© Longman Group Limited 1995 © Harcourt Brace and Company Limited 1998 © Harcourt Publishers Limited 2000 © 2005, Elsevier Limited. All rights reserved. The right of Rosemary Payne to be identified as author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, USA: phone: ((cid:2)1) 215 238 7869, fax: ((cid:2)1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. First edition 1995 Second edition 2000 Third edition 2005 ISBN 0 443 07447 X British Library Cataloguing in Publication Data Acatalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Acatalog record for this book is available from the Library of Congress Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the author assumes any liability for any injury and/or damage. The Publisher The Publisher’s policy is to use paper manufactured from sustainable forests Printed in China vii Foreword Relaxation is a word that is commonly used across layout of the content is such that specific tech- many different cultures to describe a range of niques can be readily accessed as stand-alone chap- feelings, emotions and behaviour. It is associated ters; however, for health care students and health with feelings of pleasure, control and self-assurance; professionals to benefit fully from the knowledge emotions of laughter, calmness and tranquillity; carefully and systematically brought together by activities such as resting, exercise, massage, the author, the text should be read in full. bathing, listening to music, eating, drinking alco- The book is presented in a logical sequence start- hol and relaxation training. Health professionals ing with a review of stress as a concept that can be and lay people alike are regularly informed by explained by various physiological, endocrinologi- articles in the popular press, texts and scientific cal and psychological theories. The rationale for the journals of the benefits of relaxation for health; techniques presented in subsequent chapters high- however, there is often uncertainty about what is lights the theoretical links where these are explicit meant by relaxation, which technique to choose and identifies where techniques are based on prin- and how to go about it. ciples that may not fit or may overlap with more The need for relaxation as a therapeutic interven- than one of these existing theoretical positions. As tion is evidenced through the links between stress well as the underpinning rationale, a summary of and illness; when undertaken as part of our every- the research evidence to support each technique is day activities, relaxation can provide a mechanism discussed. The importance of reviewing the evi- for lowering stress and thus offer some protection dence to inform decisions in practice is reiterated against stress-related problems. Health care profes- in Chapter 27, which includes a useful discussion sionals such as psychologists, nurses, physiother- on issues around current research, on strengths to apists, occupational therapists, speech and language date and on future directions. This chapter also therapists, social workers, GPs and professionals contains an interesting discussion around selection such as coaches and sport and exercise scientists of techniques. Chapter 23, highlighting ‘on-the- working in the health and leisure industries may all spot’ techniques, is crucial for putting into practice be involved in teaching relaxation techniques. a shortened version of what has previously been The third edition of this popular textbook retains learned. its eclectic and practical approach, presenting a Relaxation Techniqueswill continue to provide a number of additional relaxation techniques along useful guide for health professionals, students and with those previously included, all of which can be lay people who wish to increase their understand- successfully self-taught or taught by health care ing of stress, its causes and its impact on health. It personnel. The text is well illustrated and this is also provides a concise and detailed summary of helpful for gaining an understanding of the various measurement strategies that can be used to evalu- techniques and putting them into practice. The ate the outcome of interventions designed to viii FOREWORD reduce or alleviate the effects of stress. The book is selected for the right situation. For lay people, this eclectic, with no one method being presented more book raises awareness of relaxation as a strategy to favourably than another, the author acknowledg- improve physical and psychological health; and ing that in practice, physical and cognitive methods for readers wishing to teach themselves a method are often presented together. For students, this sin- of relaxation, there is plenty of choice. gle volume provides theoretical underpinning, This book provides essential information that evidence from current research and practical appli- will be useful to those involved in training others cation of many