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Applied Relaxation: Descriptionof an Effective CopingTechniqueLars-Gran st aa Psychiatric Research Center University of UppsalaPublished online: 23 Mar 2010.

To cite this article: Lars-Gran st (1988) Applied Relaxation: Description of anEffective Coping Technique, Scandinavian Journal of Behaviour Therapy, 17:2, 83-96,DOI: 10.1080/16506078809456264

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Scandinavian Joiirnal of Behasiour llierapj, 17, 83-96, 1988

Applied Relaxation: Description of an Effective Coping Technique

LARS-GORAN OST Psycliiatric Research Center University of Uppsala

llie rationale arid practice of applied relaxatiori (AR) are described iii detail. llie prrrpose of this treatiiieiit nietliod is to teach the patient a coping skill diicli will eriable hini/lier to relax rapidly iri order to coiriiteract mid ei'en- tirally abort anxiety reactioris altogether. AR generally takes 10-12 sessions aiid corisists of the followirig coin- poiients: progressive relaxation, release-only relaration, crre-controlled relaxation, differeritial relaxation, rapid relaxation, applicatioii training, arid iriaiiitenance program.

During the 1970's a number of coping techniques were developed within be- havior therapy. The primary reason for this was a dissatisfaction with the efficacy of traditional behavioral methods, e.g. systematic desensitization and flooding, in the treatment of phobias, and a need to develop new methods for treating non-situational, generalized anxiety. Among the first to describe a coping technique was Goldfried (1971) with Systematic Desensitization as Self-Control, and Suinn and Richardson (1971) with Anxiety Maiiagenrerit Training. Later came Cire-Controlled Relmatioii (Russel & Sipich, 1973), Systeniatic Rotiorial Restrirctirririg (Gold fried, Decenteceo & Weinberg, 1974), Stress-Iiiocrilatioii Trairiiiig

This paper draws heavily on an article entitled "Applied relaxation: Dcscription of a coping technique and review of controlled studies", by Ost, L-G. (1987) in Behaviour Research and Therapy, 25, 397-409. This research was supported by Grant 05452 from the Swedish Medical Research Council. The help of Anita Jerremalm and Jan Johansson in the development of applied relaxation is gratefully acknowledged. Requests for reprints should be addressed to L-G. Ost, Psychiatric Research Center, Ulleriker Hospital, S-750 17 Uppsala, Sweden.

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Scatid J Beliar nier. 17. hTo. 2 , 1958

(Meichenbaum & Turk, 1976), and Applied Relamtion (Chang-Liang & Denney, 1976). A review of the empirical evidence for these coping techni- ques up to 1978 was given by Bahios and Shigetomi (1979). The purpose of the present paper is to describe Applied Relrmtioii (AR) as we have developed it at the Psychiatric Research Center, University of Upp- sala, from 1978 onward. A second purpose is to review the empirical data from our own studies and those of others.

DESCRIPTION OF PROCEDURES As in all serious behavioral treatment, a prerequisite for using AR is a thorough behavior analysis of the patient's problems. What follows is a desc- ription of the treatment components from the first session during which the technique is described to the patient.

Rationale It is important that the patient, before'the start of the treatment, fully under- stands how AR is going to be used, and why it should work in hidher case. In order to achieve this it is necessary not only to give a general description of the method, but to tie its characteristics to the specific problems of the in- dividual patient (based on a thorough behavior analysis). When presenting the method and its rationale we have found it useful to give the patient a short written description (1-2 pages) so that he/she can follow the presentation more easily. This way it is also easier for the patient to ask questions about unclear points. The patient keeps the description and can study it at home. The next session, before starting AR, one can test whether the patient has understocd what AR is and encompasses its rationale. This is done in a short role-play in which the therapist plays the part of an interes- ted friend of the patient's wanting to know about the treatment and how it works. During this, the therapist should avoid "telling" the patient the answers but ask as many questions as needed in order to be certain that the patient has understood the rationale and how the treatment is supposed to work for himlher. In this way the therapist will know if the patient has any misunderstandings or unrealistic views about AR, and can correct these before the start of treatment. The rationale per se in includes, but is not restricted to, the following infor- mation, which is used for phobic patients. "When a person with a phobia encounters a phobic situation there are three different components in hidher reaction; a physiological (increased heart rate, blood pressure, sweating etc.), a behavioral (trying to escape from the situation, trembling etc.), and a subjective (negative thoughts like "I am

