INTRODUCING THE FIRST EXERCISE

The first standard exercise focuses on inducing a pleasant sensa- tion of heaviness in the extremities, which is similar to that experi- enced shortly before falling asleep. Patients are instructed to repeat

specific formulas over and over while maintaining a casual or a non- goal-oriented attitude. That is to say, they should refrain from forcing themselves to make anything happen. Remember, forcing oneself to experience a particular sensation is most likely to result in the experi- ence of greater levels of tension and stress, the exact opposite of what we are trying to achieve. The next step is to help patients passively imagine or visualize what it would feel like if their arms and legs were becoming heavier. Green and Green (1977) describe this pro- cess by stating that “One just tells the body what to do, usually by vi- sualizing the desired state, then detaches from the situation—steps aside, gets out of the way, so to speak—and allows the body to do it” (p. 54). Although one may find it tempting to think of carrying a

1. Prior to each training session, the therapist needs to describe, in depth, the ra- tionale and the goals for that session. It is imperative that the patient feels com- fortable with his or her understanding of this rationale.

2. The therapist needs to emphasize the importance of “no volition” or “passive concentration” to the fullest at the beginning of each and every session. 3. The therapist may suggest appropriate images for each exercise such as,

“Imagine a cool breeze brushing against your forehead as you repeat the fore- head cooling formula.” Although the patient is not required to use the same vi- sual suggestions, such images may serve as a tentative guideline. They will also help the patient differentiate between effective versus ineffective or harm- ful images (e.g., holding a warm cup of coffee while repeating, “My right arm is warm,” instead of immersing one’s hand in boiling water).

4. Each session needs to be intentionally terminated by having the patient flex the arms, take a deep breath, and open the eyes.

5. The patient needs to feel quite comfortable with each exercise before moving on to a more advanced exercise. That is to say, if the patient does not experi- ence the sensation of heaviness in the arms, do not introduce the warmth for- mula. The use of the Autogenic Progress Index (Appendix B) is highly recommended. The index needs to be completed at the end of each training session. The clinical data generated by this form can be most helpful in deter- mining when the patient is ready to transition to the next standard exercise. 6. Emphasize at the onset of the training that it is the patient’s responsibility to

practice the assigned exercise at least twice a day for approximately fifteen minutes. Little progress can be made without commitment to daily practice. 7. Encourage the patient to express his or her feelings, thoughts, and sensations

at the end of each training session. The therapist’s openness and nonjudgmental attitude toward exploring such experiences, whether mental or physical, serves as a crucial facet of the training.

heavy object to induce the sensation of heaviness, or imagining that one’s arms are leadlike, this is against Schultz’s advice. He empha- sizes that the sensation of heaviness should be a normal, agreeable, and comfortable one—very similar to what is experienced before falling asleep—which is akin to a profound experience of muscle re- laxation. For example, patients may be asked to ponder, “My right arm is comfortably, or pleasantly, heavy.” After a period of consistent daily practice, thinking or repeating the formula several times is suf- ficient to bring about the experience of muscle relaxation in the arms and the legs.

As discussed earlier, patients should be instructed that they can substantially facilitate the experience of this sensation by ensuring that their arms, shoulders, legs, and lower back are well supported. They need to be sure that no undue stress is placed upon these areas during the exercise. If they attempt to perform these exercises while holding their muscles in a rigid manner, it is quite likely that they will not be able to achieve the desired effects. That is why the therapeutic, autogenic postures described in Chapter 6 are so crucial in achieving the desired effects.

Prior to the start of the first exercise, I highly recommend review- ing the pre-exercise checklist (see Table 8.2) to ensure that the appro- priate physical or environmental preparations have been made. Next, attention needs to be paid to “the appropriate mind-set” before re- peating the specific formulas for this exercise. One of the most con- cise statements that captures the process of autogenic exercises is eloquently stated by Norris and Fahrion (1984, p. 235). You may wish to place a bookmark here and return to this paragraph at the be- ginning of each training session.

1. Complete the Autogenic Pain (or Tension) Checklist (Form A) 2. Reduce environmental stimulation and assume a training posture 3. Passive concentration on the formulas and physical sensations 4. Make mental contact with specific body parts

5. Repeat the autogenic formulas 6. Daily practice (Reminder)

At this point you will be given some autogenic training phrases, and I want you to [silently] say each phrase over and over to your- self. First, your attitude as you do this is quite important. This is the kind of thing where the more you try to relax, the less it will happen. So the best approach is to have the intention to relax, but to remain detached about your actual results. Since everyone can learn voluntary control of these processes, it is only a matter of time until you do, therefore you can afford to be detached about the results. Second, saying the phrases is good because it keeps them in mind, but it is not enough. The part of the brain that con- trols these processes, the limbic system, doesn’t understand lan- guage well, so it is important to translate the content of the phrase into some kind of image. One of the phrases is “My hands are heavy and warm.” If you can imagine what it would feel like if your hands did feel heavy or if they did feel warm, that helps to bring about the changes that we are looking for. Or use a visual image: Imagine that you are lying at the beach in the sun, or that you are holding your hands over a campfire. Whatever works for you as a relaxing image or a warmth-inducing image is the thing to use, but the imaging itself is important. Finally, if you simply trust your body to do what you are visualizing it as doing, then you will discover that it will.

In some of the original literature on autogenic training, Schultz (1932) suggested that as a way of promoting a deeper state of rest and relaxation special background formulas may be used. In some of the earlier manuals, he had his patients repeat the word “tranquility” (ruhe in German) between each formula. In later English publica- tions, the formula “I am at peace” was introduced. I encouraged my patients to use this formula or the word tranquility throughout each exercise, as suggested in the following training sequence.

Again, it is highly recommended that prior to starting the auto- genic exercises, patients familiarize themselves with the preliminary exercises that were described in Chapter 7. These exercises will help them gain much greater momentum while practicing the standard ex- ercises. As mentioned before, the preliminary exercises need not be practiced for long. Perhaps four or five times should be sufficient to master the desired effects of achieving mental contact with specific body parts.

Each formula used during the first training session is to be repeated for approximately two minutes. The choice of beginning the training with the right or the left arm solely depends on the patient’s handed- ness. That is, if he or she is right-handed it is best to make mental con- tact initially with the right arm and hand. Throughout the years of using autogenic training with chronic pain patients, especially those suffering from fibromyalgia, I have come to realize that certain addi- tional formulas can be most helpful in reducing pain and discomfort. These additional formulas (marked with an asterisk) are consistent with those developed by Schultz and actually seem to enhance the training process significantly. For example, I have observed that during the pre-sleep state (similar to the autogenic state), the muscles of the jaw tend to relax. By repeating a formula that suggests a heavy and re- laxed jaw, this process of entering a deeper state of relaxation is accel- erated. Also, since many fibromyalgia patients tend to suffer from temporomandibular joint disorder (TMJD), the focus on a relaxed jaw can be most helpful in reducing pain and discomfort as well as making them aware of the tendency to possibly grit or grind their teeth due to extremely tense muscles. I have also included additional formulas for reducing muscle tension in the shoulders and the lower back.