different techniques of relaxation. in relaxation techniques and to individuals who In this regard it is a unique and useful text. For wish to teach themselves skills of relaxation, irre- clinicians, this is a useful bench text with opportu- spective of the level of prior knowledge of the nity to extend existing practice through the intro- topic or practical experience. This third edition is duction and application of additional approaches an exciting addition to the current literature, bring- which are informed by both current research and ing further techniques and greater indepth discus- current practice. Techniques are presented with an sion and critique to the topic. Read on; you will explanation of why they are useful, how to use find the direction given by the author to be prac- them, where they have been evaluated, where they tical, meaningful and stimulating, with new points can be used interchangeably, and what needs to be of debate emerging. done to ensure that the best techniques can be Marie Donaghy ix Preface to the third edition Since the preface to the first edition of Relaxation Particular thanks are offered to Marie Donaghy Techniqueswas written, developments in the health who has been through the whole manuscript care scene have created a new emphasis on evi- making useful suggestions and contributing many dence of effectiveness. This has led to the need for of the ideas which appear in this edition. Her advice an additional chapter on the results of research. has been invaluable and I am again greatly New evidence has also been incorporated into the indebted to her. The people who so kindly helped individual chapters and may be found in their with the first and second editions are also remem- sections on evaluation. bered for their valued assistance, with a special The chapter on exercise (Ch. 14) has been appreciation in respect of Margaret Polden and rewritten to take account of developments in that June Tiley, who have sadly since died. I would field; it also contains an expanded section on the also like to acknowledge the guidance I have psychological effects of physical activity. received from the publishers, Elsevier, and to Chapter 26 now carries a passage relating to thank them for the way they have presented the audit, in acknowledgement of the importance of work. this topic, although the contribution made here is This edition focuses on the same techniques no more than an introduction to what has become as the first one, i.e. techniques which are easily a major subject. learned and which can be readily applied in the This third edition contains two new chapters, stressful situation, wherever it arises. It is hoped one on cognitive behavioural approaches, reflect- that the work in its present form will provide ing their increasingly dominant position (Ch. 22); the reader with useful additions. In essence, it the other on techniques which did not appear in remains the same book in an expanded and earlier editions (Ch. 24). There is also a glossary updated form. and a table (Appendix 3) suggesting certain tech- Rosemary Payne niques for specific conditions. Cardiff 2004 xi Preface to the first edition Afew years ago, when giving a talk on relaxation The book begins with a review of some of the techniques, I was asked by a social worker if the theory surrounding stress and relaxation. This is techniques I was describing could all be found in followed by a chapter on general procedure which one publication. I said I knew of no book which is applicable to all methods. Chapter 3 discusses contained them all. Since then, other health care stress, beginning with a further passage of theory professionals have, on different occasions, put sim- and moving on to consider a variety of practical ilar questions to me. Is there a book which focuses coping skills. The following 19 chapters deal with on the practical side of relaxation training? Can the specific techniques: 12 chapters are, broadly speak- detail of the methods be found under one cover? ing, concerned with physical or muscular tech- Many books mention relaxation techniques but niques and seven deal with mental or psychological tend not to present them in any depth, unless the methods. There follows a chapter concerning entire work is devoted to a single method. It seemed ‘on-the-spot’ techniques for dealing with stressful that there was a gap which needed to be filled. situations, using skills drawn from earlier lessons. It is estimated that 80% of modern diseases have Relaxation in the antenatal context is the subject of their beginnings in stress (Powell & Enright 1990) Chapter 25*, and is included because of the promi- and that stress-related illness accounts for at least nent role that relaxation plays in the field of obstet- 75% of GPconsultations (Looker & Gregson 1989). rics. Assessment is addressed in Chapter 26, and As concern about the safety, efficacy and cost of the final