ACT on relaxation strategies
I'm not sure if this is a clinical issue or a conceptual one, but I have a question. I've been learning about ACT and attempting to teach my colleagues about it, and this issue has been raised several times. I think I've found some answers on this web-site, but just wanted to check out my thinking.
Here's the thing: people have been asking me if ACT is specifically "anti-" traditional relaxation strategies (like deep breathing, cognitive imagery, progressive muscle relaxation...). Seems to me that on a strict level, it is -- these strategies are designed to change our affect, and (to varying degrees) they do not promote contact with the present moment. Also, as I understand it, ACT proposes that our physiological states are not under conscious control (and therefore should be accepted rather than changed).
So one person (who does a lot of work with chronic pain) asked me how ACT would explain the fact (?) that cognitive imagery results in pain reduction (suggesting that consciously controlling our thoughts does affect physiological experience). Then a supervisee asked me if doing deep breathing would specifically be ACT-inconsistent. I pointed him to centering exercises, but couldn't quite answer the question.
From what I've seen on this site (including Dr. Hayes's case formulation guidelines), relaxation is not a total no-no, and could be conceptualized as helping with a deficient life skill. My own rationale (for continuing to use it while promotiong acceptance and commitment) is that if relaxation can help to "control" anxiety (or what have you), then that's great. We can go ahead and control things that are (empirically) controllable. And then, for what remains of the anxiety/pain/etc., we are advised to practice acceptance.
Is this a consistent argument? Or am I rationalizing b/c I am still reluctant to give up some of my CBT techniques?
Thanks,
Dara Friedman-Wheeler
ACT on relaxation strategies
I use relaxation training with chronic pain patients as part of a desensitisation process.
I want the patients to relax, to get as heavy as possible, in the presence of a pain stim. This is a paradoxical response to threat and is aimed at reducing the distress associated with the experience of the pain signal. To be able to be fully present with the pain itself but without the contamination that distress causes.
I use the analogy of threat - that pain is being viewed as a kind of tiger by the CNS. The more willing they are to learn to sit with that threat the better they will cope and the more they can behave in valued ways in its presence. Additionally, the more willing they are not to feed the tiger with their distress the more energy they will have for themselves to sit with it again tomorrow.
Importantly, unlike a tiger, pain has no claws or teeth and therefore the natural distress response to a threat to their survival is misplaced with a pain signal.
Patient's have little say about feeling their pain signal but they can choose a behavioural response that limits the pain's ability to reduce their behavioural repertoire. A relaxation based response also produces desirable neuroendocrine outcomes in relation to dopamine and norepinephrine levels, which will provide benefits for the patient's behavioural management and subjective experience of pain.
These principles operate in any situation where you have a stress response to an aversive stim. Functionally targetted relaxation training works well within the ACT model when used to improve the patient's ability to choose valued behaviours.
Cheers,
Carl Graham
Re: ACT on relaxation strategies
I use relaxation and breathing exercises with my clients, not as usual, but looking at them as what I believe is an ACT process.
Fighting against unwanted experiences is done in the body. One mean in this fight is muscle tension. As we see in western films, when a bullet is extracted without anesthetic, the guy bites a wood to deal with pain. Tension is a way to deal with pain; it distracts us from unwanted feelings, as the feel of tension masks feelings of pain. The cycle pain-tension-pain is a known factor in chronic back pain. Tension immobilizes our body to prevent felling pain, but continuous tension produces more pain. In this context, relaxation is not a search of a particular state, letting go muscle tension means be opened to unwanted feeling, in the sense proposed by ACT.
When we thought in certain action, our body reacts automatically, as we can see in the pendulum experiment. Tension associated to this reaction holds in our body when our thought has leave. Letting go this tension will free us to better adapt to new contexts.
Other means to cut our feelings is to accelerate our breathing, as in some panic attacks. Breathing regularly might means not reacting automatically against sensations in this situation; not doing anything to change breath is to take risk of being dead, becoming mad, etc.
When we direct our attention to something that might be threatening, usually, we hold our breathing as a part of our readiness to react and to hear any clue of danger. Also restricting our breathing is a mean of not feeling some anxiety that we locate in our chest or our stomach. In these cases, freeing our breath implies to be opened to unpleasant experiences. It is not the abdominal or complete breathing the correct ones, the matter is to adapt it to the context, opened to the experience, whatever it was.
From this point of view, as a consequence of accepting our experiences, anxiety may disappear; but this is not the goal of relaxation exercises, the goal is to be centered in our committed actions, giving up unnecessary fights.