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ScmtdJ Behnv 7her. 17, No. 2. 1988

going to faint or lose control etc.). The strength of these components varies between patients, but previous research has found that most people experien- ce some physiological change, followed by a negative thought, which increa- ses the physiological reaction, and so on in a vicious circle. One good way of breaking this development is to focus on the physiological reactions and learn not to react so strongly. The method we are going to use to achieve this is called applied relaxation. The aim of this technique is to learn a skill of relaxation, which can be applied very rapidly and in practical- ly any situation. This skill can be compared to any other skill, e.g. learning to swim, ride a bike, or drive a car, in that it takes time and practice to learn. But, once you have mastered it you can use it anywhere. You are not restric- ted to the calm and non-stressful situation in my office or your own home. The goal is to be able to relax in 20-30 seconds and to use this skill to coun- teract, and eventually get rid of, the physiological reactions you usually experience in phobic situatins. To achieve this we are going through a gra- dual process (illustrated in Figure 1) starting with tensing and relaxing diffe- rent muscle groups. This takes about 15 minutes, and you are to practice it twice a day. Then we start to reduce it by taking the tension part away, just relaxing, which takes 5-7 minutes. The next step teaches you to connect the self-instruction relax to the bodily state of relaxation. At the end of this phase it usually takes 2-3 minutes to get relaxed. Then we teach you to do different things while still being relaxed in the rest of your body, and also relaxing while standing and walking. Relaxation time is now down to 60-90 seconds. After that, it is time for the rapid relaxation, which you practice many times a day in non-stressful situations, with the aim of getting relaxed in 20-30 seconds. Finally, you reach the stage of applying the skill in phobic situations, and I will take you to different anxiety-arousing situations coaching you how to apply the relaxation at the first signs of anxiety in these situations. Applied relaxation is thus a skill that most people can acquire with the right instructions and a lot of practice. It is a portable skill that can be used in almost any situation and is not restricted to phobias, but can be used in other situations. e.g. when having problems to fall asleep. The purpose of AR is twofold: (1) teaching the patient to recognize early.sig- nals of anxiety, and (2) learning to cope with the anxiety instead of being overwhelmed by it.

Recognizing early anxiety-signals In order to increase the patients awareness of the initial anxiety-reactions he/she is given homework assignments to self-observe and record these reac- tions. There.is a definite advantage in having the patient observe hidher reactions in natural situations instead of just talking about them during the

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Scarid J Behai* 77w, 17, ho. 2, 1988

PROGRESSIVE RELAXATION 15-20 min

CUE-CONTROLLED RELAXATION

DIFFERENTIAL RELAXATION

20-30

APPLICATION TRAIN I NG

Ses 2 3

4

5

6 7

8

9 10

..

Figure 1. Tile different compoiieiits of applied relaxation with appro=rimnte time to get relaxed at iurioirs stages.

interview. Many patients tend to perceive a phobic anxiety reaction or a panic attack as a big black lump that just appears. The easiest way to modify this belief is via structured self-observation in natural situations when the anxiety occurs, or in close proximity to it. Figure 2 depicts the head of a self-observation form that can be used for this purpose. As some patients might have difficulties in this respect, we have found it useful to introduce the self-observation gradually over a 3-week period. During the first week the form only includes Date, Situation and Intensity. For the second week a column called Reaction (what did you feel?) is inserted, and from Week 3 the form has its final appearance. Examples of early anxiety signals are increased heart rate, tension of the shoulders, butterflies in the stomach etc.

