Relaxationdialectical Behavioral Training

Everyone encounters frustrating, frightening, or irritating situations on a daily basis. For most of us, the initial feelings of anger or stress come quickly but subside as we “talk ourselves down” or get support from another person in managing the situation. In some cases, however, the intensity of the anger or anxiety can become too much to handle. At this point, some people choose to seek help from a therapist (or perhaps even a self-help book) to manage their emotions and learn a form of relaxation training.

What about for persons with autism? Intense anxiety, rapid mood changes, or a low frustration tolerance are far more common than in the typically functioning population. In addition, intense emotions often precede problem behaviors such as self-injury or aggression.

Dialectical Behavior Therapy (DBT) is one of the fastest growing approaches — because it works! It harnesses the power of CBT and mindfulness in a strategic way that gets results. Dialectical Behavior Therapy (DBT) is an evidence-based intervention developed by Dr. Marsha Linehan at the University of Washington. DBT combines cognitive behavioral techniques for emotion regulation with distress tolerance, acceptance and mindfulness practices derived from Buddhism.

Over 30 years of research in applied behavior analysis have resulted in a well-established conceptual framework of operant behavior that currently allows us to successfully decrease problem behaviors and increase adaptive skills in people with and without disabilities. Interventions for respondent behaviors, however, are under-researched. Common respondent behaviors include:

  • Screaming
  • Crying
  • Sweaty palms
  • Fist clenching
  • Trembling
  • Knee jerking
  • Rapid heartbeat
  • Gagging
  • Tensing
  • Flushing (turning red)
  • Rapid breathing
  • Nail-biting
  • Jaw-clenching
  • Grabbing onto others
  • Lip-biting
  • Flinging hands up (for protection)

One of the challenges to effective relaxation training is that the effects are gradual. However, the effort can still be worth it as it teaches a person how to independently cope with distressing emotions. Additionally, a person’s cognitive functioning is not a factor: researchers have found that knowing what an intervention was intended to do was not necessary for that intervention to work effectively in managing a person’s anxiety (Obler and Terwillinger, 1970).

This finding offers some potentially significant treatment opportunities for addressing stress, fear, and anger in people with autism. Some forms of relaxation training have already been modified for those with developmental disabilities. The most researched relaxation procedure has been a modified form of Progressive Relaxation (PR) (Lindsay and Baty, 1989; Luiselli, 1980). With PR, it is assumed that through a series of tense-release muscle exercises, an individual will become aware of the physical and emotional sensations that their body experiences in tensed and relaxed states (Bernstein and Borkovec, 1973). Thus, when the person is anxious, he or she can employ PR techniques to help alleviate the feeling of tension through the relaxation response.

However, a limitation of this procedure is that it requires the person to report back to the trainer on how they feel, which may be difficult for individuals with communication impairments (Lindsay, Baty, Michie, and Richardon, 1989; Michulka, Poppen, and Blanchard, 1988; Poppen, 1998). Other challenges can occur if the person who could benefit from relaxation training cannot necessarily tolerate demands, or has difficulty with motor imitation. A potential alternative is a method known as Behavioral Relaxation Training (BRT; Poppen, 1998; Schilling and Poppen, 1983).

BRT focuses on the training of visible behaviors that allow an observer to independently determine whether or not the trainee is relaxed. The procedures of BRT involve modeling very specifically defined positions/behaviors in 10 areas/actions of the body listed in the accompanying chart. The person is taught to imitate the appropriate behaviors and sit in an overall position that will bring on the relaxation response. The observer can score whether or not the person is relaxed by using the Behavioral Relaxation Scale (BRS), a reliable and valid checklist for recording the presence of relaxed behaviors (Poppen and Maurer, 1982; Schilling and Poppen, 1983).

Over the past five years, we have trained 19 patients referred either for clinic-based services, inpatient treatment, or outpatient consultation. Anecdotal observation indicated that training the 10 behaviors specified in the BRT procedure appeared more difficult when taught in an unspecified order, especially when behaviors involving fine motor skills (e.g., keeping eyes lightly closed) were interspersed with gross motor behaviors (e.g., keeping torso in contact with the back of a cushioned chair). Consequently, clinicians were instructed to train the 10 behaviors in a structured order from large-to-small muscle groups: body, head, shoulders, feet, hands, throat, mouth, eyes, and finally breathing and quiet.