chapter takes a look at a few topics not so psychotropic drugs grows (Sibbald et al 1993), far discussed: the relation between the approaches there is increasing interest in non-drug treatments, themselves, some ways in which they can be com- of which relaxation training is an example. bined, and a brief reference to approaches which The book is addressed to health care profession- are not included. Physical and psychiatric dis- als such as nurses, occupational therapists, physio- orders are not within the scope of this work. therapists, speech and language therapists and Techniques whose main purpose is to promote social workers; GPs and psychologists also may relaxation are termed primary. The ‘muscular’ find it useful. It can equally be used by lay people methods belong in this category, as does autogenic since it is written in a jargon-free style. training. Where relaxation is not the main purpose, Factors of practicality have governed the selec- the technique can be seen as secondary: visualiza- tion of methods. Thus, techniques which require tion, meditation and the Alexander technique fall expensive equipment or specialized expertise are not included, while the methods chosen are those *To avoid confusion, the chapter numbers have been changed which lend themselves to presentation in small to match the chapter numbers in the third edition rather than group settings. the first. xii PREFACE TO THE FIRST EDITION into this category. Other approaches which enhance to the trainer as female. The trainee is referred to as relaxation may be still further removed. These male in Chapters 2–15 and as female in Chapters include cognitive techniques such as uncovering 16–28. irrational assumptions and modifying automatic The words ‘trainer’ and ‘instructor’ are both thoughts. Here, relaxation can be seen as a side- used, the choice being largely determined by the effect rather than a goal (Fanning 1988). nature of the method: for example, in autogenics, It is not intended that health care professionals progressive relaxation and behavioural relaxation should, on the strength of reading this book, con- training the word ‘trainer’ is often used, while in sider themselves teachers of autogenics and the imagery, meditation, Alexander technique and Alexander technique. These two methods are Mitchell’s approach, the word ‘instructor’ seems included to indicate their contribution to the field; more appropriate. The word ‘therapist’ is also they are described for interest and for the applic- used where it seems fitting. ability of their central ideas. For example, images Anumber of people have helped in the making of warmth and heaviness (autogenics) are relaxing of this book. One important contributor is Keith in any context, as also is postural advice (Alexander Bellamy, whose photographs have done so much to technique). Such concepts have universal value. make the book what it is, not forgetting Sarah Indications of the effectiveness of the techniques McDermott, who acted as the model. With regard are included but the book does not set out to review to the text, Ian Hughes has given invaluable help in the evidence from the scientific literature. Other his careful reading and refining of the chapter on works do that, for example Lichstein (1988). Pitfalls measurement. I would also like to mention those associated with some methods are listed at the end who have read other chapters and to whom I am of the relevant chapters. indebted for their helpful suggestions. Alexandra The word ‘relaxation’ is used in two ways here Hough, Wendy Mair, Margaret Polden and Jim as it is in other works: first, in a general sense where Robinson have all been kind enough to do this, it signifies a global state of rest; and second, as a and Christopher Rowland Payne undertook to technique such as progressive relaxation. It is diffi- read the whole manuscript. Thanks also go to cult to avoid both meanings in a book of this sort; Michael Adams, Joyce Gibbs, Olga Gregson, however, efforts are made throughout the work to Andrzej Kokoszka, Brenda MacLachland, Pat distinguish the meanings wherever ambiguity Miller, Alison Ough, Stuart Skyte, Dinah Thom, arises. June Tiley and Elizabeth Valentine. Finally, a word The author is aware of the implications of of appreciation for the members of all the groups gender-weighted language. She is also aware of the with whom I have worked. Without them, this cumbersome phrasing that can result from a deter- book would never have been written. mination to avoid sexist forms of speech. In an attempt to avoid both traps and for the sake of clar- Rosemary Payne ity, it has been decided to refer throughout the book Cardiff 1994 3 1 Chapter Theoretical background It could be said that relaxation is doing nothing CHAPTER CONTENTS (Beck 1984). In spite of this, many people say they find it difficult to relax. Doing nothing, it seems, is Physiological theories 4 not as