The importance of home practice for progressive relaxation training

Behav. Res. Thu. Vol. 21,No. 6,pp.633-642,1983 Printed in Great Britain. All rights reserved

0005-7967183 $3.00+0.00 Copyright CI 1983 Pergamon Press Ltd

THE IMPORTANCE FOR PROGRESSIVE J. BRUCE HILLENBERG’ ‘Department

of Psychology,

OF HOME

PRACTICE

RELAXATION and FRANK

L. COLLINS

West Virginia University and ‘West Virginia Morgantown, WV 26506, U.S.A. (Received

I December

TRAINING* JR’.~~

University

School of Medicine,

1982)

Summary-The efficacy of home practice assignments was evaluated as a component of standardized progressive relaxation training. Subjects reporting general anxiety and tension problems were assigned to either a home practice relaxation, no home practice relaxation or wait-list control condition. Treatment was conducted for 10 sessions over a 5-week period. In addition, subjects in both conditions engaged in in-oivo application of their relaxation skills during a final 2-week application period. Group comparisons showed that both progressive relaxation conditions significantly improved on daily self-monitored general anxiety and tension levels relative to the wait-list control condition. Group analyses of percent subject improvements supported the effectiveness of home practice assignments, especially during the application period. No systematic differences between groups, on physiological and self-report variables, were found during several laboratory relaxation evaluation sessions. This study supports the contribution of home practice assignments to progressive relaxation training.

INTRODUCTION Specific relaxation training procedures have been shown to be effective for treating a wide variety of stress-related problems including general anxiety and tension (Borkovec, Grayson and Cooper, 1978; Israel and Beiman, 1977), migraine headaches (Attfield and Peck, 1979; Blanchard, Theobald, Williamson, Silver and Brown, 1978), tension headaches (Cox, Freundlich and Meyer, 1975; Tasto and Hinkle, 1973), hypertension (Brady, Luborsky and Kron, 1974; Shoemaker and Tasto. 1975) and sleep disturbance (Haynes, Woodward, Moran and Alexander, 1974; Lick and Heffler, 1977; Nicassio and Bootzin, 1974). In addition, relaxation training programs have been shown to be as effective as commonly employed biofeedback strategies for treating anxiety or stress-related disorders (Silver and Blanchard, 1978; Surwit and Keefe, 1978). For example, Silver and Blanchard (1978) reviewed comparisons of biofeedback and relaxation training in the treatment of psychophysiological disorders. They concluded that when considering such factors as convenience and cost, relaxation training would seem to be the initial treatment of choice for such clinical disorders. To evaluate the effectiveness of relaxation training strategies, several studies have empirically tested specific procedural components assumed to be critical to treatment outcome. For example, live relaxation instructions have been shown to produce superior effects relative to taped instructions (Beiman, Israel and Johnson, 1978; Paul and Trimble, 1970; Russell, Sipich and Knipe, 1976). In addition, several studies have suggested that relaxation training employing muscle tension-release exercises is more effective than procedures using a passive relaxation format (Borkovec, Kaloupek and Slama, 1975; Borkovec et al., 1978). However, methodological confounds limit the degree of generalization of these conclusions (Collins, 1981; King, 1980). Collins (1981) stressed that procedural differences across relaxation training studies severely limits generalization concerning the critical nature of specific components. These findings highlight the importance of utilizing standardized procedures when testing specific components thought to be critical to the efficacy of relaxation training [cf. Hillenberg and Collins (1982) for a more complete review of these issues]. One popular procedural component which has not received adequate evaluative attention is the use of home practice assignments during relaxation training. Several authors have stressed the

