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Within-subject analysis of autogenic training and cognitive coping training in the treatment of tension headache pain
J. Behav. Ther. & Exp. Psychial. Printed in Great Britain.
Vol. 12, No. 3, pp. 219-223,
WITHIN-SUBJECT COGNITIVE
0005-7!W8/81/03021945 $02.00/O 0 1981 Pergamon Press Ltd.
1981.
ANALYSIS
OF AUTOGENIC
COPING TRAINING
IN THE TREATMENT
TENSION HEADACHE NORMAN
B. ANDERSON, University
P. SCOTT
AND OF
PAIN
LAWRENCE
of North Carolina
TRAINING
and TERRY
W. OLSON
at Greensboro
Summary-Previous research on muscle-contraction headache pain suggests that relaxation training or cognitive coping training may be effectively used as alternatives to traditional medical interventions. Although each has been shown to be beneficial, a combination of the two procedures may facilitate the effects attained when one is used alone. The purpose of this study was to evaluate the separate and combined effects of relaxation training and cognitive coping training in the treatment of muscle-contraction headache pain, using single-subject methodology. This methodology provides a better opportunity to examine the day-to-day variability encountered in headache treatment, which is not usually evidenced with group designs. In addition, single-subject designs offer the practicing clinician an empirical method of evaluating treatment procedures. Fourteen muscle-contraction headache sufferers were asked to self-monitor their headache frequency, intensity, and duration for either 1 or 2 weeks. Following this baseline period, subjects received three sessions of cognitive coping training or relaxation training, followed by both treatments combined. Six additional subjects received six sessions of either coping, relaxation, or coping plus relaxation. Results showed that both coping and relaxation used alone were effective in reducing headache pain. It also appeared that in some instances, the combined effects of both treatments facilitated this reduction.
Andrasik and Westwood, 1977; Holroyd and Andrasik, 1978; Tasto and Hinkle, 1973; Fichtler and Zimmerman, 1973; McKenzie et al., 1974; Wickramasekera, 1973). One such procedure, relaxation training, has been shown to reduce headache frequency and severity when used alone (Tasto and Hinkle, 1973; Fichtler and Zimmerman, 1973) or in combination with electromyographic (EMG) biofeedback (McKenzie et al., 1974; Wickramasekera, 1973). Another self-control technique, cognitive coping training, has recently been demonstrated to reduce tension headaches (Holroyd, Andrasik and Westwood, 1977; Holroyd and Andrasik, 1978). Basically, cognitive coping training involves teaching individuals to identify maladaptive cognitive responses that are assumed to mediate the occurrence of tension headache. Clients are encouraged to attribute the cause of their
Tension or muscle contraction headache constitutes one of the most prevalent of all psychophysiological disorders. Survey data indicate that up to 70% of adults experience headaches, of which 40% can be classified as tension related (Kashiwagi, McClure and Wetzel, 1972). Tension headache is typically described as a tight, bandlike ache, that usually occurs bilaterally in the frontal, occipital, and/or suboccipital regions. Traditional medical management has relied primarily on tranquilizers, muscle relaxants, or an analgesic-sedative combination to treat episodes of head pain. Recently there has been a proliferation of reports demonstrating the efficacy of behavioral self-control techniques in the management of tension headaches (Cox, Freundlich and Meyer, 1975; Hutchings and Reinking, 1976; Chesney and Shelton, 1976; Haynes et al., 1975; Holroyd, Requests Carolina,
for reprints Greensboro,
should be addressed to P. Scott Lawrence, North Carolina 27412, U.S.A. 219
Department
of Psychology,
The University
of North
220
NORMAN
B. ANDERSON,
P. SCOTT LAWRENCE
headache to relatively specific cognitive aberrations rather than to external stimuli or complex inner dispositions. By teaching clients to cope more efficiently with environmental stressors we hoped to prevent tension headache. With rare exception (e.g. Epstein, Hersen and Hemphill, 1974), most behavioral studies on tension headache have employed between groups methodology. While this is ideal for evaluating the statistical significance of various treatment regimens, other designs may be more appropriate for assessing the clinical significance of a therapeutic procedure (Hersen and Barlow, 1976). Within-subject analysis, however, provides an opportunity to examine individual response to treatment and the day-to-day variability encountered in headache treatment. Furthermore, within-subject designs offer the practicing clinician an empirical method of systematically evaluating the efficacy of treatment procedures. The purpose of the present study was to employ a series of within-subject designs to assess the clinical effectiveness of two behavioral interventions for tension-headache. The two interventions, relaxation and cognitive coping training, were evaluated singly and in combination. Although each has been shown to be beneficial, it could be that a combination of the two procedures would be more effective than either used alone. METHOD Subjects were referred to the University of North Carolina at Greensboro Psychology Clinic by the Student Health Service located on the UNC-G campus. All subjects were screened by medical personnel at the Student Health Service and were diagnosed as having tension headache. Fourteen persons who reported having an average of four or more headache episodes a week participated in the present study. Participants included 12 females and 2 males with a mean age of 20 yr (range 18-30 yr) and a mean duration of headache problems of 5 yr (range 2-8 yr). Six subjects were able to be contacted to participate in a 7 month follow-up.
