Individualizing Relaxation Training in Spinal Cord Injury
Content
Individualizing Relaxation Training in Spinal Cord Injury: Importance of Injury Level and Person Factors
By: Sigmund Hough Psychology and Spinal Cord Injury Services, Veterans Affairs Boston Healthcare System-West Roxbury Campus, West Roxbury, Massachusetts; Department of Psychiatry, Harvard Medical School Carol Kleinginna Psychology and Spinal Cord Injury Services, Veterans Affairs Boston Healthcare System-West Roxbury Campus, West Roxbury, Massachusetts; Department of Psychiatry, Harvard Medical School Acknowledgement: We thank Marika Hess for consultation Correspondence concerning this article should be addressed to: Sigmund Hough, PhD, Spinal Cord Injury Service (#128 SCI), Veterans Affairs Boston Healthcare System-West Roxbury Campus, 1400 VFW Parkway, West Roxbury, Massachusetts 02132 Electronic Mail may be sent to: [email protected]. The relaxation response (Benson, 1975) as a natural restorative process uses various techniques (e.g., meditation, visualization, progressive muscle relaxation, breathing exercises) to relax the body so that a person can cope better with life stress, injury, and pain. Benson (1975) suggested that an individual can use one's mind to change physiology for the better, thus improving health and emotional outlook on life. Among general rehabilitation populations, the achievement of the relaxation response has been associated with decreased pain ratings by individuals with chronicpain (Linton &Gotestam, 1984). Furthermore, interventions that incorporate relaxation approaches have been suggested to lead to a reduction in clinic visits associated with chronicpain issues (Caudill, Schnable, Zuttermeister, Benson, & Friedman, 1991). The changes in daily activities necessitated by hospitalization and injury-specific requirements are likely to be chronic, can be quite stressful, and may lead to an increased sense of powerlessness (Hulse, 1997). This decreased sense of control over one's life is associated with poor adjustment outcomes, including depression (Macleod & Macleod, 1998). Anxiety and depression are frequently encountered during the spinal cord injury rehabilitation process (Kennedy & Rogers, 2000). Specific interventions that address anxiety and depression may serve to buffer the individual against stressful events even after formal intervention has ended (Craig, Hancock, Chang, & Dickson, 1998). Relaxation strategies used as part of stress management have been shown to increase self-efficacy in medical populations with corresponding improvements in depression and pain (Smarr et al., 1997), as well as anxiety (Mandel & Keller, 1986). Visual imagery and hypnosis are other techniques that may be used to increase relaxation and assist in the rehabilitation process (Appel, 1990, 1992). The ability to use relaxation is generally accepted as a positive skill in dealing with medical conditions, illness, and life stress. Relaxation interventions have been used with individuals with spinal cord injury to increase coping and adjustment to injury and to decrease pain (Bertino, 1989; Butt, 1997; Curcoll, 1992; Grzesiak,
1977). However, currently there are no proposed recommendations for particular relaxation strategies best used according to the specific level of spinal cord injury (Kleinginna-Gallaher & Hough, 2000). Interventions such as progressive muscle relaxation (Jacobson, 1974) may not work for all individuals with spinal cord injury because of different functional abilities associated with various levels of injury (seeTable 1). For example, an individual with ventilator dependency would not be able to control diaphragm muscles necessary to engage in breathing exercise. In addition, generic relaxation scripts to be followed by the health care provider or generic audiotapes to be played by the individual with spinal cord injury may increase frustration because of the inappropriateness of specific physical requests as they relate to the individual.