Progressive relaxation The first phase of AR includes teaching the patient to relax with the help of progressive relaxation (PR; Jacobson, 1938). We have used the shortened version described by Wolpe and Lazarus (1966). The large muscle groups are divided into two parts and worked through during the first sessions in

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Scatid J Beliar 7ller. 17, No. 2 , 1988

Date Situation Reaction Intensity Action (focus on the (0-10) (what did earliest signs) you do?)

the following way: Session I : Hands, arms, face, neck and shoulders. Ses- sion 2: Back, chest, stomach, breathing, hips, legs, and feet. In order to make the transition to natural situations as easy as possible we dont use taped instructions or let the patient lie on a couch during the relaxa- tion training. Instead the patient sits in a comfortable armchair and the thera- pist first models how the different muscle groups should be tensed and then relaxed. The patient does the different tension-release cycles at the same time. The therapist checks that they are properly done, and any questions or unclear points are dealt with. Then the patient closes the eyes and the thera- pist instructs him/her to tense and relax the different muscles in the right order and tempo. A tension should normally be kept for 5 sec and the subse- quent relaxation of that muscle group should be 10-15 sec before proceed- ing to the next tensing. After the relaxation in this session has been worked through, the patient is asked to rate the degree of relaxation on a 0-100 scale, where 0 is completely relaxed, 50 is normal, and 100 completely ten- se. This makes the patient familiar with the rating scale that is going to be used during homework practice. The therapist also checks if the patient experienced any problems during the relaxation and helps him/her to take care of these. As a homework assignment, the patient is to practice the relaxation twice a day, preferably morning and night, and record the practice on a form (see Figure 3). One advantage of using this type of form is that the therapist quickly can get an idea of how well the patient can relax during the home practices by looking at the difference between the before and after ratings. Furthermore, it probably reduces potential tendencies to cheat with the prac- tice, as the patient is to record the date and time of day for each training session and leave a blank row each time he/she has failed to perform the trai- ning. During the second session the relaxation instruction is started with Part 1 and the second part is added. The corresponding changes are done regarding the homework assignments. Depending on how successful the patient is during the homework relaxation trianing, the next phase in AR will start at Sessions 3-4.

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Scnnd J Beliav llier, 17, No. 2 , I988

RELAXATION TRAINING Learning to relax requires a lot of practice. Follow the instructions you have got and practice twice a day. Register at what time you practice, which component, how relaxed you were before and after the practice, and how long it took you. Also note any difficulties you might have experienced or other comments. I f you for some reason fail to do the relaxation training leave that row blank. When rating the degree of relaxation use a scale from 0 to 100. On this scale 50 =the normal value, O= totally relaxed, and 100 = maximum tension.

Figure 3. Foriit for regisrrnrioir of Iioniework relaxation training.

Release-only relaxation The purpose of this phase is to reduce the time it takes the patient to become relaxed, from 15-20 min to 5-7 min. The relase-only relaxation means that the therapist deletes the instructions concerning the tension of the muscle groups. Instead, the therapist instructs the patient to relax these muscle groups directly, starting at the top of the head and working through right down to the toes (see Appendix A). If, during this procedure, the patient should experience tension in a muscle group he/she is first to tense that group briefly and then relax it. The practice of release-only relaxation generally takes 1-2 weeks, which is then foliowed by conditioned, or cue-controlled relaxation.

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Cue-controlled relaxation The purpose of cue-controlled relaxation is to create a conditioning between the self-instruction relax and the state of being relaxed, which is relative- ly easy to achieve once the patient starts out by relaxing before the condi- tioning begings. In cue-controlled relaxation the focus is on the breathing. The session starts by letting the patient relax by him-/herself using the release-only relaxation, and signalling to the therapist by raising an index finger when he/she has achieved a state of deep relaxation. When this is done the therapist gives the following instruction cued to the patients breathing pattern. At the start of an inhalation the therapist says INHALE and during the exhalation RE- LAX. This is done 5 times and then the patient is instructed to think inha- le and relax, respectively, in relation to the breaths. After about 1 min the therapist once more instructs INHALE . . . RELAX 4-5 times, and then the patient continues on hidher own a couple of minutes. Some patients find it difficult to think inhale, and of course its enough to use only re- lax, which is the cue-word that is going to beconditioned. After this relaxa- tion, the patient is asked to estimate the time it took to become relaxed. An overwhelming majority of the patients overestimates with 50-loo%, and should be reinforced, as the correct time is fed back to them, for becoming relaxed in such a short time. The above cue-controlled relaxation cycle is repeated once more during the session after an interval of 10-15 min. By using cue-controlled relaxation there is a further reduction of the time it takes for the patient to become relaxed. Generally it takes 2-3 min with this method. Cue-controlled relaxation also requires 1-2 weeks of practice be- fore proceeding to the next phase.