Baltimore. Md.. March *Portions of these data were presented at the Merling o/ r/w Sock/y o/’ E~~/x~uorcrl Mdic~im~. 1983. West Virginia University. tTo whom all correspondence should be addressed at: Department of Psychology. 633

importance of home-based practice assignments in bringing about positive clinical change (Kanfer and Phillips, 1969; Kelley, 1955: Shelton and Ackerman. 1974; Shelton and Levy. I98 I). Kanfer and Phillips (1969) emphasized the importance of home practice strategies for increasing generalization of treatment etTects. In addition. Shelton and Levy (1981) suggest that the advantages of using systematic behavioral practice assignments include increasing the efficiency of tre~~tmeiit. increased client self-control and potential enhanced maintetlaiice of bellavior~~l change. With an emphasis on relaxation training, Bernstein and Borkovec (1973) concluded that regular home practice is critical to developing relaxation skills. In their program, clients are asked to practice at home twice daily for a 15-~20-min period. It is assumed that the frequency of home practice is directly related to the potential for positive treatment effects. Recently, Hiiicnberg and Collins (1982) emphasized that conclusions about the contribution of home practice assignments in relaxation training research are restricted. Usually a rationale is given which expresses the importance of home practice and then subjects’ reports of home practice frequency are taken at face value. Yet. several authors have pointed out the high degree of noncompliance to treatment assignments both in clinical and research interventions (Collins and Thompson. 1979: Epstein and Masek. 1978; Masur, 1981; Shelton and Levy, 1979. 1981). In addition, Collins, Martin and Hillenberg (1982) stress that noncompliance to home practice assignments during previous re’faxation training research may have gone undetected. To date only one study, a case report (Martin, Collins, Wiiienberg, Zabin and Kattell, 1981) has reported objective verification of subjects’ reports of compliance to home practice assignments. Thus an important point raised by Shelton and Levy (1979) is that lack of knowledge about actual compliance to practice assignments may make their impact on experimental outcome difficult to detect. The potential problem of noncompIiance to home practice assignments is seen against the backdrop of a more fundamental issue. Hillenberg and Collins (1982) have suggested that the home practice component of relaxation training, though assumed to be critical. has gone untested. Thus it is critical to establish that compliant home practice itself, is an important component of an efrectivc relaxation training procedure. To accurately evaluate the contribution of home practice ~~ssignrnellts for relaxation tr~~itling, two empirical issues must be addressed. First. relaxation training utilizing home practice assignments should be compared to an equally credible relaxation training procedure where no practice assignments are included. Second, compliance to home practice assignments should be objectively validated so as to enable an accurate test of the contribution of practice to the efficacy of relaxation training. Martin 6’1trl. (198 I) describe a specific objective technique for evaluating the compliance rates to assigned home practice of taped relaxation procedures. By employing audiotaped relaxation instructions spccificaliy ‘marked’ with audible tones, subjects can be asked to record the number of detected tones after each practice session (each session having an assigned tape) and these records can be matched with a master list to establish compliance rates. In utilizing this procedure, more honest rates of home practice frequency should be expected than if rates were taken at face value. It is reasonabic that subjects would not want to appear as fabricating their reports of practice frcqucncy. Yet. subjects could make a correct guess without practicing or may not accuratciy recall the number of tones at the end of a practice. Still, considering the overall strengths and limitations of the marked-tape procedure (Martin rt (I/.. 1981). this technique appears to advance the objective assessment of home practice frequency. Additionally, Collins et (11. (1982) demonstrated that the use of these procedures does not have any critical effect on preventing decreases in self-reported and monitored physiological measures of increased relaxation. The prcscnt study was designed to test the contribution of the home practice component to the efficacy of progressive rclnxation training procedures. To evaluate the contribution of practice assignments, a controlled comparison of two standardized progressive relaxation conditions (Bernstein and Borkovec. 1973). one with and one without home practice assigned was conducted. The perceived credibility of each condition was evaluated at two points during training to monitor any potential bias due to possible differences between the home practice and no home practice condition’s rationale and procedure. Since progressive relaxation training is suggested for clients with stress-reiatcd problems. the study was conducted with subjects reporting moderate to high levels of general anxiety and tension.

