INTRODUCTION

Numerous benefits have been claimed for relaxation training for a variety of health problems associated with stress and anxiety, with a body of research work to its credit (Freeman 2001); this will be reviewed in more detail later in this chapter. Edmund Jacobson, the originator of the progressive muscle relaxation training, had observed in 1905 that deeply relaxed students demonstrated no obvious startle response to sudden noise; this became his life work (Jacobson 1977). He developed a lengthy and meticulous technique, which focused on getting in touch with musculature and learning to control the tension levels. Jacobson’s method was designed so that the practitioner would eventually be able to automatically and unconsciously monitor and release unwanted tension. The process has since been adapted and shortened by others, most notably Joseph Wolpe, and has become known as the abbreviated progressive muscle relaxation training. Included in this adaptation is the tension–release cycle (e.g. make a tight fist and then release) combined with a focus on breathing. This variation is part of Wolpe’s framework called systematic desensitization, aimed at getting in touch with the individual’s tension and the body’s response, and then letting it go in a controlled manner. Freeman (2001) suggests that PMR and other muscle-based relaxation variations convey health benefits in three ways:

Autonomic responses determine whether the body needs to engage in a ‘fight-or-flight’ or ‘rest-and-digest’ scenario or to a state somewhere between these two extremes. The sympathetic division of the autonomic nervous system (ANS), associated with ‘flight-or-fight’ responses, mobilizes the body in emergency and stressful circumstances. Many of these responses are not immediately apparent to our consciousness. Physically, blood flow is redirected away from the digestive process to the smooth muscle, heart rate and blood pressure increase, with these processes triggered by the increase of circulating catecholamines, which include adrenaline and noradrenaline (Hucklebridge & Clow 2002). Associated with the stress response is the release of cortisol, which mobilizes energy reserves, increases sensitivity of tissues to neurotransmitters and inhibits the immune and inflammatory response. Freeman (2001) argues that PMR techniques blunt sympathetic arousal by training the individual to reduce oxygen requirements, achieved by the repetitive release of muscle tension combined with slowing of respirations. This makes it a useful therapeutic intervention for panic, phobias and anxiety states.

Important to well-being, endogenous opioids, such as enkephalins, dynorphins, endomorphins and β-endorphin, have been found to have a variety of effects, including analgesic, anti-inflammatory and bronchodilation (Jessop 2002). These compounds and their receptor sites have been located within immune tissues (Stephanou et al 1990). It has been argued that opioids play an important part in modulating stress responses. It has been noted that opioid production is increased in adults who exercise regularly (Freeman 2001) and is reduced in adults with enduring health problems such as chronic fatigue syndrome (Conti et al 1998). In a laboratory experiment (n = 32) to determine the role of endogenous opioids in the effects of PMR training, McCubben et al (1996) found that PMR significantly reduced diastolic pressure, but when an opioid blockade was administered, it antagonized the PMR training. Hypnotherapists could utilize the potential responses of reduced anxiety and pain relief in the development of anchors and post-hypnotic suggestions, with an intention to help build a patient’s resources (Box 6.1).

BOX 6.1 Practice points

Keep the delivery of this profound technique simple and slow – do less … well

Consider extending your perception and use of PMR as a therapist. As well as suggested uses in this chapter, PMR can be a kinesthetic induction, rapid re-induction, deepener and offers many opportunities to anchor positive resource states and can act as a link to post-hypnotic suggestions

Consider adapting the PMR script – short versions can be used prior to hypnotherapy or as homework

Introduce the session giving key benefits to the patient – these can be linked to his/her individual needs and are in themselves potential hypnotic suggestions

Humour and visual imagery can be used to draw in, engage with a resource state and build rapport – the session should not be overly technical as this can reinforce rather than alleviate anxiety

Consider closing the session with general and specific post-hypnotic suggestions

Consider using PMR to help a patient regain full consciousness at the close of a hypnotherapy session – this can help to bring focus and grounding back to the body.

Over three decades, Herbert Benson and colleagues (1984) have investigated the psychological and physiological effects associated with the relaxation response, elicited from PMR, meditation, yoga and physical exercise routines, many of which appear to be the opposite of the stress response. Stefano et al (1996: 3) have acknowledged that repetition is crucial to the relaxation response, but surmise that ‘trust or belief in expected outcomes’ can help to regulate immunological function via cognitive and neurological processes. This sense of improved well-being associated with the relaxation response has been labelled ‘remembered wellness’, which Benson (1996) has ascribed to memories of nurturance and maternal attachment. Lazar et al (2000) have investigated the relaxation response to meditation with functional magnetic resonance imaging (MRI) and mapped areas of the brain, which are responsive to opioids. Stefano et al (1996) suggests that this work demonstrates the mind–body wiring that could modulate the relationship between cognitive and physiological processes. In this review of neural processes and the relaxation response, Stefano and colleagues (1996) note that increased circulatory levels of opioids improve mood and sense of well-being, and refer to earlier work on enkephalins, which they found to have the additional benefit of stimulating immune cells. Aside from effects of opioids on heart rate, blood pressure, respiration, immune cells and mood, these compounds have also been found to stimulate antibacterial peptides in human studies (Tasiemski et al 2000). This information can provide a wealth of ideas for hypnotherapists using PMR and tailored suggestions, to enable patients to connect with feelings of being nurtured and supported.

