Personal pre-publication copy of a paper eventually published as Orne, M.T., & Whitehouse, W.G. Relaxation techniques. In G. Fink (Ed.), Encyclopedia of stress (Vol. 3). New York: Academic Press, 2000. Pp. 341-348.
University of Pennsylvania School of Medicine
I. Progressive Relaxation
II. Self-Hypnosis
III. Autogenic Training
IV. Meditation
V. Biofeedback-Assisted Relaxation
VI. Conclusions
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GLOSSARY
behavior therapy A system of psychotherapy that views mental disorders as products of maladaptive learning, which are best treated by techniques derived from classical and instrumental conditioning principles.
systematic desensitization A technique used in behavior therapy to eliminate specific fears by requiring the patient to imagine different situations involving the feared stimulus while remaining relaxed. To avoid overwhelming the patient, the imagined situations are often mastered successively in an anxiety hierarchy, from least to most fear-provoking.
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Relaxation techniques are procedures that can be learned and practiced by individuals in order to reduce physiological arousal and, thereby, alleviate or prevent stress-related symptoms. The relaxation techniques outlined in this article comprise a set of related "self-help" procedures that differ in important ways, including the extent to which cognitive strategies are engaged to augment the stress-reducing effect of common behavioral exercises. In most cases, the effectiveness of the various techniques depends on the acquisition of particular skills and, thus, is typically improved by formal instruction and regular practice.
I. PROGRESSIVE RELAXATION
For centuries, "rest and relaxation" has been a popular prescription for a wide range of maladies. The apparent curative properties of rest were being endorsed by physicians and healers long before a scientific basis for the association between stress and disease had been established. A seminal contribution toward understanding the pathophysiology of stress was the publication in 1929 of Edmund Jacobson's "Progressive Relaxation," an empirically based treatise on the role of neuromuscular tension in various somatic, neurologic, and psychiatric disorders. In this work, Jacobson noted that many instances of physical and mental disease include among their symptoms the failure to relax -- an ability that is often regained following recovery. Using electrophysiological measures, Jacobson confirmed the presence of neuromuscular tension in various disorders and was able to document the power of relaxation to dissipate stress-related symptoms. He also reported that mental operations, such as imagination, emotion, and recollection, were
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expressed in muscle contractions, a finding that proved to be an important milestone in the development of the field of psychosomatic medicine. Thus, for the first time, there was compelling scientific evidence to support the widespread belief among medical practitioners that stress and anxiety contributed to disease states and that relaxation-based therapies provided effective treatment options for many patients.
The procedures involved in progressive relaxation (PR) developed directly from Jacobson's scientific studies of muscular tension. A fundamental tenet of this approach is that tension and deep muscle relaxation are physiological opposites that cannot coexist. Thus, to the extent that neuromuscular tension underlies a particular disorder, relaxation should be an effective remedy. Moreover, PR allows patients to become actively involved in their own treatment, a feature that Jacobson regarded as an important psychological benefit of the procedure. The broader objective, however, was to teach patients to incorporate relaxation skills into their lifestyles so that they become better able to respond appropriately to future stressors by controlling the tendency to become tense.
A. Technique
A preliminary condition of training is the use of responses that allow the patient to recognize muscle contraction (i.e., tension) wherever it is present. The procedure requires the patient to alternately tense (i.e., contract) and relax (i.e., extend) each of the major
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muscle groups of the body. The goal of this exercise is to help the patient to discriminate degrees of muscular tension, which can be controlled as warranted or, in extreme cases, supplanted with deep relaxation.
Progressive relaxation attempts to cultivate whole body relaxation. Patients are encouraged to assume a comfortable position and relax. They are then instructed to clench the left or right fist as tightly as possible and to notice the tension as it creeps up from the fist to the hand to the forearm. This is followed by instructions to relax the fist and to pay particular attention to the difference they feel between tensed and relaxed states. The therapist's instructions merely guide the patient's attention to actual experiences that accompany variations in muscle tension; there is no reliance on suggestive techniques, such as hypnosis. The procedure is repeated using the opposite fist, then the upper arms, the facial muscles, the chest, stomach, and muscles of the lower back, and culminates in the muscles of the lower extremities. Each time the patient is encouraged to become aware of the difference in sensation between tension and relaxation and to allow relaxation to come to predominate.
