Coping Skills Group Page 1 Session 3: Advanced Relaxation Skills. Relaxation Skills Part II. a. Did anyone have any questions about the reading?

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1 Coping Skills Group Page 1 Session 3: Relaxation Skills Part II I. Review A. Homework 1. Relaxation handout a. Did anyone have any questions about the reading? b. What things did you find helpful? c. What ideas did you come up with when you read the handout? 2. Pain diary a. What patterns did you notice? b. Any changes from last week? c. What did you learn about your pain levels? d. How did the relaxation exercises affect your pain levels? 3. Deep Breathing/RR exercises a. What differences did you notice when using the deep breathing? b. What did you notice about your thoughts? c. How did the exercises effect your mood/pain levels? d. Did you have any difficulties with the exercises? e. What could you change to make it more effective? 4. PMR a. What did you notice about your body after practicing PMR? b. What sensations were you aware of? c. How did it affect your pain levels/tension/mood? d. What part of your body had the easiest time relaxing? e. What part of your body did you have difficulty with? f. How did you handle it? g. Anything you would want to change?

2 Coping Skills Group Page 2 5. Pain and Tension ratings Before we begin, let s take a moment and rate the level of muscle tension and pain present right now. B. Advanced skills (Go around the room and record members ratings of both muscle tension and pain) 1. Last week you learned the basic skills needed for relaxation; Deep breathing, relaxation response, and progressive muscle relaxation Today we will build on that knowledge and add to your repertoire. The goals is to learn a number of different skills which can be integrated throughout your day. Remember, integration and daily use are the keys to success. 2. Skills to be taught for the week a. Body scanning - Systematically screening for tension - Using skills to release tension when found b. Autogenics - You ve taught your body to relax muscle groups - This techniques works with the deep relaxation techniques to teach your body to relax to key words

3 Coping Skills Group Page 3 II. Body scanning A. Rationale 1. Research with a variety of chronic pain conditions have shown the effectiveness of relaxation techniques in helping people manage their pain (Malone & Strube, 1988). 2. Pain / Muscle tension cycle (use board to chart cycle of pain /muscle tension) We ve talked about the relationship between pain and muscle tension and how together they can lead to spiraling of the pain cycle. As we ve seen, it becomes important to monitor our muscle tension throughout the day to prevent its escalation. 3. So today we are going to start with body scanning which is simply a systematic method of checking for muscle tension throughout the day, then using relaxation to release the tension before it spirals. B. Instruction 1. Many people have difficulty differentiating between muscle tension and pain. Many people with chronic pain also have difficulty shifting their focus away from the pain. 2. The following exercise is designed to help you become more aware of the different sensations in your body and to increase your ability to differentiate between muscle tension and pain. 3. We will be selectively focusing our attention on each part of your body, starting with the top and moving towards the bottom.

4 Coping Skills Group Page 4 4. Attentional focus a. I m going to be reading a script which will ask you to direct your attention to different parts of your body. b. As you focus in each area, I want you to image that a bright light is shining on that area and only that area. I want you to imagine that everything else is dark and that you are only aware of the area which is in the light. c. We will be starting at the top of your body and working down to your toes. d. I will be asking you questions to help you become more aware of sensations. When I ask these questions, don t answer out loud, rather just make a mental note of whether the sensation was present or not. e. Okay, get comfortable in your chair, close your eyes if you feel comfortable, and focus on your breathing. I ll give you a few moments to get your breathing slow and regular before I start the script. C. Exercise - Attentional focus script

5 Coping Skills Group Page 5 Attentional Focus As you continue to breathe slowly and regularly, feel your body begin to relax into the chair. It is almost as if the chair is rising up to meet your body. As I read the script, I want to make mental contact only with the body part with which we are working. I d like you to imagine a spot light shining on your head and only your head is bathed in light. The rest of your body is in the dark. Focusing only on your head, I want you to become aware of any sensations that are present right now on your head. - Is your scalp tight? Are any tingling sensations present? - Are you aware of any tension, any looseness? - Is your jaw clenched or is it loose? - Is there any tension around your forehead, across your cheekbones? - Are your eyes resting quietly or are you aware of movement? You don t need to do anything right now, just become aware of the sensations that are present on your scalp and face right now. (Pause) Now the light is moving to your neck. Only your neck is bathed in light, everything else is dark. As you mentally make contact with your neck, I want you to become aware of the sensations that are present right now in your neck. -- Is there any tightness or tension? Is there any tingling or numbness? Are you aware of any temperature? Again, you don t have to do anything, you become aware of the different sensations that are present right now. Okay the light is moving to your shoulders, everything else is bathed in darkness. I want you to become aware of the sensations that are present in your shoulders right now. Take a moment and just focus on the feelings in (pause) Okay, let s focus on your arms your upper arms, elbows, your forearms, your wrists, your hands, and your fingers. How do they feel right now? (pause) How does your back feel, right now? What sensations are present in your upper and lower back? Just take a moment to notice how they feel. (pause) (pause) Now let s focus on your hips and buttocks. What sensations are you aware of right now?

