RELAXATION THEORY AND PRACTICE

RELAXATION THEORY AND PRACTICE1

DIANA ELTON, G. D. BURROWS AND G. V. STANLEY

University of Melbourne

SUMMARY This paper reviews the theoretical aspects of clinical use of relaxation and the pr.oblems inherent in its applicatio..n in a h03pital setting. It discusses, the relative usefulness of relaxation procedures in va.rious conditions. 1'his includes the advantages versus the disadvantages of group practice, the use of audio casettes, specificity of instructions and inteTdisciplinary aspects 01 patient care. Some guidelines are p\Tovided for the practice of relaxation by physiotherapists.

INTRODUCTION of relaxation in treatment of many conditions. We live in an anxiety provoking world. Generally the medical profession has been Each individual may daily face challenges, slow in adopting these approaches. for which there may be little or no solution. In recent times, there has been a growing Mechanization may rob pride of work and interest in relaxation, as a means of dealing individuality. A person could become a slave with tension and anxiety and of generally to the clock, in a constant rush to keep abreast improving the patients' well-being. It has of commitments: "the inability to relax is attracted the attention of several professions: one of the most widely spread diseases of our 1. Psychiatrists are using it more fre• time and one of the most infrequently recog.. quently in dealing with conditions where the nized" (Jones, 1953). predominant component is anxiety. Those who .A.nxiety often presents in a variety of practise hypnotherapy often adopt relaxation bodily, behavioural and psychological ways. as a standard induction procedure. Every day doctors see tense patients whose 2. Psychologists, and particularly the be• anxiety may he hypnosis and doctors prescribed "rest" which could be bio-feedback has led some general practition• variously interpreted, but which basically in• ers to use these methods to train their patients cluded relaxation. The difference here is that in relaxation. Other medical practitioners are "rest" involved passive use of relaxation, while still oriented mainly to chemotherapy. modern approaches prefer a dynamic, self.. regulating approach to relaxation. Jacobson 4. Occupational therapists in the psychiat.. (1938) attempted to place relaxation on a ric field often use group relaxation treatment scientific basis and to make it a standard to handle a variety of disorders, such as form of medical treatment" He has shown anxiety, cardio-vascular problems, gastroin.. clinically and experimentally the usefulness testinal problems and !o forth. Although they treat mainly neuroses, some patients suffering 1Received March, 1977 .. from psychoses may occasionally be included Aust.l.Physiother., XXIV, 3, September, 1978 144 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY in the group4 Many occupational therapists resides entirely in the brain and the nervous insist on detailed assessment of their patients system. There are muscular tensions associ• prior to admission to a relaxation group4 ated with all mental processes, such as 5.. Physiotherapists have used relaxation imagery, attention, cognition and so on. When principles for years. They employ them in the an ·organ is active, the muscles which control practice of obstetrics when teaching their it are also active. The sensations from con• trolling muscles evidently play a useful part patients the "natural childbirth" methods 4 They also use relaxation as a standard form of in mental processes. Without a faint tenseness treatment of asthma and other respiratory neither imagery nor thought would be sus• conditions, since it is believed to help pre.. tained. There is a reciprocal interaction be• vent bronchial constriction. Some physio.. tween the tonus in skeletal muscles and in the therapists employ relaxation methods also in smooth muscles of the viscera. This tonus orthopaedic, thoracic and neurological fields, affects the higher nervous system and therefore as an adjunct to other forms of treatment. the tension is associated with emotion. This practice is not followed by other uses Emotional processes cannot exist unless they of physiotherapeutic techniques. That is re.. are accompanied by muscular tension. Relax• grettahle, since, "relaxation should be the ation, that is, the diminution of the tension, keystone of all physiotherapeutic treatment" must bring with it a diminution of emotional (Jones op. cit.). or mental processes. Jacohson has demon.. strated, both clinically and experimentally, Interest in relaxation is shared by many evidence for his theory. Further evidence to different professions, all dealing with similar support his views comes from the behavioural patient populations.. This is of particular scientists. Wolpe (op. cit) showed that relax.. importance to the physiotherapist, who may ation was an essential part of systematic be called upon in the future to offer more desensitization, because it was antithetical to widespread services, involving relaxation tension states. Hay and Madders (1971) dem.. training, to a variety of patients. As the onstrated that relaxation therapy coupled appreciation of the use of relaxation techni• with a discussion group was successful in re.. ques grows, so will the demand for its lieving migraine headaches (presumably practitioners. To meet that demand the partly due to tension) in 69 out of 98 physiotherapist may require greater knowledge patients. of the theories underlying the practice of re.. laxation, the variety of methods of its use, Jacohson's theory may be criticized: and of the possible reasons for its effectiveness 1. He 'focused only on the neuro..musculo.. as well as the need for selectivity in acceptance sensory interaction, and did not consider of patients into such training. This paper dis.. mental relaxation, which to him was the cusses some of these issues. obvious outcome of the physical relaxatioD4 Rachman (Opr. cit.) opposed this and argued THEORETICAL CONCEPTS that therapeutically the most useful component While the empirical usefulness of relaxation of relaxation was the resultant "mental calm.. techniques seems obvious, they are more ness". Mental calmness can he achieved even difficult to explain conceptually. Various without muscular relaxation, by the use of factors require consideration: pleasant imagery, or by concentration on words such as "calm, calm" or "relax, Relaxation and Neuromuscular Control relax". Further evidence of the importance of Jacobson (op. cit.) stated that neuro.. mental relaxation comes from the studies of muscular patterns are an essential part of the Yoga, Transcendental Meditation and other mental and emotional activities of an individ• forms of mental self·controL ual. The energy expended in a neuromuscular 2.. Lader and Wing (1966) demonstrated activity is identical with and not a transform• that there were occurrences of bursts of ation of the energy of the corresponding electromyographic activity in muscles during mental and emotional activity. Jacobson a relaxation session, although the subject re· argued that it is a fallacy that human ideation ported himself to be quite relaxed. Aust.J.Physiother., XXIV, 3, September, 1978 RELAXATION THEORY AND PRACTICE 145

