1. Top of page
  2. Abstract
  6. References

Fifty-seven veterans with congestive heart failure were interviewed about their experiences and changes after participating in a three-armed randomized trial: relaxation response (RR) training, cardiac education, and usual care. The interviews were tape-recorded, transcribed, and analyzed. Half of the 20 RR group interviewees reported physical improvements, and 13 reported emotional improvements. These improvements went beyond disease management to lifestyle changes and improved family/friends relationships. Five of 16 cardiac education group interviewees reported physical improvements, and eight reported emotional improvements. These improvements consisted of a better understanding of the disease and resulted in feeling more at ease. None of the usual care group interviewees reported any improvement from study participation. Although group support contributed to the benefits reported by RR and cardiac education groups, the use of the RR techniques seems to be the factor that distinguished the improvements. The value of the RR in congestive heart failure health care is suggested by the results.

Approximately 5 million Americans live with chronic heart failure (HF), with 550,000 new cases reported each year. For those aged 65 years or older, the incidence rate is as high as 10 per 1000 persons. The total annual national medical cost for chronic HF is $24.3 billion.1 As the population ages, the incidence and cost of chronic HF will increase. The development of significant pharmaceutical treatments for chronic HF patients has led to symptom relief and reduced rates of hospitalization and death.2 Despite these advances, patient morbidity and mortality remain high and health care utilization is heavy. Further, the quality of life of chronic HF patients has been shown to be poorer than that of patients with other chronic conditions.3

Nonpharmacologic interventions such as exercise training and biobehavioral changes have been suggested as adjuvant therapy to the traditional pharmacologic approach for chronic HF.4 Among various biobehavioral interventions, the relaxation response (RR) has been widely studied and has been found to be effective in managing conditions that are prevalent among chronic HF patients, such as hypertension,5–10 coronary artery disease,11 and depression and anxiety.12–16

The RR is a state in which individuals evoke a bodily calm that has the opposite effect of the fight-or-flight response, with concomitant favorable physiologic changes.17 The RR does not occur spontaneously, but can be learned. It can be elicited by various simple and noninvasive techniques, including autogenic training, progressive muscular relaxation, meditation, guided imagery, certain types of prayer, breathing exercise, and yoga.

So far only a few pilot studies have focused specifically on studying the effects of RR on chronic HF patients. One pilot study evaluated the effects of an 8-week stress management course that involved a certain type of meditation training in elderly chronic HF patients. Fourteen participants who were assigned to the treatment group noted significant improvements in perceived stress, emotional distress, 6-minute walk performance, and depression compared with the control group.18 Another small pilot study found that after 3 weekly, 90-minute guided imagery training and home practice sessions, eight patients with New York Heart Association (NYHA) functional class III chronic HF showed improvement in some of the quality-of-life measurements. However, no significant improvement was observed on exercise performance or dyspnea scales.19

In light of the results reported by these pilot studies, we evaluated the effects of RR on chronic HF patients by conducting a three-armed randomized clinical trial. In addition to the RR arm, two control arms were included, consisting of a cardiac education (EDU) arm and a usual care (UC) arm. The EDU arm was included to control for possible effects from group support and interactions and for patients' improvement expectations simply by participating in the intervention. A special feature of this trial was the inclusion of a qualitative study. Qualitative studies can provide valuable information about how and why an intervention works or fails.20,21 This type of information is especially important for an intervention such as RR. The benefits that patients could obtain from the intervention might not be captured by the standard quality-of-life measures. In this article, we report the results from the qualitative substudy. Specifically, we describe patients' self-reported physical, emotional, and social changes after participating in a RR intervention program compared with the two control groups. We also speculate about the reasons for these changes.