Home

practice

635

To evaluate accurately the contribution of daily home practice, compliance rates were assessed through the marked-tape procedure described by Martin et al. (198 1). By establishing an objective measure of the frequency of practice for subjects in the home practice group, the degree of generalizability of the results are enhanced. Finally, two approaches were taken in evaluating self-report and physiological outcome variables related to general anxiety and tension levels. First, mean differences were evaluated by traditional group comparisons by condition. Second, since it has been emphasized that such comparisons often hide the performance of individual subjects (Chassan, 1967; Hersen and Barlow, 1976; Paul, 1966; Sidman, 1960; Skinner, 1956) group analyses of the number of subjects who statistically improved were conducted. It was assumed that the latter analyses would provide a more accurate test of the contribution of home practice assignments.

METHOD

Thirty-six volunteers from the Morgantown, West Virginia community, 12 male and 24 female, were selected from a S pool responding to advertisements for a stress-management project designed to reduce general anxiety and tension. Each respondent was asked to undergo a brief pre-treatment interview. where they completed the Trait Form of the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch and Lushene, 1970). Eligible respondents had to meet the following criterion: (I) no previous exposure to relaxation training; (2) no concurrent therapeutic treatment; and (3) absence of psychotropic medication use. Those 36 eligible Ss with the highest Trait Anxiety scores above college-level norms were selected to participate in the study. Two Ss withdrew prior to the beginning of treatment and 1 left the program due to illness. Appurutzts Physiologird measure.~. Two autonomic responses, heart and respiration rate, were monitored. Physiological recordings were obtained with a Grass Mode1 79D polygraph. Heart-rate recordings were obtained with stainless-steel disc electrodes taped to the left and right wrist of each S. A ground electrode was placed on each S’s left forearm. A nasal thermister taped to the inside of each S’s right nostril was used to measure respiration rate. Se(f-report meusures. Repeated time comparisons of trait anxiety levels were obtained with the Trait scale of the STAI (Spielberger et al.. 1970). In addition, the Anxiety Differential (Alexander and Husek, 1962) was used to evaluate state levels of anxiety. A Daily Self-Monitoring Scale (DSMS) was used to collect anxiety-tension ratings 4 times each day. This self-monitoring scale was modified for anxiety and tension ratings from the Headache Pain Rating Scale (HPRS) utilized by Collins and Thompson (1979). The scale is separated into 4 interval periods, with the S making a subjective rating of anxiety and tension levels at the end of each interval; breakfast, lunch, dinner and immediately before going to bed. Anxiety and tension ratings are made on a 5-point scale with each level behaviorally anchored in objective terms. Crerliihilit~~measure. A 5-item questionnaire developed along the lines of Borkovec and Nau’s (1972) procedure to evaluate the perceived credibility of treatment rationales was used. This questionnaire evaluated specific cognitive and behavioral correlates of perceived credibility. Home prucrice tupes. The taped relaxation instructions were identical to the instructions utilized in the group treatment sessions. The content of each tape coincided with the procedures used in the S’s preceding treatment session. Each tape contained zero, one or two audible tones. The tones used were low-frequency (approx 250 Hz) narrow-bandwidth auditory signals of I-set duration, overdubbed at a low level (50-60 dB) onto the pre-recorded tapes at selected points. Procedure

The 36 Ss selected for the study were distributed into triads matched for pre-treatment scores on the Trait scale of the STAI. Ss in each triad were then randomly assigned to either a progressive relaxationhome practice (HP) group, progressive relaxation-no home practice (NHP) group or wait-list control (WLC) group.

636

J.

BKII(I 1111 LKNHEKG

and

FKANK

L.

