- Email: [email protected]
Relaxation training: A nursing intervention for substance abusers
Relaxation Training: A Nursing Intervention for Substance Abusers Vincent H. Dodge Relaxation training is reviewed as a nursing intervention for substance abusers, using current research findings for rationale. A case study of a polysubstance abuser is used to demonstrate the clinical status of drag dependence, and how relaxation techniques can be used in treatment. Psychological and pathophysiologieal theodes of addiction are reviewed briefly and linked to relaxation therapies through recently discovered psyehophysiologicai mechanisms, with implications for substance abuse treatment. The history and modern variations of relaxation techniques are discussed, focusing on the literature of applications in substance abuse treatment. Final recommendation are drawn from the literature and case study, with implications for clinical nurse specialists. Copyright © 1991 by W.B. Saunders Company
ary J. was a 27-year-old woman, transferred from an intensive care unit for a psychiatric evaluation. Three days earlier she had been brought in to the hospital in an unconscious state after a reported overdose on diphenhydramine. A urine drug screen was positive for alcohol, marijuana, and cocaine. Her chief complaint was depression and chemical dependence: "I ran out of friends, money, dope. I was so miserable that when I finally bummed $10 1 got some beer and tried to relax; I thought a couple of Benadryl might help, too. Then I just kept taking them, to go to sleep for good." Her social history revealed an unremarkable childhood until age 14 when she started heavy use of marijuana and alcohol. After completing high school, Mary left her family and had a series of brief jobs and relationships, never longer than 8 months. Her relationships have revolved around cocaine acquisition and use, ending in polysubstance abuse and abandonment. She reported several suicide attempts, always after periods of heavy drug use, when all her resources were exhausted. She described hours of weak, dysphoric misery, craving a "fix." When this state was finally relieved by a drug, the dose was then repeated as much as possible, to 'get even higher'. Mary met the Diagnostic and Statistical Manual, Revised (IDSM-III-R] American Psychiatric Association, 1988) criteria for cocaine abuse and dependence, and has often met the same criteria for alcohol and polysubstances.
M
SUBSTANCE ABUSE
Definition and Prevalence Since the drug wave of the 1960s, substance abuse and dependence have steadily risen (Arif &
Westermeyer, 1988). In this article, drug abuse refers to the self-administration o f mind-altering substances (alcohol included) in a way that differs from generally approved medical or social practices. Drug dependence refers to a psychological and/or physical need for the drug (Schuckit, 1989). More than 2% of Americans are alcohol dependent, and the use of cocaine, amphetamines, marijuana, heroin, and sedatives plagues more than 1:1,000 of the population (Arif & Westermeyer, 1988). Psychological Theories Theories abound as to why people use drugs to such excess. Traditionally, these theories were divided into psychological and physical categories. In light of the latest psychophysiological research, these divisions are gradually meshing together. The prevalent psychological theories for drug selfadministration are to relieve an aversive, anxious state, and to induce a high or euphoric state. These two theories are well supported in behavioral literature arid commonly referred to as the negative and positive reinforcing effects o f psychoactive From the School of Nursing, University of California, Los Angeles Center for the Health Sciences. Address reprint requests to Vincent hi. Dodge 20529 S. Vermont Ave., #2, Torrance CA. Copyright © by W.B. Saunders Company 0883-941719110502-000753.00/0
Archives of Psychiatric Nursing, Vol. V, No. 2 (April), 1991: pp. 99-104
99
VINCENT H. DODGE
100
substances (Ray, 1988). Ultimately, these forces overwhelm the addict's sense of self-control, leading to alienation and living only for the drugs (Arif & Westermeyer, 1988).
Pathophysiological Theories At the same time, breakthroughs in neurophysiology have led to strong biochemical theories for the reinforcing properties of psychoactive substances. The most extensively researched mechanisms to date are the substrates to opiate reward pathways. Since the identification of endogenous opioid neuropeptides in the mid-1970s, these substrates have been shown to interact with known and unknown neuroregulatory systems, forming powerful behavioral controls in animal models. In an extensive review combining findings from ingestive behavior research and opiate reward pathways, Wise (1987) hypothesized a "final common pathway" of positive reinforcement used by natural rewards (i.e., food and water), experimental rewards (i.e., electrical midbrain stimulation), and drug rewards, from opium and ethanol to nicotine. Wise also reports on an anatomically distinct negative reinforcement pathway (periventricular system) by which opiates inhibit withdrawal symptoms. In mapping out these pathways, Watson, Trujillo, Herman, and Akil (1989) went a step further, identifying a link between positive reinforcement pathways and motor centers. They called this the limbic-motor reinforcement circuit. Their review of current evidence suggests that this circuit accounts for drug-seeking and self-administration behavior demonstrated in research animals and probably the clinical phenomena of drug addictions. Other researchers have linked these pathways to current findings in alcohol dependence research (Bloom, 1989; Blum, Briggs, & Trachtenberg, 1989). A detailed review of these state-of-the-art psychophysiological theories of addiction is beyond the scope of this article. The interested reader is referred to these sources. It suffices to conclude that powerful pathophysiological mechanisms reinforce substance abuse behavior; such a conclusion has far-reaching implications for treatment.