As outlined originally by Jacobson, the procedure involved upwards of 100 training sessions, many focusing on single muscle groups. Pragmatic concerns soon prevailed and abbreviated versions were developed, beginning with the efforts of the psychiatrist Joseph
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Wolpe, who adopted relaxation as a means to countercondition anxiety responses elicited in the context of his behavior therapeutic method of systematic desensitization. Contemporary approaches to PR attempt to promote profound whole body relaxation in a single session. They routinely involve the alternation between tensing and relaxing groups of muscles, but the procedures take place in a matter of minutes rather than days, and they frequently include hypnotic-like suggestions to facilitate relaxation.
B. Clinical Effectiveness
Progressive relaxation has been applied clinically to various medical disorders in which indicators of stress, such as sustained autonomic arousal or chronic muscle tension, are present. Both controlled and uncontrolled studies support its effectiveness in the treatment of anxiety disorders, depressive symptoms, anticipatory nausea associated with chemotherapy, tinnitus, insomnia, low back pain, hypertension, and tension headache. Evaluation of the specific contribution of PR in treating these conditions is often complicated by the inclusion of other potentially therapeutic components in the treatment protocols. At the same time, the case for some disorders (e.g., hypertension) is generally inconclusive due to the fact that, on an individual basis, stress may not be a primary etiological factor. As Herbert Benson and colleagues have noted, relaxation can lower an individual's blood pressure, but the magnitude of the effect depends on the extent to which stress plays a role in the first place. A number of studies reported in the
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literature on the clinical effectiveness of relaxation techniques have failed to make this important initial determination. Finally, classical PR may not be appropriate for certain disorders due to its potential to exacerbate symptoms. This has been reported, for example, among individuals suffering from tension headache or myofascial pain disorders, where the practice of alternately tensing and relaxing relevant muscle groups actually increased their pain. Fortunately, when such complications arise, PR can be modified to omit the muscle contraction component of the exercises, which Jacobson recommended only as a means to sensitize patients to the presence of tension in their bodies.
II. SELF-HYPNOSIS
A preponderance of data shows that virtually all hypnotic phenomena that can be elicited through suggestions administered by a therapist can also be induced by the patient using self-hypnosis. This is because heterohypnosis is fundamentally self-hypnosis and vice versa. That is, the experience of hypnosis requires an appropriately hypnotizable individual who is motivated to accomplish the goals targeted by select therapeutic suggestions, administered in a distinctively hypnotic context. By the same token, self-hypnosis can be conceptualized as an extension of heterohypnosis in which the patient carries out a procedure taught in a therapeutic relationship and is able to reinstate feelings that were originally established in heterohypnosis while imagining the words of the therapist during the self-hypnotic exercise.
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Self-hypnosis is best learned with the help of an experienced hypnotherapist who will outline the clinical objectives, dispel any misunderstanding about the procedure and its outcomes, teach techniques to induce the condition of hypnosis, and work with the patient to establish appropriate suggestions and metaphors to facilitate therapy. Routinely, skill in self-hypnosis develops as the patient practices the techniques outside the therapist's office. To encourage regular practice and to optimize the therapeutic value of self-hypnosis, however, it is helpful for the patient to maintain his or her relationship with the therapist. We have found, for example, that in the context of stress and pain management, periodic therapy sessions, or even occasional telephone contact with the therapist, can sustain the patient's motivation to practice self-hypnosis and may even compensate for deficiencies in hypnotic ability that might otherwise produce discouraging outcomes. Attention to motivational issues is, therefore, an important aspect of preparing patients for positive experiences with self-hypnosis.
Self-hypnosis embodies a particularly versatile tool for stress management. In addition to its capacity to promote deep relaxation, many individuals who practice the technique as a complement to an ongoing therapeutic relationship are also able to favorably modify their perceptions regarding the importance of the stressor, as well as their emotional reactions to it. Accordingly, for patients with sufficient hypnotic ability, self-hypnosis might well be the treatment of choice for conditions (e.g., chronic pain) that fail to respond adequately to relaxation-oriented therapies alone.
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III. AUTOGENIC TRAINING
Closely related to self-hypnosis is the formalized system of autosuggestive therapy known as autogenic training (AT). It was developed by Johannes Schultz as a form of psychophysiologic therapy in which patients could be taught a series of exercises to induce in themselves a profound state of physical and mental relaxation similar to deep hypnosis. The method grew out of Schultz's own clinical work with hypnosis, during which he noted that hypnotized patients commonly reported the sensation of heaviness in their limbs, accompanied by feelings of warmth. These observations were taken and interlaced with his belief that hypnotic suggestions were successful to the extent that the patient allowed them to happen. Specifically, in Schultz's analysis, hypnotized patients adopted a type of "passive" concentration, permitting the suggested changes to occur without trying to influence their occurrence directly. Hence, the blueprint for AT evolved. The purpose was (a) to achieve the psychophysiologic effects typical of hypnosis without the need to formally induce the condition of hypnosis and (b) to train the patient to self-administer the relevant suggestions, thereby conveying a substantial element of responsibility for treatment from the therapist to the patient.