  1. Top of page
  2. Abstract
  6. References

The Randomized Trial

In April 2000, we began a three-armed randomized trial at the Veterans Affairs Boston Healthcare System. We enrolled a total of 95 ambulatory chronic HF patients with moderate levels of symptom severity (NYHA class II or III) and reduced left ventricular ejection function (≤40%). Enrolled patients were randomly assigned with equal numbers to one of the three study groups: RR (study intervention), EDU, and UC. The details of patient recruitment and study sample characteristics are described elsewhere.22

Study Intervention

Enrolled patients who were randomized into the RR group were required to attend a 90-minute group session each week for 15 weeks to learn eight techniques to elicit the RR. The techniques included breathing awareness; mental repetition of a word, sound, phrase, or prayer; mindfulness meditation; guided body scan; progressive muscle relaxation; guided countdown; autogenic training; and guided imagery. An audiotape with guided mental repetition of a word, sound, phrase, or prayer; a guided body scan; and a mindfulness meditation exercise was purchased from the Mind/Body Medical Institute.23 The instructions for the other techniques were recorded onto three additional tapes by the study clinical psychologist using a modified version of the scripts presented in a stress reduction book by Mason24 (written permission to record the scripts was obtained from Dr. Mason). Patients were also taught to do short relaxation exercises (minis), which are modified versions of RR and involve focused breathing techniques. Minis can help reduce stress immediately and can be done at any place and any time, especially in stressful situations in everyday life such as being in a traffic jam, when confronted with someone who is irritated, and while waiting for an important telephone call. Trained clinical psychologists, with the aid of these tapes, instructed patients in group sessions on each of the techniques. Patients were asked to practice the techniques at home for 15–20 minutes twice a day using the tapes provided. They were also asked to keep a diary to record the frequency of their home practice.

Cardiac Education Program

Enrolled patients who were randomized into the EDU group were required to attend a 90-minute cardiac education lecture each week for 15 weeks. The EDU group was organized by the Cardiac Rehabilitation Education Program at the Veterans Affairs Boston Healthcare System. The facilitators of this ongoing education program are experts in the following topic areas: medical, pharmaceutical, lifestyle, nutrition, and psychosocial issues affecting people with heart disease and related conditions.

Usual Care

Patients who were randomly assigned to the UC group were not required to attend any group sessions. However, similar to patients in the RR and EDU groups, they were expected to complete the study outcome assessments by filling out questionnaires and undergoing an exercise test at baseline, 15 weeks, and at 6-month and 12-month follow-up.

Qualitative Substudy

The qualitative study was added approximately 1 year after patient recruitment started. Tape-recorded, semistructured telephone interviews were conducted with members of all three groups once they finished the study intervention and/or the first follow-up outcome assessment during the qualitative study period. The interviews consisted of open-ended questions about patients' experiences in the study, changes in their physical and emotional health and life over the course of the study, and overall evaluation of the study. Patients in the RR group were also asked about their practice of the RR at home, and members of both RR and EDU groups were asked about their experiences with the group sessions.

Patient Characteristics

Fifty-seven patients were included in the qualitative study. Of these 57 patients, 20 were in the RR group, 16 were in the EDU group and 21 were in the UC group. The unequal number of patients in each group was due to a higher dropout rate in the EDU group. Eight EDU group patients dropped out of the study before the qualitative study was completed; three claimed the speaker did not show up for the first lecture. There were three dropouts in each of the RR and UC groups. All but two of these 57 patients were male. Patients in the three study groups were similar in age (mean age 69 years) and race (83% white). They also had similar disease severity (52% with the NYHA class II) and left ventricular ejection function (mean value of 32%).


All interviews were tape-recorded and transcribed, and the data were analyzed according to grounded theory methods of qualitative analysis.25 Initially, the team developed broad codes to organize patients' accounts into overall categories such as positive, negative, or no change. Two different coders applied these broad codes independently to all patient accounts for reasons of reliability. Due to the unambiguousness of the codes, the two coders reached almost perfect agreement. The few instances of disagreement in coding were resolved in group discussions by the team. Once reliability was obtained, the thematically organized patient perspectives were analyzed further into summary themes. The method involved “constant comparison” of analytic codes. In particular, accounts of patients assigned to different arms of this study were compared. The continued comparative use of the data led to the emergence of themes from the patient-reported results of their study participation. When disagreements in interpretation evolved, they were resolved by involving the entire team in the data analysis and in the comparison of data segments.


