Relaxation Techniques: Decreasing Your Physical Stress Reactivity and Increasing Self-Awareness

So far you have attempted to cope with stress directly by eliminating or changing the sources of stress in your life. You've solved problems, communicated more effectively, and managed your time. You've clarified your goals and values, and you have organized your life. You've also tried to increase your stress resistance by improving your health behaviors and increasing your enjoyment of daily life. You have seen how your perception of stressors and outlook on life influence your stress cycle; you have worked to reduce irrational beliefs and cognitive distortion, raise your self-esteem, and increase personality characteristics that are associated with hardiness.

    But despite your best efforts to reframe problems and cope directly with stress, sometimes you may still feel stressed-and in many cases there is not a lot you can do about a problematic situation. You may simply have to accept it and live with it as well as you can, at least for a while. Even positive stress can get you overly wound up. Have you ever fallen madly in love or been so excited about an upcoming event that you've been unable to eat or sleep? In this chapter you will learn several simple relaxation techniques that you can call on when you need to reduce sympathetic arousal.

    Learning to relax has many benefits beyond increasing your ability to reduce sympathetic arousal. Relaxation techniques can also help you get in touch with your thoughts and feelings, and get better acquainted with your inner self. Relaxation techniques can help you listen to your body and prevent mild stress-related disorders from becoming chronic health problems. These techniques are especially powerful when used in combination with the other material discussed in this book. Relaxation techniques enhance your ability to discern irrational beliefs, challenge negative thinking, and develop hardiness traits. They can help you stick to your plans for improving your health behavior. The relaxation engendered by experiencing pleasure allows you to experience that pleasure more fully and to reap more health benefits from it. Relaxation helps you communicate more effectively, set clearer goals and values, evaluate problems, and dream up creative solutions. Relaxation is essential for maintaining optimal health and well-being and for preventing stress-related disorders.

THE RELAXATION RESPONSE

The relaxation response is the opposite of the stress response. It occurs naturally and is not something you have to learn; your body knows how to relax already. just as you geared up to fight or flee from the vicious dog at the beginning of this book, so too will you eventually unwind once you reach safety.

    The physiology of the relaxation response is simply the opposite of the stress response, and is governed by the activation of the parasympathetic nervous system (PNS). The parasympathetic division of the autonomic nervous system is primarily responsible for conserving and restoring energy during times of rest and recovery (Tortora & Grabowski, 1993). So, for example, while sympathetic stimulation puts gastrointestinal activity on hold, parasympathetic stimulation encourages digestion and absorption of food. Heart rate slows, and the force of the heart's contraction decreases. Blood pressure returns to resting level. Breathing becomes slower and deeper. Skeletal muscles relax. The production of stress hormones stops, and your body recovers its homeostasis.

    Too often we get out of balance and seem to be stuck in a chronic stress response. Chronic sympathetic nervous system (SNS) arousal leads to a myriad of health problems, as described in Chapter 3 (Sapolsky, 1994). Many people have found that spending more time each day in relaxation mode is an effective antidote for stress-related illness (Matheny et al., 1986). As medical researchers have come to understand the harmful effects of too much stress, they have also come to appreciate the therapeutic benefits of relaxation (Woolfolk & Lehrer, 1984; Sachs, 1991; Schneider, 1987). And research supports the practice of many physicians who are now prescribing relaxation techniques for the treatment of stress-related disorders such as headaches (Holmes & Burish, 1983; Sorbi & Tellegen, 1986), gastrointestinal problems (Hellman et al., 1990), pain due to muscle tension (Kabat-Zinn, 1990), hypertension (Benson, 1975; Patel & Marmot, 1988), heart disease (Bohachick, 1984; Ornish, 1990), insomnia (Hellman et al., 1990; Kirmil-Gray et al., 1985), academic stress (Rajendran & Kaliappan, 1990),job-related stress (Stanton, 1991), and anxiety (Borkovec et al., 1987; Sachs, 1991). Relaxation techniques have become popular for easing the pain associated with childbirth (Kitzinger, 1991; Worthington, Martin, & Shumati, 1982), for treating addiction (Rohsenow, Smith, & Johnson, 1985), and for helping people cope with chronic pain (Hellman et al., 1990; Kabat-Zinn, 1982). Relaxation techniques have been used successfully with all kinds of subjects: healthy people, hospital patients (Bohachick, 1984), children and adolescents (McDonnell & Bowden, 1989; Parrott, 1990; Smith & Womack, 1987), and college students (Archer, 1986; Rajendran & Kaliappan, 1990; Thomas & Scott, 1987).