A. Technique
Autogenic training can be carried out on an individual or group basis, although individual training can adjust more readily to
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idiosyncratic differences in the rate of skill acquisition or other needs. Environmental considerations include a slightly darkened room free of distractions, with a comfortable temperature and a chair, couch, or mattress. The verbal formulas developed by Schultz and used clinically for nearly three-quarters of a century fall into three categories of autogenic exercise: standard, meditative, and special. For illustrative purposes, we will outline only the standard autogenic exercises, whose mastery is a prerequisite for advancement to meditative (involving imagery) or special exercises (designed to treat specific organic or mental disorders). Moreover, the standard exercises are the most widely used for stress management.
1. Heaviness
Training of heaviness usually begins with the dominant arm, with the expectation that, as the exercise proceeds, heaviness will begin to generalize to other extremities. The trainee concentrates passively as the therapist repeats calmly, several times, "I am at peace. . . . My right arm (if that is the dominant arm, otherwise left arm) is heavy. . . . My right arm is heavy. . . . My right arm is heavy." As the right arm becomes heavier, the trainee begins to notice a sense of heaviness in the left arm as well. This is reinforced as the therapist slowly repeats "My left arm is heavy" a number of times, followed by "Both of my arms are heavy." The exercise is then extended to induce the spreading heaviness in each of the legs, concluding with the formula, "My arms and legs are heavy."
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2. Warmth
The second standard exercise is intended to induce the experience of warmth in the arms and legs by increasing blood flow in the extremities. Once heaviness has been achieved, the second formula is combined with the first: "I am at peace.. . . My arms and legs are heavy. . . . I am at peace. . . . My arms and legs are heavy. . . . My right arm is warm. . . . My right arm is warm. . . . My right arm is warm." The procedure continues with repetition of the appropriate verbal formulas and passive concentration as warmth develops in the other arm and in each of the legs, culminating with repetition of the phrase, "My arms and legs are warm."
3. Cardiac Regulation
The third standard exercise focuses on the awareness of one's heartbeat activity. Many trainees do not perceive their heartbeats readily unless they are hyperaroused. Such individuals may require postural alterations to sensitize cardiac awareness, such as practicing autogenic exercises with the right hand placed over the heart. The relevant verbal formula that is the focus of passive concentration is "Heartbeat calm and regular." The objective is not to slow the heart rate, but to bring it into a consistent rhythm that supports the already established feelings of heaviness and warmth.
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4. Respiration
The fourth exercise is intended to teach the self-regulation of respiratory functions. Like the cardiac regulatory exercise that precedes it, the trainees' respiration rates should have been decreased substantially during the heaviness and warmth exercises. However, unlike heartbeat activity, the rate of breathing is relatively easy to modify voluntarily, an inclination that must be resisted if passive concentration is to be maintained. Accordingly, the fourth formula is phrased, "It breathes me," to emphasize the importance of passive focus.
5. Abdominal Warmth
The fifth standard exercise attempts to induce a generalized feeling of warmth deep in the region of the solar plexus. Many trainees require an anatomy lesson to localize this target of passive concentration (i.e., halfway between the lower segment of the sternum and the navel) before the therapeutic phrase, "My solar plexus is warm," can be employed effectively. The exercise is contraindicated for persons with medical conditions involving viscera of the peritoneal cavity (e.g., diabetes, gastric tumors, ulcers).
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6. Coolness of the Forehead
The final standard autogenic exercise stems from the common observation that a cool cloth applied to the forehead reduces tension -- an effect that can also be achieved by a redistribution of blood flow away from the head (i.e., localized vasoconstriction) and toward the extremities (i.e., peripheral vasodilatation as accomplished in exercise 2). The relevant supplemental autogenic formula to be repeated at this stage of training is simply, "My forehead is cool."
Training is considered complete when the trainee is skilled at self-administration of the autogenic program. Each of the standard exercises works toward reinforcing the others to inhibit indicators of sympathetic nervous system activation, thereby promoting a generalized state of physiological and mental relaxation.
