To soothe the savage breast

Behav. Res. Ther. Vol. 31, No. 5, pp. 439-462, 1993

0005-7967/93 $6.00+ 0.00 Copyright © 1993Pergamon Press Ltd

Printed in Great Britain.All rightsreserved

INVITED TO

SOOTHE

THE

ESSAY SAVAGE

BREAST

TF~O L. ROSENTHAL Department of Psychiatry, University of Tennessee, College of Medicine, 66 North Pauline, Memphis, TN 38105, U.S.A. (Received 6 October 1992)

Summary--We review quite a range of procedures--some strange, some familiar--to calm, and spare fantasied harm. Drugs can help a whole bunch, but there is no 'free lunch.' Side-effects from long use, and the risk of abuse, make it wiser to find other means to 'unwind.' (Anxious folks spin a messful of thoughts that are stressful.) Against pressures that fluster, tranquil images muster a sense one is resting--rather than testing how much one achieves (while one's family grieves). Muscle programs to lower tense states, and pace slower, can bring manifold gains easing worry and pains. There are diverse connections among muscle flexions however those function--that can serve as an unction. Movements practiced each night do more good than the 'right' exercises in theory, left undone by the weary. Thus give choice of routines as well as calm scenes: one might dodge heart attacks if one learns to relax. It will not cheer one's mood to review woes nor brood over future collusions, intrusions, confusions, perfection, rejection and other delusions. Like over-tight shoe points, loosen Puritan viewpoints because standards too stern make adrenaline burn. Teach instead: 'Mellow visions need not earn derisions. People who play more are invited to stay more.' Massages and dancing, gentle fiction entrancing or dulcet harmonics are suitable tonics. For self-damaging actions bring on wholesome distractions. There are so many names for so many games, from social adventures to buying debentures, trip-planning, food-canning and even gold-panning. Thus cease surplus panting but cultivate planting since turmoil may go when one makes flowers grow, or elsewhere embraces Nature's several faces: oceans, rivers, or canyons, mountains, redwoods or banyans, or (thanks to some vets), peaceful contacts with pets.

INTRODUCTION M u l t i p l e facets o f clinical efforts to d e a l with p s y c h o p a t h o l o g y , stressful events, a n d p e r s o n a l calamities seek to reduce aversive m e n t a l states a n d e m o t i o n a l arousal. In part, one aims to calm the p a t i e n t because such a r o u s a l is painful. Patients often c l a m o r for relief. I n part, though, one aims to c a l m the p a t i e n t o n preventive grounds: because aversive a r o u s a l invites subsequent beliefs, actions, a n d p e r c e p t i o n s t h a t d e e p e n the p r o b l e m in a ' s n o w b a l l i n g ' e x a c e r b a t i o n cycle ( R o s e n t h a l & R o s e n t h a l , 1985). F o r instance, the recent d i v o r c r e - - g r i e v i n g t h a t her h u s b a n d has left her for a y o u n g e r w o m a n - - i s often p r e y to the wiles o f p r e d a t o r y boyfriends. Likewise, m e n in similar situations are v u l n e r a b l e to the allure o f d u b i o u s girlfriends, impulsively chosen ' O n the r e b o u n d . ' T h e rejected p e r s o n ' s sense o f loss, b e t r a y a l , o r h e a r t a c h e is n o t likely to dissolve by following well-meaning advice f r o m friends to o v e r c o m e the p a n g s b y ' b r u s h i n g u p on y o u r F r e n c h , ' o r 'redecorate your home.' Y e t the o d d s are very high that, in time, the b e r e a v e d will get p a s t feeling h u r t a n d lonely if: (1) the p e r s o n d o e s n o t lose h o p e a n d sink into d e s p a i r o r w i t h d r a w f r o m life; n o r (2) a d o p t a ' s o l u t i o n ' - - s u c h as the ill-chosen d a t i n g p a r t n e r - - w h i c h m a k e s the inevitable pains c o n s i d e r a b l y worse. O n e m i g h t say the crux o f o u t c o m e will hinge on h o w the p e r s o n copes with, o r 'fills' the e m p t y d a y s until new people, places a n d events c a n knit u p constructively the ' h o l e ' in the fabric o f life f o r m e r l y held by the unfaithful lover. W a y s o f b r i d g i n g time, a n d m e a n w h i l e c o m b a t i n g n o x i o u s a r o u s a l , n a t u r a l l y lead us into subjective perceptions. W h e n one feels 'all is lost,' it is h a r d e r to l o o k a h e a d to new goals, o r to p l a n a n d i m p l e m e n t the steps t h a t can reach new goals, t h a n w h e n one feels ' T h e r e is light at the e n d o f the tunnel.' It is a s o u n d clinical h o m i l y t h a t a n t i c i p a t o r y fears a n d worries a p p e a r worse a n d d o m o r e h a r m t h a n c o n f r o n t i n g the a c t u a l challenges. Even situations w o r t h y o f anxiety rarely equal dire anticipations. O n e r e p e a t e d l y finds t h a t p a t i e n t s ' faltering steps t o w a r d d r e a d e d tasks p r o v e easier t h a n foreseen in advance. This s a m e p a t t e r n o f pessimistic a n t i c i p a t i o n s surpassing actual 439

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experiences spans the clinical gamut: it ranges from minor, simple phobias (of heights, enclosed places, and cats, bats, rats, gnats or sprats) all the way of stark agoraphobic withdrawal by panic disorder and obsessive-compulsive patients. Fearful prevues outrunning fearful realities is by no means confined to clinical populations. For instance, in mass casualty situations, it is typical for people far removed from the site of cataclysm (who might later be affected) to show more worry than people in direct contact with the dangers. Stronger fear in people remote from the disaster has been found worldwide. Examples include earthquake threats in India (Festinger, 1957), and greater anxiety among those not yet bombed during the Blitz of England in World War II, than among the people who had faced the German air-raids (Rachman, 1978). What, then, are the intervention strategies that can neutralize aversive arousal? In principle, the list at least would need to include the following: (1) pharmacotherapies; (2) relaxation methods; (3) physical exercise, and martial arts movement disciplines; (4) distraction from dwelling on stressful cues and images; and (5) changing overly stringent (and hence self-punishing) standards for achievement. This article will consider in some detail the broad realm of non chemical counterarousal techniques. It is sometimes stated, disparagingly, that such methods are 'merely palliatives.' Webster's New Universal Unabridged Dictionary (second edn, 1983) on p. 1289 gives the following definition of the noun palliative: 'that which extenuates; that which mitigates, alleviates, or abates the violence of pain, disease, or other evil.' Considering that, when successful, the methods in question achieve their benefits mainly with no known side effects or dangers, we can ill-afford to ignore them, or to assume automatically that chemical interventions are preferable. Some limitations and dangers of pharmacotherapy

At the outset, let it be clear that I have the highest regard for the benefits of modern pharmaceuticals when used properly. There is no wish to engage in 'medicine bashing.' The concerns to be raised are not an attempt to deny the value or power of medicinal options. Rather, these virtues need to be seen in proper perspective. Risk of dependency. It is certainly better for patients to follow a prescribed regimen of psychoactive substances than to self-medicate with alcohol, opioids or other 'street drugs' to reduce distress. Yet the hazards of potent medications can go neglected. First, some medications that initially bring benefits can, over time, become harmful. This is particularly true for the neuroleptic (anti-psychotic) drugs. It is well known that chronic neuroleptic use can cause tardive dyskinesia. There are also data suggesting that sustained use of neuroleptics (frequent among public sector patients, with psychotic histories, since the late 1960s) may itself create psychotic symptoms ("neuroleptic-induced psychosis", see Downs, Akiskal, Rosenthal, Drannon, Ackerman, Downs, Walker and Arheart, 1992). Likewise, an especially hazardous adverse effect is the development of 'neuroleptic malignant syndrome' which appears to be on the rise. This condition occurs in up to 1% of patients, and carries a mortality rate of 10-30% for those so afflicted. Second, some of the anxiolytics that can be useful for short-term, acute crises may become addictive if continued as 'maintenance' treatments for prolonged periods. Such benzodiazepines as lorazepam and alprazolam may prove more harmful than helpful when used for extended durations. We and our colleagues have needed to refer outpatients placed on such regimens to be detoxified as part of sound case management (Rosenthal & Rosenthal, 1985). Not all of these patients qualified as 'addictive personalities.' Another example of well-intended but unfortunate pharmacotherapy for anxiety is the use of neuroleptics for this purpose. In the past--due to the misnomer 'major tranquilizers'--neuroleptics were often prescribed as anxiolytics. The present consensus is that these chemicals are ineffective for anxiety, yet they do entail major risks. Unfortunately, too often it is still the practice of nonpsychiatrists to prescribe a combination of a neuroleptic plus an antidepressant (such as perphenazine-amitriptyline HC1) to treat anxiety. Based on the foregoing reasons, our Psychiatry faculty teaches residents to remove patients from 'tranquilizers' as soon as possible and to prescribe the lowest effective doses. Current opinion views the antidepressants as safer for the long run. Even so, 'mood-elevating' chemicals can bring undesirable side-effects that lead patients to resist or discontinue them. Also, most antidepressants are very toxic if taken in overdose. Regrettably, many unwary physicians (frequently general practitioners)~less expert than academic psychiatrists in neuroendocrine and pharmacologic complexities--may freely prescribe anxiolytic and antidepressant medications to naive outpatients

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who, misguidedly, seek a chemical 'quick fix' for their anguish: these patients can find numerous 'Dr Feelgoods' to oblige them. Further, consider the plight of the many people with previous histories of alcohol or drug abuse who now are abstinent and 'recovering.' Those people must stay very alert when obtaining routine medical and surgical care. They must inform their physicians of their risk for relapse, and precautions--or special adjustments of routine practices--must be taken. If not, well-meaning and fully competent caregivers may inadvertently spur readdiction in those at risk, merely by giving standard doses of standard analgesics in accord with standard operating procedures. Patients and health care workers known to us--with substance use problems in their pasts--have suffered relapses in just this way. Or, they have needed to 'make waves' in order to spare themselves risking relapse from the prescriptions routinely given to compliant patients. No clinician who has ever worked on an inpatient chemical dependency unit, or has seen a person inflict self-injury as a way to obtain restricted chemicals, will be sanguine enough to assume that all persons who are at risk for substance abuse relapse are dutifully warning their physicians in advance. Medical contraindications. The limitations of chemical treatments mount steeply if psychologically distressed people are also medically impaired--as with cardiovascular diseases, liver or kidney malfunction, etc. Many complex interactions among metabolic and physiologic processes, affecting the transport of chemical agents, must be carefully weighed to devise a pharmacotherapy regimen. Sometimes, psychoactive chemicals may be precluded by the more pressing concerns of internal medicine. Must this relegate the frightened medical patient's fear and worry to an 'untreatable' category? Obviously not. A correctly-drawn conclusion to the foregoing synopsis would recognize both the virtues and limitations of pharmacotherapy: medicines used properly, in appropriate context, are wonderful blessings. But they are not panaceas. For these reasons, our colleagues and ourselves teach our residents as much as possible about nonchemical techniques for managing patients' emotional distress. Likewise, we now try to acquaint medical students with some of the options to be discussed. An informed physician will be more likely to consider extrachemical strategies when called for, and will more readily consult psychiatrists, psychologists and other behavioural scientists once made aware of the existence and helping capacity of the methods to which we now turn. The questions to be addressed can be phrased as follows: what are some of the better known techniques to 'reciprocally inhibit' (Wolpe, 1958) anxiety? Further, what are some of the other options--that for the most part have been ignored by psychology and psychiatry--which: (1) seem worthwhile to assess by research trials? Especially (2) if the writer or colleagues have some clinical case evidence suggesting that a technique has promise. RELAXATION METHODS Relaxation techniques to reduce noxious emotional states came to general prominence through the success of Wolpe's (1958) systematic desensitization therapy for phobias. Wolpe embedded a condensed version of progressive muscle relaxation within desensitization--basing it on Jacobson's (1929, 1938) prior work--to counteract distress while the patient imagines a graded stepwise hierarchy of anxiety-arousing cues to be neutralized. Now, relaxation methods range from the briefest--such as Benson's (1975) minimal "Relaxation Response" approach--to the most profound, which is surely Jacobson's (1929, 1938) deep muscle relaxation training. Edmund Jacobson was a physician and physiologist who ran a clinic for patients with anxiety or emotional problems, and related disorders, that involved 'nervous' or 'neuromuscular hypertension.' Thus, patients with inflamed mucous membranes (e.g. of the esophagus), spastic colon and asthma as well as psychiatric conditions were treated. Some would remain in residence at Jacobson's clinic for 6 months or longer. They practiced progressive relaxation of all the relevant muscle groups to all conceivable environmental stressors. By the time of discharge, the patient was a 'Grand Master' in the skills of relaxation, and could relax to counteract nearly any worrysome or noxious event. The entire realm of clinical relaxation has recently been reviewed in detail in an admirable book by Lichstein (1988). The reader is referred to that reference, and other current texts on clinical methods (e.g. Kanfer & Goldstein, 1991), for discussion of techniques not presently

