Behav. Res. Ther. Vol. 25, No. 5, pp. 397-409, 1987 Printed in Great Britain 0005-7967/87 $3.00 + 0.00 Pergamon Journals, Ltd
Address for correspondence: Dr Lars-Goran Ost, Psychiatric Research Center, Ulleraker Hospital, S-750 17 Uppsala, Sweden.
(Received 11 December 1986)
The rationale and practice of applied relaxation (AR) are described. The purpose of this treatment method is to teach the patient a coping skill which will enable him/her to relax rapidly, in order to counteract, and eventually abort the anxiety reactions altogether. A review of 18 controlled outcome studies show that AR has been used for different phobias, panic disorder, headache, pain, epilepsy, and tinnitus. The results show that AR was significantly better than no-treatment, or attention-placebo conditions, and as effective as other behavioral m ethods with which it was compared. At follow-up after 5-19 months the effects were maintained, or further improvements were obtained.
During the 1970's a number of coping techniques was developed within behavior 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 Management Training. Later came Cue-Controlled Relaxation (Russel and Sipich, 1973), Systematic Rational Restructuring (Goldfried, Decenteceo and Weinberg, 1974), Stress-Inoculation Training (Meichenbaum and Turk, 1976), and Applied Relaxation (Chiang-Liang and Denney, 1976). A review of the empirical evidence for these coping techniques up to 1978 was given by Barrios and Shigetomi (1979). The purpose of the present paper is to describe Applied Relaxation (AR) as we have developed it at the Psychiatric Research Center, University of Uppsala, from 1978 onward. A second purpose is to review the empirical data from our own studies and those of others.
It is important that the patient, before the start of the treatment, fully understands how AR is going to be used, and why it should work in his/her 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 individual 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 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 on unclear points etc. The patient keeps the description and can study it at home. The next session, before starting AR, one can test whether the patient has understood what AR is and encompasses its rationale. This is done in a short role-play in which the therapist plays the part of an interested 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 him/her. 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 includes, but is not restricted to, the following information, which is used for phobic patients: "When a person with a phobia encounters a phobic situation there are three different components in his / her reaction;
The purpose of AR is twofold: (1) teaching the patient to recognize early signals 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 patient's awareness of the initial anxiety-reactions he/she is given homework assignments to self-observe and record these reactions. There is a definite advantage of having the patient observe his/her reactions in natural situations instead of just talking about them during the 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 1 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.
[figure 1 begins] SELF-OBSERVATION OF EARLY ANXIETY SIGNALS
Date Situation Reaction Intensity Action (focus on the (O - 10) (what did earliest signs) you do?)
Fig. 1. Form for self-observation of early anxiety signals. [figure 1 ends]
The first phase of AR includes teaching the patient to relax with t he 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 the following way:
The purpose of this phase in AR is to reduce the time it takes the patient to become relaxed, from 15-20 min to 5-7 min. The release-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 the patient during this procedure 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 followed by conditioned, or 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 relatively easy to achieve once the patient starts out by relaxing before the conditioning begins.[Figure 2 begins] 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. If you for some reason fail the relaxation training leave that row blank.
When rating the degree of relaxation use a scale from 0 100. On this scale 50 the normal value, 0 = totally relaxed, and 100 maximum tension.
Date Time Component Degree of Relaxation Comments before after time
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 signaling 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 patient's breathing pattern. Just before an inhala tion the therapist says "INHALE" and just before the exhalation "RELAX". This is done 5 times and then the patient is instructed to think "inhale" and "relax", respectively, in relation to the breaths. After about one min the therapist once more instructs "INHALE ... RELAX" 4*-5 times, and then the patient continues on his/her own a couple of minutes. Some patients find it difficult to think "inhale", and of course it's enough to use only "relax", which is the cue-word that is going to be conditioned. After this relaxation the patient is asked to estimate the time it took to become relaxed. An overwhelming majority of the patients overestimates with 50-100%, 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 minutes. By using cue-controlled relaxation there is a further reduction of the time it takes for the patient to become relaxed. Genera lly it takes 2-3 min with this method. Cue-controlled relaxation also requires 1-2 weeks of practice before proceeding to the next phase.