Functional Expectations and Motor-Sensory Impairment on the Basis of Injury Characteristics Although some experiences of spinal cord injury rehabilitation may be similar across individuals, there remain factors that must be reviewed on an individual basis prior to implementing intervention for change. The individual's level of injury, degree of completeness of injury, motivation to participate in an intervention, psychosocial history, and cognitive ability to learn new techniques all must be considered
in relaxation intervention planning. Consideration of these issues allows strategic intervention development and increases the likelihood that participants will be able to maintain interest in treatment (Moverman, 1998) and achieve maximum benefit from services offered. Furthermore, one must also take into account the individual's personal life history, abilities, strengths, ethnicity, and personal preference before implementing a psychosocial intervention (Hough &Kleinginna-Gallaher, 2000; Kleinginna-Gallaher & Hough, 2001). To illustrate these concepts, we describe our work with 6 patients who had different levels of injury and other factors that suggested specific individualized relaxation strategies. METHOD Participants From a cohort receiving psychological services from an inpatient spinal cord injury program within a university-affiliated urban Veteran Affairs Medical Center, 6 individuals (1 woman, 5 men) with a spinal cord injury were selected for illustration on the basis of the diversity of rehabilitation care needs and ability to use relaxation techniques. Relaxation training is routinely available on the basis of motivation to practice a new procedure and the clinical need of such intervention to reduce pain and anxiety and increase coping skills to improve adjustment and/or manage the stress of life events. Procedure A relaxation treatment plan was created for each individual on the basis of information gathered in medical record review, clinical interview (e.g., psychological adjustment status with regards to anxiety, depression, pain, social support, psychosocial and ethnic background, psychiatric background, medical and health status, motivation, cognitive status, and prior experience with relaxation strategies) and consultation with interdisciplinary team members (e.g., medicine, neurology, nursing, physical therapy, pulmonary, psychiatry, psychology, occupational therapy, and social work) regarding abilities, strengths, and weaknesses. In addition, clinical observations were made of treatment adherence, and Global Assessment of Functioning (GAF) scores (American Psychiatric Association, 1994, p. 32) were established during initial contact. The GAF score considers psychological, social, and occupational functioning on a hypothetical continuum of mental health, excluding impairment in functioning due to physical or environmental limitations. All 6 cases had GAF scores between 53 and 62, which is within the range of moderate to mild symptoms. These individuals were not suicidal or homicidal and did not present with psychotic features. All 6 cases met criteria for an adjustment disorder related to spinal cord injury. The diagnosis of a mental disorder or absence of mental disorder and GAF scores were determined by a licensed psychologist on the basis of theDiagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria. Within the context of providing individual psychotherapy, participants were told that a part of treatment would be relaxation training in addition to talking about adjustment to injury and life situation. Specifically, they were informed that they would be taught a skill for coping with a stressful situation and that with practice they could become increasingly proficient at relaxation. Further elaboration was provided on how relaxation training could be beneficial to one's specific situation. A few diagrams and charts to depict the mind-body connection
and spinal cord injury were used to promote education and understanding to form a foundation for treatment compliance. When visual imagery was used as the relaxation intervention of choice, the Imagery Vividness Scale (Lazarus, 1977) was used as a screening tool as well as a training tool to educate the individual regarding imagery technique. Basic instructions (Lazarus, 1977) included Let's try a simple test. You will be asked to picture certain images. If your image is very clear give it a rating of 4, moderately clear equals a 3, fairly clear equals a 2, and unclear equals a rating of 1. If you cannot form an image give it a 0. After reading each item, close your eyes, picture it as clearly as you can, and then record your own rating. For example, picture a bowl of fruit or see a white sandy beach. (p. 9) The description given can be enriched during training by educating the person as to the multidimensional aspects of the vividness (e.g., ask them to say more about the image and give examples, such as the ball is red, candy apple red, round, round like a globe, bouncy, bouncy like a yo-yo going up and down ). All imagery training total scores were above 50, which is well above the recommended minimum inclusion criterion score of 30. Protocols for training were individualized to take into account the level of spinal cord injury and physical ability. Each person was informed that he or she could stop the relaxation training at any time (e.g., if there was an increase in pain or discomfort) without penalty or prejudice in regard to his or her health care. Monitoring of relaxation training occurred one-three times per week to ensure sufficient rehearsal and to evaluate the effectiveness of the practice. Participants were asked to assess satisfaction with the interventions and willingness to use them after treatment completion. CASE ILLUSTRATIONS AND RESULTS Case 1 Ms. F., a 35-year-old married Taiwanese American woman, sustained a C6 American Spinal Injury Association (ASIA) A injury following a motor vehicle accident. She was referred for psychological assessment and treatment to address emotional adjustment approximately 1 month postinjury. The goal of relaxation was to increase coping ability to improve psychological adjustment to injury and lifestyle change. Ms. F.'s primary language was Taiwanese, and, although she understood some English, her preferred language was Taiwanese. On the basis of Ms. F.'s functional level, interventions solely dependent on muscle relaxation strategies were not appropriate. Although she was able to participate in breathing exercises, she reported that she was not motivated to do them on a consistent basis. An assessment of Ms. F.'s preinjury interests revealed a strong involvement in the Buddhist religion and an interest in the arts. Meditation-based relaxation was introduced, and Ms. F. reported that she enjoyed using this strategy because of its similarity to religion-based meditation practices with which she was already familiar. As an adjunct, music-based (rather than language-based) relaxation tapes were introduced, which were more easily used by Ms. F. because English language difficulties were avoided. Her emotional adjustment improved by self-report and clinical observation. Staff informant data