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mentioned, and for expanded views of those covered. Our aims will be to call attention to strategies less widely known, and to share 'pointers' from our own and colleagues' case experiences. Guided imagery as symbolic relaxation Most people seem able to readily--and fairly vividly--imagine diverse stimulus events, including peaceful scenes. It is easy enough to 'test' visualization capacity. One starts by asking the patient to visualize some simple images--which might well begin static--such as a green triangle inscribed in an orange circle, or one red rose in a glass vase. Then one can switch to images in motion. I often give 'a mother duck slowly paddling on a pond; she is followed by fuzzy yellow baby ducklings strung out behind her.' Another example could be some large birds--hawks or eagles--gliding on thermal updrafts, who then swoop downward in search of prey. If one discovers the patient cannot attain images of these kinds, one may need to question the applicability of symbolic relaxation--which is often only one element in counterarousal guidance for strongly distressed patients. Given the capacity to visualize, it is usually helpful to have the person select--with the therapist's assistance--several familiar peaceful scenes, and to rehearse scenes at least twice per day (for about 5-6 min, at most, each time) to sharpen the skill. In bed, preparing to sleep at night, is one very suitable occasion for practice. Some break--e.g, at lunch or between duties--in the ongoing demands of the day, is another good opportunity for a mental respite. Directions for scene practice. Very often the contextual guidelines for visualizing scenes are not provided clearly to patients. It is most helpful to supply them, and we do so at least twice per imaginal situation during initial teaching: first with eyes open, as preparatory guidance with questions invited and answered; then, later, as a preamble to the illustrative scenes to be visualized in the office before practicing, and fine-tuning details, at home. Since the patients are inside their own nervous-systems, once they get 'the hang' of scene practice, they are better judges than the therapist of which details to augment or exclude. The directions we find helpful--and record on the audiotapes we sometimes lend to patients--are along these lines: "I want you to imagine that you are all alone; no demands on you, nothing you must do. If you'd be more peaceful having a pet or a loved one along for company, then your companion either must be asleep, snoozing beside you or must be out of sight even if nearby. For instance, in a scene at the beach or at a lake, you could have your spouse picking flowers or gathering wood for a campfire, just out of sight, so you can't be disturbed by a remark or a request. You must be physically comfortable. The temperature is nice, not too cold or too hot. You must visualize yourself in a comfortable position. You might be lying on a cot or a chaise or on an air mattress or on a blanket on soft sand (or grass). But you must be comfortable, able to shift position when you want, and in a very peaceful, relaxing setting. Somewhere you feel calm and at ease. "Most important of all, you must visualize the scene the way things are in real life--not like a motionless photograph or a slide. That means bringing in all your senses! Try to feel the feels, taste the tastes, smell the smells and hear the sounds that go with the scene in your mind. And try to see the scene from different angles and perspectives: close up near you; in the middle distance; and far away. For instance, if you were at the ocean, you might try to feel soft, warm sand beneath you, to taste the salty taste carried on the breezes from the sea, and to smell the tangy, iodine smells of sea-weed, fish and other ocean life. You might hear the sound of the surf pounding, drawing back and rolling in again. There might be gulls or other birds calling, a fog h o r n - - o r people's voices--way in the distance, or the sound of a plane flying high overhead. Finally, near you, where the waves break, there might be starfish and kelp washed-up, or a sandpiper walking along the moist sand. Down the beach, you might see children flying brightly-colored kites or playing catch with a big red and blue beach ball. Out in the water, not too far, there might be a sailboat or a kayak going by. Far, far out near the horizon a steamer may be passing--you may see smoke coming from its smokestack. Also, though the sky is blue, there are big, puffy clouds as well. When a cloud moves under the sun, it casts shadows; and when it passes along, the sunlight gets brighter. Those are the kinds of sense details I want you to include--just the ones that seem peaceful and natural and soothing to you. Don't get stuck on my details--they were just examples. Paint in the tastes and smells and feels and sights and sounds you find soothing. Please, now ask any questions you wish."

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The above amount of elaboration would, typically, only be given--with eyes open--as instructions at the outset of the first 1-3 sessions. In abbreviated form, they would be repeated to introduce each new practice scene. Once the patient has learned these 'ground rules,' and makes them the context of scene practice at home, the guidelines need only be stated in very sketchy, 'short-hand' fashion. The underlying rationale for explicit contextual illustrations is much the same as for other cognitive supports to facilitate information-processing (see Rosenthal & Downs, 1985). Also, depending on the preferences of the patient and therapist, instructions to produce relaxed sensations (e.g. "Let the tension flow all out of your forehead, your cheeks, your neck. Feel how your shoulders get softer and looser." etc.) can be provided or omitted. These seem more elective than starting with an introductory context that exemplifies the mental set to be adopted during scene practice. For instance, numbers of patients who had poor response to previous relaxation training without an orientation of the foregoing short, showed positive responses after the intended context was laid out for them. Finally, relaxation-enhancing supplements may improve outcomes with some patients. These options include: (1) playing peaceful music; or (2) image-enhancing sounds, such as "The Cry of the Loon" and "Sounds of a Crackling Fireplace" sold as audiocassettes in the series Gentle Persuasion: The Sounds of Nature (The Special Music Company, 1989). Other patients have (3) accompanied scene practice with favorite calming videotapes, or find the imaginal scenes greatly enhanced if (4) practiced while soaking in a hot bath, or in some favorite available setting such as (5) the garden or (6) sun-bathing on a float in the pool. These examples are given simply to remind clinicians that exploring patients' preferences and phenomenology can enhance beneficial impact. Ocular relaxation. Concern with the movements and muscles of the eye for calming purposes seems to have begun as an element of Jacobson's (1929) overall training routine for progressive relaxation. He presently felt the technique had special promise for helping insomniacs to sleep, as later research has confirmed (Lichstein, 1983, 1988). Ocular relaxation is certainly the shortest form of 'muscle' relaxation, but is included with imaginal techniques because much verbal 'suggestion' usually accompanies the ocular motions. In brief, the eye is tensed for 7 sec and then relaxed for 45 see in each of six positions as follow: (1) raise your eyes as high as possible, aiming at the top of the head; (2) move eyes down as if to look out of your chin; (3) move eyes all the way to the right as if to look out of your ear; (4) then all the way left as if to look out of your other ear; (5) rotate your eyes in a circle; and (6) then rotate your eyes in a circle going in the other direction. Lichstein (1988) concluded that the ocular method deserves further study, and not only for insomnia: since some Ss have reported the procedure 'makes their mind go blank,' potential applications are raised in terms of intrusive thoughts and obsessional concerns. Those observations become most intriguing in light of the advent of a new treatment strategy for traumatic images and memories. It may be that ocular relaxation would qualify as the unrecognized historical forebear of this recent development. Eye-movement desensitization and reprocessing. In a series of papers, Shapiro (e.g. 1989a,b, 1991) has reported striking success for a procedure devised to counteract the traumatic residues of stressful calamities--for instance, the PTSD-like symptoms of nightmares, disturbed sleep and flashbacks via imagery or intrusive memories of such assaults as rape, combat injuries to self or comrades, and various kinds of abuse in childhood. The essential feature of the method involves having the patient recall, think about and experience the emotions aroused by the traumatic event while, with eyes open, the patient 'tracks' the therapist's finger which is moved from side-to-side to evoke rhythmic, saccadic eye movements. The procedure is not known to create intense anxiety, does not entail a hierarchy of stimulus situations as in 'classical' desensitization therapies, and yet eye-movement desensitization has been found surprisingly effective. In research with numbers of trauma victims, many whose distress had endured over 20 yr and had not responded to diverse previous treatments, dramatic progress has been claimed--sometimes after just one session of eye-movement desensitization (see Shapiro, 1989a,b, 1991). Yet all that seems required is for the patient to recapture (and 'reprocess') as much as possible of the stored representations of the traumatic experiences while performing the repeated bilateral saccadic eye-movements. The method has been found successful in a controlled study and a case report; the latter (Shapiro, 1989b) best conveys explicit treatment tactics.

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We have tried the method in a very severe obsessive-compulsive disorder (OCD) case, with multiple chronic symptoms. She is a single, gifted, applied scientist in her mid-thirties, referred for behavior therapy by her psychiatrist who now maintains her on a combination of clomipramine and fluoxetine HC1. That regimen seems to have stopped the spread of avoidant rituals---creating nearly housebound status at referral--but medication has not dispelled her many handicaps, to which nearly all the techniques commonly advised for OCD (Rachman & Hodgson, 1980; Rosenthal & Steffek, 1991) have been applied. Those approaches needed to stay distinct from efforts to treat her PTSD-like traumatic memories, for which eye-movement desensitization (EMD) was tested. At referral, the patient could only drive from home to work and back--putting her on the freeway near rush hour--which might entail 2 hr each way rather than 20 min, due to legitimate fears about 'wild' drivers but, mainly, to an intrusive thought: that she had hurt or killed some person each time she hit an unseen bump. She then felt obliged to exit at the next interchange, and double-back to confirm that no helpless victim lay on the road, although she fully grasped the 'irrationality' of the OCD symptom. Otherwise, she did not drive anywhere alone---to shop, maintain social contacts, or visit a cinema--and was immobilized, except when her boyfriend visited most weekends, from his town several hours away. Her chronic worries about driving (and lateness to work jeopardizing her job), plus a host of other fears (e.g. of contaminating people she touches), had demoralized her when first seen. She was scared to try homework tasks, and scared to hope for recovery. The foregoing symptoms are responding, slowly but steadily, to a composite of response-prevention, participant and imaginal modeling, assigned approach practice tasks, milieu guidance and social influence (Rachman & Hodgson, 1980; Rosenthal & Steffek, 1991). However, she had also endured a long history of physical and verbal abuse, while growing up in a deprived home with a cruel, sardonic father and later in dating men who exploited her OCD handicaps. A suitable method was needed for her traumatic memories (emerging often during the week as nightmares, or as waking 'flashbacks'), with a format distinct from--and hence not likely to 'infect' by stimulus generalization--the other interventions. For this goal, EMD has been used with two modifications (perhaps necessitated by the patient's size or the room furnishings): (1) rather than one, two fingers are used for tracking; (2) rather than a horizontal bilateral movement, fingers trace a shallow arc--about 120° and, at highest, some 12 ins above the horizontal between her eyes--whose width per sweep ranges some 16 ins for tracking. Otherwise, trials are similar to Shapiro's (1989b) procedures. After six 40 min blocks of EMD trials (embedded within longer therapy sessions), the first traumatic image has, in main, been neutralized, and the next image added. Outcome in a less-afflicted case would seem commensurate with systematic desensitization. Yet, given the duration, scope and tenacity of patient symptoms, plus a distinctive format inviting use concurrent with other methods, the EMD technique has thus far fared well, and merits further study.

