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Relaxation Techniques for Stress Management

  • Institute of Mental Health (IMH), Colombo-04 Sri Lanka.


Relaxation techniques encompass a wide variety of Stress Management methods for slowing down the body and stilling the mind. Meditation, progressive muscle relaxation (PMR), breathing exercises, and guided imagery are relaxation techniques used frequently in clinical settings to help patients regulate their reactions to stress and achieve overall well-being.
Relaxation Techniques for Stress Management
by Dr. Sir Romesh Jayasinghe, OLS, OMR, KStI, Ph.D.(Hon), Dh.C.(USA), B.Sc. (USA),
FRSPH(UK), MITBCCT(UK), MBCS(UK), M.Inst.Psy., SNHS H.I.Dip. (Complementary Therapies), SNHS Adv.Dip. (Stress
Management), SNHS Dip. (Stress Management), SNHS Adv.Dip. (Psychotherapy & Counselling), SNHS Dip.
(Psychotherapy & Counselling), SNHS Dip. (Philosophy), SNHS Dip. (Hypnotherapy), SNHS Dip. (Child Psychology)
Relaxation techniques encompass a wide variety of Stress Management methods for slowing down the
body and stilling the mind. Meditation, progressive muscle relaxation (PMR), breathing exercises, and
guided imagery are relaxation techniques used frequently in clinical settings to help patients regulate their
reactions to stress and achieve overall well-being.
Historical Background
At the beginning of the last century, Dr. Walter B. Cannon of Harvard Medical School in America used a
series of experiments on cats to identify the "fight or flight response" (Sultanoff and Zalaquett 2000).
Cannon's classic experiments established that catecholamines increase heart rate, blood pressure, and
respiratory rate. The same reactions can be elicited through electrical stimulation of areas within the
hypothalamus in animals; likewise, the opposite reaction of hypo-arousal can be elicited through
stimulation of other regions of the hypothalamus.
Later, in the 1950s, meditative practices of yogis and Zen masters were found to produce the opposite of
the fight or flight reaction in humans (deLeon 1999). Around the same time, a Canadian researcher named
Hans Selye began to define the connection between stress and ill health; Selye described "good stress" or
eustress as distinct from a destructive type of stress that contributes to imbalance and illness. Good stress is
defined as the ability to respond to the challenges of life in a way that promotes stimulation and
encourages personal growth. Stress Management tools can facilitate this reaction. Examples of destructive,
unhealthy reactions to stress are feeling overwhelmed or anxious. Repeated exposure to such feelings may
contribute to chronic disease (Sultanoff and Zalaquett 2000).
Lending further support and credibility to relaxation techniques, Dr. Herbert Benson, a Harvard physician,
researched the physiologic effects of transcendental meditation (TM) in the early 1970s. He coined the
term "relaxation response" to refer to the stress-reducing effects of meditation, which we now know can be
elicited through a variety of relaxation practices including meditation. Benson thought that four principles
were necessary to elicit the relaxation response:
1) minimal distractions in a quiet environment.
2) a mental device or process, such as a mantra in TM, focus on the breath, or mental imagery.
3) a passive attitude that involves keeping the mind as quiet as possible.
4) a comfortable posture or position.
In the mid-1980s, another well-known physician, Dr. Dean Ornish, incorporated an extensive relaxation
program including meditation, yoga, and breathing exercises into a comprehensive lifestyle program for
patients with heart disease. Data published from a five-year trial revealed reductions in total and LDL
cholesterol, decreased anginal symptoms, and regression of coronary artery disease, thus giving further
credence to the health benefits of stress reduction. Since the Ornish program included regular aerobic
exercise, a low-fat vegetarian diet, and group support in addition to the relaxation techniques, it is difficult
to determine which component is most important in establishing the health benefits mentioned. However,
compliance with stress reduction practices seemed to correlate with the positive results seen in the study.
Many of the relaxation practices mentioned here (which are now entering the medical mainstream
through pain management, stress reduction, and general wellness programs) are rooted in ancient
religious practices including Christian and Jewish mysticism, Buddhism, and Islamic customs (deLeon 1999).
Another expert in the field of relaxation, Jon Kabat-Zinn, uses mindfulness meditation for research protocols
and clinical application. Mindfulness meditation stems from the Buddhist practice of moment-to-moment
awareness of thoughts and sensations, even when one is not actually meditating. One learns how to apply
this way of living or being in the world through a regular practice of meditation (Kabat-Zinn 1990). It is as if
the techniques of awareness and mindful attention learned during a meditation session expand out to
encompass all aspects of daily life.