    While Western medicine has given many relaxation techniques some new packaging, most of these techniques have been around in some form for thousands of years. Religious and medical practices in many cultures have used various forms of prayer, meditation, breathing, and movement to clear the mind and heal the body, to understand the meaning of life and talk to the gods.

WHO NEEDS RELAXATION TECHNIQUES?

Relaxation techniques are especially helpful for people who are "hot reactors." Hot reactors are people who startle easily, who feel stressed easily, and who tend to overreact physically to stress. Relaxation techniques are essential for people with stressrelated illnesses. They are often used in conjunction with other medical treatment modalities. But almost everyone can benefit from learning something about relaxation, even if it is just a few simple breathing exercises that will help him or her fall asleep more easily during times of stress.

Most people try several different relaxation techniques before settling into one or two that seem to work best for them. Trial and error seems to be the only reliable method for finding what will work best for you. Give each of the techniques presented in this chapter and the next a try. You will soon discover which are appealing and effective for you.

While specific instructions for each technique are given below, here are a few general suggestions for successful practice.

     1. Schedule a convenient time and place, and practice regularly. People are often tempted to call on relaxation techniques only as a last resort, once stress has hit full force. But in order for these techniques to be used effectively, they must first be practiced and learned. If you cannot control your thoughts during stress-free times, controlling them during high-stress times will be almost impossible.

     Successful practice is most readily achieved with a regular practice schedule. Many people prefer to use relaxation practice as a wind-down at the end of the day. Some find the practice energizes them, so they prefer first thing in the morning. Others find a break in the middle of the day helpful. Whatever works for you is fine.

     2. Be as comfortable as possible. Loosen tight clothing, remove eyeglasses, use a comfortable chair that supports your back. If you are lying down, use a mat or thick carpet and be in a comfortable position. Some people find that rolled towels or blankets placed under the knees and lower back help maintain spinal alignment in a comfortable position, as shown in Figure 15. 1.

     3. Try not to try. Maintain a passive attitude. Simply observe with a nonjudging awareness what is occurring. With relaxation techniques, the harder you try, the tenser you get. It can be difficult to let go of your expectations and judgments, but with practice this becomes easier. Many techniques give your mind an assignment: for example, focus on your breathing, tune in to muscle tension, or imagine a pleasant place. But the mind tends to wander. When this happens, gently bring your attention back to the technique, without judgment, scolding, or frustration. Simply let go of extraneous thoughts and regain your focus.

     4. Keep a relaxation log. Keeping track of your progress is rewarding and reinforces your commitment to relaxation practice. Beginners find a log especially helpful. Once a relaxation technique is a part of your routine, a log may not be necessary. Some people like to write a paragraph or two after every session, including ideas and feelings that came to them during practice. Others may simply note the day and time with a brief comment or two.

     5. Maintain medical treatment Protocols if you are being treated for a medical disorder. Relaxation works slowly. Inform your physician you are practicing, but continue to follow any medical treatment as prescribed.

     6. Avoid falling asleep. Relaxation techniques require concentration and active awareness. Relaxation is not the same thing as lethargy. If you start to feel sleepy, open your eyes, practice in a well-lighted room, and use a sitting posture. 0f course, you may ignore this advice if you are using relaxation at bedtime for the express purpose of falling asleep!

     7. Finish relaxation sessions by coming back slowly. At the end of your practice session, slowly bring your focus back to the here and now, gently stretch your muscles and open your eyes if they were closed. If you are lying down, roll over onto your side and then up to a sitting position. When your muscles are deeply relaxed, it is stressful to ask them to contract suddenly. You may strain your back muscles if you suddenly perform a sit-up after deep relaxation. It also feels better (and is less likely to elicit a fight-or-flight response) to ease back into the daily routine rather than shock yourself back into demanding thoughts and stress- producing pressures. Let yourself come back slowly. Try to hold on to that feeling of alert, focused relaxation as you resume your day.

