eeAUTOGENIC TRAINING A Psychophysiologic Approach in Psychotherapy By JOHANNES H. SCHULTZ, M.D. and WOLFGANG LUTHE, M.D. GRUNE & STRATTON New York and London 1959Contents Foreworp.... ix PREFACE. ....- xi PART I. METHOD 1, InrRopucTION Sebastien 1 2. Repuction or ArrereNnt STIMULI 3 Horizontal Training Posturs 3 Sitting Postures... 5 Closure of Eyes.......++- ERE ern eee eal 8 3. TRAINING FormULAr AND Passive CONCENTRATION, . . 8 Structure and Implications of the Standard Formulae. 8 Passive Concentration : 9 4, SranparD Exercises. 13 First Standard Exercis 13 Second Standard Exercise: Warmth.....-..-- 36 Third Standard Exercise: Cardiac Regulation. .. . 50 Fourth Standard Exercise: Respiration . 60 Fifth Standard Exereise: Abdominal Warmth... . . 69 Sixth Standard Exereis ‘ooling of the Forehead... . - 85 5. MepiraTive EXERCISES. we/eRig die siete wie wR G Ie ag woe 95, First Meditative Exercise: Spontancous Experience of Colors. . 100 102 d Meditative Exercise: Experience of Selected Colors... . Visualization of Conerete Objects. 105 : Visualizition of Abstract Objects. . 107 Experience of a Selected State of Secon Third Meditative Exerci Fourth Meditative Exe: Fifth Meditative Exer Feeling. ....---- .. 110 Sixth Meditative I. Visualization of Other Persons..... 114 Seventh Meditative Exer ‘Answers from the Unconscious... 117 6. SPECIAL EXBRCISES. ..--- 7 120 Organ-Specific Formulae 120 .. 123 Intentional Formulae. . PART II. APPLICATION 7. CLINICAL APPLICATION. «.--- +++ 00007" 8, Disorvers OF THE ResPiRATORY Tract Bronchial Asthma. Pulmonary Tuberculosis. .... +++ a a 9. Disorpers OF THE GASTROINTESTINAL Tract... Disorders of Deglutition . igen Gastritisvi 10. DisorpERS OF THE Canpiovascutar 8 TI 11. Disorpers oF THE ENDOCRINE System CONTENTS Peptic Uleer...- : Constipation and Diarthea. . Ulcerative Colitis. . Ap Vasonoton DisTURBANCES . Cundine Neurowes and Functional Disorders of the Heart... | Angina Peetoris and Alterations of Coronary Circulation, Alterations in Blood Pressure Disorders of Peripheral Circulation Hemorrhoids eer Blushing Headache and Migraine. Hyperthyroidism. .. Diabetes Mellitus. . 12. Disorpers OF THE UROGENITAL SYSTEM AND Sexvat Distors- ANCES. ee ceueeeeen ie 160 13. PREGNANCY | AND > Birra. 162 14. Skin DisorpERs - 167 15, OpHtHaLMoLocic DisorpERS AND , BLINDNESS - 168 16. Neuroocic DisorvERS 17. Psycuosns . 18. PsYCHONEUROSES: 19. Hasrr Dison 20. ALconotics, Drug AppICTION AND SMOKING. 21. Disorpers oF SLEEP 22. Mopirication or Perception aND REACTION TO Pauw. 23. Noncutnican APPLICATION. . Brain Injury and Epilepsy Schizophrenia, Depressive States jiety Neuroses Hypochondriasis . Hysteria . Anorexia Nervos Enuresis . Masturbation Stuttering. Writer’s Cramp Bechterew’s Diseaseil illialaen CONTENTS vil PART IL. RESEARCH AND THEORY 24. Puysiouocic CHANGES During THE STANDARD EXERCISES. - - - 227 .. 227 Neuro-Muscular Activity... -- +--+ Skin and Body Temperature... -- Heart Rate ante Blood Pressure Respiration Electroencephalography DG. TMBONY. 94. - 4-2 cette sce Fees Te PART IV. APPENDIX Bibliography. « 248 Author Index Subject Index...--.-.-5s.errereeForeword The basic clinical and experimental studies which later led to the develop- ment of autogenic training were carried out by Oskar Vogt at the turn of the century. During this stimulating period when psychoanalysis was already on its way, Oskar Vogt focussed his attention on the psychophysio- logic mechanisms of sleep and hypnosis and started to investigate the clinical potentialities of autosuggestive methods. In the course of his studies, Oskar Vogt observed that intelligent and critically minded subjects could learn to induce certain “autosuggestive states” by applying a sequence of autosuggestions patterned according to verbal approaches used during the induction phase of hypnosis. While in these “self-induced states,” a number of Vogt’s subjects experi- enced that their introspective self observation was greatly enhanced, thus enabling them to produce psychoanalytically valuable material more easily. Since many of Vogt’s subjects found themselves relaxed and re- freshed after such “exercises,” Vogt called them “Prophylaktische Ruhe- Autohypnosen” (lit. transl.: prophylactic rest-autohypnoses).* Oskar Vogt’s particular merit lies in this fact: he clearly saw that the clinical value of any autosuggestive approach does not lie in self persuasion as such (e.g., Coué), but that the autosuggestive approach could be used for the induction of mental states which, similar to hypnosis, open up psychophysiologic possibilities of clinical value. Stimulated by Oskar Vogt’s work I started in 1905 to study certain psychophysiologic mechanisms and potentialities of different technics of hypnosis. Of particular interest was the question under which circum- stances normal persons were able to hallucinate. In a number of experi- mental series the effect of different approaches was investigated. One of the stimulating findings which actually led to the development of auto- genic training, was that during these experiments most of my subjects reported a similar sequence of subjective experiences despite the fact that quite different technics of hypnosis had been used. The most outstanding and consistent self observations were the experience of a feeling of heaviness in the extremities which almost invariably was followed by a sensation of warmth. From these findings it was concluded that muscular relaxation (“heavi- ness”) and vasorelaxation (“warmth”) are basic factors in bringing about a hypnotic state. The next step was to find out if the psychophysiologic mechanisms which are responsible for inducing “heaviness” and “warmth” could be mobilized by autosuggestions and if thus a state of amplified relaxation similar to the hypnotic state would