confirmed that energy level and participation during physical therapy, occupational therapy, and nursing rehabilitative care increased as well. Case 2 Mr. D., a 55-year-old divorced Polish American man, sustained a C2 ASIA C injury with head injury following a fall from a roof while working approximately 4 months prior to admission. As a result of his injury, Mr. D. was ventilator dependent and his respiratory treatment was complicated by panic symptoms frequently experienced during routine trachea care. The goal of relaxation was anxiety reduction. As Mr. D. had limited ability to breathe off the ventilator and felt uncomfortable focusing on his breathing since his spinal cord injury, he was not able to participate in breathing exercises that he had learned prior to injury. Mr. D. was not able to participate in muscle-dependent relaxation exercises because of functional level. Mr. D. was initially exposed to a standard relaxation script but found it difficult to concentrate as a result of motivational and attention issues. He was introduced to visual imagery and also found this difficult to attend to until the visual imagery script was personalized to include his favorite activity, fishing. Once he was able to focus on a personally relevant factor within the relaxation script, he was able to maintain his motivation and participate fully in the intervention. By selfreport, he felt in better control over the anxiety. By clinical observation and staff informant data, anxiety episodes decreased 75%, which allowed him to participate more fully in available rehabilitation sessions and psychosocial activities. Case 3 Mr. E., a 42-year-old divorced English American man, sustained an L1 ASIA B injury following a motorcycle accident 15 years prior to current treatment. He was seen on an outpatient basis. The goal of relaxation training was pain reduction. He stated that participation in progressive muscle relaxation exacerbated his pain; therefore this was not an appropriate intervention for him. Although diaphragmatic breathing was not precluded by level of injury, the individual was motivated to use a nondiaphragmatic strategy because he had previously used it with good results. Specifically, he had been instructed by a previous clinician to breathe in and out while visualizing a scene or a thought of his choosing. By having the option to choose his own image, he was able to have a sense of self-control over content while at the same time following a semistructured format of relaxation intervention. His motivation to use a previously learned appropriate and effective technique was respected, and this technique was used as the cornerstone of his relaxation intervention. At the end of treatment, over a span of 4 weeks, his self-report of pain experienced had been reduced from a daily average of 7 to 3 (on a scale from 0 [none] to 10 [extreme]). Case 4 Mr. L., a 53-year-old married Irish American man, sustained a T6 ASIA A injury during military service 31 years prior to hospital admission. The goal of relaxation was to improve coping ability to increase adjustment to lifestyle change related to spinal cord injury and posttraumatic stress disorder. As a consequence of posttraumatic stress disorder, he was unable to benefit from guided visual imagery intervention because of trust-control issues and frequent occurrence of flashbacks. In particular, when
he attempted visual imagery, Mr. L. would often feel that he was losing control of the image because distressing trauma-related images would intrude. He chose to use progressive muscle relaxation for his arm, shoulder, neck, and face muscles in conjunction with diaphragmatic breathing. The structure and pace of the progressive muscle relaxation script was a sufficient distraction, which allowed him to relax without experiencing intrusive problematic thoughts. By attempting and practicing the progressive muscle relaxation steps appropriate for his level of spinal cord injury, Mr. L. was able to master this skill and reduce the experience of reported daily stress. This intervention promoted less avoidance of and resistance to rehabilitative therapies because he was better able to participate. Case 5 Mr. J., a 56-year-old married Italian American man, sustained a T12 ASIA D injury following a motor vehicle accident 5 years prior to his hospital admission. The goal of relaxation training was to increase stress management ability to effectively cope with life demands. Prior to his accident, Mr. J. had run a successful corporation and had participated in stress management as part of personal development. At the time of admission, Mr. J. was depressed and was initially disillusioned with stress management strategies. Specifically, he dismissed previously learned coping strategies as ineffective (just as other previously useful coping strategies were currently ineffective in alleviating his depression). Prior strategies were contrasted with current interventions, and Mr. J. was encouraged to modify techniques to increase their usefulness. In addition, Mr. J. found that by choosing a color to represent the intensity and vividness of anxiety, distress, sadness, anger, and fear and then visualizing its change during and after relaxation interventions, he was able to observe and encode the effect of relaxation strategies. Through practice and learning how to adapt relaxation strategies to his abilities, Mr. J. became open to reincorporating stress management strategies into his coping repertoire and enriched existing skills. Within 6 weeks, his level of depression was reduced from the moderate to mild range. Case 6 Mr. R., a 67-year-old divorced African American man, presented with an L2 ASIA C injury following complications from a surgical procedure. He was admitted for rehabilitation approximately 3 weeks after the onset of his injury. During this time, he was adjusting to a new injury and the challenges of an extended hospital stay for the first time in his life. The goal of relaxation training was reduction of anxiety related to having sustained a recent spinal cord injury. A combination of meditation and progressive muscle relaxation skills for facial and upper body muscles was useful in managing his anxiety in some situations, but he continued to experience difficulty managing stress and emotions when interacting with staff and family regarding personal care issues. Assertive communication skill training was introduced as an adjunct to relaxation skills to increase Mr. R.'s sense of mastery over stressful aspects of his hospitalization and life situation. Giving him a framework to understand and attempt to regain self-control allowed him to communicate more effectively with staff and significant others. With the stress and emotions better managed, he was able to participate more fully in rehabilitation treatment and activities in preparation for community reintegration. DISCUSSION
The methods used in this study were efficacious, suggesting that clinicians should consider injury level when selecting specific relaxation techniques for individuals with spinal cord injury. As illustrated in the preceding case studies, it is possible to tailor available and effective strategies to the specific functional and motor-sensory impairment level of different individuals (seeTable 2). By doing so, each person was able to participate fully in relaxation treatment and each displayed increased motivation to use strategies consistently and effectively. A careful assessment of an individual's previous experience with relaxation strategies as well as special preferences (e.g., classical music, outdoor activities) can facilitate development of personalized and more effective interventions.
