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Learned self-regulation and arterial hypertension utilizing biofeedback and relaxation training.

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Learned self-regulation and arterial hypertension utilizing biofeedback and relaxation training.
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Orlando, Jacqueline Zurcher-Brower, 1937-
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viii, 108 leaves. : ; 28 cm.

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Biofeedback ( jstor )
Blood pressure ( jstor )
Control groups ( jstor )
Hypertension ( jstor )
Muscle relaxation ( jstor )
Personality psychology ( jstor )
Psychological research ( jstor )
Psychology ( jstor )
Psychometrics ( jstor )
Psychophysiology ( jstor )
Biofeedback training ( lcsh )
Stress relaxation ( lcsh )
City of Gainesville ( local )
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theses ( marcgt )
non-fiction ( marcgt )

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Thesis--University of Florida.
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Bibliography: leaves 70-77.
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Typescript.
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Vita.
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By Jacqueline Zurcher-Brower Orlando.

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Full Text
LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION UTILIZING BIOFEEDBACK AND RELAXATION TRAINING
By
JACQUELINE ZURCHER-BROWER ORLANDO
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1974


ACKNOWLEDGEMENTS
My warmest thanks and appreciation to Dr. Robert Stripling, who chaired my dissertation committee. He provided appropriate direction and support, yet allowed me to feel that this undertaking was fully my own.
I am eternally indebted to Dr. Joseph Cauthen for providing the setting in which to carry out the study, and for his sensitive guidance and caring.
I am grateful to Dr. William Love, whose research in the area launched me into my own study. Dr. Franz Epting and Dr. E. L. Tolbert also provided assistance for which I am deeply appreciative.
Additional thanks to those who directly assisted me in completion of the study: Paula Saraga, John Butter, Lois English, Susan Edell, Judy Foote, Kate Bury, Tay Tanya, Dr. Betty Home, and Mary Ganikos.
I appreciate the continuing encouragement of my children, Michael and Kristine, and friend, Vernon Van De Riet.
11


TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS ................... ii
LIST OF TABLES.................... v
ABSTRACT....................... vi
CHAPTER
I INTRODUCTION .................. 1
Review of the Literature........... 4
Relaxation Training as a Method of Self-Regulation of Some Cardiac Functions ..... 5
Feedback Training as a Method of Self-Regulation of Blood Pressure ......... 8
Direct Control of Blood Pressure
Through Instrumental Conditioning .... 8 Indirect Control of Blood Pressure
Using Deep Relaxation..........10
The Moeller and Love Research Study;
Techniques, Design, and Outcome ..... 11
Summary of the Review of Literature .... 16
Psychological States Associated with Self-Control and Instruments of Assessment .... 16
Measurement of Feelings of Volition .... 17 Psychological Changes Associated with
Self-Regulation ............. 20
Measurement of Psychological State
Changes.................21
Descriptions of Certain Psychological
Processes Associated with Increased
Self-Regulation ............. 23
Equipment Utilized in the Study ....... 24
Purpose of the Study.............26
Hypotheses.................2 7
Exploratory Questions ........... 27
iii


TABLE OF CONTENTS Continued

CHAPTER Page
II DESCRIPTION OF THE STUDY............ 29
Methodology................. 29
Instruments................. 30
Subjects................... 32
Procedures.................. 32
Phase One................. 33
Phase Two................. 34
Phase Three................ 37
Phase Four................. 38
III RESULTS.................... 39
Limitations of the Study.......... 39
Dropped Subjects .............. 40
Hypotheses................. 40
Exploratory Questions ........... 47
IV DISCUSSION................... 60
Exploratory Questions ............ 63
Suggestions for Future Research ....... 68
LIST OF REFERENCES.................. 70
APPENDIX
A FORMS..................... 79
B STANDARD INSTRUCTIONS ............. 9 0
C TESTS..................... 95
D LETTERS.................... 10 5
BIOGRAPHICAL SKETCH .................. 108
iv


LIST OF TABLES
Table Page
1 Means, Standard Deviations, and the Analysis of Variance Summary for the Change in Systolic Blood Pressure Among Groups X, Y, and C .... 41
2 Results of Tukey Multiple Comparison Test of Significance of Mean Systolic Blood Pressure Change Between Groups X and Y, X and C, and
Y and C....................41
3 Means, Standard Deviations, and the Analysis of Variance Summary for the Change in Diastolic Blood Pressure Among Groups X, Y, and C 42
4 Results of Tukey Multiple Comparison Test of Significance of Mean Diastolic Blood Pressure Change Between Groups X and Y, X and C, and
Y and C................... 42
5 Means of Groups X and Y on Systolic Blood Pressure Measures Over the Six-Week Treatment Period.....................45
Means of Groups X and Y on Diastolic Blood Pressure Measures Over the Six-Week Treatment Period......................45
6 Means, Standard Deviations, and Analysis of Variance Summary Table for Scores on the I-E Scale Among Subjects in Group X, Group Y, and Group C as Achieved During the Posttesting
Se s s i on....................47
7 Means, Standard Deviations, and Analysis of Variance Summary Table for Scores on the Hy and D Scales of the MMPI Among Groups X, Y and C as Achieved During the Posttesting
Session....................48
8 Chi-Square Analysis for Experimental and
Control Group's on Projective Drawing Ratings 49
v


Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy
LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION UTILIZING BIOFEEDBACK AND RELAXATION TRAINING
By
Jacqueline Zurcher-Brower Orlando
August, 1974
Chairman: Robert Stripling
Major Department: Counselor Education
This study investigated the effects of biofeedback (elec-tromyograph) and relaxation training on the blood pressures of individuals with chronic essential hypertension. One aim was to illuminate any differences between the effects produced by two treatment schedules. A second goal was to probe various personality characteristics which are associated with increased self-regulation. A third purpose was to explore the subjects' responses to the procedure in order to develop a clinically efficient treatment, study the reported changes in the subjects' coping strategy and life styles, and clarify the psychological process whereby the physiological changes occurred.
Thirty individuals with chronic essential hypertension were assigned to one of two experimental groups or to a control group for a six-week period. One experimental subgroup, Group X, was scheduled to participate in four biofeedback sessions per week in a hospital setting. The other experimental group, Y, received one biofeedback session per week. The
vi


control group, C, received no biofeedback and no relaxation training as part of the study, and were told that they would receive biofeedback and relaxation training at the completion of the treatments of the subjects in Groups X and Y. In addition, subjects in Groups X and Y were to complete a session of autogenic training and progressive relaxation outside of the laboratory once a day on days that they received biofeedback and twice on the days when no biofeedback session was scheduled.
The results indicated that the treatment received by Group X was not statistically significant in reducing systolic blood pressure but was significant at the <.05 level in reducing the diastolic blood pressure. The mean systolic decrease of Group X was 4.2 mm Hg and the mean diastolic decrease was 1.5 mm Hg. In contrast, Group Y sustained systolic and diastolic blood pressure decreases that were statistically significant at the <.05 level. Group Y showed a mean decrease of 6.3 mm Hg in systolic measures and 9.5 mm Hg in diastolic measures.
Three licensed physicians evaluated the outcome and concluded that the treatment received by Group X failed to produce sufficient reduction in blood pressures to be clinically significant. However, the treatment received by Group Y did produce clinically significant decreases and was judged to have practical usefulness in the reduction of essential hypertension .
vii


Participation in the experimental treatment failed to produce personality changes that were statistically significant at the .05 level as measured by the Internal-External Scale, the Draw-A-Person test, and the Hy and D scales of the Minnesota Multiphasic Personality Inventory.
In general, the subjects had few complaints concerning the treatment procedure, said they felt better, and reported that they had more desirable behavior patterns as a result of participation in the study. In addition to changes in blood pressure, subjects said they had fewer headaches, less insomnia reduction in allergic reactions, decreased smoking and alcohol consumption, less prescribed medication and less nail-biting. They said that they increased in the ability to tolerate "stress," to avert tension in the skeletal muscles, and to alleviate lower back pain. Several subjects reportedly improved interpersonal relations, achieved greater sexual satisfaction, and gained a more tolerant attitude toward self and others.
The majority of the subjects said they achieved skeletal muscle relaxation following increased awareness of the kinesthetic sensation of tension, combined with the passive suggestion of autogenic phrases like "limp" and"heavy." Other subjects reported they achieved a relaxed state by having a "blank" mind.
viii


CHAPTER I INTRODUCTION
The concept of feedback is as old as the earliest form of biological evolution and is found at all levels of organization, from intracellular processes to social communication. The term "feedback" is of relatively recent origin, coined by pioneers in radio in the early 1900's [Karlins and Andrews, 1972]. Mathematician Norbert Wiener [1971] describes feedback as a method of controlling a system by reinserting into it the results of its past performance.
In psychotherapy the use of informational feedback is a central component, and its use is increasing with the emergence of many new treatment approaches. Behavior therapy; sensitivity, encounter, and Gestalt group therapies; and the video therapies, as well as training models for therapists, all make available to the patient some forms of augmented feedback that provides the means whereby he can gain new awareness about his own behavior [Lazarus, 1967 ; Rogers, 1951; Perls, 1969; Campbell and Dunnette, 1968; Carkhuff and Berson, 1967]. The informational feedback exists in a variety of forms such as the reactions of others to the patient's feelings and actions and the behavior manifested in the video-tape replay of patient-therapist interaction.
1


2
In a similar way, more refined techniques are being developed for providing an individual with feedback for specific internal bodily processes which enables one to modify what were once considered involuntary, or autonomic functions such as penile erection [Laws and Rubin, 1969]; heart rate [Hnatiow and Lang, 1965], brain waves [Kamiya, 1969], urine formation [Lapides e_t a_l. 1957], salivation [Frezza and Holland, 1971], and blood pressure [Moeller and Love, 1972]. Once a person can "see" his heartbeats or "hear" his brain waves, he has the information he needs to begin to control them. Depending upon the theoretical bias of the experimenter, the knowledge of results may be viewed as reinforcement, as in the operant conditioning paradigm, or as information. Regardless of the framework used to describe the process, the introduction of the psychophysiological feedback loop makes possible voluntary control over a variety of physiological events. This process serves as an added tool for the professional counselor to use in helping the individual take responsibility for his own behavior and its consequences. The current developments in methodology for enhancing voluntary control of internal states is perceived by many writers to be of importance [Mulholland, 1973; Hart and Tomlinson, 1970; Davidson and Krippner, 1971]. Such techniques enable man to identify his organismic needs and move from environmental support toward self-support.
The psychophysiological feedback principle, commonly called "biofeedback," is something like an internal mirror.


3
Its core lies in the detection of a physiological event and the conversion of the event into an electronic signal so that the subject can be immediately and continuously aware of the relative level or intensity of the event. Awareness of the psychological state associated with the variation in level makes possible the indirect control of the physiological event itself as the individual learns how the sensation and the event are related within himself. For example, as an individual becomes aware that his arm is feeling heavier and warmer due to vasodilation, he is being informed through the biofeedback apparatus that the muscle motor units are firing less often and the muscles in his arm are becoming increasingly relaxed [Basmajian, 1963].
The utilization of biofeedback in clinical practice requires an understanding of the interrelationships that exist between and among bodily functions and psychological states, with each individual viewed as a unique entity, differing from all others in autonomic specificity [Swartz, 1973]. Situations may evoke different patterns of response in each person [Lacey, 1967; Lang, 1970]. With regard to complex states such as anxiety and fear, it becomes important to determine what patterns of functions occur in the individual patient. Feedback must be selected and scheduled so as to optimize its integration with the problem in question, thus enhancing its therapeutic value.
This study will examine the effects of a biofeedback relaxation-training therapy when used with patients having


4
chronic elevated blood pressure of unknown etiology called "essential hypertension." Recently, essential hypertension has been brought to the attention of the public as a complex and dangerous condition which can shorten life significantly. It apparently results, in many cases, from the interaction of the person and his environment, together augmenting or producing the bodily dysfunction [Pickering, 1968]. Antihypertensive drugs are effective for some. For others, treatment with drugs is not satisfactory in that the hypertension fails to be reversed or the drugs produce undesirable side effects. A procedure not requiring the use of drugs, or as an ancillary treatment to drug therapy, is needed [Pickering, 1968; Datey et al., 1969].
Review of the Literature
During the last ten years, an increasing number of articles on the topic of operant conditioning and establishment of self-control of cardiovascular processes in humans has appeared in the literature. Swartz [1973] reported that over 250 papers had been published on the use of operant feedback techniques in the control of physiological processes. The Aldine Press has reprinted much of this work in four volumes, with an additional volume planned for each succeeding year [Barber et al. 1971; Kamiya e_t al_. 1971; Stoyva et_ al. 1972; Shapiro et al., 1973]. Blanchard and Young [1973] reviewed the research in the area of operant conditioning or self-control of four cardiac functions, heart rate level,


5
heart rate variability, blood pressure, and cardiac arrhythmias.
The purpose of this survey of the literature is to review alternatives to drug therapy in the control of blood pressure, particularly with the combined use of relaxation training and biofeedback in human subjects. As the literature suggests, the application of learning concepts such as differentiation and reinforcement enables the counselor to assist an individual in regulating his internal behavior. By becoming aware of the psychophysiological process involved in producing an undesirable physical condition, one can choose not to produce the condition in one's self. Currently, behavioral and humanistic counselors and psychologists are developing clinical treatment programs for tension and migraine headaches, insomnia, subvocalization, cerebral palsy, epilepsy, Raynaud's disease, and contraception [AHP, 1973].
Relaxation Training as a Method of Self- Regulation of Some Cardiac Functions
The use of progressive relaxation, as developed by Jacob-son [1938] and the use of various Yoga exercises [Datey et_ al. 1969] and other forms of meditation have produced a significant degree of change in cardiac and related functions. In 1939 Jacobson reported the effects of training on blood pressure. His relaxation process focused on the relaxation of various sets of muscles in a. systematic manner until the entire system was relaxed. He concluded that there is a general relationship between decreases in blood pressure and decrease in muscle activity, as shown by the electromyogram, and that


6
training in progressive relaxation results in greater decreases in electromyogram activity than self-induced relaxation without training.
Paul [1969] reported on physiological changes in college-age females who were treated with (1) a brief form of progressive relaxation training, (2) hypnosis induction and suggestions on relaxation, or (3) self-instructed relaxation. The progressive relaxation group showed significantly greater changes in heart rate than the other two groups.
Datey et a_l. [1969] combined muscle relaxation with breathing exercises in treating 47 hypertensive subjects. A specific Yoga technique called "Shavasan" was employed which enabled the subject to become increasingly alert inwardly and less conscious of the external environment, thus facilitating greater relaxation. Datey reported that in Group I (10 patients) who took no drugs, the average mean blood pressure of 134 mm Hg was reduced to 10 7 mm Hg, an average reduction of 27 mm Hg. This was statistically significant at the .05 level. In Group II (22 patients) who were controlled with drugs, the average mean blood pressure was 102 mm Hg and was not reduced. For the 15 patients in Group III whose blood pressure was not adequately controlled by drugs, a reduction in average mean blood pressure from 120 to 110 mm Hg occurred.
Schultz and Luthe [1969] attempted to aid subjects in becoming more aware of their proprioceptive sensations in addition to increasing muscle relaxation. These authors


7
formulated a series of specific exercises which develop muscle relaxation and increase peripheral blood flow and reactive vasodilation in the subject. The approach, called "autogenic therapy," was utilized with a group of hypertensives by Klumbies and Eberhardt [1966]. Blood pressure readings were taken at various intervals during the four-month study. The greatest decrease in systolic and diastolic pressures occurred in the first month of training and was attributed to the effects of the autogenic training.
Although many claims of phenomenal degrees of self-control among Yogis had been made, few data were collected until Wenger and Bagchi [1961] made autonomic recordings from over 50 Yogis in India. They concluded that changes in blood pressure and cardiac functioning were due to vagal innervation, not through control of striated muscle.
Wallace [1969] studied the effects of transcendental meditation, as taught by the Maharishi Mahesh Yogi, and found an average decrease of five beats per minute in five subjects who were measured for heart rate. In a later study, Wallace et al. [1971] found significant changes in electroencephalogram and oxygen consumption in transcendental meditators, comparing the meditation period with the 30 minutes preceding.
These studies suggest that autogenic training, progressive relaxation, Yoga, and other forms of exercise meditation can have important clinical application in the field of self-regulation. They indicate that certain bodily functions such as brain waves, oxygen consumption, and some cardiac functions


8
may be regulated through changes in muscle tension and respiration.
Feedback Training as a Method of Self- Regulation of Blood Pressure
Information feedback as well as such reinforcers as food and pleasurable stimulation has been used by researchers to enable subjects to learn to regulate their electrodermal, elec-troencephalographic, and electromyographic activity [Shapiro and Crider, 1967; Kamiya, 1969; Basmajian, 1963]. Numerous bodily processes, previously considered to be involuntary, such as salivation [Brown and Katz, 1967; Frezza and Holland, 1971], heart rate [Engel and Melmon, 1968; Hnatiow and Lang, 1965], and certain vasomotor responses [Snyder and Nobel, 1967] have been brought under the control of the subject.
Direct Control of Blood Pressure Through Instrumental Conditioning
The application of biofeedback to the control of blood pressure requires the use of a suitable blood pressure measurement and feedback system. Because direct measurement of pressure requires the surgical insertion of a pressure-transducing tube into an artery, such a means of measurement is impractical for routine research with human subjects. It has been demonstrated, however, that systolic blood pressure responses can be conditioned directly. Di Cara and Miller [1968], working with rats, used direct measurements and feedback. The question as to whether humans could also learn to


9
raise or lower their systolic blood pressure, using biofeedback, was approached by Shapiro e_t al_. [1969,1970]. Using normotensives with an indirect measurement procedure, he demonstrated that subjects reinforced for systolic blood pressure increases were able to raise or maintain their pressure, while subjects reinforced for decreases in systolic pressure were able to lower their pressure.
The Shapiro research raises the issue as to how the subjects produced the change. Did change occur as a result of somatic meditation or cognition, or had operant conditioning of autonomic activity per se taken place? Miller [1961] emphasized that this issue is of central importance in understanding the neurophysiology of learning. Katkin and Murray [1968] reviewed a number of studies that attempted to demonstrate instrumental conditioning of autonomically mediated behavior. They concluded that the Miller group convincingly demonstrated the phenomenon with animals. Some work with human subjects [Johnson and Swartz, 1967; Snyder and Noble, 1968] demonstrated such conditioning "in a manner difficult to criticize" [Crider e_t al_. 1969].
The Shapiro study, as well as others, has provided normotensive subjects with biofeedback of their blood pressure which led to statistically significant changes in blood pressure, but these changes were not sustained outside the experimental setting, without the biofeedback [Benson e_t al_. 1971; Brener and Kleinman, 1970].


10
Indirect Control of Blood Pressure Using Deep RelaxatTon
When the work of Lisina [1965], who was reported by Razran [1961] to have conditioned vasodilation instrumentally in the Soviet Union, was published in English, it appeared that she did not claim to have conditioned vasodilation directly. Lisina concluded that her subjects were able to gain voluntary control over their blood vessels by "using a number of special devices, mainly the relaxation of the skeletal musculature and changing of the depth of respiration" [1965 p. 456].
In the United States, Harrison and Mortensen [1962] were the first to demonstrate that the individual motor units in the skeletal musculature could be voluntarily controlled through the use of a biofeedback system. A motor unit fires when an impulse reaches the muscle fibers. Accompanying the impulse is an electrical potential which, when recorded, is known as the electromyogram. Basmajian [1963] has extended the previous finding and demonstrated that subjects can acquire quite subtle control over individual motor units. He observed that when subjects learned such specific control, they were able to produce "various gallop rhythms, drum-beat rhythms, and roll effect" [p. 341].
Attempting to induce deep relaxation in humans, Green et al. [1969] trained subjects to achieve zero firing in large forearm muscle bundles. The results indicated that 7 of 21 subjects were able to achieve the criterion of zero


11
firing within 20 minutes, and they were able to maintain it for 30 minutes or more.
Budzynski and Stoyva [1969] and Budzynski ej^ al. [1970] conducted studies demonstrating feedback control of the frontalis (forehead) muscles and showed that by relaxing this group of muscles, a person could alleviate tension headaches. They obtained results demonstrating that the feedback group evidenced much greater relaxation than the no-feedback and irrelevant feedback control groups. The changes in the laboratory were apparently generalized to everyday life, with subjects making comments which indicated a heightened awareness of maladaptive rising tension, an increasing ability to reduce tension, and a decreasing tendency to overreact to stress [Budzynski et al., 1970, p. 210].
The Moeller and Love Research Study; Techniques Pesign and Out~come
Reasoning that the altered blood pressures in the Shapiro [1969], Benson e_t al_. [1971], and Brener and Kleinman [1970] studies were not sustained because the human awareness to sense directly blood pressure level is not very well developed, Moeller and Love [1972] sought to devise a technique directly conditioning a concomitant physiological function for which the human body already possessed an efficient set of proprioceptors. Using muscle tension as a physiological concomitant for blood pressure, Moeller and Love [1969] used electromyographic, biofeedback training in conjunction with an adaptation of Schultz and Luthe1s autogenic


12
exercises and obtained a decrease in both systolic and diastolic blood Dressures. Moeller [1973] further investigated conditioning muscle relaxation as a concomitant for blood pressure, using a treatment regimen similar to that used in his first study. Again, using hypertensive subjects, he examined the relationships among the variables of muscle tension and systolic and diastolic blood pressure during and following the treatment. Based on this researcher's review of the literature, it appears that the Moeller study is the exception to the criticism leveled by Blanchard and Young [1973] who concluded that the self-control of cardiac functioning is, for the most part, a "promise as yet unfulfilled." Blanchard and Young's recent review indicated that (1) changes in cardiovascular functioning were studied, for the most part, in normal subjects instead of patients, and (2) the magnitude of change was related to a statistically significant rather than a clinically significant magnitude.
Miller had criticized the earlier Moeller and Love study [1972] for their use of each subject as his own control. The second Moeller study, discussed more fully below, utilized both a control group and matched pairs as well as an increased number of subjects, thus achieving a more defensible design for studies of this nature. Compared with the work of Shapiro and his colleagues at Harvard and Brener and Klein-man, the techniques .devised by Moeller and Love require longer training but appear to be as efficient in the


15
reduction of the systolic value and superior in the reduction of the diastolic value. Moeller's second study showed a mean decrease of 12 mm Hg for the diastolic and 14 mm Hg for the systolic blood pressures in their pooled treatment groups. The largest diastolic decrease in the summary of research presented by Blanchard and Young [1973] indicated a -2.0 mm Hg mean reduction by Shapiro et al_. [1972], and Brener and Kleinman [1970] reported systolic decreases of -16 mm Hg.
Moeller's use of a control group showed that the decrease in blood pressure was not due to the habituation of the subjects to the experimental surroundings. In addition, the subjects were not differentially affected by the five individuals who conducted the treatment. Although previous research demonstrated that blood pressure can be lowered, one of the main contributions of the Moeller work is that the lowered blood pressure response seemed to generalize outside the experimental setting. This would indicate that feedback of a concomitant physiological function (muscle tension) obtained a sustained reduction in blood pressure, whereas the direct blood pressure feedback used by previous investigators did not.
Moeller has suggested that the decrease in blood pressure is due, in part, to the subjects becoming less tense during periods of stress; thus, the learning of deep muscle relaxation may be generalizing itself to other situations. He speculated that the significant decrease in diastolic pressure may indicate that the peripheral resistance was


14
reduced and the arterioles of the subject may have become less resistant to the passage of blood. With the tone of the skeletal muscles considered a voluntary function and the smooth, arteriolar muscles, involuntary, Moeller suggested that both the voluntary and involuntary functions are merely correlated measures with the mediating link yet undetected. Since physicians are more interested in decreasing the diastolic level which is related to peripheral resistance [Merrill, 1966], the significance of the diastolic decrease may also indicate that the Moeller-Love relaxation procedure is of clinical value as an ancillary to other methods presently being used.
Another issue explored by Moeller was that of the cause of the decrease in systolic blood pressure produced by relaxation training and a biofeedback approach. Does muscular relaxation cause lowered pressure, or does a modification occur in the sympathetic nervous system which causes the lowered blood pressure? Or are these phenomena one and the same? Prior to Moeller's second study, little was known regarding the temporal effects of muscular relaxation and blood pressure. He found that the highest correlation between EMG change lagged two measurement periods (weeks) behind blood pressure, tending to indicate that blood pressure change was most greatly associated with the EMG change that had taken place two weeks previous. Hypothetically, any changes of the EMG measurements between sessions will be most highly correlated with the variables of blood pressure two weeks later, with the benefits of the EMG training


15
maximized at that time. This phenomenon tends to support Gelhorn's [1970] postulate that modification of the hypothalamic activation occurs through muscular relaxation and lowered cortical arousal.
In the Moeller study, subjects were assigned randomly to one of three treatment groups for a four-month period. The amount of biofeedback and relaxation exercises scheduled varied among groups. A fourth group served as a control group, receiving two laboratory sessions per week for four weeks, without feedback regarding their muscle tension, and did not receive relaxation exercises to do at home.
In using a multivariate analysis of covariance to examine the differential effects of the variation among treatment groups, an assumption was made of linearity in reduction of blood pressure. While analysis of covariance takes into account any difference among groups on the criterion variables and, accordingly, adjusts the post-treatment means of the criterion variables, this statistical procedure is not appropriate should it become more difficult for subjects to reduce blood pressure as the blood pressure level approaches the normal range. The data analysis showed no significant differences between the treatment groups; however, the initial difference between the means of the groups was sizable. This could, with a curvilinear relationship, fail to show a difference among groups when, in fact, differences attributable to the varied treatment schedules did exist. While


16
raised in the Moeller study, the question of the effect of different schedules in treatment has not been adequately answered.
Summary of the Review of Literature
The literature reviewed above suggests that elevated blood pressure of unknown etiology can be reduced through relaxation training. While it has been demonstrated that blood pressure can be conditioned directly through the use of reinforcement in the laboratory, the reduction cannot be sustained. The relaxation training method comprised of bio-feedback of muscle tension, autogenic techniques, and the progressive relaxation approach appears to generalize outside of the training sessions and permits a sustained reduction in blood pressure.
Psychological States Associated with Self-Control and Instruments of Assessment
Often there seems to be a change in one's psychological state concurrent with biofeedback training [Davidson and Krippner, 1971]. Many authors such as Kamiya [1969], Green et al. [19 70], and Honorton e_t al_. [1971], have stated that some of their subjects enter into altered states of consciousness during training of this kind. In this sense, the biofeedback paradigm appears to create a closed system in which the individual uses volition to control his physiological processes in the human situation. Green et al_. [1970]


17
stated that "it is not possible to define in an operational way the meaning of the word 'voluntary,' but all of us have a feeling of voluntary control, at least part of the time. ." [p. 3]. In the training situation, this feeling of voluntary control is important, because the subject experiences himself as the locus of control. He is the agent of change, and only through an act of his own choice is he able to demonstrate control over his own internal states.
Measurement of Feelings of Volition
This type of self-control would seem to enable people to become less subject to external control and manipulation and more inner-directed. Maslow [1962] described one of the characteristics of the self-actualized person as being able to resist rubrication. With the application of biofeedback techniques, one may move toward becoming more resistant to certain cultural biases and forms of societal conditioning [Davidson and Krippner, 1971]. The significance of the belief in fate, chance, or luck has been discussed by various social scientists over a long period of time. As early as 1899 Veblen wrote that a belief in luck or chance represented a barbarian approach to life and was generally characteristic of an inefficient society. More recently, Merton [1946] discussed the belief in luck as more or less a defense behavior, as an attempt to serve the psychological function of enabling people to preserve their self-esteem in the face of failure.