Differential relaxation In order for AR to be an efficient coping skill it must be portable, i.e. the patient should be able to use it in practically any situation. He/she must not be constricted to a comfortable armchair in the therapists office, o r hidher own home. The primary purpose of differential.re1axation is teaching the patient to relax in other situations, besides the armchair. The secondary purpose is to teach the patient not to tense the muscles that are not being used for the particular bodily activity that the patient is engaged in at the moment. The session starts with letting the patient relax by using cue-controlled re- laxation, i.e. relaxing from head to foot, scanning the body for any tensions, while sitting in an armchair. Then he/she is instructed to do certain move- ments with various parts of the body, while at the same time concentrating on being relaxed in the rest of the body, frequently scanning it for signs of

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tension. Examples of movements used are opening the eyes and looking around in the room but only moving the eyes; looking around and also moving the head; lifting one hand, one arm, and then the other; lifting one foot, one leg and then the other. While giving these instructions, the thera- pist should continuously encourage the patient to relax the parts of the body that are not engaged in the movement. This is particularly important when it comes to the arms and the legs. After this exercise, the patient is asked if he/she experienced any problematic areas and is instructed how to deal with them. Next, the same practice is done while sitting on an ordinary chair, and then sitting by a desk writing something on a piece of paper, or talking on the telephone. The above is usually enough for one session, and at the next there is first a rehearsal of sitting on an ordinary chair, or at a desk. Then one proceeds with practicing to relax while standing, and while walking. While practicing standing relaxation, it is recommended that the patient stands close to the wall (not leaning against it) because some may feel an unsteadiness, especial- ly if they want to begin the relaxation with their eyes closed. After the patient has used cue-controlled relaxation to get relaxed, most of the same move- ments as.are used while sitting can be applied. The final step of differential relaxation is practicing to relax while walking. The patient now starts to relax standing and when this is achieved he/she begins to walk, trying to be as relaxed as possible in the muscles not used during ordinary walking. Initially, one often finds that the patient walks slowly and awkwardly, but with some practice he/she will be able to walk at ordinary walking speed still being relaxed. The time it takes for the patient to relax will be reduced further during these two sessions of differential relaxation, and at the end of the second session it generally takes 60-90 sec.

Rapid relaxation The next phase in AR also has two purposes: (1) to teach the patient to relax in natural non-stressful situations, and (2) to further reduce the time it takes to get relaxed, the goal being 20-30 sec. In order to achieve these goals the patient should relax 15-20 times a day in natural situations. The therapist and the patient first have to agree upon what could serve as a cue for relaxation training for the individual patient. Examples of cues that have been used are every time one looks at the watch, makes a telephone call, opens a cupboard etc. To increase the signal-value, one can put a small piece of colored tape on the watch or the telephone recei-

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ver. After a while it may be necessary to change to another color of the tape, as the signal-value of the first may be reduced due to habituation. While relaxing in these natural situations the patient is instructed to do the following: (1) take 1-3 deep breaths and slowly exhale, (2) think "relax" before each exhalation, and (3) scan the body for tension and try to relax as much as possible in the situation at hand. During this phase the patient might also pick out certain times a day when stressed and use cue-controlled relaxation. With 1-2 weeks of practice of rapid relaxation most patients have succeeded in reducing the time it takes to get relaxed to 20-30 sec.

Application training After 8-10 sessions and weeks of homework practice, the patien! is ready to start applying the relaxation skill to cope with anxiety in natural situations. Before starting to apply AR it is important that the patient is reminded that AR is a skill, and as any other skill it takes practice to get refined. The patient should thus not expect complete effectiveness at the first application, but must be content that the anxiety ceases to increase. He/she should, however, not be discouraged if it does not work very well initially, but continue to app- ly the relaxation every time anxiety is experienced. Relatively soon, the patient will notice a larger effect of AR and eventually the anxiety reaction can be aborted altogether. The application training usually takes 2-3 sessions of relatively brief expo- sure (10-15 min) to a large array of anxiety-arousing situations. The pur- pose of this phase is to show the patient that he/she can cope with the anxiety experienced and eventually abort it altogether, During these sessions, the role of the therapist is very much like a sports coach, encouraging the patient to relax before entering the situation, to observe the initial physiological reactions, and to counteract these by using relaxation in the situation to stop the anxiety from increasing further. If few, or no reaction occurs, the relaxa- tion prior to entering the phobic situation should be discarded. Otherwise the patient will not experience the aroused anxiety and that AR is effective in counteracting it. Compared to exposure in-vivo treatment, where the exposure duration generally is 1-2 hrs, the exposure in AR is much briefer, 10-15 niin. The goal is not to extinguish the anxiety reactions in the situations, but to provide relistic opportunities for the patient to practice applying relaxation to cope with anxiety. Having this goal we consider it a better use of therapy time to sample as many relevant situations as possible, instead of maybe only 2-3 situations.

