Underlying Differences in Group Responses
Through a comprehensive analysis of all of the responses, we identified two factors that appeared to contribute to the notable differences between the UC group compared with the two intervention groups: the camaraderie, support, and cathartic opportunities provided by an empathetic group with common experiences and concerns; and the new knowledge offered by the specific intervention (the RR techniques for the RR group and information about their disease, bodies, and medications for the EDU group).
Both the RR and EDU groups benefited from the peer group interactions. Knowing they were not alone in their suffering and not the only ones experiencing frightening symptoms and limitations, was experienced as comforting. Hearing about another patient's positive experience or unexpected improvement provided hope and inspiration, gave them more confidence, and encouraged them to make lifestyle changes they would not have otherwise made. Hearing others verbalize questions and concerns that they were either unaware of or unable to express helped relieve frustration and tension. One man, with his wife supporting his assertions, summed up the general EDU group experience:
Well, I liked it all. I enjoyed it so…. I think it helped…. [I] enjoyed talking with other people … who had a lot of the same problems [I] had. [His wife notices changes and speaks for him in this instance] It helped him improve. He wasn't improving at all and he wasn't exercising and he wasn't doing a lot of the things I wanted him to do. But after he heard other people talk about it and they had improved so he felt he would improve…. It made him know that he could change too, that he could get better.
An RR group interviewee expressed similar concepts and spoke for his group:
I think it was positive…. I enjoyed being there…. It gave me a better understanding, listening to some of the difficulties that other members were having. It gave me a better appreciation and understanding of what can happen with a heart condition…. And their dealing with their stress and anger management and things of that nature.
The difference in the nature of the intervention each group received emerged as the primary factor responsible for the more extensive changes reported by the RR group as opposed to the EDU group; that is, the perception of additional control over their bodies, emotions, and behaviors as a result of learning the RR techniques. This greater control extended beyond the individual and the family into society by reducing violent behaviors, such as road rage and fistfights, and by reducing aggressive and negative judgmental attitudes, more patience when waiting, with crowds, and with opposing opinions.
Unlike the RR group, the EDU group emphasized physical and emotional relief from greater knowledge about their illness, their symptoms, their possibilities for improvement, and their entertaining more creative means of coping with their improved lifestyle changes.
[During] the 15 weeks I learned quite a bit about myself and about my heart disease…. We had excellent speakers and they did not speak like the medical terms and all that…. We had the one that discussed the value of exercise and … then there was a doctor that came in and talked about … what heart disease was, and she explained it a little more fully than I've had it explained before, so it made me aware of a lot of things that I wasn't aware of…. I know I did slow down and did not do stressful things.
The success of the RR techniques in the apparent reduction of emotional and physical stress reported by the interviewees seemed to be rooted in three basic factors: the patients' ability to use these techniques independently; the ease with which these simple tools can be incorporated into daily routines, especially while walking or driving; and the flexibility to tailor the techniques to individual temperaments and needs. One man summarized the major attributes of the practice:
First thing in the morning after you brush your teeth and use the … bathroom and all that stuff, you do your meditation. And it's better because you can start your day fresh…. And in the evening, you've got to find a quiet time…. I've learned a lot … and still learning because the tapes are becoming clearer…. The longer you listen to them, the clearer it becomes. I do the minis on the bus, the train, when I'm on the boat. Before I was scared to get on the boat. Now I'm on the boat.
One patient reported the ease with which he was able to continue his regimen even on vacation:
I believe in it. I think I've seen some changes that are positive…. I think that's part of it and then I just continued it, you know. But I still do it here. I don't know if I do it more than the average… but I do it at least once a day. I think it's doing me some good so that's why I keep it up…. I even last year took it on vacation…. I just used the portable machine…. I don't miss often.
One patient credited the study, and the RR technique in particular, for the positive changes in his life. He also commented that his wife noticed the benefits of RR:
I was so edgy and didn't know why. I'd be snapping at people like a turtle and getting very upset about things that didn't even matter…. You know what my wife would say?…“Did you do your therapy today?”… I say, “Yes, Baby.”“You did your meditation [RR techniques]? Keep up the good work! Make sure you keep it up!” With her, no snapping and barking, and just like everything else, I just toned down. I learned tolerance…. I didn't have that before…. Oh, I'd get pissed off about hardly nothing, you know? This course … changed [us] … Everything in the study … has helped me so much…. I'm me without the negative…. I'm me with the positive.
The majority of interviewees in the RR group reported that the most used and most beneficial techniques were the breathing exercises called minis. These techniques were portable and invisible; that is, they could be practiced anytime, anywhere and are inconspicuous, allowing the patient privacy and anonymity. All interviewees who reported gaining control of their anger, and in particular their road rage, credited the minis with their success: Yes ma'am…. She taught us how to use [the tapes], so I just use them…. I use one every day…. A different one. [When asked which technique he liked the best] The one that, you know, you can breathe without the [tape recorder]. They're called the minis…'cause you can do them any time. You can be out walking, you know. You don't have to wait to do them; you can do them anytime…. I don't need the tapes for the minis, but I use the tapes for the others.
I practice minis often, very often…. If I'm watching TV, I'll do it during the commercial…. Oh, at least 8–10 times a day…. And I listen to the tapes… maybe five times a week….
Twelve reported using the tapes on a regular basis. Many, however, reported having internalized the techniques and “practicing in silence.” When asked if he practiced in silence, without the tapes, one man replied:
Oh yeah, I do that quite a bit…. Once you know how to use the machine, you can do it by yourself…. I use the machine, but I can do it without the machine…. You just have to put your mind to what you are doing.