Muscular relaxation and sensory feedback options Apart from Jacobson's own accounts of progressive relaxation for clinicians (1929, 1938), and for the lay public (1962, but first edition 1934), there exists a horde of muscle relaxation variants: These seem kissing-cousins, if not siblings, in lineage. Probably best known is the 16 muscle group version, adapted from Jacobson by Bernstein and Borkovec (1973). We find good results with a simpler, isometric exercise approach. It divides the body into torso, arms, legs and neck plus head, with several 'tense-relax' flexions per area, and repetitions as needed. It can be taught to students in two, and to most patients in three or four, 90 min sessions. It also strengthens the flabby musculature so often found in anxious patients, making them better able to detect--and hence work to reduce---tension cues. However, so many similarities span muscular regimens--which also overlap nominally separate techniques, for instance, autogenic training as Lichstein (1988) notes--that earnest comparisons now seem rather futile: it is very hard to isolate any 'pure vintage' from so many related blends. What does seem essential is that patients learn the contrast between tensed and relaxed muscle states throughout the body, know how to bring on relaxed states, and practice the relaxation exercises regularly. Muscle vs imaginal relaxation. Often, 'stressed-out' people are impervious to symbolic calming modes. They have rehearsed and ruminated over fear-laden covert representations so many times

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that requests to 'imagine a peaceful scene' seem silly: they come in seeking help for belaboring just the opposite--worry-drenched--scenarios. Further, they want guidance they can follow despite anxiety, help that is palpable. A set of concrete acts leading to less tension not only brings intrinsic relief, but also raises confidence in one's own capacity to abate distress, and in the therapist's wisdom as an advisor. Better guide the person in anguish to do something, than to invite doubts that anything can help! When one perceives some restored ability to control stressors that formerly seemed beyond control, optimism and self-efficacy about taking clinical guidance (e.g. doing assigned homework), all rise in a constructive fashion (Bandura, 1986, 1988; Rosenthal and Steffek, 1991). For all these reasons, muscle relaxation often will surpass imaginal methods with very anxious patients. Only after some progress, may scene visualizations become practicable as additional counterarousal aids. In sharp contrast, 'somaticizers' who tend to express adjustment strains in bodily terms--such as patients with chronic pain out of proportion to known organic causes--may well do better with imaginal than muscle relaxation. First, such persons focus on physical discomfort and can thwart or protest against further movement demands. Second, they may distrust muscular tasks as 'testing' or challenging their physical complaints. Third, they may fear that increased muscular activity might impair pending insurance claims for workman's compensation or disability. Hence, 'peaceful scenes' to help 'get your mind off' your aching back (or neck, or head or limbs) may prove more acceptable. Jacobson 's "Self-Operations Control"

In a widely-neglected book, Jacobson (1964) presented a newer approach to anxiety and tension control. The self-operations strategy is depicted as offering more latitude for rational choice, compared to the original, progressive relaxation method. Much like some executive engineer steering one's biobehavioral system, "the individual learns to run his organism according to what he believes are its best interests." Practice does not comprise a set of muscle exercises. By directing attention to proprioceptive, 'body sense' cues, they can become better detected and interpreted. Thereby one gains improved control over body sense regulation, and its pervasive impact on mental events. Some resemblance to a Zen discipline in secular Western garb is evoked. Why has the program earned so little notice? Very likely because much time and effort must be expended on what seems an ephemeral quest: better awareness of body sense cues. In the full course of study, an hour's daily practice lying prone is allocated as follows: left arm, 7 days; right arm, 7 days; left and then right legs, 10 days each; trunk, 10 days; neck, 6 days; eye-region, 12 days; visualization (a pen moves slowly from side-to-side, then stops, then moves again very fast, during the whole first hour), 9 days; and speech region, 19 days. On day 19, one imagines saying one's name ( x 3), then one's address ( x 3) and then the U.S. President's name ( x 3) for that hour. The same sequence for the same duration (i.e. 90 total days) is then repeated from a sitting position. Consider the impatient reactions of hurry-prone North Americans if only at the tenth day of working on the legs does the entire left leg undergo progressive tension and relaxation. Another 10 days elapse before the same feat is reached with the right leg. Jacobson was not to be rushed! A sample graph of favorable tension changes during treatment spans 19 months. Consequently, the stone---be it diamond or zircon--has remained in the rough, awaiting proper assay and polishing. No derision is intended. Some troubled souls, and others of philosophical bent, make pilgrimage to the Orient and immerse themselves in contemplative disciplines for years. The largely-untested self-operations control regimen might become a dandy dissertation project for a reflective and patient graduate student. Biofeedback and meditation. It seems fair to conclude that, on average, biofeedback techniques have not delivered the marvels expected by early enthusiasts. In the fullness of time, warnings given long ago have been verified. For instance, Franks and Wilson (1973) cautioned: "The grossly exaggerated belief in the accomplishments of biofeedback, coupled with an explosive innovation in miniature but highly complex electronic devices that even the relatively inexperienced individual can use readily, has led to an upsurge of pseudoscientific investigation into the so-called 'inner nature of man.' By this time, virtually everyone in the field has become acquainted with the promise offered by the instrumental control of visceral learning or what has popularly become known as biofeedback, but few are aware of its limitations (p. 638)." More recently, the frequent rough

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equivalence of results from instrument-aided biofeedback, compared with the various relaxation (e.g. Benson's, 1975) and meditation--such as transcendental--techniques, in diverse areas of behavioral medicine has been noted by Lichstein (1988) among others. Perhaps distracting the patient from a focus on symptoms (below), plus instilling confidence that the sufferer has some control over distress, jointly account for a good share of clinical efficacy (Rosenthal, 1980). Research by such careful scholars as Blanchard gives biofeedback mixed overall reviews at best. When thermal biofeedback was combined with progressive relaxation, and/or cognitive stress-coping and/or meditation training (16 treatment sessions in all), clinically-meaningful gains in comfort (e.g. better sleep) were found in migraine, tension and in combination (vascular plus tension) headaches (Nicholson, Blanchard & Appelbaum, 1990). Some data suggest that benefits are less stable for tension than for vascular headaches (Blanchard, Appelbaum, Guarnieri, Neff, Andrasik, Jaccard and Barron, 1988). More generally, vascular headache patients given thermal biofeedback plus relaxation, or plus cognitive therapy, or instead, given 'pseudomeditation' as a control method, all improved significantly with no sharp advantages among options despite less stable gains for pseudo-meditation (Blanchard, Appelbaum, Radnitz, Morrill, Michultka, Kirsch, Guarnieri, Hillhouse, Evans, Jaccard and Barron, 1990). Those outcomes concur with past results that biofeedback for headaches may not surpass relaxation training (Blanchard, Theobald, Williamson, Silver and Brown, 1978). Even when thermal biofeedback proved more helpful (in 65% of cases vs 35%) than relaxation to treat essential hypertension, prediction of individual response was poor, and relaxation was beneficial (Blanchard, McCoy, Berger, Musso, Pallmeyer, Gerardi, Gerardi and Pangburn, 1989). Nomothetic or ideographic remedies? What if much common causation underlies the acts of judgment; information-processing and emotional attribution that mediate: (1) the acceptance; (2) rehearsal; and (3) salience for recall of any psychosocial guidance regimen? Such reasoning has been posed by various writers over the years (e.g. Bandura, 1986; Rosenthal, 1980; Rosenthal & Bandura, 1978; Rosenthal & Steffek, 1991). If it has merit, this might imply a flaw in the usual strategy for assessing treatment utility, especially if there also are strong individual differences in preference for the 'stylistic' aspects of therapy. Given such premises, should we randomly assign patients to "shoes that don't fit" and force them to be worn? Perhaps 'Yes' when a method is known to be potent for nearly all cases; perhaps 'No' otherwise. It was earlier noted that imaginal relaxation may not comfort anxious, expressive 'worry-warts,' yet be acceptable to more reserved 'somaticizing' patients, afraid to move their muscles. Likewise, will persons whose beliefs and values clash with 'introverted self-scrutiny' try harder or comply better if an oscilloscope or a thermometer externalizes the task, moving the 'locus of blame' outside of their minds? To date, clinicians have not shone in matching patients with their most-favored therapy. Thus, when alternatives are about equally effective, as a heretical option consider the following modest proposal: prepare samples (e.g. on videotape) of the possible treatments, and let the patients self-select their own nostrum, 'cafeteria style.' We then would study relative outcomes and drop-out rates, but also what sorts of people pick which techniques. It does not seem far-fetched that personal choice might enhance results over chance assignment to regimens known as roughly equivalent whether variants of biofeedback, of meditation or a diversity of methods are compared. Acupuncture. In a health-care setting, many opinions are voiced about this venerable Chinese approach. It is gaining mention as a viable option in texts on pain management (Smoller & Schulman, 1982; Turk, Meichenbaum and Genest, 1983), and one meets about as many true believers as scoffers. Conclusions as to the general merits of acupuncture may still be premature, but in one sphere there are anecdotal data worthy of notice, especially since few competing routes offer much promise to help 'compulsive' smokers kick that habit. A friend and colleague had for years made attempts to quit smoking, but without success until persuaded to try ear-staple acupuncture. In paraphrase, here is what transpired: "Before, nothing did away with the urge to smoke; it would build up over time until I just had to have a cigarette. I didn't believe the staple would do any good. But once it was in my ear, I could touch it when I craved a smoke, and the craving went away. After some months, the urge was gone. The staple was no longer needed and so was removed." The former smoker is a very conservative, critical thinker, not receptive to fads. No relapse has occurred in some 5 yr. Similar first-hand testimonials are given by others, including clinicians, that when all else had failed, smoking ceased after the ear was stapled. Hence, it does

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not seem too credulous to compare the acupuncture ear-staple method with other approaches to help chronic smokers cease and keep desisting. There is no plethora of encouraging--let alone well-validated--means to dispel tobacco addiction, making acupuncture trials appear dubious. Certainly, there seems a lack of sound theory to explain why ear-staples may quench cigarette cravings. We all subscribe to the value of theory in science. Yet now and henceforth, let us not be blinded to promising techniques because we can't explain how they work, should they prove to be effective. It is said that Herbert Spencer's idea of a tragedy was "to have a beautiful theory murdered by an ugly fact." We can ill-afford to ignore new clinical leads, just because no 'respectable' conceptual framework is yet available. Nor because a wanton fact threatens our familiar world view. A refreshing chapter by Foreyt (1990) takes a similar stance toward novel and unconventional interventions worthy of study.