18
In the field of psychology, White [1959], in discussing an alternative to drive reduction, noted how the work of many authors has converged on a belief that it is characteristic of all species to explore and to attempt to master the environment. Angyal [1941] noted also the significance of the organism's motivation toward autonomy, or the active mastery of the environment.
The first attempt to measure individual experiences in a generalized expectancy or belief in external control as a psychological variable was by Phares [1965]. The James-Phares scale was broadened and further developed by J. B. Rotter [1966]. He hypothesized that this variable is of major significance in understanding the nature of learning processes in different kinds of learning situations, and also, that consistent individual differences exist among individuals in the degree to which they are likely to attribute personal control to reward.
When a person believes that something occurs following some action of his own but is not entirely contingent upon his action, Rotter [1966] has labeled this event as a belief in "external control." If the person perceives that the event is contingent upon his own behavior or his own relatively permanent characteristics, this is termed a belief in "internal control."
This study utilized the Rotter Internal-External Scale (I-E Scale) in an attempt to examine the relationship between locus of control and amount of reduction in blood pressure.


19
It is recognized that Rotter's definition and use of "internal control" is not all that may be included in describing the experience of personal causation or a feeling of freedom; however, among the tests in print, the I-E Scale appears to measure a similar quality. In addition, the difference in the scores of subjects who receive biofeedback and relaxation training and those who do not was investigated on the internal-external dimension.
The I-E Scale is a forced choice, 29-item test in which the subject reads a pair of statements and indicates with which of the statements he agrees more strongly. The scores range from 0 (the consistent belief that individuals can influence the environment and that rewards come from internal forces) to 23 (the belief that all rewards come from external forces). Rotter [1966] describes the groups upon which the test-retest reliability was based. The elementary psychology student sample used in one of Rotter's standardizations appears to be most like the subjects in this study, compared with the other samples he describes. In a one-month retest with group administration, the elementary psychology student sample produced a reliability coefficient of .72. Rotter [1971] described a listing of references using the I-E Scale in excess of 300, including the well-known Coleman "Report on Equality of Educational Opportunity." As in the Coleman report, the clinical version was used rather than the research version, for its single score and east in Interpretation.


20
Psychological Changes Associated with Self-Regulation
Green et al_. [1969] trained subjects to achieve zero firing in large forearm muscle bundles. They reported that five of the seven subjects who achieved zero firing rapidly and sustained it for 30 or more minutes commented that they had experienced body image changes. In addition to the change in proprioceptive and internal sensations resulting from the treatment, the change in feelings toward one's self may be affected by the training process [Lesh, 1970; Jacobson, 1957; Assagioli, 1965] .
The Draw-A-Person (D-A-P) was selected for this study to explore potential body image changes associated with the treatment process. This method of measuring change in body image was developed by Machover [1948,1951]. She reported that her modification of the D-A-P, originally devised by Goodenough [1926], can be used projectively to assess those aspects of psychodynamics involved with the self-image and with body-image. Her assertion was supported by Luthe [1963] who reported that by using the Drawing-Completion Test he observed a characteristic pattern of projective changes, such as progressive differentiation of the projective responsiveness, increase of output, more shading, elaboration of details, stronger pressure of lines, increase of dynamic features, better integration and composition of the drawings, less rigidity, fewer inhibitions, faster performance, and better adaptations to the different stimuli. He further stated that


21
corresponding changes have been observed in the D-A-P; however, the research is not available in English [Luthe, 1958].
The literature on projective techniques links the term "projective" with the psychoanalytic mechanism of projection, as well as the dictionary sense of the word, namely, to project (as a cartographer might project) an almost physical extension of psychological attributes [Wolman, 1965]. From Lowenfeld's work [1947] it appears that there are basic differences among individuals with respect to the predominance of (1) the projection of body needs and conflicts and (2) the role of visual, objectively determined stimuli in the formation of the subject's body image. If so, the product cannot be interpreted in the same manner for all individuals. In the Lowenfeld study, each subject was used as his own control.
The Machover method involves a careful and detailed examination of both the content and the structural and formal aspects of the drawing, considering the absolute and relative size of the figure, placement on the page, symmetry, perspective, type of line, shading, and erasures. In evaluation, considerable attention is paid to the overall mood or tone conveyed by the figure through facial expression and postural attitude.
Measurement of Psychological State Changes
Many writers [Bibring, 1953; Alexander, 1939; Hill, 1935] related psychological states such as depression and


22
hypochondriasis with physical disease or disorders. Budzynski et al. [1970] stated that patients, after completing the training program, reported (1) a heightened awareness of maladaptive rising tension, (2) an increasing ability to reduce such tension, and (3) a decreasing tendency to overreact to stress. His work suggests that the subjects increased feelings of self-control will generalize into their everyday life, should they increase feelings of self-control.
This study explored the relationship between reduction in blood pressure through learned self-regulation and the level of depression and hypochondriasis as measured by two scales on the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI is a widely-used, well-standardized instrument designed for personality assessment [Hathaway and McKinley, 1951]. It is comprised of 550 statements covering a wide range of subject matter, from the physical condition to the morale and social attitudes of the individual being tested. The subject is asked to sort the statements into three categories: true, false, and cannot say. His responses yield scores on four validity scales and nine clinical scales. The original normative data were derived from a sample of about 700 individuals representing a cross section of the Minnesota population as obtained from visitors to the University Hospital. In this researcher's opinion, the sampling was adequate for the. ages 16 to 55 and for both sexes. The scales were developed by contrasting the normal groups with carefully studied clinical cases of which over 800 were


23
available from the neuropsychiatrie division of the University Hospital. The chief criterion of excellence was the valid prediction of clinical cases against the neuropsychiatrie staff diagnosis, rather than statistical measures of reliability and validity. A high score on a scale has been found to predict positively the corresponding final clinical diagnosis or estimate in more than 60 percent of new psychiatric admissions.
In considering the question of reliability, the characteristics of the particular population needs to be considered, as well as the range of scores within the population. No data are available on the reliability of the test for non-hospitalized individuals with essential hypertension. The reported test-retest reliabilities range from .46 to .91 with normals (covering the basic scales) over a period of from three days to one year, and cluster about a median of .76. Gynther and Rogers [1959] consider the MMPI to be the most carefully constructed and thoroughly researched inventory available for personality assessment.
Descriptions of Certain Psychological Processes Associated with" Increased Self Regulation
Few writers have explored the psychological states associated with electromyographic changes. Murphy [1969] stated that our language fails to provide labels for many of our internal processes. He wrote that the feeling, cognitive, and volitional states will lead to alterations in


24
states of consciousness, well-known to the East, upon which "human destiny almost literally may depend" [p. 523]. An open-ended interview at the conclusion of the treatment provided the subjects with an opportunity to describe their own subjective experiences during the treatment period. The interviewer recorded the verbal behavior of the subject during the termination interview. A summary of the data is presented in the chapter reporting results of this study.
Within the interview itself, an interview technique, described by Kahn and Campbell [1966], was utilized, which combined Roger's "reflection of feelings" with the use of specific questions in order to assist the subject in clarification of his own response and attitude toward aspects of his participation which he will not have thought much about.
The primary focus of the research was upon the effectiveness of learned self-regulation in the reduction of essential hypertension. Previous research literature seems to suggest the importance of understanding the subjective experience of the subject and the psychophysiological mediation process. The scope of the study included an exploratory investigation of the latter.
Equipment Utilized in the Study
A portable EMG feedback system built by Bio-Feedback Systems, Inc., Boulder, Colorado, was used to provide


25
electromyographic information to the subjects. The equipment was made available to the experimenter through the Department of Clinical Psychology, University of Florida, and is considered to be suitable for its intended purpose by Love [personal communication, 1973], a researcher in the clinical use of biofeedback at Nova University. According to the manufacturer, model PE-2 is designed to provide accurate and meaningful feedback of surface EMG levels as low as 2 microvolts. The PE-2 fulfills all of the requirements of an EMG-sensitive, noise insensitive device. The electrode leads are housed in a low-noise cable, the pre amplifier has a high input impedance and high common-mode rejection, a sharp high-pass filter removes signals below 95 Hz, and the equivalent noise generated by the pre-amplifier semi-conductors is quite small, 2 microvolts peak to peak. When the battery level fell below an acceptable level of output, new batteries were installed.
Auditory feedback is provided in the form of a series of clicks. The repetition rate of the clicks is proportional to the EMG level. Thus, as the EMG level rose, the click rate increased. The frequency of the clicks can vary from below 1 per second to approximately 100 per second. The subject is instructed to produce a slow click rate, signifying a low EMG level. The experimenter recorded the visual meter reading at one-minute intervals throughout the biofeedback session.
A KTK brand cuff sphygmomanometer and Littman stethoscope were used in blood pressure measurement.


26
Purpose of the Study
Advances in technology and the appropriate application of learning theory make it possible to explore needed therapy approaches for the treatment of those afflicted with essential hypertension (elevated blood pressure of unknown etiology). The significance of this study is noted when one considers the impact of chronic hypertension on the quality and duration of the life of an individual. Sustained blood pressure elevation often becomes associated with cardiac, cerebral, and renal functional impairments, as well as vascular complications. Drug therapy is often an unsatisfactory approach in handling the subject in treatment as indicated previously.
The purpose of this study is to assess the effectiveness of a psychophysiological approach, biofeedback relaxation therapy devised by Moeller and Love [1972] for the reduction of blood pressure in subjects with chronic essential hypertension .
The Moeller study [1973] utilized a four-month treatment schedule, in contrast to this treatment schedule which is applied on a short-term, six-week basis. In addition to comparing the effectiveness of two 6-week treatment schedules in reducing blood pressure, the study examined the subjective responses of the subjects to the treatment procedure and the perceived changes within themselves as a result of the treatment. Obtaining such information did assist in making further clinical refinements in the therapy approach.


27
The literature indicates that the Moeller-Love treatment surpasses any other nonpharmacological treatment for essential hypertension in terms of the following clinical considerations: (1) amount of decrease in systolic and diastolic blood pressure, (2) generalization outside of the experimental setting, and (3) feasibility for use in a clinical setting. In working toward greater efficiency in treatment, it is important to determine the changes produced by different treatment schedules and to observe the reactions of the subject to the treatment procedure as well as to the changes he perceives as a result of the treatment.
Hypotheses
IA. There will be no significant difference in changes on blood pressure measures among Groups X, Y, and the control group, C.
IB. There will be no clinically significant difference in changes on blood pressures among Groups X, Y, and the control group, C.
2. There will be no significant relationship between the scores of subjects in the treatment groups on the I-E Scale and amount of reduction in blood pressure.
3. There will be no significant difference among scores on the I-E Scale achieved by subjects in Groups X, Y, and C.
Exploratory Questions
1. Do scores on the Hy and D scales of the MMPI differ between the subjects in Groups X and Y as compared with Group C, at the conclusion of treatment?


28
2. Will ratings of positiveness of body image as measured by the D-A-P test differ between Groups X and Y compared with Group C at the conclusion of treatment?
3. What aspects of the treatment affect the subject in a negative manner?
4. Does self-regulation of blood pressure affect the way in which a person views his external environment with respect to his coping strategy of life style?
5. How does a subject describe the psychological process by which he effects muscle relaxation?


CHAPTER II DESCRIPTION OF THE STUDY
Methodology
In order to assess the effectiveness of a biofeedback and relaxation training approach devised for the reduction of blood pressure in hypertensive individuals, 30 subjects were selected from a group of screened volunteers and assigned to one of three groups for the duration of the study. Groups X and Y received relaxation exercises to be done twice daily outside of the treatment laboratory. In addition, Group X received biofeedback four times weekly, and Group Y, once weekly. Group C, serving as a waiting-list control group, participated in the pre- and post-measures, but received no biofeedback sessions nor relaxation training. All subjects continued prescribed drug therapy. The data collected on subjects for whom the dosage was increased or changed in kindwerenot included in the statistical analysis related to the hypotheses, but are presented in the final chapter, where the broader aspects of the study are discussed. These subjects were allowed to continue in the treatment if they wished to do so. If the dosage was reduced or discontinued, the subject remained as part of the study.
29


30
Group C was told that their treatment procedure would be undertaken at the completion of the treatment of subjects in Groups X and Y. One limitation of the study was that subjects in Group C may have viewed themselves as though they were on a waiting-list, rather than in a no-treatment group. The effect of this status upon the subjects was not determined. It is the opinion of this researcher that the expectation of no treatment following the sessions of baseline measurements and pretesting would be a source of frustration to the subjects. The literature suggests that hypertension may be related to emotional stress [Harris ejt al_. 1953] In view of the existing hypertensive states of the subjects, it was desirable to assist the subjects in the maintenance of psychological comfort insofar as possible by providing the expected treatment. In addition to the preliminary baseline data-gathering sessions and treatment, postmeasures were made during the last week of treatment and in a termination session.
Ins truments
Two types of data were collected. The physiological measures of blood pressure taken with a cuff sphygomomanometer and stethoscope were made by trained examiners with no involvement in the outcome of the study. Their competency was approved by a licensed physician. The psychological measures and ratings were secured through scores achieved on Rotter's I-E Scale, the D-A-P, and scales Hy and D of the MMPI. The


31
contrast in the formats of the tests served to reduce the possibility of boredom. In addition, an information-gathering interview provided descriptions of the subject's subjective response to the treatment.
A psychologist examined the D-A-P drawings of each subject and judged whether the postdrawing, relative to the pre-drawing, appeared to reflect a more "positive" body image. The ratings were made blind, with the criteria listed previously for use in making the global judgement. This rating technique is a modification of the scoring technique employed by Machover. The I-E Scale and MMPI subscales were administered during the posttreatment session and scored according to the standard procedures for each test.
The termination interview was developed by the experimenter in order to assess the subject's response to participation in the study. An attempt was made to elicit the subject's feelings about the treatment procedure including the training via the tapes and the changes that may have occurred as a result of successful treatment. In addition, the subjects were asked to describe the process by which they achieved lowered muscle tension. The interview was taped with the subject's consent. Relevant excerpts were selected and summarized from the tapes.


32
Subj eets
The 30 subjects were selected from a pool of volunteers who had been diagnosed by their physicians as having essential hypertension and have been under treatment for that condition for one or more years. For the purpose of this study, hypertension was defined as having blood pressures above 140 mm Hg for the systolic value and 90 mm Hg for the diastolic value [Gressell, 1949].
The subjects were between 18 and 5 5 years of age. They were not psychotic, intellectually retarded, or obese, as determined by the referring physician and the experimenter. The subjects had been taking the same kind and dosage of drugs for a period of at least one month prior to the beginning of the study.
Procedures
The location of the biofeedback laboratory was North Florida Regional Hospital in Gainesville, Florida. The hospital's Board of Trustees granted the use of adequate space to the investigator. The setting was considered appropriate for the study, as it was air-conditioned, quiet, accessible, and private.
The study was conducted in a manner consistent with the standards set forth for research with human subjects by the American Personnel and Guidance Association, the American Psychological Association, and the Committee for the Protection


33
of Human Subjects at the J. Hillis Miller Health Center, University of Florida, Gainesville [Clark, 1967; AGPA, 1961; APA, 1963; Schultz, 1969]. The first phase of the study included baseline measurement and testing, the selection of subjects, and assignment to a treatment or control group. The second phase was comprised of the actual treatment period. The third phase included posttesting, analysis of the data, and the exposition of the results of the study. The final phase was the period during which the subjects in the control group were given an opportunity to receive the biofeedback and relaxation exercises.
The following individuals were trained by the experimenter and provided assistance in the process of baseline measurement, treatment, and/or posttreatment measurements: Ms. Estelle Carson, Ms. Sue Edell, Mrs. Judy Foote, Ms. Tay Tanya, Ms. Paula Saraga, Ms. Lois Inglish, and Mr. John Butter.
Phase One
Each individual who volunteered to participate in the study was screened over the telephone regarding age, weight, and physical condition. If he or she seemed to be suitable prospects, an interview was scheduled for obtaining baseline data.
During the preliminary interview, the demographic form (Appendix Al) was completed and the "Explanation to Volunteers" (Appendix Bl) provided by the experimenter. Following this, the subject was instructed to empty his bladder.


5 4
Returning to the laboratory, his blood pressure was measured by a trained individual who had no involvement in this study or its outcome. The competency of the individual to measure accurately blood pressure was determined by the judgement of a licensed physician. With the relaxation chair placed in a position midway between reclination and an upright position, the subject's left arm was placed horizontally at the level of the fourth intercostal and the cuff was inflated until the radial pulse disappeared, thus assuring a true measurement of the systolic pressure.
After completion of the initial interview and assessment of the pertinent data related to the selection of the subjects, 30 subjects were selected and scheduled for a second session. During the second session, the subjects were given the "Instructions for Subjects" (Appendix B2). As subjects completed the testing, they were introduced to the biofeedback equipment and laboratory. At the conclusion of the second preliminary session the subject was randomly assigned to Group X, Y, or C.
Phase Two
The experimental procedure for the biofeedback session in the laboratory was based on the system followed by Love et al. [197 ]. Love's procedures represent an attempt to standardize the session in order to eliminate as much variation as possible, yet allow for personal interaction between subject and examiner. Each subject was greeted and conducted


35
to the experimental room. With the experimental chair in an upright position, the subject's systolic and diastolic blood pressure was taken three times, as previously described. The subject's forehead was cleaned with alcohol to remove any skin oil. Three EMG surface electrodes filled with Beckham electrode paste were placed approximately one inch apart over the frontalis muscle of the forehead. Earphones were placed on the subject's ears and the chair adjusted to the full reclining position. The subject was instructed to relax with his legs uncrossed and his arms on the arms of the chair.
At this time, the experimenter left the subject alone and went to the control room to monitor the subject's progress. The subject's EMG level was monitored for two of the initial trials without auditory feedback to establish a baseline at the beginning of each session. The auditory feedback was then switched on so the subject could hear his progress. He received four 5-minute trials with continuous feedback during which time he relaxed and attempted to reduce the quantity of auditory clicks. The mean of the final 10 minutes of feedback was recorded from the meter.
At the beginning of the first session, the loop gain was set on "low." When the subject achieved a mean score of approximately 20 microvolts per second for 10 minutes he was informed that the "gain" would be increased to "medium," making it more difficult for him to reduce his tension level to the previous low level. Likewise, when he achieved a mean


36
score of 20 microvolts on "medium," the "gain" was increased to "high" where it remained for the duration of the study.
The subject's blood pressure was measured and recorded. As the experimenter disconnected the subject from the apparatus, the subject was asked the questions listed on the form entitled "Conclusion Questions" (Appendix B3). Rather than discussing the affective reactions of the subject in an unstructured manner, this method was selected to minimize and standardize the amount of verbal interaction between the experimenter and subject. This procedure was followed for each scheduled session for the duration of the study.
After the first introductory session, the subject was given a tape cassette with relaxation exercises recorded on it and was told to practice twice per day at home or work, in a relaxed, reclining position, and once on the day that he was scheduled to receive feedback [Love and Love, 1973]. The 'tape consisted of instructions to alternately flex and relax the muscles of the arms, neck, face, and eyes. In addition, he was given a booklet in which to record his daily performance and feelings related to stress.
After two weeks the subject was given the second tape in the Love series, with instructions, and was told to practice as before. The second set focuses on the tension and relaxation of the foot and leg muscles and the muscles of the torso. Four weeks after the beginning of the study, the subjects in Groups X and Y were given a third set of exercises. The instructions for this


37
set were on a third tape cassette. These exercises integrate the first two sets and focus on total relaxation. This set of exercises was the last in the series and was practiced by the subject for the remaining two weeks of the study.
Phase Three
Following the treatment period, the experimenter collected the posttreatment data. The D-A-P test, the I-E Scale, and the Hy and D scales of the MMPI were administered to each subject. After the test administration was completed, an interview was conducted by the investigator with subjects in Groups X and Y. The purpose of the interview was to assess the response of the subject to the treatment, the procedures, and the effect of the treatment on the subject, so that further modifications can be appropriately made in the future. The interview was tape-recorded.
0'Conner [1972] advised against the use of change scores of psychological test scores in his discussion extending classical test theory to the measurement of change. Likewise Chronback and Ferby [1970] cautioned against the use of psychological change measurement. Therefore, a post-only comparison was made of scores on the MMPI subscales and I-E Scale. As explained earlier, it was necessary to use each subject as his own control in the D-A-P test, which was administered both pre- and posttreatment. The median or modal value of the blood pressure measures made during the final two treatment sessions was considered the postmeasure of


38
these variables for Groups X and Y. Group C was retested and measured during an additional session scheduled for that purpose .
Phase Four
The final phase of the study provided biofeedback and relaxation training exercises to those subjects in the control group, Group C. The subjects were given a choice of the treatment schedules used for Groups X and Y. At the time of this writing two control subjects have selected and completed the treatment schedule assigned to Group Y. Two control subjects are in the process of completing the Y treatment schedule. Four control subjects plan to begin the treatment schedule of their choice in September, 1974, and the remaining two have moved to other cities.


CHAPTER III RESULTS
In general, the subjects in the two experimental groups reported that they felt better as a result of participation in the study. Approximately three fourths of them achieved relaxation by autosuggestion of the desired state, using key words such as "limp" and "quiet." Criticism was minimal and usually focused on the amount of time required to participate and scheduling problems. While the mean blood pressure measures of the experimental groups were reduced both systolicly and diastolicly during the course of treatment, the effects of the change failed to be manifest on the selected personality tests when the scores of the experimental groups were compared with the control group.
Limitations of the Study
There were a few times when subjects missed biofeedback sessions. No subject missed more than 10% of his appointments. Whenever a subject did miss a scheduled appointment, the mean blood pressure measures from the previous appointment and from the following appointment were averaged and this score was entered on the data sheet.
The recording tape used to record the termination interview of subjects at the conclusion of treatment ended prior
39


40
to the interview of two subjects. Because this was not discovered until the tape was replayed, the termination interviews are incomplete, giving an N of 9 to both experimental groups. During the initial pretesting session, the investigator failed to obtain or lost one projective drawing from a subject in the experimental group and one from a subject in the control group. Hence, the N used in the chi-square analysis of the projective drawing was based on a total number of 28, rather than the planned 30.
Dropped Subjects
Four subjects who began treatment were dropped from the data analysis. Two of the four completed the treatment schedule but increased or changed their medication in kind during the early weeks of treatment as required by their physicians. One subject, advised by her physician that she "could expect no change" by participating in the study, chose to terminate rather than invest her time. The fourth subject terminated following a missed appointment on the part of the investigator due to a scheduling error.
Hypotheses
1A. There will be no significant difference in
changes on blood pressure measures among
Groups X, Y, and the control group, C.
The means of the blood pressure measures of the experimental and control groups are shown in Tables 1, 2, and 3, and include repeated measures over time.


Table 1
Means, Standard Deviations, and the Analysis of Variance Summary for the Change in Systolic Blood Pressure Among Groups X, Y, and C
Group Pre Means Post Means Change
X 153.7 149.5 -4.200 (5.996)
Y 149.3 143.0 -6.300 (5.774)
C 150.7 152.1 1.400 (5.796)
Source_______________df_________MS_________F___________
Between groups 2 158.4332 4.619*
Within groups 2_7 34.3000
Total 29 *p = .05
Note: The standard deviations are in parentheses.
Table 2
Results of Tukey Multiple Comparison Test of Significance of Mean Systolic Blood Pressure Change Between Groups X and Y, X and C, and Y and C
X
Y
X Y C
2.1 5.6
2.1
7. 7 =
5.6 7.7*
*p <.05.


Table 3
Means, Standard Deviations, and the Analysis of Variance Summary for the Change in Diastolic Blood Pressure Among Groups X, Y, and C
Group Pre Means Post Means Change
X 104. 2 102. 3 -1.900 -(3. 807)
Y 103. 5 93.2 -9.500 (7. 590)
C 100.2 101. 8 1.600 (2. 633)
Source df MS F
Between Within groups groups 2 2_7 328.0332 26.3481 12.450*
Total 29
*p = .05
Note: The standard deviations are in parentheses.
Table 4
Results of Tukey Multiple Comparison Test of Significance of Mean Diastolic Blood Pressure Change Between Groups X and Y, X and C, and Y and C
X Y C
X
8.0* 3.1
Y
8.0*
11.1'
3.1 11.1*
*p <.05.