Design All subjects
participated
in a baseline
phase
for either
1 or 2 weeks. Following this baseline period, subjects 1 and
and TERRY W. OLSON
2 received three sessions of cognitive coping training across a 4 week period. Subjects 3 and 4 received three sessions of relaxation training across 4 weeks. The purpose here was to examine singly the effects of each self-control procedure. In order to determine if the therapeutic benefit of one technique could be enhanced by the later introduction of a second, a multiple baseline design across subjects was used for subjects 5-12. Subjects 5-8 were treated with 2 weeks of relaxation training followed by 2 weeks of relaxation plus cognitive coping training. Subjects 9-12 received 2 weeks of cognitive coping training followed by 2 weeks of cognitive coping plus relaxation training. Finally, subjects 13 and 14 received 4 weeks of cognitive coping training and relaxation training combined. Several investigations have shown that self-control procedures such as relaxation and cognitive coping training are more effective than no treatment or placebo conditions in alleviating tension headache pain. For this reason, including no treatment or placebo conditions in the current study did not seem ethically justified. Measures The dependent measures in this experiment were the subject’s self-report of frequency, intensity and duration of their headaches. This information was recorded in a headache recording booklet in which the onset and cessation time of each headache was noted and assigned an intensity rating based on a 5 point numerical scale (1 = mild headache, 5 = excruciating). From these data, a daily headache activity score was derived (Budzynski et al., 1973).* Follow-up subjects collected identical headache data during the 7 month follow,-up.
TREATMENT Autogenic relaxation training This treatment was developed from the relaxation procedures outlined by Schultz and Luthe (1959) and has been used with both tension and migraine headaches. Essentially, this method involved instructing the subjects to imagine certain physiological changes occurring that are characteristically associated with deepening levels of relaxation. In a typical relaxation training session subjects reclined in a comfortable lounge chair with their eyes closed, while the therapist provided the following relaxation instructions: I feel quiet and relaxed. My right hand feels heavy and relaxed. My lower right arm is beginning to feel warm and heavy. My upper right arm feels heavy and relaxed. My left hand and arm also feels heavy and relaxed. Both my arms are now heavy, warm and comfortable. My head, face and neck are beginning to feel quite comfortable. All of the tension is slowly leaving my face and head. My chest and abdomen feel heavy and relaxed. My breathing is very slow and rhythmic. My legs and feet are beginning to feel very heavy and relaxed. All of the tension is moving down my legs and out of my toes. My entire body feels quite comfortable and serene.
*The following formula was used to compute the daily headache activity score (HA) : HA = t (I x D)/24, where I is headache intensity rating and D is the duration of each headache; there products are summed each day and divided by 24, yielding an hourly weighted average of headache activity.