3. Davison (1966) has shown that sub• anxiety. This was supported by Shor (1962) jects who were injected with curare, a sub• and others. The other important features of stance which produces complete relaxation of hypnosis are the use of suggestion and all the skeletal muscles, experienced a great imagery, alteration of attention and dissoci" deal of anxiety during this procedure. ation. These components are also used to a degree in relaxation training. Although re· 4. Jacobson did not consider the import• laxation may he part of hypnosis, it is difficult ance of suggestion in the relaxation pro• to determine when the relaxation ends and cedures, yet it is vitally important, as shown hypnotic trance state occurs, since many of studies of hypnotic analgesia (Hilgard, by the techniques used to achieve both are similar. 1969) . Some of the patients, particularly those who Relaxation and the Placebo Effect are good hypnotic subjects, may enter into a hypnotic trance just the use of relaxation It is difficult to consider any form of by training. It is useful to observe certain signs psychological approach to patients without of the hypnotic trance, such as the acknowledging the "placebo effect". The sur• eyelid flutter, change in breathing, muscular relax• prising effectiveness of placebos in relief ation, to determine what happens to each from pain is well known. Beecher (1959) individual in a "relaxed" state. showed that 35% of pain patients received relief from placebos and only 65% of pain In summary, when considering theories -of patients received relief from morphine. relaxation, variables include: neuromuscular M1cGlashan et ale (1969) proposed that hypnotic control, mental control, placebo effects and analgesia consists of two components: the spontaneous hypnotic induction. non·specific placebo effects and a distortion of perception specifically induced during deep TECHNIQUES 'OF RELAXATION hypnosis. Some of the effectiveness of hypo. There are many techniques which may he nosis is attributed to the placebo effect. The used to produce relaxation. The therapist placebo treatment cannot he viewed in should be familiar with many, hut select isolation, hut rather as a "placebo situation" those he/she is m-ost comfortable with and associated with childhood memories of those most appropriate to each particular comfort, love and caring by mother and patient. Not all patients are equally suited significant others (Elton et al., 1977). A for any particular technique. dependency on doctors, nurses and others in I. Jacobson's progressive relaxation fo• an "illness situation" may constitute a form cused initially on the use of the dom.. of regression to childhood. The trust in the inant arm only. Differentiation was stressed. members of the "helping professions" may The patient was asked to become aware not in itself he sufficient to allay anxiety and pro• only of the maximum and the minimum duce improvement (Sternbach, 1968). tensions, but also of all the possible range Anxiety is inversely related to relaxation. of tensions in between. For example: The Both placebos and relaxation techniques patient was trained to consider a total lack appear to relieve a!J.xiety and pain. It is there.. of tension as 0, and the highest possible level fore assumed that placebo effects are of tension as 10. He was then asked to pro• correlated with and inherent in relaxation duce in his dominant arm a tension of level techniques, just as they are in other forms of 8, then 5 and so on. Jacobson used both therapy. isotonic and isometric exercises to facilitate the learning of tension levels by the patient. Relaxation and Hypnosis Only after the relaxation of the dominant Hypnosis has heen used effectively in arm was achieved, were the other parts of the achieving pain relief and in the treatment of body given relaxation training. Differentiation psychosomatic and neurotic disorders for of tension levels remains a very useful relax• hundreds of years. Barber (1963) argued ation technique, particularly for patients who that the success of hypnotic treatment was are not aware of their own tension, since it largely due to lowering of the patient's has become a habitual state to them. It is AustJ.PhYsiother4' XXIV, 3, September, 