Proposed Recommendations for Maximizing Fit Between Relaxation Strategy and Injury Characteristics Variability in level and completeness of spinal cord injury-disease renders some relaxation techniques inappropriate for some individuals. Therefore, the understanding of each individual's functional level (Heimer, 1995; Pryse-Phillips & Murray, 1992) is crucial for the mental health provider developing relaxation treatments for persons with spinal cord injury. Fortunately, a range of strategies is widely used and effective in helping to produce relaxation and stress management. Although some strategies, such as progressive muscle relaxation, may be unsuitable for some people, almost all individuals with spinal cord injury may use other techniques, such as visual imagery or music-guided relaxation. In addition to the functional level associated with spinal cord injury, a preintervention assessment should also take into account the individual's cognitive level, psychosocial and ethnicity background, adjustment stage, and motivation to participate in relaxation treatment. The assessment of adjustment to injury is important to consider in the event that an individual is unwilling to participate in relaxation strategies, and adjustment to spinal cord injury and life trauma itself may become the primary treatment focus of psychotherapy. Interventions, such as relaxation training, that are refused during early stages of adjustment may be successfully reintroduced later in the rehabilitation process when the individual is more accepting and able to participate.
Finally, systematic, controlled research into the effectiveness of relaxation strategies in rehabilitation settings is needed. Case studies such as those presented here describing work with individuals with a spinal cord injury, as well as those discussing other rehabilitation populations (e.g., Dane, 1996; Sapp, Farrell, Johnson, Kirby, &Pumphrey, 1997), are useful for illustration of potentially effective interventions and to generate interest in alternative treatment planning options. However, larger sample double-blind studies that use pre- and postmeasures are now necessary to analyze treatment efficacy. Moreover, one may argue that use of the technique is as important as mastery of the skill, and, therefore a measure of use is needed as well. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Appel, P. R. (1990). Clinical applications of hypnosis in the physical medicine and rehabilitation setting: Three case reports. American Journal of Clinical Hypnosis, 33, 85 93. Appel, P. R. (1992).Performance enhancement in physical medicine and rehabilitation.American Journal of Clinical Hypnosis, 35, 11 19. Benson, H. (1975). The relaxation response. New York: Morrow. Bertino, L. S. (1989). Stress management with SCI clients. Rehabilitation Nursing, 14, 127 129. Butt, L. (1997). Stress management and spinal cord injury. SCI Psychosocial Process, 10, 18 20. Caudill, M., Schnable, R., Zuttermeister, P., Benson, H., & Friedman, R. (1991). Decreased clinic use by chronicpain patients: Response to behavioralmedicine intervention. Clinical Journal of Pain, 7, 305 310. Craig, A. R., Hancock, K., Chang, E., & Dickson, H. (1998).Immunizing against depression and anxiety after spinal cord injury.Archives of Physical Medicine and Rehabilitation, 79, 375 377. Curcoll, M. L. (1992). Psychological approach to the rehabilitation of the spinal cord injured: The contribution of relaxation techniques. Paraplegia, 30, 425 427. Dane, J. R. (1996). Hypnosis for pain and neuromuscular rehabilitation with multiple sclerosis: Case summary, literature review, and analysis of outcomes. International Journal of Clinical & Experimental Hypnosis, 44, 208 231. Grzesiak, R. C. (1977). Relaxation techniques in treatment of chronicpain.Archives of Physical Medicine and Rehabilitation, 58, 270 272. Heimer, L. (1995). The human brain and spinal cord: Functional neuroanatomy and dissection guide (2nd ed.). New York: Springer-Verlag.