6 Coping Skills Group Page 6 The light is moving to your thighs. Pay attention to the sensations that are present right now in your things. What do they feel like at this moment? (pause) Now move your attention to your calves and shins. What sensations are you aware of in your calves and shins, right now. (pause) Finally, move your attention to your feet. Become aware of sensations present right now, only in your feet. (pause). Now I m going to count backwards from 3 to 1 and with each number I want you to shift your focus back to the room so that by number one, you will be ready to open your eyes. 3 - you are aware of the sounds in the room 2- you feel your body resting against the chair 1- your eyes are opening 3. Group discussion C. Body Scanning a. What did that feel like? b. What sensations did you notice? c. What areas were harder to work with? d. What areas were easier to work with? e. When you were focusing on one area, did you notice that you forgot about other parts of your body? 1. Now, you re probably asking, How do I use this? 2. This is the first step in learning to relax tense body parts: Knowing where the tension is and targeting the specific area. 3. If you can catch your muscle tension early in the cycle and relax that muscle, you can reduce the likelihood of the tension building into more pain. (Overhead & Handout) 4. What can you do when you find a tense muscle group? (hopefully they will generate solutions, if not, start them off) What skills have you learned that you can use? (deep breathing, modified PMR, RR)

7 Coping Skills Group Page 7 5. Over the next week you will be using body scanning to reduce tension levels. People often find it helpful to pair the body scanning with a frequently occurring activity. For example, going to the bathroom. What can you pair it with?

8 Coping Skills Group Page 8 III. Autogenics A. Now we are ready to move on to another technique, Autogenics 1. Autogenic training is a systematic method that will teach your body and mind to respond quickly and effectively to your self-suggestions to relax and return to a balanced state (Davis, McKay, Esshelman, 1982). 2. In a study with chronic headache pain, this technique was found to be helpful in reducing overall pain (ter Kuile, Moniek, Spinhoven, Linssen, Zitman, Frans, et al., 1994). B. Skill 1. This training involves your use of key words while progressively working through the same parts of your body that you focused on during the attentional focus exercise. 2. When you repeat these key words remember to mentally make contact with the area of the body you are working on and get a very clear picture in your mind of the area you are working on. 3. You will be making self suggestions to your body to let go of your muscle tension and for the muscle to become warm. This warming response actually increases blood circulation to that area. 4. IMPORTANT!!! DO NOT WARM YOUR FOREHEAD OR SCALP. THEY MUST REMAIN COOL. (otherwise you might get a headache) 5. Don t try to force anything after saying the key words to yourself, just become aware of the sensations in the muscle group as they respond to your words. 6. I will say the phrases and then give you time to repeat them to yourself in your mind. Don t say them out loud, just repeat them in your mind And become aware of the sensations in that area.

9 Coping Skills Group Page 9 C. Exercise Okay, let s start by getting comfortable in your chair. Feel the chair rise up to meet your body as you sink into a more relaxed state. Close your eyes if you feel comfortable and listen to my voice as I lead you through the exercise. Take a few deep cleansing breaths as you breathe in relaxation and breathe out tension. Slow, rhythmical breaths. Now repeat to yourself in your mind. My forehead and scalp are smooth and relaxed. My forehead and scalp are smooth and relaxed. (pause) My forehead and scalp are smooth and relaxed. They are letting go. (pause) I am letting my forehead and scalp become smooth and relaxed. (long pause) My face is loose and relaxed. My face is loose and relaxed. (pause) My face is loose and relaxed. I am letting my face become loose and relaxed. (long pause) My neck is loose and relaxed. My neck is loose and relaxed. (pause) My neck is loose and relaxed. My neck is letting go. (pause) I am letting my neck become limp and relaxed (long pause) My shoulders are warm and relaxed. My shoulders are warm and relaxed (pause) My shoulders are warm and relaxed. My shoulders are letting go. (pause) I am letting my shoulders become warm, limp and relaxed. (long pause) My arms are warm and relaxed. My arms are warm and relaxed (pause) My arms are warm and relaxed. My arms are letting go. (pause) I am letting my arms become warm, limp and relaxed. (long pause)

