The InternationalJournal of the Addictions, 25(8), 861-888, 1990

Restricted Environmental
Stimulation and Smoking Cessation:
A 15-Year Progress Report
Peter Suedfeld,. PhD, FRSC
The University of British Columbia
Vancouver, British Columbia

Abstract

The first successful use of restricted environmental stimulation ther-

apy (REST) as a method of smoking cessation was reported in this
journal in 1972. Since then, close to 20 papers and articles have further
investigated this application. The results have been consistently posi-
tive and have further shown that-unlike most techniques-REST
combines synergistically with other effective treatment modalities.
The effect of REST seems to target primarily the major problem with
other known treatments in this area: It substantially reduces the relapse
rate among clients who quit smoking at the end of treatment. Further-
more, REST is safe, has no known adverse side effects, and is easily
tolerated by most participants. Nevertheless, the method has not found
wide acceptance among practitioners. This paper explores and answers
some of the concerns that may be involved in its relative lack of popu-
larity.

*Address all correspondenceto the author: Dean of the Faculty of Graduate Studies, The Uni-
versity of British Columbia, Vancouver, BC, Canada V6T 1W5.
861
Copyright 0 1990 by Marcel Dekker, Inc.
862 SUEDFELD

THE TROUBLE WITH SMOKING CESSATION TECHNIQUES

There are two things on which reviewers of the smoking cessation literature
agree. One is that intervention techniques have generally poor long-term results,
due to a uniformly rapid and sizable relapse rate-50-75 % of originally success-
ful participants-within a year after the completion of treatment (Bernstein,
1969; Bernstein and McAlister, 1976; Hunt and Matarazzo, 1973; Lichtenstein,
1982; Pechacek and McAlister, 1980).The second point of agreement is that spe-
cific treatment procedures are not of very much relevance. Among the studies
that compare alternative treatment methods in controlled designs, there seems to
be no firm evidence that these alternatives or combinations lead to different long-
term effects (Bernstein and McAlister, 1976; Lando, 1982; Lichtenstein, 1982;
Raw, 1978). The seemingly logical inference that the major treatment effects are
due to nonspecific factors such as expectancy and therapist contact (e.g., Raw,
1978) has been mostly ignored by researchers and clinicians.

REST AS A SPECIFIC SMOKING TREATMENT

The first purpose of this paper is to describe an intervention technique

whose first use in smoking cessation was reported in this journal 18 years ago.
Subsequent research has demonstrated that this technique, restricted environ-
mental stimulation therapy (REST), leads to a relatively low relapse rate and
combines synergistically with other methods. Second, I want to look at why this
technique remains largely unutilized or at least underutilixed, in spite of a series
of research studies with positive results.

REST and Smoking Cessation: A Brief Review

The first successfu1demonstration that stimulus reduction could be a useful

tool in habit modification occurred around 1970. At that time, several publica-
tions had demonstrated that REST facilitated persuasion, at least when the atti-
tudes being manipulated were trivial and peripheral, and the measures were lim-
ited to simple (most often -3 to +3) scales (Suedfeld, 1969a).
To go beyond these limitations, we needed a topic that engaged central and
important attitudes, had a clear-cut and measurable behavioral component, and
could be confronted without a breach of professional and scientific ethics. After
considerable discussion, and taking our lead from the then-fresh Report of the
Surgeon General of the United States, we decided that cigarette smoking met
these criteria perfectly. In view of the well-known difficulty of treating smokers
successfully, we did not believe that any change in actual smoking behavior was
at all likely.
RESTRICTED ENVIRONMENTAL STIMULATION 863

The 2 x 2 design of our first study (Suedfeld, Landon, Pargament, and

Epstein, 1972) became a prototype for such investigations. It was comprised of
the presentation or absence of a persuasive message in either a REST or a non-
confined condition. Again prototypically, REST consisted of 24 h spent lying
(with a request to maintain minimal movement) on a comfortable bed in a com-
pletely dark, somewhat sound-reducing chamber. The procedure that we fol-
lowed had proven in many studies to lead to a pleasant experience for most sub-
jects, and a tolerable one for almost all. Our early attrition rate was well under
10% among subjects who were scheduled for 24-h sessions but could end the
session at any time, and there had never been any sign of serious negative side
effects or aftereffects. The message took less than 2 min and consisted of a sum-
mary of the Surgeon Generals finding that cigarette smoking led to an increase
in the probability of developing various cardiovascular and pulmonary problems.
It was read in an unemotional, even monotonous, voice and presented over the
intercom about an hour before the end of the session.
While attitude data showed various complicated changes, they are not rele-
vant here. What is relevant is the behavioral aftermath. Three months after the
session, each subject reached - 70% of the original sample - received a tele-
phone call from someone who was conducting a survey on the smoking habits of
college students. No connection with the REST study was mentioned, so as to
minimize distortions due to compliance or evaluation apprehension. Among the
subjects in the two REST groups (i.e., regardless of the message), there was a
mean decrease in smoking rate of almost 40%; in the nonconfined message
group, which had merely heard the tape at the laboratory and then was sent on its
way, the mean reduction was just under 25%; and the untreated control group
showed a mean change of less than 1% after the elimination of one subject who
because of an unusually stressful 3-month interval has increased his rate 4-fold.
It seemed highly improbable that a brief, dull message could produce a sig-
nificant reduction in smoking rate after only a day in REST; nor did it seem likely
that the day in REST by itself, without even the message, could do so. Were sub-
jects misreporting their smoking habit? But why would they? The telephone sur-
vey was unconnected with their participation in the experiment. If false reports
were motivated by some societal factor, why did they occur differentially among
the four groups? Perhaps we had merely found a short-term blip in the usual re-
lapse curve. Had we then known about smoking topography, we might have in-
quired about other changes in the smoking habit, but that idea was still in the
future. The obvious thing to do was to replicate, using a representative sample of
serious smokers rather than only students, presenting substantial persuasive in-
puts, and including long-term follow-up.
In the next controlled study (Suedfeld and Ikard, 1974), the subjects had to
score as addicted-negative affect smokers of at least 5 years standing and smok-
864 SUEDFELD