Hough, S., &Kleinginna-Gallaher, C. (2000, May). B-A-C-K-M-A-P approach for implementation of psychological intervention across the dimension of age for individuals following spinal cord injury. Poster presented at Charting the Course for Rehabilitation Medicine in the 21st Century, Mystic, CT. Hulse, K. L. (1997). Psychosocial health issues for individuals with spinal cord injury. SCI Psychosocial Process, 10, 3 7. Jacobson, E. (1974). Progressive relaxation. Chicago: University of Chicago Press. Kennedy, P., & Rogers, B. A. (2000). Anxiety and depression after spinal cord injury: A longitudinal analysis. Archives of Physical Medicine and Rehabilitation, 81, 932 937. Kleinginna-Gallaher, C., & Hough, S. (2000, September).Relaxation instruction based upon level of spinal cord injury. Poster presented at 14th annual conference of the American Association of Spinal Cord Injury Psychologists and Social Workers, Las Vegas, NV. Kleinginna-Gallaher, C., & Hough, S. (2001). Ethnicity and age issues: Attitudes affecting rehabilitation of individuals with spinal cord injury. Rehabilitation Psychology, 46, 312 321. Lazarus, A. (1977). In the mind's eye: The power of imagery for personal enrichment. New York: Guilford Press. Linton, S. J., &Gotestam, K. G. (1984).A controlled study of the effects of applied relaxation and applied relaxation plus operant conditioning in the regulation of chronicpain.British Journal of Clinical Psychology, 23, 291 299. Macleod, L., & Macleod, G. (1998). Control cognitions and psychological disturbance in people with contrasting physical conditions. Disability and Rehabilitation, 20, 448 456. Mandel, A. R., & Keller, S. M. (1986). Stress management in rehabilitation. Archives of Physical Medicine and Rehabilitation, 67, 375 379. Moverman, R. (1998). Relaxation methods in rehabilitation.SCI Psychosocial Process, 11, 11 13. Pryse-Phillips, W., & Murray, T. J. (1992).Essential neurology: A concise textbook (4th ed.). New York: Elsevier. Sapp, M., Farrell, W. C., Jr., Johnson, J., Jr., Kirby, R. S., &Pumphrey, K. K. (1997). Hypnosis: Applications for rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 28, 43 49. Smarr, K. L., Parker, J. C., Wright, G. E., Stucky-Ropp, R. C., Buckelew, S. P., & Hoffman, R. W. (1997). The importance of self-efficacy in rheumatoid arthritis.Arthritis Care and Research, 10, 18 26. Submitted: October 20, 2000 Revised: September 3, 2001 Accepted: September 9, 2001
This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Rehabilitation Psychology. Vol.47 (4) US : Educational Publishing Foundation pp. 415-425. Accession Number: rep-47-4-415 Digital Object Identifier: 10.1037/0090-5550.47.4.415 00905550.47.4.415
By: Sigmund Hough Psychology and Spinal Cord Injury Services, Veterans Affairs Boston Healthcare System-West Roxbury Campus, West Roxbury, Massachusetts; Department of Psychiatry, Harvard Medical School Carol Kleinginna Psychology and Spinal Cord Injury Services, Veterans Affairs Boston Healthcare System-West Roxbury Campus, West Roxbury, Massachusetts; Department of Psychiatry, Harvard Medical School Acknowledgement: We thank Marika Hess for consultation Correspondence concerning this article should be addressed to: Sigmund Hough, PhD, Spinal Cord Injury Service (#128 SCI), Veterans Affairs Boston Healthcare System-West Roxbury Campus, 1400 VFW Parkway, West Roxbury, Massachusetts 02132 Electronic Mail may be sent to: [email protected]. The relaxation response (Benson, 1975) as a natural restorative process uses various techniques (e.g., meditation, visualization, progressive muscle relaxation, breathing exercises) to relax the body so that a person can cope better with life stress, injury, and pain. Benson (1975) suggested that an individual can use one's mind to change physiology for the better, thus improving health and emotional outlook on life. Among general rehabilitation populations, the achievement of the relaxation response has been associated with decreased pain ratings by individuals with chronicpain (Linton &Gotestam, 1984). Furthermore, interventions that incorporate relaxation approaches have been suggested to lead to a reduction in clinic visits associated with chronicpain issues (Caudill, Schnable, Zuttermeister, Benson, & Friedman, 1991). The changes in daily activities necessitated by hospitalization and injury-specific requirements are likely to be chronic, can be quite stressful, and may lead to an increased sense of powerlessness (Hulse, 1997). This decreased sense of control over one's life is associated with poor adjustment outcomes, including depression (Macleod & Macleod, 1998). Anxiety and depression are frequently encountered during the spinal cord injury rehabilitation process (Kennedy & Rogers, 2000). Specific interventions that address anxiety and depression may serve to buffer the individual against stressful events even after formal intervention has ended (Craig, Hancock, Chang, & Dickson, 1998). Relaxation strategies used as part of stress management have been shown to increase self-efficacy in medical populations with corresponding improvements in depression and pain (Smarr et al., 1997), as well as anxiety (Mandel & Keller, 1986). Visual imagery and hypnosis are other techniques that may be used to increase relaxation and assist in the rehabilitation process (Appel, 1990, 1992). The ability to use relaxation is generally accepted as a positive skill in dealing with medical conditions, illness, and life stress. Relaxation interventions have been used with individuals with spinal cord injury to increase coping and adjustment to injury and to decrease pain (Bertino, 1989; Butt, 1997; Curcoll, 1992; Grzesiak,
1977). However, currently there are no proposed recommendations for particular relaxation strategies best used according to the specific level of spinal cord injury (Kleinginna-Gallaher & Hough, 2000). Interventions such as progressive muscle relaxation (Jacobson, 1974) may not work for all individuals with spinal cord injury because of different functional abilities associated with various levels of injury (seeTable 1). For example, an individual with ventilator dependency would not be able to control diaphragm muscles necessary to engage in breathing exercise. In addition, generic relaxation scripts to be followed by the health care provider or generic audiotapes to be played by the individual with spinal cord injury may increase frustration because of the inappropriateness of specific physical requests as they relate to the individual.
