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Scandinavian Journal of
Behaviour Therapy
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Applied Relaxation: Description

of an Effective Coping
Technique
Lars-Gran st

Psychiatric Research Center University of Uppsala

Published online: 23 Mar 2010.
To cite this article: Lars-Gran st (1988) Applied Relaxation: Description of an
Effective Coping Technique, Scandinavian Journal of Behaviour Therapy, 17:2, 83-96,
DOI: 10.1080/16506078809456264
To link to this article: http://dx.doi.org/10.1080/16506078809456264

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

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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'entirally abort anxiety reactioris altogether. AR generally
takes 10-12 sessions aiid corisists of the followirig coinpoiients: 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 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 Maiiagenrerit Training. Later came Cire-Controlled
Relmatioii (Russel & Sipich, 1973), Systeniatic Rotiorial Restrirctirririg
(Goldfried, 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.

83

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 techniques up to 1978 was given by Bahios and Shigetomi (1979).

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The purpose of the present paper is to describe Applied Relrmtioii (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.

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 description 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 understands 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 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 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 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 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 information, 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
84

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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 experience some physiological change, followed by a negative thought, which increases 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 practically 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 restricted 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 counteract, and eventually get rid of, the physiological reactions you usually
experience in phobic situatins. To achieve this we are going through a gradual process (illustrated in Figure 1) starting with tensing and relaxing different 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.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 patients awareness of the initial anxiety-reactions
he/she is given homework assignments to self-observe and record these reactions. There.is a definite advantage in having the patient observe hidher
reactions in natural situations instead of just talking about them during the
85

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

PROGRESSIVE

RELAXATION

Ses
2
3

..

15-20 min

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CUE-CONTROLLED

RELAXATION

DIFFERENTIAL

RELAXATION

6
7

20-30

APPLICATION
TRAIN ING

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
86

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

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Date

Situation

Reaction
(focus on the
earliest signs)

Intensity

(0-10)

Action
(what did
you do?)

the following way: Session I : Hands, arms, face, neck and shoulders. Session 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 relaxation training. Instead the patient sits in a comfortable armchair and the therapist 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 therapist 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 subsequent relaxation of that muscle group should be 10-15 sec before proceeding 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 tense. 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 practice, 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 training.
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.
87

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

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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 afterthe practice, and how long it took you. Also
note any difficulties you might have experienced or other comments. If 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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Scatid J Behnv nier, 17,No. 2. I y w

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 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 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 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 relax, which is the cue-word that is going to beconditioned. 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-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 before 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 relaxation, 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 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

89

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Scand J Bchav Tlier. 17,No. 2 , I988

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 therapist 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, 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 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 recei90

Scarid J Rehav Ihrr. 17, No. 2, 1988

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.

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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 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 altogether.
The application training usually takes 2-3 sessions of relatively brief exposure (10-15 min) to 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 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 relaxation 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.
91

Scclnd J Bchnv

nm. 17, NO.2,

19S8

SELF-OBSERVATION OF PANIC ATTACKS

Name:
Each time you experience: (Individual description of panic attack)

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~~~~

Make a record below! Rate the intensity of the panic attack according to the following scale.
3
4
5
1
2
very intense
a little
panic
panic

Date Situation

Intensity

kledicine
Relaxation ntensity
afterwards if used)
YES
:time rnin)

Figure 4. Self-observationform 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 application training. The purpose at this point is to provide situations in which anxiety/panic attacks are elicited and counteracted. Another possibility is to proceed directly to using AR in natural situations. If this alternative is chosen,

92

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

PHOBIA PROJECT
NAME: N.N.

Form: 4
Week: 7-10

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If you just continue to d o d o

the following each week
1 : Differential relaxation
2: Rapid relaxation
3: Go by bus
4: Shop in supermarket

5:

Then in the future you will

be able to:

'

Move around freely

-+ in the cify and cope

with panic/anxiety
reactions

N
E

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 side 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

Week 1 Date

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

1, 3, 4
2
3
2, 4
1

8/6
9/6
10/6
11/6
1216
73/6
14/6

Week 2 date
2, 3
1
3
3,2

4
2

Send this form to:

Psychiatric Research Center, Uller4ker
If you have any problem call m e a t . . . .

15/6
16/6
1716
18/6
19/6
20/6
21/6

Week 3 Date
3
1, 3
2, 3
1

2
3

22/6
23/6
2416
2%
26/6
27/6
28/6

Hospital, Uppsala:

the

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 proportion of anxiety situations in which AR has been used, thc effectiveness
of AR in these situations, and whether different effects are achieved in different 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 therapist regularly, who upon receiving them calls the patient for a brief discussion 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 acquire readily. There is nothing mystical or "sacred" about AR, and the patient 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 abandon the AR-treatment due to side-effects. This is also reflected in a low attrition rate (mean of 6%in controlled studies; Ost, 1987). AR also has a wide
applicability, both regarding type of disorder (phobias, panic disorder, generalized anxiety disorder, migraine and tension headache, pain, epilepsy,
tinnitus, dyspepsia, and chemotherapy-induced side effects) and the age range (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 conditions. Furthermore, AR is as effective as all other behavioral methods with
which it has been compared.
94

Scatid J Behav n i r r . 17, No. 2, 1988

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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.
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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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