ing at least one pack a day, and were recruited through the mass media from both
sexes and all ages and socioeconomicstrata. About a dozen messages were pre-
pared, dealing with various ideological, theoretical, and practical aspects of
smoking cessation. An informant close to the subject was identified for corrobo-
rative data collection, and follow-ups were conducted monthly throughout 1 year
with a last contact at 2 years.
The design was essentially the same as that of the first study, except that
because there were now several messages they were presented at various points
about 2 h apart during the session. Nonconfmed message condition subjects were
told to stay at home for a day, during which time messages were played to them
over the telephone on the same schedule. Surprisingly,the results were quite con-
sistent with those of the pilot experiment. Both REST groups showed significant
long-term decreases in smoking (mean reductions of about 5096, with 27% com-
pletely abstinent at the end of 1 year and 39% at the end of 2), with little change
among the control subjects (mean reduction of about 1096, with 1196 and 1696
abstinent at the two yearly follow-ups). Once again, adding messages to REST
appeared to make no useful contribution.
With the publication of the work done so far, including another pilot project
using only a few subjects and some theoretical discussions, other researchers be-
came interested in using the technique. A number of variant procedures were
tested, including partial REST (visual deprivation only, reduced stimulus input
but with no reduction in kinesthetic stimulation, social isolation without reduc-
tion of sensory stimulation). A summary of seven controlled studies (Suedfeld
and Kristeller, 1982) indicated that:

a Profound REST was generally more effective than partial REST.

b. Rofound REST was always, and partial REST usually, superior to placebo
and waiting-list controls.
c. Profound REST was usually more effective than standard treatments to
which it was compared, and was always at least as effective.

At the present time, almost 20 studies using chamber REST for smoking
cessation have been published or described in conference papers (Baker-Brown
and Suedfeld, 1986; see Tables 1 and 2). The results are highly consistent. Be-
sides confuming the conclusions above, they show that:

d. Twenty-four hours of profound chamber REST is the optimal configuration

of the technique for smoking cessation.
e. The presence or absence of messages presented during REST makes little if
any difference.
f. There is no evidence to support the use of flotation REST in smoking cessa-
tion.
RESTRICTED ENVIRONMENTAL STIMULATION 865

Table 1
REST in Unimodal Smoking Cessationa

REST effect at end of follow-up

REST procedure Initial No. Follow-~p M% Iss

and study REST Ss period (months) reduction abstinent

Dark, silent chamber

Barnes, 1976 19 6 71 58
Best and Suedfeld, 14 12 68 21
1982
Deaton, 1983 4 6 68 C

Suedfeld and 40 12 34 25
Baker-Brown, 1987b
Suedfeld and Ikard, 20 24 50 39
1974
Suedfeld et al., 1972 20 3 38 C

Partial chamber REST

Christensen and 56 9 27 14
DiGiusto, 1982b
Hennessy, 1975 12 1 32 C

Ovadia, 1979b 39 3 29 15

Flotation REST
Fine, Bruno, and 12 6+ 15 8
Nestor, 1985
Forgays, 1987b 22 12 29 2
Suedfeld and 6 12 18 0
Baker-Brown, 1987

aREST with or without message is considered to be one treatment.

Kombinesseveral groups differingon variablesother thanmessages (e.g., differentREST dura-
tions); for specific treatment effects, see original publication.
CNot reported.
866 SUEDFELD

Table 2
REST in Multimodal Treatment Combinations

REST effect
Follow-~p
Other treatment period (months) M % reduction % Ss abstinent

Self-managementand satiation
Best and Suedfeld, 1982 12 40 53
Self-management
Ramirez, 1985 5 b 53

Satiation
Deaton, 1983 6 68 25

Aversion
Ovadia, 1979 3 23 8
Suedfeld and Baker-Brown, 12 45 13
1986a

Hypnotherapy
Barabasz et al., 1986a M = 19 b 47

Self-managementand social support

Tikalsky, 1984 6 b 88

Combines several groups differing on treatment variables; for specific treatment effects, see
original publication
bNot reported.

g. REST in a multimodal package potentiates effective standard techniques.

h. REST increases long-term abstinence, but not necessarily immediate success
at end of treatment.
i. REST may support controlled smoking at a much reduced rate among non-
abstinent subjects.

These data were collected by half a dozen researchers and research groups,
so that the interstudy reliability is not due to some unique aspect of a particular
laboratory, researcher, or procedural idiosyncrasy. Most of the studies were
fairly rigorous, given the general norms for habit modification work: They usu-
ally included control groups, randomized the assignment of participants to treat-
ments, and attempted to minimize nonspecific and artifactual effects. They also
tended to engage in at least relatively prolonged follow-ups, although not quite so
RESTRICTED ENVIRONMENTALSTIMULATION 867

consistently. One problem that does arise is that they do not always report both
abstinence and smoking-reduction results, and none makes an attempt to exam-
ine smoking topography among those subjects who did not attain or maintain
complete abstinence. Another shortcoming is the general reliance on self-report
measures, although corroborative techniques have sometimes been used.

REST in Multimodal Treatments

Although REST seems to work as a single-modality treatment, and is even

fairly cost-effective in that role (given the savings in therapist and client time
compared to many clinical programs), it is true that abstinence rates . . . appear
to be comparable in the long run to those attainable through other interventions
. . . (Bernstein and McAlister, 1976). What may make REST much different in
its potential application is its ability to interact synergistically with other meth-
OdS.
This ability was first noted in a study combining REST with a behavioral
self-management package comprised of self-monitoring, functional analysis
with a therapist, homework, counseling, one day of satiation smoking, and stimu-
lus control training (Best and Suedfeld, 1982; Suedfeld and Best, 1977). Clients
who had enrolled in the self-management clinic conducted by Allan Best were
given the option to volunteer for a 24-h REST session. As a sidelight on con-
sumer acceptance, it might be worth mentioning that 75%of the clients to whom
this option was offered volunteered for it. Of these, one-third were randomly as-
signed to each group: self-management only, REST only, and combination treat-
ment. Figure 1 shows the results, based on self-report and confirmed by desig-
nated informants.
Figure 1 clearly demonstrates that the combined treatment group reached a
long-term abstinence rate approximately equal to the sum of those obtained by
each of the two components alone. In other words, the effects of REST only and
self-management only summed when the two techniques were joined.
This finding sparked other experiments in which REST was used as part of a
multimodal package, the other component varying with the study. Table 2 sum-
marizes the results of such projects. Only two of these were run at our own labo-
ratory (Suedfeld and Baker-Brown, 1986); one of these demonstrated the fact
that REST does not potentiate a technique which itself is ineffective (in this case,
covert aversive conditioning; see Frederiksen and Simon, 1979; Lichtenstein,
1982; Pechacek and McAlister, 1980; Raw, 1978). Of three treatment groups
combining the procedures, two actually showed abstinence rates considerably
lower than those usually achieved through REST alone, and the third was in the
usual REST range. The failure to obtain improved success rates through a REST-
aversion combination supports previous data (Ovadia, 1979) and points to self-
868 SUEDFELD

