(p. 157) Relaxation
■ Set the agenda
■ Rate the patient’s stress/distress level
■ Review homework
■ Describe the physical stress response system
■ Review relaxation techniques for controlling stress
■ Teach deep breathing
■ Emphasize the importance of relaxation practice
■ Assign homework
(p. 158) Set Agenda, Obtain Stress Rating, and Review Homework
Begin the session in the usual fashion, by setting the agenda and evaluating the patient’s stress or distress over the previous week. Review the homework assigned in the previous session.
How the Body Creates and Reduces the Experience of Stress
Before describing how to control the stress response, use the following information to explain what is happening biologically when someone experiences a stressful event. Our nervous system has two subsystems—the sympathetic nervous system and the parasympathetic nervous system. These two systems are controlled like an internal thermostat. The sympathetic nervous system is equivalent to a heating system. When we experience something stressful, we become aroused and stress hormones (such as cortisol) are produced. These stress hormones increase bodily activities like heart rate, breathing, muscle tension, blood pressure, and perspiration. This system of arousal was designed to prepare the body for fight or flight (e.g. when confronted by a lion).
While the sympathetic nervous system heats up the body, the parasympathetic nervous system acts as a cooling system. The parasympathetic nervous system brings the body’s reactions back to normal by producing a relaxation response that slows down the heart rate and breathing, relaxes the muscles, and lowers blood pressure.
The stress thermostat function runs smoothly by gauging the heating and cooling precisely, heating up a bit when we perceive a stressful situation, cooling down when the situation has passed. This system works well when there is an occasional stressor. However, when someone experiences ongoing stress, or if the body is constantly responding to stress, the thermostat heats up, cools down, heats up, and cools down—over and over—and eventually the thermostat breaks down. The heating system stays on but the cooling system does not get activated. When the thermostat breaks, it requires a manual setting of the cooling system.
Inform patients that relaxation can be like the manual setting of the cooling system. Relaxation exercises reduce feelings of stress by slowing (p. 159) heart rate, slowing breathing, lowering blood pressure, and relaxing muscles. Relaxation practice can be used in two ways:
■ If the patient is under chronic stress, relaxation practice can help her get control over her stress thermostat, and get her nervous system and stress response system back in sync. This will help the patient feel overall more calm and in control.
■ If the patient practices relaxation regularly, she will also develop better control over her physical stress response system (heart rate, muscle tension, blood pressure, breathing, etc.). This will allow the patient much greater control over her body’s ability to quickly cool down her stress response system when stressful events occur.
The Basics of Relaxation
The core principle of relaxation is breathing. Explain that deep breathing is one of the easiest, most effective ways to reduce tension in the body. Learning to be aware of and to control one’s breathing is the first step toward controlling the physical and mental effects of stress. There are two types of breathing: chest and abdominal.
Inform the patient that most people are chest breathers. Chest breathing is shallow. The shoulders often rise with each breath and only the chest expands. This results in poor exchange of stale air for fresh air. This also contributes to fatigue, because the body’s cells aren’t able to receive the oxygen necessary for effective functioning. People tend to increase shallow chest breathing when stressed. Conversely, shallow breathing can contribute to feelings of stress.
Abdominal breathing involves slow, deep breaths using the diaphragm. The diaphragm is a large sheet of muscle, like a piece of a rubber (p. 160) balloon, stretched over the bottom of the lungs. When breathing is relaxed, the diaphragm expands down on the in-breath, creating a negative pressure that pulls air into the lungs. On the out-breath, the diaphragm relaxes back into its original position, pushing air out of the lungs. When the diaphragm moves down on the in-breath, the contents of the abdomen are naturally moved forward so that the abdomen expands. If we place our hands on our abdomen, we will feel it bulge out on the in-breath and flatten back on the out-breath.
Emphasize to the patient that learning to breathe with the diaphragm will help the body automatically shift from the stress mode to the relaxed mode. If the patient continues slow, deep abdominal breathing for several minutes, her heartbeat will slow, blood pressure will drop, blood circulation will increase—basically the nervous system will reset to a “cooled down” state—a state of physical relaxation rather than stress. As she becomes physically more relaxed, she should also begin to feel emotionally more relaxed. Once these basics are described, invite the patient to try a 3-min deep breathing exercise.
Deep Breathing Exercise
Ask the patient to rate her tension from 0 to 10, with 10 being the most tense she’s ever been. Then give the following instructions using a calm, measured voice:
Take a moment to make yourself comfortable—loosen any tight clothing, stretch for a second to remove any obvious points of tension.
Sit comfortably in a chair or lie down.
If the patient is in a chair, be sure her back is straight, her shoulders are back, and her feet are flat on the floor. Some people find it helpful to imagine a thread attached to the top of their head, pulling their head up to the heavens, elongating their neck and spine. Ask the patient to sit comfortably, with a sense of dignity.