Physical exercise and methodical movements Very often, any sound exercise program will sharply reduce chronic tension/fsedentary patients comply by diligent practice. The odds are better for younger persons whose bodies are more resilient, and who resist motor activity less than habitual 'couch potatoes.' For instance, some overzealous pupils--medical and other graduate students are cases in point--give up customary athletics they formerly enjoyed due to the perceived pressures of their studies. They display surprise when told to resume their familiar exercises or instead be required to learn muscle relaxation. They are easily prodded into movement, and usually find that workouts counteract much of the anxiety (and typically worry about grades) that brought them to seek help. In contrast, many older patients disdain, detest and convince themselves they can't make time for, regular exercise. Since 'half a loaf is better than none,' it may help if one accepts whatever options--swimming, biking, tennis, golf, dancing, skating, walking--they like most or mind least. Sometimes, a recalcitrant patient will only entertain greater physical activity after rehearsing relaxation exercises has increased comfort and peace of mind. Conversely, the same aches and pains that so often accompany poor muscle tone in emotionallydistressed people, can be exploited to 'prime the pump.' Simple movement routines suitable for the floor at home (hence, do-able in any weather, without extra travel time) may bring relief, and also spur the person on to further movement regimens. During a protracted spell of lumbar disc miseries, two programs stood out in merit and have since helped numbers of my patients. The first is very suitable for changing longstanding inactivity, for pain complaints, and for very fragile (e.g. geriatric) patients. It entails a graded set of stretching exercises that can be gradually elaborated (Anderson, 1980). The second can usually decrease the back and shoulder aches that so often accompany strong emotionality, while also lowering tension and toning the musculature. It is based on the engaging theory that the stronger the rest of the torso becomes, the less work the back must do, and it has been validated on large samples of Ss with back complaints (Melleby, 1982). Other good texts exist, and readers may prefer them. Note that all muscle movement and palpation options are nonverbal. Massage and directions to "turn this" or "raise that" can bypass symbolic storage that is overloaded with stressful ideas and conclusions that have been too often rehearsed and brooded over. When applying movement methods, one must stay alert to consulting physicians, physical therapists, etc. to assure the patient can tolerate the exercises assigned. Massage. After a long tense day, many people relish a back-rub, and admire those whose 'magic fingers' can unknot the body. Even the most sluggish and demoralized cases will usually allow another's labors to loosen their muscles. Here is a robust means to 'unwind,' devoid of chemicals, with good odds for success but few risks of side-effects. Massages thus provide the luxury of a 'wholesome fix' for people who enjoy and can afford them. Bearing witness to these advantages, in large health-care settings there often circulate by word-of-mouth among clinicians--for each other as well as their patients--the names of gifted massage-givers. When one hasn't a clue to finding an adept masseuse or masseur, athletics trainers at high schools or colleges, physical therapists and colleagues at rehabilitation units seem plausible advisors. Do not be surprised if a chiropractor is recommended. Whatever the virtues and shortcomings of chiropractic as a theory or a general therapy, its graduates gain considerable expertise in how to manipulate a body for the comfort of its owner. In a like vein, soaking in hot water can expand muscle fibers and undo 'tight' places. Therefore, it may help distressed patients to suggest they indulge in long, hot baths

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or showers (or soak in a hot tub or sauna) at the end of a taxing day and after each exercise workout. (If followed, this guidance may promote a slower pace and a kinder stance toward self as well.) Sometimes, a patient may choose a leisurely soak or bubble-bath as a relaxation scene. The bathtub is also an apt place to practice imaginal relaxation, since the hot water combines with peaceful imagery to induce a tranquil state. After such 'hydrotherapy', visualizations that failed to bring calm when tried in more hectic contexts may become effective. Likewise, early in muscle practice, the patient may feel strain or soreness even if relaxed. The discomfort may respond to soaking in hot water, and to local application of heating pad or hot water bottle on the hurting area. Despite their simplicity, these kinds of plain home remedies are too readily ignored in our overly gimmick-ridden electronic era. Foot reflexology. A special variety of foot massage--involving pressure on specific regions----comprises the techniques of reflexology whose pressure points seem analogous to the loci of needle-placements in acupuncture. The approach may share historic roots with yoga, transcendental meditation and shiatsu disciplines. In reflexology, zones of the entire body are mapped onto sites in the foot--where all the main nerves terminate. The theory entails the flow of 'intangible life energy' across 10 zones that run the length of the body (Norman, 1988). However one regards this conceptualization, the application can be wonderfully liberating in the hands of a skilled practitioner. One is left buoyant and pleasantly loose throughout the body. Although self-help directions can be followed, if the method is to be given a fair test, it should be demonstrated by a virtuoso. (Be prepared to hear, and to ignore, some pseudoscientific pronouncements, e.g. that thus and so 'has lots of light.') The critical issue is how well a technique works, and not the sophistication or rigor of the rationale chosen to explain its effects. Hence, follow the motto of the "Order of the Garter": "Honi soit qui mal y pense." In the view of its champions, the scope of foot reflexology is much broader than recapped thus far. For instance, it is recommended to end arguments: "It's always been part of the folklore that making up is the best part of an argument. The truth of the matter is that it's often hard to initiate lovemaking when we feel like killing each other. But it's not so hard to grab a foot! In fact, some successfully married couples use personal rituals to end arguments or to stop talking about a touchy subject for the moment. Reflexology can be that ritual. Literally, take a foot and start in. You don't even have to say 'I'm sorry.' Your hands say it for you. What frequently happens is that as you relax and calm down, you can see things more clearly and get the situation in better perspective. (Norman, 1988, p. 164.)" T'ai Chi and other martial arts. The origins of the Oriental martial arts, and subtle relationships among them, are best left to experts and adepts. In practical terms, T'ai Chi systems consist of slow, relaxed movement--involving posture, balance, breathing and concentration--that comprise a method to attain self-control. As do other martial arts--such as Kung Fu, Karate, Tae Kwon Do and Jujitsu--T'ai Chi approaches derive from Shao-lin Temple Boxing. Unlike the more aggressive styles, where muscular vigor may be critical, T'ai Chi demands neither speed nor strength for practice. It thus is felt suitable even for the very young and elderly, as well as for adults in their prime. Workers in modern China are often required to rehearse T'ai Chi during exercise breaks as a fitness regimen (Galante, 1981). Since common elements span various martial arts disciplines, regular practice of any form may offer similar generic benefits. Whatever the form, during exercises a person must turn way from the ordinary cares of living and, instead, focus attention upon executing coordinated motor acts. A main goal is the "harmonious merging of thought and action (Galante, 1981, p. 23)." Such respites from worry, anger, fear or ruminating over stressors, seem intrinsically restful and soothing to emotionally-distressed people. Major components of T'ai Chi practice include relaxation, reduced awareness of self, a slow and steady pace, and coordinating motions with each other, with slow, rhythmic breathing, and with meditation (attained via concentration and contemplation). These features, combined with biomechanical guidance--in keeping the spine erect, in learning to shift weight from foot to foot--may underlie the physical and mental benefits claimed by T'ai Chi's many advocates. Similar elements compose the body exercises of Hatha yoga, and echo some steps of Jacobson's "self-operations control" (above). A brief routine can be rehearsed in 15 min or less (its proponents advise longer daily sessions for life). The actual exercises are best taught by a skilled instructor, but are described and illustrated with photos in introductory manuals (e.g. AI Huang, 1987;

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Galante, 1981). Many colleges offer inexpensive Continuing Education courses in T'ai Chi (and related systems) for the general public, as at times do local churches, YMCAs, YWCAs, etc. What first drew our attention to T'ai Chi were its positive effects recounted by a resident in a nursing home. The lady entered the home in her seventies, after a mild stroke. She was dysphoric, made few friends, remained isolated and lonely, and focused much of her time and thought on her own disappointments and troubles. Although she recovered most of her physical function, her emotional outlook remained bleak. Soon after she turned 80, a volunteer instructor began to offer T'ai Chi lessons at the nursing home. Along with one other resident, our lady took the opportunity; she became seriously devoted to learning T'ai Chi forms, and their spiritual underpinnings. Over time, a remarkable transformation--not easily attributed to any other source--began to be evident. Harmony improved in all spheres. Her personal philosophy became more tolerant, her mood and outlook more positive. She grew less prone to hurt or angry feelings, and her social relations blossomed. Now nearly age 85, she reports greater satisfaction and peace of mind than ever before. This case is in line with many other first-hand testimonials for T'ai Chi. It seems fair to ask whether ballet or other dance classes, acrobatics and related kinesthetic disciplines that teach a lexicon of graceful movements, would yield benefits comparable to T'ai Chi? A plausible answer might be: "Very likely,/f three conditions are met." First, a student must be able to perform all necessary motions safely (not readily true for most octogenarians). Second, the practice must not occur in a competitive context (i.e. Who achieves the longest pirouettes? the highest leaps or somersaults? etc.). Third, individual differences toward philosophical trappings must be allowed for. Some patients will relish, but others will reject, the Zen-Taoistic argot that surrounds martial arts training. For those who resist an Oriental mystique, there are more mundane Western counterparts. The Alexander Technique. Many years ago, in an interview for our campus newspaper, the late Aldous Huxley expressed his profound admiration for an actor's, F. M. Alexander's, system of posture correction. Elsewhere, Huxley wrote of his mentor's work: "There is a correct or 'natural' relationship between the neck and the trunk and . . . normal functioning of the total organism cannot take place except when the neck and trunk are in this right relationship . . . For some obscure reason the great majority of those who have come in contact with urbanized, industrial civilization tend to lose the innate capacity for preserving the correct relation between the neck and trunk, and consequently never enjoy completely normal organic functioning. Alexander and the teachers he has trained reestablish the correct relationship and teach their pupils to preserve it consciously (see Gelb, 1987, p. xi)". Despite protestations that the Alexander Technique "was not like yoga, massage or Eastern psycho-philosophy; it did not involve doing exercises, and it was much more sophisticated than posture or relaxation training. (Gelb, 1987, p. 1)," one can discern many parallels with those other methods. All aim to change poor movement habits, and to promote relaxation during action. Alexander's own self-diagnosed flaws when speaking under stress initially were: (1) stiffening the neck, thus pulling his head back; (2) 'forcing' his larynx; and (3) inhaling breath in gasps. His procedures were evolved to remedy such biochemical mistakes, and their effects on the distribution of tension in the body. At base, practice seeks to readjust how the head--akin to the end of a lever--is carried in relation to the neck and torso. This postural relearning often brings trainees a feeling of 'unstrung' muscular feedback in place of strain. Thus, if you venture into an Alexander lesson, prepare to hear, and be asked to recite as a quasi-mantra, words along these lines: "My neck is free; my head is moving forward and upward; my trunk is lengthening and widening." One wonders about the degree that the Alexander principles serve the flip side of what foot reflexology deals with at the other end of the spinal column? In any case, we are properly admonished that prose does not convey the cues of movement coordinations any better than the sensations of color or of taste upon the printed page (Barlow, 1980; Gelb, 1987). It seems highly plausible that habitual malaligned stance and awkward motion will tax body harmonies and, conversely, that more adroit standing and moving will improve well-being. This appears most relevant given the sedentary lifestyle and positions--sitting down at school, at work, at play, driving vehicles--of 'advanced,' mechanized society. Hence, the benefits claimed for Alexander training in cases of rheumatism, spondylosis, back pain, arthritis and other disorders involving posture, breathing and stress-reactivity seem credible (see Barlow, 1980). The