TENSION Following the initial session, subjects were asked to practice the procedure once a day and to record the date and time of each practice on a standard recording sheet. In addition, subjects were also instructed to utilize their relaxation skills whenever they began to experience a headache. These practice sheets were brought to each therapy session where they were checked by the therapist. All subjects reported practicing the relaxation procedure at least once a day. Cognitive coping training This treatment emphasized the altering of subject’s negative or maladaptive self-verbalizations toward environmental stressors (Meichenbaum, 1974). Each subject was given a rationale that focused on the connection between environmental stressors, cognitions about those stressors, and tension headache. They were told that by changing one’s reaction to a stressor (via changing thought patterns), one could possibly prevent the onset of a headache. Treatment progressed in four stages. Initially, a list of stressful situations was constructed. Here, the subjects indicated situations or events that tended to trigger tension or anxiety. Second, each subject was given aid by the therapist in identifying any maladaptive thoughts or beliefs that might have been contributing to their anxiety in these situations. Emphasis was placed on identifying negative thoughts that occurred either before, during or after a stressful event. Third, subjects were given a list of cognitive coping statements designed to replace their negative selfstatements. These coping statements were divided into four categories: preparing for the stressor (e.g. “Don’t worry, I know I’ll do just fine”); confronting and handling the stressor (e.g. “I’m sure I am performing as well as anyone else”); dealing with feelings of being overwhelmed (e.g. “A little anxiety is normal and it doesn’t mean I’m falling apart”), and reinforcing self-statements (e.g. “Congratulations-you handled that situation very well”). The final stage involved having the subjects practice using their coping statements while imagining stressful events. The therapist verbally presented subjects with three anxiety provoking situations and had them recite a coping statement aloud while still visualizing the scene. After the first session subjects were instructed only to say the coping statements covertly. Subjects receiving coping training were also asked to practice this procedure at least once a day, and to record their practice dates and times on a standard sheet. All subjects reported practicing at least once a day. They were also asked to use the coping statements given them, or their own self-generated coping statements, whenever they were faced with a stress-producing situation or began to experience a headache. Coping plus relaxation Subjects who received training simultaneously
the combined approach were given in both procedures outlined above.
RESULTS Figure treatment Subjects
1 depicts the results of the three procedures on daily headache activity. 1 and 2, and subjects 3 and 4 who
HEADACHE
221
received coping training and relaxation training respectively, all were able gradually to reduce their self-report of daily headache activity to zero levels by the end of treatment. This effect remained constant through four post-treatment days. Subjects 5-8 and subjects 9-12, who received either relaxation or coping respectively, followed by the two treatments combined, attained reduced levels of headache activity after 4 weeks, and were reporting a cessation of headaches at post-treatment (Subjects 11 and 12) and at 7 month follow-up (Subjects 9 and 10 and 5-8). Subjects 5 and 6 and subjects 9 and 10, however, showed a sudden and somewhat dramatic reduction of their headaches when the combination of treatments was administered. That is, for subjects 5 and 6, when cognitive coping training was added to relaxation training daily headache activity dropped off to near zero level. Similarly, for subjects 9 and 10, who initially received coping training followed by coping plus relaxation training, there was an even clearer effect of the combined approach since their baseline levels were originally higher. These four subjects also demonstrated much less day-to-day variability in their headaches when the two treatments were combined. Seven month follow-up data attained from subjects 5-8 showed maintenance of the therapeutic effects. Finally, subjects 13 and 14 (coping plus relaxation) also evidenced a gradual decline in headache activity.
DISCUSSION The present study explored the clinical efficacy of relaxation training and cognitive coping training for tension headaches. All participants were able to achieve zero levels of daily headache activity. This study adds to the literature on headache treatment which demonstrates that behavioral self-control procedures are statistically superior to non-treatment and placebo controls. The current study shows that cognitive training and
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and
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Fig. I. Daily headache activity presented in two-day blocks. After a baseline period, subjects received either Coping (Subjects 1 and 2), Relaxation (Subjects 3 and 4), Coping followed by Coping plus Relaxation (Subjects 9-12), Relaxation followed by Coping plus Relaxation (Subjects 5-8), or Coping plus Relaxation (Subjects 13 and 14).
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.
234.
Bosel~ne
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I
TENSION
autogenic training are both valid methods for helping clients achieve clinically significant reductions in headache pain. In this study, all subjects were reporting zero levels of headache activity at post treatment and follow-up. One purpose of the present study was to compare the relative effectiveness of autogenic relaxation training versus cognitive approaches for the reduction of headaches. Generally, all subjects showed reductions in headache activity using either of these approaches singly. Thus, either autogenic relaxation training or cognitive training may be used with headache clients, although some therapists may find autogenic training easier to implement. The addition of the combination procedure had somewhat different effects on the various pairs of subjects, some subjects showing a sudden decrement in headache activity with reduced variability, while others showed additional gradual declines in headache activity. Subjects 11 and 12, however, showed a sudden increase in headache activity for a few sessions before headaches reduced to a near zero level. Wolpe (1977) has pointed out that in most outcome research, clinical problems based on cognitive misconceptions have not been separated out from identical problems based on direct emotional conditioning. In the current study, it is possible that some subjects’ headaches were related primarily to cognitive factors, others to autonomic factors and still others to both cognitive and autonomic factors. The effect of adding a second treatment, as in the combination condition, could have depended on the particular cognitive or autonomic basis of the headache. For example, subjects whose headaches were autonomically based would not be expected to show much additional improvement when coping training was added onto an already effective relaxation training. Finally, within-subject designs were shown to be a useful method of evaluating client’s response to treatment. These designs provide an opportunity for the practicing clinician to
HEADACHE
223
become more systematic in evaluating treatment success, and they provide a means for examining empirical questions on a case by case basis.
