“The Act of Caring Is the First Tru Step in the Power to Heal

STRESS REDUCTION TECHNIQUES AND THERAPIES

COURSE DESCRIPTION

You may think you don’t have a lot of control over the stress in your life, but you have more control than you might think. There are many ways to manage and reduce stress by using stress-relieving techniques and therapies.

The goal of this course is to provide an overview of the techniques and therapies to reduce and manage stress, which include self-awareness, cognitive restructuring, sound healing and music therapy, meditation, nature, imagery, biofeedback, art, and dance.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to do the following:

1. Identify how self-awareness can help an individual manage stress. 2. Describe the roles of cognitive restructuring, cognitive behavior therapy, and effective communication in stress management. 3. Identify the ways sound and music therapy affect the body and reduce stress. 4. Examine the effects of meditation on stress. 5. Discuss the stress-reduction benefits of interacting with nature. 6. Describe the stress-reduction benefits of biofeedback. 7. Describe the benefits of art therapy in reducing stress. 8. Identify the benefits of dance therapy in stress management. 9. Explain how imagery can be used to manage stress.

INTRODUCTION

Are you stressed? If you are like most individuals, the answer is probably yes. More than half of working adults say they are concerned with the amount of stress in their lives (American Psychological Association [APA], 2006). Stress is a global epidemic. Stress management starts with identifying the sources of stress in your life and taking steps to reduce and manage these stressors. You can change the stressful situation or change your reaction to the stressor. This can be accomplished by using a variety of techniques and therapies that help you feel calmer and more relaxed.

While the body’s reactions can vary, there are four types of stress (Trivieri & Anderson, 2002):

 Physical stress can include trauma, illness, intense physical labor, environmental pollution, inadequate light, childbirth, noise, toxins, inadequate oxygen, hypoglycemia, hormonal or chemical imbalances, dietary stress, substance abuse, and dental problems.

 Psychological stress can include fear, resentment, information overload, worry, shame, guilt, jealousy, self-criticism, and anxiety. It can also include the loss of a sense of control, beliefs and attitudes, and a worldview.

 Psychosocial stress can include relationship difficulties, a lack of social support, and isolation.

 Psychospiritual stress can include a joyless life; meaningless work; and a crisis of values, meaning, and purpose.

EFFECTIVE STRESS-MANAGEMENT TECHNIQUES

Stress is a normal psychological and physiological reaction to the demands and challenges of life. Stress management techniques provide individuals with the tools to effectively manage stress.

SELF-REFLECTION AND SELF-AWARENESS

Rew (2005) defines self-reflection as “the process of turning one’s attention or awareness inward to examine thoughts, feelings, beliefs, and behaviors” (p. 429). It is a deliberate process with a goal of discovery and learning. Self- awareness, or being aware of the self, is the tendency to focus attention on the private aspects of the self. It includes self-exploration, recognizing one’s strengths and weaknesses, and knowing one’s self. Payne (2005) notes that increasing self-knowledge comes from listening to ourselves: what we are, who we are, and how we are.

By increasing our self-awareness, we understand our outward behavior and how others respond to it, thereby improving our personal relationships. Self-awareness is closely linked to the concept of living in the present. Lessons learned from the past are important in helping us perform our best in the present. Living this way produces greater peace of mind; self-awareness can thus be seen as a stress management tool (Payne, 2005; Seaward, 2012).

Payne (2005) lists several ways to improve self-awareness:

 Become aware of your personal thinking style: Sometimes people think in a focused way, and at other times they think more broadly. Mode of thinking is connected to self-esteem. Those with an internal locus of control (that is, a tendency to believe they have control over their lives and environment) tend to have higher self-esteem than those who have an external locus of control (little or no control over the environment). Thinking is more positive with an internal locus of control.

 Be aware of your intuitive powers: Intuition can provide much information about the inner self and involves “an intense feeling of certainty that may be accompanied by a sense of mystery or confusion” (Rew, 2005, p. 432).

 Be aware of your emotions and feelings: This principle is not about self- indulgence but instead about self-examination and an exploration of ways in which you might need to change. With this method, you examine your emotional patterns: how you express yourself spontaneously or in controlled

ways, how you share your feelings, and how you use catharsis to move forward.

 Be aware of your body: This awareness includes how you are breathing and how your digestion, skin, or muscles feel.

 Be aware of the environment: How are you obtaining information through sight, sound, smell, touch, and taste? This awareness involves a keen awareness of what is being seen, smelled, heard, touched, and tasted from the surrounding environment.

 Be aware of how you relate to others: People can tell a lot about you by what you show of yourself, your appearance, your general demeanor, and what you say. Verbal and nonverbal behavior also tells a story about who you are. Your level of assertiveness is an aspect of relating and a means of insisting on having your interests respected while others advance their goals.

COGNITIVE RESTRUCTURING

Holocaust survivor and noted author and psychoanalyst Victor Frankl said in his book, Man’s Search for Meaning, “Everything can be taken away from man but one thing—the last human freedom, to choose one’s attitude in any given set of circumstances.” We know that stressors abound in life and that an individual’s perception of the stressor, not the stressor itself, makes for either a mountain or a molehill.

Cognitive restructuring is a coping technique that substitutes negative, self-defeating thoughts with positive, affirming thoughts to change the perception of the stressor from threatening to nonthreatening (Seaward, 2012).

Negative thoughts often result from low self-esteem and perpetuate the problem by suppressing or obliterating feelings of self-worth and self-acceptance. Some studies have shown that, on average, a child hears 400 negative comments for every positive one. Negative comments become conditioned (learned) responses that are carried into adulthood in the form of negative thoughts. Catastrophic headlines and negative media messages are also part of our everyday lives, and this negative perspective leads to negative thinking that can have an addictive and destructive quality (Seaward, 2012).

Two personality traits are closely related to locus of control, which has been shown to affect health:

 Pessimism, a personality trait heavily grounded in negativism, promotes toxic thoughts, a term coined in the 1980s.