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curious reader can gain some grasp of the procedures from the two cited manuals and their illustrations (Barlow, 1980; Gelb, 1987). Both texts are clearly-written, useful introductions by experts. However, as with the other nonverbal regimens, demonstrations by skilful teachers will convey more, better and faster than words. For whatever reasons, few physical therapists known to us are well-versed in the Alexander Technique, T'ai Chi and related methods. In contrast, dancers and musicians are often conversant with the Alexander Technique, and college fine arts departments may have persons with expertise, who can recommend suitable teachers. Clinicians will need to identify reliable trainers in the community when advising patients to test such movement programs. We might sum up as follows: there is no onus in balanced tonus; take care in reaching for careful teaching. Breathing. Hippocrates wrote that "breathing is the basic rhythm of life." Yet it is generally neglected throughout Western society. Few children are taught correct breathing unless to prepare them for singing or playing wind instruments. Apart from the meditation-movement disciplines such as yoga and T'ai Chi just discussed, and La Maze training for expectant mothers who plan 'natural' childbirth, preventive guidance in respiratory dynamics is rare. Hence, many writers impute multiple symptoms--including ideopathic high blood pressure, migraine, metabolic acidosis that raises the risk of diabetes and kidney failure, faintness and vertigo, down to anxiety spells and panic attacks--to improper breathing and its psychophysiological consequences. Many of the techniques earlier mentioned include respiratory hygienics as part of their claimed benefits. A most useful synthesis of the harmful consequences of hyperventilation, and ways to help clients overcome it through breathing retraining, is provided by Fried (1987). One key point made is that chronic mild hyperventilation in the form of rapid shallow breathing may have subtle but harmful cumulative effects, not immediately evident, unlike marked apnea or spasmodic gasps. Fried also invokes hyperventilation (which can take diverse forms) to unify one (the breathing) aspect of malfunction spanning a host of stress-related disorders. For instance, consider research data that T'ai Chi can help rheumatoid arthritis patients (Kirsteins, Dietz & Hwang, 1991). Jacobsonian self-operations, progressive relaxation and the Alexander Technique are also reported as beneficial. Do the gains stem from better musculo-skeletal coordination, from a calmer state or from more harmonious breathing? We do not yet have causal answers, but some combination of motor, mental and respiratory factors seems most plausible. The same reasoning applies equally well to hypertensive-cardiovascular and anxiety-panic illnesses. In discussions of relaxation (usually made the keyword for a subject-matter index or a computer literature search), careful reading will reveal that improved breathing is cited as a noteworthy element to promote progress across nearly all techniques (see Foreyt, 1990; Lichstein, 1988). Naive readers will be struck by how readily faulty breathing can induce chest pain and other distress (Fried, 1987). Likewise, it used to be considered harmless to ask patients to take many, fast, shallow breaths to show them the effects of improper breathing. Indeed, a recent self-help book advises this practice to convince panic sufferers that poor respiratory habits invite panic symptoms (Clum, 1990, pp. 51-57). Clinicians need to be aware that real dangers lurk in such demonstrations, since they can trigger symptoms (even seizures) in otherwise healthy persons. Requiring hyperventilation by the patient is not a sound way to get one's point across, especially in our litigious era of malpractice lawsuits. Among the signs denoting hyperventilation are thoracic breathing, with little use of the diaphragm and frequent sighs during respiration. It is of interest that normal breathers can imitate hyperventilation but find it difficult and uncomfortable. The incidence of hyperventilation in the general population appears to run about 15%--no rare event. Fried (1987) discusses research devices and criteria to measure hyperventilation and its physiological effects. One of these, respiratory alkalosis, will interest readers since it is associated with neuronal hyperexcitability which may in part underlie some of the startle-prone overreactivity of psychiatric patients. In any event, depth and rhythm of breathing do alter heart rate, blood pressure, excitability of the cerebral motor cortex, and--in interaction with blood sugar level--EEG output which typically slows when enough CO2 is lost. Reciprocally, some clinical evidence suggests that idiopathic epileptic seizures may decrease when breathing becomes more normal. A last set of symptoms associated with poor breathing reads like a lexicon of nonspecific, 'psychosomatic' complaints. These include: reduced pain tolerance and stronger reactions to contact stimuli; poorer attention and judgment; nausea

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and vomiting; weakness, fatigue, fainting and syncope; apprehension and nervousness; palpitations, sweating and trembling; plus concrete breathing problems. Surely there is 'God's plenty' here, to account for a myriad of inferred antecedent-consequent relationships! A helpful discussion of sequential steps for treating hyperventilation in the absence of organic pathology is supplied. What does Fried (1987, pp. 88-118) propose? In essence, such familiar tactics as yogic breathing, transcendental meditation, and their behavioral kin including: (1) teaching diaphramatic breathing; (2) progressive (deep) muscle relaxation; (3) Benson's "Relaxation response"; (4) peaceful guided imagery; plus (5) biofeedback when indicated. Thus, whatever weight one assigns to the respiratory component of stress-related disorders, the interventions remain those time-tested options earlier discussed. We come full circle, back to the relaxation methods that began this section. It seems appropriate to close the topic of relaxation with a fragment of the prayer attributed to Joseph Cardinal Cushing (1980, p. 167): "Slow me down, Lord! Ease the pounding of my heart by the quieting of my mind. Steady my hurried pace with a vision of the eternal reach of time. Give me the calmness of the everlasting hills. Break the tensions of my nerves and muscles with the soothing music of the singing streams. Help me to know the magical restoring power of sleep. Teach me the art of taking minute vacations .... of slowing down to look at a flower, to chat with a friend, to pat a dog, to read a few lines from a good book. Remind me each day of the fable of the hare and the tortoise, that I may know that the race is not always to the swift; that there is more to life than measuring its speed . . . " DISTRACTION STRATEGIES The verb to distract derives from the Latin (tractus as in tractor), meaning to pull away from, or divert from, an event. All effective distractors must, at least, lure attention from some cues--usually stressful--to other cues that are benign, or preferably, soothing. Wisely chosen, a distractor can serve other goals too. For example, physical exercise strengthens flabby muscles as well as also interfering with unpleasant ruminations about one's shortcomings and misfortunes. Each procedure already discussed can serve a distracting function. Consider martial arts practiced after the workday. This may dissolve job pressures while promoting tranquility. Unless a patient suffers marked anticipatory anxiety about the workplace, the same practice early in the day may not dispel career strains as completely. Likewise, in the quotation given earlier advising foot reflexology to halt spouse combat, most methods can be made to perform double duties, just as most can be conveyed vicariously, through modeling tactics, as well as by direct experience. We lack a reliable taxonomy of distractions. Usually, the 'double duty' cases just illustrated are more a matter of clinical wisdom, matched to specific circumstances and patients, than the objective legacy of applied science. If a robust classification of distractors is achieved, it will need to embody a distinction between shifting attention only, vs also trying to shift customary frame of reference, or overly stringent standards, in the process. The technical literature on both 'pure' and 'attitude changing' distraction options is reviewed in depth elsewhere (Rosenthal, 1980; Rosenthal & Steffek, 1991). Our present emphasis will be on clinical gambits, both tested and potential. As with the construction of in vivo and imaginal task hierarchies--nearly always less stressful when the patients get the harder situations behind them and coast downward, rather than dreading the need to devise the coming worst items until they reached--let us follow a descending order of complexity.

Changing maladaptive criteria and attitudes Assume that your patient--say a stubborn middle-aged executive, accustomed to giving orders---engages in actions and patterns of reasoning that are clearly detrimental to his own welfare. What can a diligent clinician do to foster change? At base, there are three options: you can wait indefinitely, hoping for an opportunity to intervene easily and also hoping the patient keeps coming while you wait. Although this strategy may avoid short-run confrontations, one can fairly denote it as the cop-out solution. It is rarely viable if prolonged (unlike 'stalling' for brief intervals when discretion proves the better part of valor). Instead, you might bravely sound your

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klaxons of dissent and, as tactfully as possible but firmly, oppose the self-damaging behavior. Honest therapists cannot escape resorting to this frontal-attack solution from time to time, as we shall see. However, when one can switch the patient's perceptual vantage point, one may be able to promote considerable change quickly, with little controversy or resistance. If feasible, this end-run solution is very efficient. Contrast and context. On a platter holding four raisins, one added or removed will be noticed. On the same platter holding 1004 raisins, one more or less will not be detected. In the eyes of a lonely patient, accustomed to four birthday cards, receiving only three will be sad. In the eyes of someone deluged annually with hordes of birthday cards, one more or less will not be visible. Likewise, residents of Nome, Alaska, very used to cold weather, may feel too warm at 65°F on a trip to St Paul. But visitors from Yuma, Arizona--adapted to desert heat--will feel the same St Paul temperature as chilly. The person who gives many speeches, drives over many high bridges, or meets many new customers every week will not devote much advance concern to yet one more. The person who rarely speaks, crosses bridges, or meets new people will spend a lot of time anticipating the next upcoming encounter. A patient with moderate arthritis who coaches, and compares self to, many vigorous athletes may perceive the arthritis as a great affliction. Place the same patient on a ward of paraplegics, or among victims of crippling muscular dystrophy and that arthritis may well appear more trivial. These premises were tested in two experiments with unassertive college students. Some were given a peer model depicted as comparably timid. For others, the model was portrayed as clearly more inhibited than the Ss. Another group received a model drastically less assertive than themselves. The last, control, group was not given any comparison model. A rigorous test of assertion was then conducted. Every Ss was individually required to confront a stubborn telephone opponent, who was really an assistant trained to pit standardized obstacles against the student's assertive efforts. On multiple measures, students who observed the very submissive model proved far more steadfast than the other groups. As predicted, they shifted away from the behavior of the sharply contrasting standard of judgment (i.e. gross timidity) in both studies. It was as if the drastically timid model became a benchmark for unassertiveness: compared to the model, Ss' own problems appeared much smaller, with a resultant rise in bravery (Hung, 1979; Hung, Rosenthal & Kelley, 1980). Oddly enough, it is hard to find clear extensions of contrast principles to practical service delivery settings. Some anecdotal support comes from many years of working with inpatient substance abusers. There is not much one can do to motivate abstinence in persons who wish to keep on 'drinking and drugging.' A number of times, such intransigent users came voluntarily for treatment after an auto accident in which they were the only passenger, among equally intoxicated peers, who escaped death or maiming. In each case, the explanation for their change of heart was much the same and followed contrast reasoning along these lines: "When I found out what had happened to the others, while I got off Scot free, I figured someone up there was sending me a message that I better shape up or else." Likewise, confirmed teenage users are often very resistant to change. One suspects that forcing them onto adolescent units, where they can choose like-minded peers as associates, is most often an exercise in futility (compare Mosbach & Leventhal, 1988). On the other hand, forced admission to an adult unit of voluntary patients seeking help is often salutary. Instead of a cohesive member of a rebellious subgroup, the adolescent becomes a very small minority facing the consensus of chronic (and more experienced) abusers. Their personal horror stories about the hazards of chemical dependence are in sharp contrast to the false glamor that teenage users often assign to addictive experiences (and compare Smoller & Schulman, 1982, pp. 40-41.) Also, members of therapy and support groups are often cheered to find their own handicap appears smaller in contrast to the plights of their colleagues. Working therapists will hear similar comments whether the group meets to counteract agoraphobia, depression or dysfunctional upbringing as youngsters. From such observations, I have counselled patients to seek out and befriend fellow sufferers with more intense versions of their own handicap. When followed, that advice has usually led to improved morale because my patients perceive they are relatively less disadvantaged. "In the kingdom of the blind, the one-eyed man is King." We must sound a note of caution. The goal is not to thrust the patient into some abyss of terminally-ill and suffering companions! One wants contact with reference figures who are 'a lot worse off' compared to oneself, but not so trapped in misery as to depress anybody. For these reasons, the ideal comparison models