COLLINS JK

Pt~,-tt~~~ttrrrtrt r.clcr.~utiotr cl~crlucrtiotr. Upon arrival for the pre-treatment evaluation, each S was seated in a reclining chair in the evaluation room. The experimenter then briefly explained the evaluation procedure. answering any questions and obtaining a signed consent form. Next the stainless-steel electrodes and the nasal thermister were attached and each S filled out the pre-level Anxiety Differential. Then each S was asked to try and get as relaxed as possible, with their eyes closed, during a 30-min period while their heart and respiration rate were recorded. At the end of the 30-min interval. the experimenter returned to the evaluation room and removed the electrodes and nasal thermister. Each S then filled out the post-level Anxiety Differential. Finally, all Ss received DSMSs for a l-week period with instructions in their use. Heart and respiration rates were quantified by counting the frequency of beats and respirations per minute for the first and last 10 min of the final 25 min of recording. The first 5 min of the recording period was defined as an adaptation period and not scored. A random sample (20%) of the heart- and respiration-rate scores were independently restored. Interscorer agreement was dctcrmined by the number of agreements over the number of agreements plus disagreements (Hawkins and Dotson. 1975). Ttwttw~~t. Each trcatmcnt group was instructed in progressive relaxation training (Bernstein and Borkovcc, 1973) by a graduate student in clinical psychology. The groups met twice per week for 5 weeks. All relaxation instructions were presented to Ss from a printed script so that standardization across groups would be assured. In order to cvaluatc the cffccts of home practice, the groups were presented different treatment rationales. The HP group was given a rationale which included the importance of daily home practice in mastering relaxation skills. The NHP group was presented a rationale which stated that only group treatment sessions were necessary for mastering relaxation skills. Both treatment rationales contained counter-demand instructions (Borkovec et al., 1978) informing the Ss not to expect improvement until the 9th session. The counter-demand rationale was used to help control for expectancy effects on the self-report measures used. After each rationale was presented at the initial group session, those Ss in the HP and NHP groups filled out a treatment credibility questionnaire. In addition, Ss in both groups filled out the credibility questionnaire again during the 6th treatment session. Subjects in the HP group were given taped relaxation instructions to be used twice daily during Sessions l-7. Each S was instructed to record the number of audible tones detected from each practice tape immediately after each practice assignment. After the 10th treatment session. both HP and NHP Ss were asked to apply their relaxation skills in daily situations associated with anxiety and tension over a 2-week application period. Rdtr.\-rrtiotl cdurrtiort .sc.s.riott.r. Two evaluation sessions were held corresponding to the 3rd and 5th week of treatment. In addition. a final evaluation session was held during the last day of the ‘-week maintenance period. These relaxation evaluations were identical to the pre-treatment evaluation session. Both treatment and WLC Ss participated in all relaxation evaluation sessions. Sc~/‘-report uss~~sstmlt. Throughout the 5-week treatment and 2-week application periods, all Ss. both treatment and WLC, filled out DSMSs. The self-monitoring scales provided weekly mean anxiety and tension ratings for each S. In addition, the Trait form of the STAI was completed by all S’s at the end of the treatment and application phases of the study. RESULTS The mean (SD = 5.91) populations; 1970). A one-way NHP. WLC) experimental A Group revealed no sessrons. Intcrscorcr

pre-treatment Trait Anxiety scores were 49.45 (SD = 3.77) for males and 50.64 for fcmalcs. This is noticeably higher than the normal values for college-level 37.68 (SD = 9.69) for males and 38.25 (SD = 9.14) for females (Spielberger rf al., analysis of variance was computed to evaluate the initial equivalence of groups (HP, on the Trait form of the STAI. No significant differences between Ss in each condition was obtained on pre-treatment scores (F(2,30) = 0.38. P > 0.05). x Time repeated-measures analysis of variance of the treatment credibility scores significant interactions or main effects between treatment groups at the 1st or 6th agrecmcnt

for the heart-

and respiration-rate

values

was 0.89.