Substance Abuse Treatment Traditional treatment for alcoholism and drug dependence has been psychological except for few exceptions, i.e., methadone clinics. By and large,
these psychological treatments have been unsuccessful, especially for alcohol dependence. Major outcome surveys have found that alcoholics achieve 1-year abstinence without treatment at a rate of 10% to 12%, while most traditional programs succeed at a rate of 10% to 22%, which is scarcely better than the natural history of the disorder (Chick, Ritson, Connaughton, Stewart, & Chick, 1988; Emrick, 1975). This general failure rate of 80% may simply reflect that psychologically oriented interventions are being applied to a physiologically rooted problem. Biomedical research may soon have some pharmacological solutions to the substance abuse problem, but in the meantime, addicts like Mary J. bounce in and out of treatment efforts in a vicious cycle of relapses. In the last 4 years Mary has completely abstained from drugs twice. She lived in a 12-step center for 2 months, reaching step four before using cocaine with some old friends, which ended the treatment. More recently she stopped on her own, staying at a supportive friend's home until the depression and craving overcame her. After 4 long weeks she moved in with a dealer. RELAXATION TRAINING
In the immediate search for interventions capable of altering the addict's pathophysiological bondage to drug use, clinicians have turned to relaxation training techniques. Historically, these techniques have provided a critical connection between the mind and body, allowing therapists and clients to deliberate some psychological control over their physiological processes.
Development of Techniques Edmund Jacobson, M.D., is credited with the first modem relaxation technique, progressive muscle relaxation (1929, 1938). This meticulous procedure involves tension and relaxation of several muscle groups while in a comfortable position. He also pioneered the measurement of muscle relaxation using electromyography (EMG). His basic research and technique still underlie many popular relaxation applications. At the same time, a form of self-induced hypnosis, later called autogenic training (AT), was being developed in Germany. This process focuses attention on six sensations, including heaviness, warmth, calming of the heart, and cooling of the forehead. First introduced in the United States by
101
RELAXATION TRAINING
Schultz and Luthe (1959), AT has remained moderately popular (Lickstein, 1988). The cultural revolution of the 1960s revived older relaxation techniques, created new ones, and imported foreign ones. Most notable are the Eastern meditation and yoga techniques that led to Transcendental Meditation (TM), a broadly marketed and researched version of yoga relaxation (Lickstein, 1988). Herbert Benson investigated TM within the science of behavioral medicine and eventually published his own secular version of TM in The Relaxation Response (1975). Benson's research linked relaxation techniques with control of autonomic activity in numerous physiological studies (i,e., reducing hypertension and vascular headache). Modern Variations and Commonalities
Many variations of the above-mentioned techniques are used by today's health professionals. The primary interventions not previously cited are biofeedback, passive muscle relaxation, imagery, breathing techniques, and prayer (Klajner, Hartman, & Sobell, 1984; Lichstein, 1988; Snyder, 1988). These reviews cite original sources that offer details on each technique for the interested reader. All effective variations share common elements that require consideration. Benson (1975) originally identified four procedural elements essential to all relaxation techniques: (I) a quiet environment, (2) a mental device, i.e., mantra, (3) a passive attitude, and (4) a comfortable position of decreased muscle tone. Poppen (1988) added "rules for relaxation." This is the rationale provided to the trainee regarding conditions and outcomes expected with relaxation. All relaxation techniques are directed at reducing certain tensions or arousals. The desired change may be an increase in global well-being by daily TM, or prevention of tension headaches by EMG biofeedback on dorsal neck muscles. The most effective approaches typically select and combine various techniques based on specific treatment goals (Brallier, 1988; Snyder, 1988). Through learning and practicing relaxation, the client can gain a degree of voluntary control over dysphorie somatic experiences as well as create certain euphoric changes. In a very recent publication, Everly and Benson (1989) reviewed the anatomy and physiology of arousal. They directly contrasted the adrenergic
mechanisms of arousal with the relaxation response. Relaxation induces physiological changes "with generalized decreased sympathetic nervous system a c t i v i t y . . , neurologic desensitization of the limbic system or its sympathetic efferents or both" (Everly & Benson, 1989). Skilled relaxation allows the client voluntarily to influence the core psychophysiological mechanisms of drug dependence. Numerous comparison and combination studies have tested the ability of relaxation techniques to relieve symptoms and improve results on scales and measures. However, the majority of research suffers from methodological flaws, i.e., small samples, poor controls, no longitudinal measures, etc. When firm conclusions have been drawn, they have been favorable, neutral, or often conflicting. Very few studies show harmful effects from these techniques, but most applications at present are implemented with provisional empirical support (Lichstein, 1988; Sims, 1987; Snyder, 1988). RELAXATION THERAPY FOR SUBSTANCE ABUSERS