10 Coping Skills Group Page 10 My chest and back are warm and relaxed. My chest and back are warm and relaxed (pause) My chest and back are warm and relaxed. My chest and back are letting go. (pause) I am letting my chest and back become warm, limp and relaxed. (long pause) My buttocks and hips are warm and relaxed. My buttocks and hips are warm and relaxed (pause) My buttocks and hips are warm and relaxed. My buttocks and hips are warm and relaxed (pause) I am letting my buttocks and hips become warm, limp, and relaxed. (long pause) My legs are warm and relaxed. My legs are warm and relaxed (pause) My legs are warm and relaxed. My legs are letting go. (pause) I am letting my legs become warm, limp, and relaxed. (long pause) Now just become aware of the sensations in your body. Notice any warmth, any heaviness,.. the feelings of relaxation that are present in your body right now. Okay, now slowly start stretching your body by gently moving your feet, your legs, your arms, your neck..and open your eyes. D. Group discussion 1. What did that feel like? 2. What sensations did you notice? 3. What areas were harder to work with? 4. What areas were easier to work with? 5. When you were focusing on one area, what happened in the other areas of your body? Did they remain relaxed?

11 Coping Skills Group Page 11 IV. Visualization A. Rationale Has anyone ever noticed that during a daydream you are not as aware of things around you or your pain? Visualization is a way to systematically refocus your attention away from your pain by creating mental images of pleasurable, relaxing things. In a variety of studies with chronic pain patients visualization and imagery skills were found to be an effective component for managing pain levels. (McKay, Davis, Fanning, 1981; Newshan & Balamuth, 1991; Turner & Jensen, 1993). Visualization involves suspending your conscious flow of thoughts, while you focus on a scene that you create in your mind. Visualization takes your relaxation skills one step further because you refocus your attention away from your pain, using a scene that is incompatible with the experience of pain. For instance, imagine yourself sunbathing on a pleasant, warm beach; fishing in your favorite spot; walking through the woods with a friend; resting on a hill over looking the city; sitting in your favorite chair or overlooking a garden (Mckay, Davis, Fanning, 1981). B. Skill Let s do one together. The key is to make the scene as vivid as possible by creating as many details and involving as many senses as possible. Make it as real as you possible can. Be aware of temperature; is it cool, warm? Is there a breeze blowing or is it calm. What does the ground feel like under your feet? If you are barefooted, is there dew on the grass, is it cool on the bottom of your feet? Or if there is dirt, can you feel any pebbles? What are the colors like, bright and vivid or subtle and muted?

12 Coping Skills Group Page 12 Okay, before we begin I want you to again get comfortable in your chair. Close your eyes and take a few deep cleansing breathes. (read the passage slowly, allowing time for the participants to develop the images) Slowly take in a long deep breath and then slowly exhale through your mouth. Now, see yourself walking along a dry dirt trail in the mountains. It s a warm summer day. The sky is a deep, deep blue. On either side of the trail there are clumps of bright green grass, shimmering with dew and you notice that as the grass thickens, it becomes dotted with yellow and violet flowers. You continue to walk along the trail looking around at all the color. (pause) The air is warm and clear with the slight sent of pine as you pass by a cluster of long needled pine trees. You notice as the needles sway ever so slightly to a very mild, warm breeze. Above you a gray-blue bird flies by, not too far above the treetops. (pause) You notice the trail has begun to take you on a slight down slope, as you hear a quiet shushing noise in the background. As you continue to walk ahead, you notice the sound begins to get louder and the air becomes noticeably cooler until finally you come upon a gently, flowing brook. You stop for a moment allowing your eyes to follow the water, smoothly drifting along. Little bubbles come to the surface here and there and continue to flow along with the current. (pause) You gently move away from the brook as you continue along the trail. As the path begins to turn, you suddenly find yourself in a beautiful, tranquil meadow. The meadow is surrounded by gently sloping hills and you can hear the brook in the distance. Brilliantly colored flowers of different shapes and sizes dot the meadow and are visited by an occasional butterfuly. You feel very safe and content here and find a place in the tall dry grass to lie down. (pause)