 Victimization is an attitude where one feels specifically targeted by events or circumstances and believes that he or she has no choice but to suffer the consequences. “Victims” seek pity and sympathy from friends and validate their own perceptions of personal violation.

Thoughts and attitudes such as these have been shown to depress the immune system, decrease the longevity of cancer clients, and affect mental health. Psychologists use the term self-fulfilling prophecy to describe the link between perceptions, beliefs, and related behaviors (Seaward, 2012).

Cognitive restructuring can be achieved through four simple steps:

1. Be aware of stressors and acknowledge them. Identify why these situations and events are stressors and identify the emotions associated with them.

2. Reappraise the situation. See whether a different (more objective) viewpoint changes your perspective about the situation. Understand which situations you can control and which must be accepted as out of your control.

3. Adopt the new frame of mind, substituting a negative perspective for a positive one.

4. Evaluate whether this process worked and, if so, how beneficial it was so you can decide whether to use it again (Seaward, 2012).

EFFECTIVE COMMUNICATION

The ability to effectively communicate is an essential tool in managing stress. If most people were to list their top 10 stressors, they would probably find that at least half of them dealt with relationships with family, friends, and co-workers. Strong relationships require good communication skills. The average person spends 75 percent of the day communicating with others. The degree of perception and

© ALLEGRA Learning Solutions, LLC All Rights Reserved. 5 interpretation required, as well as the many layers of meaning in every interaction, leave much room for misinterpretation and, therefore, can cause much stress (Seaward, 2012).

Effective communication is one of life’s most essential skills. Communication includes the ability to express thoughts and feelings in understandable words and the ability to listen, clarify, and process information as it is intended. Verbal communication involves speaking, hearing, writing, and reading and is actually a series of thoughts and perceptions described through words, and it has two components:

 Encoding is the process by which the speaker attempts to frame thoughts and perceptions into words.

 Decoding is the process by which the listener translates, dissects, analyzes, and interprets the message (Lojek, 2009; Seaward, 2012).

Nonverbal communication is any communication that does not include words. It conveys both linguistic (i.e., related to language) as well as emotional messages (Lojek, 2009). Examples include postures, gestures, clothing and appearance, the use of paralanguage (the meaning conveyed by voice tone, rhythm, volume, emphasis, and pitch, such as “uh-hum” or “hmmm”), bodily contact and proximity, respect for personal space, eye contact, and facial expressions (Cawthorn, 2002; Lojek, 2009).

Effective communication involves accurate listening, the use of silence, appropriate body language, reflecting (e.g., repeating someone else’s words to demonstrate listening), summarizing what was said, and self-awareness (Cawthorn, 2002).

Effective listening, attending, and responding involve several key elements (Seaward, 2012):

 Pay total attention to what the speaker is saying, not to one’s own thoughts. Do not prepare rebuttals or comments while someone is speaking.

 Maintain eye contact, but do not stare continually.

 Avoid the use of words that are emotional or prejudiced to keep the listener from becoming disinterested.

 Use minimal encouragers (such as “oh” or “uh-huh”) to tell the speaker you are both on the same wavelength.

 Paraphrase what is said to help ensure understanding.

 Ask questions to clarify statements.

 Use empathy to reflect and share feelings and galvanize the listening experience.

 Provide feedback to the speaker as appropriate.

 Use language appropriate to the audience and attack issues, not people.

 Avoid information overload so the information presented can be effectively received.

 Enhance your vocabulary to effectively articulate your issues, and resolve problems as they arise so they do not fester.

EFFECTIVE STRESS MANAGEMENT THERAPIES

There are many therapies to effectively reduce and manage stress.

Music Therapy and Sound Healing

Creativity heals the physical body while stimulating, calming, and transporting the mind to a sublime place where holistic healing can occur. The process of making or listening to music is a wonderfully creative experience that heightens awareness and brings joy and an undeniable connection to spirit. Music and sound healing also help bridge differences and connect people of different cultures, backgrounds, and experiences through shared experiences, thus healing communities through creative expression.

Music and sound healing can help:

• Heal emotional injuries, • Develop a capacity for self-reflection,

• Reduce symptoms of disease, and • Alter behaviors and thinking patterns.

When the brain hears soothing music, or an individual engages in creative work, the parasympathetic nervous system is aroused.

As part of the creative process, music can:

• Decrease anxiety and stress • Increase release of endorphins and other neurotransmitters • Decrease pain • Calm brain activity • Improve immune function to prevent illness and disease • Restore emotional balance • Provide a sense of peace and relaxation • Increase a sense of hope and optimism, psychological well-being, and motivation • Increase compassion toward ourselves and others • Alter perception of time • Improve energy levels, coping skills, and communication • Enhance self-understanding and insight

Music Therapy

Music is a powerful tool that has been linked to healing throughout history, as it has the power to heal the body, mind, and spirit.

Music and sound healing are safe, inexpensive, easy to use, and nonthreatening modalities that support a healing environment, and they can be used successfully with individuals of all ages and disabilities.

These music modalities can be used for healing:

• Singing helps individuals with speech impairments improve their articulation, rhythm, and breath control.

• Playing instruments improves gross and fine motor coordination. Drumming is especially good for stress reduction.

• Rhythmic movement facilitates and improves an individual’s range of motion, joint mobility, agility, strength, balance, coordination, gait consistency, respiration patterns, and muscular relaxation.

• Improvising offers a creative, nonverbal means of expressing feelings.

• Composing facilitates the sharing of feelings, ideas, and experiences.

• Listening is used for many therapeutic applications, including the development of cognitive skills, such as attention and memory.

Sound Healing

Sound healing is the use of vibrational frequencies of sound forms, combined with music or its elements (such as rhythm, melody, and harmony), to promote healing. The effectiveness of healing sounds is based on the ability of harmonics to create vibrational changes that may occur in the physical body or in the mental, emotional, and etheric bodies.

These are examples of sound healing modalities that are effective in reducing stress:

• Singing bowls are ancient instruments often used in combination with meditation, Gregorian chant, and overtone chanting.

• Chanting can synchronize brain waves to achieve states of relaxation, produce the physiologic effects of an internal painkiller, and act as a healing agent in the body. It is practiced by many cultures, religious organizations, and ethnic groups.