A WORD ABOUT RELAXATION ANXIETY

In some cases, people experience increased anxiety when they practice relaxation techniques (Borkovec et al., 1987). This may involve a discomfort with "letting go" and a fear that one is losing control (Rice, 1992). If you notice that these techniques increase your anxiety, discuss this problem with your therapist or teacher. You may wish to use healthy pleasures or exercise instead of relaxation techniques to help you relax at this time.

    Some people occasionally experience a panic attack during practice. A panic attack is like an acute stress response and typically includes a fast, pounding heartbeat, rapid shallow breathing, and feelings of panic and anxiety. If this happens to you, try to breathe deeply, interrupt your practice, and calm yourself down by talking to a friend, going for a walk, or doing some chores. If possible, try to remember the thoughts and feelings that triggered the attack and examine them when you feel ready.

TUNING IN: INCREASING YOUR AWARENESS OF THE PHYSICAL SIGNS OF STRESS

The techniques in this chapter have as their theme tuning in to physical stress symptoms and using your awareness, breathing, and movement to reduce these symptoms. The first exercise presented here is the body scan. The Body Scan exercise on page 322 is designed to help increase awareness of physical sensations-the messages your body is continuously sending to your brain but that are often ignored because you are too busy doing something else. Learning to tune in to these messages can help you become aware of physical stress symptoms at an early stage, sometimes before you are conscious of feeling stressed. Ideally, early awareness will improve body-mind communication so that your body won't need to shout so loudly to get your attention.

    Practice the body scan several times in a quiet, comfortable place. Then try to perform a quick body scan periodically throughout your normal daily life. Briefly close your eyes and scan your body for sensations. Once you are familiar with the technique, this may take as little as one minute.

PROGRESSIVE RELAXATION

Progressive relaxation, or progressive muscular relaxation as it is sometimes called, is a relaxation technique developed by Edmund Jacobson in the early part of this century (Jacobson, 1929, 1976). Jacobson's groundbreaking work was some of the first to convince Western scientists that people can achieve control over what were once considered involuntary physiological functions, such as heart rate, metabolic rate, and level of resting muscle contraction. His progressive relaxation technique remains one of the most popular for the treatment of physical stress disorders such as insomnia, hypertension, and pain due to muscle tension, including headaches, low back pain, and temporomandibular joint (TMJ) syndrome (Seaward, 1997).

    Jacobson noticed that many of his patients exhibited a great deal of excess muscle tension. He theorized that physical tension leads to mental tension, which increases physical tension, and so forth. He suggested that by breaking this cycle, a person could instead start a cycle the other way. By physically relaxing, one could possibly achieve mental relaxation as well. Progressive relaxation teaches people how to relax and how to become aware of unnecessary muscle tension both during relaxation and throughout the day. Jacobson felt that by reducing chronically overtense muscles, people could better cope with stress.

    Progressive relaxation asks you to alternately contract, then relax specific muscle groups. The goal is for you to become aware of the difference between feelings of muscle contraction and muscle relaxation. Each muscle group is contracted for 5 to 7 seconds, and then relaxed for 20 to 30 seconds. Initially, you contract designated muscle groups 100 percent, then let go quickly to achieve as deep a relaxation as possible in that group. Over time, you progressively (hence the name) contract groups with less and less force until you are barely contracting each muscle group. In this way you become able to discriminate between true deep relaxation and unnecessary levels of muscle tension, and you gain voluntary control over tense muscles.

    One of the goals of progressive relaxation training is to help you achieve differential relaxation throughout the day. Here you are contracting only those muscles necessary to accomplish the task at hand while all others are relaxed (McGuigan, 1984). So, for example, if you are driving a car, you will need some muscular contraction to depress the accelerator, brake, and clutch, and some to steer. Posture muscles remain activated to maintain good sitting alignment. Unnecessary muscle contraction would include hunching your shoulders, gripping the steering wheel, and clenching your jaw (McGuigan, 1984).

