What is it?

Relaxation is not a panacea and is seldom used on its own. There are a number of relaxation techniques, including guided imagery, controlled breathing, progressive muscle and isometric relaxation. Relaxation involves voluntarily releasing tension and reducing arousal of the central nervous system. Arousal may produce hyperventilation and so learning to breathe more slowly in a controlled manner counteracts this effect. Muscles also become tense when someone is anxious, so it is important to teach patients to develop an awareness of excessive muscle tension and what situations produce it. This can be taught through a series of exercises where the patient is instructed to progressively tense and then relax the muscles throughout the body. This procedure needs to be taught by a skilled practitioner and practised for a period of time before it can be effectively implemented in anxiety-provoking situations. Isometric relaxation is an abbreviated form of muscle relaxation that can be quickly invoked in anxiety-provoking situations. Guided imagery can assist with various forms of relaxation by providing a script and images of peaceful surroundings

Does it work?

While relaxation strategies are often considered to be an effective component of treatment for a variety of disorders (e.g., social phobia, panic attacks), there is no specific evidence to suggest that relaxation is essential. Thus, relaxation is most effective when used as a one component of treatment, rather than as treatment itself (Barlow et al., 1998). Typically, relaxation strategies are included in the early stages of treatment as they are a skill that can be taught easily to the patient, can provide a sense of control over anxiety symptoms and impart a sense of mastery in the early stages of treatment. Some patients are afraid that being relaxed might lead to loss of control and could lead to panic. They will do better if they use PMR and progress very gradually. Supervision is essential.

How do you do it?


Progressive muscle relaxation (PMR):

1. As with any technique, explain the rationale for PMR to the patient:
   
   'today I will be teaching you a relaxation technique that, if practiced regularly, will help you feel less uptight and less tense. When you feel anxious and worried you tend to experience tension in various parts of your body. For example, many people feel tension in their neck and shoulders, others in their back or jaw, and some in their head or around their eyes. The idea behind progressive muscle relaxation is to teach you how to become more aware of when and where you feel tension in your body. To teach you this, I will be asking you to moderately tense the muscles in your body, one by one, starting with your hands and moving down to your feet. Once you've tensed a particular muscle, and held the tension for about 7-10 seconds, I will then ask you to relax and allow the muscle to go limp for about 15-20 seconds. This will allow you to experience a sense of relaxation before we move on.'
   Answer any questions and provide more details as necessary.
   
   
2. Ask the patient to get comfortable in the chair and clear his or her mind of any worries or thoughts. Explain that clearing the mind may not happen readily at first, but it will become easier with practice. Some people find it useful to think calming expressions to themselves when using this technique such as: 'relax', 'let go of any tension', 'be calm'.
   
   
3. The patient should then practice the slow breathing method for about a minute. 'Now I would like you to breathe in for 3 seconds, 1 - 2 - 3, and out for 3 seconds, 1 - 2 - 3.' You can also ask them to imagine that the tension is flowing out of their body with each breath out.
   
   
4. Ask the patient to continue to breathe slowly in and out, and to curl their hands into a fist. Let them hold the tension for 7-10 seconds, and then relax the muscle. You may ask them to notice the looseness in their hand now it is relaxed and to contrast this with the tension just felt in this muscle. Also, make sure that the patient is tensing their muscles moderately and that he or she is not experiencing any pain. Further, when letting go of the tension the patient should let go instantly and feel the muscle go immediately limp.
   
   
5. Continue to instruct the patient to tense and relax his or her muscles in the following order:
   

   Lower arms - bend your hand down at the wrist, as though you were trying to touch the underside of your arm, then relax. Upper arms - tighten your biceps by bending your arm at the elbow, then relax. Shoulders - lift your shoulders up as if trying to touch your ears with them, then relax. Neck - stretch your neck gently to the left, then forward, then to the right, then to the back in a slow rolling motion, then relax. Forehead and scalp - raise your eyebrows, then relax. Eyes - screw up your eyes, then relax. Jaw - clench your teeth (just to tighten the muscles), then relax. Tongue - press your tongue against the roof of your mouth, then relax. Chest - breathe in deeply to inflate your lungs, then breath out and relax. Stomach - push your tummy out to tighten the muscle, then relax. · Upper back - pull your shoulders forward with your arms at your side, then relax. Lower back - while sitting, lean your head and upper back forward, rolling your back into a smooth arc thus tensing the lower back, then relax. Buttocks - tighten your buttocks, then relax. Thighs - while sitting, push your feet firmly into the floor, then relax. Calves - lift your toes off the ground towards your shins, then relax. Feet - gently curl your toes down so that they are pressing into the floor, then relax.