Home

Table

637

practice

I. Mean values for the STAI (Trait scale) by experimental condition Treatment

Compliance

rates,fbr

Group

N

Pre

post

HP

12

NHP

10

WLC

II

49.33 (4.33) 51.40 (4.43) 50.18 (6.69)

41.75 (7.56) 43.80 (9.00) 49.64 (8.12)

Post-application 42.38 (8.43) 45.60 (10.49) 51.09 (9.95)

HP Ss

Compliance to the home practice assignments for Ss in the HP group was evaluated in two ways. First, the percentage of self-reported home practice assignments was assessed for each S by dividing the number of practice tapes which the S indicated he or she had used by the total number of tapes assigned. Second, for each reported home practice assignment, the number of tones reported by the S was compared with a master list containing each tape’s actual number of tones. The percentage of agreement was used as an objective measure of compliance. The mean percentage of agreement was used as an objective measure of compliance. The mean percentage of self-reported home practice was 57.08 (SD = 28.88) while the mean percentage of these reported practices which could be objectively detected by the marked tape procedure was 61.67 (SD = 25.37). Treatment group comparisons

Mean values for repeated time comparisons of Trait Anxiety scores on the STAI and rated anxiety-tension levels on the DSMS are presented in Tables 1 and 2, respectively. Group x Time repeated-measures analyses of variance were performed on these values. The results indicated a significant Group x Time interaction for daily self-monitored general anxiety-tension levels (F( 14,206) = 1.80, P < 0.05). Post-hoc Duncan multiple range tests indicated that both treatment groups reported significantly lower levels of general anxiety and tension than WLC Ss from Treatment Week 3 through the final application week on the DSMS. There were no significant differences between the HP or NHP groups. In addition, the HP group reported significantly lower anxiety-tension levels at Treatment Week 1 than the other two groups, with no differences between the NHP and WLC groups, with no differences between the two treatment groups. Mean values for heart rate, respiration rate and Anxiety Differential initial levels and within-session changes for the relaxation evaluations are presented in Tables 3 and 4, respectively. Group x Time repeated-measures analyses of variance performed on changes across sessions in initial levels and within-session changes revealed no significant differences on any measure. Group comparison

of percent

S improvement

Both self-report and physiological data were evaluated to establish the percentage of Ss who improved significantly in each experimental condition. Ss whose change scores on each measure improved more than 1.65 times the standard error of measurement were classified as ‘significantly

Table 2. Mean values for the DSMS Treatment Pre

I

2

3

bv exoerimental

week 5

4

HP (N = 12) general 1.39 (0.58)

1.19 (0.48)

1.51 (0.76)

1.51 (0.72)

1.53 (0.68)

1.44 (0.76)

1.61 (0.10)

1.62 (0.47)

1.57 (0.17)

I.1 I (0.46)

I .06 (0.27)

I .03 (0.39)

7

0.86 (0.29)

0.89 (0.35)

I .28 (0.73)

I .23 (.085)

1.62 (0.41)

1.57 (0.73)

levels

I .26

I .46

I .27

(0.80)

(0.89)

(0.58)

WLC (N = 1 I) general I .63 (0.40)

6

levels

NHP (N = IO) general

1.70 (0.15)

condition

Application week

levels

I .43 (0 34)

63X

and FRANK L. COLLINS JR

J. BRUCE HILLENRERC

Table 3. Mean values for heart rate, respiration Differential initial levels by experimental Relaxation

Evaluation

rate and Anxiety condition

Session

Treatment GPXlp

middle

PK

Heart HP NHP WLC

HP NHP WLC

HP NHP WLC

76.26 (10.13) 81.42 (10.20) 69.07 (8.44) 16.61

(2.60) 15.19 (4.26) 15.12 (3.90) 65.33 (5.68) 67.90 (X.X7) 66 73 (12.X4)

post

Post-application

rate 76.30 (8.73) 77.80 (12.09) 71.64 (6.38) mte

75.9 I (8.89) 79.01 (9.41) 71.42 (10.56)

17.02 17.63 (3.15) (2.95) 16.13 16.17 (3.80) (4.47) 16.45 16.65 (3.66) (6 55) Anxiety Diti’crentlal

