I often hear about relaxation techniques in pop psychology. We also discussed them in the mental health section of our Occupational Therapy (OT) curriculum when we explored anxiety. But are they effective and science-based?
Stress and anxiety are common but relatively nebulous issues that can be hard to treat – especially as the cause of stress can be difficult to localize and anxiety has no direct apparent “cause”. Prolonged psychological stress or anxiety can even manifest a variety of physiological symptoms – high blood pressure, poor cognitive performance, mood problems, gastrointestinal disturbance, changes in eating habits, weight changes, somatic symptoms, and substance abuse.
Prolonged or excessive stress and anxiety are recognized by the DSM as psychiatric disorders if they persist and interfere with a person’s ability to engage in daily activities. Now, that is a gross oversimplification and there are many kinds of anxiety disorders with specific symptoms, but a lengthy description is beyond the scope of this article. For more information, consult the DSM (Axis I).
Due to the discomfort of these symptoms, many people seek professional treatment (some never do). Patients with mild to moderate cases or who are averse to pharmaceutical treatment may seek/require relatively mild treatment methods. In those cases, it is important to consider the efficacy of the interventions used in order to ensure a high quality of health care.
Treatments for stress generally fall into two categories: cognitive behavioural therapy (CBT) and pharmaceutical intervention. Sometimes a combination of techniques is necessary to provide relief and treatment depends on severity of distress and the level of impact on daily life. CBT can incorporate some first-line techniques to help moderate stress and anxiety such as relaxation and meditation.
Some of these techniques are progressive muscle relaxation (PMR), relaxation therapy, meditation, and transcendental meditation (TM). The goal from an OT perspective is, after initial professional training, to give the patient some measure of control over their symptom management and increase independence.
PMR This is basically what is sounds like – tensing and relaxing muscles. The idea is to relieve tension in the muscles, producing a feeling of relaxation and therefore hopefully lessening feelings of anxiety. Also, if the patient is concentrating on their muscles rather than their worries, they focus and relax mentally as well. This is also used as a technique for tension-related insomnia.
Relaxation Therapy The aim of relaxation therapy is to use psychological methods to treat the psychological feeling of stress/anxiety, thereby reducing physiological symptoms. If one can reduce their state of arousal, they could theoretically also prevent themselves from feeling more and more anxious, allowing them to internally recognize and manage their own anxiety before it becomes severe (or develops into a panic attack).
Meditation This is a relatively broad term, but generally involves clearing one’s mind and concentrating on something – usually breathing, a chant, or some other relaxing imagery – in a silent, distraction-free environment. The theory is that meditation reduces the heart and breathing rate. There are also questionable claims that meditation directly reduces the production of cortisol.
TM This is a technique that has basically the same characteristics of meditation, but with added East Indian flair. During this meditation the person concentrates on and repeats a mantra. The goal is to experience different levels of consciousness (note that these levels are derived from spiritual belief and are not supported with research) – specifically the transcendental/pure consciousness (4th) level. TM differs from other methods in that there is a specific target in mind. Whereas the other methods are aimed at reducing anxiety (in whatever amount that may be), this methods seeks to reach a specific level of consciousness with anxiety reduction as a secondary effect.
What most of these techniques have in common is that the supporting evidence is weak, but generally positive. Note that these techniques are still apparently inferior to other psychiatric interventions (i.e., CBT). They are not demonstrably harmful when used with other therapies, but the objective benefits are questionable. They seem appropriate as a first-line treatment for patients with mild to moderate symptoms, but may not be effective in patients with co-morbid conditions that affect arousal or muscle tone.
However, the evidence for TM is suspect. TM suffers from publication bias – specifically, multiple publications of the same data falsely bolsters evidence of efficacy. Also, there is reason to believe that it is no more effective than regular meditation. Studies of TM that report positive results sometimes fail to incorporate adequate controls to account for this effect. Also, so far there is no support for the varying levels of consciousness proposed to accompany the process. Furthermore, as the aim is to reach a certain level of consciousness rather than to marginally reduce anxiety, patients may actually experience anxiety or frustration if (or arguably, when) they fail.
In all cases it’s difficult to separate the positive effects from the general interactions with therapists. People may feel improvement simply because someone is finally helping them, not because of any specific method used.
Reducing stress outside of pharmaceutical intervention essentially depends on a person’s ability to self-regulate. Giving a patient some measure of control over their treatment reduces dependence on the therapeutic relationship and increases self-reliance. So it makes sense that interventions would attempt to enhance self-controlled anxiety management. However, evidence for the efficacy of these methods are mixed. They may not work for everyone and they require initial training/supervision by a professional.
There is a plethora of self-help books on the topic of stress reduction, but attempting the techniques above without seeking professional help could lead to exacerbation of symptoms (due to prolonged absence of treatment) and incorrect application of methods. While it’s possible that a well-crafted video or book may guide someone sufficiently on their own, people are generally not skilled at evaluating their own progress. That is where a trained professional who sees these symptoms all the time can also be helpful.
In any case, with regard to TM in particular, there is no evidence that the addition of a mystical belief system increases effectiveness. Certainly if a patient wishes to add a metaphysical element to their own meditation, there is no indication to necessarily discourage it (nor is that our role), but there is also no need to promote it. It is out of scope for a health care practitioner (HCP) to impose spiritual beliefs onto their patients/clients and there is no evidence that there are more positive outcomes with TM over other therapies.
HCPs should avoid language that makes these treatments sound more effective than they generally are. While the results indicate that they are an improvement over doing nothing, they are less effective than regular CBT. They are a good supplement to maintain independent anxiety reduction, to give the patient a measure of control, and possibly reduce feelings of helplessness. But as independent methods, they have questionable efficacy.
Chronic anxiety is a serious health condition and the above techniques require training and commitment, if they work for the patient at all – they aren’t a guarantee. If someone promises to cure anxiety in X number of “simple” steps or claims that a mystical belief added to therapy increases efficacy, be skeptical.
*Cross-posted at Skeptic North.