• Harmonics give melodies color, direction, and context. It results when tones are sounded simultaneously.

• Toning uses the conscious sustaining of sounds and tones produced by the voice of the individual.

• Drumming is effective for stress reduction, exercise, self-expression, camaraderie and support, spirituality, and meditation.

• Vibrational healing is used to help reach a perfect harmony of all seven chakras, because each of the body’s tissues, organs, acupuncture meridians, and chakras has a musical note.

MEDITATION

Meditation is a mind-body practice with many methods and variations that are all grounded in the silence and stillness of present-moment awareness. During the past three decades, there has been a significant amount of research, and meditation’s health effects have been well documented. The practice offers improvement in the symptoms of various disease conditions in addition to the experience of a deeper spiritual connection.

As a result, meditation was the first mind-body intervention adopted by mainstream health-care providers and incorporated into many types of evidence-based therapeutic programs (Dakwar & Levin, 2009). Micozzi (2006) notes, “Many studies have found that various practices of meditation appear to produce physical and psychological changes” (p. 293).

Meditation may be practiced in many ways, including, but not limited to, deep breathing, focusing on different parts of the body, walking meditation, mindfulness meditation, centering prayer, and Transcendental Meditation®. Most often, meditation starts with choosing a quiet place free from distractions. You sit or rest quietly with your eyes closed while noticing your breathing and physical sensations. All intruding thoughts are gently observed and released without judgment. You can also achieve a relaxed yet alert state by focusing on a pleasant idea or thought, or by chanting a phrase or special sound silently or aloud.

Practicing meditation once or twice a day for 20–30 minutes can produce measurable metabolic effects that are exactly the opposite of the body’s fight or flight response. In their study on the effects of meditation on stress, Mohan, Sharma, and Bijlani (2011) demonstrated that it produced a relaxation response in adults who had practiced meditation, as well as in adults who had never practiced meditation before the study.

Other physiological changes that occur with regular meditation practice include the following (Carlson, Speca, Patel, & Goodey, 2004; Eliopoulos, 2004; Freeman, 2004; Lane, Seskevich, & Pieper, 2007; National Center for Complementary and Alternative Medicine [NCCAM], 2012; Seaward, 2012; Shin, 2012; Trivieri & Anderson, 2002):  Improved airflow to the lungs  Increased energy level  Decreased blood cortisol levels (a major stress hormone)

 Increased skin resistance (due to decreased anxiety and perspiration)  Decreased heart and respiration rates  Decreased blood pressure  Decreased muscle tension  Increased alpha waves (due to increased relaxation)  Decreased pain and pain perception

Nairn (2001) states, “The effect of meditation, in the beginning, will be a gradual understanding of what is meant by tranquility, what is meant by the mind becoming tranquil. It is not something contrived or imposed or imported from outside. It is the arising of what is already within us. As the mind becomes tranquil, many things begin to become clear. Things that were not formerly clear to us about ourselves, the world around us, the way we are living, relationships. We become clear about everything” (p.13).

According to researchers at the University of California, Davis, and the University of California, San Francisco, meditation has many positive psychological benefits, including an individual’s stress-management skills and increasing an individual’s overall sense of well-being. These positive changes that occur during meditation are associated with greater activity of telomerase, an enzyme important for the long-term health of cells in the body. Telomerase has been associated with a reversal or slowing down of the aging process as well as an improvement in immune function. Meditators demonstrated the greatest improvement on various psychological measures (e.g., observing one’s experience in a nonreactive manner) and purpose in life (viewing one’s life as meaningful, worthwhile, and aligned with long-term goals and values) and had higher levels of telomerase than non-meditators (UC Davis News and Information, 2010).

Neuroscientists have found that meditators mentally shift their brain activity to different areas of the cortex. In other words, brain waves in the stress-prone right frontal cortex move to the calmer left frontal cortex. This mental shift decreases the negative effects of stress, mild depression, fear, and anxiety (Allen, 2003).

The following psychological changes occur with regular meditation practice (Carlson et al., 2004; Eliopoulos, 2004; Freeman, 2004; Keng, Smoski, & Robins, 2011; Lane, Seskevich, & Pieper, 2007; Lykins & Baer, 2009; NCCAM, 2012; Ornstein, 2008; Seaward, 2012; Trivieri & Anderson, 2002):

 Improved mental and emotional health  Increased productivity and creativity at work

 Reduced perception of stress  Reduced anxiety and depression  Increased degree of self-actualization  Increased locus of control  Improved sleep  Decreased tendency to worry  Improved concentration and focus

Scientists now embrace the concept of ongoing brain development and neuroplasticity (the lifelong ability of the brain to change). MRIs show that new brain cells (neurons) can be created with certain types of activities, and connections between neurons can grow. An example of neuroplasticity can be found in the brains of those who routinely meditate. By practicing meditation, changes in the brain occur, resulting in the formation of new neural pathways (plasticity). These new pathways formed from a regular meditation practice help reduce “brain noise” and (along with positive physical and psychological effects) result in an increased sense of well-being and sense of peace and calm (Davidson, & Lutz, 2008).

NATURE

Have you ever walked barefoot on the grass, listened to the ocean or the rush of a river, heard the sounds of baby birds chirping in the spring, smelled the desert after a summer thunderstorm, or marveled at the silence of a winter snowfall? These sensory experiences can help us feel peaceful, awe-struck, humbled, exhilarated, and connected to the grander world beyond ourselves.

Many physical, psychological, emotional, and spiritual benefits come from being able to experience nature, even in small amounts. For example, simply looking at a representation, such as a landscape painting, or being in a garden dominated by greenery, flowers, or water, is significantly more effective in promoting recovery or restoration from stress than looking at scenes of rooms, buildings, or towns.

In addition, consider these findings:

 Research shows that clients in rooms with views of nature heal faster and leave the hospital earlier than those whose rooms have no view or a poor view. Patients who have a window or view of nature have fewer postoperative complications, fewer headaches, less nausea, better pain relief, and less stress than those who did not have a window or natural view (McUsic, 2006; Ulrich, 2002).