The PMR method has a strong record of clinical efficacy and is an acknowledged standard strategy for a number of somatic states, including anxiety and stress, and features as part of clinical training in psychology (Pawlow & Jones 2002, Turner et al 1992). It is recommended that patients receive individual live instruction; indeed Lehrer and Woolfolf (1994) have argued that one-to-one training is crucial to effective training as well as any evaluative research. Relaxation techniques are increasingly being used as a non-pharmacological intervention by nurses, occupational therapists and medical practitioners in a variety of healthcare settings. DeMarco-Sinatra (2000), a nurse practitioner in the USA, believes that teaching relaxation techniques can be an appropriate role for nurses in both in-patient and out-patient settings. He argues that the activity supports patient autonomy and is cost-effective as a method of health promotion. We argue here that PMR and other forms of relaxation training are valuable additions to the hypnotherapy toolbox. Aside from being part of standard hypnotherapy induction training, PMR skills need to be updated and developed in ongoing training and supervision.

RESEARCH WORK

Many studies have investigated relaxation techniques; these have included imagery, guided relaxation and more structured techniques, such as PMR. Variations of PMR have developed, including the Mitchell Method, which involves body postures that are opposite to the physical responses to stress and anxiety (e.g. fingers spread rather than clenched). In autogenic relaxation training, the focus is on experiencing physical sensations in different parts of the body (e.g. heaviness or warmth) as a learnt sequence. Creative imagery and visualization techniques are also commonly described as relaxation techniques, and although they can be guided by pre-recorded audiotape guidance or a facilitator, any visual suggestions (e.g. beach or paradise setting) are usually interpreted and developed by the patient (Vickers & Zollman 1999). In practice (and in many of the studies located), some of the relaxation techniques described are a combination of techniques (e.g. 25 min of PMR ending with 5 min of imagery) or are not fully described in the research reports, making it difficult to evaluate their individual clinical effectiveness or otherwise.

There is early literature documenting the beneficial effects of PMR training in experimental studies on both psychological states and physiological functioning. For example, studies have found reduced sympathetic nervous system activity and cortisol levels following PMR training (McGrady et al 1987). Since then, a further 13 clinical studies have been conducted examining the immunological effects of PMR training. Some results are contradictory. For example two studies found there were no effects on white blood cells following PMR sessions (Peavey et al 1985, Hall et al 1993) while in contrast McGrady et al (1992) reported a decrease in white blood cells (WBCs) and neutrophils. Carlson and Hoyle’s (1993) review of the PMR literature has concluded that providing the instruction in a one-to-one situation was more effective than with a group. Devine and Westlake (1995) conducted a meta-analysis of 116 studies involving patients who have cancer, with statistically significant reductions reported for levels of anxiety, depression, mood, pain, nausea, vomiting and pain. In clinical practice, PMR and other relaxation techniques, have been used for a number of years as supportive interventions for patients living with cancer (Sloman 2002), managing chemotherapy-related nausea and vomiting (Molassiotis 2000) and coping with chronic pain (Seers 1993).

In assessing the benefits of relaxation for chronic pain, Carroll and Seers (1998) conducted a systematic review. They included only controlled trials with 10 or more participants per treatment arm. The studies were assessed for methodological quality using a modified 3-item scale (Jadad et al 1996). Four studies in the review showed significant differences favouring relaxation for within-session changes, compared with no treatment controls. PMR was used in six of the studies mostly using audio-taped instruction. In Sloman’s (1995) oncology study (n = 67) a significant difference was found for the ‘live’ relaxation vs ‘no treatment’ group for a pain sensation visual analogue scale. In one of the larger chronic pain studies (n = 75) reviewed, Seers (1993) again using ‘live’ rather than audio-taped PMR instruction vs control, two groups reported a significant difference for pain and anxiety, favouring PMR. The reviewers concluded that there was not enough conclusive evidence for a direct effect of relaxation techniques on chronic pain, but suggest that effects on coping and anxiety may contribute to the overall well-being of patients living with chronic pain. A second systematic review by Carroll and Seers (1998) of relaxation techniques, examined outcomes for patients with acute pain. Only seven (362 patients) out of a possible 40 studies were eligible for inclusion using the modified Jadad et al (1996) scale. When considering pain outcomes, only three out of the seven reported significantly less pain in the relaxation groups.