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  2. Abstract
  6. References

We focused on two primary themes in the patient-reported changes in health: physical and emotional improvement.

Physical Improvement

RR Group. Half of the 20 RR group interviewees reported physical benefits that included decreased chest pain and decreased pain in general, a decrease in heart size, decreased blood pressure, easier breathing, less fatigue, and an increased ability to relax and sleep. All of these physical changes were self-reported by patients as their own perception, except one patient who reported that his doctor said his heart was smaller now. Following are sample patient responses:

Well, I haven't had any problems. For a while there I was having problems with congestive heart failure almost every night…. I was waking up in the middle of the night. I was having trouble breathing. I haven't had that problem in a couple of months…. I can't say for sure it was the techniques or what, but I can say that I haven't had any problems in a while now…. I don't have any fatigue. My heart is actually normal now … I just had an echocardiogram and my left refraction is 53% and that's normal.

Thank God, I feel very, very good…. I can exercise now too … with the bike and light weights in the house. As a matter of fact, I saw my heart doctor … and he said my heart is smaller…. I don't know if it was the relaxation. I'm on the same medication … it hasn't changed…. No surgeries.

One man expressed surprise at his newly acquired ability to lower his blood pressure, and another, at his ability to slow down his heart.

[I got] more than I expected really 'cause I wasn't, like I said, I just put it down…. You know, lots of people fly off the handle, and you know, really, it makes sense. You know, sit back, relax, you know 'cause I can lower my blood pressure…. Just by relaxing, I can get it real low if, you know, I want to. It was more than I expected.

People say it's good for the heart, helps you relax a little bit, and it sounds good, so you do it. And I think it has done that. I mean I can actually know I slowed down my heart. It used to pound … but then by using the methods, my heart beats nice and calm and regular.

Patients reported that the techniques helped them with breathing and reducing or eliminating pain.

Well, I do it [RR program] in the evening. Yeah, I could almost say that I do it every night … when I'm laying in bed…. I try to control my breathing because … I've always had a habit. If I think about breathing, I start almost losing my breath. So I just kind of slow myself down … almost every night.

I have no cartilage in my knee … I got arthritis bad. You name it, I got it. What the meditation has done is come into my life and release the pain…. I don't take the pain medication no more…. I was taking 500 mg every 4 hours …. I'll say about 4 months ago I was getting these [migraine] headaches…. So what I basically do is relax and do minis … and within moments, it's gone…I don't take no medication… Not since I've been in the program.

EDU Group. In contrast to the RR group, only five out of 16 EDU group interviewees reported physical improvements. Two suspected that the improvements were due to the new medication they were taking. One indicated being able to do a lot of things after returning home from the group meeting. Another patient said his tiredness got better without elaborating on why it got better. Only one of the five patients explained in more detail his physical improvement:

I noticed I've been able to do things a little bit more than I was able to before I started it [EDU group] and because I've learned a little bit more about what I can and cannot do. Well, of course, another thing too is you're able to discuss a few of the things that you are not quite sure of and that helps a lot in setting things in your mind I think…. The shortness of breath is almost an immediate change. I don't know why, but I didn't do anything particularly in the hospital to change that, but I noticed that when I started … walking, for instance, I didn't have to slow down and sit down for a while. I was able to continue on for a good [amount] of time.

UC Group. None of the UC group interviewees reported improvement in physical health related to heart symptoms. On the contrary, 10 of the 21 interviewees reported that their symptoms got worse, as indicated by needing more medication for chest pain, breathing worse, walking less distance, and memory loss.