 A study of children with attention deficit disorder (ADD) found they functioned better than they normally would after participating in activities in green, natural settings, and the “greener” a child’s play area, the less severe his or her attention deficit symptoms (Taylor, Kuo, & Sullivan, 2001).  Residents in inner city dwellings with more green space have demonstrated less aggression, violence, and mental fatigue than their counterparts living in relatively barren buildings (Taylor, Kuo, & Sullivan, 2001).  Researchers at the University of Maryland have found a correlation between trees and crime in the Baltimore, Maryland area. When the city and county planted 10 percent more trees, the incidence of robbery, theft, burglary, and shootings decreased by approximately 12 percent (Engler, 2012).  Exposure to nature reduces irritability, inattentiveness, and impulsivity (Taylor, Kuo, & Sullivan, 2001).  Nature has a distracting influence on clients and caregivers, provides relief from pain and stress, and taps into the most basic senses of life and living. People with cancer, for example, respond positively to living, growing things in the environment because they are strong metaphors for life (Leibrock, 2000).  Live interior plants increase employee productivity and attentiveness, as well as reduce physical discomfort and stress (Lohr, 2005; Schweitzer, Gilpin, & Frampton, 2004).

Within only three to five minutes, being exposed to nature or natural views can result in positive psychological, emotional, and physiological changes, such as (McCaffrey, 2007; McUsic, 2006; National Wildlife Federation, 2012; Ulrich, 2002):

 Increased positive feelings and calmness  Reduced negativity, fear, anger, depression, or sadness  Decreased suicidal thoughts and attempts  Reduced stressful thoughts  Reductions in blood pressure, heart rates, heart activity, muscle tension, and brain electrical activity  Decreased headaches, digestive disorders (including nausea), and chronic pain  Decreased pain medication use  Decreased postoperative complications  Increased fitness levels (due to enjoyment of being outdoors)  Increased levels of vitamin D (reducing risk of osteoporosis, cardiovascular disease, and diabetes) © ALLEGRA Learning Solutions, LLC All Rights Reserved. 13

 Reduced symptoms of attention deficit hyperactivity disorder (ADHD)  Improved scholastic performance in math, reading, writing, and listening  Improved cognition and creativity  Decreased emotional lability  Decreased irritability and restlessness  Increased critical thinking skills  Increased kindness and enhanced social interactions  Increased commitment to relationships and community

For individuals with disabilities, spending time in nature can provide mental, spiritual, and physical healing. Experiences in the outdoors can be empowering and even life-changing (Schultz, 2005).

Healing, Therapeutic Gardens For Reducing Stress

One of the most common ways to incorporate nature into one’s life is to create a healing garden. Healing gardens can take many different forms. The types below provide a wide range of options for discovery and stress reduction.

Medicinal Gardens

When designing a healing garden, medicinal plants are often included for their healing properties rather than strictly for their visual or sensual purposes. Many plants can be used in a medicinal garden, including aromatic herbs (especially rosemary, thyme, mint, and basil), annuals (like chamomile and lemon grass), biennials (such as calendula), perennials (such as Echinacea), bulbs (including allium), shrubs (such as witch hazel), and trees (including lemon and ginkgo biloba). Common plants used in medicinal gardens include the following (Plants for a Future, 2012; Therapeutic Landscapes Network, 2012):

 Lavender. Fragrant and colorful, this plant is visually pleasing and can have a calming effect and reduce stress.  Echinacea (coneflower). Considered to support a strong immune system, blooming for many weeks and requiring little maintenance, Echinacea attracts butterflies, hummingbirds, and other birds.  Chamomile. Delicate with white flowers, chamomile attracts bees and other pollinators and is an excellent herb for treating various digestive disorders, nervous tension, and some skin problems.  Mints. Coming in many varieties, mints have a wonderful fragrance and can be used to treat fevers, headaches, digestive disorders, and other minor ailments.

 Aloe. Also called the “elixir of youth,” aloe is an evergreen perennial succulent. The leaves and seeds are edible, and the clear gel contained within the leaf is an excellent treatment for wounds, burns, and other skin disorders.

A medicinal garden can also reflect the culture of the surrounding area. Many healing plants provide an excellent source of education about, and connection to and support of, one’s culture and traditional healing modalities.

Sensory Gardens

Many gardens include sensory exploration as a central theme. For example, plants that create visual interest (in terms of shape, size, or color), plants that support healing (such as plants that attract birds), and plants that can be smelled, touched, and tasted provide a range of healing experiences for patients of all ages and all developmental and intellectual abilities. These gardens support physical, emotional, spiritual, and psychological growth, exploration, and stimulation and can be designed for specific age groups, such as children, or individuals of all ages.

The Oklahoma State University Botanic Garden is an excellent example of a sensory garden. This garden has a gathering area and special sections of the garden for each of the five senses. In each of these sections, there are interpretive signs describing each of the plants. For example, in the “touch” garden, wax leaf begonias, caladium, lamb’s ear, Mexican feather grass, globe thistle, heavenly bamboo, and wooly sage are just some of the plants selected for their diverse textures. Plants and features (such as walkways, water fountains, wind chimes, and pots) are meant to be touched and provide a variety of tactile experiences from rough, soft, smooth, bristly, fuzzy, firm, feather-like, or even sticky. Every part of the plant (bark, leaves, stem, blooms, seed pods, fruits, etc.) is meant to be explored and experienced. In addition, this garden follows the Americans with Disabilities Act (ADA) guidelines. There are raised garden beds for individuals in wheelchairs and Braille signs for the sight-impaired (Schnelle & Holmes, 2009). Sensory gardens provide individuals with a way to focus on something outside themselves, incorporate the healing power of touch and smell, and provide beauty. All these promote relaxation and a sense of calm.