6. As you progress through the muscles, it is useful to periodically remind the patient to clear away any thoughts or worries from their mind, and to keep all the other muscles in the body relaxed as they progress through the exercise.
   
   
7. At the end, allow the patient to remain still for a few minutes and experience the feeling of relaxation throughout the body. Ask the person to slowly openly their eyes.

Tips:

• if the patient prefers, you can record the exercise on to a cassette to facilitate practice.
• when at home, the patient should find a quiet place to practice this technique.
• remind the patient that to benefit from PMR he or she will need to practice this form of relaxation at least once a day.
• making a regular time to relax, such as on awakening, will increase the likelihood of the patient using this technique.
• 15-20 minutes of PMR per day is ideal, but 5 minutes is better than nothing!
  
  
  

Provide the rationale for this technique:
When you get anxious your rate of breathing increases. This overbreathing is often referred to as 'hyperventilation'. When you overbreathe you breathe out too much carbon dioxide which leads to a decrease in the level of carbon dioxide in the blood. The decreased level of carbon dioxide causes or worsens a number of symptoms such as breathlessness or light-headedness. You may experience these symptoms if you have panic attacks. To get rid of these symptoms, the level of carbon dioxide in the blood must be steadied. One way of achieving increased levels of carbon dioxide is to breathe into a paper bag. A large proportion of the air you breathe out is carbon dioxide, therefore, by re-breathing your old air you are taking higher amounts of carbon dioxide into your lungs.

Although breathing into a paper bag is simple and effective, it may not always be convenient or socially appropriate to pull out your paper bag in public! Additionally, although breathing into a paper bag is effective during a panic attack, this method cannot prevent hyperventilation in the future. An alternative method which is less obvious to other people and more effective in the long run is the slow breathing exercise. This method will help you to control your hyperventilation. Also, by learning slow and regular breathing habits you will help to prevent future episodes of hyperventilation and other symptoms of panic.

The following exercise is to be practised four times every day for at least five minutes each time, AND at the first signs of panic or anxiety. Combining slow breathing with relaxation is particularly helpful.

(To be practised regularly and at the first signs of anxiety or panic).

1. Hold your breath and count to 6 (do not take a deep breath).
2. When you get to 6, breathe out and say the word relax to yourself in a calm, soothing manner.
3. Breathe in and out slowly through your nose in a six-second cycle. Breathe in for three seconds and out for three seconds. This will produce a breathing rate of 10 breaths per minute. Say the word relax to yourself every time you breathe out.
4. At the end of each minute (after 10 breaths) hold your breath again for 6 seconds and then continue breathing using the six-second cycle.
5. Continue breathing in this way until all the symptoms of overbreathing have gone. It is important for you to practise this exercise so that it becomes easy to use any time you feel anxious. It is helpful to time it using the second hand of your watch or nearby clock.

References and recommended reading:

1. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambridge University Press.
2. Bourne, E. J. (1995). The Anxiety and Phobia Workbook (Second Edition). USA: New Harbinger Publications Inc.
3. Barlow, D. H., Lawton Esler, J., Vitali, A. E. (1998). Psychosocial Treatments for Panic Disorders, Phobias, and Generalized Anxiety Disorder. In P. E. Nathan and J. M. Gorman (Eds.). A Guide to Treatments that Work. New York: Oxford University Press.
4. Davis, M., Eshelman, E. R., & McKay, M. (1995). The Relaxation & Stress Reduction Workbook (Fourth Edition). USA: New Harbinger Publications Inc.
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.