43
The mean systolic and diastolic measures for Group X were obtained in the following manner: on each measurement occasion, the systolic and diastolic pressures were taken twice and recorded in order to provide a modal value. When a change in the blood pressures occurred between the first and second measurements, no modal score existed. A third measurement Mas then made and the median score, based on the three measurements, was recorded. The prescore is the arithmetic mean of the modal or median values obtained during the baseline measurement sessions. A median or modal value was obtained at each treatment session and averaged to provide a weekly mean score. The postscore is the average of the median or modal values obtained at the last two treatment sessions.
The mean systolic and diastolic measure for Group Y were obtained in the same manner, except that the mean score for each week was averaged from the median or modal value taken at the single treatment session. The postmean is the average of the means of the median or modal values taken prior to the final treatment session and at a posttreatment measurement session.
Whenever a subject missed a treatment session and did not complete it at a later date, the average between the median or modal value obtained immediately prior to and following the missed session was recorded as the value for that session. The mean premeasures for Group C were obtained in the same manner as for Groups X and Y. The control group's


4 4
postmean scores were obtained during the final measurement sessions scheduled for that purpose.
As shown in Table 1, the analysis of variance indicated a systolic change among Groups X, Y, and C which was statistically significant at the .05 level. The Tukey multiple comparison procedure which provides protection against experi-mentwise error was used to locate the difference between the means (Table 2). It was found that Group X does not differ significantly from Groups C and Y, but that Group Y is significantly different from C. Therefore, the treatment that Group Y received appears to produce a statistically significant difference in diastolic blood pressure, and an inspection of the means shows the change to be a decrease.
In Table 3, the analysis of variance indicates a diastolic change among Groups X, Y, and C which was statistically significant at the .05 level. The Tukey multiple comparison test showed that both groups X and Y were different from Group C, but not significantly different from each other (Table 4). As shown, the change is negative and indicates a decrease in mean diastolic blood pressure. Hypothesis 1A is rejected.
A trend analysis was run on the repeated measures of blood pressure recorded at weekly intervals for the experimental groups. The performance of the groups was found not to parallel over time. The comparisons of the profile analyses were not relevant because of the lack of parallelism (Table 5).


Table 5
Means of Groups X and Y on Systolic Blood Pressure Measures Over the Six-Week Treatment Period
Means of Groups X and Y on Diastolic Blood Pressure Measures Over the Six-Week Treatment Period
Weeks
90


45
IB. There will be no clinically significant difference in changes on blood pressures among Groups X, Y, and the control group, C.
Three Florida licensed physicians with no involvement in this study nor its outcome were selected to render their judgments as to the clinical significance of the reductions obtained in blood pressure within the experimental groups. Dave Pawlinger, M.D.; Robert Ashley, M.D.: and W. C. Evans, M.D., concluded that the treatment received by Group X failed to produce sufficient reduction in blood pressure to be clinically worthwhile (Appendix D). The treatment received by Group Y did result in decreases in blood pressure that were large enough to have practical usefulness in the management of essential hypertension. Thus, the clinical worth of the treatment received by Group Y was confirmed, and Hypothesis IB is rejected.
2. There will be no significant relationship between the scores of subjects in the treatment groups on the I-E Scale and amount of reduction in blood pressure.
The mean reduction in blood pressure was calculated by
weighting the diastolic measure twice. The Pearson product-
moment correlation of 0.06 did not achieve the magnitude to
reach statistical significance at the <.05 level. Hypothesis
2 has failed to be rejected.
3. There will be no significant difference among scores on the I-E Scale achieved by subjects in Groups X, Y, and C.
Analysis of variance of scores indicates that no differences among the groups were statistically significant at the


4 7
<.05 level of confidence; thus, the hypothesis failed to be rejected. The results are shown in Table 6.
Table 6
Means, Standard Deviations, and Analysis of Variance Summary Table for Scores on the I-E Scale Among Subjects in Group X, Group Y, and Group C as Achieved During the Posttesting Session
Standard Standard Group Means Deviations Error
X 10.7000 4.4485 1.4067
Y 12.4000 7.2449 2.2910
C 14.800 4.1312 1.3064
Source_____________df_________MS_ ____F_
Between groups 2 42.4336 .0257 Within groups 2J7 29.7815
Total 29
In addition to the main hypotheses investigated in this study, five questions of an exploratory nature were examined.
Exploratory Questions
1. Do scores on the Hy and D scales of the MMPI differ between the subjects in Groups X and Y as compared with Group C, at the conclusion of treatment?
Analysis of variance was used to determine if a statistically significant difference existed among the groups. The groups were not found to be significantly different from each other at the .05 level (Table 7).


48
on the Hy and D scales of the MMPI do not statistically differ among Groups X, Y, and C.
Table 7
Means, Standard Deviations, and Analysis of Variance Summary Table for Scores on the Hy and D Scales of the MMPI Among Groups X, Y, and C as Achieved During the Posttesting Session
Group Hy Scale Means D Scale Means
X 22.000 (6.5490) 25.000 (4.1096)
Y 21.400 (6.7773) 23.700 (6 .9290)
C 23.900 (6.0268) 26.500 (8.8349)
Variable Source df MS F
Hy Between groups 2 17.0371 0 .639
Within groups 27 38.7150
Total 29
D Between groups 2 19.6348 0. 651
Within groups 27
Total 29
Note: The standard deviations are in parentheses.
2. Will ratings of positiveness of body image as measured by the D-A-P test differ between Groups X and Y compared with Group C at the conclusion of treatment?
Dr. Betty Horne, a clinical psychologist with no involvement in the outcome of the study, rated the projective drawings of all of the subjects. The post figure drawing of each


49
subject was judged to be substantially different or not different from a figure drawing completed in the baseline measuring session. If "different," then a second judgement was made as to whether the second drawing was positive (+) or negative (-) when compared to the first. A chi-square analysis used to test for proportion showed that the rated difference between the drawings of the experimental and control groups was not statistically different at the .05 level as shown in Table 8.
Table 8
Chi-Square Analysis for Experimental and Control Groups on Projective Drawing Ratings
Rating
Control
Experimental
Total
No difference Negative difference Positive difference
6 2 2
6 7 6
12
9 8
Total
10
19
2 9
2
x
df
2.4926 2.
3. What aspects of the treatment affect the subject in a negative manner?
The taped termination interviews were monitored by Mary
Ganikos, Specialist in Education. Ms. Ganikos is a counselor
and has no involvement in the outcome of the study. She


5 0
selected excerpts, and summarized the negative aspects of the treatment as follows:
1. Two subjects complained that the treatment received by Group X was an imposition and "confining."
2. Six subjects disliked the tapes and felt the instructions given were not sufficiently clear.
3. One person disliked the required form.
4. Three subjects experienced scheduling problems.
5. The remaining subjects responded idiosyncratically, suggesting improvements ranging from using a direct, in-artery measure of blood pressure to obtaining a greater number of subjects "because the more you have, the more you help."
Four subjects spontaneously provided the following information related to their negative experiences associated with the treatment procedure. The other subjects were asked to describe the undesirable aspects so that the procedures could be improved in the future.
Subject 1. The four times a week may be too much I remember that the first time I come in each week it seems more effective, but by the last time you don't want to sit down so much. Two or three times would be better, with a day in between. The tapes were very boring, and I felt resentful, especially when it was very late, and instead of going to sleep I would have to do my exercises.
Subject 2. The tapes don't help me because I'm not at all ... is the word 'subjective?' Suggest-able? I'm not at all influenced by words as so many people are. Words are not emotional. I don't get so close to them. I didn't use words very well in speech. I only read. I just have a built-in resistance towards anything anyone tells me. I figure ninety-nine percent of the time it isn't so. Nothing that is told me on the tapes has any influence on me. Perhaps I'm ove.r-critical on this point. Teaching
at the University I get so much B.S. Maybe that is it.
Subject 3. Improve the study? Directly monitor the blood pressure and not use the head-band approach.


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Subject 4. I can't think of any way.
Subject 5. The four times a week was a little bit much for me, confining. On the days when I didn't feel particularly good it was a chore for me .
Subject 6. Nothing much. I have a hearing problem that I'm ashamed of sometimes when Paula well, with different voices I just don't hear much. [Question: Did you hear the clicks?] Yes, I heard them ... I been to the doctor and he says there isn't anything I can do about it.
Subject 7. The scheduling was mixed up. The last time I came in I waited for 15 minutes and this might have thrown the blood pressure machine off.
Subject 8. After the first two tapes I could go to sleep, but after the last one, between it and the recorder I got, well, I didn't get too much benefit out of it. Whenever it would cut off, I would think it was the recorder, then I found out the tapes had breaks in it she said 'a feitf minutes' but it felt like fifteen minutes. I got other things to do.
Subject 9. You didn't give clear instructions about the tapes and I got my second one late.
Subject 10. You need to give clearer instructions about the tapes.
Subject 11. I resented filling out the forms
. the categories didn't always fit how I felt.
Sometimes I didn't feel exactly happy, and I think that it should allow for different shades.
Subject 12. You should get more people into the study. The more you have, the more people you help.
Subject 13. Get people coming in on time so you don't have to wait. I guess that's hard to do, to get people to come in when they're supposed to.
Subject 14. If you had some money, get some GSR equipment ... I think, you know, you should measure both ways. People with high blood pressure tend to sweat a lot, you know, that would give you a little more calibration to the blood pressure. I am hot two or three times a week for no reason. There must be something.


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Subject 15. The location should be more central.
Subject 16. Expectation is an important factor, and I really felt surprised that you were going to ask me some questions in addition to picking up the questionnaire. It would have been better if you would have said, 'Look, I want to ask you some questions, too,' instead of just coming in and, here we are, and you have your equipment, and it is totally unexpected but otherwise it was fine.
Subject 17. Generally if you could put the tapes on some background music, that has a tendency to relax you also, like a real soft background.
Subject 18. At first I found it difficult to get into the tapes, but after a while I got to where I looked forward to doing them.
Subjects 19 and 20. Malfunction in tape recording.
4. Does se If-regulation of blood pressure affect the way in which a person views his external environment with respect to his coping strategy or life style?
The excerpts selected by Ms. Ganikos are presented below She summarized the responses as follows:
1. Most of the subjects seem to use the techniques that they learned to increase the degree of relaxation during their daily lives, in the physiological sense.
2. Most of the subjects experienced a new awareness of the sensation of tension and were able to avert tension headaches, "spells" of high blood pressure, chronic body tension, and anxiety.
3. Most subjects experienced changes in their life styles, in that they became less rigid and perfectionistic about time, neatness, and the need to achieve, and could perform better at work, home, and school.
4. Two subjects reported no change attributable to participation in the study.
Information concerning the subjects' life styles or coping behavior was elicited by an open-ended question,


53
spontaneously volunteered, or, in one case, directly requested.
Subject 1. When nothing is happening, like in class, I now become aware that I am a little tense, I don't know why there must be some reason for it. Like, when nothing is happening, then I pay attention to myself and I feel tense. Before the study I never had any manifestations of tension, except maybe the high blood pressure.
Subject 2. These results mine has been consistently going down. There has been no decline in my outside stress. Before I knew what to do, but now I am more reinforced. I haven't changed the method I use to relax but now the idea is reinforced that it is doing some good. And I will hold that relaxation for a longer period than before. I can't hold that under normal conditions. And I go to sleep much faster now.
Subject 3. I think I have relaxed some ... it has done some good.
Subject 4. I feel like it helped me, not as far as my blood pressure, but my emotional well-being, my headaches and things like that. When I used to be getting a headache I'd wait until it got bad and then I'd try to do something about it. Now I don't let a lot of little things upset me. I don't worry in advance about how things are going to come out. For example, six extra people spent the night at our house Friday night ... I just sort of took it in stride. I think too that a part of it is being able to express myself to my husband. I don't worry about if he is going to object. I go ahead and sometimes explain the reason. [Question: How about the headaches you mentioned?] It did decrease the number of them. I learned to recognize when I was getting one. I just concentrated on it. I read some articles on biofeedback, and if it is worth the effort that other people are putting in on it, it certainly is worth my effort. Now I try to keep from overdoing. Even my tennis game is better ... we played doubles last night, my husband and I, and we are winning ... I guess it is because I don't overdo and am more relaxed playing.
I sense the feelings of relaxation. Before I would think I was relaxed, but now I seem to feel it. If I go into a situation that I think is going to cause me tension, I say 'no' I'm going to stay relaxed.
When I say 'My face is smooth,' I have sort of a drawing sensation up in here. I used to have sinus


5 4
trouble up there, but when I say 'my forehead is smooth,' it kinda drains out. I used to wake up about 4 o'clock in the morning but now I don't do that.
Subject 5. It was revealing in several ways it made you aware of parts that were tense that I really wasn't aware of ... I started paying attention .
Subject 6. Sometimes when tempers get up a little bit ... I never was too bad but I just let things so.
Subject 7. I can calm down better. With the tape I could relax ... I used the Dean's office if it was during the day. There are a lot of tensions in the office, right at this minute. [Explanation of inter-personal conflicts omitted.] In my case this was helpful. It was a particularly bad time and normally I stay hyper. I can shoot my pressure up. Using the tapes I could lower it so I could get by.
Subject 8. No reported effect.
Subject 9. I used to be the type to want to get everything done now I can go off and leave the dishes. This has a lot to do with my childhood. I felt pressured. Now I realize that I don't have to.
It gave me a new perspective of the values of things. I don't know why doing this did it, but it did! I can't explain how sitting in that chair, hearing those clicks. (laughs).
Subject 10. I use it constantly. One day I had a headache; I sat down and thought about the tapes. I did learn that my body tells me things ... I didn't realize how tense I was 'til I relaxed. Before I resented the loss of time from things I should be doing. I felt guilty when I relaxed. Now I am making some changes; I am going back to school ... I have been able to take things more casually.
Subject 11. I definitely know that I have a problem.
Subject 12. I've had terrific headaches the last six years ..I've been on medication the whole time. I had constant headaches. Nothing would eradicate them. Constantly, day and night. After my first three sessions on the machine and listening to the tapes, I haven't had a headache since. You're some


55
kind of woman, I'll tell you that, lady! Prior to the time I started taking training with you and your staff out there, the least little thing my family would do, I'd fly off the handle. I don't do that any more. Right now I'm working 16 hours a day I don't hurt any more. I just got a $1,400 raise. They weren't going to give me the promotion at the Post Office because they didn't think I would take the pressure with the headaches and all, but now they decided to I'm working 16 hours on the new job and I still feel fine. No headaches at all. And a few weeks ago I went by to Dr. McCollough and he checked my pressure and he cut my medicines in half.
Subject 13. I'm trying to pull some grades up that were bad.
Subject 14. I'm more aware of the importance of relaxing, not that I'm any more able to relax, but I'm more aware of it.
The only thing we can control is our thoughts.
You might as well relax because people are going to criticize you anyway.
Subject 15. Well, I tried to relax and slow down. Today I was late but I didn't do my normal rushing out here, like you said. You are getting me into bad habits! That is so ingrained in me. Between you and the nurse, you're getting me to slow down.
Subject 16. What I said was I had difficulty relaxing my face versus my arms, my extremities.
Subject 17. No, I don't believe that I have actually slowed down any, I just haven't had time to.
Subject 18. I seem to feel better, I don't knoiv how to describe it. I feel loose and get along better all through the day. One thing, I know that I used to be a lot more nervous and tight in my shoulders but now, when I start to feel like that, I move around or do something else.
Subjects 19 and 20. Malfunction in tape recorder.


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5. How does a subject describe the psychological process by which he effects muscle relaxation?
The descriptions of the process were selected by Ms.
Ganikos and are summarized as:
1. Most of the subjects seem to mentally repeat the key words learned from the tapes, shifting their awareness through different areas of their bodies until they reach a "numb" or "floating" state.
2. The remaining subjects strive to achieve a "blank" mind and "nothing" feeling.
The subjects were asked how they achieved a feeling of
relaxation.
Subject 1. How? It is nothing special. It is like doing anything else, you don't think of what to do, you just do it.
Subject 2. It's relaxing the face and throat muscles. The rest of my body I don't have any connection with it really. I can disengage myself from it as far as relaxation is concerned. My trouble is in my mind neither my worries nor my joys are from my limbs. Whatever I do, I do in my head.
Subject 3. Sometimes I'd let my mind just be blank, and sometimes I'd try to project my mind somewhere else. Sitting down in the tropics, down on the beach. I just try to lay there and let my mind go blank and see what it does to the clicks per second.
Subject 4. Mainly by relaxing the muscles in my face and my forehead, and also by changing positions. When I used to be riding along in the car on a trip my legs and shoulders would be tired, but by changing positions, by not holding myself up tense, I feel better. I get more comfortable when I am sitting down.
Subject 5. Trying to clear just not think of anything or something pleasant, not a project or anything to do. No one thing every day was different. It's still easier for me to relax the top part of me, not the legs, and it is still a problem that I haven't solved yet. The legs are still the hardest part. That was very interesting to me why should the legs be the hardest part. That is still a mystery. It's an awareness-type thing. It


5 7
has made me aware of the effects that parts of the body has on the whole body. Generally whenever I am doing something and I feel something tightening up in me, the tapes go through my mind. The one that fits that particular need ... I 'hear' it. First I realize this is tight or that is tight, the jaw, the hand, the legs, and then I relate that part back to the tapes.
Subject 6. Relaxation is a numb feeling. I do it by thinking of nothing.
Subject 7. The key words ... I went by 'limp,' 'relaxed,' words like that.
I would say like 'my arms are limp' and go all over my body like that, probably in the same order because I am a creature of habit. I would try not to think of anything, because I have a bad habit of trying to do several thinks at once read and watch TV, and such things as that.
Subject 8. That tick tick tick got to singing a song to you and then I drop off to sleep. I guess it was a very tell-taleing little instrument. I put everything away from my mind. Just say forget it all. But if I knew that I was going to be there for several hours I couldn't do it, my mind would start making plans. I felt that might be why I could relax here it was just a short time. I think about things at work at night.
Subject 9. I hear the words. I sit and I hear the words.
Subject 10. Just repeating I was calm, comfortable and relaxed, especially my forehead. I get floating sensations. I hypnotize myself.
Subject 11. I memorized the tapes and did it from memory the last three weeks. You don't take as long but you don't really relax.
Subject 12. I done exactly as the lady said on the tapes. Like she told you to get in a comfortable position don't cross your arms and don't cross your legs. She give you the different positions and she explain to you the muscles. Then she went to the forehead which is where I kept the burning headache before. That's where you put the sense-i-gram, that's what I call it [referred to the electrode]. At first it sounded like a machine gun, but after two or three sessions with that machine, I got it down to inhere it


58
sounded like a water faucet dripping. Now, really, I don't know how to thank ya. You worked wonderful things for me, I'll tell you that.
Let me explain to you how it felt to me. The tapes start off with the right arm. By the time it gets to the left arm, the right arm doesn't feel like you have it any more ... it is not asleep, but in a perfectly relaxed position. Then I'd concentrate on bringing that machine down. The way it felt to me as I'd relax one portion of my body, then another, it felt like floating on Cloud Nine. You don't have any sensation to you, like asleep, but I don't know what sleep feels like because I'm asleep.
Subject 13. I just sit back and shift my awareness all over and feel it relaxing. I became aware of what I was feeling and just let it go. I'd just feel floaty, not so pushing down. Sometimes I'd just blank my mind out, and feel what is there.
Subject 14. By being conscious that if I tell myself to relax, I do.
Subject 15. I relax different days in different ways. I know where the electrodes are. I try to do the neck and face. That's really trying to beat the machine, I know. The time the girl was here with the red hair, I didn't know her, and felt very impersonal. The clicks were the lowest then because I wasn't trying to please anyone. Maybe it was the movie the night before or maybe. .
Subject 16. On my face I feel with my fingers to feel the tension and I look with, my eyes to see how far I get. On the rest of my body I have no special way. I think I could feel the difference. I could feel the tensing and relaxing more readily than on my face. Relaxing didn't happen all at once. I felt I got better at it. At first the whole side of me would tense. The more I did it the more I could narrow it doitfn.
Subject 17. I relax by sitting down in a chair with a can of beer. And I use the phrases from the tape s.
Subject 18. In two ways: first, I shift my awareness all over my body, and where I find a spot of tension, I relax it by letting go. Then, when I am quite relaxed, I use the key words, like 'limp' to


achieve a greater relaxed state. It's quite beneficial. I have profited a great deal by being in this program.
Subjects 19 and 20. Malfunction in tape recording


CHAPTER IV DISCUSSION
One of the purposes of the study was to examine the efficiency of two treatment schedules in decreasing high blood pressure. The results appear to favor the treatment assigned to Group Y. The importance of the outcome of the study seems to lie in the fact that those who participated in a treatment which required only one biofeedback session weekly reduced their blood pressures more than those who were required to schedule four sessions per week in the hospital setting.
While the amount of reduction sustained by the experimental groups did not approach that achieved by the Moeller study [1973] it should be noted that (1) the pre mean blood pressures of the subjects in this study were less than those in Moeller's experiment, and (2) Moeller's treatment period extended for 16 weeks, in contrast to the 6-week duration of the treatment in this study.
Clinical impressions. The most apparent difference between Groups X and Y seemed to be related to the degree of personal responsibility the subjects assumed for their "commitment" or involvement in the study. The subjects in Group X established a deeper interpersonal relationship with the
60


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experimenter and her assistants, and it is possible that the quality of this relationship interferred with their performance. In addition, approximately 30% of the subjects in Groups X and Y indicated that they were less apt to complete the practice session outside of the laboratory on days that they attended the biofeedback session, because of the time required to participate.
Group X seemed to relate to the experimenter and her assistants as to an authority figure. In general, two response patterns seemed to emerge. First, several subjects seemed eager to gain the approval of the experimenter by reporting their "good" behavior, such as diligence at carrying out the practice sessions outside of the laboratory, attempts to avoid tension related to conflict situations, the diminution of headaches and insomnia. The subjects verbalized a variety of excuses for not completing the practice sessions and for being late for appointments. Their complaints ranged from a dislike of the wording used on the tapes to the noise produced by the hospital's air conditioning system. They seemed to have a need to place "blame" outside themselves for their feelings of failure at not achieving the desired state of relaxation.
In both cases, the interpersonal relationship afforded the subjects an opportunity to develop an expectation of reinforcement external to themselves. This opportunity was less available for members of Group Y since the number of biofeedback sessions was 75% less.


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It is also possible that the Group X subjects experienced greater desire to learn to control themselves than those in Group Y. When the subjects were assigned, four individuals placed in Group X withdrew before the treatment began due to the number of required visits to the hospital setting. None of the Group Y subjects withdrew for this reason. Therefore, it is possible that the subjects in Group X differed from those in Group Y at the beginning of the study. Relaxation is dependent, in part, upon the subject's ability to let go of tension and not control himself, in the sense of using active volition. To the experimenter, it seemed that the psychological need for increased self-control required to complete the treatment schedule of Group X was associated with a behavior pattern in which the subjects used external manipulation of themselves. They appeared to try to make themselves relax in the same active manner by which they volitionally increase tension. The results achieved by the subjects on the I-E Scale suggests that this might be the case, although the means were not different enough to reach statistical significance.
No procedure was established to insure consistent practice for all subjects outside of the laboratory setting. It is the opinion of this researcher that the subjects in Group X failed to be as consistent in home practice as those in Group Y. This judgement was based on the unrecorded remarks made by the subjects rather than on an analysis of the data on the practice sheets. In general, subjects felt that the time required to travel to and from the hospital setting and


63
to participate in the biofeedback session interferred with their ability to complete an additional session of relaxation at home on the same day. It seems probable that Group X actually received less progressive relaxation and autogenic training than was proposed since they participated in four biofeedback sessions in the laboratory each week. The practice sheets on which the subjects recorded responses related to the practice sessions were collected but no verbal feedback was given to the subjects.
The logistics of carrying out the study presented certain difficulties in keeping uniform personal interactions among groups. An attempt was made to structure interaction with the subjects, but the subjects in Group X frequently sought the attention of the experimenter and her assistants. It was thought that a lack of response would be viewed as rejection and might lead to a termination in participation. Therefore, deeper relationships emerged than were planned.
Conclusion. It seems apparent, for a complexity of reasons, that the treatment assigned to those subjects in Group X was not as clinically efficient in reducing high blood pressure as the treatment assigned to Group Y.
Exploratory Quest ions
According to the statistical analysis, the scores of subjects do not differ among groups on the Hy and D scales of the MMPI to the extent where the differences approached


64
statistical significance. An inspection of the means (Table 6) shows that Group Y, who reduced their pressures the most, scored lower on the hypochrondriasis and depression scales than Group X, and that Group X scored lower than the control group. Were the number of subjects larger for each group, the direction of the differences would suggest that the treatment may tend to reduce the characteristics measured by these scales. While the overall mean score on the Hy scale fell within normal limits on the MMPI, the mean for D scale, which related to feelings of depression, were elevated two standard deviations above the mean for the general population.
Individuals who score high on this scale are characterized as silent, retiring, tending to sidestep troublesome situations, respectful of others, overcontrolling of their impulses, inhibited, worrying, frank, sensitive, indecisive, moody, and somewhat withdrawn. An elevated score indicated low frustration tolerance, poor morale, feeling blue, discouraged, dejected, and useless. This scale is described as the best single index of immediate satisfaction and comfort in living [Van De Riet and Wolking, 1968]. These adjectives seemed to be consistent with the experimenter's observation of the subjects involved in the study.
If the subjects in the experimental group have developed a more positive body image as a result of participation in the study, the ratings of the drawings failed to demonstrate the change. The chi-square analysis showed no significant difference between the ratings of the experimental and control subjects at the .05 level.