Memorial Gardens

One way to soothe a grieving soul and reduce the stress of coping with death and dying is to provide a memorial garden. These are places to reconnect with the individuals who have died or make peace with parts of ourselves that may need healing. The connection with nature helps to remind individuals that they are part of a greater cycle of life and death. The ability to watch the seasons and the accompanying changes in the garden allows the opportunity to experience both the positive and negative aspects of the cycle of life and death. Water is often a primary element in a memorial garden, since it supports personal contemplation and meditation. Carefully chosen sculptures and art objects can also be part of a memorial garden.

An example of one such garden is Carley’s Magical Garden at the Children’s Hospital and Health Center in San Diego, California. Named after a three-year-old child who died of leukemia in 1997, the garden was created to represent Carley—a magical, impish child, according to her parents—and support young patients who are struggling with the day-to-day anxieties of their diseases. Designed so children could play, rest, and find comfort just outside their rooms, the garden has inspired several other gardens at the hospital. The “Garden of Dreams” (the largest garden), contains a bird fountain, brightly colored overhead butterflies, a sailboat river, and a sculpture dedicated to Carley. The “Buggy Garden” and the “Friendship Garden” depict how Carley would wander outside her room during her treatment episodes and befriend many creatures she found there, including spiders and hummingbirds. The Buggy Garden has a caterpillar bench, a large dragonfly, and a small tiled fountain where children can play with the water. The Friendship Garden has a vine-covered gazebo, turtle fountain, and interactive playhouse (Vendome Group, 2012).

Meditative Gardens

Meditative gardens are designed to provide a place to retreat and create an environment where everything is soothing and peaceful. They lend themselves to contemplation and meditation. The place where meditation takes place is ideally cool, calm, and quiet (Scripps Networks, 2012). This type of garden can embody any one of a number of “personalities” and styles.

 A Japanese or Chinese garden could incorporate sand, fine gravel, Zen elements, a fish pond, cherry blossoms, a Japanese maple tree, a pagoda or bridge, carved stone sculptures, pathways, and geometric simplicity.  A southwestern (United States) garden could include cacti, sand, drought- resistant plants, shady desert plants, rocks, and simple designs.  An English garden might include roses, lots of flowering plants, a pond or water feature, arbors, and colorful pots.  An Islamic, Persian, or Arabic inspired garden could include water elements, shade, tiles, and palm trees.

IMAGERY

The imagination is probably an individual’s least initialized health resource. Imagination can be used to remember and re-create the past, develop insight into the present, influence physical health, enhance creativity, inspire, and anticipate the future (Trivieri & Anderson, 2002).

Trivieri and Anderson (2002) define imagery as a “flow of thoughts that one can see, hear, feel, smell, or taste in one’s imagination” (p. 245). Imagery is the natural way for the nervous system to store, access, and process information. It is a rich, symbolic, highly personal language that involves fantasy as well as experience and is the interface between the mind and the body (Trivieri & Anderson, 2002). Imagery and intuition are part of our nonlogical thinking and they connect us with our inner subjective reality (Zahourek, 2002).

Historically, people have believed that imagery could magically influence present and future health and prosperity. Indigenous cultures and shamans still use it with ancient healing rituals since they view the mind, body, and spirit as a whole. They believe that rituals, visions, and images are the bridge between the physical world and the healing power of the spiritual realm (Seaward, 2012; Zahourek, 2002).

Imagery can be used on its own or in conjunction with therapeutic touch, meditation, biofeedback, Reiki (pronounced “ray-kee”), reflexology, and other holistic practices (Schaub & Dossey, 2005; Seaward, 2012).

Therapeutic Characteristics of Imagery

Imagery has three main characteristics that provide value to health-care providers and assist in the healing process:

 It directly affects physiology.

 It provides insight and perspective into health through the mental processes of association and synthesis.

 It is intimately connected to the emotions, which are at the root of many health conditions.

Imagery can affect heart rate, blood pressure, respiratory patterns, oxygen consumption, carbon dioxide elimination, brainwave rhythms, the electrical characteristics of the skin, local blood flow and temperature in tissues, gastrointestinal motility and secretions, sexual arousal, levels of hormones and neurotransmitters in the blood, and immune system function (Schaub & Dossey, 2005; Trivieri & Anderson, 2002).

In addition, imagery helps people find meaning in events and situations and helps them understand and control their patterns of thinking. It makes the mind more receptive to new information; helps reduce fear, anxiety, and pain; and directly affects physiology, especially the sympathetic nervous system stress responses.

Imagery is a versatile therapeutic intervention that is often used in conjunction with hypnosis, biofeedback, desensitization, and cognitive behavioral techniques. It can be used at any stage of a therapeutic process, but healing patterns are more easily established when individuals are relatively healthy than when they are faced with a serious disease. No research has yet been able to determine the specific kind of imagery that works best for a given type of client, symptom, illness, or disease (Trivieri & Anderson, 2002; Zahourek, 2002).

Types of Imagery

There are many different types of imagery, however, the most useful are the experiential types, which include active, receptive, process, and end-state imagery (Leddy, 2006; Zahourek, 2002).

 Active imagery uses conscious and deliberate effort to develop concrete and symbolic images. These images can be either a wise entity or inner guide or general healing images that include events, people, places or things, light, warmth, or heat. This approach is best used to address symptoms.

 Receptive imagery addresses the emotional significance of symptoms. This form occurs spontaneously and allows images to “bubble up” into the conscious mind without a specific effort. It often occurs in the early stages of sleep or just prior to awakening.

 Process imagery uses a step-by-step approach to achieve the individual’s goal. It is the rehearsal of a procedure or event.

 End-state imagery asks individuals to imagine their final, healed state.

Guided Imagery Guided imagery involves the purposeful use of mental images by working with another person to achieve a desired therapeutic goal. It does not require elaborate equipment and it is safe and noninvasive (Payne, 2005). In this method, a person deliberately forms mental images while in a deeply relaxed state.

Guided imagery has been used to reduce phobias, complement other therapies, and facilitate a peaceful death. It has also been used to reduce chronic pain, allergies, high blood pressure, stress-related

© ALLEGRA Learning Solutions, LLC All Rights Reserved. 19 gastrointestinal symptoms, and functional urinary and reproductive irregularities (including premenstrual syndrome and dysmenorrhea); accelerate healing from acute injuries (including sprains, strains, broken bones, and symptoms of the flu, cold, and infections); and help with addictions, bulimia, and psoriasis (Leddy, 2006; Trivieri & Anderson, 2002; Zahourek, 2002).