Brief Review of the Literature The literature evaluating relaxation applications for substance abuse has been equally inconsistent yet promising. In an exemplar study, Peniston and Kulkosky (1989) achieved a remarkable 80% success rate in treating chronic alcoholics with et-0 brainwave biofeedback training. Twenty chronic alcoholics from a Veterans Administration alcohol treatment unit were randomly assigned to traditional treatment (N = I0) and the experimental treatment (N = 10). While connected to EEG feedback devices, the experimental group was instructed to visualize abstinence/alcohol rejection scenes and imageries of increased et wave amplitudes, and scenes of normalization of their personalities. The groups were compared on several measures. Plasma 13-endorphins (BEND) were drawn repeatedly as a physiological indicator of the stress of abstinence, The Beck Depression Inventory (BDI) w~is the primary psychological measure, and all 20 alcoholic and their informants were contacted monthly for 13 months to follow up on drinking behavior. The traditional treatment group showed a significant rise in plasma BEND after treatment, presumably due to the stress of abstinence. Their
VINCENT H. DODGE
102
BDI scores stayed high (depressed), and eight of 10 relapsed within the year. The a-wave biofeedback group had no rise in plasma BEND, their BDI scores were reduced by half, and only two of 10 subjects relapsed during 13 months of follow-up. The authors hypothesize that experimental subjects underwent a personality change, based on the research measures and clinical observation that seven of them attended vocational and junior college programs successfully during the follow-up period. Initially, these results are stunning, but a closer look is warranted. The experimental group had only 10 subjects. To qualify for the study they had to have been hospitalized at least four times prior for alcohol treatment. Consequently, they were all very aware that this new treatment was something special, and placebo or Hawthorne effects may account for the unusual results. Nevertheless, like many relaxation studies, the preliminary results are impressive, and well-designed replications are in order. TM researchers have generated many studies supporting the efficacy of TM in preventing and reducing drug abuse (Clements, Krenner, & Molk, 1988). These authors argue that regular TM practice creates an overall stability and well-being that reduces drug problems secondarily, similar to the "personality changes" noted by Peniston and Kulkosky (1989). Other authors review the TM studies more critically. Lichstein (1988) emphasizes the lack of controls and self-selection of subjects in most studies. Major TM studies that did use random sampling of substance abusers found the typical 2-year relapse rate of 80%, paralleling the natural history of addictive disorders. The most prevalent use of relaxation training is as an adjunct or component within drug dependence programs. Friedman and Glickman (1987) surveyed 22 residential drug treatment programs for adolescents, correlating 221 treatment variables with treatment outcome. Several positive correlations were found; the highest correlation with treatment success was "training in bodily and mental relaxation" (Friedman & Glickman, 1987); [r = .64). They evaluated 23 different specific therapy methods used, and relaxation training was the only one found to be positively associated with treatment outcome. Other countries use their own versions of relaxation training to counter substance abuse. A prime
example is the Nav-Chetna Center in India, described by Sharma and Shukla (1988). This drug rehabilitation center provides a variety of services, using yoga in a crucial role through every stage of treatment. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are international mainstays for the management of drug abuse. Kutner and Zahourek (1988) elucidate several basic AA principles and practices as relaxation and visualization techniques. AA has long recognized that any lasting sobriety is predicated on calmness, serenity, and maturity. Klajner, Hartman, and Sobell (1984) conducted an extensive literature review of the treatment of substance abuse using relaxation training. Their final broad conclusion was that "the available evidence offers neither clear support nor clear disconfirmation of the efficacy of such techniques" (Klajner, Hartman, & Sobell, 1984, pp. 50-52). They also made valuable recommendations to the clinician/researcher: I. Use appropriatecontrolgroups,includingevaluation of actual expectationsgeneratedby placebotreatment. 2. Have adequate follow-upassessment, ideallyover 18 months. 3. Use proper assessment measures, including precipitants, anxiety, substance abuse, perceivedsense of control, and pretreatmentmotivation(includingpositiveand negative reinforcements). 4. Optimizetraining: The length and quality of the particular training used should not be less than the optimal conditionsestablishedin priorresearchusingthe particular relaxationtechnique. 5. Matchclientand treatment:If the relaxationtechniques learneddo not readilymeet the addict's specificneedsand orientation(i.e., locus of control), he or she will quickly stop practicing. 6. Continuerelaxationtechniquesaftertreatment,including monitoringfor complianceand providingadequateincentives and boostersessions.
Treating Mary J. Mary J.'s assessment focused on past coping strategies and present goals and motivation. Together with her therapist, she concluded that the 12-step program provided the best environment she knew to begin drug-free living. The therapist favored this decision because the program offered daily monitoring of drug-seeking behavior, urine testing, and a peer network with common goals.