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may well be people who begin far worse off than the patient [contrast], yet eventually attain a good result. Perhaps hearing such tales ("Let me tell you how low I had sunk when I hit bottom. If I could get clean and put my life back together, so can y o u . . . " ) , is part of the positive impact of groups like Alcoholics Anonymous. In any case, some potential applications of contrast principles are straightforward: would it benefit first-offence criminals of all ages to spend a few days in a maximum-security prison (rather than 'desensitizing' them to jail in gradual steps of strong incarceration)? Would overweight cardiovascular patients benefit from enforced contacts with morbidly obese cases? Or cigarette smokers from exposure to advanced emphysema cases? When first diagnosed with somatization disorder, would the patient benefit from meeting someone else who is wiser and poorer after repeated surgical procedures? Would the sedentary, 'neurasthenic' patients described in conjunction with hyperventilation profit if shown the bad backs, constricted lives, and medical bills of older couch potatoes? Might impulsive spouses, more prone toward divorce than compromise, reassess their stance if exposed to much more distressed couples and to the legal fees, emotional and financial drains that others, once divorced, must endure? On a case-by-case basis, when indicated, I have tried to tell (or better, show) patients what they seem to be heading for. Sometimes the object lesson has prompted favorable changes, and other times no visible change whatsoever. Since, at least to date, the strategy has not backfired, it is offered for readers to explore with their patients, given that one proceeds cautiously both in selecting suitable cases, and choosing appropriate contrast models or situations.

Applying social influence Much more often than embedding the patient in some new context that quickly alters relative perceptions, one will need to try a frontal attack. Whether termed 'teaching,' or 'exhortation,' or 'persuasion' the realities are adversary. The clinician is convinced the patient's welfare requires the doing or stopping of whatever the patient refuses to do or stop. Often, the mind is willing but the flesh is weak so that one hears some such refrain as: "Doctor, I know you're right. You want to help. And when I can get some more time (or feel better, finish this project, attain this milestone, or clear this hurdle, etc.), I'm going to do what you say. Just not now." Since refusals and procrastination envelop relaxation practice, constructive recreation, decreasing frantic pacing and other guidance aiming to counteract excessive arousal, there seems no way to skip the compliance issue, even in an essay on behavioral calming techniques. First-off, voluntary patients often visit the consulting room expecting to be told what to do even if they choose to ignore it. If one abdicates this aspect of the Healer role (see Frank, 1961), patients may well be disappointed and lose confidence in one's integrity. Moreover, sometimes people come knowing pretty accurately both what they need to do and what the Doctor is likely to advise. Therapy--resort to a Healer--becomes a face-saving catalyst to take (or rejoin) a wholesome route that has been deferred in favor of more checkered paths. I find that caring 'music' can cushion blunt words and make them more palatable. For instance (in a sweetly reasonable manner): "Look, you're paying me for my advice. You don't have to follow it, but I have to give it. Unless you begin some regular exercise, I'm going to have to set some of our sessions at a gym and watch you work o u t . . . " Or " O f course you're discouraged. You came to me because you couldn't live the way you were going. Of course it's hard to change what comes easy to you. Besides, you have the idea you'll try what I say when you're feeling better. Think about the flip side--my idea. Do these things and then you'll start to feel better." One way to detour around a head-on clash is to make one's directions provisional or experimental: "I know you don't think this will really help. But you're a bright person--don't close your mind. How about we put it on purely a trial basis. Make time (for exercise, recreation, etc.) the way I want you to just long enough to give it a fair test. That means at least 6-8 weeks. Don't even start unless you'll keep it up for 6-8 weeks. Then, you decide. It will be totally up to you to judge. If it doesn't help, don't continue, but first give it a fair t r i a l . . . ' It is essential not to show impatience with prolonged faltering and false starts. So long as one hews to the same themes, one is caring and fulfilling the cultural role of good healer. If the patient stumbles and the healer grumbles there is risk the endeavor will be viewed as a 'contest', and the therapist's annoyance becomes evidence of 'an ego trip' rather than concern for the patient's welfare. By the same token, BRT 31/5~B

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if you preach 'slow but steady', practice it as well. How fast the patient implements guidance is far less important than that compliance is taking place. Praise, support and encourage the positive direction of 'slow but steady' changes. Unbeknown to many clinicians, a rich literature exists in social psychology on variables governing persuasion and compliance. Most of this work entails laboratory analogs, but will repay extending those results to therapeutic encounters. If one can locate a copy, Abelson (1959) capsules the old literature in clear, 'bottom line' prose, and current texts on the subject (e.g. Higginbotham, West & Forsyth, 1988) can carry the reader close to the recent research articles. If one can ignore the dated Hullian theorizing, it is hard to surpass Salter's (1949) early book on the exercise of therapeutic social influence; it is a vivid primer on how to structure verbal rhetoric persuasively. In this age of the television talk show, common sense has become scarcer than hens' teeth. Hence, it is essential to make new projects as appealing as possible. Here are some examples. Outdoor activities (biking, boating, walking) have greater chance to succeed if one tells the patient where pretty settings can be found. Similar reasoning applies to sites, restaurants, spectacles, exhibits, concerts, theatricals and even congenial church congregations, when striving to cajole overworking but underplaying patients out of their solitary ruts. Such efforts also exhibit caring on the part of the therapist. Likewise, music is portable and easily available to occupy attention. It has been used for centuries to create solemn or hopeful moods, e.g. at funerals. Thus, in his Urn Burial, Thomas Browne (1658, p. 57) notes: "They made use of music to excite or quiet the affections of their (bereaved) friends, according to different harmonies." Now consider the context and wrap-up of floor-exercises or stationary biking. While stretching, peddling, or leg-lifting, boredom can be blocked and peace enhanced if the person also plays some of her favorite gentle music (not hard rock or heavy metal) and if, afterward, she soaks in hot water. Bubble-baths while listening to Bach or Vivaldi are not to be spurned! Therapists need to keep aware of means to ease the execution of homework, and to inform patients about those easier ways. I believe the patient is renting one's expertise and is entitled to its full use--just as one would share 'tips' with loved ones. A range of additional ploys to modulate assigned tasks is elsewhere discussed (Rosenthal & Rosenthal, 1985), and some illustrative concrete distractors will be given below. It is germane to close this section and approach the next by issuing a challenge to any reader who is secure that she (or he) is 'mellow'. At some convenient point within the next 4 months, can you set aside a long weekend (or any three consecutive days) during which you will: (1) hide all clocks and watches; (2) turn off the telephone or take it off the hook; and (3) not consult any print or electrical medium (including radio, television, VCR, newspapers) or personal computer? If you surmount these first hurdles, can you also not use any motor vehicles (on land, water, or in air) those same 3 days? Choose any conveyance you wish to reach, and return from, wherever you choose to place yourself for the interim; but no motorized transportation in the 3 day respite from technology. If you truly can fulfill the foregoing conditions, here is a last, 'black belt' requirement. Can you forego spending any money--by cash, credit, check, charge or bank card--during the same interval? Unless you are really comfortable in meeting all the stated conditions, you still may have lessons to learn in 'self-emancipation'. Altering personalphilosophies. My favorite of all 'inspirational' messages to renovate the lifestyles of stress-prone patients is as follows: "The secret of happiness is not to become overly involved in your own life." It is quite taxing for the clinician to bring about major changes in the value 'maps' that have steered the patient's past decisions. The task is made harder because one must seek to instill priorities that often run counter to our rather adolescent and strongly materialistic society, which gives precedence to the outward symbols of prestige and success. What has generally worked best for me, after rapport and trust have been established, is to review the patient's history in condensed form, and conclude that review in this vein: "So all these goals and aspirations that carried you forward in your career (or business, profession, education, etc.) have taught you to sprint. But now you've made it as a lawyer (physician, executive, etc. or into Medical School, etc.), and you need to adjust your pace to the 'long haul.' You're no longer in a sprint. Now you're in a marathon, and you need to learn to pace your life accordingly." After further discussion--often invoking the Serenity Prayer and the AA concept, 'take one day at a time'--I usually recommend a very few text materials. Most often included is a little book by Hoff (1983), The Tao of Pooh, which states Taoist ideas of finding harmony by not forcing one's

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imperatives on events. In simple language, it offers ways to 'go with the flow' instead of headbanging. Patients are told to read it three times: once to learn what it contains, next as a set of guidelines to steer conduct toward better balance, and later--some months after--to review, and assess progress then attained. The other texts are The Book of Ecclesiastes, to illustrate the futility of desperate overstriving as well as that life's seasons alter goals, and Voltaire's Candide, to epitomize why it is wise to give up 'perfectionism' and, instead, to 'cultivate one's garden.' When indicated, especially with older people who lament the decline of standards in today's world, Montaigne's Essays, which advise disengagement from mundane concerns, are helpful, especially "To Learn How To Philosophize Is To Learn How To Die." If patients complain bitterly about how life (or the nation, the younger generation, etc.) has deteriorated, do not argue. One may agree with their views, and even recommend any of the few writers who openly share such premises (e.g. Ringer, 1983) but who also propose ways to minimize personal distress. Even on the assumption that "the sky is falling!", it does not console dysthymic patients to brood on the manifold woes of the world. One can ask scholarly but obsessional patients to contrast who survives (i.e. the young couple with simple values and clear but humble priorities) with who dies in Bergman's film The Seventh Seal, and with the protagonist in Racine's play Ph~dre (or in the Coen brothers' film Barton Fink), who invites doom by heeding well-meant but dubious advice. Finally, if any of the foregoing parables raises religious concerns, request the patient to ponder the issues and then pray over them (or consult a minister) for 'a second opinion.' Although philosophies may not change, thus far no patients have claimed that the viewpoints just sketched were overruled by a divine veto. Without making the attempt, one cannot conclude that creating profound value changes is a hopeless endeavor. The same applies when Cupid too often leads your patient astray. In the context of an affectionate relationship with a stable partner, sex is undoubtedly diverting and is, perhaps, nature's best tranquilizer. Unfortunately, many people--often otherwise sensible single young professionals--have rash tastes. For whatever reasons, possibly a craving for excitement, they are 'turned on' by 'borderline' women (as illustrated in the film Fatal Attraction) and by 'narcissistic' men (Sherlock and Mycroft Holmes are fair examples), but more often by the courtship dances of 'psychopaths' of both sexes. The diligent clinician must alert the infatuated patient to the dangers that lurk. The film Raising Arizona exemplifies a male sociopath but is too funny for warning lovelorn patients. It is hard to find accurate but vivid portraits of sociopaths except for brief vignettes such as follows (from Bryson, 1990, p. 30): "Once we established that I was only prepared to love her for her mind, she became quite sensible and even rather charming. She told me in great and frank detail about her . . . dizzying succession of marriages to guys who were now in prison or dead as a result of shootouts, [with wildly] candid disclosures like, 'Now Jimmy kilt his mother. I never did know why, but Curtis never kilt nobody except once by accident when he was robbing a gas station and his gun went off. Floyd--my fourth husband--he never kilt nobody neither, but he used to break people's arms if they got him riled . . . I don't know whatever became of Floyd . . . He was real cute, but he had a temper on him. I got a two-foot scar right across my back where he cut me with an ice pick. You wanna see it?" To help patients identify, and guard against sociopaths, the best 'text' may be a recent collection of short stories, Rock Springs (Ford, 1987). Either the author was raised among psychopaths or has some genius for finding them. So many characters are vivid case studies in sociopathy (more compelling than the DSM-III and DSM-III-R accounts) that one can recommend the stories to students. If at risk for exploitation by a psychopath, the patient assigned the book often will exclaim "That's just like X--no wonder we could never settle down!" The riotous Paper Moon (Brown, 1973), serves a similar function to prepare unsuspecting innocents for the tricks of con-men.