To date, 12 studies have been conducted to evaluate the teaching and treatment applicability of BRT with individuals with mental retardation. These studies demonstrated that the participants could acquire BRT more rapidly and more effectively than other forms of relaxation training. Additionally, participants demonstrated improvement in short-term memory and attention (Lindsay, Baty, Michie, and Richardson, 1989; Lindsay, Fee, Michie, and Heap, 1994; Lindsay and Morrison, 1996; Morrison and Lindsay, 1997).
In the neurobehavioral unit in-patient and out-patient programs at the Kennedy Krieger Institute, we have begun investigating the potential of BRT as an addition to the comprehensive behavioral treatment interventions we use for children with developmental disabilities and severe behavior problems (Paclawskyj, 2002, 2004, 2005).

Our data demonstrate significant benefits when the structured training sequence was utilized. For the group as a whole:
1. Patients were taught to engage in BRT for an average of seven minutes and required an average of two hours to achieve mastery.
2. Those patients trained using the structured sequence displayed more improvements across untrained behaviors (m=4) than those trained in a random order (m=1). That is, training in the structured order on average required teaching only 6/10 responses, as opposed to having to teach 9 or all 10 responses when a random order was used.

We now use the structured teaching sequence only, and have seen shortened training times as a result. For the patients for whom BRT was added as a standard intervention, we saw greater than expected improvements for target behaviors such as tantrums in response to noise, compulsive skin picking, and self-injury and aggression co-occurring with agitation and screaming. We hope to continue our work in treatment evaluation to identify which persons are the best candidates for such treatment and in which problem areas is it most useful.

References

Bernstein, D. A., and Borkovec, T. D. (1973). Progressive Relaxation Training. Champaign, IL: Research Press.

Lindsay, W. R., and Baty, F. J. (1989). Group relaxation training with adults who are mentally handicapped. Behavioural Psychotherapy, 17, 43-51.

Lindsay, W. R., Baty, F. J., Michie, A. M., and Richardson, I. (1989). A comparison of anxiety treatments with adults who have moderate and severe retardation. Research in Developmental Disabilities, 10, 129-140.

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Lindsay, W. R., Fee, M., Michie, A., and Heap, I. (1994). The effects of cue control relaxation on adults with severe mental retardation. Research in Developmental Disabilities, 15, 425-437.

Lindsay, W. R., and Morrison, F. M. (1996). The effects of behavioural relaxation on cognitive performance in adults with severe intellectual disabilities. Journal of Intellectual Disability Research, 40, 285-290.

Luiselli, J. K. (1980). Relaxation training with the developmentally disabled: A reappraisal. Behavior Research of Severe Developmental Disabilities, 1, 191-213.

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Michulka, D. M., Poppen, R. L., and Blanchard, E. B. (1988). Relaxation training as a treatment for chronic headaches in an individual having severe developmental disabilities. Biofeedback and Self Regulation, 13, 257-266.

Obler, M., and Terwilliger, R. F. (1970). Pilot study in the effectiveness of systematic desensitization with neurologically impaired children with phobic disorders. Journal of Consulting Psychology, 34, 314-318.

Paclawskyj, T. R. (2002). Behavioral Relaxation Training (BRT) with children with dual diagnoses. The NADD Bulletin, 5, 81-82.

Paclawskyj, T. R. (2004). Applied behavior analytic treatment of anxious symptoms in persons with developmental disabilities. Presentation at the 21st Annual Conference of the National Association for the Dually Diagnosed, Vancouver, BC, Canada.

Paclawskyj, T. R. (2005). Applied Behavior Analysis and Relaxation Training. Workshop presentation for Discovering a Practical and Positive Approach to Mental Health Issues: A State of the Art Forum on Mental Health. Monroe Township, NJ.

Poppen, R. (1998). Behavioral relaxation training and assessment, 2nd ed. Thousand Oaks, CA: SAGE Publications.

Poppen, R., and Maurer, J. (1982). Electromyographic analysis of relaxed postures. Biofeedback and Self-Regulation, 7, 491-498.

Schilling, D., and Poppen, R. (1983). Behavioral relaxation training and assessment. Journal of Behavior Therapy and Experimental Psychiatry, 14, 99-107.

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Dr. Paclawskyj is a research scientist at the Kennedy Krieger Institute. She is also an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine. She joined the Hopkins/KKI faculty in 2001. Dr. Office 2011 for mac download. Paclawskyj is a Case Manager in the Neurobehavioral Unit Outpatient Clinic at Kennedy Krieger Institute, an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine, as well as a Faculty Associate in the Department of Special Education at the Johns Hopkins University School of Professional and Business Education. Dr. Paclawskyj is an associate editor of the journal, Research in Developmental Disabilities.