RELAXATION TRAINING
Initial psychological testing established M a r y ' s baseline as moderately depressed and high external locus o f control (LOC). The therapist educated Mary about the pathophysiological dysphoria associated with abstinence and presented relaxation training as a way of controlling and reversing the dysphoric arousals without drug use. Initially, they met daily for a half-hour of relaxation training followed by brief psychotherapy. A passive muscle relaxation technique was used to capitalize on her external orientation and need for immediate results. Progress was measured by trained observation and Mary's self-reports (Poppen, 1988). During relaxation Mary was instructed to silently repeat a word with each exhalation; she chose the word " f r e e d o m . " As her skill increased and she succeeded in deep relaxation alone between sessions, the therapist taught her a cue-controlled brief relaxation technique. Mary was asked silently to repeat her cue word periodically during the psychotherapy time. When faced with a threatening issue or situation, Mary slowly chanted the cue word to counteract the impending tension (Lichstein, 1988). After 3 weeks, retesting showed a shift toward internal LOC and decreased depression. Mary was then ready to add meditation and imagery (internal) techniques to her relaxation repertoire. As drug stressors and temptations arose, Mary dealt with the arousal first through imagery and desensitization during relaxation. She and the therapist began meeting weekly with a group of residents to share and explore other techniques. Mary learned a form of physiological self-control that could fill the pervasive space in her life that drugs once filled. This was her " f r e e d o m . " CONCLUSIONS
Impfications f o r Clinical N u r s e Specialists
Nurses can lay claim to the vast majority of professional hours spent in the treatment of substance abusers. Psychiatric clinical nurse specialists are in an ideal position to implement relaxation research findings in drug treatment programs and private practice. Many nurse researchers and clinicians have published instructive articles to guide such nursing practice (Brallier, 1988; Mast, Meyers, & Urbanski, 1987; Sims, 1987; Titlebaum, 1988), and to review nursing research on relaxation (Snyder, 1988). Several of these authors ad-
103
vocate the efficacy of relaxation training to augment psychotherapy and therapeutic milieux. The psychophysiological underpinnings o f relaxation make it a particularly appropriate intervention for nurses using a holistic approach that focuses on client health. REFERENCES
Arif, A., & Westermeyer, J. (1988). Manual of drug and alcohol abuse. New York, NY: Plenum. Benson, H. (1975). The relaxation response. New York, NY: Morrow. Bloom, F. (1989). Which molecular and cellular actions of ethanol mediate reinforcement? In A. Goldstein (Ed.), Molecular and cellular aspects of the drug addictions
(pp. 142-158). New York, NY: Springer-Verlag. Blum, K., Briggs, A., & Trachtenberg, M. (1989). Ethanol ingestive behavior as a function of central neurotransmission. Experientia, 45, 444-452. Brallier, L. (1988). Biofeedback and holism in clinical practice. Holistic Nursing Practice, 2(3), 26-33. Chick, J., Ritson, B., Connaughton, J., Stewart, A., & Chick, J. (1988). Advice versus extended treatment for alcoholism: A controlled study. British Journal of Addiction, 83, 159-170. Emrick, C. (1975). A review of psychologicallyoriented treatment of alcoholism: II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. Journal of Studies on Alcoholism, 36(1), 88-108. Everly, G., & Benson, H. (1989). Disorders of arousal and the relaxation response: Speculations on the nature and treatment of stress-related diseases. International Journal of Psychosomatics, 36(1-4), 15-21. Friedman, A., & Glickman, N. (1987). Residential program characteristics for completion of treatment by adolescent drag abusers. Journal of Nervous and Mental Disease, 175(7), 419-424. Jacobson, E. (1929). Progressive relaxation. Chicago, IL: University of Chicago. Jacobson, E. (1938). Progressive relaxation (2ad ed.). Chicago, IL: University of Chicago. Klajner, F., Hartman, L., & Sobell, M. (1984). Treatment of substance abuse by relaxation training: A review of its rationale, efficacy, and mechanisms. Addictive Behaviors, 9, 41-55. Kutuer, G., & Zahourek, R. (1988). Relaxation/imagery with alcoholics in group treatment. In R.P. Zahourek (Ed.). Relaxation and imagery: Tools for therapeutic communication and intervention. Philadelphia, PA: Sanders. Lichstein, K:.(1988). Clinical relaxation strategies. New York,
NY: Wiley. Mast, D., Meyers, J., & Urbanski, A. (1987). Relaxation techniques a self-learning module for nurses: Unit I. Cancer Nursing, 10(3), 141-147. Peniston, E., & Kulkosky, P. (1989). Alpha-brainwavetraining and beta-endorphin levels in alcoholics. Alcoholism, 13(2), 271-279.
104
Poppen, R. (1988). Behavioral relaxation training and assessment. New York, NY: Pergamon. Ray, B. (1988). Learning factors in substance abuse. Washington, DC: United States Government Printing Office. Schuckit, M. (1989). Drug and alcohol abuse. New York, NY: Plenum. Schultz, J., & Luthe, W. (1959). Autogenic training: A psychophysiologic approach in psychotherapy. New York, NY: Grune & Stratton. Sharma, K., & Shulka, V. (1988). Rehabilitation of drugaddicted persons: The experience of the Nav-Chetna Center in India. Bulletin on Narcotics, 40(1), 43-49. Sims, E. (1987). Relaxation training as a technique for helping patients cope with the experience of cancer: A selective
VINCENT H. DODGE
review of the literature. Journal of Advanced Nursing. 12, 583-591. Snyder, M. (1988). Relaxation. Annual Review of Nursing Research, 6, 111-128. Titlebaum, H. (1988). Relaxation. Holistic Nursing Practice, 2(3), 17-25. Watson, S., Trujillo, K., Herman, J., & Akil, H. (1989). Neuroanatomical and neurochemical substrates of drugseeking behavior: Overview and future directions. In A. Goldstein (Ed.), Molecular and cellular aspects of the drug addictions. New York, NY: Springer-Verlag. Wise, R. (1987). The role of reward pathways in the development of drug dependence. Pharmacological Therapy, 35, 227-63.