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Scclnd J Bchnv nm. 17, NO. 2, 19S8

SELF-OBSERVATION OF PANIC ATTACKS Name: Each time you experience: (Individual description of panic attack)

~~~~

Make a record below! Rate the intensity of the panic attack according to the follo- wing scale.

1 2 a little panic

3 4 5 very intense

panic - Date Situation Inten-

sity Relaxation YES -

ntensity afterwards :time rnin)

kledicine if used)

Figure 4. Self-observation form for panic attacks.

The above description of the application training holds primarily for phobic patients where fairly clear-cut anxiety-eliciting situations can be pinpointed. Regarding generalized anxiety and panic disorder patients, some kind of stressful situation in the therapy session, e.g. hyperventilation, physical exercise, and imagery of anxiety-arousing situations, can be used in applica- tion training. The purpose at this point is to provide situations in which anxi- ety/panic attacks are elicited and counteracted. Another possibility is to pro- ceed directly to using AR in natural situations. If this alternative is chosen,

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S C L I I I ~ J Behnr nler, 17, hb. 2, 1958

Date Week 2 8/6 2, 3 9/6 1

10/6 3 11/6 3,2 1216 1 73/6 4 14/6 2

PHOBIA PROJECT

NAME: N.N.

date Week 3 Date 15/6 3 22/6 16/6 1, 3 23/6 1716 2, 3 2416 18/6 1 2% 19/6 26/6 20/6 2 27/6 21/6 3 28/6

Form: 4 Week: 7-10

If you just continue to d o d o ' the following each week

2: Rapid relaxation 3: Go by bus

5: E

Then in the fu ture you will be able to: Move around freely

-+ in the cify and cope with panic/anxiety reactions

1 : Differential relaxation A

4: Shop in supermarket N L

Record the respective figure in the columns below each time you have performed the practice task. Make any comments that you may have on the reverse s ide of the form. Do not skip the practice a n y week but keep practicing regularly. This is particularly important during the first 6 months after the treatment. Then send m e the form in the way that we have agree upon. Good Luck!

Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Week 1

1, 3, 4 2 3 2, 4 1

Send this form to: Psychiatric Research Center, Uller4ker Hospital, Uppsala: t h e I I f you have any problem call m e a t . . . . Figure 5. Record form during inniiitennitce progrnm.

the importance of instructions to get the patient's expectancy at the right level should be stressed. In order for the therapist to get a clear picture of the efficacy of AR for the patient, the self-observation form depicted in Figure 4, or a similar one, is recommeded. By using this, the therapist gets information regarding the pro- portion of anxiety situations in which AR has been used, thc effectiveness of AR in these situations, and whether different effects are achieved in diffe- rent situations.

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Maintenance program For AR, as for any other skill, it is important to keep practicing after the end of treatment in order not to "forget" the skill, or get "rusty". The patient is encouraged to develop the habit of scanning the body at least once a day, and if noticing any tension, use the rapid relaxation to get rid of it. He/she should also practice differential or rapid relaxation twice a week on a regular basis. Furthermore, the patient is carefully instructed that no treatment can inoculate against anxiety reactions in the future, and to be prepared that a setback can occur at any time, after a long anxiety-free period. It may also be positive to predict setbacks and see them as a good thing, an opportunity to practice AR. We have previously described a maintenance program for agoraphobia (Jansson, Jerremalm & Ost, 1984) in which the patient has an individually tailored form (see Figure 5 ) to record hidher continued practice during the first 6 months after the end of treatment. These forms are mailed to the thera- pist regularly, who upon receiving them calls the patient for a brief discus- sion on what has happened since the last contact, whether the tasks for the next period should be changed etc.