Scientific Principles
Relaxation techniques are thought to promote three main changes for the person incorporating these
practices into a daily routine:
1) refocusing of attention, which may involve reframing thoughts.
2) increased body awareness.
3) reintegration of the body and mind through practices such as conscious breathing and meditation.
These three principles are interconnected. Refocusing of attention in an acute setting may mean noticing
bodily reactions to tension and directing one's breath to those tense areas.
Over time, as relaxation practices become routine, one's thinking may be reframed toward a healthier
perspective with increased awareness of bodily sensations. Reintegration of the body and mind involves
quieting the mind by focusing on the breath or on a mantra (a specific word, phrase, or sound used as a
healing incantation, central to many meditative practices). Over time, this practice is thought to allow an
individual to develop a higher level of alertness and consciousness about both oneself and life in general
(Sultanoff and Zalaquett 2000).
Relaxation techniques work by eliciting the relaxation response as described in the Historical Background
section above. The relaxation response is characterised by decreased heart rate, respiratory rate, oxygen
consumption, and muscle tension, as well as increased alpha wave brain activity. Relaxation practices
seem to produce these changes to a greater extent and more efficiently than sleep. For example, reports
from Dr. Benson's work show that oxygen (O2) consumption diminishes by 8% during restful sleep over the
course of four to five hours, while the relaxation response results in a 10 to 17% reduction of O2 consumption
in a matter of minutes (deLeon 1999).
In one small, controlled clinical trial involving Transcendental Meditation (TM) specifically, adults who had
been practicing TM for a mean period of 22.4 years experienced significant reduction in Total Peripheral
Resistance (TPR) and Systolic Blood Pressure (SBP) during a twenty minute Transcendental Meditation
session, compared to the non-practicing control group who rested with eyes closed for that same period of
time (Barnes et al. 1999).
Another small study showed diminished lipid peroxide levels in elderly subjects who had been practicing
Transcendental Meditation for 16.5 years on average, compared to a non-practicing control group. Lower
lipid peroxide levels could, in theory, result in reduced oxidative damage (see section on Additional Clinical
Outcomes below). There were some potentially confounding variables in the latter study, however,
suggesting that more research is necessary to establish whether TM is in fact responsible for the reduced
lipid peroxide levels observed.
Clinical Evaluation & Applications
For general stress reduction and well-being, individuals can learn relaxation techniques through a variety of
methods, including videotapes, audiotapes, books, distance learning courses and community classes.
However, it is best for patients with specific medical or psychological issues to visit a healthcare professional
or Relaxation Therapy specialist to determine the most appropriate relaxation method and to reduce
potential negative side effects, such as relaxation-induced anxiety (see section on Risks, Side Effects,
Adverse Events below).
Many relaxation practitioners are also clinical psychologists, psychotherapists or social workers who tend to
be very effective in teaching these techniques and counselling patients appropriately. Other medical
professionals, including general primary care physicians and psychiatrists, may also apply these techniques
in their practices. Techniques are usually taught to patients on a one-on-one basis but may also be taught
in a group setting. Experts suggest that the techniques be taught in a setting that is conducive to
relaxation, including a quiet room with natural light, soothing background music, and the presence of
plants, soft colours, and pleasant art work. Some people ecen go as far as to suggest that the process of
selecting an appropriate practitioner should take into account whether he or she practices the relaxation
techniques in his or her own life (Sultanoff and Zalaquett 2000).
Some experts feel that relaxation techniques are applicable to many psychiatric disorders and almost all
common complaints encountered in a typical primary care medical setting. The following are some
interesting examples supported by scientific literature.
A recent controlled clinical trial compared infertile women receiving either group support or cognitive-
behavioural therapy together with relaxation training, with a control group receiving only usual care for
infertility. The relaxation training included meditation, progressive relaxation, guided imagery, and yoga.
The three-arm trial found that women receiving either group support or cognitive-behavioural therapy in
conjunction with relaxation training were more likely to become pregnant than the control group during a
one-year follow-up (Domar et al. 2000). Although the confounding of multiple variables makes it difficult to
determine which specific technique was most effective for the desired outcome of pregnancy, the study
at least suggests that relaxation may be a useful adjunct for the treatment of infertility.
Treatment of acute and chronic pain is a common application of relaxation techniques which is supported
by clinical evidence. One study of patients undergoing colorectal surgery demonstrated that those who
listened to guided imagery tapes progressively reported less subjective pain, and required fewer opioid
analgesics (such as morphine or codeine) following surgery, than controls who did not hear the tapes.