Functional Expectations and Motor-Sensory Impairment on the Basis of Injury Characteristics Although some experiences of spinal cord injury rehabilitation may be similar across individuals, there remain factors that must be reviewed on an individual basis prior to implementing intervention for change. The individual's level of injury, degree of completeness of injury, motivation to participate in an intervention, psychosocial history, and cognitive ability to learn new techniques all must be considered
in relaxation intervention planning. Consideration of these issues allows strategic intervention development and increases the likelihood that participants will be able to maintain interest in treatment (Moverman, 1998) and achieve maximum benefit from services offered. Furthermore, one must also take into account the individual's personal life history, abilities, strengths, ethnicity, and personal preference before implementing a psychosocial intervention (Hough &Kleinginna-Gallaher, 2000; Kleinginna-Gallaher & Hough, 2001). To illustrate these concepts, we describe our work with 6 patients who had different levels of injury and other factors that suggested specific individualized relaxation strategies. METHOD Participants From a cohort receiving psychological services from an inpatient spinal cord injury program within a university-affiliated urban Veteran Affairs Medical Center, 6 individuals (1 woman, 5 men) with a spinal cord injury were selected for illustration on the basis of the diversity of rehabilitation care needs and ability to use relaxation techniques. Relaxation training is routinely available on the basis of motivation to practice a new procedure and the clinical need of such intervention to reduce pain and anxiety and increase coping skills to improve adjustment and/or manage the stress of life events. Procedure A relaxation treatment plan was created for each individual on the basis of information gathered in medical record review, clinical interview (e.g., psychological adjustment status with regards to anxiety, depression, pain, social support, psychosocial and ethnic background, psychiatric background, medical and health status, motivation, cognitive status, and prior experience with relaxation strategies) and consultation with interdisciplinary team members (e.g., medicine, neurology, nursing, physical therapy, pulmonary, psychiatry, psychology, occupational therapy, and social work) regarding abilities, strengths, and weaknesses. In addition, clinical observations were made of treatment adherence, and Global Assessment of Functioning (GAF) scores (American Psychiatric Association, 1994, p. 32) were established during initial contact. The GAF score considers psychological, social, and occupational functioning on a hypothetical continuum of mental health, excluding impairment in functioning due to physical or environmental limitations. All 6 cases had GAF scores between 53 and 62, which is within the range of moderate to mild symptoms. These individuals were not suicidal or homicidal and did not present with psychotic features. All 6 cases met criteria for an adjustment disorder related to spinal cord injury. The diagnosis of a mental disorder or absence of mental disorder and GAF scores were determined by a licensed psychologist on the basis of theDiagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria. Within the context of providing individual psychotherapy, participants were told that a part of treatment would be relaxation training in addition to talking about adjustment to injury and life situation. Specifically, they were informed that they would be taught a skill for coping with a stressful situation and that with practice they could become increasingly proficient at relaxation. Further elaboration was provided on how relaxation training could be beneficial to one's specific situation. A few diagrams and charts to depict the mind-body connection
and spinal cord injury were used to promote education and understanding to form a foundation for treatment compliance. When visual imagery was used as the relaxation intervention of choice, the Imagery Vividness Scale (Lazarus, 1977) was used as a screening tool as well as a training tool to educate the individual regarding imagery technique. Basic instructions (Lazarus, 1977) included Let's try a simple test. You will be asked to picture certain images. If your image is very clear give it a rating of 4, moderately clear equals a 3, fairly clear equals a 2, and unclear equals a rating of 1. If you cannot form an image give it a 0. After reading each item, close your eyes, picture it as clearly as you can, and then record your own rating. For example, picture a bowl of fruit or see a white sandy beach. (p. 9) The description given can be enriched during training by educating the person as to the multidimensional aspects of the vividness (e.g., ask them to say more about the image and give examples, such as the ball is red, candy apple red, round, round like a globe, bouncy, bouncy like a yo-yo going up and down ). All imagery training total scores were above 50, which is well above the recommended minimum inclusion criterion score of 30. Protocols for training were individualized to take into account the level of spinal cord injury and physical ability. Each person was informed that he or she could stop the relaxation training at any time (e.g., if there was an increase in pain or discomfort) without penalty or prejudice in regard to his or her health care. Monitoring of relaxation training occurred one-three times per week to ensure sufficient