1978 146 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY equally important for patients who have per.. and relaxation of one limb at a time, coupled petual tension in one or more muscle groups, with a suggestion "it is getting limp and for example, the shoulder girdle muscles. heavy". Usually the procedure started with the Constant awareness of the level of tension is lower limbs, to upper limbs, and then the rest valuable therapeutically. of the oody. The Jacobson technique presented some The patient was relaxed in a sitting position. problems: This had an advantage when he was asked to (a) The treatment time varied from a mini.. relax often at home and at work" Imagery of mum of 12 half-hourly treatments 3..4 a pleasant scene was included in the procedure. times per week, followed by 1-2 hours It was usually non-directive, or semi-guided" of home practice daily, to a year or Breathing and attention to the bodily processes longer of daily treatments. were stressed. (h) No imagery was used, since Jacobson This method has various advantages over saw it as associated with tension of the the former two. It is faster and usually more associated muscle groups. interesting for the patient and appears easy (c) The instructions were sometimes difficult to learn. It includes instruction of more for the patient, the use, for example, of frequent, but shorter practice periods, for such terms as hand flexors, hand ex• example a minute or two each hour, which tensors. Some knowledge of anatomy is more manageable than one hour twice daily. seemed needed fully to comprehend them, It incorporates relaxation into the daily life unless demonstration was used. of the individual, and allows for both definite 2. Farmer (1967) partially adopted Jacob.. instructions, and for individual variations. son's techniques. He also commenced training 4. Other techniques. with the use of the dominant arm only, and (a) Kleinsorge and Klumbies (1964) method used differential relaxation. Farmer used has the patient repeat a combination of breathing in oonjunction with relaxation. both and mental relaxation in• When the patient breathed out, he was asked physical structions, such as: "I am very to say the word "relax". When he breathed in, much at rest. arm is very heavy. he was asked to say the word "tense". When My right My left arm very heavy. heart is the dominant arm was relaxed, other parts is My beating strong and well. My breathing is of the body received relaxation training" very relaxed. head feels Usually the patient was asked to imagine his My pleasantly cool." This method seems to travel rapidly own calm, happy, sedative scene. from part to part and from function to This technique is useful because of its fWlction. It requires a great deal of con.. emphasis on different degrees of relaxation, centration by the patient, and the the introduction of breathing and imagery. therapist. It appears too taxing for many Its problems are: the instructions given to of the patients requiring treatment.. patients are imprecise, for instance "add a (h) Boorne and Richardson (1931) pro• small amount of tension, increase it hy a vided a more colourful contribution: little bit" without defining what a "little divide the body into a rainbow of colours, bit" may mean. There was no uniformity of such as a red head, orange shoulders, instruction, for instance Farmer would say yellow arms and chest, a green waistline, "relax the muscles of your shoulder", and a blue thighs, purple legs and feet. Instead few minutes later "relax your shoulder". One of mentioning only the parts of the body, instruction refers to the muscles, and the other the therapist trains the patient to learn one to the joint, which is confusing to some the "colour scheme" and then just quotes patients. The alternation between tension and them, for instance, "concentrate on the relaxation instructions is also rather taxing colour of your head and notice your re• for some patients. laxed breathing". This method requires 3. Burrows (1976) offered a simpler and longer time, it may he difficult for the equally effective technique, by using tension colour blind and the unimaginative Aust.J.Physiother., XXIV, 3. September, 1978 RELAXATION THE'ORY AND PRACTICE 147