    Progressive relaxation can be implemented in several ways. Jacobson's original training procedure required a great deal of practice time in its initial stages. People practicing the technique would focus on one muscle group for an entire 45-minute session. Today, many therapists recommend going through all 16 groups in one session and then progressing to shorter versions after three or four sessions if you wish (Bernstein & Given, 1984). See pages 324 and 325 for exercises.

TUNING IN AND MINDFULNESS

The body scan and relaxation exercises can enhance your experience of mindfulness, as presented in Chapter 11. Increasing your awareness of muscle tension and other physical sensations during relaxation helps increase your awareness during simple activities such as eating and walking. You may wish to give the mindful exercises in Chapter 11 another try and to enjoy being in the present moment more often and more fully during your daily life.

TAKE A DEEP BREATH

When stress management teachers run into former students, the teachers are sometimes inclined to ask, "So, has the course been helpful?" Of course the students are obliged to say yes. The teacher may then ask, "And are you still using any of the relaxation techniques?" The former students usually break eye contact at this point, give a weak smile, trying to remember what those techniques were anyway, and confess, "Well, I do use the breathing."

    Deep breathing is the easiest and most accessible relaxation technique (Loehr & Migdow, 1986). It can be used any time and any place. Breathing has often been called the bridge between body and mind. It can occur as either an automatic or conscious act. Most of the time, we give little thought to our breathing; we are occupied with other matters. If we had to consciously remember to breathe, we would have little time to think about anything else! But we can easily switch from automatic to conscious control whenever we wish, and we can use this bridge to help calm both body and mind.

    The next time you feel stressed, notice what happens to your breathing. It tends to become shallow and irregular, and your chest feels constricted. It is natural to hold your breath when you are stressed. In fact, simply breathing in this fashion will cause you to feel stressed-it works in both directions. Similarly, forcing yourself to breathe more deeply automatically begins to make you feel more relaxed.

    The breath has been regarded as a pathway to the soul in many cultures. The word inspiration is used for both breathing and thoughts that seem to well up from a deeper source; it evolved from the same Latin root as spirit. Many traditions have recognized the link between breathing and life energy. In yoga practice, deep breathing is called pranayama and refers to the control of one's energy or life force (Ornish, 1990). Deep breathing can help you control your energy level. It can help you recover from that scattered, fragmented feeling that occurs with stress, and to feel more calm, directed, and focused.

ABDOMINAL BREATHING

When you are relaxed, abdominal breathing comes naturally. Watch a baby, young child, or even your pet cat or dog, and you will see abdominal breathing. Abdominal breathing is also called diaphragmatic breathing because the diaphragm muscle rather than the chest muscles accomplishes the breathing. If you felt your abdomen rising and falling as you practiced the Breathing Awareness exercise, you were performing abdominal breathing.

    The diaphragm is a big, strong muscle that stretches across your chest from side to side and from front to back. It separates your chest from your abdomen. When this muscle contracts, it pulls down toward your abdomen, creating a vacuum as your lungs expand. Air is drawn in; inhalation occurs. When the diaphragm relaxes, the lungs contract, and you exhale.

    When you inhale deeply, your rib cage opens and rises to allow your lungs to expand fully. This action involves the deep muscles of your chest and shoulders as well as your diaphragm. When you breathe tensely and shallowly, these muscles are activated as well, but without the full assistance of your diaphragm.

PHYSICAL ACTIVITY AND THE RELAXATION RESPONSE

Tense, relax. Deep breathing. Become aware of your body. All these relaxation techniques remind us once again of the benefits of exercise, so perhaps this is a good place to mention again that physical activity can help reduce physiological arousal and increase the relaxation response (Folkins & Sime, 1981; Holmes & Roth, 1988; Long & Haney, 1988). Exercise can help not only to increase your allaround stress resistance but serves well as an intervention for acute stress. Angry with someone? Hit a tennis ball. Frustrated with a difficult problem set? Go for a run. Exercise is a great way to get stress out of your system.