Fig. 1. Percentage of clients abstinent (Best and Suedfeld, 1982).

management training as the potentiated active treatment in the study by Best and
Suedfeld (1982).
Data reported by Tikalsky (1984) are especially noteworthy. Combining
REST with self-management training and the establishment of a social support
group, he found a 6-month abstinence rate of 88%, far above that of any tech-
nique or combination of techniques currently in clinical use. While this was a
clinical treatment study rather than a controlled experiment, it clearly justifies
the effort of a rigorous replication; and, taken together with the other reports, it
validates a suggestion that REST is deserving of further study or incorporation
into other treatment packages (Frederiksen and Simon, 1979, p. 520).

THE MEASUREMENT OF MAINTENANCE

All reviewers and workers concerned with the modification of smoking

(and other habits) have emphasized the question of relapse - or, to put it more
positively, maintenance (see, e.g., Brownell, Marlett, Lichtenstein, and Wilson,
1986, for an excellent discussion). Given that this is consensually the crucial is-
sue in smoking cessation, surprisingly few investigators report maintenance rates
in any explicit fashion.
RESTRICTEDENVIRONMENTAL STIMULATION 869

Changes in Smoking Behavior

To begin with, we should consider complicated versus simple measures.

Complicated measures really derive from a simple one: change in smoking rate.
This index, commonly used in the literature, reports number of cigarettes smoked
(e.g., per day) during follow-up, usually as a percentage of the baseline pretreat-
ment number. Thus, it is possible to track changes in smoking behavior that are
more subtle than the gross smokinglabstinent categorization. Unfortunately,
smoking rate conceals a host of complex variables. Participants who have not
quit may have changed their brand to one that delivers more nicotine and tars to
the body; they may smoke their cigarettes closer to the butt; they may inhale
more deeply than before. Such topographical change (e.g., Pechacek and
McAlister, 1980)is not revealed by even an accurate count of the number of ciga-
rettes smoked. In fact, it can hardly be assessed unless the client is institutional-
ized at least temporarily. Institutionalization is impractical in most smoking
studies, and would be a rather reactive procedure; it may be better to accept the
loss of subtle continuity in measuring treatment outcome and rely on the simple,
clear-cut criterion of abstinence (Schwartz, 1987).
Even this strategy is not without controversy. One important issue is the
definition of relapse. Does a single cigarette suffice to put someone in that cate-
gory, or is a minimum of x cigarettes over y days a better criterion? And, if the
latter, what are the appropriate values of x and y? Another problem is the period
of time asked about at follow-up: Did the subject smoke at all since the last
follow-up? The last week? Yesterday? However, these issues can at least be re-
solved operationally for a given study, without the empirical problems of smok-
ing topography.

Point-Prevalence Abstinence

The traditional presentation of abstinence results is the point-prevalence ab-

stention curve, with data points indicating the proportion of clients who are absti-
nent at each follow-up period. There are several problems with this tradition,
both in presenting an accurate picture of treatment success and in trying to meas-
ure maintenance rate. The magnitude of these problems has attracted increasing
attention in the past few years (Gregson and Gates, 1986; Orleans and Shipley,
1982; Shumaker and Grunberg, 1986).
With the now customary approach, treatment success is easily overesti-
mated. Let us look at some of the potential problems.
I . Attribution of delayed abstinence. In contrast to the implication of
point-prevalence data, individuals who are still smoking at the end of treatment
but become abstinent at some time during follow-up should not be counted as
a70 SUEDFELD

successes. Unless one stipulates an untestable incubation effect, their delayed

smoking cessation cannot be attributed to the treatment.
2. Duration of abstinence. Point-prevalence abstention equates mainte-
nance throughout the entire follow-up period with relapse followed by quitting
again. As the most obvious objection, we may consider that in the latter case the
follow-up period after the second cessation episode is shortened, sometimes con-
siderably so. Shorter follow-ups usually yield higher apparent success. In some
of our own studies, we have had clients who reported abstinence only at the last
(12-month) follow-up; they could have been counted as abstainers, even though
as this was the last point of data collection there was absolutely no information
about the duration of their success.
3. Attribution of regained maintenance. Reattainment of cessation after
posttreatment relapse poses the same problem as delayed quitting, mentioned
above: Any attribution to the original treatment is highly speculative. The data
therefore may again inflate the purported success rate of the intervention.
4. Stability of smokindabstinent groups. Another major flaw of point-
prevalence reports is that they can conceal changes in category membership.
There is no indication as to how many of the individuals included in a particular
data point are the same as those in previous and subsequent ones. In principle,
every datum could consist of a completely or partly different group of subjects,
none of whom is actually abstinent in any meaningful sense. Let us say that we
have a study with 100 subjects and a 4-month follow-up. At the first follow-up
point, Subjects No. 1-25 are abstinent; at the second, Nos. 26-50 are abstinent,
1-25 having relapsed; and so on. At the end of the follow-up period, we could
claim a 25% abstinence rate, but actually none of the subjects would be a stable
treatment success. This is obviously an unrealistic and extreme example, but it
illustrates the danger of a spuriously positive picture of cessation maintenance.