result. After a period of trial ixPart I: METHOD 1. Introduction Psychophysiologic psychotherapy is based on the assumption that psy- chologic functions cannot occur independently of physiologic processes or without the involvement of some organic structure. This assumption im- plies that mental or other functions of the nervous system are to be viewed in context with other bodily functions and with the consequences arising from the forces and the interaction of the individual’s genetic and environ- mental constellation. In accordance with this orientation, and in contrast to so-called “mental methods” (e.g., psychoanalysis), autogenic training approaches mental and bodily functions simultaneously. The basic principles of autogenic training were conceived as long ago as 1910. Stimulated by the work of Oscar Vogt‘ on hypnosis and sleep, Schultz concentrated on exploring the potentialities of autosuggestion. The aim was to find an effective psychotherapeutic approach which would elim- inate the unfavorable aspects of hypnotherapy, such as the passivity of the patient and his dependence on the therapist. Schultz observed that most of his patients spontaneously reported a feel- ing of heaviness in the limbs during the initial phases of hypnosis. In addi- tion to this muscular relaxation, a feeling of warmth in the extremities was usually noted soon afterwards. Basing his initial approach on these observa- tions, Schultz attempted to induce a hypnotic state by asking his patients first to think of heaviness in the limbs, then to imagine a feeling of warmth in the extremities. When corresponding effects were reported by a patient, concentration on the activity of the heart and subsequently on respiration was added. Because of the tranquillizing and agreeable effects of warm. baths and cool compresses on excited patients, Schultz then asked his sub- jects to think of warmth in the abdominal region and finally to imagine, “My forehead is cool.” These six physiologically oriented steps: heaviness and warmth in the extremities, regulation of cardiac activity and respiration, abdominal warmth and cooling of the forehead, became the core of autogenic training. During his initial studies, Schultz very soon observed that the best results were reported by those subjects who, assumed a casual and passive attitude during concentration on, for example, heaviness and warmth in the limbs. Gradually, the technique was refined. A number of approaches, verbal form- ulae and training postures were tried out, and from this evolved what are today called the ‘‘autogenic standard exercises.” For advanced trainees an- 12 INTRODUCTION other series of exercises, focusing on certain mental activities, was added, In distinction to the physiologically oriented standard exercises, the latter ones are called “meditative exercises.” Later clinical observations led to the development of a number of physiologically oriented, “organ-specific exer. cises” which were designed to meet the pathophysiologic requirements of certain disorders (e.g., bronchial asthma, pulmonary tuberculosis) more specifically. Similar to the organ-specific exercises, another category of com- plementary approaches, the “intentional formulae,” were designed to in- fluence more specifically certain mental functions and behavior deviations, Both the organ-specific exercises and the intentional formulae are always applied in addition to or in combination with the standard exercises. For purposes of quick orientation, a number of points concerning applica- bility, predictability and control of autogenic therapy may be presented: Clinical results demonstrate that many patients suffering from a variety of long- standing psychosomatic disorders like chronic constipation, bronchial asthma, car- diospasm, and sleep disorders have been cured or have improved considerably in periods ranging from two to eight months. Jt has been observed that behavior disorders and motor disturbances like stut- tering, writer’s cramp, nocturnal enuresis, certain states of anxiety and phobia and other neurotic disorders can be treated effectively. Over periods ranging from a few weeks to several months, depending on the particular case, patients have reported that their anxiety, insecurity and neurotic reactions have smoothed out or have gradually lost their significance. Generally, an increase in emotional and physiologic tolerance, with a considerable decrease in the previous need for reactive affective discharge, is reported. Social contact becomes less inhibited and more natural. In- terpersonal relations are reported as warmer and more intimate with certain persons and less emotionally involved with others. It has been noted that autogenic therapy improves self-regulatory functions and thus not only enhances a person’s over-all capacity for psychophysiologic adapta- tion but also increases bodily resistance to all kinds of stress. Furthermore, it has been observed that with the help of autogenic training un- conscious material becomes more readily available. Dream material and memories can be more easily reproduced by trainees than by other patients, and free associa- tion also appears to be enhanced. In contrast to other psychotherapeutic approaches, relatively little time is re- quired for this type of therapy. When each step of a series of mental exercises has been introduced to the patient, only periodic control sessions for guiding the patient are required. The patient carries out his own therapy by performing a number of mental exercises for about ten minutes twice a day. Group therapy is possible. : The effectiveness and the progress of the therapy can be controlled by physiologi¢ and psychologic tests. In most cases it can be predicted, after only a few sessions, whether or not the patient will respond to the