17.43 (2.06) 16.45 (4.97) 16.39 (2.60)

76.50 (9.64) 83.03 (5.44) 74.52 (9.37) Resplratmn

59.0x (9.00) 62.50 (12.19) 66.36 (12.15)

56.50 (9.23) 65.30 (17.26) 67.1X (11.75)

56.67 (8 39) 61.20 (14.57) 70.45 (I 5.82)

improved’ (P < 0.05) on that dependent variable. These data were analyzed by Group x Time repeated-measures analyses of variance. Ss who significantly improved were assigned a 1 and Ss who did not improve were assigned a 0 for all analyses. The percentage of Ss within each condition who significantly improved on the Trait scale of the STAI is presented in Table 5. Improvement on this measure of trait anxiety level was determined by changes in scores at the final treatment session and the maintenance relaxation evaluation session from pre-treatment levels. A Group x Time repeated-measures analysis of variance indicated no significant differences between groups. The percentage of Ss within each condition with significantly improved mean general anxiety-tension ratings on the DSMS is presented in Table 6. Improvement on daily self-monitored anxiety-tension levels was determined by changes in mean general ratings each week of treatment

Table 4. Mean values for heart rate. respiration rate and Anxiety Dill’erential within-session changes by experimental condltmn Relaxatmn

Evaluation

Session

Tre;ltment Group HP NHP WLC

HP NHP WLC

HP NHP WLC

Fe

middle

post

Heart rate -1 73 1.2x -166 (2 X5) (3 13) (3 13) -~4.12 1.38 ~ 4 00 (3.06) (3 45) (4 94) 3.08 ~ 4.09 -3.57 (2 77) (4.24) (5 14) Respiratmn rate ~ 0.86 -0.50 -0.8X (I .09) (0.67) (1.32) -0.41 +(I.56 flJ.86 (1.69) (I .48) (1.72) -0.34 -0.70 to. I8 (0.82) (1.32) (1.55) Anxiety DilTerential - 5.42 -9.50 ~ 7.00 (X.38) (7.34) (4.92) 10.40 13.50 13.00 (X.X2) (X.58) (8.49) ~1091 10.00 -x.91 (I? 5X) (I? 53) (10.25)

Post-application - 2.50 (2.31) -0.99 (2.65) -2.69 (5.59) 0.90 (0.92) ~O.hl (1.58) -0.56 (0.86) -4.67 (6.X7) ~ 10..50 (11.10) m-8.36

Home

practice

639

Table 5. Percentage of Ss who improved significantly (Trait scale) by experimental condition Group