Close your eyes, and focus your attention on your breath. Breathe mainly through your nose. You can leave your mouth closed, or slightly open—whichever allows the muscles in the jaw to feel most relaxed. Breathe slowly into your abdomen. When you’ve completed inhaling, (p. 161) hold your breath for a few seconds before exhaling. This helps slow your breathing. Feel your belly rising and falling. If this is the first time you are doing this, you may want to place your hand on your belly to feel it rising and falling.
Bring your attention to your breathing. Notice the feeling of your belly expanding and contracting. Maybe you feel your clothes against your belly. Or you sense the feeling of cool air entering your nose on the inhale, and warm air exiting on your exhale. [Wait quietly for 10–15 s.]
Notice any places you have muscle tension. As you exhale, see if you can let go of just a bit of that tension. You might imagine the tension flowing out on your exhaled breath. [Wait quietly for 15–30 s.]
When any noises occur, incorporate them into the exercise—for example:
If you hear noises around you, just notice them. You don’t need to be bothered. There is nothing you need to do about them. If you want, you can label them, like “Ah, a car honking” or “A dog barking” [use whatever noises are actually occurring].
Continue the exercise for a total of 3–5 min. Then ask the patient to rerate her tension level. If it has dropped, ask her what she makes of that, and underscore the effectiveness of this exercise. If it did not drop significantly, let her know that with practice, she will gain more control over her tension and be able to reduce it using breathing and relaxation exercises.
This breathing technique is a core to almost all relaxation exercises. Let the patient know that she can use this exercise anytime she is feeling stressed or tense. It is a good tool to reset the nervous system. Also let her know that if she practices on a regular basis, she will get better at this, and will learn to reduce tension very rapidly, sometimes even with a couple of breaths.
■ A small number of people sometimes have a “paradoxical response” to some forms of relaxation. They find that they become panicky when engaging in (p. 162) relaxation (they find their breath speeds up, their heart starts racing, they become quite anxious and fearful). If this happens, discontinue relaxation. Assess the phenomenon to see if there is any history of such panic. Are the conditions in which the patient is able to relax? If so, try to incorporate those features into the practice.
Such reactions may be associated with a need to not lose control. Some people may be more comfortable with their eyes open. You might suggest the patient direct her gaze at a blank or nonmoving surface like the floor or wall, and then allow herself to slightly unfocus. You might also try having the patient give herself the instructions either mentally or out loud in a soft voice. ■
Types of Relaxation
Progressive Muscle Relaxation (PMR).
This exercise is often used to teach people who have either never tried relaxation before or not done it in some time. The basic idea is simply to tense muscle groups, and then let go. Using diaphragmatic breathing and letting go after tensing helps to relax the muscles. This is an excellent place for some people to start. However, this exercise may not be appropriate for people with spasticity, because the tensing may aggravate pain.
The focus of this exercise is on increasing awareness of breath and using breath to control arousal. This is a core part of any relaxation exercise, and is essentially the exercise described previously.
This exercise uses mental imagery to help achieve a sense of calm. Typically a recording helps the patient create images that can help her enter a relaxed state. Many people find this a very easy and enjoyable way of relaxing. However, some people find the voices and sounds distracting.
Many meditation exercises involve observing your experiences, such as your breath, sounds, or thoughts. Joining a meditation group is highly recommended to increase the likelihood that the patient will continue.
(p. 163) Mindfulness.
Mindfulness is a specific form of meditation that has become very popular in recent years.
Yoga and Tai Chi.
These are exercises that involve some movement, but are intended to increase relaxation.
Encourage the patient to try as many different types of relaxation as possible. Some people like relaxation exercises that involve audiotapes or CDs. Others prefer quiet exercises. Some people like exercises in which there is no movement while other people like the movement that Yoga and Tai Chi use. Emphasize to the patient that there is no “right exercise” or “right way” to perform it.
Learning to Relax
It is important to conduct relaxation exercises in the office with the patient so that you can teach her how to do them, answer questions, address problems, observe the patient for any signs of difficulties, and check how well they work for the patient.
