Behav. Res. Thcr. Vol. 25, No. 5, pp. 397409, 1987 000577967/87 53.00 + 0.

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Printed in Great Britain Pergamon Journals Ltd

APPLIED RELAXATION: DESCRIPTION OF A COPING

TECHNIQUE AND REVIEW OF CONTROLLED STUDIES

LARS-G~RAN
&T
Psychiatric Research Center, University of Uppsala, Sweden

(Received I1 December 1986)

Summary-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 methods with which it was compared. At follow-up after
Z-19 months the effects were maintained, or further improvements were obtained.

INTRODUCTION

During the 1970s 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 Desensi-
tization 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-Znocuhtion 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.

DESCRIPTION OF THE PROCEDURES IN

APPLIED RELAXATION

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 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 (l-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 patients 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

Address for Correspondence: Dr Lam-GBran Ckt, Psychiatric Research Center, UllerHker Hospital, S-750 17 Uppsala,
Sweden.

397
398 hiIS-G(jRAN t)ST

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; 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 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 reluxarion. 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 set and to use this skill to counteract,
and eventually get rid of, the physiological reactions you usually experience in phobic
situations. To achieve this we are going through a gradual process starting with
tensing and relaxing different muscle groups. This takes about 15 min, 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 min. The next step teaches you to connect the
self-instruction Relax to the bodily state of relaxation. 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. After that it is time for the rapid relaxation, which you
practice many times a day in non-stressful situations. 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 in falling 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
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.
 Applied relaxation 399

SELF-OBSERVATION
OF EARLYANXIETYSIGNALS

Date Situation Reaction Intensity Action

What did
(focus on the ( - lo) you do?)
earliest signs)

Fig. 1. Form for self-observation of early anxiety signals.

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 the following way:
Session 1: 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 set and the
subsequent relaxation of that muscle group should be 10-15 set 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 &lo0 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 Fig. 2). 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 naturally done regarding the homework assignments.
Depending on how successful the patient is during the homework relaxation training the next phase
in AR, will start at session 34.

Release-only relaxation
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 l-2 weeks, which is then followed by
conditioned, or cue-controlled relaxation.

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.
 RELAXATIONTRAINING
Learning to relax requires a lot of practice. Follow the instructions
you have got and practice twice a day. Register at what time you prac-
tice, which component, how relaxed you were before and after the prac-
tice, 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 - 100. On this
scale 50 the normal value, 0 = totally relaxed, and 100 = maximum tension.

Fig. 2. Form for registration of homework relaxation training.

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. Just before an inhalation
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 minuttzs. 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 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-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 l-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
 Applied relaxation 401

in the therapists office, or his/her own home. The primary purpose of differential relaxation 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 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
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 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. Then one proceeds with practising to relax while standing, and while walking.
While 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
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
but 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) teaching the patient to relax in natural
non-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
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 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
l-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 l-2 weeks of practice on 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
relaxation skill in natural
important that the patient
to get refined. The patient
weeks of homework practice the patient is ready to start applying the
situations to cope with anxiety. Before starting to apply AR it is
is reminded that AR is a skill, and as any other skill it takes practice
should thus not expect complete effectiveness at the first application,
402 LARS-G&AN &T

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 (IO-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.
Compared to exposure in vivo treatment, where the exposure duration generally is l-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 elicited 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 patients 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 been
used, the effectiveness of AR in these situations, and whether different effects are achieved in
different situations.

Maintenance program
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 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 and
dst, 1984) in which the patient has an individually 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.

REVIEW OF CONTROLLED STUDIES

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.

Type of patients
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
 Applied relaxation 403

SELF-OBSERVATION OF PANIC AT 'ACKS

Name :

Each time you experience: [Individual description of panic attack]

Make a record below: Rate the intensity of the panic attack

according to the following scale.
1 2 3 4 5
a little very intense
panic panic

Date Situation r sity

I-
Inten- I 1Relal tion
YES
Intensity
NO afterwards
Yedicine
if used)
(time min)

Fig. 3. Self-observation form for panic attacks.

neurosis, sleep-onset 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 to 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 O-22%) of the AR-patients dropped out. This compares favorably to a median of 12%
(range O-35%) for exposure in vivo treatments of agoraphobia reviewed by Jansson and t)st (1982).
404 LARS-G~RAN t)sr

Table I. Review of controlled

Treatment
Study Problem n Treatments Assessments time sess.
ost l?I al. Social phobia 32 I. Phys. reactors-AR Behavioral test I2w lo-12
(1981) 2. Phys. reactors-SST Heart rate
3. Behav. reactors-AR Self-rating of anxiety
4. Behav. reactors-SST Social Situations Q,
Ost er al. Claustrophobia 34 1. Behav. reactors-Exp. Behavioral test IO w a-10
(1982)
2. Behav. reactors-AR Heart rate