13 Coping Skills Group Page 13 It feel so good to sink down into the grass and let yourself deeply relax. The sun shines warmly on your body and hands. As you inhale, you take in the scent of the meadow and the flowers while the bird softly call to each others in the trees. (pause) A small white cloud in the deep blue sky floats off in the distance. Slowly the cloud drifts closer and closer. Watching the cloud, you notice how soft and billowy it appears. (pause) The cloud moves closer and gradually begins to drift in front of the sun until it completely covers it. The cloud is now very bright in the sky. As the sunbeams highlight the brilliant edges of the cloud notice how the cloud s edges sharply contrast against the deep blue sky. Just focus on the quality of the cloud for a few moments; it s softness, it s puffiness, and brilliant hue in the sky. (pause) The cloud slowly drifts by, once again revealing the sun. You feel warm and comfortable and very much in harmony with your surroundings. (pause) Notice the sensations in your body as you become more and more deeply relaxed. (pause) The time has come for you to return, so you stand up and begin walking back up the trail out of the meadow. You pass the gently flowing brook with its quiet melodic rushing of water (pause) You pass the tree lined landscape with the pine trees swaying gently in the breeze. Slowly, you find yourself coming back to the room, feeling very calm, relaxed, and peaceful. (pause) Slowly you become aware of your body as it rests heavily and fully relaxed in your chair. You become aware of the sounds around you and gently stretch and wiggle toes, feet, fingers, and hands. Slowly as you come back to the room you carry with you the feelings of being calm, peaceful, and relaxed. (pause) When you are ready, slowly open your eyes.

14 Coping Skills Group Page 14 V. Wrap up C. Group discussion 1. Let s go around and rate pain and tension levels right now? (go around and ask each participant for each rating and record then compare against starting numbers at the beginning of group) 2. How did that feel? 3. What were the easiest images to create? 4. Which ones were harder? 5. Could you hear the sounds/feel the grass,breeze,warmth? 6. Where you able to focus your attention fully into the scene? 7. How did this exercise effect your pain/tension/mood? 8. How can you use this during the upcoming week? A. Homework 1. Pain diary 2. Deep breathing x5/day for 5 minutes combined with body scanning 3. Practice relaxation x2/day use combination of PRM, autogenics, RR or visualization Track use on relaxation logs 4. Complete the DAS for the next session (need to do this one!) B. Goal setting 1. Take 5 minutes and write out 1 goal for this week and how you are going to accomplish it. 2. What are the obstacles that you might run into, and how will you overcome them.

15 Coping Skills Group Page 15 References Newshan, G. & Balamuth, R. ( ). Use of imagery in a chronic pain outpatient group. Imagination, Cognition, and Personality, 10(1), Malone, M. & Strube, M. (1988). Meta-analysis of non-medical treatments for chronic pain. Pain, 34, Ter Kuile, M., Spinhoven, P., Linssen, A., Zitman, F., et al. (1994). Autogenics training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups. Pain, 58, Turner, J. & Jensen, M. (1993). Efficacy of cognitive therapy for chronic low back pain. Pain, 52,

16 Coping Skills Group Page 16 Body Scanning. Scan your body throughout the day Regular intervals Pair it with a routine activity. Relaxation techniques Deep breathing Progressive Muscle Relaxation Relaxation Response Autogenics

17 Coping Skills Group Page 17 Progress Note: Patient was referred to the Coping Skills Psychoeducational Group by Dr. and was seen on / /. Patient participated for the third session of the group which covered advanced relaxation skills for coping with pain. Patient was given instruction on the following topics: 1) attentional focus, 2) body scanning, 3) autogenics, and 4) visualization. Patient participated in exercises and demonstrated basic compentency in attentional focus, autogenics, and visualization. Patient set goals focused on implementing the information for the upcoming week. Homework assignments to be completed for next session are: 1) Complete Pain Diary 2) Practice selected relaxation techniques x2 daily 3) Practice scanning/deep breathing throughout the day (minimum x4/day) 4) RTC / / Patient was seen for 90 minutes.