In another study of patients with chronic pain, those who participated in a behavioural programme using
relaxation techniques reduced their visits to a doctor or other healthcare professional by 36% during the
one-year follow-up (deLeon 1999). Follow-up of patients under the care of Kabat-Zinn and colleagues at
the Stress Reduction Clinic at the University of Massachusetts Memorial Medical Centre in Worcester,
Massachusetts USA, showed reduced symptoms of pain, better coping skills, and continued long-term
practice of meditation in patients with chronic pain (Kabat-Zinn et al. 1987).
In addition, Jon Kabat-Zinn and colleagues demonstrated, in a relatively small study, that participants with
generalised anxiety and panic disorders did better clinically if they participated in mindfulness meditation
training and practice than those who did not (Kabat-Zinn et al. 1992).
Other clinical trials suggest that relaxation techniques also decrease symptoms associated with
premenstrual syndrome (PMS), diminish pain perception and enhance coping skills in migraine sufferers,
and improve function, decrease utilisation of medical services, and increase the rate of return to work in
patients with chronic pain (deLeon 1999).
Research also suggests that relaxation techniques may help relieve chronic tension headaches (Annequin
et al. 2000); reduce the pain intensity, number of tender points, and emotional distress caused by
Fibromyalgia (Leventhal 1999), and improve sleep quality and decrease wakefulness in those with chronic
insomnia (Morin et al. 1999). Another intriguing potential clinical application of mindfulness meditation is
psoriasis. In a single-blinded, randomised, controlled clinical trial of 37 subjects, half of the participants
underwent ultraviolet phototherapy (UVB) or photo-chemotherapy (PUVA) for psoriasis with a mindfulness
meditation audiotape playing in the background, while the other half underwent these treatments without
the tapes. Inspection by physicians who were blinded to whether the patients had listened to the tapes,
found significant improvement in the psoriatic lesions of those who had listened to the meditation tapes
during treatment compared to the controls (Kabat-Zinn et al. 1998). Those who practice relaxation
techniques regularly also tend to report greater self-esteem and self-confidence (Sultanoff and Zalaquett
Relaxation techniques are also thought to be useful adjuncts in the treatment of adjustment disorder,
addictions, irritable bowel syndrome, gastritis, peptic ulcer disease, inflammatory bowel disease,
arrhythmias, asthma, diabetes, and social phobias, although these applications may not have been as
extensively researched as the clinical applications discussed above. In children, relaxation techniques may
be beneficial for those suffering from impulsivity due to hyperactivity and disruptive behaviour (Sultanoff
and Zalaquett 2000).
Risks, Side Effects, Adverse Reactions & Contraindications
Relaxation techniques are non-invasive and, therefore, tend to be considered very safe. Rarely, though,
anxiety may be increased by the practice of relaxation techniques. This phenomenon, known as
Relaxation Induced Anxiety (RIA), is characterised by heightened physiologic arousal and reactivity.
Although equally rare, autogenic discharges may occur in some patients. Autogenic discharges are
defined as sudden, unexpected emotional or physical experiences that may include pain, heart
palpitations, muscle twitching, and crying spells. These side effects can elevate blood pressure and may be
dangerous for those with hypertension (Sultanoff and Zalaquett 2000).
Caution should be exercised in the case of schizophrenia and other forms of active psychosis. Relaxation
practices may be counterproductive with such patients and therefore should probably be avoided
(Sultanoff and Zalaquett 2000).
The Future of Relaxation Techniques
The validity and efficacy of relaxation techniques are gaining greater acceptance. Some would like to see
more focused research on the exact mechanism of action, such as the effects of neuro-endocrinology on
blood pressure (Barnes et al. 1999). In addition, given the reduction of lipid peroxide levels seen in a study
cited in the section on Mechanism of Action, relaxation practices may have the potential to decrease free
radical-induced oxidative damage. Such an anti-oxidative effect might be of value for prevention and
adjunctive treatment of conditions associated with aging, such as coronary artery disease (Schneider et al.
Walter B. Cannon: Science and Society by Elin L. Wolfe, et al
Stress of Life by Hans Selye
The Relaxation Response by Herbert Benson
Dr. Dean Ornish's Programme for Reversing Heart Disease by Dean Ornish
Full Catastrophe Living: How to Cope with Stress, Pain and Illness Using Mindfulness Meditation
by Jon Kabat-Zinn
Evaluating Stress: A Book of Resources by Carlos P. Zalaquett & Richard J. Wood
Conquering Infertility by Alice D. Domar & Alice Lesch Kelly
Behavioural Relaxation Training and Assessment by Roger Poppen
Full-text available
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