    A stress management student we'll call David once experienced a great deal of frustration serving on a campus committee. One man in particular, a senior faculty member, drove him crazy. This man would argue, whine, bully, and generally behave in a very unprofessional manner. The other committee members tried to mollify him and move the committee's work forward as well as they could. Fortunately, the work of this committee was almost complete, so David only had a few more weeks of meetings.

    David usually worked out in the late afternoon, but one day, he happened to do his workout in the morning, before the noon meeting. His workout was quite vigorous and consisted of a run followed by 30 minutes of weight lifting. After his workout, he felt great. He arrived at the committee meeting feeling happy and relaxed. Nothing bothered him that day, not even the senior professor's ranting and raving. lt just didn't seem important. David couldn't believe what a difference that workout had made in his ability to tolerate the stress of the committee meeting.

BODY AWARENESS MAY INCREASE YOUR NEED FOR FITNESS

Some people find that tuning in to their bodies does not feel good. Body awareness reminds them that their muscles are tense and out of shape, and that sitting at a desk all day is leading to a decline in their physical condition. When this occurs three options are available: (1) stop being aware of your body, (2) keep feeling bad about your deconditioned body, or (3) start exercising to improve your physical condition.

    If certain areas of your body always feel tight, try some strengthening and stretching exercises. These often help decrease tension and pain, especially if these exercises are performed regularly for several weeks. Stretching and strengthening tight muscles is an important part of physical therapy. If you have ever been to a physical therapist or athletic trainer for an injury, you probably received an exercise prescription to help stretch and strengthen injured muscles.

    Strengthening exercises are often performed using some form of resistance training, such as weight lifting or calisthenics. Good sources on how to lift weights are the books by Fahey (1994) and Westcott (1994), listed in the references at the end of this chapter. One of the best sources on stretching is the book Stretching by Bob Anderson (1980).

RELAXATION THROUGH BODY WORK: HATHA YOGA

Some types of activity incorporate relaxation and meditation techniques into their practice. Examples are many of the martial arts, Tai chi ch'uan (Jin, 1992; Seaward, 1997), and yoga (Ornish, 1990; Seaward, 1997).

    The ancient tradition of yoga offers many stress management benefits (Patel, 1984). Indeed, most relaxation techniques are connected in some way to a form of yoga. The word yoga comes from the Sanskrit word for yoke, and means to bring together, to unite and make whole. It refers to the union of body, mind, and spirit. While stress management is one benefit of yoga practice, its true purpose is to help the practicer attain spiritual enlightenment. Yoga is not based in any particular religious tradition and its practices can complement those of any religion.

    Hatha yoga is the branch of yoga that emphasizes physical postures that incorporate breath control and mental concentration. Within hatha yoga, there is a wide variety of approaches that range from very strenuous to quite gentle and relaxing. All forms increase strength and flexibility. If you are new to yoga and would like to give it a try, a yoga class is preferable to trying postures from a book, especially if you have any kind of physical limitations or have not exercised in a long time. Effective technique often requires expert coaching. Hatha yoga has become quite popular over the last 20 years, so finding a class has become easier.

SUMMARY

1. Practicing relaxation skills allows you to voluntarily reduce sympathetic arousal and thus counteract the fight-or-flight response.

2. Relaxation techniques can help increase self-awareness. They enhance your ability to discern irrational beliefs, challenge negative thinking, and develop hardiness traits.

3. Relaxation practice helps you communicate more effectively, set clearer goals and values, evaluate problems, dream up creative solutions, and improve health behavior.

4. Regular relaxation is essential for maintaining optimal health and well-being.

5. The relaxation response is governed by the parasympathetic branch of the autonomic nervous system. The relaxation response is associated with a slow, calm heartbeat; low resting blood pressure levels; slow, deep breathing; and relaxed muscles. While the fight-or- flight response inhibits digestion, parasympathetic stimulation encourages the digestion and absorption of food.

6. Regular relaxation practice can help prevent and treat stress-related illness such as headaches, gastrointestinal problems, pain due to muscle tension, hypertension, heart disease, insomnia, and anxiety.