B. Clinical Effectiveness
Autogenic training is widely used in conjunction with biofeedback techniques to promote stress reduction, although many clinicians employ autogenic therapy as a solitary method to achieve self-regulation of the autonomic nervous system. Attempts to assess the
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specific effectiveness of autogenic therapy by reviewing the relevant scientific and clinical literatures are, however, impeded by several factors (e.g., small nonrandom samples, poor controls, and wide variation in training protocols and extent of training). Quantitative reviews that ignore the idiosyncratic aspects of individual studies and focus, instead, on the magnitude of treatment effects across studies, relative to no treatment or to other nonpharmacologic techniques (e.g., biofeedback, meditation, progressive relaxation, self-hypnosis), tend to conclude that AT is as efficacious, on the whole, as other biobehavioral interventions for most psychosomatic disorders. Stress-related conditions that are claimed to respond positively to AT include respiratory problems (e.g., bronchial asthma) and circulatory disorders (hypertension, Raynaud's disease, tachycardia, and cardiac arrhythmia), insomnia, and anxiety.
IV. MEDITATION
Meditation refers to a collection of practices, generally of eastern origin, that induce a change from the ordinary in a person's mental focus, with the result that metabolic activity is slowed and the practitioner often feels relaxed and refreshed. Two general forms have been identified, consisting of "concentrative" and "nonconcentrative" methods.
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In the concentrative approach, typified by transcendental meditation, the individual is seated in a quiet environment and directs his or her focus to a single, repetitive stimulus, such as a word or sound recited mentally as the person takes in or exhales breaths of air. The objective is to remain singleminded. If distracting thoughts should intrude, the meditator is directed to simply dismiss them and to bring attention back to the focal stimulus. The technique, along with its religious and philosophical trappings, was popularized in the western hemisphere in the late 1960s by the Maharishi Mahesh Yogi, whose disciples included many celebrities of the period.
A prominent form of nonconcentrative meditation in use medically is mindfulness meditation, which is derived from Buddhist tradition. The technique does not necessarily lead to a profoundly relaxed state, as is typical of concentrative forms of meditation. Rather, the primary goal is to obtain insight into the self by learning to catalogue moment-to-moment changes in experience.
Mindfulness meditation begins with a single object of focus (e.g., breathing) to establish calmness, but the mental focus is gradually expanded to include any ambient stimuli, thoughts, feelings, and physical sensations that enter awareness. Unlike concentrative meditation, practitioners of mindfulness do not regard these experiences as distractions to be ignored, but dispassionately focus on each until their attention wanders, whereupon they simply note where their thoughts have taken them before redirecting attention back to their in-the-moment experiences. Various formal and informal exercises have been developed to facilitate the adoption of mindfulness as a lifestyle approach -- to foster an appreciation for the importance of living in the present moment.
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A. Clinical Effectiveness
A number of scientific investigations of transcendental meditation were undertaken in the early 1970s by Robert Wallace and Herbert Benson, which documented the ability of meditation to induce deep relaxation and to oppose sympathetic arousal. Among the physiological changes produced during meditation were substantial decreases in the rate and volume of respiration, with correspondingly reduced levels of oxygen consumption and carbon dioxide production. In addition, a slowing of the heart rate, accompanied by increases in skin resistance and decreases in blood lactate levels, signified an overall reduction in anxiety or arousal. Furthermore, studies of the electroencephalogram (EEG) confirmed the presence of a low-arousal state -- a pattern featuring a predominance of alpha activity, with occasional brief transitions toward theta and deep sleep-like delta frequencies. What was not found in these early studies was evidence that meditation affected blood pressure significantly, which Benson and colleagues soon realized was due to the fact that their sample of experienced meditators had quite low blood pressure to begin with. Subsequent research determined that meditation was effective in reducing blood pressure in individuals with stress-related hypertension. Studies have also found that meditation is associated with an improvement in respiratory and cardiovascular functioning, sleep disturbance, and depression, as well as in the treatment of addictive disorders.
As mentioned previously, nonconcentrative forms of meditation, such as mindfulness, do not induce relaxation uniformly. In fact,
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although relaxation states often occur when practicing the technique because the intended goal is greater self-awareness, no particular physiological outcome should be anticipated. Nevertheless, mindfulness meditation appears to be notably useful for the management of chronic pain, where learning to identify the everyday pain sensations apart from their emotional and evaluative components helps lessen the degree of suffering that is otherwise endured.