Emotional Improvement

RR Group. A majority of RR group interviewees (13 out of 20) claimed that they experienced emotional improvements as a result of participation in the study. These improvements included reduction in anger and frustration, anxiety, fear, and depression. Practice of the RR techniques reportedly eased their emotional tensions and led to feelings of well-being, improved family and social relations, and reduction in dangerous behaviors such as road rage and fistfights. One man related an example of his recent ability to control his explosive anger as a result of learning a mini (a short focused-breathing exercise):

They've got a contractor upstairs doing the apartment above us and I know the guy…. He's throwing joint compound … out the window on top of my vegetables … and I come out there and my cabbage leaves are white and stuff…. I looked down in the garden and I said, “What?!” Then, whoosh, here comes this white watery mix down on top of my strawberries. I said, “Hey … why are you throwing that stuff out the window? You know you're throwing it right down on my vegetable garden?”“Oh, why don't you just wash it off?” [he said.] I said, “What!” You know, I almost lost it … but I took a deep breath, did a little mini right there…. I just smiled at him, shook his hand, and I told him what happened…. [Before] I would have punched him out. I just laughed and just walked away…. I said, “You know, just wash it off!”

A number of RR interviewees specifically mentioned control of “road rage” as an unexpected benefit of the study:

One of the things I learned was tolerance…. I'm a lot more easygoing now…. I don't get as mad as much. You know I deal with my stress a little better than I used to…. I used to have a lot of road rage and I'm not like that anymore.

Well, the biggest thing was it taught me how to control some of my road rage…. I'm able to better cope with the frustration. I would get very frustrated. And now I just do my little mini and I don't get so frustrated.

I am very relaxed now…. I was very tense before. For instance, when I was driving my car I would totally grip the steering wheel like I was going to brake…. Now, I got away from it…. I used to get very angry before. Now, I don't do that anymore.

Many RR group interviewees reported better relations with their spouses and children:

You know, I used to scream and yell at my daughter, what do you call it, be very critical of her. Now I'm better.

Well, I guess you could say I'm more tranquil with [family members]. You know? How can I say it? I don't jump the gun like I used to.

My wife did say one thing to me one day. We went somewhere and she said, “I'm amazed! You used to get mad at that.” She noticed … that I wasn't going crazy!

A general feeling of well-being, including less depression, anxiety, and fear, emerged in most of the reports of emotional improvements. One man even claimed his reduced anxiety led to positive creative surges:

Generally, when I would get stressed out I would just lay down for 10, 15 minutes and kind of like shut everything off … as best I could. And with this breathing thing, I notice that kind of during it and toward the end of it … my creative thinking was working a lot better…. It was very positive. In fact, if for no reason other than that, I would continue doing these things.

In addition to the emotional improvements mentioned above, 13 interviewees reported that they felt more relaxed from the practice of the RR techniques:

I feel more relaxed … when I do it…. I think it relaxed you more, made you more aware of your tension…. I could feel the tension in me more after I started the study… So it made me more aware…. [Others] said I seemed more relaxed.

EDU Group. Like the RR group, interviewees in the EDU group (8 out of 16) also reported reduced stress, increased awareness, and a general shift toward more positive behaviors and attitudes about themselves and their conditions. One man, stressing the value of the lecture series offered in the group, echoed the general nature of the improvements:

Not physically, but mentally I feel more at ease…. I feel a little bit more at ease from what I learned over there … understanding what the people at the hospital are trying to do…. I learned a lot … much more than I expected…. Oh, it worked … tell them it eases their mind and gets rid of some of the anxiety…. I liked the information…. I liked the one [in which] the lady viewed the heart and showed the blockages and different things that would go wrong…. It made me understand what was really going on inside my body.

Another man expressed the value of the interactions among group members:

You were able to get ideas of what other people were going through, and we would discuss both things between ourselves. And I think you learn more that way than trying to read it out of a book or something…. You have other people to talk over with their experiences and how they feel about it. So we are talking among ourselves and this helps a lot because some phrases aren't clear to them and they'd be clearer to me and I'll explain that and they'll explain what isn't clear to me…. So this group thing works out better than if you have a doctor or nurse explain things to you because they automatically explain it to you in as short a time as possible and in medical terms.