7. Guidelines for successful relaxation practice include the following: (1) schedule a convenient time and place; (2) be as comfortable as possible; (3) try not to try; (4) keep a relaxation log; (5) avoid falling asleep; (6) finish relaxation sessions by coming back slowly.

8. Maintain medical treatment protocols if you are being treated for a medical disorder, and do not rely on relaxation for an immediate cure.

9. Occasionally people experience anxiety or even panic attacks during relaxation practice. If this happens, breathe deeply, interrupt your practice, and calm yourself down by talking to a friend, going for a walk, or involving yourself in familiar tasks.

10. The Body Scan exercise is designed to help increase your awareness of physical sensations that are normally ignored when you are busy.

11. Progressive muscular relaxation is a relaxation technique designed by Edmund Jacobson in the 1920s. Jacobson was one of the first researchers to convince Western scientists of the value of relaxation practice. Progressive muscular relaxation asks you to alternately contract then relax specific muscle groups, and it increases your awareness of muscle tension levels.

12. Mindfulness exercises are powerful relaxation techniques.

13. Deep breathing may be the easiest and most accessible relaxation technique. Despite its simplicity, its relaxation effects can be very powerful.

14. Abdominal breathing, or diaphragmatic breathing, results from contraction of the diaphragm muscle rather than the chest muscles. Abdominal breathing is associated with relaxation.

15. Physical activity can help reduce physiological arousal and increase the relaxation response during the period of time following exercise.

16. Certain forms of physical activity such as hatha yoga, Tai chi ch'uan, and many of the martial arts incorporate relaxation and meditation techniques into their practice.

Anderson, B. Stretching. Bolinas, CA: Shelter Publications, 1980.

Archer, J. Stress management: Evaluating a preventive approach for college students. journal of American College Health 34: 157-160, 1986.

Benson, H. The Relaxation Response. New York: Morrow Press, 1975.

Bernstein, DA, and BA Given. Progressive Relaxation: Abbreviated methods. RL Woolfolk and PM Lehrer (eds). Principles and Practice of Stress Management. New York: Guilford Press, 1984.

Bohachick, P. Progressive relaxation training in cardiac rehabilitation: Effect on psychologic variables. Nursing Research 33: 283-287, 1984.

Borkovec, TD, AM Mathews, A Chambers, S Ebrahimi, R Lytle, and R Nelson. The effects of relaxation training with cognitive and nondirective therapy and the role of relaxationinduced anxiety in the treatment of generalized anxiety. Journal of Consulting and Clinical Psychology 55: 883-888, 1987.

Davis, M, ER Eshelman, and M McKay. The Relaxation and Stress Reduction Workbook. Oakland, CA: New Harbinger Publications, 1995.

Fahey, TD. Basic Weight Training for Men & Women. Mountain View, CA: Mayfield, 1994.

Folkins, CH, and WE Sime. Physical fitness training and mental health. American Psychologist 55:373- 389,1981.

Gillespie, PR, and L Bechtel. Less Stress in 30 Days. New York: Signet Books, 1986.

Hellman, CJ, M Budd, J Borysenko, DC McClelland, and H Benson. A study of the effectiveness of two group behavior medicine interventions for patients with psychosomatic complaints. Behavioral Medicine 16: 165-173, 1990.

Holmes, DS, and TG Burish. Effectiveness of biofeedback for treating migraine and tension headaches: A review of the evidence. Journal of Psychosomatic Research 27: 515-532,1983.

Holmes, DS, and DL Roth. Effects of aerobic exercise training and relaxation training on cardiovascular activity during psychological stress. Journal of Psychosomatic Research 32: 469-474,1988.

Jacobson, E. Progressive Relaxation. Chicago: University of Chicago Press, 1929.

Jacobson, E. You Must Relax! New York: McGraw-Hill, 1976.

Jin, P. Efficacy of Tai Chi, brisk walking, meditation, and reading in reducing mental and emotional stress. Journal of Psychosomatic Research 36: 361-370, 1992.