65
Three aspects were probed by the experimenter during the course of the termination interview: (1) the negative aspects of the procedures, (2) the effect of increased self-regulation of blood pressure on one's coping strategy or life style, and (3) the process by which the subjects achieve muscle relaxation. The purpose of these questions was to provide information on which to modify procedures.
Three subjects expressed dissatisfaction regarding delays in the appointments. This complaint could be reduced in future undertakings if "free" time would be scheduled between the treatment appointments of subjects, so that if one subject is late, the others will not also have to wait. The subjects sometimes found the instructions on the tapes confusing. Several initially remarked about soreness from tensing specifi muscle groups. It is the opinion of the experimenter that dif ficulty in following instructions was partly related to individual's personality traits rather than to the instructions on the tapes. Some subjects experienced a dislike for the key words used, such as "quite quiet," and "limp."
The relaxation techniques employed in the reduction of blood pressure seemed to sensitize the subjects to feelings of psychological and physiological tension and provided a strong suggestion as to the undesirability of tension. The heightened awareness led to a variety of changes considered by most to be desirable. One subject in Group X, who reported that he was less perfectionistic and more easy-going, implied that the experimenter was to "blame" for the change in his


66
behavior. This incident provides an insight into conflict experienced by some. The idea of placing one's self and one's own organismic needs before the cultural values of "hard" work, the importance of "suffering," and the need to appear as "perfect" as possible to others proved to be a difficult shift.
The psychological process through which relaxation was effected seemed to involve the use of passive suggestion of key phrases. Most subjects experienced the inability to actively "make" themselves relax, but learned instead to first become aware of the feeling of tension and, next, to discontinue the tensing process. Several subjects who did not comment on this difference continued to try to relax by making their minds "a blank" or by "doing nothing" and experienced some success. Others used manipulation of their daily living patterns to reduce "stress," by not "working so hard," adopting a less demanding attitude, or paying more attention to the task at hand rather than to a future goal.
Implications for counseling. The goals of traditional psychotherapy, humanism, behaviorism, and the new "fourth force" called transpersonal psychology have in common a belief that increased awareness of one's own processes, be they psychological or physiological, will lead toward greater personal freedom and growth. One function of the therapist is to assist the individual to better know himself through feedback of information. The content of the information depends upon the therapist's orientation; the cognitive therapists impart


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"insights," the Rogerians "relect feelings," the behaviorists produce change of maladaptive, classically conditioned responses; and those within the emerging "fourth force" encourage the individual to "experience himself" by becoming more aware of his organism's true needs, in contrast to those imposed by the culture.
Inherent in the use of relaxation training is the assumption that physiological tension in the skeletal musculature impairs full awareness of one's experience. Individuals often attempt to avoid the experience of feelings that are unpleasant, such as fear, anger, or loss, by increasing muscle tension. Unaware of the underlying avoidances, these individuals often report symptoms such as chronic anxiety, headaches, and pain. For many, the incident that precipitated the muscle tension has been resolved, but the tension has remained as an undesirable habit or unobserved behavior.
Relaxation training assists the individual to get in touch with himself in that relaxation reduces the perceptual static and facilitates fuller experience of one's self. As the subjects reported, they became more aware of the process by which they produce tension, and now experience a choice between continuing to tense themselves or becoming relaxed. In addition, the experimenter thinks that the subjects perceived that the nature of the task conveyed to the subjects a belief that inappropriate tension is a negative quality; the subjects were indirectly rewarded for removal of tension and for remaining relaxed. For many, staying "relaxed" became a


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higher priority goal than being on time, getting a task accomplished within an established time period, or repressing or controlling anger and frustration. Subjects, through awareness of the mind-body interactions reported that they used the phrases learned in the recorded exercises to achieve the desired relaxation state.
It appears that relaxation training can be useful both as an adjunct to a verbal psychotherapy and as a method in itself. The experimenter noted that subjects became more fluent verbally and emotionally expressive as relaxation progressed. Often subjects remarked about the emergence of repressed memories or "forgotten" events. Simply re-experiencing the earlier feelings seems to be therapeutic for some. Others reported that they did not "feel" different but observed, among other things, that they were less demanding of themselves, took less medication, stopped smoking, had fewer headaches, improved interpersonal relationships, achieved greater sexual satisfaction, were more tolerant of stress at work, and reduced insomnia, teeth grinding, nail biting, the consumption of alcohol and the intake of fattening foods. Two of the twenty individuals in the experimental groups felt that participation had little or no value.
Suggestions for Future Research
The results of this study demonstrate the usefulness of the application of a short-term relaxation program to a


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stress-related condition such as essential hypertension. The need exists for further investigation of the interaction between the psychological and physiological components in organismic functioning.
In particular, it is suggested that future research efforts be directed toward the development of improved techniques to enable an individual to shift from a state of active volition to passive volition.


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7 5
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7 6
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APPENDIX A FORMS


7 9
Personal Data
1. Name___ 2. Age_ 3. Sex_
(last) (first)
4. Address__
(street) (town) (zip)
5. Phone_ 6. How do we contact you?_
7. Referred by:_
8. Physician__
(name) (address)
9. Marital Status: circle one Married, divorced, single,
separated, widowed
10. Occupation_
11. How tall are you?__In the past year have you
gained_ or lost_ more than ten pounds without trying
to_, or dieting_? Describe situation_
12. Have you been told that you have heart disease: yes_ no_
vascular condition: yes_ no_
IF NO, SKIP TO #16
13. Has a doctor told you that you had:
an abnormal electro-cardiogram (EKG) _
an abnormal chest X-ray _
angina pectoris _
none of these
14. Has a doctor told you that you had:
a blood clot in an artery _
a blood clot in a vein _
an enlarged heart _
none of these _
15. Has a doctor told you that you had:
a heart attack or coronary scarlet fever
a heart murmur heart failure
low blood pressure rheumatic fever
high blood pressure none of these
16. Do you worry about your heart a lot? yes_ no


so
IF MALE, SKIP TO #19
17. Are you pre-menopausal
menopaus al" post-menopausal"
18. Do you take birth control pills? no_ yes
brand
19. Do you have bad headaches? yes_ no_
IF NO, SKIP TO #28
20. Are they getting more frequent? yes no
21. How often do you get these headaches? every day
several times a week once a xveek once a month or less
22. These headaches usually occur: in the morning
in the evening during the day varies
23. These headaches usually last: less than one hour
several hours several days
i
24. Does tension or nervousness trigger your headaches:
yes_ no_
25. Can you usually tell when you are going to get a headache? yes__no_
26. Do other people in your family have severe headaches?
yes_ no_
27. What medication do you take for your headache?_
Helps?___
28. Do you have any allergies? yes_
(please describe)
no
29. Do you often have: _cramping and gas with your bowel
movements
_sweating palms
_trouble getting your breath
_sleep problems
_nervous twitches
_rapid heart beat
_indiges tion
_gas
_cold feet or hands when you are
under stress


81
30. How would you rate the tension in your life?
_less than most anyone
_less than most
_about the same as most people
_more than most
_more than most anyone
31. Have you had or do you have any of the following conditions? (please check)
Current
Condition Previously Currently medication
anemia _
apoplexy or stroke _____
arthritis '
alcoholism ______ _____
asthma or hay fever ^^j-^ __!________
bleeding tendency _
cancer _
cataracts [^^^ ~ZZ_
cirrhosis _______
congenital heart disease _____ _____ _____________
diabetes _
epilepsy ^ ____________
eczema _
emphysema _____________
glaucoma _____ _______ _____Z__I___
gout __________
heart disease _
high cholesterol _
high blood pressure _
kidney disease _
mental disorder _
leukemia ~ ________
kidney stones _
lung trouble _
nervous breakdown _
migraine headaches ^~________ ____________Z
pernicious anemia _____ _
rheumatic heart disease _
stomach or duodenal ulcer _
thyroid disease or goiter _
other
What medications do you carry in your purse or have at home?
32. What kinds of physical exercise do you routinely engage in?
33. What kinds of religious spiritual, or meditative activities do you engage in? Describe_
34. How do you relax?


82
STANDARD CONSENT FORM
Subject:_ Date:
I authorize the performance upon _
the following treatment: the subject's forehead muscle tension will be monitored through the use of electromyograph equipment, and the information made available to the subject via auditory feedback. The subject will be encouraged to lower his degree of muscle tension. In addition, he will receive a series of relaxation exercises recorded on cassette tapes, to be played and practiced at home. Repeated measures of his blood pressure will be made by a competent examiner using a cuff sphygmomanometer and Littman stethoscope.
The nature and purpose of this treatment, possible alternative methods of treatment, the risks involved, and the possibilities of complications have been explained to me verbally and in writing by _.
I fully understand that the procedure or treatment to be performed is experimental and not routine medical treatment. I also understand that I may not benefit from the treatment and that the consequences are not completely predictable. Furthermore, it is agreed that the information gained from these investigations may be used for educational purposes which may include publication. I understand that I may withdraw my consent at any time.
SIGNED_
WITNESS_
I, the undersigned, have defined and fully explained this treatment procedure to the above individual.
SIGNED_
The proposed research has been approved by the Health Center Committee for the Protection of Human Subjects. If you have any further inquiries, they may be addressed to the Investigator or to the Committee for the Protection of Human Subjects, c/o Dean of the College of Medicine for the Health Center.
Attachment A


83
DESCRIPTIVE CONSENT FORM
Title: LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION UTILIZING BIOFEEDBACK AND RELAXATION TRAINING.
The subject will be taught techniques of deep muscle relaxation through the use of biofeedback and relaxation exercises. It is expected that the elevated blood pressures associated with essential hypertension will be reduced as a function of deep relaxation. It this is demonstrated to occur, the harmful effects of sustained elevated blood pressure will diminish.
Repeated measures of blood pressure will be made, and, should the reading indicate an increase over the baseline measurements, a physician will be consulted before the subject will be allowed to continue in the treatment.
I have read and understand the above described treatment procedure in which I am to participate and have received a copy of this description.
SIGNED:
WITNESS:
INVESTIGATOR:
Attachment B


84
Subject_
BLOOD PRESSURE DATA SHEET
SD SD SD SD I. Baseline Measures: 1) a, b, c,
2) a, b, c,
3) a, b, c,
Systolic (S) Diastolic (D)
II. Treatment Measures:
Treatment
Week Session
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, c,
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, c,
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, c,
1 a, b, c,
2 a, b, c,
3 a, b, c,
4' a, b, c,


85
II. Treatment Measures, con't. Treatment
Week Session SD SD SD SD
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, c,
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, Pi
1 a, b, c,
2 a, b, c,
3 a, b, c,
4 a, b, c,
1 a, b, c,
2 a, b, c,
5 a, b, c,
4 a, b, c,
III. Post Treatment Measures:
1) a, b, c,
2) a, b, c,
3) a, b, c,
Systolic Diastolic _
CHANGE SCORES: Systolic Diastolic


86
Subject_ Group
Practice Record Chart Week Day I
A.M._ Did not complete
Fully attentive_ Mostly attentive_ Little attention_
Very tense_ Moderate tension_ Little tension_
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
P.M._ Did not complete_
Fully attentive_ Mostly attentive_ Little attention_
Very tense_ Moderate tension_ Little tension_
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
Day II
A.M._ Did not complete
Fully attentive_ Mostly attentive_ Little attention_
Very tense_ Moderate tension_ Little tension_
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
P.M._ Did not complete__
Fully attentive_ Mostly attentive__ Little attention_
Very tense_ Moderate tension_ Little tension_
Mood: happy Appropriate_ Depressed_
Describe any feelings of unexpected bodily sensations that occurred during the practice session_
Day III
A.M._ Did not complete
Fully attentive_ Mostly attentive_ Little attention_
Very tense_ Moderate tension_ Little tension_
Mood: happy Appropriate_ Depressed_
Describe any feelings of unexpected bodily sensations that occurred during the practice session_


Day III (con't.)
P.M._
Fully attentive
Very tense_
Mood: happy_
Did not complete
Mostly attentive Moderate tension Appropriate_
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
Day IV
A.M.
Fully attentive Very tense_ Mood: happy
Did not complete
Mostly attentive Moderate tension Appropriate_
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
P.M._
Fully attentive Very tense_ Mood: happy
Did not complete
Mostly attentive Moderate tension Appropriate_
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
Day V
A.M.
Did not complete
Fully attentive
Very tense_
Mood: happy_
Mostly attentive Moderate tension Appropriate_
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
P.M._
Fully attentive Very tense_ Mood: happy
Did not complete
Mostly attentive Moderate tension Appropriate__
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
Day VI
A.M._
Fully attentive
Very tense_
Mood: happy_
Did not complete
Mostly attentive Moderate tension" Appropriate_
Little attention
Little tension_
Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_


88
Day VI (con't.)
P.M._ Did not complete_
Fully attentive_ Mostly attentive_ Little attention
Very tense_ Moderate tension_ Little tens ion
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
Day VII
A.M._ Did not complete
Fully attentive_ Mostly attentive_ Little attention
Very tense_ Moderate tension_ Little tension_
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
P.M._ Did not complete_
Fully attentive_ Mostly attentive_ Little attention
Very tense_ Moderate tension_ Little tension_
Mood: happy_ Appropriate_ Depressed_
Describe any feelings or unexpected bodily sensations that occurred during the practice session_
What feelings are you aware of just prior to the practice sessions ?_
What feelings often occur at the conclusion of the practice sess ion?
What events have occurred in your life (during this week) to which you have reacted with increased tension?_
How have you behaved during this week that has produced feelings of deep relaxation? Describe your behavior_
Use reverse side for any additional comments.
Thank you for your cooperation.


APPENDIX B STANDARD INSTRUCTIONS


90
Instructions for Volunteers
The purpose of this study is to look at the actual effects of a new treatment approach on the reduction of blood pressure. We will need volunteers with high blood pressure who also meet certain other criteria that are determined by the experimental design of the study. Everyone who participates will be required to have the consent of his physician, and will continue to take his prescribed medication on a regular basis during the duration of the experimental treatment. Our study will attempt to lower blood pressure by teaching you how to relax your muscles.
After you have completed the forms and questionnaires, we will select certain individuals and assign them to a specific treatment schedule. It is important that you fully understand what you will be required to do before you will know if it is possible for you to participate. Are there any questions so far?
After we go over the data that you are completing now, we will notify you if we will use you in the study, and ask you to return for two more preliminary sessions before your treatment will be initiated. Next time you will fill out some additional questionnaires, and have your blood pressure measured. In the last preliminary session, the principles of biofeedback will be explained, and you will have a chance to try out the equipment. There will be some relaxation exercises for you to do at your home or office, twice a day.


91
This will require that you have access to a tape player that will handle tapes like these (show cassette tape) and that you have a quiet place in which to lie down and do them. You will be required to attent a training session using the biofeedback equipment either once of four times a week, depending on the group that you get assigned to. The biofeedback laboratory is located at North Florida Regional Hospital where you will find ample parking space.
In order to keep the study free from the unknown effects that each of you might have upon the other, in terms of enthusiasm or motivational level, we ask that you do not discuss your treatment schedule or any other aspects of the study with each other. When it is concluded, we will have a big party, and we can talk about our experiences then.
If you are not selected to participate, it does not mean that this treatment approach could not be of help to you in reducing your blood pressure, but rather that we have enough individuals in your age range with the same blood pressure level. All of you will be informed of the results of this study when it is completed and the data are analyzed.
When you have completed the forms, please go to the bathroom, empty your bladder, and return to your chair so that my
co-worker, Ms._, can record your blood pressure with
this cuff. We will always take it 3 times in succession to get a reliable reading.
Any questions? Thank you. You will hear from us next
week.


9 2
Instructions to Subjects
All of you here today will be subjects in the study, but will not have the same treatment schedule. In order to know more about each of you, we ask that you complete the questionnaire and drawing that are being passed out to you, in folders. Place your name, last name first, on the tab of the folder. All of your records will be coded in order to preserve your privacy. No one will know what your answers are, except me. In return for my promise of confidentiality, I hope that you will feel free to answer as honestly as possible. Any questions?
When you have completed the questionnaires and drawing, please use the bathroom located in the next room. After you empty your bladder, return to your chair.
I am looking forward to our next session so that I can explain the use of the biofeedback equipment to each of you, and give you a chance to operate it yourself. Thank you for coming.


Full Text
LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION
UTILIZING BIOFEEDBACK AND RELAXATION TRAINING
By
JACQUELINE ZURCHER-BROWER ORLANDO
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1974

ACKNOWLEDGEMENTS
My warmest thanks and appreciation to Dr. Robert Strip¬
ling, who chaired my dissertation committee. He provided
appropriate direction and support, yet allowed me to feel
that this undertaking was fully my own.
I am eternally indebted to Dr. Joseph Cauthen for pro¬
viding the setting in which to carry out the study, and for
his sensitive guidance and caring.
I am grateful to Dr. William Love, whose research in the
area launched me into my own study. Dr. Franz Epting and
Dr. E. L. Tolbert also provided assistance for which I am
deeply appreciative.
Additional thanks to those who directly assisted me in
completion of the study: Paula Saraga, John Butter, Lois
English, Susan Edell, Judy Foote, Kate Bury, Tay Tanya, Dr.
Betty Horne, and Mary Ganikos.
I appreciate the continuing encouragement of my children,
Michael and Kristine, and friend, Vernon Van De Riet.
n

TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS ii
LIST OF TABLES v
ABSTRACT vi
CHAPTER
I INTRODUCTION 1
Review of the Literature â–  4
Relaxation Training as a Method of Self-
Regulation of Some Cardiac Functions 5
Feedback Training as a Method of Self-
Regulation of Blood Pressure 8
Direct Control of Blood Pressure
Through Instrumental Conditioning .... 8
Indirect Control of Blood Pressure
Using Deep Relaxation 10
The Moeller and Love Research Study;
Techniques, Design, and Outcome 11
Summary of the Review of Literature .... 16
Psychological States Associated with Self-
Control and Instruments of Assessment .... 16
Measurement of Feelings of Volition .... 17
Psychological Changes Associated with
Self-Regulation 20
Measurement of Psychological State
Changes 21
Descriptions of Certain Psychological
Processes Associated with Increased
Self-Regulation 23
Equipment Utilized in the Study 24
Purpose of the Study 26
Hypotheses 27
Exploratory Questions 27
ii i

TABLE OF CONTENTS - Continued
CHAPTER Page
II DESCRIPTION OF THE STUDY 29
Methodology 29
Instruments 30
Subjects 32
Procedures 32
Phase One 33
Phase Two 34
Phase Three 37
Phase Four 38
III RESULTS 39
Limitations of the Study 39
Dropped Subjects . 40
Hypotheses 40
Exploratory Questions 47
IV DISCUSSION 60
Exploratory Questions 63
Suggestions for Future Research 68
LIST OF REFERENCES 70
APPENDIX
A FORMS 79
B STANDARD INSTRUCTIONS 90
C TESTS 95
D LETTERS 10 5
BIOGRAPHICAL SKETCH 108
IV

LIST OF TABLES
Table Page
1 Means, Standard Deviations, and the Analysis
of Variance Summary for the Change in Systolic
Blood Pressure Among Groups X, Y, and C .... 41
2 Results of Tukey Multiple Comparison Test of
Significance of Mean Systolic Blood Pressure
Change Between Groups X and Y, X and C, and
Y and C 41
3 Means, Standard Deviations, and the Analysis
of Variance Summary for the Change in Dia¬
stolic Blood Pressure Among Groups X, Y, and C . 42
4 Results of Tukey Multiple Comparison Test of
Significance of Mean Diastolic Blood Pressure
Change Between Groups X and Y, X and C, and
Y and C 42
5 Means of Groups X and Y on Systolic Blood
Pressure Measures Over the Six-Week Treatment
Period 45
Means of Groups X and Y on Diastolic Blood
Pressure Measures Over the Six-Week Treatment
Period 45
6 Means, Standard Deviations, and Analysis of
Variance Summary Table for Scores on the I-E
Scale Among Subjects in Group X, Group Y, and
Group C as Achieved During the Posttesting
Session 47
7 Means, Standard Deviations, and Analysis of
Variance Summary Table for Scores on the Hy
and D Scales of the MMPI Among Groups X, Y
and C as Achieved During the Posttesting
Session 48
8 Chi-Square Analysis for Experimental and
Control Groups on Projective Drawing Ratings . . 49
v

Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION
UTILIZING BIOFEEDBACK AND RELAXATION TRAINING
By
Jacqueline Zurcher-Brower Orlando
August, 1974
Chairman: Robert Stripling
Major Department: Counselor Education
This study investigated the effects of biofeedback (elec¬
tromyograph) and relaxation training on the blood pressures
of individuals with chronic essential hypertension. One aim
was to illuminate any differences between the effects produced
by two treatment schedules. A second goal was to probe various
personality characteristics which are associated with increased
self-regulation. A third purpose was to explore the subjects'
responses to the procedure in order to develop a clinically
efficient treatment, study the reported changes in the sub¬
jects' coping strategy and life styles, and clarify the psycho¬
logical process whereby the physiological changes occurred.
Thirty individuals with chronic essential hypertension
were assigned to one of two experimental groups or to a con¬
trol group for a six-week period. One experimental subgroup,
Group X, was scheduled to participate in four biofeedback
sessions per week in a hospital setting. The other experimen¬
tal group, Y, received one biofeedback session per week. The
vi

control group, C, received no biofeedback and no relaxation
training as part of the study, and were told that they would
receive biofeedback and relaxation training at the completion
of the treatments of the subjects in Groups X and Y. In addi¬
tion, subjects in Groups X and Y were to complete a session
of autogenic training and progressive relaxation outside of
the laboratory once a day on days that they received biofeed¬
back and twice on the days when no biofeedback session was
scheduled.
The results indicated that the treatment received by
Group X was not statistically significant in reducing systolic
blood pressure but was significant at the <.05 level in reduc¬
ing the diastolic blood pressure. The mean systolic decrease
of Group X was 4.2 mm Hg and the mean diastolic decrease was
1.5 mm Hg. In contrast, Group Y sustained systolic and dia¬
stolic blood pressure decreases that were statistically sig¬
nificant at the <.05 level. Group Y showed a mean decrease
of 6.3 mm Hg in systolic measures and 9.5 mm Hg in diastolic
measures.
Three licensed physicians evaluated the outcome and con¬
cluded that the treatment received by Group X failed to pro¬
duce sufficient reduction in blood pressures to be clinically
significant. However, the treatment received by Group Y did
produce clinically significant decreases and was judged to
have practical usefulness in the reduction of essential hyper¬
tension .
vi 1

Participation in the experimental treatment failed to
produce personality changes that were statistically signifi¬
cant at the .05 level as measured by the Internal-External
Scale, the Draw-A-Person test, and the Hy and D scales of the
Minnesota Multiphasic Personality Inventory.
In general, the subjects had few complaints concerning
the treatment procedure, said they felt better, and reported
that they had more desirable behavior patterns as a result of
participation in the study. In addition to changes in blood
pressure, subjects said they had fewer headaches, less insomnia,
reduction in allergic reactions, decreased smoking and alcohol
consumption, less prescribed medication and less nail-biting.
They said that they increased in the ability to tolerate
"stress," to avert tension in the skeletal muscles, and to
alleviate lower back pain. Several subjects reportedly im¬
proved interpersonal relations, achieved greater sexual satis¬
faction, and gained a more tolerant attitude toward self and
others.
The majority of the subjects said they achieved skeletal
muscle relaxation following increased awareness of the kines¬
thetic sensation of tension, combined with the passive sugges¬
tion of autogenic phrases like "limp" and"heavy." Other sub¬
jects reported they achieved a relaxed state by having a
"blank" mind.
viii

CHAPTER I
INTRODUCTION
The concept of feedback is as old as the earliest form
of biological evolution and is found at all levels of organi¬
zation, from intracellular processes to social communication.
The term "feedback" is of relatively recent origin, coined by
pioneers in radio in the early 1900's [Karlins and Andrews,
1972]. Mathematician Norbert Wiener [1971] describes
feedback as a method of controlling a system by reinserting
into it the results of its past performance.
In psychotherapy the use of informational feedback is a
central component, and its use is increasing with the emer¬
gence of many new treatment approaches. Behavior therapy;
sensitivity, encounter, and Gestalt group therapies; and the
video therapies, as well as training models for therapists,
all make available to the patient some forms of augmented
feedback that provides the means whereby he can gain new
awareness about his own behavior [Lazarus, 1967 ; Rogers,
1951; Peris, 1969; Campbell and Dunnette, 1968; Carkhuff and
Berson, 1967]. The informational feedback exists in a
variety of forms such as the reactions of others to the
patient's feelings and actions and the behavior manifested
in the video-tape replay of patient-therapist interaction.
1

In a similar way, more refined techniques are being
developed for providing an individual with feedback for
2
specific internal bodily processes which enables one to modify
what were once considered involuntary, or autonomic functions
such as penile erection [Laws and Rubin, 1969]; heart rate
[Hnatiow and Lang, 1965], brain waves [Kamiya, 1969], urine
formation [Lapides et_ ad., 1957], salivation [Frezza and
Holland, 1971], and blood pressure [Moeller and Love, 1972].
Once a person can "see" his heartbeats or "hear" his brain
waves, he has the information he needs to begin to control
them. Depending upon the theoretical bias of the experimen¬
ter, the knowledge of results may be viewed as reinforcement,
as in the operant conditioning paradigm, or as information.
Regardless of the framework used to describe the process, the
introduction of the psychophysiological feedback loop makes
possible voluntary control over a variety of physiological
events. This process serves as an added tool for the profes¬
sional counselor to use in helping the individual take respon¬
sibility for his own behavior and its consequences. The cur¬
rent developments in methodology for enhancing voluntary con¬
trol of internal states is perceived by many writers to be
of importance [Mulholland, 1973; Hart and Tomlinson, 1970;
Davidson and Krippner, 1971]. Such techniques enable man to
identify his organismic needs and move from environmental
support toward self-support.
The psychophysiological feedback principle, commonly
called "biofeedback," is something like an internal mirror.