therapy. Autogenic training can be applied to about eighty to ninety per cent of adults of{REDUCTION OF AFFERENT STIMULI 3 all ages: ‘Treatment of persons with severe mental deficiencies, is usually regarded as impossible, as is treatment of psychotics. The method has been applied successfully to adolescents and children, although pelow the age of ten difficulties may be frequent and no success has been reported with children. below the age of six. Clinical observations and experimental data indicate that autogenic therapy © ts of systematic mental manipulation of psychophysiologic functions involving functional changes of highly differentiated mecha- nisms in the diencephalic area. Since the verbal content of the autogenic formulae, as well as the duration and sequence of the exercises, must be dapted to the patient’s functional state, @ careful and critical carefully a control of the patient’s training symptoms is required. For these reasons the application of autogenic training must remain in the hands of physi- cians, who are able to evaluate the patient’s condition and the symptoms he notices during the therapy- 2. Reduction of Afferent Stimuli and a successful therapeutic result from autogenic exercises, afferent. stimuli must be reduced to the lowest: possible physiologic level. The exercises should be practiced jn a quiet room with reduced lighting so as to exclude the possibility of disturbance. Whether the subject lies on a couch or sits on @ chair, all restrictive clothing (e-£-5 glasses, belt, girdle, necktie, wristwatch) should be loosened or removed. For a successful beginning, Hor1zoNTAL Position The beginner will find that the easiest way to learn the autogenic exer- cises is to do them while relaxing on @ couch or bed. He should lie on his back so as to exercise systematic control of several important factors. The legs should be slightly apart and relaxed so that the feet are in- clined outward at a ‘v-shaped angle. In many cases, some support (a folded blanket) under the knees will help to provide maximum relaxation for the proximal muscles of both legs. The heels should not touch each other. Trunk, shoulders, and head should be in & symmetric position. Particular care should be taken to determine the most relaxing position for the head, neck and shoulder sections by trying out different pillows to support them.The arms should lie relaxed and slightly bent beside the trunk. The § gers should remain slightly spread and flexed and should not touch 4 trunk. Failure to observe one or another of these points may result in und sirable side-effects during or after the exercises. The most frequent con sequences of an asymmetric position of the head or incomplete relaxatioy of neck and shoulder muscles during the exercises are residual tensions o stiffness in the neck or shoulder regions. Relaxation of the neck and shoul. der sections remains incomplete or even impossible, in some instances, owing to the use of foam-rubber upholstery, mattresses and pillows. Case 1: A 46-year old engineer who preferred doing the exercises on the floor, us- ing only a pillow to support his head and neck, complained during one of the con- trol sessions that his exercises (heaviness, warmth, heart-regulation) had not been going well. He also reported occasional stiffness in the neck and shoulders. In the therapist’s office, however, and during earlier phases of the treatment, he had had no particular difficulties and regularly reported satisfactory results. Detailed in- quiry revealed that the patient had recently exchanged his feather-filled pillow for a foam-rubber one. When he reverted to the less resilient feather pillow during the exercises, satisfactory results were obtained. Case 2: A 43-year old architect reported that his exercises were much more efi- cient when he performed them lying on the floor rather than on his foam-rubber mattress. In bed he had difficulty in relaxing because “something” kept pressing against his back and legs,REDUCTION OF AFFERENT STIMULI 3 From these and similar observations, it appears that preference should be given to semiresilient or nonelastie materials for the pillows and up- holstery of the training couch, bed or chair. Another point, one frequently overlooked in group-training in wards, is that the majority of patients will relax more completely and perform the exercises more effectively when given some support for the knees. Case 3: A 33-year old housewife tried regularly for 10 days to establish warmth in her right leg, without success. No particular difficulties had been reported during the “heaviness” phase of the training. ‘The patient reported that the feeling of warmth in the right and left arm had been readily experienced at the first attempt. A thorough discussion revealed that heaviness in both legs had been achieved occa- sionally, but that the legs in those instances had been distinctly less heavy than the arms. The next day, with the knee-joints adequately supported so that the legs were resting comfortably in a slightly flexed position, the patient experienced an increased sensation of heaviness in both legs and slight warmth in the distal parts of the right leg. Two days later, “agreeably flowing warmth” in both legs was re- ported. While doing the exercises on a couch or on the floor, it is advisable that the shoes be removed. When a light-weight blanket is used for cover, it should not be tightly wrapped around the trunk or legs, since any restric- tion or pressure, especially on the feet and toes, may have a distracting effect (afferent stimuli) on the trainee during the exercises. By the same token, the feet must not touch parts of the bedstead or even come too close to it. Other disturbing factors may be one elbow or hand lying too close to a cold wall or so near to