Continuous Abstinence

To present a more informative analysis, maintenance should be reported by

identifying those clients who are abstinent at the end of treatment and calculating
the proportion of those who remain abstinent throughout each follow-up period
(continuous abstinence). In this way, we get a measure of abstinence through
successive follow-up data collections to the end of follow-up.
Continuous abstinence data avoid many of the pitfalls of the current point-
prevalence method, but there is one situation in which they could lead to an over-
estimate of treatment potency. This would be the case with intervention tech-
niques that have low immediate success rates but high long-term maintenance of
cessation. Hypothetically, we could have a method that induces 10%of the cli-
ents to quit smoking, but does so in such a way that they all remain abstinent, for a
RESTRICTED ENVIRONMENTALSTIMULATION 87 1

Table 3
Maintenance Rate (%ontinuous Point Prevalence?: A Reanalysis of UBC Data

Number abstinent

Post- 1-year Maintenance Quit

Study and treatment group (N) treatment follow-up %a %b

Suedfeld and Ikard, 1974

REST only (17) 7 4 57 24
REST + messages (20) 12 5 42 25
Messages only (17) 4 0 0 0
Untreated control (18) 0 0 0 0

Best and Suedfeld, 1982

REST incl. messages (14) 4 3 75 21
REST + self-management (15) 15 8 53 53
Self-management only (15) 12 2 17 13

Suedfeld and Baker-Brown, 1986

REST + aversion/expectancy (18) 12 6 50 33
2 REST + aversion combm. (38) 18 4 22 11
Aversion only (19) 3 1 33 5

Suedfeld and Baker-Brown, 1987

Standard REST + messages (9) 7 4 57 44
3 24-h REST group (27) 9 4 44 15
4 12-h REST group (30) 9 4 44 13

aMaintenance rate = N abstinent at all follow-ups/N abstinent at end of treatment x 100.

q u i t rate = N abstinent at all follow-ups/Ncompleting all follow-ups x 100.

final success rate of 10%but a maintenance rate of 100%.Thus, both initial quit
rates and maintenance rates need to be reported.

Maintenance After REST: Strategic Implications

In the absence of actual continuous abstinence data, available point-preva-

lence data can be reanalyzed to provide what might be called continuous point-
prevalence rates. In Table 3, maintenance is defined as a report of zero smoking
at every follow-up point after treatment. This is only an estimate of actual con-
tinuous maintenance, since it is conceivable that some smoking has occurred be-
tween follow-ups; on the other hand, it is a rigorous estimate because a client who
872 SUEDFELD

was smoking at any follow-up was counted as relapsed, regardless of the extent
of smoking in either time or number of cigarettes. The table presents mainte-
nance rates extracted in this way by a reanalysis of some of the old data from our
own program. The estimated maintenance rates after REST converge at about
50%yabout twice as high as those commonly accepted as characterizing the lit-
erature (see, e.g., Hunt and Bespalec, 1974; Shumaker and Gnmberg, 1986). The
unusually high maintenance rates (percentage of subjects who were abstinent at
every follow-up throughout 12 months, using as the baseline those who had quit
at end of treatment) are in most - although not all - cases combined with only
average quit rates (using total number of followed-up subjects as the baseline),
indicating that the initial impact of REST is less impressive than its effect on
long-term maintenance. It is worth noting that nonstandard REST procedures
yield low quit rates but still tend to retain high maintenance rates.
The conclusion drawn from the comparative success rates and estimated
maintenance rates leads to an implication for smoking intervention strategies.
Briefly, the optimal approach seems to be to combine an appropriate technique
that reliably maximizes immediate cessation rates with REST, which maximizes
maintenance of cessation once it has been achieved. The choice of the other
technique will be discussed presently.
Let us go back for a second look at Fig. 1. Rather than merely observing the
final results, examine how those results came about: that is, the shapes of the two
single-treatment curves. What becomes immediately apparent is the difference
in their shapes and how the bimodal treatment curve combines the essential na-
ture of both. Specifically, the data for self-management show the typical high
end-of-treatment abstinence rate, followed by the typical high relapse rate;
REST shows a low success rate at the end of treatment followed by very little
relapse during the ensuing year of follow-up. The combination has high
posttreatment abstinence with high maintenance, just as the strategic suggestion
above would indicate.

WHY IS REST UNDERUTILIZED?

In view of the fairly impressive array of data, it may be surprising to see that
REST is not in fact a common component of smoking clinic methods. Slow ac-
ceptance may be understandable given its origin as a procedure in experimental
laboratories. As one reviewer put it, Sensory deprivation is an experimental
paradigm rather than a treatment and it is strange to see it turn up as a treatment
for smoking (Raw, 1978, p. 464). While the same could be said of other tech-
niques (e.g., aversive conditioning), REST appears to be the only one to have
evoked such explicit statements of surprise. But it is now more than 15 years and
some 20 studies later, and little change seems to have occurred. Why? There ap-
RESTRICTED ENVlRONMENTfi STMULATION 873

pear to be basically two kinds of reasons. One covers a variety of rational and
practical issues; the other is unthinking, unscientific, and uninformed.

Some Reasonable Concerns

Is REST a Placebo?

The question of whether REST acts as a placebo in smoking treatments has

been raised repeatedly by reviewers (e.g., Bernstein and McAlister, 1976;
Frederiksen and Simon, 1979). According to Bernstein and McAlister (1976, p.
92), the sensory deprivation approach must be evaluated against credible pla-
cebo treatments, subjects unaided efforts, and other interventions. At this
point, the status of REST as other than a placebo treatment appears to be at least
as settled as for most techniques. As mentioned, the first study was expected by
the experimenters to support the null hypothesis; subjects presumably had no
specific expectations, since they were merely volunteers for a sensory depriva-
tion experiment rather than for smoking cessation treatment. The message may
have served as a nonspecific treatment for the REST and nonconfined subjects
who heard it, but it clearly did not contribute to the impact of REST since the
message and no-message groups had identical success rates. The attitude and
self-report measures related to smoking may have induced a set, but it was the
same set in all treatment groups.
In later studies, treatment combinations involved as much therapist atten-
tion for non-REST as for REST group participants, and orientations in our pro-
gram have emphasized the experimental and therefore tentative nature of the pro-
cedure. Most recently, one study (Suedfeld and Baker-Brown, 1986) used a sub-
tractive expectancy placebo design (Suedfeld, 1984b) and showed positive ex-
pectancy effect for an aversive treatment but none for REST. The repeated fail-
ure of flotation REST to yield favorable outcomes has gone against the strong
expectations of both the clients and the investigators. All of these results support
other findings that expectancy has but little effect on objectively quantifiable (as
opposed to subjective) measures in REST (Barabasz and Barabasz, 1990; Sued-
feld, 1969b; Suedfeld, Landon, Epstein, and Pargament, 1971). Thus REST ef-
fects cannot be easily explained by reference to nonspecific components.