ary J. was a 27-year-old woman, transferred from an intensive care unit for a psychiatric evaluation. Three days earlier she had been brought in to the hospital in an unconscious state after a reported overdose on diphenhydramine. A urine drug screen was positive for alcohol, marijuana, and cocaine. Her chief complaint was depression and chemical dependence: "I ran out of friends, money, dope. I was so miserable that when I finally bummed $10 1 got some beer and tried to relax; I thought a couple of Benadryl might help, too. Then I just kept taking them, to go to sleep for good." Her social history revealed an unremarkable childhood until age 14 when she started heavy use of marijuana and alcohol. After completing high school, Mary left her family and had a series of brief jobs and relationships, never longer than 8 months. Her relationships have revolved around cocaine acquisition and use, ending in polysubstance abuse and abandonment. She reported several suicide attempts, always after periods of heavy drug use, when all her resources were exhausted. She described hours of weak, dysphoric misery, craving a "fix." When this state was finally relieved by a drug, the dose was then repeated as much as possible, to 'get even higher'. Mary met the Diagnostic and Statistical Manual, Revised (IDSM-III-R] American Psychiatric Association, 1988) criteria for cocaine abuse and dependence, and has often met the same criteria for alcohol and polysubstances.
M
SUBSTANCE ABUSE
Definition and Prevalence Since the drug wave of the 1960s, substance abuse and dependence have steadily risen (Arif &
Westermeyer, 1988). In this article, drug abuse refers to the self-administration o f mind-altering substances (alcohol included) in a way that differs from generally approved medical or social practices. Drug dependence refers to a psychological and/or physical need for the drug (Schuckit, 1989). More than 2% of Americans are alcohol dependent, and the use of cocaine, amphetamines, marijuana, heroin, and sedatives plagues more than 1:1,000 of the population (Arif & Westermeyer, 1988). Psychological Theories Theories abound as to why people use drugs to such excess. Traditionally, these theories were divided into psychological and physical categories. In light of the latest psychophysiological research, these divisions are gradually meshing together. The prevalent psychological theories for drug selfadministration are to relieve an aversive, anxious state, and to induce a high or euphoric state. These two theories are well supported in behavioral literature arid commonly referred to as the negative and positive reinforcing effects o f psychoactive From the School of Nursing, University of California, Los Angeles Center for the Health Sciences. Address reprint requests to Vincent hi. Dodge 20529 S. Vermont Ave., #2, Torrance CA. Copyright © by W.B. Saunders Company 0883-941719110502-000753.00/0
Archives of Psychiatric Nursing, Vol. V, No. 2 (April), 1991: pp. 99-104
99
VINCENT H. DODGE
100
substances (Ray, 1988). Ultimately, these forces overwhelm the addict's sense of self-control, leading to alienation and living only for the drugs (Arif & Westermeyer, 1988).
Pathophysiological Theories At the same time, breakthroughs in neurophysiology have led to strong biochemical theories for the reinforcing properties of psychoactive substances. The most extensively researched mechanisms to date are the substrates to opiate reward pathways. Since the identification of endogenous opioid neuropeptides in the mid-1970s, these substrates have been shown to interact with known and unknown neuroregulatory systems, forming powerful behavioral controls in animal models. In an extensive review combining findings from ingestive behavior research and opiate reward pathways, Wise (1987) hypothesized a "final common pathway" of positive reinforcement used by natural rewards (i.e., food and water), experimental rewards (i.e., electrical midbrain stimulation), and drug rewards, from opium and ethanol to nicotine. Wise also reports on an anatomically distinct negative reinforcement pathway (periventricular system) by which opiates inhibit withdrawal symptoms. In mapping out these pathways, Watson, Trujillo, Herman, and Akil (1989) went a step further, identifying a link between positive reinforcement pathways and motor centers. They called this the limbic-motor reinforcement circuit. Their review of current evidence suggests that this circuit accounts for drug-seeking and self-administration behavior demonstrated in research animals and probably the clinical phenomena of drug addictions. Other researchers have linked these pathways to current findings in alcohol dependence research (Bloom, 1989; Blum, Briggs, & Trachtenberg, 1989). A detailed review of these state-of-the-art psychophysiological theories of addiction is beyond the scope of this article. The interested reader is referred to these sources. It suffices to conclude that powerful pathophysiological mechanisms reinforce substance abuse behavior; such a conclusion has far-reaching implications for treatment.