3
Its core lies in the detection of a physiological event and
the conversion of the event into an electronic signal so
that the subject can be immediately and continuously aware
of the relative level or intensity of the event. Awareness
of the psychological state associated with the variation in
level makes possible the indirect control of the physiological
event itself as the individual learns how the sensation and
the event are related within himself. For example, as an
individual becomes aware that his arm is feeling heavier and
warmer due to vasodilation, he is being informed through the
biofeedback apparatus that the muscle motor units are firing
less often and the muscles in his arm are becoming increasingly
relaxed [Basmajian, 1963].
The utilization of biofeedback in clinical practice
requires an understanding of the interrelationships that
exist between and among bodily functions and psychological
states, with each individual viewed as a unique entity, dif¬
fering from all others in autonomic specificity [Swartz,
1973]. Situations may evoke different patterns of response
in each person [Lacey, 1967; Lang, 1970]. With regard to
complex states such as anxiety and fear, it becomes important
to determine what patterns of functions occur in the individ¬
ual patient. Feedback must be selected and scheduled so as
to optimize its integration with the problem in question,
thus enhancing its therapeutic value.
This study will examine the effects of a biofeedback
relaxation-training therapy when used with patients having

4
chronic elevated blood pressure of unknown etiology called
"essential hypertension." Recently, essential hypertension
has been brought to the attention of the public as a complex
and dangerous condition which can shorten life significantly.
It apparently results, in many cases, from the interaction of
the person and his environment, together augmenting or pro¬
ducing the bodily dysfunction [Pickering, 1968]. Antihyper¬
tensive drugs are effective for some. For others, treatment
with drugs is not satisfactory in that the hypertension fails
to be reversed or the drugs produce undesirable side effects.
A procedure not requiring the use of drugs, or as an ancil¬
lary treatment to drug therapy, is needed [Pickering, 1968;
Datey ejt al_. , 1969] .
Review of the Literature
During the last ten years, an increasing number of arti¬
cles on the topic of operant conditioning and establishment
of self-control of cardiovascular processes in humans has
appeared in the literature. Swartz [1973] reported that over
250 papers had been published on the use of operant feedback
techniques in the control of physiological processes. The
Aldine Press has reprinted much of this work in four volumes,
with an additional volume planned for each succeeding year
[Barber et al. , 1971; Kamiya ert aJ. , 1971; Stoyva et_ al_. ,
1972; Shapiro e_t aJ. , 1973]. Blanchard and Young [1973] re¬
viewed the research in the area of operant conditioning or
self-control of four cardiac functions, heart rate level,

s
heart rate variability, blood pressure, and cardiac arrhythmias.
The purpose of this survey of the literature is to review
alternatives to drug therapy in the control of blood pressure,
particularly with the combined use of relaxation training and
biofeedback in human subjects. As the literature suggests,
the application of learning concepts such as differentiation
and reinforcement enables the counselor to assist an individ¬
ual in regulating his internal behavior. By becoming aware of
the psychophysiological process involved in producing an un¬
desirable physical condition, one can choose not to produce
the condition in one's self. Currently, behavioral and human¬
istic counselors and psychologists are developing clinical
treatment programs for tension and migraine headaches, insomnia,
subvocalization, cerebral palsy, epilepsy, Raynaud's disease,
and contraception [AHP, 1973].
Relaxation Training as a Method of
Self-Regulation of Some Cardiac Functions
The use of progressive relaxation, as developed by Jacob¬
son [1938], and the use of various Yoga exercises [Datey e_t al. ,
1969] and other forms of meditation have produced a significant
degree of change in cardiac and related functions. In 1939
Jacobson reported the effects of training on blood pressure.
His relaxation process focused on the relaxation of various
sets of muscles in a. systematic manner until the entire system
was relaxed. He concluded that there is a general relation¬
ship between decreases in blood pressure and decrease in
muscle activity, as shown by the electromyogram, and that

6
training in progressive relaxation results in greater de¬
creases in electromyogram activity than self-induced relaxa¬
tion without training.
Paul [1969] reported on physiological changes in college-
age females who were treated with (1) a brief form of pro¬
gressive relaxation training, (2) hypnosis induction and
suggestions on relaxation, or (3) self-instructed relaxation.
The progressive relaxation group showed significantly greater
changes in heart rate than the other two groups.
Datey et al. [1969] combined muscle relaxation with
breathing exercises in treating 47 hypertensive subjects. A
specific Yoga technique called "Shavasan" was employed which
enabled the subject to become increasingly alert inwardly
and less conscious of the external environment, thus facili¬
tating greater relaxation. Datey reported that in Group I
(10 patients) who took no drugs, the average mean blood pres¬
sure of 134 mm Hg was reduced to 107 mm Hg, an average reduc¬
tion of 27 mm Hg. This was statistically significant at the
.05 level. In Group II (22 patients) who were controlled
with drugs, the average mean blood pressure was 102 mm Hg and
was not reduced. For the 15 patients in Group III whose
blood pressure was not adequately controlled by drugs, a
reduction in average mean blood pressure from 120 to 110 mm
Hg occurred.
Schultz and Luthe [1969] attempted to aid subjects in
becoming more aware of their proprioceptive sensations in
addition to increasing muscle relaxation. These authors

7
formulated a series of specific exercises which develop mus¬
cle relaxation and increase peripheral blood flow and reac¬
tive vasodilation in the subject. The approach, called
"autogenic therapy," was utilized with a group of hyperten¬
sives by Klumbies and Eberhardt [1966] . Blood pressure read¬
ings were taken at various intervals during the four-month
study. The greatest decrease in systolic and diastolic pres¬
sures occurred in the first month of training and was attrib¬
uted to the effects of the autogenic training.
Although many claims of phenomenal degrees of self-
control among Yogis had been made, few data were collected
until Wenger and Bagchi [1961] made autonomic recordings from
over 50 Yogis in India. They concluded that changes in blood
pressure and cardiac functioning were due to vagal innerva¬
tion, not through control of striated muscle.
Wallace [1969] studied the effects of transcendental
meditation, as taught by the Maharishi Mahesh Yogi, and found
an average decrease of five beats per minute in five subjects
who were measured for heart rate. In a later study, Wallace
et al. [1971] found significant changes in electroencephalo¬
gram and oxygen consumption in transcendental meditators,
comparing the meditation period with the 30 minutes preceding.
These studies suggest that autogenic training, progres¬
sive relaxation, Yoga, and other forms of exercise meditation
can have important clinical application in the field of self¬
regulation. They indicate that certain bodily functions such
as brain waves, oxygen consumption, and some cardiac functions

8
may be regulated through changes in muscle tension and respi¬
ration.
Feedback Training as a Method of
Self- Regulation of Blood Pressure
Information feedback as well as such reinforcers as food
and pleasurable stimulation has been used by researchers to
enable subjects to learn to regulate their electrodermal, elec-
troencephalographic, and electromyographic activity [Shapiro
and Crider, 1967; Kamiya, 1969; Basmajian, 1963]. Numerous
bodily processes, previously considered to be involuntary, such
as salivation [Brown and Katz, 1967; Frezza and Holland, 1971],
heart rate [F.ngel and Melmon, 1968; Hnatiow and Lang, 1965],
and certain vasomotor responses [Snyder and Nobel, 1967] have
been brought under the control of the subject.
Direct Control of Blood Pressure
Through Instrumental Conditioning
The application of biofeedback to the control of blood
pressure requires the use of a suitable blood pressure mea¬
surement and feedback system. Because direct measurement of
pressure requires the surgical insertion of a pressure-
transducing tube into an artery, such a means of measurement
is impractical for routine research with human subjects. It
has been demonstrated, however, that systolic blood pressure
responses can be conditioned directly. Di Cara and Miller
[1968], working with rats, used direct measurements and feed¬
back. The question as to whether humans could also learn to

9
raise or lower their systolic blood pressure, using biofeed¬
back, was approached by Shapiro et_ a_l. [1969,1970]. Using
normotensives with an indirect measurement procedure, he
demonstrated that subjects reinforced for systolic blood
pressure increases were able to raise or maintain their pres
sure, while subjects reinforced for decreases in systolic
pressure were able to lower their pressure.
The Shapiro research raises the issue as to how the sub
jects produced the change. Did change occur as a result of
somatic meditation or cognition, or had operant conditioning
of autonomic activity per se taken place? Miller [1961]
emphasized that this issue is of central importance in under
standing the neurophysiology of learning. Katkin and Murray
[1968] reviewed a number of studies that attempted to demon¬
strate instrumental conditioning of autonomically mediated
behavior. They concluded that the Miller group convincingly
demonstrated the phenomenon with animals. Some work with
human subjects [Johnson and Swartz, 1967; Snyder and Noble,
1968] demonstrated such conditioning "in a manner difficult
to criticize" [Crider e_t aM. , 1969].
The Shapiro study, as well as others, has provided
normotensive subjects with biofeedback of their blood pres¬
sure which led to statistically significant changes in blood
pressure, but these changes were not sustained outside the
experimental setting, without the biofeedback [Benson et_ aM. ,
1971; Brener and Kleinman, 1970].

10
Indirect Control of Blood Pressure
Using Deep Relaxation
When the work of Lisina [1965] , who was reported by
Razran [1961] to have conditioned vasodilation instrumentally
in the Soviet Union, was published in English, it appeared
that she did not claim to have conditioned vasodilation
directly. Lisina concluded that her subjects were able to
gain voluntary control over their blood vessels by "using a
number of special devices, mainly the relaxation of the
skeletal musculature and changing of the depth of respira¬
tion" [1965, p. 456].
In the United States, Harrison and Mortensen [1962] were
the first to demonstrate that the individual motor units in
the skeletal musculature could be voluntarily controlled
through the use of a biofeedback system. A motor unit fires
when an impulse reaches the muscle fibers. Accompanying the
impulse is an electrical potential which, when recorded, is
known as the electromyogram. Basmajian [1963] has extended
the previous finding and demonstrated that subjects can
acquire quite subtle control over individual motor units.
He observed that when subjects learned such specific control,
they were able to produce "various gallop rhythms, drum-beat
rhythms, and roll effect" [p. 341].
Attempting to induce deep relaxation in humans, Green
et al. [1969] trained subjects to achieve zero firing in
large forearm muscle bundles. The results indicated that 7
of 21 subjects were able to achieve the criterion of zero

11
firing within 20 minutes, and they were able to maintain it
for 30 minutes or more.
Budzynski and Stoyva [1969] and Budzynski et_ a[1970]
conducted studies demonstrating feedback control of the fron¬
talis (forehead) muscles and showed that by relaxing this
group of muscles, a person could alleviate tension headaches.
They obtained results demonstrating that the feedback group
evidenced much greater relaxation than the no-feedback and
irrelevant - feedback control groups. The changes in the labo¬
ratory were apparently generalized to everyday life, with
subjects making comments which indicated a heightened aware¬
ness of maladaptive rising tension, an increasing ability to
reduce tension, and a decreasing tendency to overreact to
stress [Budzynski et^ al. , 1970 , p. 210].
The Moeller and Love Research Study;
Techniques, Design, and Outcome
Reasoning that the altered blood pressures in the Sha¬
piro [1969], Benson et_ al_. [1971], and Brener and Kleinman
[1970] studies were not sustained because the human awareness
to sense directly blood pressure level is not very well
developed, Moeller and Love [1972] sought to devise a tech¬
nique directly conditioning a concomitant physiological func¬
tion for which the human body already possessed an efficient
set of proprioceptors. Using muscle tension as a physio¬
logical concomitant for blood pressure, Moeller and Love
[1969] used electromyographic, biofeedback training in con¬
junction with an adaptation of Schultz and Luthe's autogenic

12
exercises and obtained a decrease in both systolic and dia¬
stolic blood pressures. Moeller [1973] further investigated
conditioning muscle relaxation as a concomitant for blood
pressure, using a treatment regimen similar to that used in
his first study. Again, using hypertensive subjects, he
examined the relationships among the variables of muscle ten¬
sion and systolic and diastolic blood pressure during and
following the treatment. Based on this researcher's review
of the literature, it appears that the Moeller study is the
exception to the criticism leveled by Blanchard and Young
[1973] who concluded that the self-control of cardiac func¬
tioning is, for the most part, a "promise as yet unfulfilled."
Blanchard and Young's recent review indicated that (1) changes
in cardiovascular functioning were studied, for the most part,
in normal subjects instead of patients, and (2) the magnitude
of change was related to a statistically significant rather
than a clinically significant magnitude.
Miller had criticized the earlier Moeller and Love study
[1972] for their use of each subject as his own control.
The second Moeller study, discussed more fully below, uti¬
lized both a control group and matched pairs as well as an
increased number of subjects, thus achieving a more defensible
design for studies of this nature. Compared with the work of
Shapiro and his colleagues at Harvard and Brener and Klein-
man, the techniques .devised by Moeller and Love require
longer training but appear to be as efficient in the

13
reduction of the systolic value and superior in the reduction
of the diastolic value. Moeller's second study showed a mean
decrease of 12 mm Hg for the diastolic and 14 mm Hg for the
systolic blood pressures in their pooled treatment groups.
The largest diastolic decrease in the summary of research
presented by Blanchard and Young [1973] indicated a -2.0 mm
Hg mean reduction by Shapiro ejt al_. [1972], and Brener and
Kleinman [1970] reported systolic decreases of -16 mm Hg.
Moeller's use of a control group showed that the decrease
in blood pressure was not due to the habituation of the sub¬
jects to the experimental surroundings. In addition, the
subjects were not differentially affected by the five indi¬
viduals who conducted the treatment. Although previous
research demonstrated that blood pressure can be lowered,
one of the main contributions of the Moeller work is that the
lowered blood pressure response seemed to generalize outside
the experimental setting. This would indicate that feedback
of a concomitant physiological function (muscle tension)
obtained a sustained reduction in blood pressure, whereas
the direct blood pressure feedback used by previous investi¬
gators did not.
Moeller has suggested that the decrease in blood pres¬
sure is due, in part, to the subjects becoming less tense
during periods of stress; thus, the learning of deep muscle
relaxation may be generalizing itself to other situations.
He speculated that the significant decrease in diastolic
pressure may indicate that the peripheral resistance was

14
reduced and the arterioles of the subject may have become less
resistant to the passage of blood. With the tone of the skel¬
etal muscles considered a voluntary function and the smooth,
arteriolar muscles, involuntary, Moeller suggested that both
the voluntary and involuntary functions are merely correlated
measures with the mediating link yet undetected. Since physi¬
cians are more interested in decreasing the diastolic level
which is related to peripheral resistance [Merrill, 1966], the
significance of the diastolic decrease may also indicate that
the Moeller-Love relaxation procedure is of clinical value as
an ancillary to other methods presently being used.
Another issue explored by Moeller was that of the cause
of the decrease in systolic blood pressure produced by relax¬
ation training and a biofeedback approach. Does muscular
relaxation cause lowered pressure, or does a modification
occur in the sympathetic nervous system which causes the
lowered blood pressure? Or are these phenomena one and the
same? Prior to Moeller's second study, little was known
regarding the temporal effects of muscular relaxation and
blood pressure. He found that the highest correlation be¬
tween EMG change lagged two measurement periods (weeks)
behind blood pressure, tending to indicate that blood pres¬
sure change was most greatly associated with the EMG change
that had taken place two weeks previous. Hypothetically,
any changes of the EMG measurements between sessions will be
most highly correlated with the variables of blood pressure
two weeks later, with the benefits of the EMG training

15
maximized at that time. This phenomenon tends to support
Gelhorn's [1970] postulate that modification of the hypothal¬
amic activation occurs through muscular relaxation and lowered
cortical arousal.
In the Moeller study, subjects were assigned randomly
to one of three treatment groups for a four-month period.
The amount of biofeedback and relaxation exercises scheduled
varied among groups. A fourth group served as a control
group, receiving two laboratory sessions per week for four
weeks, without feedback regarding their muscle tension, and
did not receive relaxation exercises to do at home.
In using a multivariate analysis of covariance to exam¬
ine the differential effects of the variation among treatment
groups, an assumption was made of linearity in reduction of
blood pressure. While analysis of covariance takes into
account any difference among groups on the criterion vari¬
ables and, accordingly, adjusts the post - treatment means of
the criterion variables, this statistical procedure is not
appropriate should it become more difficult for subjects to
reduce blood pressure as the blood pressure level approaches
the normal range. The data analysis showed no significant
differences between the treatment groups; however, the initial
difference between the means of the groups was sizable.
This could, with a curvilinear relationship, fail to show a
difference among groups when, in fact, differences attribut¬
able to the varied treatment schedules did exist. While

16
raised in the Moeller study, the question of the effect of
different schedules in treatment has not been adequately
answered.
Summary of the Review of Literature
The literature reviewed above suggests that elevated
blood pressure of unknown etiology can be reduced through
relaxation training. While it has been demonstrated that
blood pressure can be conditioned directly through the use
of reinforcement in the laboratory, the reduction cannot be
sustained. The relaxation training method comprised of bio¬
feedback of muscle tension, autogenic techniques, and the
progressive relaxation approach appears to generalize out¬
side of the training sessions and permits a sustained reduc¬
tion in blood pressure.
Psychological States Associated with
Self-Control and Instruments of Assessment
Often there seems to be a change in one's psychological
state concurrent with biofeedback training [Davidson and
Krippner, 1971]. Many authors such as Kamiya [1969], Green
et al. [1970], and Honorton et_ a_l. [1971], have stated that
some of their subjects enter into altered states of con¬
sciousness during training of this kind. In this sense,
the biofeedback paradigm appears to create a closed system
in which the individüal uses volition to control his physio¬
logical processes in the human situation. Green et_ al^. [1970]

17
stated that "it is not possible to define in an operational
way the meaning of the word 'voluntary,' but all of us have
a feeling of voluntary control, at least part of the time.
. [p. 3]. In the training situation, this feeling of
voluntary control is important, because the subject experi¬
ences himself as the locus of control. He is the agent of
change, and only through an act of his own choice is he able
to demonstrate control over his own internal states.
Measurement of Feelings of Volition
This type of self-control would seem to enable people
to become less subject to external control and manipulation
and more inner-directed. Maslow [1962] described one of the
characteristics of the self-actualized person as being able
to resist rubrication. With the application of biofeedback
techniques, one may move toward becoming more resistant to
certain cultural biases and forms of societal conditioning
[Davidson and Krippner, 1971]. The significance of the
belief in fate, chance, or luck has been discussed by various
social scientists over a long period of time. As early as
1899 Veblen wrote that a belief in luck or chance represented
a barbarian approach to life and was generally characteristic
of an inefficient society. More recently, Merton [1946]
discussed the belief in luck as more or less a defense
behavior, as an attempt to serve the psychological function
of enabling people to preserve their self-esteem in the face
of failure.

18
In the field of psychology, White [1959], in discussing
an alternative to drive reduction, noted how the work of
many authors has converged on a belief that it is character¬
istic of all species to explore and to attempt to master the
environment. Angyal [1941] noted also the significance of
the organism's motivation toward autonomy, or the active
mastery of the environment.
The first attempt to measure individual experiences in
a generalized expectancy or belief in external control as a
psychological variable was by Phares [1965]. The James-
Phares scale was broadened and further developed by J. B.
Rotter [1966], He hypothesized that this variable is of
major significance in understanding the nature of learning
processes in different kinds of learning situations, and
also, that consistent individual differences exist among
individuals in the degree to which they are likely to attrib¬
ute personal control to reward.
When a person believes that something occurs following
some action of his own but is not entirely contingent upon
his action, Rotter [1966] has labeled this event as a belief
in "external control." If the person perceives that the
event is contingent upon his own behavior or his own rela¬
tively permanent characteristics, this is termed a belief in
"internal control."
This study utilized the Rotter Internal-External Scale
(I-E Scale) in an attempt to examine the relationship between
locus of control and amount of reduction in blood pressure.
%

19
It is recognized that Rotter's definition and use of "internal
control" is not all that may be included in describing the
experience of personal causation or a feeling of freedom;
however, among the tests in print, the I-E Scale appears to
measure a similar quality. In addition, the difference in
the scores of subjects who receive biofeedback and relaxation
training and those who do not was investigated on the inter¬
nal-external dimension.
The I-E Scale is a forced choice, 29-item test in which
the subject reads a pair of statements and indicates with
which of the statements he agrees more strongly. The scores
range from 0 (the consistent belief that individuals can in¬
fluence the environment and that rewards come from internal
forces) to 23 (the belief that all rewards come from external
forces). Rotter [1966] describes the groups upon which the
test-retest reliability was based. The elementary psychology
student sample used in one of Rotter's standardizations
appears to be most like the subjects in this study, compared
with the other samples he describes. In a one-month retest
with group administration, the elementary psychology student
sample produced a reliability coefficient of .72. Rotter
[1971] described a listing of references using the I-E Scale
in excess of 300, including the well-known Coleman "Report
on Equality of Educational Opportunity." As in the Coleman
report, the clinical, version was used rather than the re¬
search version, for its single score and east in interpreta¬
tion .

20
Psychological Changes Associated
with Self-Regulation
Green et_ al_. [1969] trained subjects to achieve zero
firing in large forearm muscle bundles. They reported that
five of the seven subjects who achieved zero firing rapidly
and sustained it for 30 or more minutes commented that they
had experienced body image changes. In addition to the change
in proprioceptive and internal sensations resulting from the
treatment, the change in feelings toward one's self may be
affected by the training process [Lesh, 1970; Jacobson, 1957;
Assagioli, 1965] .
The Draw-A-Person (D-A-P) was selected for this study to
explore potential body image changes associated with the
treatment process. This method of measuring change in body
image was developed by Machover [1948,1951]. She reported
that her modification of the D-A-P, originally devised by
Goodenough [1926], can be used projectively to assess those
aspects of psychodynamics involved with the self-image and
with body-image. Her assertion was supported by Luthe [1963]
who reported that by using the Drawing-Completion Test he
observed a characteristic pattern of projective changes, such
as progressive differentiation of the projective responsive¬
ness, increase of output, more shading, elaboration of details,
stronger pressure of lines, increase of dynamic features,
better integration and composition of the drawings, less
rigidity, fewer inhibitions, faster performance, and better
adaptations to the different stimuli. He further stated that

21
corresponding changes have been observed in the D-A-P; how¬
ever, the research is not available in English [Luthe, 1958].
The literature on projective techniques links the term
"projective" with the psychoanalytic mechanism of projection,
as well as the dictionary sense of the word, namely, to pro¬
ject (as a cartographer might project) an almost physical
extension of psychological attributes [Wolman, 1965]. From
Lowenfeld's work [1947] it appears that there are basic dif¬
ferences among individuals with respect to the predominance
of (1) the projection of body needs and conflicts and (2) the
role of visual, objectively determined stimuli in the forma¬
tion of the subject's body image. If so, the product cannot
be interpreted in the same manner for all individuals. In the
Lowenfeld study, each subject was used as his own control.
The Machover method involves a careful and detailed
examination of both the content and the structural and formal
aspects of the drawing, considering the absolute and relative
size of the figure, placement on the page, symmetry, perspec¬
tive, type of line, shading, and erasures. In evaluation,
considerable attention is paid to the overall mood or tone
conveyed by the figure through facial expression and postural
attitude.
Measurement of Psychological State Changes
Many writers [Bibring, 1953; Alexander, 1939; Hill,
1935] related psychological states such as depression and

22
hypochondriasis with physical disease or disorders. Budzynski
et al. [1970] stated that patients, after completing the
training program, reported (1) a heightened awareness of mal¬
adaptive rising tension, (2) an increasing ability to reduce
such tension, and (3) a decreasing tendency to overreact to
stress. His work suggests that the subjects increased feel¬
ings of self-control will generalize into their everyday life,
should they increase feelings of self-control.
This study explored the relationship between reduction
in blood pressure through learned self-regulation and the
level of depression and hypochondriasis as measured by two
scales on the Minnesota Multiphasic Personality Inventory
(MMPI) . The SIMP I is a widely-used, well-standardized instru¬
ment designed for personality assessment [Hathaway and
McKinley, 1951]. It is comprised of 550 statements covering
a wide range of subject matter, from the physical condition
to the morale and social attitudes of the individual being
tested. The subject is asked to sort the statements into
three categories: true, false, and cannot say. His responses
yield scores on four validity scales and nine clinical scales.
The original normative data were derived from a sample of
about 700 individuals representing a cross-section of the
Minnesota population as obtained from visitors to the Univer¬
sity Hospital. In this researcher's opinion, the sampling
was adequate for the. ages 16 to 55 and for both sexes. The
scales were developed by contrasting the normal groups with
carefully studied clinical cases of which over 800 were

23
available from the neuropsychiatric division of the Univer¬
sity Hospital. The chief criterion of excellence was the
valid prediction of clinical cases against the neuropsychi¬
atric staff diagnosis, rather than statistical measures of
reliability and validity. A high score on a scale has been
found to predict positively the corresponding final clinical
diagnosis or estimate in more than 60 percent of new psychi¬
atric admissions.
In considering the question of reliability, the charac¬
teristics of the particular population needs to be considered,
as well as the range of scores within the population. No
data are available on the reliability of the test for non-
hospitalized individuals with essential hypertension. The
reported test-retest reliabilities range from .46 to .91
with normals (covering the basic scales) over a period of
from three days to one year, and cluster about a median of
.76. Gynther and Rogers [1959] consider the MMPI to be the
most carefully constructed and thoroughly researched inven¬
tory available for personality assessment.
Descriptions of Certain Psychological Processes
Associated with Increased Self-Regulation
Few writers have explored the psychological states
associated with electromyographic changes. Murphy [1969]
stated that our language fails to provide labels for many
of our internal processes. He wrote that the feeling, cog¬
nitive, and volitional states will lead to alterations in

2 4
States of consciousness, well-known to the East, upon which
"human destiny almost literally may depend" [p. 523]. An
open-ended interview at the conclusion of the treatment
provided the subjects with an opportunity to describe their
own subjective experiences during the treatment period. The
interviewer recorded the verbal behavior of the subject dur¬
ing the termination interview. A summary of the data is
presented in the chapter reporting results of this study.
Within the interview itself, an interview technique,
described by Kahn and Campbell [1966], was utilized, which
combined Roger's "reflection of feelings" with the use of
specific questions in order to assist the subject in clari¬
fication of his own response and attitude toward aspects of
his participation which he will not have thought much about.
The primary focus of the research was upon the effective¬
ness of learned self-regulation in the reduction of essential
hypertension. Previous research literature seems to suggest
the importance of understanding the subjective experience of
the subject and the psychophysiological mediation process.
The scope of the study included an exploratory investigation
of the latter.
Equipment Utilized in the Study
A portable EMG feedback system built by Bio-Feedback
Systems, Inc., Boulder, Colorado, was used to provide

25
electromyographic information to the subjects. The equipment
was made available to the experimenter through the Department
of Clinical Psychology, University of Florida, and is con¬
sidered to be suitable for its intended purpose by Love
[personal communication, 1973], a researcher in the clinical
use of biofeedback at Nova University. According to the manu¬
facturer, model PE-2 is designed to provide accurate and mean¬
ingful feedback of surface EMG levels as low as 2 microvolts.
The PE-2 fulfills all of the requirements of an EMG-sensitive,
noise-insensitive device. The electrode leads are housed in
a low-noise cable, the pre-amplifier has a high input impe¬
dance and high common-mode rejection, a sharp high-pass filter
removes signals below 95 Hz, and the equivalent noise gener¬
ated by the pre-amplifier semi-conductors is quite small,
2 microvolts peak to peak. When the battery level fell below
an acceptable level of output, new batteries were installed.
Auditory feedback is provided in the form of a series of
clicks. The repetition rate of the clicks is proportional to
the EMG level. Thus, as the EMG level rose, the click rate
increased. The frequency of the clicks can vary from below
1 per second to approximately 100 per second. The subject is
instructed to produce a slow click rate, signifying a low EMG
level. The experimenter recorded the visual meter reading at
one-minute intervals throughout the biofeedback session.
A KTK brand cuff sphygmomanometer and Littman stetho¬
scope were used in blood pressure measurement.