rehearsal and to evaluate the effectiveness of the practice. Participants were asked to assess satisfaction with the interventions and willingness to use them after treatment completion. CASE ILLUSTRATIONS AND RESULTS Case 1 Ms. F., a 35-year-old married Taiwanese American woman, sustained a C6 American Spinal Injury Association (ASIA) A injury following a motor vehicle accident. She was referred for psychological assessment and treatment to address emotional adjustment approximately 1 month postinjury. The goal of relaxation was to increase coping ability to improve psychological adjustment to injury and lifestyle change. Ms. F.'s primary language was Taiwanese, and, although she understood some English, her preferred language was Taiwanese. On the basis of Ms. F.'s functional level, interventions solely dependent on muscle relaxation strategies were not appropriate. Although she was able to participate in breathing exercises, she reported that she was not motivated to do them on a consistent basis. An assessment of Ms. F.'s preinjury interests revealed a strong involvement in the Buddhist religion and an interest in the arts. Meditation-based relaxation was introduced, and Ms. F. reported that she enjoyed using this strategy because of its similarity to religion-based meditation practices with which she was already familiar. As an adjunct, music-based (rather than language-based) relaxation tapes were introduced, which were more easily used by Ms. F. because English language difficulties were avoided. Her emotional adjustment improved by self-report and clinical observation. Staff informant data
confirmed that energy level and participation during physical therapy, occupational therapy, and nursing rehabilitative care increased as well. Case 2 Mr. D., a 55-year-old divorced Polish American man, sustained a C2 ASIA C injury with head injury following a fall from a roof while working approximately 4 months prior to admission. As a result of his injury, Mr. D. was ventilator dependent and his respiratory treatment was complicated by panic symptoms frequently experienced during routine trachea care. The goal of relaxation was anxiety reduction. As Mr. D. had limited ability to breathe off the ventilator and felt uncomfortable focusing on his breathing since his spinal cord injury, he was not able to participate in breathing exercises that he had learned prior to injury. Mr. D. was not able to participate in muscle-dependent relaxation exercises because of functional level. Mr. D. was initially exposed to a standard relaxation script but found it difficult to concentrate as a result of motivational and attention issues. He was introduced to visual imagery and also found this difficult to attend to until the visual imagery script was personalized to include his favorite activity, fishing. Once he was able to focus on a personally relevant factor within the relaxation script, he was able to maintain his motivation and participate fully in the intervention. By selfreport, he felt in better control over the anxiety. By clinical observation and staff informant data, anxiety episodes decreased 75%, which allowed him to participate more fully in available rehabilitation sessions and psychosocial activities. Case 3 Mr. E., a 42-year-old divorced English American man, sustained an L1 ASIA B injury following a motorcycle accident 15 years prior to current treatment. He was seen on an outpatient basis. The goal of relaxation training was pain reduction. He stated that participation in progressive muscle relaxation exacerbated his pain; therefore this was not an appropriate intervention for him. Although diaphragmatic breathing was not precluded by level of injury, the individual was motivated to use a nondiaphragmatic strategy because he had previously used it with good results. Specifically, he had been instructed by a previous clinician to breathe in and out while visualizing a scene or a thought of his choosing. By having the option to choose his own image, he was able to have a sense of self-control over content while at the same time following a semistructured format of relaxation intervention. His motivation to use a previously learned appropriate and effective technique was respected, and this technique was used as the cornerstone of his relaxation intervention. At the end of treatment, over a span of 4 weeks, his self-report of pain experienced had been reduced from a daily average of 7 to 3 (on a scale from 0 [none] to 10 [extreme]). Case 4 Mr. L., a 53-year-old married Irish American man, sustained a T6 ASIA A injury during military service 31 years prior to hospital admission. The goal of relaxation was to improve coping ability to increase adjustment to lifestyle change related to spinal cord injury and posttraumatic stress disorder. As a consequence of posttraumatic stress disorder, he was unable to benefit from guided visual imagery intervention because of trust-control issues and frequent occurrence of flashbacks. In particular, when