Substance Abuse Treatment Traditional treatment for alcoholism and drug dependence has been psychological except for few exceptions, i.e., methadone clinics. By and large,
these psychological treatments have been unsuccessful, especially for alcohol dependence. Major outcome surveys have found that alcoholics achieve 1-year abstinence without treatment at a rate of 10% to 12%, while most traditional programs succeed at a rate of 10% to 22%, which is scarcely better than the natural history of the disorder (Chick, Ritson, Connaughton, Stewart, & Chick, 1988; Emrick, 1975). This general failure rate of 80% may simply reflect that psychologically oriented interventions are being applied to a physiologically rooted problem. Biomedical research may soon have some pharmacological solutions to the substance abuse problem, but in the meantime, addicts like Mary J. bounce in and out of treatment efforts in a vicious cycle of relapses. In the last 4 years Mary has completely abstained from drugs twice. She lived in a 12-step center for 2 months, reaching step four before using cocaine with some old friends, which ended the treatment. More recently she stopped on her own, staying at a supportive friend's home until the depression and craving overcame her. After 4 long weeks she moved in with a dealer. RELAXATION TRAINING
In the immediate search for interventions capable of altering the addict's pathophysiological bondage to drug use, clinicians have turned to relaxation training techniques. Historically, these techniques have provided a critical connection between the mind and body, allowing therapists and clients to deliberate some psychological control over their physiological processes.
Development of Techniques Edmund Jacobson, M.D., is credited with the first modem relaxation technique, progressive muscle relaxation (1929, 1938). This meticulous procedure involves tension and relaxation of several muscle groups while in a comfortable position. He also pioneered the measurement of muscle relaxation using electromyography (EMG). His basic research and technique still underlie many popular relaxation applications. At the same time, a form of self-induced hypnosis, later called autogenic training (AT), was being developed in Germany. This process focuses attention on six sensations, including heaviness, warmth, calming of the heart, and cooling of the forehead. First introduced in the United States by
101
RELAXATION TRAINING
Schultz and Luthe (1959), AT has remained moderately popular (Lickstein, 1988). The cultural revolution of the 1960s revived older relaxation techniques, created new ones, and imported foreign ones. Most notable are the Eastern meditation and yoga techniques that led to Transcendental Meditation (TM), a broadly marketed and researched version of yoga relaxation (Lickstein, 1988). Herbert Benson investigated TM within the science of behavioral medicine and eventually published his own secular version of TM in The Relaxation Response (1975). Benson's research linked relaxation techniques with control of autonomic activity in numerous physiological studies (i,e., reducing hypertension and vascular headache). Modern Variations and Commonalities
Many variations of the above-mentioned techniques are used by today's health professionals. The primary interventions not previously cited are biofeedback, passive muscle relaxation, imagery, breathing techniques, and prayer (Klajner, Hartman, & Sobell, 1984; Lichstein, 1988; Snyder, 1988). These reviews cite original sources that offer details on each technique for the interested reader. All effective variations share common elements that require consideration. Benson (1975) originally identified four procedural elements essential to all relaxation techniques: (I) a quiet environment, (2) a mental device, i.e., mantra, (3) a passive attitude, and (4) a comfortable position of decreased muscle tone. Poppen (1988) added "rules for relaxation." This is the rationale provided to the trainee regarding conditions and outcomes expected with relaxation. All relaxation techniques are directed at reducing certain tensions or arousals. The desired change may be an increase in global well-being by daily TM, or prevention of tension headaches by EMG biofeedback on dorsal neck muscles. The most effective approaches typically select and combine various techniques based on specific treatment goals (Brallier, 1988; Snyder, 1988). Through learning and practicing relaxation, the client can gain a degree of voluntary control over dysphorie somatic experiences as well as create certain euphoric changes. In a very recent publication, Everly and Benson (1989) reviewed the anatomy and physiology of arousal. They directly contrasted the adrenergic
mechanisms of arousal with the relaxation response. Relaxation induces physiological changes "with generalized decreased sympathetic nervous system a c t i v i t y . . , neurologic desensitization of the limbic system or its sympathetic efferents or both" (Everly & Benson, 1989). Skilled relaxation allows the client voluntarily to influence the core psychophysiological mechanisms of drug dependence. Numerous comparison and combination studies have tested the ability of relaxation techniques to relieve symptoms and improve results on scales and measures. However, the majority of research suffers from methodological flaws, i.e., small samples, poor controls, no longitudinal measures, etc. When firm conclusions have been drawn, they have been favorable, neutral, or often conflicting. Very few studies show harmful effects from these techniques, but most applications at present are implemented with provisional empirical support (Lichstein, 1988; Sims, 1987; Snyder, 1988). RELAXATION THERAPY FOR SUBSTANCE ABUSERS