patients, and may he generally over.. 'awareness of the body and its pattern of complex. On the other hand, it may be tensions; individualization -of the technique effective with patients who are weak on as required by the patient; and the therapist's anatomy, but strong on colour visualiz• knowledge of the neurophysiology underlying ation. the technique. Ideally, it is suggested that 5. Elton (1977) focused on the joints relaxation is most beneficial when given in• rather than the muscle groups, ,arguing that dividually to the patient, so that all his needs one cannot keep muscles tense when the joints are considered and a treatment programme they are attached to are relaxed. For example, is designed arQund them. If audio tapes are "relax the muscles of your forearm", used in to be used, they should he made individually most other approaches. She argues for simplic• for each patient. ity of instructions and orderliness. Joints RELAXATION IN GROUPS are relaxed one after another in an orderly sequence. Bilateral tension and relaxation is At present, many practitioners give training used. The order of tension and relaxation is in relaxation in group situations. Group Ie~ difierent to· most other approaches. F{)r in• laxation has both advant,ages and disadvant• stance, hoth upper limbs may be tensed at ages. first, then hoth lower limbs, then the face. Some of the advantages are that more Relaxation then may proceed from face, to patients may he treated in a limited space lower limbs and finishing with upper limbs. of time; groups provide friendship and social• Variations evolved from discussion with network links for the patients; meeting others, patients who were worried about maintaining and hearing of their problems may help the tension in a particular part of the body. patient feel less isolated. Groups may be Female patients were often unwilling to keep used as a catal'yst for discussion, and the their faces tense since they worried about members of a group may provide a support creating wrinkles. Some patients could not system for each other. Finally, modelling is maintain tension in their toes, because of the easier in groups, where the more capable development of cramp. Breathing was added members act as models for the others. only after the patient learned full body relax• Among the disadvantages are that the ation. The patients were asked to say the space given to each patient is not always word "relaxed" on expiration. The therapist adequate in a group. There may be insufficient insisted on seeing their lips move as they couches, lying on the hard floor may present said this. Then they were instructed to say problems, and so forth. A group does not the word "calm" on inspiration, and "relax• always cater to the individual needs of the ed" on expiration. This usually resulted in patient, it does not allow for the individual complete concentration on the task and has variations-it is aimed at the "mythical previously been used successfully by many average"; homogeneity of a group is difficult othel practitioners. to attain. Also a therapist handling several In summary, there are many relaxation group members may find it difficult to observe techniques. All of them are useful for some, deleterious effects of the programme on one hut not for all patients. The efficacy of the of the participants. The more severely dis• technique depends not only on the patients' turbed the patient, the more need for in• suitability for it, hut also on the belief in dividual attention. its merit by the therapist. This implies that if All the above disadvantages are augmented you are convinced that something will help the if audio-cassettes are used. Lately there has patient, it often will. Individualization is been a growing interest in the use of these needed for the patients who do not benefit cassettes. It was believed that it saved the from a particular technique. therapist's time, provided uniform instruct· The general guidelines for any successful ions and permitted training of patients by relaxation technique are: simplicity of in• semi-skilled personnel. This has led in some structions, that is, ones that the patient will instances to their inappropriate use. If tapes understand; sensory component, that is, are to he used in a group therapy of relax- Aust./.Physiother., XXIV, 3, September, 1978 148 THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY ation, certain guidelines need to he observed: group therapy. Some hospitals are under.. Initial detailed patient screening is essential. staffed, and such shortages are frequently This may include an interview, a careful compensated for by less individual attention taking of history, and the use of psychological of patients by physiotherapists