3. Behav. reactors-WLC Self-rating of anxiety

4. Phys. reactors-Exp. Claustrophobia Scale-Anxiety

5. Phys. reactors-AR Claustrophobia Scale-Avoidance
6. Phys. reactors-WLC Proportion clinically improved

&t er al. Agoraphobia 40 I. Phys. reactors-AR Behavioral test 12w 12

(1984a) 2. Phys. reactors-Exp. Heart rate
3. Behav. reactors-AR Self-rating of anxiety
4. Behav. reactors-Exp. Proportion clinically improved

Ckt ef al. Blood phobia 18 I Applied Relaxation Behavioral test 9w9

(1984b) 2. Exposure A. rating of fainting behavior
Self-rating of anxiety
Heart rate, Blood pressure

Jerremalm Social phobia 38 I. Phys. reactors-AR Behavioral test 12w l&l2

et a/. (1986a)
2. Phys. reactors-SIT Heart rate

3. Phys. reactors-WLC Self-rating of anxiety

4. Cogn. reactors-AR Thought index

5. Cogn. reactors-SIT Social Situations Q.
6. Cogn. reactors-WLC
Jerretnalm er Dental phobia 38 I. Cogn. reactors-AR Behavioral test 9w9
al. (1986b) 2. Cogn. reactors-SIT Heart rate
3. Phys. reactors-AR Self-rating of anxiety
4. Phys. reactors-SIT Thought index
sterner e, Blood phobia 32 I. Applied relaxation Behavioral test IO w 5-10
al. (1986) 2. Applied tension A. ratmg of fainting behavior
3. Combination (I + 2) Self-rating of anxiety
Thought index
Heart rate, Blood pressure, EDA
StjernlGf Mixed 20 I. Progressive relaxation Headache sum 6w 6
er al. (1983) headache 2. Applied relaxation Headache frequency
Headache intensity
Medicine use

Larsson & Tension and 32 I. Applied relaxation Headache sum SW 9

Melin (1986) mixed head- 2. Information-contact Headache frequency
ache 3. Self-registration Headache free days
(adolescents) Headache duration
Proportion clinically improved

Larsson et Tension and 46 I. Therapist-assisted AR Headache sum 5wa

al. (1986a) migraine 2. Self-help AR Headache frequency
headache 3. Self-registration Headache free days
(adolescents) Headache duration
Proportion clinically improved

Larsson er Tension and 36 I. Self-help AR Headache sum 5 w 3-9

al. (1986b) mixed head- 2. Problem discussion Headache frequency
ache 3. Self-registration Headache free days
Headache duration
Proportion clinically improved

Linton & Pain 17 I. Waiting list Self-oberv. of pain intensity 5w 25

Melin (1983) (low back) 2. Regular treatment Medication
3. RT+AR Activity

Linton & Pain I5 I. Waiting list Self-observ. of pain intensity 5w 15

GBtestam (back and 2. Applied relaxation Medication
(1984) joints 3. AR + Operant program Activity
Beck Depression Inventory

Linton er Pain 28 I. Waiting list Self-observ. of pain intensity 9 w S-17

al. (1985) (back and 2. Regular treatment Medication
3. RT + AR + Operant pr. Sleep disturbance
Activity
Beck DepressIon Inventory
 Applied relaxation 405

studies using applied relaxation

Drop- Percent F- Percent

out %3 Results improvement P RCSUltS improvement
I +3:0 l>2; 3=4 1:54, 2~34, 3~38, 4~39 -
2+4:0 1=2;3=4 1:7, 2:9, 3:3, 4:0
1=2;4>3 l:39, 2~34, 3~37, 4159

I +4:6 1>2>3; 4=5=6 l:lOO, 2:6l, 3:-37, l4m Improvements

4-6:o maintained
2+5:0 l=2-3; 5>4>6 1:59, 2~37, 3:15, 4174,
5:lOO. 6:8
1>2>3; 4=5=6 1:92, 2:60, 3: -I, 4:30,
5:79,6:-II

1>2>3; 5>4>6 l:lOO, 2:50, 4:50, 5:lOO

I +3:6 l=2; 3=4 1:70, 2~69, 3~49, 4:55 l5m 1+3=2+4 I +3:72, 2+4:61
2+4:13 I=2; 3=4 l:46, 2:38, 3:100, 4:76 1+3=2+4 I +3:49, 2+4:85
1=2; 3=4 1:58, 2:31, 3:60, 4:54 1+3=2+4 1+3:65, 2+4:59
1+3=2+4 1 + 3:58, 2 +4:4l 1+3=2+4 1~3~72, 2+4:59
1:22 I=2 l:70, 2:55 6m I=2 1:86, 2:80
2:o I=2 1:79, 2:40 I=2 l:79. 2:80
I=2 1:40, 2:5l I=2 1:51, 2:42
I=2
I +4:5 1=2>3; 4=5>6 l:54, 2:53, 3:5, 4:5l, -
5:53. 6:15
2+5:5 1=2>3; 4=5=6 l:SO: 2:38, 3:2, 4:5,
5~7, 6~2
1=2>3; 5>4=6 l:32, 2:53, 3:0, 4:29,
5:55, 6:14