In guided imagery, specific words, symbols, and ideas are used to elicit images. For example, imagine holding a juicy, bright yellow lemon. Feel its coolness, its weight, and the texture of its skin. Now imagine cutting it open, bringing it to your nose, and smelling it. Imagine biting into it and sucking the sour juice into your mouth. What did you experience as you imagined this? Did you salivate? Did you have any other physical reactions?

Guided imagery draws on all the senses: sound, taste, movement, vision, touch, and inner sensation. They work best when integrated thoroughly with the person’s entire being. You probably salivated more with the description of the lemon image than you would if you were told simply to imagine salivating.

Guided imagery sessions often use a preexisting scripted process that usually lasts 20– 25 minutes and begins with a general relaxation technique that helps to center the mind. A typical format includes identifying the problem, goal, or disease and then incorporating the following (Leddy, 2006):

 The individual finds a comfortable place to recline or sit.

 Extremities are uncrossed and the eyes are closed or focused on one spot or object in the room.

 The person focuses on his or her breath, uses abdominal breathing, and with each breath says “in” and “out.”

 The individual may feel the body becoming heavy and warm.

 The images of the problem, goal, or disease are developed, as well as the inner and external (treatment or healing) resources.

 If the thoughts wander, the individual brings the mind back to thinking of his or her breathing and relaxed body.

 The session ends with images of the desired state of well-being.

Effective suggestions for the sessions include the following (Leddy, 2006):

 In your mind, go to a place that feels good and that you enjoy.

 What do you see, feel, taste, hear?

 Take a few deep breaths.

 Imagine yourself the way you want to be (describe the desired goal specifically).

 Imagine the steps you need to take to be how you want to be.

 Practice these steps now in the place where you feel good.

 What is the first thing you will do to help yourself be how you want to be?

 Remember that you can return to this place, this feeling, this way of being whenever you need to.

 When you are ready, you may return to the room we are in.

 You will feel relaxed and refreshed and ready to resume your activities.

 You may open your eyes slowly and tell me about the experience when you are ready.

To facilitate relaxation, individuals can use commercial audiotapes of verbal suggestions, music, sounds of nature, pictures of objects or places, aromas, scented candles or oils, or another person giving suggestions in a soft, pleasant voice to assist in the image formation (Leddy, 2006).

Examples of imagery include beaches with waves, a salty sea breeze, warm sand, and the colors of the sunset or lush green meadows with blue skies and puffy clouds. Mountain images, including lakes and flowers, singing birds, and the smell of pine trees or the sound of a stream, are also helpful. For healing, images can include visualizing good monsters eating bad monsters or personifying the immune system’s cells as soldiers destroying cancer cells. For self-esteem building, some use the image of a tightly closed flower bud that opens to become a beautiful flower (Leddy, 2006).

Several types of words can help the practitioner during the guided imagery session (Leddy, 2006):

 Metaphors imply comparisons. For example, “You feel relaxed, like a warm waterfall.”

 Truisms are statements that the intellect accepts as accurate. For example, “As you take in your next breath, oxygen is flowing into your lungs and into every cell in your body.”

 Synesthesia is the combination of several senses simultaneously. For example, “Can you feel the color of the sky?”

 Linkages connect certain statements, behaviors, and actions with thoughts. For example, “Once more . . . relax deeply . . . and feel yourself really sinking into the surface of the floor and feel supported by this surface.”

 Mirroring involves repeating the client’s words or descriptions instead of using your own.

BIOFEEDBACK THERAPY

Biofeedback is a tool used to change habitual reactions to stress that can cause pain or disease. Biofeedback teaches people with stress-related disorders to recondition their responses so they gain control over the system causing their stress symptoms.

The word biofeedback was coined in the late 1960s. Biofeedback machines measure the primary physiological reactions of the body when it is stressed (including blood pressure, heart rate, skin temperature, perspiration levels, and muscle tension). Individuals use biofeedback machines to allow them to “see” or “hear” the activity in the body. The individual then employs a method to reduce stress and is provided with feedback about biological measures. For example, one type of machine may detect electrical signals in the muscles and trigger a flashing light or beep when muscles grow tense. Individuals using this type of machine can slow down the flashing or beeping noise by consciously relaxing their muscles (Anselmo, 2013; Mayo Clinic, 2013).

Types of Biofeedback

There are many types of biofeedback equipment ranging from small, hand-held devices to large instruments. A therapist may use any one of a number of biofeedback machines and techniques to measure electrical signals from the heart, brain, muscles, or skin. Determining the technique that is correct for each person depends on the individual’s specific health problems and therapy goals.

Biofeedback techniques include the following (Mayo Clinic, 2013):

Electromyography (EMG) biofeedback. This type provides information about the body's muscle tension so individuals can practice relaxing specific muscles or muscle groups.

Temperature (thermal) biofeedback. Sensors attached to the fingers or feet measure skin temperature. Skin temperature often drops when a person is under stress.

Galvanic skin response training. Sensors measure the activity of sweat glands and the amount of perspiration on the skin, alerting the person that they are experiencing anxiety.

Heart rate variability biofeedback. This type of biofeedback measures the variability between each beat of the heart. When a person is stressed, that variability is irregular due to the imbalance between the sympathetic and parasympathetic nervous systems. When individuals see this irregularity, they can use their stress management techniques to reduce the variability and simultaneously reduce their blood pressure and improve lung function (through deep breathing).

Specialists who provide biofeedback training include psychiatrists, psychologists, dentists, internists, nurses, and physical therapists.