Distractors to quench worry and rumination Heartache and dread, magnified by subjective dwelling upon their expected costs, likely do humans more harm than overt calamities. In the West, Montaigne (ca 1580) may have been first to conclude "The thing I fear most is fear." In his discussions of self-efficacy, Bandura (e.g. 1986, pp. 425-449) has probably best aimed scientific scrutiny at the destructive impact of negative assumptions about one's capabilities. Even when a situation looks hopeless, one will strain one's blood vessels less by not dwelling on the painful facts. For example, I personally suspect that the 21 st century will star 'The Four Horsemen of the Apocalypse,' but am certain it is not constructive

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to brood on that prospect. There is ample evidence that various distractors can reduce emotional arousal (Rosenthal, 1980). Rather than 'reinforcement', distraction from noxious states may be one of the benefits often achieved by coaxing depressed patients into 'rewarding' activities. Likewise, when patients respond to hypnosis (see Harmon, Hynan & Tyre, 1990), or to such paradoxical suggestions as "If you must worry, set aside just 1 hour a day and do all your worrying then", it seems likely that distraction from customary mental sets is part of any progress that occurs. What are some viable distraction tactics? Humor. Working with distressed people, I try to minimize their exposure to violent films, worry-laden newscasts and a focus on 'thrills' for fun--which all trigger stress-related catacholamines, raising heart-rate and blood pressure (Rosenthal & Rosenthal, 1985). As another expression of caring, therapists can aid patients to select funny, in lieu of stressful, diversions. Any clinician knows that it helps dysphoric people to laugh. It also helps keep their attention on one's counsel. Readers are strongly urged to develop a repertoire of jokes that will make the points you seek to reach in a memorable way. [If successful, the humorous style of this essay will have held interest and attention better than drier prose.] To treat or to teach, colorful messages will capture more attention, and thus have more chance to survive and steer changes (Rosenthal & Downs, 1985). Likewise, it is safer to offer an anxious person stories or films known to be entertaining but not too upsetting, rather than risk the spontaneous selection of more grisly fiction. For these reasons we prepare, and periodically update, lists of recommended reading and viewing for clients. If Voltaire could write "I have never made but one prayer to God, a very short one: 'O Lord, make my enemies ridiculous.' ", and if the Koran can propose "He deserves Paradise who makes his companions laugh.", it is quite fitting for working clinicians to take pains in this sphere. Besides humorous material, other recreational literature and films that can compete with more lurid or frightening options are worth saving and organizing for patients. A sample collection of such reliable distractors is presented in Table 1. Its contents have worked well in our milieu, based on the reactions of patients and friends, and are not just a list of personal preferences. For instance, some of my favorite movies (e.g. the Charlie Chaplin comedies, King of Hearts, Kiss of the Spider Woman, La Cage aux Folles and Nashville, as well as the Nova and National Geographic nature series) and "escape" writers (e.g. Dashiell Hammett, Ira Levin, James McClure, Dorothy Sayers, Rex Stout) are excluded because they proved too variable locally in capturing attention or, if engrossing, failed to lower stressful emotions. Clinicians are best advised to conduct informal 'market research' to suit the ethnocultural, socioeconomic and regional ideosyncracies of their settings and clienteles. However, the items given in Table 1 should comprise helpful points of departure. Also included is some nonfiction (mainly travel memoirs) and some fairy tales for adults. The modern master of that form, J.R.R. Tokien (1966, pp. 46-71) wrote that the special virtues of fairy stories are Fantasy [forming mental images of idealized creations]; Recovery [regaining one's youthful health and clear vision of the world]; Escape [from "the noise, stench, ruthlessness, and extravagance of the internal-combustion engine." and from "hunger, thirst, poverty, pain, sorrow, d e a t h . . . (and) the ancient limitations" of humankind]; and Consolation [by the joy of an ending that turns looming loss into, at least, bittersweet triumph]. As such, fairy tales can be prime distractors for harassed, dysthymic and ruminative patients. Since many listed titles are available in multiple editions and reprintings across many years, or are distributed by a number of cinema firms in various nations, dates and publishing details are only given if felt essential to help readers locate off-beat, nonmainstream items. Recreation. Ironically, convincing patients to do what they most enjoy can entail hard work. Although not well-described by 'workaholics', 'Type A personalities', masochistic 'enablers' or similar overworked catch-phrases, many harassed patients are their own worst enemies. The prime candidates for behavioral psychotherapies tend to be 'oversocialized' dysthymics, who are too 'hard on themselves.' These stress-prone people are very adept at delaying gratification or skipping it entirely, even when craving legitimate pastimes. One may need to explain the Yerkes-Dodson Law--that overstriving hampers performance--and often to use the kinds of directive social influence---earlier illustrated to prompt physical exercises--as means to change habitual self-denial. For these cases, it helps to liken their neglect of self-reward and restful distraction to the neglect

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of 'capital equipment', as though driving a vehicle that lacks lubricants or shock-absorbers. On average, these persons will enjoy low-key diversions, for instance, restful communion with mountains, forests, seacoasts, brooks or skyscapes, /f one can push them to try such "down time" options: clinicians will succeed more often if armed with pithy rationales for pastoral interludes, e.g. 'God is a better architect than people.' One can also demonstrate that pleasure derived from nature can in part be gained from a rock- or a flower-garden, or even a window-box. Of course, one should encourage any wholesome diversions that tempt a person. They qualify as distractions from excessive worry or self-critical rumination. At times, one must prod the person: " D o try out a sampling of new activities. Any ones you want if they don't sound too boring", as well as prodding the person's memory about favorite old pastimes that too long have lain fallow. To short-cut the process of search for promising distractors, we have developed a brief yet comprehensive Leisure Interests Checklist (LIC), that quickly helps identify recreations with good odds of pleasing the patient. Both the properties (Rosenthal, Montgomery, Shadish, & Lichstein, 1989), and the clinical uses (Rosenthal & Rosenthal, 1985), of the LIC are elsewhere discussed. There may (or will) be other suitable devices to identify diversions. Clinicians can save much time and frustration if ready with such an organized 'map' of the realm of play, because often the beleagered p e r s o n - - o r distressed spouses seeking common ground--wiU not know 'what would be fun', and hence cannot select it, unless given a menu of illustrations. At some ill-starred conjunctions of adversity, when all the "fans have been hit and are blowing the patient's way", there is little the doctor can do right then to deliver solace. One viable strategy is to focus the patient on a (plausible) better future. After a little practice, it is not hard to teach patients how to build fantasy bridges to 'a happier tomorrow.' The crux of the matter is to entangle the patient's attention in a task both complex and appealing enough that distraction from present woes can occur. For instance, the housebound agoraphobic can p l a n - - w i t h the aid of actual maps and tour b o o k s - - a n eventual trip to Europe or the Orient that can be taken "after you have made enough progress in treatment." The chronic invalid who is secondarily depressed can plan the contours of a hoped-for garden, or career, or home, or a cultural or gastromic orgy, for a later time when surgery, chemotherapy, organ transplant or orthopedic recovery is complete and the patient able to reap those benefits. Thus, the mental 'bridge' will be stronger if the shut-in selects which plays, museums, concerts and stores she will visit in London, or what Michelin-featured restaurants (and which of their dishes) he will relish, once able to visit France, etc. Note that the future bridge must lead to a goal quite feasible (financially, medically, intellectually) or the same contrast principles covered earlier may create an intensified state of relative deprivation and invite demoralization. Don't let a badly head-injured patient with little chance for regaining full function plan on medical or law school. Don't allow people to count on 'dream' vacations or mansions they will never be able to afford. Don't lure terminally-ill or paraplegic cases into visions of becoming the toast of the sports world; (it would likely arouse their distrust). In other words, aim attention at distractors that should be readily attainable 'once the sun shines again.' Do not foster self-deception in the patient: that risks despair (if not now, then perhaps later on), as well as charges of ethical transgressions or malpractice. However, one can be creative in helping overcome obstacles. For instance, such pursuits as sailing or flying may cost too much done alone, but may well become attainable if one steers the patient to join a club for would-be pilots or helmsmen, sharing expenses among the members. Likewise one can point out where and how wonderful vacations in majestic wilderness settings are realistic prospects for little money, given some free time for the trip, plus advance planning to keep costs low, etc. Foreyt, too, advises that (1990, p. 175): "Providing knowledge and understanding about future events and helping to provide a sense of control . . . [i.e. to raise self-efficacy, are among] the most effective strategies for reducing stress." Pets. Ant farms, bird-feeders, catnip balls, fish tanks and squirrel-wheels are doubtless more wholesome distractors than the contemporary mass media. Since my wife often tells students and new colleagues "Every night I come home to 300 4- pounds of dog.", it is appropriate to conclude with the virtues of animal friends. Late in World War II, Veterans' hospitals were having difficulty rehabilitating combat victims exposed to mass casualties among peers, or heavy bombardment. These patients--once termed 'shell-shocked'--might lie in bed, mute and largely immobile, as if in stupor. One of the few ways to pull them out of such quasi-cataleptic withdrawal was to provide

Adult Fairy Tales Douglas Adams: The Universe of Douglas Adams (4 books, Pocket Books); The Long Tea-Time of the Soul (Simon & Shuster, 1988). Lawrence Block: Random Walk* (TOR, 1988). J.R.R. Toikien: The Hobbit: The Lord of the Rings (3 books); The Tokien Reader (all Ballantine Books). Kurt Vonnegut: Cat's Cradle (Holt, Rinehart & Winston); The Sirens of Titan: Jailbird; Slapstick (all Delacorte Press). Oscar Wilde: The Fairy Tales (9 stories). C'r~/l)etectlve F"~lioa Lawrence Block [many, e.g.]: The Thief Who Couldn't Sleep; When the Sacred Ginmill Closes; The Burglar in the Closet (in paper various, e.g. Charter, Jove). G.K. Chesterton: The Father Brown Stories (e.g. The Complete Father Brown (Wordsworth Editions, 1989); The Club of Queer Trades (Carroll & Graf, 1987). Agatha Christie [most e.g.]: At Bertram's Hotel: By the Pricking of My Thumbs; Endless Night; Third Girl; Curtain; the Mousetrap and other plays (in hardback all Dodd, Mead; in paper, various, e.g. Bantam, Dell, Pocket Books). Aaron Elkins: Old Bones; the Dark Place; Fellowship of Fear (Mysterious Press). Martha Grimes [many, e.g.]: The Man with a Load of Mischief; The Old Fox Deceiv'd; I Am the Only Running Footman; the Five Bells and Bladebone (Dell paperbacks). Tony Billerman [most e.g.]: Dancehall of the Dead; The Ghostway; A Thief of Time; Talking God; Coyote Waits (Harper & Row hardbacks; Avon or Harper paperbacks). John Mortimer, [the Rumpole series]: Rumpole of the Bailey; the Trials of Rumpole; Rumpole's Return; Rumpole and the Golden Thread; Rumpole for the Defense (Penguin paperbacks). Bill Pronzini, B.N. Malzberg and M.H. Greenberg (Eds): The Arbor House Treasury of Mystery and Suspense (Arbor House, 1981). Bill Pronzini and M.H. Greenberg (Eds): 13 Short Detective Novels (Bonanza, 1987). Ellergy Queen [many of the earlier books and the "'Wrightsville"/scenic books, e.g.]: The Chinese Orange Mystery: The American Gun Mystery; Cat of Many Tails; Double, Double (various, e.g. Ballantine paperbacks). Janwillem Van De Wetering [most of the "Amsterdam Cop" series, e.g.]: Outsider in Amsterdam; Tumbleweed; The Corpse on the Dike; Death of a Hawker; The Rattle-rat; Hard Rain (most are Ballantine paperbacks).