the edge of the mattress that the arm may slide down. Some patients may complain that the texture of the blanket causes distracting sensations on the hands, ete. The functional effects (afferent stimulation) of such details are frequently underestimated. Sirrinc PosrurEs Autogenic training can be performed in a sitting posture provided that certain anatomic, physiologic, and other factors of a more technical na- ture are taken into account. There are two sitting postures which comply with the principle of achieving optimal conditions of muscular relaxation by minimizing proprioceptive and exteroceptive afferent stimulation: (a) the reclining chair posture and (b) the simple sitting posture. In both sitting postures, it is easy to achieve natural muscular relaxation so long as cer- tain conditions are carefully fulfilled. The reclining chair posture requires an armchair with a high back so that trunk and head may rest passively and comfortably in a reclining position. The vertical distance between floor and seat should correspondFig. 2. The reclining chair posture.to the length of the traince’s shanks so that the upholstery does not exert, any pressure on the dorsal parts of the thighs and does not interfere with local circulation. Short persons usually fecl more comfortable if their feet have some support. The length of the seat should be equal to that of the trainee’s thighs so that the small of his back rests comfortably against the back of the armchair. The armrests should enable the patient to Test his forearms at a cubital angle of about 120-130 degrees. This semiflexed position of the arms corresponds approximately to the physiologic balance of tension between the relevant flexor and extensor muscles when not in- nervated. Any pronounced flexion or extension of the arms would result in an increase of proprioceptive activity and consequently have unfavor- able effects (afferent stimulation) on the physiologic conditions required for the exercises. The hands and fingers may rest in a relaxed position on the armrests or, preferably, hang loosely toward the inner side of the arm- chair. The legs should be approximately parallel to each other, while the thighs are at a slight angle. The feet should rest firmly on the floor to give solid support to the weight of the more proximal parts of the legs. The feet should form a slight angle, with the heels slightly apart. The simple sitting posture is the one most frequently adopted in auto- genic training. This posture is of great practical value because it may beThe simple sitting posture: (a) side view; (b) front view.A j a iastatliteimcsiittaaticiiaedl Bass, Fic. 3. The simple sitting posture: (a) side view; (b) front view. used with a straight chair or any type of sitting support. However, both feet must rest solidly on the ground and the edge of the seat must not exert any pressure on the thighs. This posture may require some prelim- inary training for the individual to achieve generalized muscular relaxa- tion. When aiming at the lowest level of afferent and efferent nervous activity, it is essential to develop a posture of the trunk, head and arms which permits a state of generalized relaxation of the striated (voluntary) musculature. To accomplish such a state of relaxation in the sitting posi- tion, the patient should straighten up completely while both arms are hanging down, and then suddenly relax completely; this will result in a vertieal collapse of trunk, shoulders and neck. In this posture, active in- nervation of the voluntary muscles is reduced to a minimum and the body is supported by the skeleton and the ligamentous apparatus only; in other words, the body is hanging and resting on its bones and ligaments. As a functional consequence, the lumbar lordosis (existing normally dur- ing erect posture) is modified and the back assumes an arched form. As the cervical muscles relax, the head drops forward. The arms, which up to now have been hanging loosely down the trunk, should now swing for- ward and be dropped on the thighs so that hands and fingers hang loosely between the knees without touching each other. In this position a proxi- mal section of the forearm rests on the central portion of each thigh. It should be observed that, to avoid pressure on the abdomen, the trunk collapses vertically without bending forward,8 TRAINING FORMULAE AND PASSIVE CONCENTRATION To test the trainee’s state of reluxation, it is recommended that he lift his hand, which should drop of its own accord. CiosurE OF EyEs A further reduction of afferent stimulation by closing the eyes is desir. able as soon as optimal body posture in either of the three training pos. tures is established. The psychophysiologic implications of closing the eyes under conditions of extreme passivity have been frequently elaborate in connection with phenomena observed during hypnosis. From relevant studies it is known that there exists a functional relationship between the phenomenon of eye closure, certain eye movements and particular Dosi- tions of the eyeball, and certain states of mental activity. Here, closing the eyes serves the same purpose as in falling asleep. It should be explained to the trainee that, during the learning stage, any active innervation of the eye muscles must be avoided and that any particular effort to provoke or to maintain certain positions of the eyeballs may cause headache or ocular migraine. Case 4: A 48-year old lawyer complained during the second week of his auto- genic training (“right arm heavy’) about slight headaches during and after the exercises. After some discussion, it was disclosed that the patient had read an article about hypnosis in which the upper-inner position of the eyeballs was described as very helpful for reaching a hypnotic state. From this article the patient had assumed that his progress in establishing heaviness would be faster if he would practice this during the exercises. After being told to discontinue this procedure, his headaches disappeared and normal progress continued. With closure of the eyes, all requisite conditions are established for a mental state of a very low level of afferent and efferent nervous activity. 