and others in questionnaires. Other important aspects to the helping professions. Many a physio• he considered are the degree of motivation therapist may feel guilty about the non• for change by the individual, the ability to acceptance of a patient and may prefer to persevere, to understand the instructions. give a group treatment rather than no treat• Imagination greatly adds to successful ment at all. This is not the best answer to this therapy. problem. The first session should be individual, so REFERENCE.S that the patient may assess whether he can BARBER, T. X. (1963): "The Effects of Hypnosis on Pain. A Critical Review of Experimental and Clini• benefit from that particular cassette. Patient cal Findings". Psychosomatic Medicine, 8, 24 : 303. responses are also assessed hy the therapist. BEECHER, H. K. (1959): Methods for Measuring The programme of training should be dis• Pain in Measurement of Subjective Responses. cussed with each individual, to ensure co.. N.Y., Oxford. operation, a contractual arrangement and an BOO1\:fE, E.. J. and RICHARDSON, M. A. (1931): integrated treatment regimen, and an immedi• Relaxation in Everyday Life. Methuen & Co. Ltd., London. ate follow-up after group session should assess BURROWS, G. D. (1976) : Unpublished communication the effect of the group practice on each at lecture, Society for Clinical and Experimental individual. Hypnosis Course Introductory, Melbourne. DISCUSSION AND SUMMARY DAVISON, G. (1966): "Anxiety Under Total Curaris". Journal of Nervous & Mental Disorders, 443. Increased interest in the use of relaxation ELTON, DIANA (1975..1977): Cognitio..AfJective Con .. techniques led to the re..assessment of the trol of Pain. Doctoral thesis unpublished, Uni• possible role of the physiotherapist applying versity of Melbourne. these techniques as a member of an inter• ELTON; DIANA, BURROWS, G. D. and STANLEY, G. v~ disciplinary team. (1977): "Psychological Control of Pain". The Australian Journal of Clinical Hypnosis, 5, 1 ~ 12. The therapist has a right to determine FARMER, R. C. (1967): "Technique for the Develop• whether a particular patient is suited for a ment of Rapid Relaxation of the Skeletal Museu• particular group relaxation programme. lapura: Combating Anxiety in the Real-Life Homogeneity of. a group is desirable lor Situation". La Trohe University Manual, Psycho• logy Clinic. maximal benefit of this type of training. One H.\.y, K. M. and MADDERS, J. (1971): "Migraine unsuitable patient may disrupt the whole Treated by Relaxation Therapy". Journ.al of the dynamics of a group. Some patients do not Royal College of General Practice, 24 :1664. benefit from group relaxation and alternative HILGARD, E. R. (1969): "Pain as a Puzzle for therapies may he needed. Psychology and Physiology". American Psycholo• gist, 24, 2 : 103. The ideal size of a group is 6..8 patients. JACOBSON, E .. (1938): Progressive Muscle Relaxation. Larger groups are usually not so effective. University of Chicago Press, Chicago. Detailed prior history taking is essential. JONEJSI, H. M. (1953): "A Review of Relaxation". Frequent re-assessments should follow. Physical Therapy, 34 : 570~ Discussion with other members of the team KLEINSORGE, H. and KLUMBIES, G. (1964): Techni• are helpful. Occasionally the reason for re.. que of Relaxation. Brootal, John Wright & Sons ferral of a patient to a group relaxation Ltd. therapy includes a need to make the patient LADER, M. H. and WING, LORNA (1966): Physio• logical Measurements, Sedative Drugs and Morbid less tense and easier to manage in therapy. Anxiety. Oxford University Press, New York. Another reason may be "to give the patient LOMONT, J. F. and EDWARDS, J. E. (1967): "The something to do". These reasons may be in• Role of Relaxation in Systematic Desensitivity". appropriate and the situation should be dis.. Behaviour Research and Therapy, 5 : 11. cussed with the referring doctor. MCGLASHAN, T. H., EVANS, F. J. and ORNE, M. T. (1969): "The Nature of Hypnotic Analgesia and These suggestions are guidelines for an Placebo Response to Experimental Pain". Psycho.. optimum method of carrying out relaxation somatic Medicine, 31, 3. Aust.!.Physiother., XXIV, 3, September, 1978 RELAXATION THEORY AND PRACTICE

RACHMAN, S. (1965): "Studies in Desensitization, STERNBACH, R. A. (1968): Pain: A Psychophysio~ the Separate Effect of Relaxation and D.esensiti~ logical Analysis. New York Academic Press, 33, zation". Behaviour Research and Therapy, 3 : 245. 34: 45. SHOR, R. E. (1962): "Three Dimensions of Hypnotic Depth". International Journal of Clinical and WOLPE, J. (1958): Psychotherapy by Reciprocal In• Experimental Hypnosis, 25, 10: 23. hibition. Stanford University Press.

Aust.J.Physiother., XXIV, 3, September, 1978