he attempted visual imagery, Mr. L. would often feel that he was losing control of the image because distressing trauma-related images would intrude. He chose to use progressive muscle relaxation for his arm, shoulder, neck, and face muscles in conjunction with diaphragmatic breathing. The structure and pace of the progressive muscle relaxation script was a sufficient distraction, which allowed him to relax without experiencing intrusive problematic thoughts. By attempting and practicing the progressive muscle relaxation steps appropriate for his level of spinal cord injury, Mr. L. was able to master this skill and reduce the experience of reported daily stress. This intervention promoted less avoidance of and resistance to rehabilitative therapies because he was better able to participate. Case 5 Mr. J., a 56-year-old married Italian American man, sustained a T12 ASIA D injury following a motor vehicle accident 5 years prior to his hospital admission. The goal of relaxation training was to increase stress management ability to effectively cope with life demands. Prior to his accident, Mr. J. had run a successful corporation and had participated in stress management as part of personal development. At the time of admission, Mr. J. was depressed and was initially disillusioned with stress management strategies. Specifically, he dismissed previously learned coping strategies as ineffective (just as other previously useful coping strategies were currently ineffective in alleviating his depression). Prior strategies were contrasted with current interventions, and Mr. J. was encouraged to modify techniques to increase their usefulness. In addition, Mr. J. found that by choosing a color to represent the intensity and vividness of anxiety, distress, sadness, anger, and fear and then visualizing its change during and after relaxation interventions, he was able to observe and encode the effect of relaxation strategies. Through practice and learning how to adapt relaxation strategies to his abilities, Mr. J. became open to reincorporating stress management strategies into his coping repertoire and enriched existing skills. Within 6 weeks, his level of depression was reduced from the moderate to mild range. Case 6 Mr. R., a 67-year-old divorced African American man, presented with an L2 ASIA C injury following complications from a surgical procedure. He was admitted for rehabilitation approximately 3 weeks after the onset of his injury. During this time, he was adjusting to a new injury and the challenges of an extended hospital stay for the first time in his life. The goal of relaxation training was reduction of anxiety related to having sustained a recent spinal cord injury. A combination of meditation and progressive muscle relaxation skills for facial and upper body muscles was useful in managing his anxiety in some situations, but he continued to experience difficulty managing stress and emotions when interacting with staff and family regarding personal care issues. Assertive communication skill training was introduced as an adjunct to relaxation skills to increase Mr. R.'s sense of mastery over stressful aspects of his hospitalization and life situation. Giving him a framework to understand and attempt to regain self-control allowed him to communicate more effectively with staff and significant others. With the stress and emotions better managed, he was able to participate more fully in rehabilitation treatment and activities in preparation for community reintegration. DISCUSSION
The methods used in this study were efficacious, suggesting that clinicians should consider injury level when selecting specific relaxation techniques for individuals with spinal cord injury. As illustrated in the preceding case studies, it is possible to tailor available and effective strategies to the specific functional and motor-sensory impairment level of different individuals (seeTable 2). By doing so, each person was able to participate fully in relaxation treatment and each displayed increased motivation to use strategies consistently and effectively. A careful assessment of an individual's previous experience with relaxation strategies as well as special preferences (e.g., classical music, outdoor activities) can facilitate development of personalized and more effective interventions.
Proposed Recommendations for Maximizing Fit Between Relaxation Strategy and Injury Characteristics Variability in level and completeness of spinal cord injury-disease renders some relaxation techniques inappropriate for some individuals. Therefore, the understanding of each individual's functional level (Heimer, 1995; Pryse-Phillips & Murray, 1992) is crucial for the mental health provider developing relaxation treatments for persons with spinal cord injury. Fortunately, a range of strategies is widely used and effective in helping to produce relaxation and stress management. Although some strategies, such as progressive muscle relaxation, may be unsuitable for some people, almost all individuals with spinal cord injury may use other techniques, such as visual imagery or music-guided relaxation. In addition to the functional level associated with spinal cord injury, a preintervention assessment should also take into account the individual's cognitive level, psychosocial and ethnicity background, adjustment stage, and motivation to participate in relaxation treatment. The assessment of adjustment to injury is important to consider in the event that an individual is unwilling to participate in relaxation strategies, and adjustment to spinal cord injury and life trauma itself may become the primary treatment focus of psychotherapy. Interventions, such as relaxation training, that are refused during early stages of adjustment may be successfully reintroduced later in the rehabilitation process when the individual is more accepting and able to participate.
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This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Rehabilitation Psychology. Vol.47 (4) US : Educational Publishing Foundation pp. 415-425. Accession Number: rep-47-4-415 Digital Object Identifier: 10.1037/0090-5550.47.4.415 00905550.47.4.415