REFERENCES Budzynski T., Stoyva J., Adler C. and Mullaney D. (1973) EMG biofeedback and tension headache: A controlled study, Psychosom. Med. 35,484~496. Chesney M. and Shelton J. L. (1976) A comparison of muscle relaxation and electromyogram biofeedback treatment for muscle contraction headache, J. Behav. Ther. & Exp. Psychiat. 7,221-225. Cox D. J., Freundhch A. and Meyer R. G. (1975) Differential effectiveness of electromyogram biofeedback treatments for muscle contraction headache, J. Consult. C/in. Psychol. 43,892-899. Epstein L. H., Hersen M. and Hemphill D. P. (1974) Contingent music and anti-tension exercise in the treatment of a chronic tension headache patient, J. Behav. Ther. & Exp. Psychiat. $59-63. Fichtler H. and Zimmerman R. R. (1973) Changes in reported pain from tension headaches, Percept. Motor Skills36,312. Haynes S. N., Griffin P., Mooney D. and Parise M. (1975) Electromyographic biofeedback and relaxation intructions in the treatment of muscle contraction headache, Behav. Ther. 6,672-678. Hersen M. and Barlow D. (1976) Sing/e Case Experimental Designs. Pergamon Press, New York. Holroyd K. A., Andrasik F. and Westwood T. (1977) Cognitive control of tension headache, Cog. Ther, Res. 1,121-133. Holroyd K. A. and Andrasik F. (1978) Coping and the selfcontrol of chronic tension headache, 1. Consult. Clin. Psycho/. 45(5), 1036-1045. Hutching D. F. and Reinking R. H. (1976) Tension headaches: what form of therapy is most effective?, Biofeedback and Self-Regulation 1, 1833190. Kashiwagi T., McClure J. N. and Wetzel K. D. (1972) Headache of psychiatric disorders, Dis. Nerv. System 33,659-663. Meichenbaum D. H. (1974) Cognitive Behavior Modification. General Learning Press, Morristown, N.J. McKenzie R. E., Ehrisman E. J., Montgomery P. S. and Barnes R. H. (1974) The treatment of headache by means of electroencephalographic feedback, Heuduche 14, 164-172. Schultz J. and Luthe W. (1959) Autogenic Training: A Psychophysiologic Approach to Psychotherapy. Grune &Stratton, New York. Tasto D. L. and Hinkle J. E. (1973) Muscle relaxation treatment for tension headaches, Behav. Res. Ther. 11, 347-349. Wickramasekera I. (1973) Temperature feedback for the control of migraine, J. Behav. Ther. & Exp. Psych&t. 4,343-345.
Vol. 12, No. 3, pp. 219-223,
WITHIN-SUBJECT COGNITIVE
0005-7!W8/81/03021945 $02.00/O 0 1981 Pergamon Press Ltd.
1981.
ANALYSIS
OF AUTOGENIC
COPING TRAINING
IN THE TREATMENT
TENSION HEADACHE NORMAN
B. ANDERSON, University
P. SCOTT
AND OF
PAIN
LAWRENCE
of North Carolina
TRAINING
and TERRY
W. OLSON
at Greensboro
Summary-Previous research on muscle-contraction headache pain suggests that relaxation training or cognitive coping training may be effectively used as alternatives to traditional medical interventions. Although each has been shown to be beneficial, a combination of the two procedures may facilitate the effects attained when one is used alone. The purpose of this study was to evaluate the separate and combined effects of relaxation training and cognitive coping training in the treatment of muscle-contraction headache pain, using single-subject methodology. This methodology provides a better opportunity to examine the day-to-day variability encountered in headache treatment, which is not usually evidenced with group designs. In addition, single-subject designs offer the practicing clinician an empirical method of evaluating treatment procedures. Fourteen muscle-contraction headache sufferers were asked to self-monitor their headache frequency, intensity, and duration for either 1 or 2 weeks. Following this baseline period, subjects received three sessions of cognitive coping training or relaxation training, followed by both treatments combined. Six additional subjects received six sessions of either coping, relaxation, or coping plus relaxation. Results showed that both coping and relaxation used alone were effective in reducing headache pain. It also appeared that in some instances, the combined effects of both treatments facilitated this reduction.