Kabat-Zinn,J. An outpatient program in behavioral medicine for chronic pain based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry 4: 33-48, 1982.

Kabat-Zinn, J. Full Catastrophe Living.- Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delta, 1990.

Kirmil-Gray, K, JR Eagleston, CE Thoresen, and VP Zarcone, Jr. Brief consultation and stress management treatments for drug-dependent insomnia: Effects on sleep quality, self-efficacy, and daytime stress. Journal of Behavioral Medicine 8: 79-99, 1985.

Kitzinger, S. The Complete Book of Pregnancy and Childbirth. New York: Alfred A. Knopf, 1991.

Loehr, JE, and JA Migdow. Take a Deep Breath. New York: Villard Books, 1986.

Long, BC, and CJ Haney. Coping strategies for working women: Aerobic exercise and relaxation interventions. Behavior Therapy 19: 75-83, 1988.

Matheny, KB, DW Aycock, JL Pugh, WL Curlette, and KAS Cannella. Stress coping: A qualitative and quantitative synthesis with implications for treatment. The Counseling Psychologist 14: 499-549, 1986.

McDonnell, L, and ML Bowden. Breathing management: A simple stress and pain reduction strategy for use on a pediatric service. Issues in Comprehensive Pediatric Nursing 12: 339-344,1989.

McGuigan, FL. Progressive Relaxation: Origins, principles, and clinical applications. RL Woolfolk and PM Lehrer (eds). Principles and Practice of Stress Management. New York: Guilford Press, 1984.

Ornish, D. Dr. Dean Ornish's Program for Reversing Heart Disease. New York: Ballantine Books, 1990.

Parrott, L. Helping children manage stress: Some preliminary observations. Child and Family Behavior Therapy 12: 69-73, 1990.

Patel, C. Yogic therapy. RL Woolfolk and PM Lehrer (eds). Principles and Practice of Stress Management. New York: Guilford Press, 1984.

Patel, C, and MG Marmot. Efficacy versus effectiveness of relaxation therapy in hypertension. Stress Medicine 4: 282-289, 1988.

Rajendran, R, and KV Kaliappan. Efficacy of behavioural programme in managing the academic stress and improving academic performance. Journal of Personality and Clinical Studies 6: 193-196, 1990.

Rice, PL. Stress and Health. Pacific Grove, CA: Brooks/Cole, 1992.

Rohsenow, DJ, RE Smith, and S Johnson. Stress management training as a prevention program for heavy social drinkers: Cognitions, affect, drinking and individual differences. Addictive Behaviors 10: 45- 54, 1985.

Sachs, BC. Coping with stress. Stress Medicine 7: 61-63, 1991.

Sapolsky, RM. Why Zebras Don't Get Ulcers. New York: WH Freeman & Co., 1994.

Schneider, CJ. Cost effectiveness of biofeedback and behavioral medicine treatments: A review of the literature. Biofeedback and Self-Regulation 12: 71-92, 1987.

Seaward, BL. Managing Stress. Boston: Jones and Bartlett, 1997.

Sorbi, M, and B Tellegen. Differential effects of training in relaxation and stress-coping in patients with migraine. Headache 26: 473-481, 1986.

Smith, MS, and WM Womack. Stress management techniques in childhood and adolescence. Clinical Pediatrics 26: 581-585, 1987.

Stanton, HE. The reduction of secretarial stress. Contemporary Hypnosis 8: 45-50, 1991.

Thomas, BJ, and A Scott. A student stress management and referral system. Journal of American College Health 3: 232-233, 1987.

Tortora, GJ, and SR Grabowski. Principles of Anatomy and Physiology. New York: HarperCollins, 1993.

Westcott, WL. Strength Fitness: Physiological Principles & Training Techniques. Dubuque, IA: Brown & Benchmark, 1994.

Woolfolk, RL, and PM Lehrer (eds). Principles and Practice of Stress Management. New York: Guilford Press, 1984.

Worthington, EL,Jr, GA Martin, and M Shumate. Which prepared childbirth coping strategies are effective? Journal of Obstetric, Gynecologic, and Neonatal Nursing 11: 45-51, 1982.