26
Purpose of the Study
Advances in technology and the appropriate application
of learning theory make it possible to explore needed therapy
approaches for the treatment of those afflicted with essen¬
tial hypertension (elevated blood pressure of unknown eti¬
ology). The significance of this study is noted when one
considers the impact of chronic hypertension on the quality
and duration of the life of an individual. Sustained blood
pressure elevation often becomes associated with cardiac,
cerebral, and renal functional impairments, as well as vas¬
cular complications. Drug therapy is often an unsatisfactory
approach in handling the subject in treatment as indicated
previously.
The purpose of this study is to assess the effectiveness
of a psychophysiological approach, biofeedback relaxation
therapy devised by Moeller and Love [1972], for the reduction
of blood pressure in subjects with chronic essential hyper¬
tension .
The Moeller study [1973] utilized a four-month treatment
schedule, in contrast to this treatment schedule which is
applied on a short-term, six-week basis. In addition to com¬
paring the effectiveness of two 6-week treatment schedules in
reducing blood pressure, the study examined the subjective
responses of the subjects to the treatment procedure and the
perceived changes within themselves as a result of the treat¬
ment. Obtaining such information did assist in making further
clinical refinements in the therapy approach.

27
The literature indicates that the Moeller-Love treat¬
ment surpasses any other nonpharmacological treatment for
essential hypertension in terms of the following clinical
considerations: (1) amount of decrease in systolic and dia¬
stolic blood pressure, (2) generalization outside of the
experimental setting, and (3) feasibility for use in a clin¬
ical setting. In working toward greater efficiency in treat¬
ment, it is important to determine the changes produced by
different treatment schedules and to observe the reactions of
the subject to the treatment procedure as well as to the
changes he perceives as a result of the treatment.
Hypotheses
1A.
There will be no
changes on blood
Groups X, Y, and
significant difference in
pressure measures among
the control group, C.
IB. There will be no clinically significant
difference in changes on blood pressures
among Groups X, Y, and the control group, C.
2. There will be no significant relationship
between the scores of subjects in the treat¬
ment groups on the I-E Scale and amount of
reduction in blood pressure.
3. There will be no significant difference
among scores on the I-E Scale achieved by
subjects in Groups X, Y, and C.
Exploratory Questions
1. Do scores on the Hy and D scales of the MMPI
differ between the subjects in Groups X and
Y as compared with Group C, at the conclusion
of treatment?

28
2.Will ratings of positiveness of body image as
measured by the D-A-P test differ between
Groups X and Y compared with Group C at the
conclusion of treatment?
3.What aspects of the treatment affect the
subject in a negative manner?
4.Does self-regulation of blood pressure affect
the way in which a person views his external
environment with respect to his coping strategy
of life style?
5.
How does a subject describe
process by which he effects
the psychological
muscle relaxation?

CHAPTER II
DESCRIPTION OF THE STUDY
Methodology
In order to assess the effectiveness of a biofeedback
and relaxation training approach devised for the reduction
of blood pressure in hypertensive individuals, 30 subjects
were selected from a group of screened volunteers and
assigned to one of three groups for the duration of the study
Groups X and Y received relaxation exercises to be done twice
daily outside of the treatment laboratory. In addition,
Group X received biofeedback four times weekly, and Group Y,
once weekly. Group C, serving as a waiting-list control
group, participated in the pre- and post-measures, but
received no biofeedback sessions nor relaxation training.
All subjects continued prescribed drug therapy. The data
collected on subjects for whom the dosage was increased or
changed in kindwerenot included in the statistical analysis
related to the hypotheses, but are presented in the final
chapter, where the broader aspects of the study are discussed
These subjects were allowed to continue in the treatment if
they wished to do so. If the dosage was reduced or discon¬
tinued, the subject remained as part of the study.
29

30
Group C was told that their treatment procedure would
be undertaken at the completion of the treatment of subjects
in Groups X and Y. One limitation of the study was that sub¬
jects in Group C may have viewed themselves as though they
were on a waiting-list, rather than in a no-treatment group.
The effect of this status upon the subjects was not determined.
It is the opinion of this researcher that the expectation of
no treatment following the sessions of baseline measurements
and pretesting would be a source of frustration to the sub¬
jects. The literature suggests that hypertension may be
related to emotional stress [Harris et_ al. , 1953] . In view
of the existing hypertensive states of the subjects, it was
desirable to assist the subjects in the maintenance of psycho¬
logical comfort insofar as possible by providing the expected
treatment. In addition to the preliminary baseline data-
gathering sessions and treatment, postmeasures were made dur¬
ing the last week of treatment and in a termination session.
Ins truments
Two types of data were collected. The physiological
measures of blood pressure taken with a cuff sphygomomanometer
and stethoscope were made by trained examiners with no in¬
volvement in the outcome of the study. Their competency was
approved by a licensed physician. The psychological measures
and ratings were secured through scores achieved on Rotter's
I-E Scale, the D-A-P, and scales Hy and D of the MMPI. The

31
contrast in the formats of the, tests served to reduce the
possibility of boredom. In addition, an information-gather¬
ing interview provided descriptions of the subject's subjec¬
tive response to the treatment.
A psychologist examined the D-A-P drawings of each sub¬
ject and judged whether the postdrawing, relative to the pre¬
drawing, appeared to reflect a more "positive" body image.
The ratings were made blind, with the criteria listed pre¬
viously for use in making the global judgement. This rating
technique is a modification of the scoring technique employed
by Machover. The I-E Scale and MMPI subscales were adminis¬
tered during the posttreatment session and scored according
to the standard procedures for each test.
The termination interview was developed by the experi¬
menter in order to assess the subject's response to partici¬
pation in the study. An attempt was made to elicit the sub¬
ject's feelings about the treatment procedure including the
training via the tapes and the changes that may have occurred
as a result of successful treatment. In addition, the sub¬
jects were asked to describe the process by which they achieved
lowered muscle tension. The interview was taped with the sub¬
ject's consent. Relevant excerpts were selected and summar¬
ized from the tapes.

32
Sub j ects
The 30 subjects were selected from a pool of volunteers
who had been diagnosed by their physicians as having essen¬
tial hypertension and have been under treatment for that con¬
dition for one or more years. For the purpose of this study,
hypertension was defined as having blood pressures above 140
mm Hg for the systolic value and 90 mm Hg for the diastolic
value [Gressell, 1949].
The subjects were between 18 and 55 years of age. They
were not psychotic, intellectually retarded, or obese, as
determined by the referring physician and the experimenter.
The subjects had been taking the same kind and dosage of drugs
for a period of at least one month prior to the beginning of
the study.
Procedures
The location of the biofeedback laboratory was North
Florida Regional Hospital in Gainesville, Florida. The hos¬
pital's Board of Trustees granted the use of adequate space
to the investigator. The setting was considered appropriate
for the study, as it was air-conditioned, quiet, accessible,
and private.
The study was conducted in a manner consistent with the
standards set forth for research with human subjects by the
American Personnel and Guidance Association, the American
Psychological Association, and the Committee for the Protection

33
of Human Subjects at the J. Hillis Miller Health Center, Uni¬
versity of Florida, Gainesville [Clark, 1967; AGPA, 1961;
APA, 1963; Schultz, 1969]. The first phase of the study
included baseline measurement and testing, the selection of
subjects, and assignment to a treatment or control group.
The second phase was comprised of the actual treatment period
The third phase included posttesting, analysis of the data,
and the exposition of the results of the study. The final
phase was the period during which the subjects in the control
group were given an opportunity to receive the biofeedback
and relaxation exercises.
The following individuals were trained by the experimen¬
ter and provided assistance in the process of baseline mea¬
surement, treatment, and/or posttreatment measurements: Ms.
Estelle Carson, Ms. Sue Edell, Mrs. Judy Foote, Ms. Tay Tanya
Ms. Paula Saraga, Ms. Lois Inglish, and Mr. John Butter.
Phase One
Each individual who volunteered to participate in the
study was screened over the telephone regarding age, weight,
and physical condition. If he or she seemed to be suitable
prospects, an interview was scheduled for obtaining baseline
data.
During the preliminary interview, the demographic form
(Appendix Al) was completed and the "Explanation to Volun¬
teers" (Appendix Bl) provided by the experimenter. Following
this, the subject was instructed to empty his bladder.

34
Returning to the laboratory, his blood pressure was measured
by a trained individual who had no involvement in this study
or its outcome. The competency of the individual to measure
accurately blood pressure was determined by the judgement of
a licensed physician. With the relaxation chair placed in a
position midway between reclination and an upright position,
the subject's left arm was placed horizontally at the level
of the fourth intercostal and the cuff was inflated until the
radial pulse disappeared, thus assuring a true measurement of
the systolic pressure.
After completion of the initial interview and assessment
I
of the pertinent data related to the selection of the subjects,
30 subjects were selected and scheduled for a second session.
During the second session, the subjects were given the
"Instructions for Subjects" (Appendix B2). As subjects com¬
pleted the testing, they were introduced to the biofeedback
equipment and laboratory. At the conclusion of the second
preliminary session the subject was randomly assigned to
Group X, Y, or C.
Phase Two
The experimental procedure for the biofeedback session
in the laboratory was based on the system followed by Love
et al. [197 ]. Love's procedures represent an attempt to
standardize the session in order to eliminate as much varia¬
tion as possible, yet allow for personal interaction between
subject and examiner. Each subject was greeted and conducted

35
to the experimental room. With the experimental chair in an
upright position, the subject's systolic and diastolic blood
pressure was taken three times, as previously described. The
subject's forehead was cleaned with alcohol to remove any skin
oil. Three EMG surface electrodes filled with Beckham elec¬
trode paste were placed approximately one inch apart over the
frontalis muscle of the forehead. Earphones were placed on
the subject's ears and the chair adjusted to the full reclin¬
ing position. The subject was instructed to relax with his
legs uncrossed and his arms on the arms of the chair.
At this time, the experimenter left the subject alone
and went to the control room to monitor the subject's prog¬
ress. The subject's EMG level was monitored for two of the
initial trials without auditory feedback to establish a base¬
line at the beginning of each session. The auditory feedback
was then switched on so the subject could hear his progress.
He received four 5-minute trials with continuous feedback
during which time he relaxed and attempted to reduce the
quantity of auditory clicks. The mean of the final 10 minutes
of feedback was recorded from the meter.
At the beginning of the first session, the loop gain was
set on "low." When the subject achieved a mean score of
approximately 20 microvolts per second for 10 minutes he was
informed that the "gain" would be increased to "medium," mak¬
ing it more difficult for him to reduce his tension level to
the previous low level. Likewise, when he achieved a mean

36
score of 20 microvolts on "medium," the "gain" was increased
to "high" where it remained for the duration of the study.
The subject's blood pressure was measured and recorded.
As the experimenter disconnected the subject from the appara¬
tus, the subject was asked the questions listed on the form
entitled "Conclusion Questions" (Appendix B3). Rather than
discussing the affective reactions of the subject in an un¬
structured manner, this method was selected to minimize and
standardize the amount of verbal interaction between the
experimenter and subject. This procedure was followed for
each scheduled session for the duration of the study.
After the first introductory session, the subject was
given a tape cassette with relaxation exercises recorded on
it and was told to practice twice per day at home or work,
in a relaxed, reclining position, and once on the day that
he was scheduled to receive feedback [Love and Love, 1973].
The *tape consisted of instructions to alternately flex and
relax the muscles of the arms, neck, face, and eyes. In addi¬
tion, he was given a booklet in which to record his daily
performance and feelings related to stress.
After two weeks the subject was given the second tape
in the Love series, with instructions, and was told to
practice as before. The second set focuses on the tension
and relaxation of the foot and leg muscles and the muscles
of the torso. Four weeks after the beginning of the study,
the subjects in Groups X and Y were given a third set of
exercises. The instructions for this

37
set were on a third tape cassette. These exercises integrate
the first two sets and focus on total relaxation. This set
of exercises was the last in the series and was practiced by
the subject for the remaining two weeks of the study.
Phase Three
Following the treatment period, the experimenter col¬
lected the posttreatment data. The D-A-P test, the I-E
Scale, and the Hy and D scales of the MMPI were administered
to each subject. After the test administration was completed,
an interview was conducted by the investigator with subjects
in Groups X and Y. The purpose of the interview was to
assess the response of the subject to the treatment, the pro¬
cedures, and the effect of the treatment on the subject, so
that further modifications can be appropriately made in the
future. The interview was tape-recorded.
O'Conner [1972] advised against the use of change scores
of psychological test scores in his discussion extending
classical test theory to the measurement of change. Like¬
wise , Chronback and Ferby [1970] cautioned against the use of
psychological change measurement. Therefore, a post-only
comparison was made of scores on the MMPI subscales and I-E
Scale. As explained earlier, it was necessary to use each
subject as his own control in the D-A-P test, which was admin¬
istered both pre- and posttreatment. The median or modal
value of the blood pressure measures made during the final
two treatment sessions was considered the postmeasure of

38
these variables for Groups X and Y. Group C was retested and
measured during an additional session scheduled for that pur¬
pose .
Phase Four
The final phase of the study provided biofeedback and
relaxation training exercises to those subjects in the con¬
trol group, Group C. The subjects were given a choice of the
treatment schedules used for Groups X and Y. At the time of
this writing two control subjects have selected and completed
the treatment schedule assigned to Group Y. Two control sub¬
jects are in the process of completing the Y treatment sched¬
ule. Four control subjects plan to begin the treatment
schedule of their choice in September, 1974, and the remain¬
ing two have moved to other cities.

CHAPTER III
RESULTS
In general, the subjects in the two experimental groups
reported that they felt better as a result of participation
in the study. Approximately three - fourths of them achieved
relaxation by autosuggestion of the desired state, using key
words such as "limp" and "quiet." Criticism was minimal and
usually focused on the amount of time required to participate
and scheduling problems. While the mean blood pressure mea¬
sures of the experimental groups were reduced both systolicly
and diastolicly during the course of treatment, the effects
of the change failed to be manifest on the selected person¬
ality tests when the scores of the experimental groups were
compared with the control group.
Limitations of the Study
There were a few times when subjects missed biofeedback
sessions. No subject missed more than 10% of his appointments.
Whenever a subject did miss a scheduled appointment, the mean
blood pressure measures from the previous appointment and
from the following appointment were averaged and this score
was entered on the data sheet.
The recording tape used to record the termination inter¬
view of subjects at the conclusion of treatment ended prior
39

40
to the interview of two subjects. Because this was not dis¬
covered until the tape was replayed, the termination inter¬
views are incomplete, giving an N of 9 to both experimental
groups. During the initial pretesting session, the investi¬
gator failed to obtain or lost one projective drawing from a
subject in the experimental group and one from a subject in
the control group. Hence, the N used in the chi-square
analysis of the projective drawing was based on a total num¬
ber of 28, rather than the planned 30.
Dropped Subjects
Four subjects who began treatment were dropped from the
data analysis. Two of the four completed the treatment sched¬
ule but increased or changed their medication in kind during
the early weeks of treatment as required by their physicians.
One subject, advised by her physician that she "could expect
no change" by participating in the study, chose to terminate
rather than invest her time. The fourth subject terminated
following a missed appointment on the part of the investigator
due to a scheduling error.
Hypotheses
1A. There will be no significant difference in
changes on blood pressure measures among
Groups X, Y, and the control group, C.
The means of the blood pressure measures of the experi¬
mental and control groups are shown in Tables 1, 2, and 3,
and include repeated measures over time.

41
Table 1
Means, Standard Deviations, and the Analysis of
Variance Summary for the Change in Systolic
Blood Pressure Among Groups X, Y, and C
Group
Pre Means
Post Means
Ch ange
X
153.7
149.5
-4.200
(5.996)
Y
149.3
143.0
-6.300
(5.774)
C
150.7
152.1
1.400
(5.796)
Source
df
MS
F
Between
groups
2
158.4332
4.619*
Within groups
2_7
34.3000
Total
29
*p = .05
Note: The standard deviations are in parentheses.
Table 2
Results of Tukey Multiple Comparison Test
of Significance of Mean Systolic Blood Pressure
Change Between Groups X and Y, X and C, and Y and C
X
Y
C
X Y C
2.1 5.6
2.1 -- 7.7*
5.6 â–  7-7*
*p <.05.

42
Table 3
Means, Standard Deviations, and the Analysis of
Variance Summary for the Change in Diastolic
Blood Pressure Among Groups X, Y, and C
Group
Pre Means
Post Means
Change
X
104.2
102.3
-1.900
-(3.807)
Y
103.5
93.2
-9.500
- (7.590)
C
100.2
101.8
1.600
(2.633)
Source
df
MS
F
Between
groups
2
328.0332
12.450*
Within groups
2_7
26.3481
Total
29
*p = .05
Note: The standard deviations are in parentheses.
Table 4
Results of Tukey Multiple Comparison Test
of Significance of Mean Diastolic Blood Pressure
Change Between Groups X and Y, X and C, and Y and C
X
Y
C
X Y C
8.0* 3.1
8.0* -- 11.1*
3.1 • 11.1*
*p <.05 .

43
The mean systolic and diastolic measures for Group X
were obtained in the following manner: on each measurement
occasion, the systolic and diastolic pressures were taken
twice and recorded in order to provide a modal value. When a
change in the blood pressures occurred between the first and
second measurements, no modal score existed. A third measure¬
ment was then made and the median score, based on the three
measurements, was recorded. The prescore is the arithmetic
»
mean of the modal or median values obtained during the base¬
line measurement sessions. A median or modal value was
obtained at each treatment session and averaged to provide a
weekly mean score. The postscore is the average of the median
or modal values obtained at the last two treatment sessions.
The mean systolic and diastolic measure for Group Y were
obtained in the same manner, except that the mean score for
each week was averaged from the median or modal value taken at
the single treatment session. The postmean is the average of
the means of the median or modal values taken prior to the
final treatment session and at a posttreatment measurement
session.
Whenever a subject missed a treatment session and did
not complete it at a later date, the average between the
median or modal value obtained immediately prior to and
following the missed session was recorded as the value for
that session. The mean premeasures for Group C were obtained
in the same manner as for Groups X and Y. The control group's

44
postmean scores were obtained during the final measurement
sessions scheduled for that purpose.
As shown in Table 1, the analysis of variance indicated
a systolic change among Groups X, Y, and C which was statis¬
tically significant at the .05 level. The Tukey multiple
comparison procedure which provides protection against experi-
mentwise error was used to locate the difference between the
means (Table 2). It was found that Group X does not differ
significantly from Groups C and Y, but that Group Y is sig¬
nificantly different from C. Therefore, the treatment that
Group Y received appears to produce a statistically signifi¬
cant difference in diastolic blood pressure, and an inspec¬
tion of the means shows the change to be a decrease.
In Table 3, the analysis of variance indicates a dia¬
stolic change among Groups X, Y, and C which was statistic¬
ally significant at the .05 level. The Tukey multiple com¬
parison test showed that both groups X and Y were different
from Group C, but not significantly different from each
other (Table 4). As shown, the change is negative and indi¬
cates a decrease in mean diastolic blood pressure. Hypothesis
1A is rejected.
A trend analysis was run on the repeated measures of
blood pressure recorded at weekly intervals for the experi¬
mental groups. The performance of the groups was found not
to parallel over time. The comparisons of the profile analy¬
ses were not relevant because of the lack of parallelism
(Table 5).

mm Hg
45
T ab 1 e 5
Means of Groups X and Y on Systolic Blood Pressure
Measures Over the Six-Week Treatment Period
Weeks
Means of Groups X and Y on Diastolic Blood Pressure
Measures Over the Six-Week Treatment Period
Weeks

46
IB. There will be no clinically significant
difference in changes on blood pressures
among Groups X, Y, and the control group, C.
Three Florida licensed physicians with no involvement
in this study nor its outcome were selected to render their
judgments as to the clinical significance of the reductions
obtained in blood pressure within the experimental groups.
Dave Pawlinger, M.D.; Robert Ashley, M.D.: and W. C. Evans,
M.D., concluded that the treatment received by Group X failed
to produce sufficient reduction in blood pressure to be clin¬
ically worthwhile (Appendix D). The treatment received by
Group Y did result in decreases in blood pressure that were
large enough to have practical usefulness in the management
of essential hypertension. Thus, the clinical worth of the
treatment received by Group Y was confirmed, and Hypothesis
IB is rejected.
2. There will be no significant relationship
between the scores of subjects in the treatment
groups on the I-E Scale and amount of reduction
in blood pressure.
The mean reduction in blood pressure was calculated by
weighting the diastolic measure twice. The Pearson product-
moment correlation of 0.06 did not achieve the magnitude to
reach statistical significance at the <.05 level. Hypothesis
2 has failed to be rejected.
3. There will be no significant difference among
scores on the I-E Scale achieved by subjects
in Groups X, Y, and C.
Analysis of variance of scores indicates that no differ¬
ences among the groups were statistically significant at the

47
<.05 level of confidence; thus, the hypothesis failed to be
rejected. The results are shown in Table 6.
Table 6
Means, Standard Deviations, and Analysis of Variance
Summary Table for Scores on the I-E Scale
Among Subjects in Group X, Group Y, and Group C
as Achieved During the Posttesting Session
Group
Me ans
Standard
Deviations
Standard
Error
X
10.7000
4.4485
1.4067
Y
12.4000
7.2449
2.2910
C
14.800
4.1312
1.3064
Source
df
MS
F
Be tween
groups 2
42.4336
.0257
Within
groups 27
29.7815
Total
29
In addition to the main hypotheses investigated in this
study, five questions of an exploratory nature were examined.
Exploratory Questions
1. Do scores on the Hy and D scales of the MMPI
differ between the subjects in Groups X and Y
as compared with Group C, at the conclusion
of treatment?
Analysis of variance was used to determine if a statis¬
tically significant difference existed among the groups. The
groups were not found to be significantly different from each
other at the .05 level (Table 7).

48
on the Hy and D scales of the MMPI do not statistically dif¬
fer among Groups X, Y, and C.
Table 7
Means, Standard Deviations, and Analysis of Variance
Summary Table for Scores on the Hy and D Scales
of the MMPI Among Groups X, Y, and C
as Achieved During the Posttesting Session
Group
Hy Scale Means
D Scale
Means
X
22.000 (6.5490)
25.000
(4.1096)
Y
21.400 (6.7773)
23.700
(6.9290)
C
23.900 (6.0268)
26.500
(8.8349)
Variable
Source
df
MS
F
Hy
Between groups
2
17.0371
0.6 39
Within groups
27
38.7150
Total
29
D
Between groups
2
19.6348
0.651
Within groups
27
Total
29
Note: The standard deviations are in parentheses.
2. Will ratings of positiveness of body image as
measured by the D-A-P test differ between
Groups X and Y compared with Group C at the
conclusion of treatment?
Dr. Betty Horne, a clinical psychologist with no involve
ment in the outcome of the study, rated the projective draw¬
ings of all of the subjects. The post figure drawing of each

49
subject was judged to be substantially different or not dif¬
ferent from a figure drawing completed in the baseline mea¬
suring session. If "different," then a second judgement was
made as to whether the second drawing was positive (+) or
negative (-) when compared to the first. A chi-square analy¬
sis used to test for proportion showed that the rated differ¬
ence between the drawings of the experimental and control
groups was not statistically different at the .05 level as
shown in Table 8.
Table 8
Chi-Square Analysis for Experimental and
Control Groups on Projective Drawing Ratings
Rating
Control
Experimental
Total
No difference
6
6
12
Negative difference
2
7
9
Positive difference
2
6
8
Total
10
19
29
x2 = 2.4926.
df = 2.
3. What aspects of the treatment affect the
subject in a negative manner?
The taped termination interviews were monitored by Mary
Ganikos, Specialist in Education. Ms. Ganikos is a counselor
and has no involvement in the outcome of the study. She

50
selected excerpts, and summarized the negative aspects of
the treatment as follows:
1. Two subjects complained that the treatment received by
Group X was an imposition and "confining."
2. Six subjects disliked the tapes and felt the instructions
given were not sufficiently clear.
3. One person disliked the required form.
4. Three subjects experienced scheduling problems.
5. The remaining subjects responded idiosyncratically,
suggesting improvements ranging from using a direct, in¬
artery measure of blood pressure to obtaining a greater
number of subjects "because the more you have, the more
you help."
Four subjects spontaneously provided the following infor
mation related to their negative experiences associated with
the treatment procedure. The other subjects were asked to
describe the undesirable aspects so that the procedures could
be improved in the future.
Subject 1. The four times a week may be too much
. . . I remember that the first time I come in each
week it seems more effective, but by the last time
you don't want to sit down so much. Two or three
times would be better, with a day in between. The
tapes were very boring, and I felt resentful, especi¬
ally when it was very late, and instead of going to
sleep I would have to do my exercises.
Subject 2. The tapes don't help me because I'm
not at all ... is the word 'subjective?' Suggest-
able? I'm not at all influenced by words as so many
people are. Words are not emotional. I don't get
so close to them. I didn't use words very well in
speech. I only read. I just have a built-in resis¬
tance towards anything anyone tells me. I figure
ninety-nine percent of the time it isn't so. Nothing
that is told me on the tapes has any influence on me.
. Perhaps I'm ove.r-critical on this point. Teaching
at the University I get so much B.S. Maybe that is it.
Subject 3. Improve the study? Directly monitor
the blood pressure and not use the head-band approach.

