, J C, ABC relaxation model 11 goal-directed visualization 168, Thinking styles 8–9, 12, 142–143,
Smoking, giving up 165, 166–168 170 197–198
288 INDEX