Andrasik and Westwood, 1977; Holroyd and Andrasik, 1978; Tasto and Hinkle, 1973; Fichtler and Zimmerman, 1973; McKenzie et al., 1974; Wickramasekera, 1973). One such procedure, relaxation training, has been shown to reduce headache frequency and severity when used alone (Tasto and Hinkle, 1973; Fichtler and Zimmerman, 1973) or in combination with electromyographic (EMG) biofeedback (McKenzie et al., 1974; Wickramasekera, 1973). Another self-control technique, cognitive coping training, has recently been demonstrated to reduce tension headaches (Holroyd, Andrasik and Westwood, 1977; Holroyd and Andrasik, 1978). Basically, cognitive coping training involves teaching individuals to identify maladaptive cognitive responses that are assumed to mediate the occurrence of tension headache. Clients are encouraged to attribute the cause of their
Tension or muscle contraction headache constitutes one of the most prevalent of all psychophysiological disorders. Survey data indicate that up to 70% of adults experience headaches, of which 40% can be classified as tension related (Kashiwagi, McClure and Wetzel, 1972). Tension headache is typically described as a tight, bandlike ache, that usually occurs bilaterally in the frontal, occipital, and/or suboccipital regions. Traditional medical management has relied primarily on tranquilizers, muscle relaxants, or an analgesic-sedative combination to treat episodes of head pain. Recently there has been a proliferation of reports demonstrating the efficacy of behavioral self-control techniques in the management of tension headaches (Cox, Freundlich and Meyer, 1975; Hutchings and Reinking, 1976; Chesney and Shelton, 1976; Haynes et al., 1975; Holroyd, Requests Carolina,
for reprints Greensboro,
should be addressed to P. Scott Lawrence, North Carolina 27412, U.S.A. 219
Department
of Psychology,
The University
of North
220
NORMAN
B. ANDERSON,
P. SCOTT LAWRENCE
headache to relatively specific cognitive aberrations rather than to external stimuli or complex inner dispositions. By teaching clients to cope more efficiently with environmental stressors we hoped to prevent tension headache. With rare exception (e.g. Epstein, Hersen and Hemphill, 1974), most behavioral studies on tension headache have employed between groups methodology. While this is ideal for evaluating the statistical significance of various treatment regimens, other designs may be more appropriate for assessing the clinical significance of a therapeutic procedure (Hersen and Barlow, 1976). Within-subject analysis, however, provides an opportunity to examine individual response to treatment and the day-to-day variability encountered in headache treatment. Furthermore, within-subject designs offer the practicing clinician an empirical method of systematically evaluating the efficacy of treatment procedures. The purpose of the present study was to employ a series of within-subject designs to assess the clinical effectiveness of two behavioral interventions for tension-headache. The two interventions, relaxation and cognitive coping training, were evaluated singly and in combination. Although each has been shown to be beneficial, it could be that a combination of the two procedures would be more effective than either used alone. METHOD Subjects were referred to the University of North Carolina at Greensboro Psychology Clinic by the Student Health Service located on the UNC-G campus. All subjects were screened by medical personnel at the Student Health Service and were diagnosed as having tension headache. Fourteen persons who reported having an average of four or more headache episodes a week participated in the present study. Participants included 12 females and 2 males with a mean age of 20 yr (range 18-30 yr) and a mean duration of headache problems of 5 yr (range 2-8 yr). Six subjects were able to be contacted to participate in a 7 month follow-up.