■ There are a few nuances to conducting relaxation exercises with MS patients. First, if the patient has spasticity, do not use exercises that require tensing the muscle groups where the spasticity is present. This can induce cramping or cause pain. Also, you may have your own methods of inducing relaxation. Avoid using imagery that may be related to MS symptoms or problems. For example, many relaxation induction techniques suggest sensory changes such as feeling limbs as being heavy, numb, or tingly. These are all MS symptoms, and so may trigger anxiety and arousal rather than relaxation. It is best to simply avoid the use of sensory suggestions unless you are certain that the patient does not have those symptoms. Likewise, many relaxation inductions use suggestions of warmth, or imagery such as imagining taking a warm bath. For patients with heat sensitivity, such suggestions may also have negative associations. We have used “imagining yourself floating in a comfortably cool stream” for patients with heat sensitivity. The suggestion has the effect of shifting consciousness, just as the sensory suggestions are intended, and therefore can contribute to a relaxed state. ■
(p. 164) Relaxation Exercises
As a therapist you likely have many relaxation exercises at your disposal, and we encourage you to use anything you are comfortable with and that you feel the patient will respond to. PMR and the body scan are two relaxation exercises described in the patient workbook. Both of these are good places to start for people who have not had much experience with relaxation (again, avoid or adapt the PMR exercise as necessary for patients with spasticity). In the following section, a guided imagery relaxation exercise that suggests immune system enhancement has been provided. It is important to note that this exercise is not intended to have an effect on the immune system above and beyond what any relaxation exercise has. You might introduce it by saying something like the following:
If you practice relaxation on a regular basis, it may have a positive effect on your overall health and on your immune system. This is a guided imagery exercise that uses imagery from the immune system. Now this exercise is not necessarily any better for you than any other, but I’ve found many patients like it. Would you like to try it?
Immune-Focused Relaxation Strategy
Before you begin, ask the patient to rate her tension on a scale from 0 to 10.
Go ahead and find a comfortable position, sitting either in a chair or on the floor. If you feel more comfortable lying down, you may do that instead. Now, if you are comfortable, I would like you to close your eyes, or just gaze softly down at the floor. And, I would like you to turn your attention to your breathing … breathing into your belly, and out [note—it is helpful to time the “in” and “out” to the patient’s inhale and exhale] … Notice the regular rate, rhythm, and volume of your breaths … Notice how with each breath in, your stomach gently rises … and with each breath out, your stomach slowly falls … I would like you to prepare for your first deep, belly breath, inhaling through your nose … and holding for your count of 3 … 2 … 1… And release the air through your mouth, feeling the (p. 165) warm air whooshing out. Now allow your regular pattern of breathing to resume … [pause for 15 s]. Again, inhale through your nose, drawing more air into your belly, completely filling your lungs with air … and hold for your count of 3 … 2 … 1… and then slowly, slowly release the air through your mouth … noticing the warm air and feeling of relaxation spreading … And, again, allow your breathing to return to a regular rhythm, and feel yourself breathing in a pattern that is comfortable for you. [Pause for 15 s …]
As I speak, you can pay attention to words, or not, as you choose. The only thing that is important right now is how you feel … calm … peaceful … relaxed … If you want, you can begin—with each breath—to notice tension melting away and you may begin to feel your body becoming lighter … as though you are carrying less and less weight. And, as you become lighter, you sense a light … you can see it coming … maybe it starts as a small pin-sized light … maybe you can see it coming from inside of you … Either way, allow the light to grow and envelop you in a soothing, calming embrace … As the light surrounds you, you feel it, soothing and gentle … it carries you … floating … soothing … calming … supporting … healing. The light carries you through space … and you find yourself floating, and surrounded by this soft, healing light. You feel safe, cared for. Connected. [Pause for 20 s …]
Breathe in the light, feel the light inside you … moving gently into your lungs … and through your lungs… into your blood stream … and into your heart… feel the light throughout your belly and chest, glowing brighter with each breath in … feel the light move in to your back, into your spine … feel your chest and spine fill with the bright, healing light … as the nerves in your spine fill with healing light, bringing a gentle strength … Feel how it is both powerful and calming at the same time … feel the light grow out from the nerves into the spine, relieving tension in each vertebrae… Perhaps you can feel this bright, calming, healing light moving out through your nerves to other parts of the body … down into the lower back… down into the thighs… the calves … all way down into the feet. Feel with each breath how the light comes in to your belly and chest, and flows down into the lower back, thighs, calves, and feet … each breath bringing a calming, healing light … Perhaps you also feel that the healing light (p. 166) moves out from your chest into the shoulders, through the nerves and blood vessels, into your shoulders and upper arms … into your forearms … hands … andfingers … Let the gentle, calming, healing light flow throughout your body with each breath … feel the light moving up through your neck … feel the light envelop your head and brain … an embracing, healing light … Allow the light to course throughout your body, healing, calming, embracing … Perhaps you can feel your body’s life energy … feel it strengthening … [Pause for 20–30 s …]