Clinical Indicators for Biofeedback

Biofeedback treatments can be beneficial for the following stress- related disorders and conditions (Anselmo, 2013; Mayo Clinic, 2013):

 Insomnia  Anxiety  Phobias  Alcoholism and addiction  Attention-deficit hyperactivity disorder (ADHD)  Stroke  Migraine and tension headaches  Some cardiac arrhythmias  Some forms of paralysis (such as Bell's palsy)  Hypertension  Some types of pain (e.g., back pain)

Biofeedback therapy is not recommended for individuals with severe psychosis or obsessional neurosis. It is also contraindicated for diabetics and those with endocrine

ART THERAPY

Nearly everyone has found themselves doodling while talking on the phone, keeping a personal journal, or painting or sculpting as a hobby. As people do these things, they find that their feelings and ideas change, and they may even feel themselves transported away from their everyday problems. Involvement with art can alter feelings, reduce stress, clear the mind, and raise consciousness. Involvement with art is, indeed, a therapeutic process (Lippin & Micozzi, 2006).

The ability of the arts to enhance health has been known since the beginning of time. Early, preliterate human beings naturally embodied feelings, attitudes, and thoughts in symbols. The ancient Greeks recognized the connection between healing and the arts through their use of aesthetics in buildings, healing gardens, and temples, where the arts played a predominant role in healing (Lippin & Micozzi, 2006). Florence Nightingale, an advocate for aesthetics, healing, and recovery, talked about the importance of beautiful objects of all colors and their effect on recovery.

The 21st century has already seen a dramatic increase in attempts to inject variety into healing environments in the form of color, design, and art and in the use of music, movement, and healing gardens. Health-care providers now realize that interventions need to take place at the level of the spirit as well as the level of the body and the cell (Donnelly, 2007).

All across the United States, the therapeutic aspect of art is gaining recognition. In cooperation with The Joint Commission and the Americans for the Arts, the Society for Arts in Healthcare (SAH) found that 2,500 U.S. hospitals use the arts to create healing environments, support client mental health and emotional recovery, and develop positive working environments (Knutson, 2006).

The hospital arts movement continues to grow through architectural design, interior design, and the strategic placement of fine art in health-care settings, such as lobbies, waiting rooms, client rooms, and high-tech intervention areas (Lippin & Micozzi, 2006).

What Is Art Therapy?

Established in 1969, the American Art Therapy Association describes art therapy as the use of art in a creative process, providing the opportunity for nonverbal expression and communication and fostering self-awareness and personal growth. Art therapy initiates a strengthened partnership between the nonverbal, artistic, spatial right- brain function and the more analytical, logical, and verbal left- brain function, and it serves to balance and integrate these two cognitive functions (Seaward, 2012).

The field of expressive arts is based on the belief that each person has worth, dignity, and the capacity for creative self-direction (Cantwell, 2006). Art therapy is based on the premise that many thoughts, feelings, and insights cannot be expressed verbally because several abstract constructs of the mind lack the necessary vocabulary to describe the focus, intensity, and understanding of encounters that the mind tries to process and grasp (Seaward, 2012). Creative arts allow that to happen.

As Donnelly (2007) explains, “The arts distinguish us among species and make us uniquely human” (p. 165). When we use art as a technique that allows inner knowing to explore freely, we create a balance between our inner and outer paradigms (Wetzel, 2006). Engaging in the arts is life affirming and life enhancing (Lippin & Micozzi, 2006).

Passive exposure to the arts, including music, dance, painting, sculpture, poetry, and drama, has also been shown to have healing properties. Passive exposure provides a means of imaginative expression that circumvents the blocks between the conscious and unconscious mind (Shealy, 1996).

Benefits of Art Therapy

Art therapy has been shown to improve relaxation and help participants be more aware of physical and emotional issues (Repar & Patton, 2007). One of the greatest impacts of art could be the potential to synthesize and integrate issues such as pain, loss, and death (Lippin & Micozzi, 2006).

Ultimately, clients find their way to a deeper understanding of their own issues. Many people find that the spontaneous, uncensored nature of art therapy provides a powerful, healing, and revealing therapeutic release (Kim, 2006; Nieves, 2006). Because it works on a nonverbal level, art therapy is an excellent form of therapy and relaxation for individuals whose traumas are buried too deep for words or for children who do not have the words to describe their distress.

Art therapy has been shown to have a number of other effects:

 It decreases perceived pain, reduces the amount of pain medication needed, decreases anxiety levels, and lowers blood pressure, heart rate, and respiratory rates (Kim, 2006; Nieves, 2006).

 Use of the arts leads to self-knowledge, self-discovery, mood change, and emotional catharsis (e.g., weeping, laughing, sexual activity) that can induce pleasure and relaxation (Monti, et al., 2006).

 Drawing can serve as a bridge between the health-care provider and the client, family, and surrounding world. It can increase pleasure, motivation, and learning, and ultimately influence behaviors. It can provide a sense of hope and optimism that has been linked to positive effects on the immune system (Lippin & Micozzi, 2006; Monti, et al., 2006).

Types of Art Therapy

Drawing, painting, craftwork, and model making are all forms of art therapy. There is no formula to determine which techniques are best. The decision can be based on the health-care provider’s experience or the individual’s preference (Cantwell, 2006).

Clients may draw parts of their bodies that unconsciously concern them or they may draw something they have been unable to verbalize. The goal is not to produce a skillful finished work of art but to follow spontaneous impulses as they utilize form, lines, colors, and textures. Realizing that there is no right or wrong form of expression, because it comes directly from the person, supports the goal of having clients engage in art without fearing shame, ridicule, derision, or embarrassment so they can cast off their “inner critic” (Lippin & Micozzi, 2006).

Some have suggested that the colors an individual selects in art therapy have associated meanings: red (passionate emotional peaks), orange (life change), yellow (energy), blue and green (happiness and joy), purple (highly spiritual nature), brown (stability), black (grief or personal empowerment), and gray (ambiguity) (Seaward, 2012).

DANCE AND MOVEMENT THERAPY

Dance is a universal form of expression. Throughout the world, people have danced to celebrate, to bond together as communities, to share sentiments, and to heal the sick. Dance and movement provide expressions of the mind, body, and spirit and are powerful media for therapy (Picard, 2000).