Why Does REST Work?

A number of reviewers have contended that REST will not become widely
accepted until an adequate theoretical base is established to explain its empirical
success. Raw (1978, p. 465) suggested that research to identify the effective
components of this method is necessary. Explanations other than an active and
874 SUEDFELD

specific treatment status for REST now seeming unlikely, we must consider why
it is effective. The field has gone from having "many facts but no theories" to
"many facts and many theories" (Suedfeld, 1980). Unfortunately, the empirical
testing of theories has lagged seriously. Most reviews of the REST literature con-
tent themselves with listing and explaining the alternative explanations, leaving
the issue of validity and testability open. Some firm theoretical bases have, how-
ever, started to appear.
Through the course of evolution and their individual life, human beings
have acquired a selective focusing of attention on ambient stimuli and informa-
tion because being prepared to cope with events in the environment is conducive
to survival. Information-processing capacity being limited, the result of this bias
is to ignore all but the most intense endogenous information. Further, in order to
facilitate the processing of environmental inputs, many stimulus-response se-
quences become automatized and chained to certain initiating cues.
In REST, the normal flow of exogeneous stimuli is suddenly and very dras-
tically reduced. As a result, attention can be (in fact, must be, if the processing of
information is a basic human need) refocused to the ongoing internal generation
of physiological, cognitive, affective, memorial, imaginal, and other stimulation.
This enables REST participants to concentrate on working out personal prob-
lems, including (if so desired) those related to the continuation or termination of
their smoking habit.
Second, the removal of specific smoking-related cues seems to have two
effects. One is the intemption of "automatic," overlearned response sequences
culminating in smoking. After REST, most nonabstinent clients report that they
no longer smoke mechanically. For the first time since they had originally ac-
quired the habit, they have to make a conscious decision to activate each step in
the smoking behavior sequence. This makes it much easier to interrupt that se-
quence, or not to take even the first step. The other is that conditioned cravings
for a cigarette are extinguished in many subjects. The urge that some smokers
have learned to feel in situations where they normally smoke - while drinking
coffee, chatting with friends, and so on - is not aroused, and withdrawal symp-
t o m fail to appear or at least are very weak (e.g., Christensen and DiGiusto,
1982;Suedfeld and Ikard, 1973;Vernon, 1963). Consequently, quitting smoking
is much easier than they expected or had experienced on previous attempts. Even
those who relapse, frequently because they are going through a particularly
stressful period in their life, claim that the automaticity and the craving have been
largely eliminated, and that returning to abstinence will be easier once the need
for the stress management via smoking is over.
Both of these components seem to contribute to an increased feeling that the
person is in control of whether to continue smoking. While self-efficacy meas-
ures have not been administered in the course of REST research, it seems reason-
RESTRICTED EMENTALSTIMULATION 875

able to hypothesize that such measures (as well as, e.g., health locus of control)
would show an appropriate change. This would also explain repeated reports that
subjects undergoing REST for a particular purpose such as the treatment of
smoking or essential hypertension manifest a wider range of positive aftereffects
in the context of health behavior, interpersonal relations, assertiveness, and the
like (Suedfeld and Best, 1977; Roy, 1987).
This proposed explanation has some advantages. Its postulates are rela-
tively simple and understandable. It is particularly relevant to smoking cessation
(and more generally to habit modification). The increase of self-perceived con-
trol over smoking may be crucial in improving maintenance (Lichtenstein, 1982;
Marlatt and Gordon, 1980). As we have seen, REST may be relevant to exactly
this point. The approach also suggests ways to increase maintenance success
even more, perhaps by adding messages related to relapse hazards and relapse
prevention (Marlatt and Gordon, 1980; Shiffman, 1982). It is tied into a general
cognitive framework, allowing validity to be explored both on that level and on
the level of neurological, biochemical, and psychophysiological substrata. It is
compatible not only with the experimental and applied data, but also with sub-
jects self-reports and professionals clinical observations. It connects REST
with broader areas and theories related to habit and life-style change. Last, and
importantly, it can serve as the basis for empirically testable hypotheses.

The Choice of Other Treatments

Another practical as well as theoretical concern is the basis for choosing

techniques to be used jointly with REST in the multimodal applications that seem
to be most successful. Selecting a technique that is most effective on its own is an
obvious strategy. The problem with it is that no one such technique has been
clearly identified; and in any case, the potency of a method when used alone does
not logically guarantee that it is optimal for inclusion in a combination.
Perhaps the choice can be made in a more theoretically relevant way. That
way would be to look at the effects of REST on processes other than smoking per
se (see, e.g., Suedfeld, 1980; Zubek, 1969), and using techniques whose power
could be related to those effects. For example, we know that REST induces states
of deep relaxation. Therefore, methods whose success is related to heightened
-
arousal for example, fear induction, aversive conditioning - would probably
be counteracted, rather than potentiated, by REST (an explanation quite compat-
ible with current fmdings). On the other hand, low-arousal approaches such as
hypnotherapy and meditation should be reinforced by REST, again a hypothesis
supported by the literature so far.
REST also improves learning and memory. One would therefore expect that
behavioral strategies using conditioning and cognitive change would combine
876 SUEDFELD

well with it. Further, since REST is known to decrease defensiveness against
novel or dissonant messages, persuasive arguments (again related to cognitive
modification) should be enhanced. The findings here are somewhat mixed, with
behavioral self-management training having been found to be a good combina-
tion with REST and messages having some, but not a reliable, effect on the total
impact of the treatment.
Demand characteristics should also be considered here. Because of the cog-
nitive changes noted above, one would expect REST subjects to be particularly
sensitive to expectations communicated by the therapist or researcher. Experi-
mental research has found that experimenter expectancy affects subjective re-
ports, but not objective performance measures in the REST laboratory (Jackson
and Pollard, 1962; Landon, 1976). Generally, however, interventions that have
strong positive nonspecific components should do well in combination with
REST;unfortunately, there has been very little research on the role of expectancy
and other placebo factors in the various smoking cessation treatments.