51
Subject 4. I can't think of any way.
Subject 5. The four times a week was a little
bit much for me, confining. On the days when I
didn't feel particularly good it was a chore for
me .
Subject 6. Nothing . . . much. I have a hear¬
ing problem that I'm ashamed of . . . sometimes
when Paula . . . well, with different voices I just
don't hear much. [Question: Did you hear the
clicks?] Yes, I heard them ... I been to the
doctor and he says there isn't anything I can do
about it.
Subject 7. The scheduling was mixed up. The
last time I came in I waited for 15 minutes and this
might have thrown the blood pressure machine off.
Subject 8. After the first two tapes I could go
to sleep, but after the last one, between it and
the recorder I got, well, I didn't get too much
benefit out of it. Whenever it would cut off, I
would think it was the recorder, then I found out
the tapes had breaks in it . . . she said 'a few
minutes' but it felt like fifteen minutes. I got
other things to do.
Subject 9. You didn't give clear instructions
about the tapes and I got my second one late.
Subject 10. You need to give clearer instruc¬
tions about the tapes.
Subject 11. I resented filling out the forms
. . . the categories didn't always fit how I felt.
Sometimes I didn't feel exactly happy, and I think
that it should allow for different shades.
Subject 12. You should get more people into the
study. The more you have, the more people you help.
Subject 13. Get people coming in on time so you
don't have to wait. I guess that's hard to do, to
get people to come in when they're supposed to.
Subject 14. If you had some money, get some GSR
equipment ... I think, you know, you should measure
both ways. People with high blood pressure tend to
sweat a lot, you know, that would give you a little
more calibration to the blood pressure. I am hot
two or three times a week for no reason. There must
be something.

52
Subject 15. The location should be more central.
Subject 16. Expectation is an important factor,
and I really felt surprised that you were going to
ask me some questions in addition to picking up the
questionnaire. It would have been better if you would
have said, 'Look, I want to ask you some questions,
too,' instead of just coming in and, here we are, and
you have your equipment, and it is totally unexpected
. . . but otherwise it was fine.
Subject 17. Generally if you could put the tapes
on some background music, that has a tendency to relax
you also, like a real soft background.
Subject 18. At first I found it difficult to get
into the tapes, but after a while I got to where I
looked forward to doing them.
Subjects 19 and 20. Malfunction in tape recording.
4. Does self-regulation of blood pressure affect
the way in which a person views his external
environment with respect to his coping strategy
or life style?
The excerpts selected by Ms. Ganikos are presented below
She summarized the responses as follows:
1. Most of the subjects seem to use the techniques that they
learned to increase the degree of relaxation during their
daily lives, in the physiological sense.
2. Most of the subjects experienced a new awareness of the
sensation of tension and were able to avert tension
headaches, "spells" of high blood pressure, chronic body
tension, and anxiety.
3. Most subjects experienced changes in their life styles,
in that they became less rigid and perfectionistic about
time, neatness, and the need to achieve, and could per¬
form better at work, home, and school.
4. Two subjects reported no change attributable to partici¬
pation in the study.
Information concerning the subjects' life styles or cop¬
ing behavior was elicited by an open-ended question,

53
spontaneously volunteered, or, in one case, directly requested.
Subject 1. When nothing is happening, like in
class, I now become aware that I am a little tense,
I don't know why . . . there must be some reason for
it. Like, when nothing is happening, then I pay
attention to myself and I feel tense. Before the
study I never had any manifestations of tension,
except maybe the high blood pressure.
Subject 2. These results . . . mine has been con¬
sistently going down. There has been no decline in
my outside stress. Before I knew what to do, but now
I am more reinforced. I haven't changed the method
I use to relax but now the idea is reinforced that it
is doing some good. And I will hold that relaxation
for a longer period than before. I can't hold that
under normal conditions. And I go to sleep much faster
now.
Subject 3. I think I have relaxed some ... it
has done some good.
Subject 4. I feel like it helped me, not as far as
my blood pressure, but my emotional well-being, my
headaches and things like that. When I used to be
getting a headache I'd wait until it got bad and then
I'd try to do something about it. Now I don't let a
lot of little things upset me. I don't worry in
advance about how things are going to come out. For
example, six extra people spent the night at our house
Friday night ... I just sort of took it in stride.
I think too that a part of it is being able to express
myself to my husband. I don't worry about if he is
going to object. . . I go ahead and sometimes explain
the reason. [Question: How about the headaches you
mentioned?] It did decrease the number of them. I
learned to recognize when I was getting one. I just
concentrated on it. I read some articles on biofeed¬
back, and if it is worth the effort that other people
are putting in on it, it certainly is worth my effort.
Noav I try to keep from overdoing. Even my tennis game
is better ... we played doubles last night, my hus¬
band and I, and we are winning ... I guess it is
because I don't overdo and am more relaxed playing.
I sense the feelings of relaxation. Before I would
think I Alias relaxed, but now I seem to feel it. If
I go into a situation that I think is going to cause
me tension, I say 'no' I'm going to stay relaxed.
When I say 'My face is smooth,' I have sort of a
drawing sensation up in here. I used to have sinus

54
trouble up there, but when I say 'my forehead is
smooth,' it kinda drains out. I used to wake up
about 4 o'clock in the morning but now I don't do
that.
Subject 5. It was revealing in several ways . . .
it made you aware of parts that were tense that I
really wasn't aware of ... I started paying atten¬
tion .
Subject 6. Sometimes when tempers get up a little
bit ... I never was too bad . . . but I just let
things so.
Subject 7. I can calm down better. With the tape
I could relax ... I used the Dean's office if it
was during the day. There are a lot of tensions in
the office, right at this minute. [Explanation of
inter-personal conflicts omitted.] In my case this
was helpful. It was a particularly bad time and
normally I stay hyper. I can shoot my pressure up.
Using the tapes I could lower it so I could get by.
Subject 8. No reported effect.
Subject 9. I used to be the type to want to get
everything done . . . now I can go off and leave the
dishes. This has a lot to do with my childhood.
I felt pressured. Now I realize that I don't have to.
It gave me a new perspective of the values of
things. I don't know why doing this did it, but it
did! I can't explain how sitting in that chair, hear¬
ing those clicks. . . (laughs).
Subject 10. I use it constantly. One day I had a
headache; I sat down and thought about the tapes. I
did learn that my body tells me things ... I didn't
realize how tense I was 'til I relaxed. Before I
resented the loss of time from things I should be
doing. I felt guilty when I relaxed. Now I am making
some changes; I am going back to school ... I have
been able to take things more casually.
Subject 11. I definitely know that I have a prob¬
lem.
Subject 12. I've had terrific headaches the last
six years . . ..I've been on medication the whole time.
I had constant headaches. Nothing would eradicate
them. Constantly, day and night. After my first
three sessions on the machine and listening to the
tapes, I haven't had a headache since. You're some

55
kind of woman, I'll tell you that, lady! Prior to
the time I started taking training with you and your
staff out there, the least little thing my family
would do, I'd fly off the handle. I don't do that
any more. Right now I'm working 16 hours a day . . .
I don't hurt any more. I just got a $1,400 raise.
They weren't going to give me the promotion at the
Post Office because they didn't think I would take
the pressure with the headaches and all, but now they
decided to . . . I'm working 16 hours on the new job
and I still feel fine. No headaches at all. And a
few weeks ago I went by to Dr. McCollough and he
checked my pressure and he cut my medicines in half.
Subject 13. I'm trying to pull some grades up
that were bad.
Subject 14. I'm more aware of the importance of
relaxing, not that I'm any more able to relax, but
I'm more aware of it.
The only thing we can control is our thoughts.
You might as well relax because people are going
to criticize you anyway.
Subject 15. Well, I tried to relax and slow down.
Today I was late but I didn't do my normal rushing
out here, like you said. You are getting me into bad
habits! That is so ingrained in me. Between you and
the nurse, you're getting me to slow down.
Subject 16. What I said was I had difficulty
relaxing my face versus my arms, my extremities.
Subject 17. No, I don't believe that I have actu¬
ally slowed down any, I just haven't had time to.
Subject 18. I seem to feel better, I don't know
how to describe it. I feel loose and get along better
all through the day. One thing, I know that I used
to be a lot more nervous and tight in my shoulders
but now, when I start to feel like that, I move around
or do something else.
Subjects 19 and 20. Malfunction in tape recorder.

56
5. How does a subject describe the psychological
process by which he effects muscle relaxation?
The descriptions of the process were selected by Ms.
Ganikos and are summarized as:
1. Most of the subjects seem to mentally repeat the key
words learned from the tapes, shifting their awareness
through different areas of their bodies until they reach
a "numb" or "floating" state.
2. The remaining subjects strive to achieve a "blank" mind
and "nothing" feeling.
The subjects were asked how they achieved a feeling of
relaxation.
Subject 1. How? It is nothing special. It is
like doing anything else, you don't think of what to
do, you just do it.
Subject 2. It's relaxing the face and throat
muscles. The rest of my body I don't have any con¬
nection with it really. I can disengage myself from
it as far as relaxation is concerned. My trouble is
in my mind . . . neither my worries nor my joys are
from my limbs. Whatever I do, I do in my head.
Subject 3. Sometimes I'd let my mind just be
blank, and sometimes I'd try to project my mind some¬
where else. Sitting down in the tropics, down on the
beach. I just try to lay there and let my mind go
blank and see what it does to the clicks per second.
Subject 4. Mainly by relaxing the muscles in my
face and my forehead, and also by changing positions.
When I used to be riding along in the car on a trip
my legs and shoulders would be tired, but by changing
positions, by not holding myself up tense, I feel
better. I get more comfortable when I am sitting
down.
Subject 5. Trying to clear . . . just not think
of anything or something pleasant, not a project or
anything to do. No one thing . . . every day was dif¬
ferent. It's still easier for me to relax the top
part of me, not the legs, and it is still a problem
that I haven't solved yet. The legs are still the
hardest part. That was very interesting to me . . .
why should the legs be the hardest part. That is
still a mystery. It's an awareness-type thing. It

57
has made me aware of the effects that parts of the
body has on the whole body. Generally whenever I am
doing something and I feel something tightening up
in me, the tapes go through my mind. The one that
fits that particular need ... I 'hear' it. First
I realize this is tight or that is tight, the jaw,
the hand, the legs, and then I relate that part back
to the tapes.
Subject 6. Relaxation is a numb feeling. I do it
by thinking of nothing.
Subject 7. The key words ... I went by 'limp,'
'relaxed,' . . . words like that.
I would say like 'my arms are limp' . . . and go
all over my body like that, probably in the same order
because I am a creature of habit. I would try not to
think of anything, because I have a bad habit of try¬
ing to do several thinks at once . . . read and watch
TV, and such things as that.
Subject 8. That tick tick tick got to singing a
song to you and then I drop off to sleep. I guess it
was a very tell-taleing little instrument. I put
everything away from my mind. Just say forget it all.
But if I knew that I was going to be there for several
hours I couldn't do it, my mind would start making
plans. I felt that might be why I could relax here
. . . it was just a short time. I think about things
at work at night.
Subject 9. I hear the words. I sit and I hear
the words.
Subject 10. Just repeating I was calm, comfortable
and relaxed, especially my forehead. I get floating
sensations. I hypnotize myself.
Subject 11. I memorized the tapes and did it from
memory the last three weeks. You don't take as long
. . . but you don't really relax.
Subject 12. I done exactly as the lady said on the
tapes. Like she told you to get in a comfortable
position . . . don't cross your arms and don't cross
your legs. She give you the different positions and
she explain to you the muscles. Then she went to the
forehead which is where I kept the burning headache
before. That's where you put the sense-i-gram, that's
what I call it [referred to the electrode]. At first
it sounded like a machine gun, but after two or three
sessions with that machine, I got it down to where it

58
sounded like a water faucet dripping. Now, really,
I don't know how to thank ya. You worked wonderful
things for me, I'll tell you that.
Let me explain to you how it felt to me. The
tapes start off with the right arm. By the time it
gets to the left arm, the right arm doesn't feel like
you have it any more ... it is not asleep, but in
a perfectly relaxed position. Then I'd concentrate
on bringing that machine down. The way it felt to me
as I'd relax one portion of my body, then another, it
felt like floating on Cloud Nine. You don't have any
sensation to you, like asleep, but I don't know what
sleep feels like because I'm asleep.
Subject 13. I just sit back and shift my awareness
all over and feel it relaxing. I became aware of what
I was feeling and just let it go. I'd just feel
floaty, not so pushing down. Sometimes I’d just blank
my mind out, and feel what is there.
Subject 14. By being conscious that if I tell
myself to relax, I do.
Subject 15. I relax different days in different
ways. I know where the electrodes are. I try to do
the neck and face. That's really trying to beat the
machine, I know. The time the girl was here with the
red hair, I didn't know her, and felt very impersonal.
The clicks were the lowest then because I wasn't try¬
ing to please anyone. Maybe it was the movie the
night before or maybe. . . .
Subject 16. On my face I feel with my fingers to
feel the tension and I look with my eyes to see how
far I get. On the rest of my body I have no special
way. I think I could feel the difference. I could
feel the tensing and relaxing more readily than on my
face. Relaxing didn't happen all at once. I felt I
got better at it. At first the whole side of me would
tense. The more I did it the more I could narrow it
down.
Subject 17. I relax by sitting down in a chair
with a can of beer. And I use the phrases from the
tapes.
Subject 18. In two ways: first, I shift my aware¬
ness all over my body, and where I find a spot of
tension, I relax it by letting go. Then, when I am
quite relaxed, I use the key words, like 'limp' to

59
achieve a greater relaxed state. It's quite bene¬
ficial. I have profited a great deal by being in
this program.
Subjects 19 and 20. Malfunction in tape recording.

CHAPTER IV
DISCUSSION
One of the purposes of the study was to examine the
efficiency of two treatment schedules in decreasing high
blood pressure. The results appear to favor the treatment
assigned to Group Y. The importance of the outcome of the
study seems to lie in the fact that those who participated
in a treatment which required only one biofeedback session
weekly reduced their blood pressures more than those who were
required to schedule four sessions per week in the hospital
setting.
While the amount of reduction sustained by the experi¬
mental groups did not approach that achieved by the Moeller
study [1973], it should be noted that (1) the pre mean blood
pressures of the subjects in this study were less than those
in Moeller's experiment, and (2) Moeller's treatment period
extended for 16 weeks, in contrast to the 6-week duration of
the treatment in this study.
Clinical impressions. The most apparent difference
between Groups X and Y seemed to be related to the degree of
personal responsibility the subjects assumed for their "com¬
mitment" or involvement in the study. The subjects in Group
X established a deeper interpersonal relationship with the
60

61
experimenter and her assistants, and it is possible that the
quality of this relationship interferred with their perfor¬
mance. In addition, approximately 30% of the subjects in
Groups X and Y indicated that they were less apt to complete
the practice session outside of the laboratory on days that
they attended the biofeedback session, because of the time
required to participate.
Group X seemed to relate to the experimenter and her
assistants as to an authority figure. In general, two response
patterns seemed to emerge. First, several subjects seemed
eager to gain the approval of the experimenter by reporting
their "good" behavior, such as diligence at carrying out the
practice sessions outside of the laboratory, attempts to avoid
tension related to conflict situations, the diminution of
headaches and insomnia. The subjects verbalized a variety of
excuses for not completing the practice sessions and for being
late for appointments. Their complaints ranged from a dislike
of the wording used on the tapes to the noise produced by the
hospital's air conditioning system. They seemed to have a
need to place "blame" outside themselves for their feelings of
failure at not achieving the desired state of relaxation.
In both cases, the interpersonal relationship afforded
the subjects an opportunity to develop an expectation of rein¬
forcement external to themselves. This opportunity was less
available for members of Group Y since the number of biofeed¬
back sessions was 75% less.

62
It is also possible that the Group X subjects experienced
greater desire to learn to control themselves than those in
Group Y. When the subjects were assigned, four individuals
placed in Group X withdrew before the treatment began due to
the number of required visits to the hospital setting. None
of the Group Y subjects withdrew for this reason. Therefore,
it is possible that the subjects in Group X differed from
those in Group Y at the beginning of the study. Relaxation is
dependent, in part, upon the subject's ability to let go of
tension and not control himself, in the sense of using active
volition. To the experimenter, it seemed that the psychologi¬
cal need for increased self-control required to complete the
treatment schedule of Group X was associated with a behavior
pattern in which the subjects used external manipulation of
themselves. They appeared to try to make themselves relax
in the same active manner by which they volitionally increase
tension. The results achieved by the subjects on the I-E
Scale suggests that this might be the case, although the means
were not different enough to reach statistical significance.
No procedure was established to insure consistent prac¬
tice for all subjects outside of the laboratory setting. It
is the opinion of this researcher that the subjects in Group
X failed to be as consistent in home practice as those in
Group Y. This judgement was based on the unrecorded remarks
made by the subjects rather than on an analysis of the data
on the practice sheets. In general, subjects felt that the
time required to travel to and from the hospital setting and

63
to participate in the biofeedback session interferred with
their ability to complete an additional session of relaxation
at home on the same day. It seems probable that Group X
actually received less progressive relaxation and autogenic
training than was proposed since they participated in four
biofeedback sessions in the laboratory each week. The prac¬
tice sheets on which the subjects recorded responses related
to the practice sessions were collected but no verbal feedback
was given to the subjects.
The logistics of carrying out the study presented certain
difficulties in keeping uniform personal interactions among
groups. An attempt was made to structure interaction with
the subjects, but the subjects in Group X frequently sought
the attention of the experimenter and her assistants. It was
thought that a lack of response would be viewed as rejection
and might lead to a termination in participation. Therefore,
deeper relationships emerged than were planned.
Conclusion. It seems apparent, for a complexity of
reasons, that the treatment assigned to those subjects in
Group X was not as clinically efficient in reducing high
blood pressure as the treatment assigned to Group Y.
Exploratory Questions
According to the statistical analysis, the scores of
subjects do not differ among groups on the Hy and D scales of
the MMPI to the extent where the differences approached

64
statistical significance. An inspection of the means (Table
6) shows that Group Y, who reduced their pressures the most,
scored lower on the hypochrondriasis and depression scales
than Group X, and that Group X scored lower than the control
group. Were the number of subjects larger for each group,
the direction of the differences would suggest that the treat¬
ment may tend to reduce the characteristics measured by these
scales. While the overall mean score on the Hy scale fell
within normal limits on the MMPI, the mean for D scale, which
related to feelings of depression, were elevated two standard
deviations above the mean for the general population.
Individuals who score high on this scale are character¬
ized as silent, retiring, tending to sidestep troublesome
situations, respectful of others, overcontrolling of their
impulses, inhibited, worrying, frank, sensitive, indecisive,
moody, and somewhat withdrawn. An elevated score indicated
low frustration tolerance, poor morale, feeling blue, discour¬
aged, dejected, and useless. This scale is described as the
best single index of immediate satisfaction and comfort in
living [Van De Riet and Wolking, 1968]. These adjectives
seemed to be consistent with the experimenter's observation
of the subjects involved in the study.
If the subjects in the experimental group have developed
a more positive body image as a result of participation in
the study, the ratings of the drawings failed to demonstrate
the change. The chi-square analysis showed no significant
difference between the ratings of the experimental and control
subjects at the .05 level.

65
Three aspects were probed by the experimenter during
the course of the termination interview: (1) the negative
aspects of the procedures, (2) the effect of increased self¬
regulation of blood pressure on one's coping strategy or life
style, and (3) the process by which the subjects achieve mus¬
cle relaxation. The purpose of these questions was to provide
information on which to modify procedures.
Three subjects expressed dissatisfaction regarding delays
in the appointments. This complaint could be reduced in
future undertakings if "free" time would be scheduled between
the treatment appointments of subjects, so that if one subject
is late, the others will not also have to wait. The subjects
sometimes found the instructions on the tapes confusing.
Several initially remarked about soreness from tensing specific
muscle groups. It is the opinion of the experimenter that dif¬
ficulty in following instructions was partly related to in¬
dividual's personality traits rather than to the instructions
on the tapes. Some subjects experienced a dislike for the
key words used, such as "quite quiet," and "limp."
The relaxation techniques employed in the reduction of
blood pressure seemed to sensitize the subjects to feelings
of psychological and physiological tension and provided a
strong suggestion as to the undesirability of tension. The
heightened awareness led to a variety of changes considered
by most to be desirable. One subject in Group X, who reported
that he was less perfectionistic and more easy-going, implied
that the experimenter was to "blame" for the change in his

66
behavior. This incident provides an insight into conflict
experienced by some. The idea of placing one's self and
one's own organismic needs before the cultural values of
"hard" work, the importance of "suffering," and the need to
appear as "perfect" as possible to others proved to be a dif¬
ficult shift.
The psychological process through which relaxation was
effected seemed to involve the use of passive suggestion of
key phrases. Most subjects experienced the inability to
actively "make" themselves relax, but learned instead to first
become aware of the feeling of tension and, next, to discon¬
tinue the tensing process. Several subjects who did not com¬
ment on this difference continued to try to relax by making
their minds "a blank" or by "doing nothing" and experienced
some success. Others used manipulation of their daily living
patterns to reduce "stress," by not "working so hard," adopt¬
ing a less demanding attitude, or paying more attention to the
task at hand rather than to a future goal.
Implications for counseling. The goals of traditional
psychotherapy, humanism, behaviorism, and the new "fourth
force" called transpersonal psychology have in common a belief
that increased awareness of one's own processes, be they psy¬
chological or physiological, will lead toward greater personal
freedom and growth. One function of the therapist is to assist
the individual to better know himself through feedback of
information. The content of the information depends upon the
therapist's orientation; the cognitive therapists impart

67
"insights," the Rogerians "relect feelings," the behaviorists
produce change of maladaptive, classically conditioned re¬
sponses; and those within the emerging "fourth force" encour¬
age the individual to "experience himself" by becoming more
aware of his organism's true needs, in contrast to those im¬
posed by the culture.
Inherent in the use of relaxation training is the assump¬
tion that physiological tension in the skeletal musculature
impairs full awareness of one's experience. Individuals often
attempt to avoid the experience of feelings that are unpleas¬
ant, such as fear, anger, or loss, by increasing muscle ten¬
sion. Unaware of the underlying avoidances, these individuals
often report symptoms such as chronic anxiety, headaches, and
pain. For many, the incident that precipitated the muscle
tension has been resolved, but the tension has remained as an
undesirable habit or unobserved behavior.
Relaxation training assists the individual to get in
touch with himself in that relaxation reduces the perceptual
static and facilitates fuller experience of one's self. As
the subjects reported, they became more aware of the process
by which they produce tension, and now experience a choice
between continuing to tense themselves or becoming relaxed.
In addition, the experimenter thinks that the subjects per¬
ceived that the nature of the task conveyed to the subjects a
belief that inappropriate tension is a negative quality; the
subjects were indirectly rewarded for removal of tension and
for remaining relaxed. For many, staying "relaxed" became a

68
higher priority goal than being on time, getting a task accom¬
plished within an established time period, or repressing or
controlling anger and frustration. Subjects, through aware¬
ness of the mind-body interactions , reported that they used
the phrases learned in the recorded exercises to achieve the
desired relaxation state.
It appears that relaxation training can be useful both
as an adjunct to a verbal psychotherapy and as a method in
itself. The experimenter noted that subjects became more
fluent verbally and emotionally expressive as relaxation pro¬
gressed. Often subjects remarked about the emergence of
repressed memories or "forgotten" events. Simply re-experi¬
encing the earlier feelings seems to be therapeutic for some.
Others reported that they did not "feel" different but
observed, among other things, that they xvere less demanding
of themselves, took less medication, stopped smoking, had
fewer headaches, improved interpersonal relationships,
achieved greater sexual satisfaction, were more tolerant of
stress at work, and reduced insomnia, teeth grinding, nail
biting, the consumption of alcohol and the intake of fattening
foods. Two of the twenty individuals in the experimental
groups felt that participation had little or no value.
Suggestions for Future Research
The results of this study demonstrate the usefulness of
the application of a short-term relaxation program to a

69
stress-related condition such as essential hypertension. The
need exists for further investigation of the interaction
between the psychological and physiological components in
organismic functioning.
In particular, it is suggested that future research
efforts be directed toward the development of improved tech¬
niques to enable an individual to shift from a state of
active volition to passive volition.

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APPENDIX A
FORMS

79
Personal Data
1.
Name
2. Age 3. Sex
(last) (first)
4.
Address
(street)
(town) (zip)
5.
Phone 6. How
do we contact you?
7.
Referred by:
8.
Physician
(name)
(address)
9.
Marital Status: circle one
Married, divorced, single,
separated, widowed
10.
Occupation
11.
How tall are you?
In the past year have you
gained or lost more
than ten pounds without trying
to , or dieting
? Describe situation
12.
Have you been told that you
IF NO, SKIP TO #16
have heart disease: yes no
vascular condition: yes no
13.Has a doctor told you that you had:
an abnormal electro-cardiogram (EKG)
an abnormal chest X-ray
angina pectoris
none of these
14. Has a doctor told you that you had:
a blood clot in an artery
a blood clot in a vein
an enlarged heart
none of these
15. Has a doctor told you that you had:
a heart attack or coronary
a heart murmur
low blood pressure
high blood pressure
scarlet fever
heart failure
rheumatic fever
none of these
16.Do you worry about your heart a lot? yes
no

80
IF MALE, SKIP TO #19
17.
Are
you pre-menopausal
menopaus al
post-menopaus al
18.
Do
you
take birth control pills?
no
yes
brand
19.
Do
you
have bad headaches? yes
no
IF NO, SKIP TO #28
20. Are they getting more frequent? yes no
21. How often do you get these headaches? every day
several times a week
once a week
once a month or less
22. These headaches usually occur: in the morning
in the evening
during the day
varies
23. These headaches usually last: less than one hour
several hours
several days
24. Does tension or nervousness trigger your headaches:
yes no
25. Can you usually tell when you are going to get a head¬
ache? yes no
26. Do other people in your family have severe headaches?
yes no
27. What medication do you take for your headache?
Helps?
28. Do you have any allergies? yes
(please describe)
no
29. Do you often have: cramping and gas with your bowel
movements
sweating palms
trouble getting your breath
sleep problems
nervous twitches
rapid heart beat
indigestion
gas
cold feet or hands when you are
under stress

81
30. How would you rate the tension in your life?
less than most anyone
less than most
about the same as most people
more than most
more than most anyone
31. Have you had or do you have any of the following
conditions? (please check)
Current
Condition Previously Currently medication
anemia
apoplexy or stroke
arthritis
alcoholism
asthma or hay fever
bleeding tendency
cancer
cataracts
cirrhosis
congenital heart disease
diabetes
epilepsy
eczema
emphysema
glaucoma
gout
heart disease
high cholesterol
high blood pressure
kidney disease
mental disorder
leukemia
kidney stones
lung trouble
nervous breakdown
migraine headaches
pernicious anemia
rheumatic heart disease
stomach or duodenal ulcer
thyroid disease or goiter
other
What medications do you carry in your purse or have at home?
32. What kinds of physical exercise do you routinely engage
in?
33. What kinds of religious spiritual, or meditative activi¬
ties do you engage in? Describe
How do you relax?
34.