UC Group. UC group interviewees almost unanimously reported being resigned to feeling depressed about their conditions and did not harbor any hope for improvements. Most were indifferent to the study and believed it did not change them in any way.

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.


  1. Top of page
  2. Abstract
  6. References

In this article, we describe the self-reported physical, emotional, and social changes of veteran chronic HF patients after participation in RR training, an EDU program, and UC. We also speculated about reasons for these changes. In comparison to the EDU control group, a higher percentage of RR group interviewees reported improvements in physical and emotional health, whereas none of the usual care interviewees reported improvements as a result of participating in this study. The improvements reported by the EDU group interviewees were more directly related to the disease itself, whereas improvements reported by RR group interviewees referred to aspects of their lives beyond their disease.

Most RR group interviewees credited the RR techniques directly, and some indirectly, for emotional, physical, and social improvements. Many spoke of a new-found ability to control or diffuse habitual hostility, including aggressive behaviors such as road rage and fistfights. Equally significant were reports of physical improvements, including claims of the ability to reduce or eliminate pain, regulate breathing, improve the quality and duration of sleep, and even control vital signs such as blood pressure and heart rate. They reported that the increased feelings of well-being and control spontaneously led to improved relations with family and friends, and generally improved their quality of life.

One interesting finding observed in both RR and EDU groups was that there were more emotional improvements reported than physical improvements. This finding indicated that while patients might not experience physical improvements, both types of interventions, RR and EDU, had a positive influence on these patients' emotional well-being.

The value of social support provided by the group members is evident in both RR and EDU group interviewees. Although peer group support contributed to positive results in both groups, it did not account for the qualitative differences between the two groups. RR group interviewees spoke of a sense of greater empowerment, of no longer feeling helpless in the face of forces beyond their control. They expressed surprise, relief, and often elation at having techniques that they could incorporate into their daily routine and tailor to their individual temperaments and needs. These techniques helped them cope with emotional and physical fluctuations at will. Moreover, we found positive associations between the interviewees' self-reported duration and frequency of RR practice and perceptions of improvements in emotional and physical well-being and quality of life.

Other studies have explored patient-reported effects on quality of life using various group interventions that involved cognitive-behavioral stress management techniques, including RR and meditation.26–30 In all of these studies, subjects in the control arm were not exposed to group interactions (e.g., patients on the waiting list). With the inclusion of a control arm that was also exposed to group interactions, our study was able to distinguish the intervention effects that resulted from the RR practice from those that resulted from group interactions. In addition, all other studies were primarily based on quantitative data, while our qualitative data obtained from patient interviews provided rich information that allowed us to speculate and identify the reasons why the RR is effective.

One limitation of this study was that the physical, emotional, and social changes were self-reported and reflected patients' own perceptions. Since our study was not designed to verify patient self-reported changes with the actual changes, future studies are needed to verify the results from this qualitative study by objective physical measures. While the analysis of the quantitative questionnaire data and the exercise test results from the main trial is still in process, it is encouraging to observe positive results from the qualitative substudy. The results of this qualitative study suggest that RR techniques could offer an additional strategy for engaging patients in their own care. This approach has the advantage that it can be practiced at the patient's residence or any other location. No adverse effects have been reported and skill training is relatively simple. Clinicians have an important role to play in introducing patients to these new practices and in encouraging compliance with a practice regimen.

Acknowledgment and disclosure: The authors thank the veterans who volunteered to participate in the study and the personnel who contributed to this project in recruitment and by conducting study intervention, qualitative interviews, and analysis. This research was supported by the Department of Veterans Affairs, Health Services Research and Development Grant (IIR 99–241). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.


  1. Top of page
  2. Abstract
  6. References
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