3. Training Formulae and Passive Concentration Structure anp ImpuicaTions or THE STANDARD FORMULA The particular form, content and sequence of the different standard for- mulae are based on clinical and experimental observations of psychophy* iologic changes (e.g., muscular relaxation: Tee vasodilatation’ “warmth”) as they occur normally during sleep, during hypnosis 0° as the result of pertinent, therapeutic procedures, iTRAINING FORMULAE AND PASSIVE CONCENTRATION 9 The verbal structure of each formula is kept as simple as possible and is guided by the following principles: (a) The content should aim directly at the functional result wanted (e.g., “My forehead is cool’); (b) The verbal content and the sequence of different formulae should be critically adapted to the functional implications of the physiologic mechanisms involved (e.g., first step: “heaviness” = muscular relaxation; second step: “warmth” = vasodilatation; not vice versa) ; (c) The verbal structure and content should not imply any active, goal- secking effort on the part of the patient but, rather, should emphasize a passive, casual attitude toward the specific functional result to be achieved (e.g., “My right arm is warm”, not “I want my right arm to be warm”). (d) The formula should not include or imply any negations (e.g., “My legs and feet are heavy; my feet are warm” are good formulae, while “My feet are not cold any more” is not). (e) The verbal content should be adapted to the functional state of the trainee (e.g., in cases in which “My right arm is warm” causes disagree- able circulatory reactions, one should substitute “My right arm is slightly warm” or “My right hand is warm’’). The trainee’s passive and casual attitude toward the intended functional changes is regarded as one of the most important factors of the autogenic approach. Usually, a discussion of this requirement with the patient is necessary. It should be pointed out to the patient that the human organ- ism is equipped with systems, mechanisms and regulatory principles that work automatically: for instance, the heart beating by itself, the respira- tory mechanisms coordinated by certain nervous centers and not requiring any voluntary control, the numerous other mechanisms responsible for defecation, excretion, menstruation, sleep, etc., with all these functions being interrelated and coordinated by neural centers, the work of which need not concern the patient at present. Any more or less conscious con- cern on the part of the patient with one or another function or system which usually works automatically may initiate new functional disturb- ances or add to others already existing. According to clinical observation, the best approach is to let the various systems and mechanisms do their job without giving them any sort of mental attention. It should be pointed out that the content of the verbal formulae and the sequence of the differ- ent exercises are designed to support and reinforce the organism’s natural tendency for multifunctional self-regulation. Passive CONCENTRATION The mental activity applied during autogenic exercises is conceived of as “passive” concentration and may best be explained in contrast to what usually is called concentration or, more precisely, “active” concentration.a; 10 TRAINING FORMULAE AND PASSIVE CONCENTRATION Concentration in the usual sense is a highly complex mental function and has been defined as “the fixing of attention or a high degree of intensit of attention” (J. Drever, 1955) or as “the centering of attention on = tain parts of experience” (H. C. Warren, 1934). Concentrating, in the usual sense, on some problem or activity may be conceived of ag a process of mental focusing, with an active, goal-directed investment of mental energy and will power, which implies an active effort of the person toward the intended functional result (e.g., copying a difficult design as correctly as possible). This usual type of concentration is thought of as “active” concentration because of the goal-directed efforts toward the final fune. tional result to be achieved. The decisive difference between this usual type of “active” concentra- tion and the “passive” concentration used during autogenic exercises lies in the person’s attitude toward the functional result to be achieved. “Pas. sive” concentration implies a casual attitude and functional passivity toward the intended outcome of his concentrative activity, while “active” concentration is characterized by the person’s concern, interest, attention and goal-directed active efforts during the performance of a task and in respect to the final functional result. From a psychophysiologic point of view the trainee’s passive concen- tration during the exercises is prepared by (a) the reduction of exterocep- tive and proprioceptive stimulation, and (b) by the particular verbal structure of the formula which implies that it (the relevant system) works automatically. In addition to this, the trainee’s casual and passive atti- tude toward any more or less specific functional effects is emphasized again during the practical application of the formula during the exercises. Apart from the trainee’s indifferent and passive attitude toward the various functions of his body, two other functional factors, both of which belong in the category of concentrative activities, are required for the successful application of a given formula: (1) mental contact with