82
STANDARD CONSENT FORM
Subject:
Date:
I authorize the performance upon
the following treatment: the subject's forehead muscle ten¬
sion will be monitored through the use of electromyograph
equipment, and the information made available to the subject
via auditory feedback. The subject will be encouraged to
lower his degree of muscle tension. In addition, he will
receive a series of relaxation exercises recorded on cassette
tapes, to be played and practiced at home. Repeated measures
of his blood pressure will be made by a competent examiner
using a cuff sphygmomanometer and Littman stethoscope.
The nature and purpose of this treatment, possible alterna¬
tive methods of treatment, the risks involved, and the possi¬
bilities of complications have been explained to me verbally
and in writing by .
I fully understand that the procedure or treatment to be per¬
formed is experimental and not routine medical treatment. I
also understand that I may not benefit from the treatment and
that the consequences are not completely predictable. Further
more, it is agreed that the information gained from these
investigations may be used for educational purposes which may
include publication. I understand that I may withdraw my con¬
sent at any time.
SIGNED
WITNESS
I, the undersigned, have defined and fully explained this
treatment procedure to the above individual.
SIGNED
The proposed research has been approved by the Health Center
Committee for the Protection of Human Subjects. If you have
any further inquiries, they may be addressed to the Investi¬
gator or to the Committee for the Protection of Human Subjects
c/o Dean of the College of Medicine for the Health Center.
Attachment A

83
DESCRIPTIVE CONSENT FORM
Title: LEARNED SELF-REGULATION OF ARTERIAL HYPERTENSION
UTILIZING BIOFEEDBACK AND RELAXATION TRAINING.
The subject will be taught techniques of deep muscle relaxa¬
tion through the use of biofeedback and relaxation exercises.
It is expected that the elevated blood pressures associated
with essential hypertension will be reduced as a function of
deep relaxation. It this is demonstrated to occur, the harm¬
ful effects of sustained elevated blood pressure will diminish.
Repeated measures of blood pressure will be made, and, should
the reading indicate an increase over the baseline measure¬
ments, a physician will be consulted before the subject will
be allowed to continue in the treatment.
I have read and understand the above described treatment
procedure in which I am to participate and have received a
copy of this description.
SIGNED:
WITNESS:
INVESTIGATOR:
Attachment B

84
Subject
BLOOD PRESSURE DATA SHEET
S D S D S D
I. Baseline Measures: 1) a, b, c,
2) a, b, c,
3) a, b, c,
Systolic (S) Diastolic (D)
S D
II. Treatment Measures:
Treatment
Week Session
A la
2 a
3 a
4 a
B la
2 a
3 a
4 a
C la
2 a
3 a
4 a
D la
2 a
3 a
4 a
b, c,

II. Treatment Measures, con't
Treatment
Week Session
1
2
3
4
1
2
3
4
1
2
S D S D
a, b,
a, b ,
a, b ,
a, b,
a, b,
a, b ,
a, b,
a, b,
a, b ,
a, b,
III. Post Treatment Measures:
1) a, b,
2) a, b,
3) a, b,
Systolic Diastolic
CHANGE SCORES: Systolic Diastolic

86
Subj ect
Group
Practice Record Chart - Week
Day I
A.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension —
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
P.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
Day II
A.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
P.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension —
Mood: happy Appropriate Depressed
Describe any feelings of unexpected bodily sensations that
occurred during the practice session â– 
Day III
A.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings of unexpected bodily sensations that
occurred during the practice session

87
Day III (con't.)
P.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
Day IV
A.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
P.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
Day V
A.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
P.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
Day VI
A.M. Did
Fully attentive
Very tense
Mood: happy
not complete
Mostly attentive
Moderate tension
Appropriate
Little attention
Little tension
Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session

88
Day VI (con't.)
P.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
Day VII
A.M. Did not complete
Fully attentive Mostly attentive Little attention
Very tense Moderate tension Little tension ~
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
P.M. Did not complete
Fully attentive Mostly attentive Little attention_
Very tense Moderate tension Little tension
Mood: happy Appropriate Depressed
Describe any feelings or unexpected bodily sensations that
occurred during the practice session
What feelings are you aware of just prior to the practice
sessions ?
What feelings often occur at the conclusion of the practice
session?
What events have occurred in your life (during this week) to
which you have reacted with increased tension?
How have you behaved during this week that has produced
feelings of deep relaxation? Describe your behavior
Use reverse side for any additional comments.
Thank you for your cooperation.

APPENDIX B
STANDARD INSTRUCTIONS

90
Instructions for Volunteers
The purpose of this study is to look at the actual
effects of a new treatment approach on the reduction of blood
pressure. We will need volunteers with high blood pressure
who also meet certain other criteria that are determined by
the experimental design of the study. Everyone who partici¬
pates will be required to have the consent of his physician,
and will continue to take his prescribed medication on a regu¬
lar basis during the duration of the experimental treatment.
Our study will attempt to lower blood pressure by teaching
you how to relax your muscles.
After you have completed the forms and questionnaires, we
will select certain individuals and assign them to a specific
treatment schedule. It is important that you fully understand
what you will be required to do before you will know if it is
possible for you to participate. Are there any questions so
far?
After we go over the data that you are completing now, we
will notify you if we will use you in the study, and ask you
to return for two more preliminary sessions before your treat¬
ment will be initiated. Next time you will fill out some
additional questionnaires, and have your blood pressure mea¬
sured. In the last preliminary session, the principles of
biofeedback will be explained, and you will have a chance to
try out the equipment. There will be some relaxation exer¬
cises for you to do at your home or office, twice a day.

91
This will require that you have access to a tape player that
will handle tapes like these (show cassette tape) and that
you have a quiet place in which to lie down and do them. You
will be required to attent a training session using the bio¬
feedback equipment either once of four times a week, depending
on the group that you get assigned to. The biofeedback labo¬
ratory is located at North Florida Regional Hospital where you
will find ample parking space.
In order to keep the study free from the unknown effects
that each of you might have upon the other, in terms of enthu¬
siasm or motivational level, we ask that you do not discuss
your treatment schedule or any other aspects of the study
with each other. When it is concluded, we will have a big
party, and we can talk about our experiences then.
If you are not selected to participate, it does not mean
that this treatment approach could not be of help to you in
reducing your blood pressure, but rather that we have enough
individuals in your age range with the same blood pressure
level. All of you will be informed of the results of this
study when it is completed and the data are analyzed.
When you have completed the forms, please go to the bath¬
room, empty your bladder, and return to your chair so that my
co-worker, Ms. , can record your blood pressure with
this cuff. We will always take it 3 times in succession to
get a reliable reading.
Any questions? Thank you. You will hear from us next
week.

92
Instructions to Subjects
All of you here today will be subjects in the study, but
will not have the same treatment schedule. In order to know
more about each of you, we ask that you complete the question¬
naire and drawing that are being passed out to you, in folders.
Place your name, last name first, on the tab of the folder.
All of your records will be coded in order to preserve your
privacy. No one will know what your answers are, except me.
In return for my promise of confidentiality, I hope that you
will feel free to answer as honestly as possible. Any ques¬
tions?
When you have completed the questionnaires and drawing,
please use the bathroom located in the next room. After you
empty your bladder, return to your chair.
I am looking forward to our next session so that I can
explain the use of the biofeedback equipment to each of you,
and give you a chance to operate it yourself. Thank you for
coming.

93
Conclusion Questions
Directions for Administration: The following questions are
to be asked to each subject during the period of time follow¬
ing the biofeedback session as the electrodes are being
removed. No response will be made by the examiner unless
asked a direct question by the subject.
1. How did the session seem to go today?
2. How do you feel now?
3. Do you have any questions?
Unusual responses are to be noted in each subject's folder.

APPENDIX C
TESTS

95
THE INTERNAL-EXTERNAL SCALE
Directions for administration: Read aloud. "This is a
questionnaire to find out the way in which certain im¬
portant events in our society affect different people.
Each item consists of a pair of alternatives lettered
"a" or "b." Please select the one statement of each
pair (and only one) which you more strongly believe to
be the case as far as you are concerned. Be sure to
select the one you actually believe to be more true, not
the one you think you should choose, or the one you would
like to be true. This is a measure of your personal
belief: as you read it, you will see that there are no
right or wrong answers.
Record your answers on the answer sheet provided by
checking statement "a" or "b." PRINT YOUR NAME ON YOUR
ANSWER SHEET.
Please answer these items carefully and do not spend too
much time on any one item. Be sure to make a choice for
each pair of statements. In some instances you may dis¬
cover that you believe both statements or neither one to
be true. Select the one you believe to be the most true
for you. Also, try to respond to each pair of statements
independently when making your choices: do not be influ¬
enced by previous choices."
Scoring:
The score
These are
is the total number of
listed below.
external
choices.
1.
filler
7.
a
13. b
19.
filler
25.
a
2.
a
8.
filler 14. filler
20.
a
26.
b
3.
b
9.
a
15. b
21.
a
27.
filler
4.
b
10.
b
16. a
22.
b
28.
b
5.
b
11.
b
17. a
23.
a
29.
a
6.
a
12.
b
18. a
24.
filler
THIS SHEET IS NOT TO BE GIVEN TO THE SUBJECT

96
Name
1.
a.
b.
16.
a.
b.
2.
a.
b.
17.
a.
b.
3.
a.
b.
18.
a.
b .
4.
a.
b.
19.
a.
b.
5.
a.
b.
20.
a.
b.
6.
a.
b.
21.
a.
b.
7.
a.
b.
22.
a.
b.
8.
a.
b.
23.
a.
b.
9.
a.
b.
24.
a.
b.
10.
a.
b.
25.
a.
b.
11.
a.
b.
26.
a.
b.
12.
a.
b.
27.
a.
b.
13.
a.
b.
28.
a.
b.
14.
a.
b.
29.
a.
b.
15.
a.
b.
30.
a.
b.

97
1. a.
Children get into trouble because their parents punish
them too much.
b.
The trouble with most children nowadays is that their
parents are too easy with them.
2. a.
Many of the unhappy things in people's lives are partly
due to bad luck.
b.
People's misfortunes result from the mistakes they make
3. a.
One of the major reasons why we have wars is because
b .
people don't take enough interest in politics.
There will always be wars, no matter how hard people
try to prevent them.
4. a.
In the long run, people get the respect they deserve
in this world.
b.
Unfortunately, an individual's worth often passes un¬
recognized no matter how hard he tries.
5. a.
The idea that teachers are unfair to students is non¬
b.
sense .
Most students don't realize the extent to which their
grades are influenced by accidental happenings.
6. a.
Without the right breaks one cannot be an effective
leader.
b.
Capable people who fail to become leaders have not
taken advantage of their opportunities.
7. a.
No matter how hard you try some people just don't like
b.
you.
People who can't get others to like them don't under¬
stand how to get along with others.
8. a.
Heredity plays the major role in determining one's
b.
personality.
It is one's experiences in life which determine what
they're like.
9. a.
I have often found that what is going to happen will
happen.
b.
Trusting to fate has never turned out as well for me
as making a decision to take a definite course of
action.
10. a.
In the case of the well-prepared student there is
rarely if ever such a thing as an unfair test.
b.
Many times exam questions tend to be so unrelated to
course work that studying is really useless.
11. a.
Becoming a success is a matter of hard work, luck has
little or nothing to do with it.
b.
Getting a good job depends mainly on being in the
right place at the right time.

98
12. a.
The average citizen can have an influence in govern¬
ment decisions.
b.
This world is run by the few people in power, and
there is not much the little guy can do about it.
13. a.
When I make plans, I am almost certain that I can make
them work.
b.
It is not always wise to plan too far ahead because
many things turn out to be a matter of good or bad
fortune anyhow.
14. a.
b.
There are certain people who are just no good.
There is some good in everybody.
15. a.
In my case getting what I want has little or nothing
to do with luck.
b.
Many times we might just as well decide what to do by
flipping a coin.
16. a.
Who gets to be the boss often depends on who was lucky
enough to be in the right place first.
b.
Getting people to do the right things depends upon
ability, luck has nothing to do with it.
17. a.
As far as world affairs are concerned, most of us are
the victims of forces we can neither understand,
nor control.
b.
By taking an active part in politics and social affairs
the people can control world events.
18. a.
Most people don't realize the extent to which their
lives are controlled by accidental happenings.
b.
There really is no such thing as "luck."
19. a.
b.
One should always be willing to admit mistakes.
It is usually best to cover up one's mistakes.
20. a.
It is hard to know whether or not a person really
likes you.
b.
How many friends you have depends on how nice a person
you are.
21. a.
In the long run the bad things that happen to us are
balanced by the good ones.
b .
Most misfortunes are the result of lack of ability,
ignorance, laziness, or all three.
22. a.
With enough effort we can wipe out political corrup¬
tion.
b.
It is difficult for people to have control over the
things politicians do in office.

99
23. a.
b.
24. a.
b.
25 . a.
b.
26. a.
b.
27. a.
b.
28. a.
b.
29. a.
b.
Sometimes I can't understand how teachers arrive at
the grades they give.
There is a direct connection between how hard I study
and the grades I get.
A good leader expects people to decide for themselves
what they should do.
A good leader makes it clear to everybody what their
jobs are.
Many times I feel that I have little influence over
the things that happen to me.
It is impossible for me to believe that chance or luck
plays an important role in my life.
People are lonely because they don't try to be friendly.
There's not much use in trying too hard to please
people, if they like you, they like you.
There is too much emphasis on athletics in high school.
Team sports are an excellent way to build character.
What happens to me is my own doing.
Sometimes I feel that I don't have enough control over
the direction my life is taking.
Most of the time I can't understand why politicians
behave the way they do.
In the long run the people are responsible for bad
government on a national as well as on a local
level.

100
MINNESOTA MULTIPHASIC PERSONALITY INVENTORY
(Hy and D)
Directions for administration: Read aloud. "This inventory
consists of numbered statements. Read each statement and
decide whether it is true as applied to you or false as
applied to you. You are to mark your answers on the
answer sheet provided. If a statement is TRUE or MOSTLY
TRUE, as applied to you, put a check after the "T." If
a statement is FALSE or MOSTLY FALSE as applied to you,
put a check in the space after the "F." If a statement
does not apply to you or if it is something that you don't
know about, make no mark on the answer sheet.
Remember to give your own opinion of yourself. Do not
leave any blank spaces if you can avoid it.
In marking your answers on the answer sheet, be sure that
the number of the statement agrees with the number on the
answer sheet. Erase completely any answer you wish to
change. Go ahead."
THIS SHEET IS NOT TO BE GIVEN TO THE SUBJECT

101
1. I have a good appetite.
2. I wake up fresh and rested most mornings.
3. I am easily awakened by noise.
4. I like to read newspaper articles on crime.
5. My hands and feet are usually warm enough.
6. My daily life is full of things that keep me interested.
7. I am about as able to work as I ever was.
8. There seems to be a lump in my throat much of the time.
9. I enjoy detective or mystery stories.
10. I am very seldom troubled by constipation.
11. I am troubled by attacks of nausea and vomiting.
12. I feel that it is certainly best to keep my mouth shut
when I'm in trouble.
13. At times I feel like swearing.
14. I find it hard to keep my mind on a task or job.
15. I seldom worry about my health.
16. At times I feel like smashing things.
17. I have had periods of day, weeks, or months when I
couldn't take care of things because I couldn't "get
along, or get going."
18. My sleep is fitful and disturbed.
19. Much of the time my head seems to hurt all over.
20. My judgement is better than it ever was.
21. Once a week or oftener I feel suddenly hot all over,
without apparent cause.
22. I am in just as good physical health as most of my friends.
23. I prefer to pass by school friends, or people I know but
have not seen for a long time, unless they speak to
me first.
24. I am almost never bothered by pains over the heart or in
my chest.
25. I am a good mixer.
26. Everything is turning out just like the prophets of the
Bible said it would.
27. I sometimes keep on at a thing until others lose their
patience with me.
28. I wish I could be as happy as others seem to be.
29. I think a great many people exaggerate their misfortunes
in order to gain the sympathy and help of others.
30. Most of the time I feel blue.
31. Sometimes I tease animals.
32. I am certainly lacking in self-confidence.
33. I usually feel that life is worth while.
34. It takes a lot of argument to convince most people of
the truth.
35. I think most people would lie to get ahead.
36. I go to church almost every week.
37. I believe in the second coming of Christ.
38. I have little or no trouble with my muscles twitching
or jumping.
39. I don't seem to care what happens to me.
40. I am happy most of the time.

102
41. Some people are so bossy that I feel like doing the
opposite of what they request, even though I know they
are right.
42. Often I feel as if there were a tight band around my head.
43. I seem to be about as capable and smart as most others
around me.
44. Most people will use somewhat unfair means to gain profit
or an advantage rather than to lose it.
45. The sight of blood neither frightens me nor makes me
sick.
46. Often I can't understand why I have been so cross and
grouchy.
47. I have never vomited blood or coughed up blood.
48. I do not worry about catching diseases.
49. I commonly wonder what hidden reason another person may
have for doing something nice for me.
50. I believe that my home life is as pleasant as that of
most people I know.
51. Criticism or scolding hurts me terribly.
52. My conduct is largely controlled by the customs of those
around me.
53. I certainly feel useless at times.
54. At times I feel like picking a fist fight with someone.
55. I have often lost out on things because I couldn't make
up my mind soon enough.
56. Most nights I go to sleep without thoughts or ideas
bothering me.
57. During the past few years I have been well most of the
time.
58. I have never had a fit or convulsion.
59. I am neither gaining nor losing weight.
60. I cry easily.
61. I cannot understand what I read as well as I used to.
62. I have never felt better in my life than I do now.
63. I resent having anyone take me in so cleverly that I
have had to admit that it was one on me.
64. I do not tire quickly.
65. What others think of me does not bother me.
66. I frequently have to fight against showing that I am
bashful.
67. I have never had a fainting spell.
68. I seldom or never have dizzy spells.
69. My memory seems to be all right.
70. I am worried about sex matters.
71. I find it hard to make talk when I meet new people.
72. I am afraid of losing my mind.
73. I frequently notice my hand shakes when I try to do
something.
74. I can read a long while without tiring my eyes.
75. I feel weak all over much of the time.

103
76.
77.
78.
79.
80.
81.
82.
83.
84.
85 .
86.
87.
88.
89.
90.
91.
92 .
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
I have very few headaches.
Sometimes, when embarrassed, I break out in a sweat,
which annoys me greatly.
I have had no difficulty in keeping my balance in walk¬
ing.
I do not have spells of hay fever or asthma.
I wish I were not so shy.
I enjoy many different kinds of play and recreation.
I like to flirt.
In walking I am very careful to step over sidewalk
cracks.
I hardly ever notice my heart pounding and I am seldom
short of breath.
I have at times stood in the way of people who were try¬
ing to do something, not because it amounted to much
but because of the principle of the thing.
I get mad easily and then get over it soon.
I brood a great deal.
I dream frequently about things that are best kept to
myself.
I believe I am no more nervous than most others.
I have few or no pains.
Sometimes without any reason or even when things are
going wrong I feel excitedly happy, "on top of the
world."
I can be friendly with people who do things which I
consider wrong.
I have difficulty in starting to do things.
I sweat very easily even on cool days.
It is safer to trust nobody.
When in a group of people, I have difficulty thinking
about the right things to talk about.
When I leave home I do not worry about whether the door
is locked and the windows closed.
I do not blame a person for taking advantage of someone
who lays himself open to it.
At times I am all full of energy.
My eyesight is as good as it has been for years.
I drink an unusually large amount of water every day.
Once in a while I laugh at a dirty joke.
I am troubled by attacks of nausea and vomiting.
I am always disgusted with the law when a criminal is
freed through the arguments of a smart lawyer.
I work under a great deal of tension.
I am likely not to speak to people until they speak to me.
I have periods in which I feel unusually cheerful with¬
out any special reason.

APPENDIX D
LETTERS

W. C. EVANS, JR., M.D.
225 S.W. 7th Terrace
Gainesville, Florida 32601
105
Telephone: 372-8461
7/5/74
Dear Ms. Orlando:
I have reviewed the statistics on means, medians, and
modals of your B.P. experiment with biofeedback and find
them very interesting. I will attempt to give you my opinion
as regards the clinical practicality of such.
I do not know the differences between applied methods in
Group X and Group Y. Clinically (notwithstanding mathematical
significance) I would say that the difference betx^een Group X
and control group is of no value or practical usefulness.
However, the difference between Group Y and control seems
clinically applicable and could be of value in management of
hypertensive patients.
If I can help you further, do let me know.
Best wishes ,
W. C. Evans, Jr., M.D.

106
TOWER MEDICAL GROUP
209 N.W. 75th Street (Tower Road)
Gainesville, Florida 32601
Daniel B. Cox, M.D., Cardiology
Jared C. Kniffen, M.D., F.A.C.P., Gastroenterology
Arthur A. Mauceri, M.D., Infectious Diseases and
Immunology
David F. Pawliger, M.D., Hematology
July 29, 1974
Jacqueline Orlando
407 N.W. 39th Road
Gainesville, Florida 32601
Dear Jackie:
I have reviewed the data that you submitted on the effect
of relaxation training using autogenic therapy and EMG feed¬
back on essential hypertension. You asked me to comment from
a clinician's viewpoint on the significance of the blood pres¬
sure changes. This is somewhat difficult to do without know¬
ing the circumstances under which the readings were obtained.
The questions that I would ask are 1) How was the blood pres¬
sure measured; 2) Is each blood pressure recording the result
of a single reading or the average of several determinations;
3) Was the study done in a "blind" fashion?
In Group X only three patients had what I would consider
to be a meaningful reduction in systolic pressure and none had
a meaningful reduction in diastolic pressure. In Group Y two
patients had a meaningful reduction in systolic and five
patients a meaningful reduction in diastolic pressure. There
was no meaningful change in pressure recorded in Group C. If
one compares the median (not the mean) pressures in each group
before and after relaxation training, the only group that had
an apparent change was Group Y with a 7 mm decrease in systolic
and a 9 mm decrease in diastolic pressure.
It has been shown that reduction in diastolic pressure
will decrease the incidence of certain complications of hyper¬
tension. However, the reduction in diastolic pressure must
be sustained in order to achieve this benefit. Fifty per
cent of patients in one of your groups had a clinically sig¬
nificant reduction in diastolic pressure, but in order to
judge the clinical usefulness of this response, I would have
to know that the diastolic pressures remained at a lower level
for a significant period of time.
Sincerely yours,
David F. Pawliger, M.D.

107
EVALUATION FOR JACKIE ORLANDO
MEAN, MEDIAN AND MOTILE MEASURES
OF BLOOD PRESSURE IN GROUPS
X, Y, AND Z
7/27/74
Groups X and Y reported being treated with biofeedback and
Group Z a control group.
1. Analysis interpretation of Group X of the 10 patients in
Group X, all have mild to moderate systolic and diastolic
hypertension in the pretreatment measurements. In the
posttreatment measurements, the systolic component had
returned to normal and two of the 10 of the patients in
the diastolic component remained elevated, and all 10 in
the posttreatment. The drop in diastolic pressure was
significant enough to return the systolic pressure read¬
ings to normal in two of the 10 patients. It did not
appear to significantly lower the diastolic pressure in
Group Y. All patients of this group have both systolic
and diastplic hypertensive components. Two in this group
had diastolics above 110 which falls into a moderately
severe hypertensive range. In Group Y in the posttreat¬
ment group readings the systolic measurements remained at
or above the defined limits for systolic hypertension.
The diastolic components appeared to be significantly
lowered in seven of the 10 patients of the patients of
the control group, again, all had both systolic and dia¬
stolic components to their hypertension. At the end of
the control period, all remained hypertensive with essen¬
tially no change in their blood pressure readings.
2. In a short study of biofeedback, effects on the control of
hypertension, it appears that, in at least a few patients,
there has been some significant reduction in their blood
pressure, especially in the diastolic component. The
reduction appeared to be greatest in those who had moder¬
ately severe diastolic levels. The study was of very
short duration and a very long term evaluation would be
necessary to determine the effectiveness of biofeedback
in lowering hypertensive risks. The promise that some
patients may be controlled in the future without medica¬
tion or surgery would seem to merit further investigation
of this treatment modality.
Robert Ashley, Jr., M.D.

BIOGRAPHICAL SKETCH
Jacqueline Zurcher-Brower Orlando was born June 11,
1937, in Sioux Falls, South Dakota. She was graduated from
the Academy of the Holy Names in 1955, and received her B.A.
in philosophy and speech from Barry College in 1959. The
Master's degree in rehabilitation counseling was awarded to
her at the University of Florida in 1963. She completed
additional graduate courses at Florida State University,
Tallahassee, Florida. In 1971 Jacqueline returned to the
University of Florida to complete the requirements for the
Doctor of Philosophy degree in counselor education.
Jacqueline has two children, Michael James and Kristine
Orlando, and resides in Gainesville, Florida.
108

I certify that I have read this study and that, in my
opinion, it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Robert 0. Stripling, Chairman
Professor of Education
I certify that I have read this study and that, in my
opinion, it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Joseph C. Cauthen
Doctor of Medicine
I certify that I have read this study and that, in my
opinion, it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Lov^^
of Behavioral Sciences
William A
Professor
Nova University
I certify that I have read this study and that, in my
opinion, it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Franz R^/Eptim
Assistant Professor of^
Psychology

I certify that I have read this study and that, in my
opinion, it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
W. IT. Tolbert
Associate Professor of
Education
This dissertation was submitted to the Department of
Counselor Education in the College of Education and to the
Graduate Council, and was accepted as partial fulfillment
of the requirements for the degree of Doctor of Philosophy.
August, 1974
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 08553 6174




PAGE 1

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