CONCLUSIONS Applied relaxation is a flexible coping technique that most patients can ac- quire readily. There is nothing mystical or "sacred" about AR, and the pa- tient is continuously aware of what is done during the therapy sessions, and why it is done. Furthermore, there are very few side effects of AR. The relaxation-induced anxiety reactions described by Heide and Borkovec (1983, 1984) have only been encountered in four patients (three with panic disorder and one with migraine) treated in our laboratory. In all instances, these reactions were overcome by taking a pause and talking about them, and then the relaxation training could continue. We have in no case had to aban- don the AR-treatment due to side-effects. This is also reflected in a low attri- tion rate (mean of 6% in controlled studies; Ost, 1987). AR also has a wide applicability, both regarding type of disorder (phobias, panic disorder, gen- eralized anxiety disorder, migraine and tension headache, pain, epilepsy, tinnitus, dyspepsia, and chemotherapy-induced side effects) and the age ran- ge (7-66 years in controlled studies) for which this method is suitable (Ost, 1987). The results of AR in 18 controlled outcome studies (Ost, 1987) show that it is significantly better than both no-treatment and attention-placebo condi- tions. Furthermore, AR is as effective as all other behavioral methods with which it has been compared.

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The effects of AR are also durable, at least at follow-ups 5-19 months after the end of treatment. The assessments not only showed a maintained effect, but a further sizeable improvement in 9 out of 12 studies.

REFERENCES Barrios, B.A., & Shigetomi, C.C. (1979). Coping-skills training for the

management of anxiety: A critical review. Behaviour Research and Therapy, 10, 491-522.

Chang-Liang, R., & Denney, D.R. (1976). Applied relaxation as training in self-control. Journal of Counseling Psychology, 23, 183-1 89.

Goldfried, M. (1971). Systematic densensitization as training in self- control. Journal of Consulting and Clinical Psychology, 37,

Goldfried, M., Decenteceo, E.T., & Weinberg, L. (1974). Systematic ratio- nal restructuring as a self-control technique. Behavior Therapy, 5,

Heide, F.J., & Borkovec, T.D. (1983). Relaxation-induced anxiety: Para- doxical anxiety enhancement due to relaxation training. Journal of Consulting and Clinical Psychology, 51, 171-182.

Heide, F.J., & Borkovec, T.D. (1984). Relaxation-induced anxiety: Mecha- nisms and theoretical implications. Behaviour Research and Thera-

Jacobson, E. (1938). Progressive relasation. Chicago: University of Chi- cago Press.

Jansson, L., Jerremalm, A., & Ost, L-G. (1984). Maintenance procedures in the behavioral treatment of agoraphobia: A program and some data. Behavioural Psychotherapy, 12, 109-1 16.

Meichenbaum, D., & Turk. (1976). The cognitive-behavioral management of anxiety, anger, and pain. In: P.O. Davidson, (Ed.), The behavio- ral management of anxiety, depression and pain. New York: Brun- ner/Mazel.

Ost, L-G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25,

Russel, R.K., & Sipich, J.F. (1973).-Cue-controlled relaxation in the treat- ment of test anxiety. Journal of Behavior Therapy and Esperimen- tal Psychiatry, 4, 47-49.

Suinn, R.M., & Richardson, F. (1971). Anxiety management training: A nonspecific behavior therapy program for anxiety control. Behavior Therapy, 2, 498-510.

Wolpe, J., & Lazarus, A.A. (1966). Behavior therapy techniques. New York: Pergamon.

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APPENDIX A: RELEASE-ONLY RELAXATION Breathe with calm, regular breaths and feel how you relax more and more for every breath . . . Just let go. Relax your forehead . . . eyebrows . . . eyelids . . . j a w s . . . tongue and throat . . . lips . . . your entire face. Relax your neck . . . shoulders . . . arms . . . hands . . . and all the way out to your fingertips. Breathe calmly and regularly with your stomach all the time. Let the relaxation spread to your stomach . . . waist and back. Relax the lower part of your body, your behind . . . thighs . . . knees . . . calves . . . feet . . . and all the way down to the tips of your toes. Breathe calmly and regularly and feel how you relax more and more by each breath. Take a deep breath and hold your breath for a couple of seconds . . . and let the air out slowly . . . slowly . . . Notice how you relax more and more.

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