The Choice of a REST Technique

Given the number of possible variables in REST, the identification of the

most cost-effective procedure is important and may daunt some potential users.
Some relevant answers have by now been developed. Partial-REST studies,
mentioned before, generally indicate the superiority of extensive stimulus reduc-
tion (darkness, silence, restricted mobility) over less thorough approaches. There
is also a recent parametric study that varied REST duration (12 vs 24 h) and mes-
sage presentation schedule (massed near the beginning and end of the session vs
distributed throughout the session vs presented on demand vs no message; Sued-
feld and Baker-Brown, 1987). As opposed to chamber REST, the flotation tech-
nique appears to be ineffective, at least in the session numbers and durations
tested so far (Baker-Brown and Suedfeld, 1986; Forgays, 1987). To summarize,
the most effective procedure is the 24-h session lying in darkness and silence,
with either no messages or the messages distributed across the entire period.
Comparisons with other techniques have been made. As shown in Tables 1
and 2, chamber REST is more effective than the average and about as good as the
best category of intervention procedures in this area. Comparison with unaided
efforts has been made in the case of untreated controls, with reliably superior
outcomes for chamber REST.Comparing the technique with unaided efforts in a
wider context runs into the insuperable problem of different populations. All in-
tervention programs, including ours, get only those smokers who have tried -
most of them repeatedly and fervently - to quit without help and have failed.
RESTRICTED ENVIRONMENTAL STIMULATION 877

Is REST Acceptable to Potential Clients?

A good answer to this question is obviously required before one would

adopt the technique: Regardless of its efficacy, it would hardly be worth consid-
ering if no one wanted to participate in it. But this is not really a problem at all. In
our own research, we try to have samples of smokers that are representative of the
population in terms not only of smoking history and profile but also demographic
characteristics. Our recruiting relies heavily on interviews in newspapers and on
the electronic media, posters displayed in community centers, laundromats, pub-
lic libraries, and the like. Our volunteers fully reflect the range of smoking and
demographic variables in the community, and we get them in large numbers. As a
general rule, we have waiting lists of 100 to 200 people.
The recent popularization of flotation REST further demonstrates the wide
acceptability of the concept. In every major North American city, and in an in-
creasing number of cities in Europe and elsewhere, ordinary citizens pay to spend
an hour or so floating in darkness and silence. The current rate in the United
States and Canada is between $15 and $25 per hour, and there are enough cus-
tomers to support six tank manufacturers and dozens of facilities. There is a thriv-
ing industrial association, the Floatation Tank Association, as well as the more
professionally and scientifically oriented International REST Investigators So-
ciety. Hundreds of stories, almost exclusively favorable, have publicized the
phenomenon in all of the mass media from newspapers and magazines (includ-
ing, e.g., Omni, Psychology Today, Playboy, and Vogue) to radio and television.
At this point, many urban dwellers who pay attention to the media will have at
least some familiarity with REST, and a positive preconception of the experi-
ence.
One further piece of evidence relates to smoking clinic clients specifically.
As described previously, one of our studies (Best and Suedfeld, 1982) used sub-
jects who had originally signed up to participate in a clinical intervention based
on self-management techniques. When these individuals were asked if they
would be willing to spend 24 h under REST conditions as an additional or alter-
native treatment, 75 % responded affirmatively.

Is REST Acceptable to Actual Participants?

Once again, the answer is an unqualified yes. This concern is derived from
the horror stories coming out of the early research. Current standard procedures
minimize uncertainty and anxiety; when such procedures are followed, quantita-
tive measures of subjective stress and discomfort do not reliably distinguish be-
tween REST participants and unselected comparison groups in normal environ-
878 SUEDFELD

ments (Suedfeld, 1980). Many participants wish to remain in the chamber after
the end of the 24 h and/or ask to repeat the experience.
One advantageof the procedure is that it can be terminated easily and imme-
diately, either by the participant or by the monitor, if the response to the environ-
ment is negative. However, considerably fewer than 10%of all participants quit
before the scheduled end of a 24-h session. Extremely seldom will a monitor de-
cide to take out a subject who appears to be reacting badly but is reluctant to quit.
Those who do come out early rarely express serious emotional upset, but an exit
interview and follow-up interviews or phone calls should be held with such cli-
ents, as with successful session completers, to allow them to discuss their reac-
tions and feelings.
The occurrence of prolonged negative side effects or aftereffects is so un-
usual as to be negligible, at least among samples not made up of psychiatric pa-
tients; for example, the rate of maladaptive consequences requiring professional
intervention was reported at 3/100of 1% (1 person out of well over 3,000 sub-
jects; Suedfeld, 1980).

Is If Dificult to Establish a REST Facility?

Fear of excessive expense and complications in using the procedure is an-

other realistic deterrent. Obviously, setting up such a facility takes some space
and money. Neither, however, involves extraordinary resources. Any normal-
sized room that is not on a major internal or external traffic route can reasonably
serve as the location. While prefabricated sound- and light-shielded chambers
can be purchased, they are expensive ($6,000- 10,000) and almost always unnec-
essary. If the room has no external windows, one need only to add some
soundproofing insulation to the walls, ceiling, and the inside of the door; insula-
tion or thick carpeting on the floor is sufficient. If there is an external window, it
can be completely blocked and sound insulated.
The equipment needed consists of a bed, a chemical toilet, a container for
water and liquid diet food, and an intercom. Supplies - bed linens, disinfectant,
toilet paper, food, audio tapes - must be provided, cleaned, and maintained. The
intercom should be set up so that a monitor can constantly listen to the subject
and can also respond or present stimuli into the chamber; the monitor, located in a
nearby control room, will also need office furniture, a bed, and basic amenities.It
should be noted that one control room, with one monitor, can be connected to any
number of treatment chambers; here, if ever, economics of scale are a reality.
Figures 2a and 2b show a standard REST chamber (photo and schematic).
The monitor can be a student, paraprofessional, or technician; the therapist
can devote his or her time with the client to the relatively complex issues of the
intervention and its place in the clients life without spending any of it on the
RESTRICTED ENVIRONMENTAL STIMULATION 879

REST CHAMBER

Fig. 2. REST chamber: photo and schematic.