V. BIOFEEDBACK-ASSISTED RELAXATION
Many of the bodily processes affected by relaxation techniques are normally unavailable to conscious awareness; hence, they would elude any casual attempts at voluntary control. Biofeedback rectifies this situation through the use of sensors and instrumentation capable of detecting, amplifying, and displaying the relevant biological signals. Armed with information regarding the moment-to-moment status of their blood pressure, heart rate, muscle tension, or electrical activity of the brain, patients are in a position to observe any correlations between thoughts and behavior and corresponding changes in these physiological modalities. Once such relationships are discovered, it becomes possible to achieve self-regulation of these systems with the help of biofeedback. In many cases, this self-regulation can be maintained outside the therapist's office (i.e., without reliance on instrumentation) by carrying out the cognitive or motor strategies that were previously demonstrated to affect relevant aspects of the person's physiology.
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Biofeedback is used in the treatment of many disorders, some with central nervous system involvement (e.g., cognitive and attentional problems, depression), others involving the circulatory system (e.g., cardiac arrhythmia, hypertension, orthostatic hypotension), and others involving localized neuromuscular dysfunction (e.g., urinary or fecal incontinence, tension headache). As an aid to relaxation, however, two modalities are generally preferred: electromyographic (EMG) feedback and temperature feedback.
A. Electromyographic Biofeedback
Electromyographic biofeedback is employed to monitor and display muscle tension. Although almost any muscle that can be monitored with skin surface electrodes is a viable target for EMG biofeedback, three muscle groups tend to be favored: the frontalis muscle (forehead), the masseter (jaws), and the trapezius (shoulders). The reason these muscles receive special attention is that they are particularly prone to contract during stressful situations. The goal of EMG training is to use the biofeedback information to learn particular cognitive or behavioral strategies that reliably induce relaxation in the targeted muscle site. EMG biofeedback is designed to accomplish the same objectives as Jacobson's progressive relaxation technique, while permitting the patient to observe his or her progress.
B. Temperature Biofeedback
Thermal biofeedback is used to relay information about skin temperature to the patient. To accomplish relaxation, the patient is
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trained to elevate the skin temperature of the hands and/or feet. The instrumentation can be quite simple (e.g., an outdoor thermometer taped to a finger or toe is usually adequate), making it convenient for patients to practice the technique at home. The physiological mechanism that supports the intended alterations in skin temperature is an increase in blood flow in the extremities, which opposes the usual sympathetic responses to stress, involving peripheral vasoconstriction.
C. Clinical Effectiveness
Biofeedback-assisted relaxation is the most commonly employed application of biofeedback techniques. EMG procedures have been found to be effective in the treatment of anxiety, insomnia, and various psychosomatic disorders, such as colitis, hypertension, gastric ulcers, and tension headaches. Thermal training has been particularly helpful in the treatment of migraine headache and Raynaud's disease -- a vascular disorder involving the sensation of extreme cold in the hands and feet. It is frequently combined with autogenic phrases, imagery, and breathing exercises.
VI. CONCLUSIONS
Whether provoked by life events, physiological disturbances, or our own anxious thoughts, stress is an inescapable part of human
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experience that demands biological and behavioral adjustments. Unfortunately, when exposed to persistent stress, constitutionally vulnerable individuals or persons with inadequate coping resources may suffer adverse health and psychologic consequences. The development of relaxation skills provides a safe, pleasurable, and cost-effective preventive measure to reduce the experience of stress before it takes a serious toll. Given the wide variety of efficacious techniques available, consideration of which procedure to incorporate into a stress management program should be guided, in part, by the suitability of the method to the individual's lifestyle. The most significant benefits of relaxation techniques usually accrue when practice becomes part of a daily routine.
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Bibliography
Benson, H. (1975). "The Relaxation Response." Morrow, New York.
Davis, M., Eshelman, E. R., and McKay, M. (1988). "The Relaxation and Stress Reduction Workbook," 3rd ed. New Harbinger, Oakland, CA.
Kabat-Zinn, J. (1991). "Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness." Delacorte, New York.
Lehrer, P. M., and Woolfolk, R. L. (1993). "Principles and Practice of Stress Management," 2nd ed. Guilford, New York.
The preceding paper is a reproduction of the personal pre-publication copy of a submission to the Encyclopedia of Stress (Orne, M.T., & Whitehouse, W.G. Relaxation techniques). It was eventually published as Orne, M.T., & Whitehouse, W.G. Relaxation techniques. In G. Fink (Ed.), Encyclopedia of stress (Vol. 3). New York: Academic Press, 2000. Pp. 341-348.). This personal pre-publication copy is reproduced here with the kind permission of Elsevier for Academic Press.Single copies of this article can be downloaded and printed only for the reader's personal research and study. Please consult the published version to cite quotations.