Brief Review of the Literature The literature evaluating relaxation applications for substance abuse has been equally inconsistent yet promising. In an exemplar study, Peniston and Kulkosky (1989) achieved a remarkable 80% success rate in treating chronic alcoholics with et-0 brainwave biofeedback training. Twenty chronic alcoholics from a Veterans Administration alcohol treatment unit were randomly assigned to traditional treatment (N = I0) and the experimental treatment (N = 10). While connected to EEG feedback devices, the experimental group was instructed to visualize abstinence/alcohol rejection scenes and imageries of increased et wave amplitudes, and scenes of normalization of their personalities. The groups were compared on several measures. Plasma 13-endorphins (BEND) were drawn repeatedly as a physiological indicator of the stress of abstinence, The Beck Depression Inventory (BDI) w~is the primary psychological measure, and all 20 alcoholic and their informants were contacted monthly for 13 months to follow up on drinking behavior. The traditional treatment group showed a significant rise in plasma BEND after treatment, presumably due to the stress of abstinence. Their
VINCENT H. DODGE
102
BDI scores stayed high (depressed), and eight of 10 relapsed within the year. The a-wave biofeedback group had no rise in plasma BEND, their BDI scores were reduced by half, and only two of 10 subjects relapsed during 13 months of follow-up. The authors hypothesize that experimental subjects underwent a personality change, based on the research measures and clinical observation that seven of them attended vocational and junior college programs successfully during the follow-up period. Initially, these results are stunning, but a closer look is warranted. The experimental group had only 10 subjects. To qualify for the study they had to have been hospitalized at least four times prior for alcohol treatment. Consequently, they were all very aware that this new treatment was something special, and placebo or Hawthorne effects may account for the unusual results. Nevertheless, like many relaxation studies, the preliminary results are impressive, and well-designed replications are in order. TM researchers have generated many studies supporting the efficacy of TM in preventing and reducing drug abuse (Clements, Krenner, & Molk, 1988). These authors argue that regular TM practice creates an overall stability and well-being that reduces drug problems secondarily, similar to the "personality changes" noted by Peniston and Kulkosky (1989). Other authors review the TM studies more critically. Lichstein (1988) emphasizes the lack of controls and self-selection of subjects in most studies. Major TM studies that did use random sampling of substance abusers found the typical 2-year relapse rate of 80%, paralleling the natural history of addictive disorders. The most prevalent use of relaxation training is as an adjunct or component within drug dependence programs. Friedman and Glickman (1987) surveyed 22 residential drug treatment programs for adolescents, correlating 221 treatment variables with treatment outcome. Several positive correlations were found; the highest correlation with treatment success was "training in bodily and mental relaxation" (Friedman & Glickman, 1987); [r = .64). They evaluated 23 different specific therapy methods used, and relaxation training was the only one found to be positively associated with treatment outcome. Other countries use their own versions of relaxation training to counter substance abuse. A prime
example is the Nav-Chetna Center in India, described by Sharma and Shukla (1988). This drug rehabilitation center provides a variety of services, using yoga in a crucial role through every stage of treatment. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are international mainstays for the management of drug abuse. Kutner and Zahourek (1988) elucidate several basic AA principles and practices as relaxation and visualization techniques. AA has long recognized that any lasting sobriety is predicated on calmness, serenity, and maturity. Klajner, Hartman, and Sobell (1984) conducted an extensive literature review of the treatment of substance abuse using relaxation training. Their final broad conclusion was that "the available evidence offers neither clear support nor clear disconfirmation of the efficacy of such techniques" (Klajner, Hartman, & Sobell, 1984, pp. 50-52). They also made valuable recommendations to the clinician/researcher: I. Use appropriatecontrolgroups,includingevaluation of actual expectationsgeneratedby placebotreatment. 2. Have adequate follow-upassessment, ideallyover 18 months. 3. Use proper assessment measures, including precipitants, anxiety, substance abuse, perceivedsense of control, and pretreatmentmotivation(includingpositiveand negative reinforcements). 4. Optimizetraining: The length and quality of the particular training used should not be less than the optimal conditionsestablishedin priorresearchusingthe particular relaxationtechnique. 5. Matchclientand treatment:If the relaxationtechniques learneddo not readilymeet the addict's specificneedsand orientation(i.e., locus of control), he or she will quickly stop practicing. 6. Continuerelaxationtechniquesaftertreatment,including monitoringfor complianceand providingadequateincentives and boostersessions.
Treating Mary J. Mary J.'s assessment focused on past coping strategies and present goals and motivation. Together with her therapist, she concluded that the 12-step program provided the best environment she knew to begin drug-free living. The therapist favored this decision because the program offered daily monitoring of drug-seeking behavior, urine testing, and a peer network with common goals.