Prose categorya

Woody Allen: Take the Money and Run ( 1968; Bananas ( 197 I); Annie Hall ( 1977); Hannah and Her Sisters (1986). Robert Altman D., Bud Cort, Sally Kellerman: Brewster McCIond (1970).* Antonella Attilli, Salvatore Caseio: Cinema Paradiso (1989). Stephane Audran: Babette's Feast (1987). Dan Aykroyd, Eddie Murphy: Trading Places (1982). Humphrey Bogart, Jennifer Jones: Beat the Devil (1954). Marion Brando, Matthew Broderick: The Freshman (1990). Mel Brooks D., Gene Wilder, Cleavon Little: Blazing Saddles (1974). George Burns, Walter Matthau: The Sunshine Boys (1975). George Burns, Art Carney: Going in Style (1979). Nicholas Cage, Cher: Moonstruck (1988).* John Cleese: The Secret Policeman's Ball (1981); Clockwise (1986); Fawlty Towers (4 tapes). Coon brothers D., Nicholas Cage, Holly Hunter: Raising Arizona (1987).* Pauline Collins, Tom Conti: Shirley Valentine (1989).* Kevin Costner, Susan Sarandon: Bull Durham (1988).* Kevin Costner D., Mary McDonnell: Dances with Wolves (1990). Tom Cruise, Rebecca De Murnam: Risky Business (1983). Richard Dreyfuss, Sonia Bragia: Moon Over Parador (1988). James Garner, Joan Hackett: Support Your Local Sheriff(1969). James Garner, Sally Field: Murphy's Romance (1985). Ruth Gordon, Bud Cort: Harold and Maude (1971). Alec Guiness: Kind Hearts and Coronets (1949); The Lavender Hill Mob (1950); The Man in the White Suit (1951); The Captain's Paradise (1953); The Ladykillers (1955); The Horse's Mouth (1958). Tom Hanks, Elizabeth Perkins: Big (1988). Dustin Hoffman, Jessica Lange: Tootsie (1982). Paul Hogan, Linda Kozlowski: Crocodile Dundee (1986). Glenda Jackson, Melina Mercouri: Nasty Habits (1977). Kevin Kline, Jamie Lee Curtis: A Fish Called Wanda (1988).* Kevin Kline, Susan Sarandon: January Man (1989).* Nina Landis, Steven Kearny: Rikki & Pete (1988).* Shirley MacLaine, Alan Arkin: Woman Times Seven (1967).

Film video (VCR) tapesd

Table 1. Illustrative list of prose (left column) and cinema (right column) distractors found reliable for patients in our milieu (will need tuning to local clienteles, plus periodic updating)

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Melina Mercouri, Jules Dassin: Never on Sunday (1960).* Nobuko Miyamoto, Tsutomu Hamazaki: Taxing Woman (1987). Paul Newman, Robert Redford: The Sting (1973). Lawrence Oliver, Michael Caine: Sleuth (1972). Ryan and Tatum O'Neal: Paper Moon (1973). Peter O'Toole, Alastair Sire: The Ruling Class (1972).* Rob Reiner D., Cart Elwes, Mandy Patinkin: The Princess Bride (1987). Rob Reiner D., Billy Crystal, Meg Ryan: When Harry Met Sally (1989). Peter Sellers: The Mouse That Roared (1959); Waltz of the Toreadors (1962); Dr Strangelove (1964); A Shot in the Dark (1964); The Pink Panther (1964); What's New Pussycat? (1965); After The Fox 0966); The Party (1968); Return of the Pink Panther (1975); Being There (1980). Jacques Tati: Mr Hulot's Holiday (1953); Man Oncle (1958). Peter Ustinov, Jonathan Winters: Viva Max (1969). Jamie Uys D., Marious Weyers, Sandra Prinsloo: The Gods Must Be Crazy 0984). Robin Williams: An Evening with Robin Williams, Live and Uncensored (1982); Moscow on the Hudson (1984); Robin Williams Live! (1987).

*Denotes material not recommended for very conventional, "ultraconservative", or literal-minded patients. "Many older book titles listed can be found in used paperback stores as well as libraries. bMost serious works listed are rich in themes or parables that allow clinicians to invoke plot or character elements as guidance content. CSpans many more funny events than contained in the film. dNearly all films are comedies or comical. They are listed alphabetically by surname of star or co-star, except when the Director (denoted by D.,) is given, whose name then determines alphabetic locus.

Robert Crichton: The Secret o f Santa Vittoria (Simon & Schuster; Dell paperback, 1967). Joe David Brown: Paper Moon ~ (first titled Addle Pray; Signet paperback). Clarence Day: Life with Father; Life with Mother (Simon & Schuster/Washington Square, 1970). Jules Feiffer: Little Murders; Jules Feiffer's America* (S. Heller, Ed., Knopf, 1982). Stella Gibbons: CoM Comfort Farm (Penguin, [1938] 1985). Joseph Heller: Catch-22 (Dell paperback). The New Yorker Cartoon Album 1975-1985 (Viking, 1985). The World Encyclopedia o f Cartoons (M. Horn, Ed., Chelsea House, 1980. Terry Southern: Blue Movie* (Signet/Plume, 1985). John K. Toole: A Confederacy of Dunces* (Grove Press paper, 1987). Leonard Wibberley: The Mouse That Roared; The Mouse on the Moon (Bantam paperbacks, 1965).

Humor

Memoimfrravd Bill Bryson: The Lost Continent (Harper/Perennial). Robertson Davies: One Half o f Robertson Davies (Penguin). Nika Hazelton: UPS and Downs (Harper & Row, 1989). David Niven: The Moon's a Balloon: Bring on the Empty Horses (both G.P. Putnam's). Stephen Pern: The Great Divide (Penguin Travel, 1989). Kurt Vonnegnt: Wampeters, Foma & Granfalloons; Palm Sunday (both Delacorte Press). "Good Read" Mainstream Fiction b Robertson Davies: The Deptford Trilogy (3 books or 1 composite); The Rebel Angels; High Spirits (in Viking hardbacks or Penguin paperbacks). Ellen Gilchrist [many*, e.g.]: In the Land of Dreamy Dreams; Victory Over Japan; Drunk with Love; The Anna Papers; Light Can Be Both Wave and Particle; 1 Cannot Get You Close Enough (Little, Brown, hardback or paper). Walker Percy: The Moviegoer; The Thanatas Syndrome (Ivy/Ballantine paperbacks). Muriel Spark [many, the 3 examples were chosen for their humor]: The Comforters; The Prime of Miss Jean Brodie; The Abbess of Crewe [filmed as Nasty Habits]; (various, e.g. Lippincott hardbacks; Putnam/Perigee paperbacks). Ann Tyler: Dinner at the Homesick Restaurant; The Accidental Tourist (Knopf hardbacks; Berkley paperbacks).

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parakeets (often budgerigars). The amiable birds supplied hours of contact (not possible for the busy staff) with the withdrawn patients: they usually responded with slowly dawning interest, that rose to requesting food for the bird, and culminated in restored speech and activity (in 2 wk or less) after entry of the feathered playmate. More recently, considerable research--mainly done at schools of Veterinary Medicine or Public Health--confirms that pets are good for people's mental health. Thus, pet owners report more satisfaction and happiness with life than petless persons. On the one hand, pets facilitate interaction both within the home and among strangers. (One way to meet potential dating-partners is to walk an attractive animal in a plausible locale and wait for an attractive person to praise it.) There is little doubt that pets' antics and affection can distract one from workaday concerns and morbid pre-occupations. Also, they nearly always make simple, predictable demands unlike one's fellow humans---especially those with control over one's career or well-being. Hence, we may conjecture that, as stimuli, pets have a 'cleansing' impact on sensory storage too filled with stressful imagery. Pets' regular needs and routines also enhance patients' ability to control predictably this facet of life, thereby raising owners' self-efficacy. Furthermore, people deprived of companionship from advanced age, restrictions on movement, and even stigmatization due to psychiatric illness or AIDS, still can have a pet. Pets serve various useful family functions ranging from preparing children to cope with death, to offering common activities for parents and progeny to share. Based on adolescents' self-reports, contact with animals reduces stress; when upset, over 70% sometimes turned to their pets. A study at a low income housing complex found that a tank of goldfish placed in tenants' homes significantly reduced diastolic blood pressure over time, but human visits to a comparison group did not lower blood pressure even though decreasing loneliness. Other results suggest that pets can abate anxiety and dysphoria while raising owner's exercise (dogs need walks, especially for apartment-dwellers). The foregoing data are rather tentative---coming from fairly unsophisticated research methods--but are all reported in an edited volume by Sussman (1985). Newer research, of somewhat better quality, is surveyed in a book by Cusack (1988) which supplies the specific references. Here are the key findings: owning pets seems to predict higher survival rates in victims of heart attack or severe angina. Pet owners report better health and morale. Some data suggest that cancer rates and, especially, cardiovascular diseases, are lower among elderly pet owners. For elderly, withdrawn Veterans, contact with a puppy (reminiscent of the parakeet ploy) surpassed access to a plant or wine as ways to trigger conversation and more appropriate social responsiveness. In a study with dysphoric patients, conventional psychotherapy was less effective than when, (in another group), it was combined with regular access to a dachshund. Case anecdotes suggest that contact with dolphins can stimulate autistic children constructively, just as visits from dogs have benefitted invalids and the aged in diverse settings. Horseback riding has been found to improve both moral and (as a motor exercise), posture and movement cadences in the riders. Finally, in both children and adults, substantial and convergent evidence shows a slowing of biorhythms while interacting with pets. Thus, petting one's dog reduced both diastolic and systolic blood pressures and heart rate. It proved at least as calming as listening to autogenic relaxation directions, and equal to the autogenic relaxation plus dog petting (see Cusack, 1988, pp. 63-73). Despite room for improvements in design (inviting thesis projects), the weight of evidence seems very convincing. Perhaps one conclusion should be: caressing cuddly canines can counteract cumulative calamitous concerns! Surely another conclusion needs to be that not only music "Hath charms to soothe the savage breast." greatest debt is to the psychologistswho taught me the trade: ProfessorsAlbert Bandura, Quinn McNemar and John W. Thibaut, Ph.Ds. I am gratefulto my friends and colleagues,John M. Downs, M.D., D.Ph.--who reviewed and improved the material on pharmacotherapy--and to M. Jacques Durac and Renate Rosenthal, Ph.D.--for their many helpful suggestionson the manuscript. Thanks to Ms Paula June Gray who patientlyendured typingmany prose revisions. Acknowledgements--My

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