N

HP NHP WLC

12 IO II

Post-treatment (““J

on the STAI

Post-application ?‘:,I

75 70 36

75 60 45

and application from pre-treatment values. Repeated-measures analyses of variance indicated significant Group x Time interactions for general ratings (F (12, 177) = 3.15, P < 0.001). Post-hoc Duncan multiple range tests for general anxiety-tension ratings indicated that a significantly greater percentage of HP Ss reported improvement than the NHP and WLC Ss during the 2-week application period. In addition, a significantly greater percentage of HP Ss reported improvement than the WLC Ss at Treatment Weeks 3 and 4. Finally, a significantly greater percentage of HP Ss reported improvement than no home practice Ss during treatment Week 1. Heart-rate, respiration-rate and Anxiety Differential measures from the relaxation evaluation sessions were assessed for both within-session changes and initial level value changes across sessions. The percentage of Ss in each experimental condition who showed significant improvement on between- and within-session changes are presented in Tables 7 and 8, respectively. Withinsession changes were determined by pre to post differences during each of the 4 relaxation evaluation sessions. Between-session changes were determined by comparing initial-level values for the 2 treatment and 1 application evaluation sessions from the pre-treatment session levels. Repeated measures indicated significant Group x Time interactions for Anxiety Differential initial levels (F (4, 60) = 2.72, P < 0.05) respiration-rate initial levels (F(4, 59) = 3.24, P < 0.05) and within-session heart-rate changes (F(6, 90) = 3.09, P < 0.05). Post-hoc Duncan multiple range tests indicated that a significantly greater percentage of HP and NHP Ss improved on initial Anxiety Differential values than WLC Ss at the 2nd evaluation session. In addition, a significantly greater percentage of HP Ss improved on initial Anxiety Differential values than NHP and WLC Ss at the final 2 evaluation sessions. Post-hoc Duncan multiple range tests for respiration-rate initial levels indicated that a significantly greater percentage of NHP and WLC Ss improved than HP Ss at the final evaluation session. Finally, post-hoc Duncan multiple range tests for heart-rate within-session changes indicated that a significantly greater percentage of NHP Ss improved than HP and WLC Ss at Evaluation Sessions 2 and 3. Table 6. Percentage

of’ Ss significantly improved experimental condition Treatment

GXWp HP NHP WLC

I

27 40 45

Application

week

5

I

2

General levels 58 50 50 33 30 40 9 I8 55

82 40 45

75 40 45

2

58 20 36

week

on the DSMS by

3

4

Table 7. Percentage of ss who significantly Improved on heart rate, respiration rate and Anxiety Differential changes within session by exverimentai condition Relaxation

Evaluation

Session

Treatment Group

Prc

HP NHP WLC

33 40 36

HP NHP WLC

33 IO 27

HP NHP WLC

83 90 82

middle

post

Heart rate 42 42 80 60 54 45 Respiration rate 50 42 44 IO 45 I8 Anxiety differential x3 64 70 90 55 55

Application post 42 20 36 42 40 36 64 60 55

640

J. BRUCE HILLENBERG and FRANK L. COLLINS JK

Table 8. Percentage of Ss who significantly improved on heart rate, respiration rate and Anxiety DitTerential initial levels between sessions by experimental condition Relaxation

Evaluation

Session

Treatment Group

middle

HP NHP WLC

25 30 9

HP NHP WLC

25 II IX

HP NHP WLC

75 70 36

post Heart rate 42 00 IX Respiratm rate I7 30 Y Anxiety differential 75 40 27

Post-applicatmn 42 50 36

30 IX x3 40 36

DISCUSSION

The present study supports the importance of home practice assignments in standardized progressive relaxation training. Group comparisons showed that the HP and NHP conditions were significantly improved on self-monitored daily anxiety and tension relative to the WLC group. No differences were found between these groups as treatment progressed. However, comparisons of the percentage of subjects by condition showing significant improvement supported the effectiveness of the home practice component on self-monitored daily anxiety and tension during the final 2-week application period. Support for home practice assignments is strengthened since the analysis of improvement by subject gives a more accurate picture of the strength of each treatment condition (Hersen and Barlow, 1976). Additionally, no differences in treatment credibility were found between the HP and NHP conditions. Since there were no differences, the differential treatment effects cannot be attributed to each groups initial and subsequent impression of credibility or expectancy for improvement. The reliability of these results are enhanced since credibility was assessed both at the beginning and the latter stage of treatment (Kazdin and Wilcoxin, 1976). In this way, both the perceived credibility of the initial treatment rationales and possible changes in perception as each treatment progressed were controlled for. Though home practice assignments appeared to contribute to the efficacy of progressive relaxation training, the critical nature of these assignments would have been more accurately evaluated if a higher percentage of compliance had been established. Subjects in the HP condition reported practicing on the average just under 60”/:, of their practice assignments. In addition, on the average only 600/, of these reported practices could be objectively determined to have occurred by the marked-tape procedure. Overall, combining self-reported and objectively-detected practice reveals a significant level of non-compliance to the home practice component. In view of the previous findings, the present study raises several important issues and questions about the use of home practice assignments in progressive relaxation research. First, even though a rationale is presented for the importance of home practice, it appears unrealistic to expect complete compliance to the home practice regimen used in the present study. This raises serious questions about the actual frequency of home practice engaged in by subjects during previous reported relaxation training studies where practice assignments were given. Thus only by reporting objective compliance rates can valid conclusions be made about the contribution of home practice assignments to strength of specific relaxation training procedures. In the empirical investigation of treatment effectiveness, it is important to determine the actual degree to which subjects engaged in critical procedural components. Second, it is possible that subjects found the typical pattern of twice-daily practice to be too demanding. Therefore, since this study supports the use of home practice assignments, there may be a specific minimum number or pattern of practices required for clinical improvement. To date, this question has not been empirically investigated. Finally, since home practice appears to increase the treatment efficacy of progressive relaxation training.