If there is a part of your body that worries you, from MS or for any other reason, bring it to mind … If many parts come to mind, allow one to come forward. Know that you can choose another part next time. Don’t worry about choosing the right part to focus on … Just allow the healing light to flow into the part of the body … and allow the light to bring a gentle enveloping calm … allow your body to accept this healing and soothing light. Allow it to calm the immune system … as you feel the light moving through, see it: glowing … calming … healing… Allow the light to surround your nerves… calming … healing … relaxing … [Pause for 15–20 s …]
Notice that each time you inhale, you inhale the light that surrounds you … the light becomes brighter… even more calming… As you exhale, you exhale the darkness of whatever bad feelings you have… the fatigue, or pain, or tightness, or whatever you feel … you can see it flowing out of you on each breath that you exhale … Feel the light move through your body … through the nervous system … coursing through … And each time you inhale, the gentle power becomes stronger … calming the nerves … healing the nerves … Each time you exhale, you release more of the bad feelings or physical pains … these just flow out of you … Allow that light to stay with you … bright… calming … soothing… healing … [Pause for 1–2 min …]
Continue to breathe gently … noticing perhaps that your regular rate, rhythm, and volume of air has changed. You may notice deeper, slower breaths. And feel the oxygen carried through your veins … Keeping your eyes closed, gently begin to notice the world outside of (p. 167) you … Notice the sounds … perhaps of your breathing, or of others … Notice the textures … Of your clothes on your skin … of the support from the chair, floor, or wall … You can let the light stay inside you, or if you prefer, allow it to slowly fade, leaving its calmness, soothing and relaxing, behind. As you bring yourself back, remember this calmness … this kindness … gentleness … and know that you can return to this at any time you choose.
Continue breathing, keeping your eyes closed as long as you like. When you are ready, open your eyes, and come back to the room, feeling calmer, soothed, and at peace.
Finding Support for Relaxation
It is helpful if patients can find support outside of therapy to continue their relaxation. Most communities offer a variety of meditation and yoga classes. Many local MS society chapters have also begun offering Yoga and Tai Chi tailored specifically for people with MS. Classes can be very useful in helping people practice on a regular basis. It is also nice way for people to meet other people who have similar interests. Encourage your patient to look into these resources.
Many patients also find it helpful to have audio recordings of relaxation exercises. There are many relaxation exercises available for free on the Internet. These are audio or video files that can be played directly from the site, or downloaded for use at any time. Search under “relaxation exercise” or “relaxation exercise and audio”; several sites should be readily available. At the time of this writing, several universities have provided a variety of relaxation exercises on their Web sites, including the University of Wisconsin at http://forms.uhs.wisc.edu/relaxation.php, the University of Pittsburgh Medical Center at http://healthylifestyle.upmc.com/StressRelaxation.htm, and Loyola University at www.loyola.edu/campuslife/healthservices/counselingcenter/relaxation.html. These exercises are of all different lengths, from a few minutes to 15 min. Some include basic instruction while others do not. Some have just a voice, while some include music or other sounds. Encourage your patient to try different exercises.
(p. 168) Relaxation Practice
Emphasize that practicing relaxation is one of the most critical aspects of stress management training. Study after study has shown that practicing relaxation has profound benefits on stress hormones, the immune system, and, perhaps most importantly, a person’s sense of well-being. The more the patient practices, the better she will become at controlling her body’s response to stressful events.
It is best to practice at a set time once a day. However, if the patient does not feel she can practice each day, select a target number of times she thinks she can practice in the coming week. While once a day is optimal, it is better to set a realistic and achievable goal, than to have one that the patient knows she cannot make.
Review the following tips for relaxation practice:
■ Practice in a quiet part of your home where you are not likely to be disturbed.
■ Do not practice after taking stimulants such as coffee or cigarettes.
■ Avoid practicing after using alcohol or drugs that change your thinking.
■ If you have trouble sleeping, try doing relaxation right before going to bed.
■ If you have stressful days, try doing relaxation in the morning.
Having patients keep track of their relaxation, as well as how effective it is in reducing tension, will help them track their progress in learning how to control their tension and arousal. Most people find at the beginning that their tension does not go down much after practice. But after a few weeks of consistent practice, patients will likely notice that relaxation substantially reduces tension. Have patients use the Relaxation Log in the workbook to keep track of the kinds of relaxation exercises they use, and to rate their level of tension before and after the exercise on a scale from 1 (no tension) to 10 (extreme tension).
(p. 169) Homework
• Have the patient practice relaxation. Help the patient choose a time of day, frequency of practice, and length of practice that works best for her.
• Check if the patient wants to search for relaxation recordings on the Internet, or if she would like to find a mediation, yoga, or Tai Chi group.
• After the patient has been practicing for a week, and feels that she is able to control her level of stress and arousal at least somewhat, have her begin trying the 3-min deep breathing exercise at least once a day when she experiences tension.
• Assign workbook reading as appropriate.
• Discuss any assignments relevant to the patient’s goals.