Dance and movement therapy is the psychotherapeutic use of movement as a process that supports the interconnected body, mind, and spirit. Dance and movement therapy supports the individual’s emotional, cognitive, physical, and social integration, while also employing traditional methods of psychotherapy (American Dance Therapy Association, 2013; Arts for Healing, 2013). Dance therapy is concerned with genuine, creative movement and establishing unity of mind, body, and spirit with a focus on body movement as a manifestation of thoughts and feelings. Dance is the essence of “embodiment” (Block & Kissell, 2001).

Therapeutic Benefits of Dance and Movement

The mind, body, and spirit are integrated in dance and movement therapy. As a result, it has been demonstrated to be clinically effective in achieving the following (Becker, 2002; Picard, 2000):

 Developing an improved body image  Improving self-concept  Increasing self-esteem and self-awareness  Facilitating attention  Enhancing relationships with others, self, and spirit  Ameliorating depression  Decreasing fears and anxieties  Expressing anger  Decreasing feelings of isolation  Improving communication skills  Decreasing body tension  Reducing chronic pain

 Enhancing circulatory and respiratory functions  Promoting healing

Dance therapy settings may include psychiatric centers, adult day care facilities, community mental health centers, infant developmental centers, correctional facilities, schools, and rehabilitation facilities, as well as private practice outside an institution.

HUMOR THERAPY

An Apache myth tells of how the creator endowed human beings, the two-leggeds, with the ability to do everything—talk, run, see, and hear. But he was not satisfied until the two-leggeds could do just one thing more—laugh. And so men and women laughed and laughed and laughed! Then the creator said, “Now you are fit to live.” —LARRY DOSSEY (2001)

What is humor therapy? In its broadest sense, it is whatever one does to put mirth into a client encounter (Adams, et al., 2006). Humor is a universal and complex phenomenon. It is a holistic health practice that integrates physiologic, psychosocial, and spiritual well- being. The culture, society, or ethnic group in which humor occurs influences its style and content as well as the situations in which it is used and is considered appropriate.

Studies have demonstrated that humor is a social relationship and occurs in a social environment. Humor promotes group cohesion, initiates relationships, relieves tension during social conflict, and can be a means of expressing approval or disapproval of social action (Wooten, 2000).

Humor can stimulate the immune system, enhance perceptual flexibility, and renew spiritual energy. In Anatomy of an Illness, Cousins (1979) describes how he used humor to help him recover from a debilitating disease. Many credit him as being the catalyst for a new specialty: humor therapy.

Humor and Laughter Defined

Humor and laughter are often confused as being the same thing but they are quite different. Wooten (2000) provides the following definitions:

 Humor: A quality of perception and attitude toward life that enables an individual to experience joy even when faced with adversity; a perception of the absurdity or incongruity of a situation.

 Laughter: A physical behavior that occurs in response to something perceived as humorous, amusing, or surprising. This behavior engages most of the muscle groups and organ systems within the body. Laughter is often preceded by physical, emotional, or cognitive tension.

Laughter and Stress

The harmful effects of stress upon an individual’s health are well known. Diseases such as hypertension, insomnia, ulcerative colitis, and coronary heart disease are, in part, the result of prolonged stress. Stress and negative emotions have been associated with immunosuppression. These negative emotions alter blood levels of epinephrine and cortisol.

The pleasant feelings associated with mirthful laughter may modify some of these neuroendocrine components of the stress response. In addition, there is a general decrease in stress hormones that constrict blood vessels and suppress immune activity after being exposed to humor (Berk, 1996).

Current research in the areas of psychology, physiology, and psychoneuroimmunology is defining the specific changes affected by the experience of mirthful laughter. Mirthful laughter has been shown to do the following (Berk, 1996; Seaward, 2009; Wooten, 2000):

 Increase the number and activity of natural killer cells (which attack infected cells and some types of cancer cells)

 Increase the number of activated T cells (these cells are “turned on and ready to go” to fight infections)

 Increase the level of the antibody IgA (which fights upper respiratory tract infections)

 Increase the levels of gamma interferon (which activates many immune components)

 Increase levels of complement (which helps antibodies to pierce infected cells)

Using Humor to Reduce Stress

Developing a Sense of Humor

Despite much discussion about what constitutes humor, how does one go about cultivating a sense of humor so that it can be incorporated into healing and helping the therapeutic process? Cultivating a sense of humor and reducing stress can be accomplished through the following (Eliopoulos, 2004; Robinson, 1991; Smith, Kemp, & Segal, 2010):

 Laugh at yourself, and give yourself permission to be human and make mistakes. None of us is perfect, and when we laugh and gently poke fun at ourselves, we lighten up and learn to be less serious.

 Visit a comedy club or listen to humorous CDs on the way to work.

 Pay attention to personal self-talk and replace negative thoughts with positive ones.

 Collect funny material from comedy writers and comedians.

 Tell jokes or stories.

 Focus on being with funny people and on being someone others like to be with because you are pleasant.

 Read more books (fiction and nonfiction) and watch less television.

 Write a story, fable, or poem every now and then to improve your imagination and creativity.

 Share your vision to make others laugh. Laughter is contagious and is needed in all lives. Humor shared is humor doubled.

 Learn to exaggerate when describing a situation or story.

 Develop a humor kit or tickler notebook with funny notes, letters, and love poems so you have a humor capsule of things that make you laugh or smile.

 Plan to play. A part of the richness of life, play enables people to live and grow. Infants and children play to learn. Many animals play at least some time in their lives. As adults, we play to relax, to interact with others, to gain a perspective on our lives, and to grow. When we truly play, we seek to impress no one, and we produce no product. We just enjoy being in the moment, being spontaneous, and laughing. Have fun with toys.

SUMMARY

Stress is one of the major causes of illness and disease. Stress-reduction techniques and therapies are varied and can include self-awareness, cognitive restructuring, sound healing and music therapy, meditation, imagery, interaction with nature, biofeedback, art, dance, and humor. These modalities are useful and popular because they are often easy to use, usually do not require a great deal of money, and are accessible to almost anyone at any time. They provide a holistic approach to supporting the mind, body, and spirit and improving overall health and well-being.

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