Very good discussion, folks.
Very good discussion, folks. I believe that "relaxation training" is a general heading under which there is a great variety of techniques with sometimes very divergent goals. The clearest example I can think of relates to meditation, rather than clinical relaxation training per se, but I see these two areas as having a great deal of overlap.
I once ran across a study of two different types of meditation, and I failed, at the time, to note the authors or source of the study, but it left a lasting impression of me. Researchers monitored a number of physiological measures on two groups of trained meditators, one group of whom was doing a classical yogic-type meditation, and the other practicing zen. Among the things they monitored was the brain's orienting response, which shows awareness of a stimulus, and the brain's startle response. After the groups had gotten into a deep meditative state, a loud noise was suddenly presented. The yogic meditators showed neither an orienting nor a startle response; they were tuned out, floating off somewhere in space. The zen practitioners, however, showed the orienting response consistently, but not the startle response, in contrast to "normal" subjects. They were there, in the present moment, but serenely undisturbed in it.
The results of that study fit perfectly with my own experience of these two types of meditation. I learned the yogic-type first, and it enabled me to have many blissful moments of floating in a serene, undisturbed state. Later, and with more difficulty, I learned the zen way, in which I remain present and aware but still feel serene. I found the yogic-type of meditation easier to learn, and more quickly positively reinforcing. However, I have found the zen techniques to have much more generalizability to everyday life, since I don't have to escape from stimuli to avoid overreacting to them.
Since I had this discovery, I have been endeavoring to adapt the relaxation strategies I use with clients to be more in line with the zen-type of focusing on the present moment, not tuning out sut tuning in. I have come to see the real goal of relaxation techniques as mindfulness--that is, getting people to deescalate from their chronic overreactions to stressors, their worries and fantasies, their nightmares and flashbacks, and into the present moment and acceptance of present experience.
John W. Balchunas, MS
Licensed Psychologist (WV)
Licensed Psychological Associate (KY)
Study on meditation
Hi,
I think I read the same study but, if it's the same, I remember the details a little differently. It was done by the group (I forget the name) but I know the Dalai Lama has done some work with them. Anyway, they had 3 subjects - someone not meditating but reading a book in which he was totally absorbed, one person practicing concentration meditation (focused on one thing and one thing only) and another practicing mindfulness meditation (focused on breath but open to whatever comes up then just letting it go.) Then, randomly, there would be loud disturbances and the 3 subjects' reactions were measured. The reader initially reacted greatly (let's call that 100) but, over time, he become accustomed to it and his reaction slowly went down until he didn't even notice it. The concentration meditator reacted very little (we'll call that a 15) but he, too, became accustomed to it and eventually did not notice the disturbance. The mindfulness meditator also had a low reaction (15 again) but he was always a 15. The belief is that, in mindfulness, you're always open to what's going on as if it's the first time and you don't become accustomed to things because you recognize that they're never exactly the same.
By the way, I also use relaxation techniques in my job as a psych nurse and my job as a yoga teacher/therapist. It's always on focusing on the body, not trying to change anything, just being aware of what is going on in your forehead, your eyelids, your eyes, etc. Bringing awareness to the area seems to naturally relax the area. People don't usually notice anything about their bodies unless it is something painful. (What I use for pain is to have the person totally get into what the pain is like. What color, texture, size; does it have a smell, a taste? Not avoiding it but really immersing yourself in it does work to reduce the pain for most people. People who are open to it, I think.)
That is probably the same
That is probably the same study, and the differences in the details probably result from the fact that I read the study probably 20 years ago, and have talked about it so many times since then that I have distorted its details. If anyone does know the names of the authors or publication source for this study, I'd be really grateful if you would pass this along, since I have long been wanting to reread the study for precisely that reason. In Zen parlance, I have long been talking about my concept of the study rather than the actual study itself!
John W. Balchunas, MS
Licensed Psychologist (WV)
Licensed Psychological Associate (KY)
ACT on relaxation strategies
Regarding imagery and pain, my understanding of the recent literature is that distraction does not really work with chronic or persistent pain. Getting involved in an activity, you are interested in does distract one form pain, if it is not aimed at reducing pain; if it is entered into as a desired, or interesting activity in itself. That is, it seems to work if it is under appetitive rather than aversive control.
Mind you, there are all kinds of imagery techniques, for all kinds of purposes, and it can be hard to differentiate exactly what is going on in some studies.