880 SUEDFELD

mechanical aspects of running a REST session. Training should emphasize the

establishment of a low-key, noninvasive relationship with the client and a thor-
ough understandingof the equipment. This understanding is then to be transmit-
ted to the clients; every actual and probable question should be answered fully
and truthfully. Aside from these factors, there is no specialized knowledge that
the monitor really needs. Postsession debriefing should preferably be conducted
by the therapist, to facilitate rapport, obtain insight into the client's experience,
emphasize the importance of the experience, and lay the foundation for future
therapeutic interactions.
This is not a place for detailed analysis of the practical aspects of running a
REST establishment. In the mid-1970s it was estimated (Bode, 1980) that turn-
ing a room into a chamber costs approximately $1,000; to equip it would run to
about $500; and operating costs are about $5 per 24-h session plus the salary of
the monitor. At the present time, the costs may be higher but probably not by very
much. Certainly, the gain in outcome success is likely to outweigh the additional
expenditure and to warrant appropriate adjustments of the treatment charges.

Some Less Realistic Deterrents

The Bugaboo of Early Reports

The history of REST (sensory deprivation, perceptual isolation) began with

the reports emanating from Donald 0. Hebb's laboratory at McGill University.
These were so colorful as to excite instant attention from both professionals and
the lay public. Results included effects on a wide range of dependent variables.
The most dramatic and the most emphasized were reported hallucinations, emo-
tional lability, and supposedly unexpected aversive reactions. All of these are
quite striking for a procedure that merely asked subjects to lie on a bed for a few
days, wearing cardboard cuffs, gloves, and translucent Gundeld goggles and lis-
tening to a constant hum from a fan (Bexton, Heron, and Scott, 1954).
Unfortunately for these amazing effects, they have been shown to result
from an inseparable mixture of unvarying, monotonous, and meaningless stimu-
lation, on the one hand, and a collection of experimental artifacts, on the other.
The array of mechanical homogenizers of stimulation produced physical dis-
comfort as well as perceptual isolation. The typical procedures of early research-
ers involved legal release forms holding the project exempt from liability in case
of psychologicaldamage and "panic buttons" to be activated for instant release in
case of - obviously - panic (both of which cast doubt upon any statement that
no adverse effects are expected), and a general aura of portentous mystery
aroused anxiety before the subject even saw the chamber. The expectancies that
this approach inculcated were well demonstrated in a famous study (Orne and
RESTRICTED ENVIRONMENTAL STIMULATION 881

Scheibe, 1964) that elicited the most dramatic sensory deprivation effects us-
ing only the the ancillary anxiety-arousing trappings without any actual change
in ambient stimulation.
While some early experimenters perceived this problem (Lilly, 1956; Jack-
son and Pollard, 1962; Suedfeld, 1969b), it was not until major changes in the
standard procedures that the misleading nature of the original findings became
obvious. The mechanical appendages and monotonous stimulation were re-
placed by a comfortable stint in a dark, quiet room. orientations became reassur-
ing, informal, and informative. Legal releases and panic buttons were abolished.
With more careful approaches and more rigorous designs, we found that halluci-
nations, emotional storms, and intolerable stress all disappeared. After hundreds
of experiments, the authoritative reviewer of the area commented upon the
marked differences between the McGill results and those of numerous other
laboratories, and suggested that the unusual McGill phenomena were produced
by some unique interaction of several variables of a procedural, personality, or
motivational nature. Whether this unique set of conditions will ever be discov-
ered is debatable (Zubek, 1973, p. 14). Nearly two decades later, it has still not
been discovered nor replicated.

Political Assaults

Criticisms of REST research and applications have been based on political

grounds for several reasons (Fields, 1976; McGuffin, 1975; Shallice, 1972;
Suedfeld, 1980). One is that Hebbs original research was partly intended to in-
vestigate the psychological mechanisms of the brainwashing of UN prisoners
of war in North Korean and Chinese camps, and both the issue of brainwashing
and the funding of research by defense agencies became entangled with the po-
litical activism of the late 1960s and early 1970s. Second, the REST procedure
was confused unwittingly by some, and misidentified deliberately by others,
with solitary confinement of prisoners (e.g., the Baader-Meinhof gang in West
Germany) and intensive interrogation of suspects (e.g., of alleged IRA terrorists
in Ulster). During the activist years, these misconceptions not only deterred sci-
entists and practitioners from considering REST as a useful method, they led to
both verbal and physical assaults (ranging up to threats of assassination) upon
REST researchers.
Since this matter has been dealt with at length elsewhere (Suedfeld, 1980,
1990), it does not require extensive discussion here. Briefly, solitary confine-
ment in modem Western prisons entails little if any stimulus reduction; does not
have empirically demonstrable destructive effects on the great majority of pris-
oners, and in fact is sought out by many; and is aversive primarily because of the
circumstances under which it is imposed and the inferior treatment it carries with
882 SUEDFELD

it as far as recreation, education, and interaction with guards and other inmates
are concerned (Suedfeld, Ramirez, Deaton, and Baker-Brown, 1982). Both
brainwashing and intensive interrogation rely primarily on overstimulation
and intense stimulus bombardment; these are occasionally interrupted for brief
periods to arouse fear and uncertainty about their resumption. None of these situ-
ations has anything substantive in common with either experimental or clinical
REST approaches.