Home

practice

641

concurrent strategies such as time management, behavioral contracting, stimulus control and reinforcement for criterion compliance levels could be employed to increase the frequency of subject practice. Another important finding was the lack of congruency between subject-monitored outcome and the designated laboratory assessments. Though support for the home practice component was seen on several self-report variables, both group analyses of averaged results and percent subject improvement found no systematic differences between groups on within-session changes of relaxation level, as defined by self-report and physiological variables, during the laboratory evaluation periods. In addition, no systematic differences between groups were seen on physiological values taken at the beginning of each evaluation period. One plausible interpretation of these findings is that only under in-oivo conditions could differences between the treatment and wait-list control conditions be seen on variables (i.e. physiological, cognitive) evaluating a S’s ability to become relaxed during a designated situation (Andrasik and Holroyd, 1980; Barlow and Wolfe, 1981; Lazarus, 1981). The presence of learned relaxation skills would be more critically evaluated under conditions which previously elicited symptoms of general anxiety and tension. Thus the non-representative nature of the relaxation evaluation sessions may have prevented possible differences between groups in relaxation skills from being detected. It seems reasonable to suggest that monitoring changes in subject symptomology (behavioral, physiological, cognitive) should increase in validity and generalizability when conducted under realistic conditions. In the present study, the self-monitoring of daily anxiety and tension came closest to this goal. Results from the present study would also appear to have implications for the clinical goals of progressive relaxation training. The effectiveness of the home practice component was most obvious during the application period in the latter stage of treatment. It was during this period when treatment subjects were attempting to use their new relaxation skills as they coped with difficult in-uivo situations. Thus home practice may be a central component in helping subjects learn applied relaxation skills. This conclusion supports the growing interest in viewing relaxation training as teaching active in-vivo coping skills (Chang-Liang and Denny, 1976; Deffenbacher, 1976; King, 1980). According to this model, the critical test of the effectiveness of progressive relaxation training is whether subjects can utilize their new skills to alleviate specific symptoms in problem situations. To enhance the acquisition of applied relaxation abilities. it seems appropriate to not only teach subjects and clients how to relax in laboratory and home settings, but also how to use the relaxation skills under real conditions (King, 1980). Additional research is needed to empirically test which other components (e.g. self-monitoring, role-playing, h-z%~ practice assignments with subsequent evaluation and feedback) might contribute to the effectiveness of progressive relaxation in teaching subjects and clients to show clinically-significant change under actual conditions. Acknowledgemenrs-This research was based upon a thesis submitted by the first author in partial fulfillment of the requirements for the Master of Arts degree at West Virginia University. Appreciation is expressed to committee members Barry A. Edelstein and B. Kent Parker, to our group leaders Jeffrey Knight. Ruth Baer. Tom DiLorenzo and Karen Gil; and to our research assistants Bruce Liller, Peg Crockett. Jens Nygard and Dwamidar Kini.

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