I try to take the same attitude you do; asking myself “is it ACT consistent?” I think with a lot of techniques it is not so much what you do, as why you are using them, and how they fit into the therapy overall. I think this is in line with what Russ and Mary were saying.
Personally, I have stopped using “relaxation” techniques all together as I see it as a control strategy. More importantly, my clients seem to see them as this as well. I use mindfulness, awareness of breathing, and body sensations, or even awareness of sounds, and most people find this relaxing. I put a lot of effort into trying to get the idea across that this is not the point. Everyone wants to get that nice feeling, and seem to slip back into that control agenda of relaxation, me included. Make it nicer, make it softer, make my mind more quiet. However the point, particularly with chronic pain, is to get into the experience (be in the present moment and accept welcome in the sensations), defuse from the cognitions linked to those sensations, and if possible engage in some action that is in line with what is important to you.
Having said that I have got a couple of pain clients at the moment where relaxation type skills would be useful. I don’t know how this will go, however my plan is to work on mindfulness skills, and then get them to attend to body sensations of loosening/tightening, stretching, and even relaxing while trying to notice the changing sensations, and noticing their judgments/evaluations of those sensations. Much as we do when assisting in increasing exercise/activity with chronic pain
relaxation/breathing /awareness and pain
I've used awareness with relaxed breathing for people experiencing chronic pain for a while - before becoming aware of ACT! The way I use it is to guide the person through awareness of how their attention moves and that no experience lasts forever - even pain - and just to 'go with' the moment by moment drifting of attention. Initially people have remarked that they either attended to the painful sensation more than they 'wanted to', or that they avoided attending to the painful sensation. As time goes on, though, their attention wanders fluidly to and from different sensations including pain, without the evaluation of it's unpleasantness.
It can take time for people who are not used to sitting still. And yes, I still use relaxation training for certain situations such as sleep management, or when high levels of arousal prevent the person from attending to much else other than pain.. I'm not particularly bothered about whether it is consistent with ACT - more happy that it's helping the person sit with their problem rather than running about getting stressed.
ACT on relaxation starategies
Mindful slow breathing as a way of being present, accepting experience, centreing, grounding, etc is very different to slow breathing with the purpose of reducing anxiety.
I find this a helpful metaphor to clarify this:
Mindful breathing is like an anchor that holds you steady in the midst of an emotional storm. An anchor won't get rid of a storm. It just holds you steady until the storm passes of its own accord.
(I.e. we focus on our breath to stay grounded and present; not to control the anxiety. Of course, anxiety frequently reduces as a by-product of mindfulness. You can also extend this meatphor: e.g we can ask, what happens if you wave the anchor at a storm in order to make the storm go away?)
Cheers, Russ
ACT on relaxation strategies
Russ,
I really like your anchor metaphor. I think your point about relaxation as a by-product of mindful breathing is right on. When I talk people through mindful breathing, I actually mention to them that they are likely to feel relaxed, but the purpose of the breathing exercise is to practice opening up to all of your experiences (e.g., imagine that with each in breath you expand, get biggger, become more willing to hold your expereinces, and see if you can use your out breath to notice and if you are willing, drop any sense of defensiveness). I also try to link any sense of peacefullness to the experience of the observer self. In other words, mindful breathing is a path to the place where you are not your thoughts, feelings, bodily sensations, memories and behavioral predispositions.
Andy
Re: ACT on relaxation strategies
Hi Dara,
You raise an interesting question/issue. I've struggled w/this in the past, as well. What I think makes the most sense is not to do away with breathing or relaxation strategies, but to use them in ACT-consistent ways. For instance, a relaxation or breathing exercise would not be done with the purpose of controlling anxiety, but would be more of an awareness exercise as you said (e.g. notice the breath, feel it entering and leaving, feel your muscles tense and relax without attempting to control the sensations, notice how tension, thoughts, sensations will come and go). They can look almost identical in practice with a different focus.
The bottom line is to go with what works--does breathing/relaxation exercise really reduce anxiety? In the ST or LT? Does it help a person to live a valued life? Or does it then make the person's life about "controlling anxiety?" And how does that work for the person? That should help guide the function of the exercises.
As for the literature you're talking about with cognitive imagery and pain reduction, I'd have to see the exact studies. But it's possible that the imagery led to mindfulness and awareness of pain and reduced the avoidance of the pain sensations rather than successfully "controlling anxiety" through "controlling thoughts" (you can take a look at the vast ACT and chronic pain literature for support for acceptance-based interventions for pain).
Just some preliminary thoughts...hope it's helpful.
Mary