the part of the body indicated by the formula (e.g., the right arm), and : (2) maintenance of a steady flow of a filmlike (verbal, acoustic or VIS ual) representation of the autogenic formula in the mind. From experimental and clinical observations, it is known that the fune- tional effect of physiologically oriented formula (e.g., “My right arm 8 warm”) depends on and varies with the particular type of mental com tact with the relevant part(s) of the body (e.g., the whole right arm). mn instances in which the trainee does not establish proper mental contac with the part of the body indicated by the formula, inadequate, paradoxie, or no results will be obtained. Case 5: A 28-year old salesman who was training on “My right arm is wa"TRAINING FORMULAE AND PASSIVE CONCENTRATION: 11 complained of an uncomfortable, sometimes even painful “blood pressure” in his right hand and fingers. N able “warmth” in the other parts of the right arm was observed. A diseu: ed that the patient, instead of establishing mental ight arm, was training with a “mental focus” on his right hand. it was nece: transitory measure to continue the exercises with focusing on the upper section of the right arm until this part heeame warm and the pressure-like sensation in hand and fingers had subsided completely. Later, the s continued by establishing mental contact with the whole right arm, wed trainee) observed, while applying r plexus is warm,” that “warmth” was alternating between the solar plexus nd the intrapelvie regions. It was recalled that during the exercise, the formula, “My solar plexus is warm,” was repeatedly interrupted by intruding associations of a different formula which aims at increase of intrapelvic circulation. In general, it has been found very helpful to tell the patient to try to visualize mentally the relevant part of the body before he starts working with the corresponding formula. Occasionally, it can be observed that the trainee during the exercises spontaneously turns his head slightly toward the relevant side as if he were looking at the right (or left) arm. In some cases the patient’s mental contact may be facilitated or reinforeed by slightly stroking or touching the corresponding parts of the body just before or during the exercise. Localized faradization has been reported as very helpful in establishing, in the case of exceptional difficulties, an ade- quate functional contact with certain parts of the body.°* Even the more experienced trainees who begin training on “My solar plexus is warm” will find it easier to obtain corresponding functional results if a thorough discussion and pictorial demonstration of the relevant anatomicophysio- logical relations takes place prior to the actual introduction of the formula. In trainees who did not know where and what the solar plexus was, fune- tional results were obtained only after corresponding explanations were given. An adequate mental contact with the relevant part of the body appears to serve as an important connecting factor in the chain of neural elaborations which are responsible for working out the final physiologic result. Once having established mental contact with that part of the body indicated by the formula to be applied, the traince starts concentrating ‘on the autogenic formula while maintaining a casual attitude toward the intended functional result throughout the exercise. The majority of trainees will find the verbal form of mental repetition the most adequate type of mental activity for passive concentration. Others may prefer to visualize the formula in print or as a neon-light advertisement which they may switch on and off at will. Usually, a few questions and brief ex- planations are needed to find out whether acoustic, visual or simple verbal repetition is the form most suitable for the trainee’s passive concentration12 TRAINING FORMULAE AND PASSIVE CONCENTRATION during the exercises. In cases in which no definite decision in this Tespect can be reached ad hoe, the different modalities of mental activity (acoustig visual, verbal) may be tried out during the first exercises. Onge decided upon, however, the form should not be changed (from visual to Verbal op acoustic, for example, or vice versa) during later Phases of the therapy, Whether the visual, the acoustic or the verbal modality of mental es tivity be chosen for passive concentration, it important for the trainee to keep the text of the formula running in his mind, like a film or Tecord for about 30 to 60 seconds. In the beginning this may be rather difficutt because intruding thoughts may disturb or interrupt the mental training film. A patient who complains about such difficulties should be reminded that passive concentration is new to his brain and that intruding thoughts are quite normal. The best thing in such instances is for the trainee not to worry about these distractions nor pay any particular attention to them but to start with the formula over again as soon as he becomes aware that something has interrupted the training film. After a certain period of regular training, it will become easier to keep the training film going, until finally he learns to switch the formula on and off with ease. Passive concentration on a given formula of the physiologically oriented exercises should not normally exceed one or two minutes. During the ini- tial phase of autogenic therapy, it is preferable to restrict each exercise to about 30 to 60 seconds. Longer periods of passive concentration in the beginning create difficulties for the majority of patients and tend to pro- voke undesirable states of tension. Another reason for keeping the physi- ologie exercises brief is the functional aim of the training: certain mental mechanisms must operate in such a way that finally a very brief period of passive