Evidence of efficacy for stress-relief techniques

I often hear about relaxation techniques in pop psychology. We also discussed them in the mental health section of our Occupational Therapy (OT) curriculum when we explored anxiety. But are they effective and science-based?

Background
Stress and anxiety are common but relatively nebulous issues that can be hard to treat – especially as the cause of stress can be difficult to localize and anxiety has no direct apparent “cause”. Prolonged psychological stress or anxiety can even manifest a variety of physiological symptoms – high blood pressure, poor cognitive performance, mood problems, gastrointestinal disturbance, changes in eating habits, weight changes, somatic symptoms, and substance abuse.

Prolonged or excessive stress and anxiety are recognized by the DSM as psychiatric disorders if they persist and interfere with a person’s ability to engage in daily activities. Now, that is a gross oversimplification and there are many kinds of anxiety disorders with specific symptoms, but a lengthy description is beyond the scope of this article. For more information, consult the DSM (Axis I).

Due to the discomfort of these symptoms, many people seek professional treatment (some never do). Patients with mild to moderate cases or who are averse to pharmaceutical treatment may seek/require relatively mild treatment methods. In those cases, it is important to consider the efficacy of the interventions used in order to ensure a high quality of health care.

Treatments for stress generally fall into two categories: cognitive behavioural therapy (CBT) and pharmaceutical intervention. Sometimes a combination of techniques is necessary to provide relief and treatment depends on severity of distress and the level of impact on daily life. CBT can incorporate some first-line techniques to help moderate stress and anxiety such as relaxation and meditation.

Some of these techniques are progressive muscle relaxation (PMR), relaxation therapy, meditation, and transcendental meditation (TM). The goal from an OT perspective is, after initial professional training, to give the patient some measure of control over their symptom management and increase independence.

PMR This is basically what is sounds like – tensing and relaxing muscles. The idea is to relieve tension in the muscles, producing a feeling of relaxation and therefore hopefully lessening feelings of anxiety. Also, if the patient is concentrating on their muscles rather than their worries, they focus and relax mentally as well. This is also used as a technique for tension-related insomnia.

Relaxation Therapy The aim of relaxation therapy is to use psychological methods to treat the psychological feeling of stress/anxiety, thereby reducing physiological symptoms. If one can reduce their state of arousal, they could theoretically also prevent themselves from feeling more and more anxious, allowing them to internally recognize and manage their own anxiety before it becomes severe (or develops into a panic attack).

Meditation This is a relatively broad term, but generally involves clearing one’s mind and concentrating on something – usually breathing, a chant, or some other relaxing imagery – in a silent, distraction-free environment. The theory is that meditation reduces the heart and breathing rate. There are also questionable claims that meditation directly reduces the production of cortisol.

TM This is a technique that has basically the same characteristics of meditation, but with added East Indian flair. During this meditation the person concentrates on and repeats a mantra. The goal is to experience different levels of consciousness (note that these levels are derived from spiritual belief and are not supported with research) – specifically the transcendental/pure consciousness (4th) level. TM differs from other methods in that there is a specific target in mind. Whereas the other methods are aimed at reducing anxiety (in whatever amount that may be), this methods seeks to reach a specific level of consciousness with anxiety reduction as a secondary effect.

Effectiveness
Supporting evidence ranges from weak (meditation) to generally positive (relaxation). Some of these techniques (PMR) are still somewhat inferior to other psychiatric interventions (i.e., CBT). None appear demonstrably harmful when used with other therapies, but the objective benefits are questionable in those techniques with weaker supporting evidence. These techniques seem appropriate as a first-line treatment for patients with mild to moderate symptoms, but may not be effective in patients with co-morbid conditions that affect arousal or muscle tone.

However, the evidence for TM is suspect. TM suffers from publication bias – specifically, multiple publications of the same data falsely bolsters evidence of efficacy. Also, there is reason to believe that it is no more effective than regular meditation. Studies of TM that report positive results sometimes fail to incorporate adequate controls to account for this effect. Also, so far there is no support for the varying levels of consciousness proposed to accompany the process. Furthermore, as the aim is to reach a certain level of consciousness rather than to marginally reduce anxiety, patients may actually experience anxiety or frustration if (or arguably, when) they fail.

In all cases it’s difficult to separate the positive effects from the general interactions with therapists. People may feel improvement simply because someone is finally helping them, not because of what they are being helped with.

Summary
Reducing stress outside of pharmaceutical intervention essentially depends on a person’s ability to self-regulate. Giving a patient some measure of control over their treatment reduces dependence on the therapeutic relationship and increases self-reliance. So it makes sense that interventions would attempt to enhance self-controlled anxiety management. However, evidence for the efficacy of these methods are mixed. Some work better than others, they may not work for everyone, and they require initial training/supervision by a professional.

There is a plethora of self-help books on the topic of stress reduction, but attempting the techniques above without seeking professional help could lead to exacerbation of symptoms due to prolonged absence of treatment and incorrect application of methods. While it’s possible that a well-crafted video or book may guide someone sufficiently on their own, people are generally bad at evaluating their own progress. That is where a trained professional who sees these symptoms all the time can also be helpful.

In any case, with regard to TM in particular, there is no need to add a mystical belief system in order to increase effectiveness. Certainly if a patient wishes to add a metaphysical element to their own meditation, there is no need to necessarily discourage it, but there is also no need to promote it unnecessarily. It is beyond the scope of a health care practitioner (HCP) to impose spiritual beliefs onto their patients/clients and there is no evidence that there are more positive outcomes with TM over other therapies.

HCPs should avoid language that makes these treatments sound more effective than they generally are. While the results indicate that some of these therapies are an improvement over doing nothing, they can be less effective than regular CBT. They are a good supplement to maintain independent anxiety reduction, to give the patient a measure of control, and possibly reduce feelings of helplessness.

Chronic anxiety is a serious health condition and the above techniques require training and commitment, if they work for the patient at all – they aren’t a guarantee. If someone promises to cure anxiety in X number of “simple” steps or claims that a mystical belief added to therapy increases efficacy, be skeptical.

*The author of this article is a recently-graduated student of OT. This article is for information purposes only and should not replace medical advice. The treatments discussed in this article are most effective under the supervision and/or training of a professional HCP. Talk to your doctor or therapist before trying any of these methods.

Note: Minor edits for clarity, 4 December 2009.

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  • Kim Hebert

    Kim Hébert is an occupational therapist. She is interested in the promotion of science and reason, particularly regarding therapeutic health interventions. She blogs occasionally about occupational therapy and other health topics at Science-Based Therapy. Her hobbies are art and astronomy. **All views expressed by Kim are her personal views alone, and do not necessarily reflect the opinions of current or former employers, associations, or other affiliations. All information is provided for discussion purposes only, and should not be used as a replacement for consultation with a licensed and accredited health professional.