easy as it sounds, and the existence of a Psychological theories 8 wealth of relaxation techniques appears to endorse this view. The ‘specific effects’ hypothesis and unitary ‘Relaxation’ is often used with reference to theories 10 muscles, where it signifies release of tension and Case scenarios 11 the lengthening of muscle fibres, as opposed to the shortening which accompanies muscular tension, Stress management 12 or contraction. Such a definition could be applied Types of relaxation technique 12 to the methods described in the earlier chapters of ‘Deep’ and ‘brief’ relaxation 13 this book. However, since relaxation has a mental, Somatic and cognitive techniques 13 as well as a physical dimension, this definition is too restricted for our purposes. Skill acquisition and motor learning Amore comprehensive view comes from Ryman theory 13 (1995), who defines relaxation as ‘a state of con- sciousness characterized by feelings of peace, and release from tension, anxiety and fear’. This emphasizes psychological aspects of the relaxation experience, such as the pleasant sensation and absence of stressful or uncomfortable thoughts. Thus, the word ‘relaxed’ is used to refer either to lax muscles or to peaceful thoughts. It is assumed that a link exists between them since an apparently general state of relaxation can be induced by using either physical or psychological methods. Relaxation can be said to have three aims (Titlebaum 1988): 1. As a preventive measure, to protect body organs from unnecessary wear, and in particular, the organs involved in stress-related disease (Selye 1956, 1974). 4 INTRODUCTION 2. As a treatment, to help relieve stress in con- AUTONOMIC NERVOUS SYSTEM ditions such as essential hypertension (Patel & controls physiological arousal Marmot 1988), tension headache (Spinhoven et al 1992), insomnia (Lichstein 1983), asthma (Henry et al 1993), immune deficiency (Antoni et al 1991), SYMPATHETIC NERVOUS PARASYMPATHETIC NERVOUS panic (Öst 1988) and many others. Relaxation SYSTEM SYSTEM strategies may help to make the body’s innate enables the body to cope with restores a state of calm to the body threat and challenge healing mechanisms more available. 3. As a coping skill, to calm the mind and allow Figure 1.1 The autonomic nervous system. thinking to become clearer and more effective. Stress can impair people mentally; relaxation can individual to make a physical response. The help to restore clarity of thought. It has been found changes are collectively known as the ‘fight–flight that positive information in memory becomes more response’ which is characterized by an increase in: accessible when a person is relaxed (Peveler & ● heart rate Johnston 1986). ● blood pressure Mechanisms thought to be responsible for bringing ● blood coagulation rate about the state of relaxation have been explored, ● blood flow to voluntary muscles giving rise to a number of theories. Some of these ● glucose content of the blood emphasize physiological aspects, such as auto- ● respiratory rate nomic activity and muscle tension, while others ● acuity of the senses focus on psychological elements such as attitudes ● sweat gland activity towards the self. The major theories are briefly and a decrease of: described below. ● activity in the digestive tract. PHYSIOLOGICAL THEORIES In the absence of challenge or excitement, these actions are reversed: the sympathetic nervous sys- tem loses its dominance and the parasympathetic Body systems associated with the states of stress assumes control. The actions of these systems are and relaxation include: shown in greater detail in Figures 1.2 and 1.3. ● the autonomic nervous system Some of the changes which occur as a result of ● the endocrine system and sympathetic stimulation produce noticeable symp- ● the skeletal musculature. toms, such as an increased respiratory rate, stom- achcramps and cold sweat. States such as fear and The autonomic nervous system anger illustrate this and underline the association Physiological arousal is governed by the autonomic between the emotions and the internal organs. nervous system. This has two branches: the sym- When the changes are pronounced and occur fre- pathetic, which increases arousal when the organ- quently, the organs concerned can become fatigued ism is under threat, and the parasympathetic, and this has given rise to the concept of psycho- which restores the body to a resting state. Their somatic illness (p. 27). The relaxation response actions are involuntary and designed to enable the method of Benson aims to counteract the effects of organism to survive (Fig. 1.1). sympathetic activity by promoting the action of the In a situation of challenge, excitement or danger parasympathetic nervous system (Ch. 21), thereby the sympathetic nervous system increases the exploiting the reciprocal nature of the two parts of activity of the heart and redistributes blood from the autonomic nervous