RELAXATION TRAINING
Initial psychological testing established M a r y ' s baseline as moderately depressed and high external locus o f control (LOC). The therapist educated Mary about the pathophysiological dysphoria associated with abstinence and presented relaxation training as a way of controlling and reversing the dysphoric arousals without drug use. Initially, they met daily for a half-hour of relaxation training followed by brief psychotherapy. A passive muscle relaxation technique was used to capitalize on her external orientation and need for immediate results. Progress was measured by trained observation and Mary's self-reports (Poppen, 1988). During relaxation Mary was instructed to silently repeat a word with each exhalation; she chose the word " f r e e d o m . " As her skill increased and she succeeded in deep relaxation alone between sessions, the therapist taught her a cue-controlled brief relaxation technique. Mary was asked silently to repeat her cue word periodically during the psychotherapy time. When faced with a threatening issue or situation, Mary slowly chanted the cue word to counteract the impending tension (Lichstein, 1988). After 3 weeks, retesting showed a shift toward internal LOC and decreased depression. Mary was then ready to add meditation and imagery (internal) techniques to her relaxation repertoire. As drug stressors and temptations arose, Mary dealt with the arousal first through imagery and desensitization during relaxation. She and the therapist began meeting weekly with a group of residents to share and explore other techniques. Mary learned a form of physiological self-control that could fill the pervasive space in her life that drugs once filled. This was her " f r e e d o m . " CONCLUSIONS
Impfications f o r Clinical N u r s e Specialists
Nurses can lay claim to the vast majority of professional hours spent in the treatment of substance abusers. Psychiatric clinical nurse specialists are in an ideal position to implement relaxation research findings in drug treatment programs and private practice. Many nurse researchers and clinicians have published instructive articles to guide such nursing practice (Brallier, 1988; Mast, Meyers, & Urbanski, 1987; Sims, 1987; Titlebaum, 1988), and to review nursing research on relaxation (Snyder, 1988). Several of these authors ad-
103
vocate the efficacy of relaxation training to augment psychotherapy and therapeutic milieux. The psychophysiological underpinnings o f relaxation make it a particularly appropriate intervention for nurses using a holistic approach that focuses on client health. REFERENCES
Arif, A., & Westermeyer, J. (1988). Manual of drug and alcohol abuse. New York, NY: Plenum. Benson, H. (1975). The relaxation response. New York, NY: Morrow. Bloom, F. (1989). Which molecular and cellular actions of ethanol mediate reinforcement? In A. Goldstein (Ed.), Molecular and cellular aspects of the drug addictions
(pp. 142-158). New York, NY: Springer-Verlag. Blum, K., Briggs, A., & Trachtenberg, M. (1989). Ethanol ingestive behavior as a function of central neurotransmission. Experientia, 45, 444-452. Brallier, L. (1988). Biofeedback and holism in clinical practice. Holistic Nursing Practice, 2(3), 26-33. Chick, J., Ritson, B., Connaughton, J., Stewart, A., & Chick, J. (1988). Advice versus extended treatment for alcoholism: A controlled study. British Journal of Addiction, 83, 159-170. Emrick, C. (1975). A review of psychologicallyoriented treatment of alcoholism: II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. Journal of Studies on Alcoholism, 36(1), 88-108. Everly, G., & Benson, H. (1989). Disorders of arousal and the relaxation response: Speculations on the nature and treatment of stress-related diseases. International Journal of Psychosomatics, 36(1-4), 15-21. Friedman, A., & Glickman, N. (1987). Residential program characteristics for completion of treatment by adolescent drag abusers. Journal of Nervous and Mental Disease, 175(7), 419-424. Jacobson, E. (1929). Progressive relaxation. Chicago, IL: University of Chicago. Jacobson, E. (1938). Progressive relaxation (2ad ed.). Chicago, IL: University of Chicago. Klajner, F., Hartman, L., & Sobell, M. (1984). Treatment of substance abuse by relaxation training: A review of its rationale, efficacy, and mechanisms. Addictive Behaviors, 9, 41-55. Kutuer, G., & Zahourek, R. (1988). Relaxation/imagery with alcoholics in group treatment. In R.P. Zahourek (Ed.). Relaxation and imagery: Tools for therapeutic communication and intervention. Philadelphia, PA: Sanders. Lichstein, K:.(1988). Clinical relaxation strategies. New York,
NY: Wiley. Mast, D., Meyers, J., & Urbanski, A. (1987). Relaxation techniques a self-learning module for nurses: Unit I. Cancer Nursing, 10(3), 141-147. Peniston, E., & Kulkosky, P. (1989). Alpha-brainwavetraining and beta-endorphin levels in alcoholics. Alcoholism, 13(2), 271-279.
104
Poppen, R. (1988). Behavioral relaxation training and assessment. New York, NY: Pergamon. Ray, B. (1988). Learning factors in substance abuse. Washington, DC: United States Government Printing Office. Schuckit, M. (1989). Drug and alcohol abuse. New York, NY: Plenum. Schultz, J., & Luthe, W. (1959). Autogenic training: A psychophysiologic approach in psychotherapy. New York, NY: Grune & Stratton. Sharma, K., & Shulka, V. (1988). Rehabilitation of drugaddicted persons: The experience of the Nav-Chetna Center in India. Bulletin on Narcotics, 40(1), 43-49. Sims, E. (1987). Relaxation training as a technique for helping patients cope with the experience of cancer: A selective
VINCENT H. DODGE
review of the literature. Journal of Advanced Nursing. 12, 583-591. Snyder, M. (1988). Relaxation. Annual Review of Nursing Research, 6, 111-128. Titlebaum, H. (1988). Relaxation. Holistic Nursing Practice, 2(3), 17-25. Watson, S., Trujillo, K., Herman, J., & Akil, H. (1989). Neuroanatomical and neurochemical substrates of drugseeking behavior: Overview and future directions. In A. Goldstein (Ed.), Molecular and cellular aspects of the drug addictions. New York, NY: Springer-Verlag. Wise, R. (1987). The role of reward pathways in the development of drug dependence. Pharmacological Therapy, 35, 227-63.