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 the therapist's office, or his/her own home. The primary purpose of differential relaxation is aching the patient to relax in other situations, be sides the armchair. The secondary purpose is teach the patient not to tense the muscles that are not being used for the particular bodily activity at the patient is engaged in at the moment. The session starts with letting the patient relax by using cue-controlled relaxation, i.e. relaxing from head to foot, scanning the body for any tensions, while sitting in an armchair. Then he/she instructed to do certain movements 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 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 head, one arm, and then the other; lifting one foot, one leg and then the other. While giving these instructions the therapist could 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 instructed how to deal the 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. Then one proceeds with practising to relax while standing, and while walking. Whil e practising standing relaxation it is recommended that the patient stands close to the wall (not leaning against it) because some may feel an unsteadiness, especially 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 movements as are used while sitting can be applied. The final step of differential relaxation is practising to relax while walking. The patient now starts relax standing and when this is achieved h e/she begins to walk, trying to be as relaxed as possible 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 it 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.
The next phase in AR also has two purposes: (1) teaching the patient to relax in natural in-stressful situations, and (2) 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 the watch, makes a telephone call, opens a cupb oard etc. To increase the signal-value one can it a small piece of colored tape on the watch or the telephone receiver. 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 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 on rapid relaxation most patients have succeeded in reducing the time it takes to get relaxed to 20-30 seconds.
After 8-10 sessions and weeks of homework practice the patient is ready to start applying the relaxation skill in natural situations to cope with anxiety. Before starting to apply AR it is important that t he 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 apply 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 a ltogether. The application training usually takes 2-3 sessions of relatively brief exposure (10-15 min) a large array of anxiety-arousing situations. The purpose of this phase is to show the patient that he/she can cope with the anxiety experienced and eventually abort it altogether. During the 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 r elaxation in the situation to stop the anxiety from increasing further. Compared to exposure in vivo treatment, where the exposure duration generally is 1-2 hr, the exposure in AR is much briefer, 10-15 min. The goal is not to extinguish the anxiety reactions in the situations, but to provide realistic 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. 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 as application training. The purpose at this point is to provide situations in which anxiety/panic attacks are eli cited and extinguished. Another possibility is to proceed directly to using AR in natural situations. If this alternative is chosen 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 Fig. 3, or a similar one, is recommended. By using this the therapist gets information regarding the proportion of anxiety situations at which AR has b een used, the effectiveness of AR in these situations, and whether different effects are achieved in different situations.
For AR, as for any other skill, it is important to keep practising applied relaxation 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 differentia l 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 and Ost, 1984) in which the patient has an individu ally tailored form to record his/her continued practice during the first 6 months after the end of treatment. These forms are mailed to the therapist regularly, who upon receiving them calls the patient for a brief discussion on what has happened since the last contact.
Applied relaxation as described above or variations of it, has been used in 18 controlled outcome studies in my laboratory, or by colleagues in Uppsala. These studies are summarized in Table 1.
AR was developed for treating phobic patients, but it is by no means restricted to that disorder. As can be seen from Table 1 AR has also been used for panic disorder, headache (tension, migraine and mixed), pain (back and joints), epilepsy (both in children and adults), and tinnitus. Furthermore, AR has in recently completed, but not yet published, studies been used for migraine and gastric catarrh. In clinical practice AR has also been found useful for patients with "cardiac neurosis", sleep-ons et insomnia, and for cancer patients with chemotherapy-induced nausea, to name a few. AR is thus applicable for a wide range of disorders as well as a large age span. The controlled studies comprise patients from 7 (Dahl et al., 1985) to 66 (Jerremalm et al., 1986b). Still older patients have been treated in clinical practice applications. Furthermore, our experience shows that AR is a coping skill that a very large majority (90-95%) of the patients can acquire. The funnel approach described above seems t o promote a gradual increase in the proficiency that is aimed for. It is, of course, also important that the patient has been given a rationale for the treatment he,/she is going to receive. Another fact of interest is the comparatively low attrition rate. Across the 18 studies only 6% (range 0-22%) of the AR-patients dropped out. This compares favorably to a median of 12% range(0-35%) for exposure in vivo treatments of agoraphobia reviewed by Jansson and Ost (1982).
Breathe with calm, regular breaths and feel how you relax more and more for every breath ... Just let go ... Relax your forehead ... eyebrows. . . eyelids ... jaws ... 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 ... thig hs ... 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.