system. the viscera to the voluntary muscles. Blood pres- However, activity of the parasympathetic sys- sure and respiratory rate are increased; sensory tem is not always benign (Poppen 1988). Asthma is awareness is heightened, and there is a mechanism exacerbated by bronchial constriction and gastric for losing excess heat. These factors enable the ulcers by acid secretion. Both bronchial constriction Theoretical background 5 Spinal Lateral chain Structures Effects of stimulation cord of ganglia Pupil dilated Iris muscle Slightly relaxed Superior Blood vessels in head Vasoconstriction cervical ganglion Salivary glands Secretion inhibited Oral and nasal mucosa Mucus secretion inhibited Skeletal blood vessels Vasodilatation Heart Rate and force of contraction increased T1 11 22 33 Coronary arteries Vasodilatation 44 Coeliac Trachea and bronchi Bronchodilation 55 ganglion 66 77 Stomach Peristalsis reduced 88 Sphincters closed 99 Intestines Peristalsis and tone decreased 1100 Vasoconstriction 1111 Liver Glycogen glucose conversion increased 1122 L1 11 Superior Spleen Contracted L2 22 mesenteric Adrenaline and noradrenaline L3 33 ganglion Adrenal medulla secreted into blood Large and small intestine Peristalsis reduced Sphincters closed Kidney Urine secretion decreased Inferior mesenteric Bladder Smooth muscle wall relaxed ganglion Sphincter closed Sex organs and genitalia Generally vasoconstriction Figure 1.2 The sympathetic outflow, the main structures supplied and the effects of stimulation. Solid lines ———, preganglionic fibres; broken lines ---, postganglionic fibres. (From Waugh & Grant 2001.) and acid secretion are associated with parasympa- the action of the internal organs in response to thetic dominance, yet the conditions of asthma environmental stimuli. and gastric ulcer are often relieved by relaxation When a situation is perceived to be stressful the and aggravated by stress. The theory is not consist- brain immediately responds by stimulating the ent regarding these conditions (Ch. 27, p. 232). adrenal medulla to release the catecholamines adrenaline and noradrenaline. The function of these neurotransmitters is to prepare the organs for action The endocrine system by, for example, increasing alertness and redistrib- Closely associated with the autonomic nervous sys- uting the blood. Acting in the longer term, the tem are the endocrine system and the adrenal glands. pituitary gland releases the adrenocorticotrophic These are situated above the kidneys (Fig. 1.4) and hormone (ACTH). This stimulates the adrenal cor- consist of medulla and cortex (Fig. 1.5). Their tex to produce mineralocorticoids and glucocorti- function is to produce hormones which modify coids, the most important of which is cortisol, which 6 INTRODUCTION Spinal Cranial nerve Ganglia Structures Effects of stimulation cord numbers Pupil constricted Iris muscle Contracted III Ciliary Lacrimal gland Tear secretion increased VII Salivary glands: Saliva secretion increased Pterygopalatine submandibular IX sublingual X Submandibular parotid gland Saliva secretion increased Heart Rate and force of contraction decreased Otic Coronary arteries Vasoconstriction Trachea and bronchi Bronchoconstriction Secretion of gastric juice and Stomach peristalsis increased Small intestine Digestion and absorption increased Blood vessels dilated Liver and gall bladder Secretion of bile increased Pancreas Secretion of pancreatic juice increased Kidney Urine secretion increased Secretion of intestinal juice and Small intestine peristalsis increased Secretions and peristalsis increased Large intestine Sphincter relaxed Muscle of wall contracted Bladder Sphincters relaxed Male: erection Sex organs Female: variable; depending and genitalia on stage in cycle Figure 1.3 The parasympathetic outflow, the main structures supplied and the effects of stimulation. Solid lines ———, preganglionic fibres; broken lines ---, postganglionic fibres. (From Waugh & Grant 2001.) helps to maintain the fuel supply to the muscles. and the stress response is no longer needed, the In this way it supports the action of the cate- neurotransmitter acetylcholine is released to restore cholamines (Waugh & Grant 2001) (Fig. 1.6). There a state of balance in the autonomic nervous system. is also evidence suggesting that the stimulation of The organs which were previously stimulated normal levels of cortisol enhances the immune sys- now weaken their hold and their actions subside. tem (Looker & Gregson 1989, Jefferies 1991). High levels of cortisol, such as those created by prolonged The skeletal musculature stress or by pharmacological doses are, however, associated with a suppressed immune system. Jacobson (1938) proposed that the release of tension Under challenge, all the above hormones are in the skeletal musculature had the effect of calm- released. When the situation of challenge passes, ing the mind. The neuromuscular system is thus