Today: The Bugaboo Lives On

Scientists and practitioners interested in the REST technique have long felt
that the misleading negative connotations of sensory deprivation have contin-
ued to inhibit an objective evaluation of the field. There is a pervasive impression
that journal editors, granting agencies, academic administrators, and other gate-
keepers do not approach proposals involving REST with an open mind. To cite
but two recent examples: In one program comparing a particular treatment
method for smoking with the combination of that method plus REST, the latter
package obtained success rates approximately twice as high as the former. Nev-
ertheless, when the REST researcher left that institution, the director of the clinic
dropped the REST component and converted the space to an office, explaining
that the unimodal technique was good enough without REST. Second, an arti-
cle describing the therapeutic use of REST was rejected by a journal. One of the
reviewers wrote that no matter how good the design or the results were, such pa-
pers should not be published because the use of REST should not be encouraged.
Of course, examples are not proof, There is in fact no easy way to establish
whether projects using REST tend to receive more hostile reception than those
concentrating on more standard techniques, and it is certainly true that positive
decisions have been made on REST-related research proposals and articles. The
fact that discussions of the use of the method in smoking cessation have been
included in most recent reviews and in the major handbook on behavioral health
(Suedfeld, 1984a) is evidence of that.
Nevertheless, it is interesting to see how the field is viewed by our col-
leagues. One way to evaluate that is to look at what may be the one most impor-
tant contact point between psychologists of the present and those of the future:
the introductory psychology textbook. A brief paper (Scott, Cooper, and Adams,
1980) rated the attitudes of 24 text authors about sensory deprivation: 10 were
judged as neutral, 10 as mostly unfavorable, and 4 as entirely unfavorable. None
was mostly or entirely favorable.
More recently, Suedfeld and Coren (1989) analyzed 185 textbooks pub-
lished between 1956 and 1986. Declining from a peak of almost 100% in books
published in the period 1966-1970, about 75% of those published since then
RESTRICTED ENVIRONMENTAL STIMULATION 883

5 60-

8 50-

5
40-

30-
Lu
a 20-

10 - 0 NEGATIVE
0 POSITIVE.
0 U?...

YEAR OF PUBLICATION

Fig. 3. Characterization of REST effects in introductory psychology textbooks (Suedfeld and

Coren, 1988).

have at least mentioned stimulus restriction, devoting an average of around 450

words to the topic. Amazingly, the modal reference is still to the work of the
McGill group, whose research is not only more than 30 years old but has been
superceded, criticized, reinterpreted, and found to be largely nonreplicable. The
most frequently reproduced illustration still shows the subject with cuffs, gog-
gles, etc., a procedure that has been abandoned by almost all researchers in the
past 15 years or more.
On the other hand, there seems to be some basis for hoping that this is im-
proving - at least if one is an optimist. For example, Figure 3 shows that the
percentage of texts that cite only negative aspects of REST is declining, while
mixed or positive statements have been increasing since 1970. In fact, the overall
evaluation of REST-related comments is that these were 95- 100%negative until
1980; of books published from 1980 to 1985, only 90%;and of those published
in 1986 only about 80%, take this tack. Last, between 1975 and 1986 there has
been an increase from 0% to almost 40%in books mentioning the therapeutic use
of REST.
The presentation of a topic in introductory texts is not a trivial issue. It is
likely that Undergraduate students often assume that because a finding appears
in a textbook it must be true . ..there is considerable pressure to include mention
884 SUEDFELD

of a study if all the other texts in a field mention it, thereby confusingfrequency of
note with reliability (Sommer and Sommer, 1984, p- 1318; emphasis mine).
Since one generation of introductorypsychology students provides the next gen-
eration of psychologists (and editors, peer reviewers, etc.), the cognitivelaffec-
tive set induced early may lead to long-term attitudes that are difficult to modify.
The result is that even colleagues who are open-minded about the technique
tend to demand a higher level of proof for its use than they would for that of other
procedures. For example, the smoking cessation data have proven quite consis-
tent across a respectable number of researchers and many studies. For another
(almost any other) method, they would probably elicit more exhaustive consid-
eration by scholars in the field, and more confident judgments, than have been
typical; cf. the very recent comment that These findings . . . are provisional, but
merit replication (Kamarck and Lichtenstein, 1985, p. 22). That level of hesi-
tancy seems excessive, although no one would advocate blind acceptance. A
more realistic appraisal, and an appropriate suggestion, is that [REST] appears
to be so nonaversive, yet effective, that it could prove to be a particularly signifi-
cant procedure when employed either by itself or in conjunction with other meth-
ods. It certainly justifies some large-scale prospective evaluations (Evans,
1984, p. 694). Perhaps more such reviews, and ongoing changes in textbook cov-
erage, will eventually open psychology and related disciplines to a more objec-
tive and therefore more accurate appreciation of REST as a useful technique in
research and treatment.

ACKNOWLEDGMENT

I am grateful for grants received from the U.S.National Institutes of Health

(National Heart, Lung and Blood Institute, Grant No. IROML-25918); the Natu-
ral Sciences and Engineering Research Council of Canada (Grant A-9589); and
The University of British Columbia. The work of my laboratory could not have
been carried out without this research support, nor without the collaboration of
many colleagues,students, and research participants. The contributions of Gloria
Baker-Brown, Elizabeth J. Ballard, Susan Bluck, Roderick A. Borrie, John
Deaton, Frederick F. Ikard, P. Bruce Landon, and Carmen E. Ramirez were par-
ticularly important in the research covered by this report, which also benefited
greatly from discussions with Neil E. Grunberg, G. Alan Marlatt, Ovide F.
Pomerleau, and Stephen M. Weiss. An earlier version of this paper was presented
at the Conference on Smoking Prevention and Cessation, Fred Hutchinson Can-
cer Research Center, Seattle, Washington, March, 1987.
RESTRICTED ENVIRONMENTAL STMULATION 885

THE AUTHOR

Peter Suedfeld, PhD Born in

Budapest and received his education in
the United States, with BA from Queens
College (CUNY) and the MA and PhD
from Princeton. He has taught at the
University of Illinois and Rutgers Uni-
versity. Since 1972 he has held various
administrative positions and been Pro-
fessor of Psychology at the University of
British Columbia in Vancouver, BC,
Canada. His research includes archival,
laboratory, and field studies of human
adaptation to challenging or stressful
environments: in the area of substance misuse, he has experimented on the use
of restricted environmental stimulation as a treatment technique. He is a Fellow
of the Royal Society of Canada, the American and Canadian Psychological As-
sociations, the Academy of Behavioral Medicine Research, and the Society of
Behavioral Medicine.

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