Design All subjects
participated
in a baseline
phase
for either
1 or 2 weeks. Following this baseline period, subjects 1 and
and TERRY W. OLSON
2 received three sessions of cognitive coping training across a 4 week period. Subjects 3 and 4 received three sessions of relaxation training across 4 weeks. The purpose here was to examine singly the effects of each self-control procedure. In order to determine if the therapeutic benefit of one technique could be enhanced by the later introduction of a second, a multiple baseline design across subjects was used for subjects 5-12. Subjects 5-8 were treated with 2 weeks of relaxation training followed by 2 weeks of relaxation plus cognitive coping training. Subjects 9-12 received 2 weeks of cognitive coping training followed by 2 weeks of cognitive coping plus relaxation training. Finally, subjects 13 and 14 received 4 weeks of cognitive coping training and relaxation training combined. Several investigations have shown that self-control procedures such as relaxation and cognitive coping training are more effective than no treatment or placebo conditions in alleviating tension headache pain. For this reason, including no treatment or placebo conditions in the current study did not seem ethically justified. Measures The dependent measures in this experiment were the subject’s self-report of frequency, intensity and duration of their headaches. This information was recorded in a headache recording booklet in which the onset and cessation time of each headache was noted and assigned an intensity rating based on a 5 point numerical scale (1 = mild headache, 5 = excruciating). From these data, a daily headache activity score was derived (Budzynski et al., 1973).* Follow-up subjects collected identical headache data during the 7 month follow,-up.
TREATMENT Autogenic relaxation training This treatment was developed from the relaxation procedures outlined by Schultz and Luthe (1959) and has been used with both tension and migraine headaches. Essentially, this method involved instructing the subjects to imagine certain physiological changes occurring that are characteristically associated with deepening levels of relaxation. In a typical relaxation training session subjects reclined in a comfortable lounge chair with their eyes closed, while the therapist provided the following relaxation instructions: I feel quiet and relaxed. My right hand feels heavy and relaxed. My lower right arm is beginning to feel warm and heavy. My upper right arm feels heavy and relaxed. My left hand and arm also feels heavy and relaxed. Both my arms are now heavy, warm and comfortable. My head, face and neck are beginning to feel quite comfortable. All of the tension is slowly leaving my face and head. My chest and abdomen feel heavy and relaxed. My breathing is very slow and rhythmic. My legs and feet are beginning to feel very heavy and relaxed. All of the tension is moving down my legs and out of my toes. My entire body feels quite comfortable and serene.
*The following formula was used to compute the daily headache activity score (HA) : HA = t (I x D)/24, where I is headache intensity rating and D is the duration of each headache; there products are summed each day and divided by 24, yielding an hourly weighted average of headache activity.
TENSION Following the initial session, subjects were asked to practice the procedure once a day and to record the date and time of each practice on a standard recording sheet. In addition, subjects were also instructed to utilize their relaxation skills whenever they began to experience a headache. These practice sheets were brought to each therapy session where they were checked by the therapist. All subjects reported practicing the relaxation procedure at least once a day. Cognitive coping training This treatment emphasized the altering of subject’s negative or maladaptive self-verbalizations toward environmental stressors (Meichenbaum, 1974). Each subject was given a rationale that focused on the connection between environmental stressors, cognitions about those stressors, and tension headache. They were told that by changing one’s reaction to a stressor (via changing thought patterns), one could possibly prevent the onset of a headache. Treatment progressed in four stages. Initially, a list of stressful situations was constructed. Here, the subjects indicated situations or events that tended to trigger tension or anxiety. Second, each subject was given aid by the therapist in identifying any maladaptive thoughts or beliefs that might have been contributing to their anxiety in these situations. Emphasis was placed on identifying negative thoughts that occurred either before, during or after a stressful event. Third, subjects were given a list of cognitive coping statements designed to replace their negative selfstatements. These coping statements were divided into four categories: preparing for the stressor (e.g. “Don’t worry, I know I’ll do just fine”); confronting and handling the stressor (e.g. “I’m sure I am performing as well as anyone else”); dealing with feelings of being overwhelmed (e.g. “A little anxiety is normal and it doesn’t mean I’m falling apart”), and reinforcing self-statements (e.g. “Congratulations-you handled that situation very well”). The final stage involved having the subjects practice using their coping statements while imagining stressful events. The therapist verbally presented subjects with three anxiety provoking situations and had them recite a coping statement aloud while still visualizing the scene. After the first session subjects were instructed only to say the coping statements covertly. Subjects receiving coping training were also asked to practice this procedure at least once a day, and to record their practice dates and times on a standard sheet. All subjects reported practicing at least once a day. They were also asked to use the coping statements given them, or their own self-generated coping statements, whenever they were faced with a stress-producing situation or began to experience a headache. Coping plus relaxation Subjects who received training simultaneously
the combined approach were given in both procedures outlined above.