concentration on a given formula will serve to initiate the intended physiologic changes, in a reflex-like manner, almost instantly. Beginners usually report that “heaviness” or “warmth” only becomes noticeable when they continue the exercises long enough (e.g., for 4 to 10 minutes). Such a practice should be discouraged. Even in cases in which no characteristic or intense sensations of heaviness or warmth are reported within 60 seconds of passive concentration, the physiologically oriente exercises should not be prolonged beyond 90 seconds. In this respect it should be pointed out to the trainee that regular application of short: term exercises will train the involved mechanism in such a way that after a certain period of training it will be possible to obtain the physiologi¢ effects of certain formulae in less than 30 seconds. In patients who Ts used prolonged periods of passive concentration in the beginning, seve" difficulties are often encountered in advanced phases of autogenic therapy and in applying certain exercises under everyday circumstances for P™° tical purposes,STANDARD EXERCISES 13 : Since, usually, it is difficult for the beginner to judge the passage of time during a state of passive concentration, it is very helpful to do the training of the new formulae repeatedly under the therapist’s super- vision until the patient has developed an adequate sense of timing. As a rule, each new formula is introduced by the therapist after discussion with the patient. After the patient has assumed one of the specific training postures and has closed his eyes, the therapist starts repeating the (whole set of) formulae in a low and suggestive voice for about 30 to 40 seconds. A subsequent period of about 30 seconds of silence gives the trainee an opportunity for continuing with passive concentration on the new for- mula. After this brief period of passive concentration the patient comes back to normal by: 1. flexing his arms (and legs) vigorously, 2. breathing deeply, 3. opening his eyes. 4. Standard Exercises First Stanparp Exercise: HEAVINESS The physiologically oriented standard series of autogenic training begins with exercises in passive concentration aiming at muscular relaxation. Empirical observations in everyday life and studies of bodily changes occurring during sleep and hypnosis indicate that relaxation of the volun- tary muscles is one of the first physiologic symptoms characteristic of a reduction in mental activity. The feeling of being tired and the process of falling asleep are frequently associated with a feeling of heaviness in the limbs or in the whole body. In keeping with these empiric observations, and with other psycho- physiologic and pharmacophysiologic findings, “heaviness” has been chosen as the central theme of the first exercise. In order to facilitate topo- graphically oriented mental contact during passive concentration, the heaviness exercises should begin with the extremity that already plays a predominant role in everyday life, namely, the right or left arm. The formula to be applied should be: “My right arm is heavy” for right-handed persons. “My left arm is heavy” for left-handed persons.14 STANDARD EXERCISES It has been found that passive concentration will be facilitated an, that the physiologic effects of the autogenic exercises in Seneral wil] be enhanced if this first formula is associated with peaceful images Which provide a calming background for the trainee’s state of mind, This is why the first physiologically oriented formula of each exercise should be applied in combination with a “background” formula such as: “I am at Peace,” About 80 per cent of trainees spontaneously respond with highly charac. teristic associations, as, for example, lying on a peaceful sunny beach or lying on a meadow on a beautiful summer day. The patient should be asked to recall a peaceful image that corresponds with the training pos. ture. When the exercises are done in a sitting posture, it is appropriate to think of “sitting in a boat while drifting over a peaceful lake.” However, once the trainee has selected his image, he should be told to use the same background image throughout the autogenic therapy. Switching to other images during later phases of the standard series may have an inhibiting effect on the progress of autogenic therapy. For the first exercises, which should be limited to about 30 to 60 sec- onds of passive concentration, the following pattern has been adopted: Trainee, lying down on a couch, relaxes in typical training posture and closes his eyes. Doctor (in calm voice): “I am at peace... . My right arm is heavy.* I am at peace. ... My right arm is heavy... My right arm is heavy. ... My right arm is heavy.” Trainee: Continues with passive concentration on “My right arm is heavy” for about 20 seconds. Doctor: “Come back to normal.” Trainee: (a) flexes his arms vigorously, (b) breathes deeply, (c) opens his eyes. The trainee should develop the habit of systematically innervating toes, feet, legs, shoulder, arms, fingers, neck and head directly after he has opened his eyes. This procedure is important in several respects. By slightly moving the different parts of the body, the trainee makes sure he has everything under control. At the same time, particular after-effects, such as residual tensions or residual heaviness in the training arm, can be detected (e.g., by comparison of the training arm with the other extremities). Furthermore, from a physiologic point of view, this type of control provides functional contrast to the relative absence of afferent and efferent nervous activity dur- ing the exercise. For the same reason, the trainee should maintain some de- gree of motor activity during the interval following each exercise. It 18 suggested that fingers, toes and feet should be innervated more or less sy" tematically. It has frequently been observed that when there is no motor * Repeat several times,STANDARD EXERCISES 15 activity between exercises, the autogenie state of relaxation will establish itself in a reflex-like manner and/or that the trainee will fall asleep. Usually, three exercises are done successively with about one minute between. After cach, the doctor or trainee should take notes of what has happened during the exercises. The patient should be encouraged to re- port his impressions and feelings during and after passive concentration. Frequently, the trainee will answer, “The same as before,” or “Nothing.” In such cases, it should be explained that autogenic therapy has to be adapted to the symptoms the trainee reports, as well as to other observa- tions of a more objective nature (see pp. 227ff.). Practically no exercise will be the same as yesterday’s or even the one just completed. There is always something to report. It should be emphasized that even those things which the traince may regard as “funny” or “not important” may be valuable pointers for the therapist. The notes about each exercise serve as controls for the trainee and the doctor. Notes also provide a valuable source of information, particularly in those cases in which difficulties are encoun- tered during later phases of therapy. As a rule, the trainee should neither be told what symptoms may develop nor what the indications are for changing the formula or adding a new exercise. To avoid anticipation and bias, it is preferable for the trainee to have no particular knowledge of the sequence of further advanced phases of the autogenic training. A difficulty that is frequently overlooked is the trainee’s experimenta- tion on his own, or his development of too much interest in the symptoms occurring during passive concentration. Very often, a trainee begins to watch himself during the exercises and may even, for example, start lift- ing both arms in order to make a comparison between them while sup- posedly engaged in passive concentration. Any such attention or specific innervation during the exercises reduces passive concentration and may render it impossible. Only during later phases, after the standard series has been mastered satisfactorily, and only in certain cases (e.g., writer’s cramp; sce p. 203), may a direct transition from passive concentration to motor activity be indicated. During the first session, the trainee should be assured that he will re- member particular symptons or sensations after the exercises and that he need not pay attention to them during passive concentration. The exercises should be terminated as soon as distracting symptoms develop, such as the desire to cough or sneeze or tickling sensations on the skin. It is difficult for the beginner to maintain passive concentration when such sensations occur. As a rule, bowels and bladder should be emptied before the exercises are begun. The trainee should be warned against getting up suddenly from a state of passive concentration or immediately after having terminated the last16 STANDARD EXERCISES exercise. Since passive concentration on a certain formula affects auto nomic regulation (see pp. 227-246), a short period (40-60 seconds) shoul be allowed for the readjustment of certain physiologic systems, A. traing who gets up too quickly usually suffers from dizziness. : Autogenic training is best practiced after lunch, after supper and before going to sleep. When a trainee falls asleep during the exercises, it ig sug. gested that the exercises be retraced as soon as the trainee awakes, al. though no negative effects have been reported from the omission Of this procedure. Each new formula should be discussed with the trainee and introduced by the therapist. After the new formula has been introduced, the trainee may continue the autogenic exercises on his own. However, the doctor should see the trainee on three subsequent days and practice the new formula with him. A valuable reinforcement of the patient’s training film is provided by repetition of the formula; also, in most cases a new formula, raises a number of questions and problems which need careful discussion, The trainee may have encountered difficulties, or there may be certain symptoms which help to indicate the trainee’s functional state in respect to immediate or future changes in the therapeutic course (see Case 8), In principle, the trainee should be encouraged to contact the therapist in the event that any particular symptoms have occurred during, between, or after the exercises. After the first exercise, about 60 per cent of a group of 200 trainees reported a distinct feeling of heaviness in the training arm. Very strong effects were noted by 4 per cent, and a rather slight and not very signifi- cant sensation of heaviness was noted by 15 per cent of the cases. No results were observed by 21 per cent. A closer examination of the group which reported no effects revealed that about 65 per cent were not relaxed. Those who reported a sensation of heaviness can be classified by their additional remarks as follows: (a) Feeling of estrangement and detachment of the training arm - 30% (b) Feeling of weakness or lameness in the training arm 3% (c) Numbers or reduced sensibility in the training arm 3% (d) Paresthesia, tingling, twitching or rheumatic-type sensations 28% (e) A feeling of lightness in the non-training arm ae lo No comment Topographically, the localization of the heaviness sensation also shows certain variations. About 60 per cent are equally divided between a feel- ing of heaviness in the whole arm and distinctive sensations of heaviness in different parts of the forearm. Other trainees reported isolated heav ness in the upper arm, the hand, the elbow and/or the wrist joint.