RESULTS Figure treatment Subjects
1 depicts the results of the three procedures on daily headache activity. 1 and 2, and subjects 3 and 4 who
HEADACHE
221
received coping training and relaxation training respectively, all were able gradually to reduce their self-report of daily headache activity to zero levels by the end of treatment. This effect remained constant through four post-treatment days. Subjects 5-8 and subjects 9-12, who received either relaxation or coping respectively, followed by the two treatments combined, attained reduced levels of headache activity after 4 weeks, and were reporting a cessation of headaches at post-treatment (Subjects 11 and 12) and at 7 month follow-up (Subjects 9 and 10 and 5-8). Subjects 5 and 6 and subjects 9 and 10, however, showed a sudden and somewhat dramatic reduction of their headaches when the combination of treatments was administered. That is, for subjects 5 and 6, when cognitive coping training was added to relaxation training daily headache activity dropped off to near zero level. Similarly, for subjects 9 and 10, who initially received coping training followed by coping plus relaxation training, there was an even clearer effect of the combined approach since their baseline levels were originally higher. These four subjects also demonstrated much less day-to-day variability in their headaches when the two treatments were combined. Seven month follow-up data attained from subjects 5-8 showed maintenance of the therapeutic effects. Finally, subjects 13 and 14 (coping plus relaxation) also evidenced a gradual decline in headache activity.
DISCUSSION The present study explored the clinical efficacy of relaxation training and cognitive coping training for tension headaches. All participants were able to achieve zero levels of daily headache activity. This study adds to the literature on headache treatment which demonstrates that behavioral self-control procedures are statistically superior to non-treatment and placebo controls. The current study shows that cognitive training and
r
ss lland
10 $&
20
30
‘lo
50
12
.
.
of
Blocks
1234567
two
.
of two
.
Coping
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.
,23456?
C.
I
Coping
Blocks
, Coping
reloxatlon
days
1234567
and
days
.-, Pod treatment
Ss 13 and
I4
/ 234567
Ss 5ond6
Blocks
1234567
of two
days
I234567
__ _ ._
.__-
.-._
----
_ . .~_
_,
_ ^. _ _
^ - .-
._
- ..
I^
_
o
. .
_
._
-
,mOn+hfoilow-"pweek
Fig. I. Daily headache activity presented in two-day blocks. After a baseline period, subjects received either Coping (Subjects 1 and 2), Relaxation (Subjects 3 and 4), Coping followed by Coping plus Relaxation (Subjects 9-12), Relaxation followed by Coping plus Relaxation (Subjects 5-8), or Coping plus Relaxation (Subjects 13 and 14).
1234567
.
234.
Bosel~ne
60-l
6.
ss 3and4
ss I Md 2 ~_$mselIne
I
TENSION
autogenic training are both valid methods for helping clients achieve clinically significant reductions in headache pain. In this study, all subjects were reporting zero levels of headache activity at post treatment and follow-up. One purpose of the present study was to compare the relative effectiveness of autogenic relaxation training versus cognitive approaches for the reduction of headaches. Generally, all subjects showed reductions in headache activity using either of these approaches singly. Thus, either autogenic relaxation training or cognitive training may be used with headache clients, although some therapists may find autogenic training easier to implement. The addition of the combination procedure had somewhat different effects on the various pairs of subjects, some subjects showing a sudden decrement in headache activity with reduced variability, while others showed additional gradual declines in headache activity. Subjects 11 and 12, however, showed a sudden increase in headache activity for a few sessions before headaches reduced to a near zero level. Wolpe (1977) has pointed out that in most outcome research, clinical problems based on cognitive misconceptions have not been separated out from identical problems based on direct emotional conditioning. In the current study, it is possible that some subjects’ headaches were related primarily to cognitive factors, others to autonomic factors and still others to both cognitive and autonomic factors. The effect of adding a second treatment, as in the combination condition, could have depended on the particular cognitive or autonomic basis of the headache. For example, subjects whose headaches were autonomically based would not be expected to show much additional improvement when coping training was added onto an already effective relaxation training. Finally, within-subject designs were shown to be a useful method of evaluating client’s response to treatment. These designs provide an opportunity for the practicing clinician to
HEADACHE
223
become more systematic in evaluating treatment success, and they provide a means for examining empirical questions on a case by case basis.
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