I + 3:17 1~2; 3=4 l:85, 2:23, 3:100, 4:60 IOm 92% had completed
2+4:ll 1=2,3=4 I: -7, 2:50, 3:73, 4:65 dental treatments
1=2,3=4 1:65, 2~57, 3:78, 4:70
1=2;4>3 1:39, 2:53, 3:-4, 4:38
I:9 2>I;2=3, I=3 l:73, 2:lOO. 3:90 6m l=2=3 l:86, 2~95, 3:85
2:o l=2=3 l:94, 2:100, 3:89 l=2=3 l:lOo, 2:100, 3:68
3:9 l=2=3 l:46, 2157, 3~63 1=2=3 l:43, 2~65, 3:71
1=2=3 1:52, 2:70, 3:73 l-2=3 l:59, 2:56, 3:59

I:0 I=2 l:36, 2:36 -

2:o I=2 l:36, 2:27

I=2 1:64, 2:3l

I:9 l>2=3 l:67, 2: -I, 3: -2 6m l=2=3 1:41, 2:ll, 3:15
2:15 1>3; l-2 l:40, 2:10, 3: -6 l>3; I=2 1:62, 2:16. 3:ll
3:o l>2=3 l:46, 2:6, 3: -9 1=2==3 1:46, 2:13, 3:15
l=2==3 l:37, 2: -2, 3: -8 l=2=3 1:14, 2: -6, 3:0
1>2-3 1:82, 2:8, 3:0 1~203 1:55, 2:38, 3~29
I:13 l=2>3 l:29, 2:23, 3:0 5m l=2>3 l:59, 2~46, 3~2
2~6 1=2>3 l:40, 2:19, 3:3 1=2>3 1:55, 2:40, 3:5
3:lS 1=2>3 1:41, 2:17, 3:2 l=2>3 1:57, 2:35, 3:5
1=2=3 l:9, 2:20, 3:6 l=2=3 l:12, 2:25, 3: -5
l=2=3 1:50, 2:38. 3:9 1=2>3 1:64, 2:50, 3:o
I:8 I>213 l:41, 2:16, 3: -2 5m l>2=3 l:56, 2:5, 3:2l
2:lO l==2>3 l:30, 2:24, 3: -2 I>213 1:45, 2:22, 3:17
3:o 1>2=3 l:30, 2:3, 2: -2 l>2=3 146, 2:3, 3:15
l>2-3 l:24, 2:14, 3:0 1>2=3 1:36, 2:14, 3:lO
I>213 l:50, 2:8, 3:10 1>2.=3 1:67, 2:40, 3:30
l-3:0 3>l; 2-3 1: -23, 2:17. 3:28 -
3>l I: -42, 3:30
3>1=2
l-3:0 2>l; I=3 1:3, 2:3l, 3:25 9m 2~3 2135, 3~7
3>1=2 1:3, 2:5l, 3:87 2-3 2182, 3:75
2=3>l
2=3>l I: -2, 2~45, 3:34 2==3 2~4, 3~42
l-3:0 3>1=2 I: -3, 2:5, 3:23
3>1+2 I +2:21, 3:67
3>1=2 I:-11, 2:-3, 3:18
321; 1=2;2=3 1: -8, 2~3, 3~27
I-2-3 1: -8, 2:2, 3:17
406 LARS-G&AN Osr

Table I.

Treatment
Study Problem n Treatments Assessment? time scss.

Dahl et al. Epilepsy 18 I. AR + Gpcraat program Self-obs. of seizure frequency 6w6

(1985) (children 2. Attention control Estimation of seizure duration
7-l 7 yrs) 3. Traditional care Seizure index
Dahl er al. Epilepsy 18 I. AR + Operant program Self-obs. of seizure frequency 6w 6
(1986) 2. Attention control
3. Waiting list
Scott et al. Tinnitus 24 I. Waiting list Self-obs. of tinnitus loudness 2-3 w 10
(1985) 2. AR + Distraction Self-obs. of tinnitus discomfort
Lindberg training Self-ohs. of depression
er al. (1986) Self-obs. of irritation
tht (1987) Panic 18 1. Progressive relaxation Self-obs. of panic attacks 14w 14
disorder 2. Applied relaxation Self-obs. of general anxiety
Hamilton Anxiety Scale
STAI-Trait
STAI-State
Proportion clinical improved
AR = Applied relaxation, SST = Social skills training, Exp. = Exposure in viva, WLC = Waiting list control, SIT = Self-instructional
training, RT = Regular treatment. %My the most important measures, are included. ?he numbers before the colon refers to the
treatments. Numbers refer to the treatment groups. > = Significantly better than. l = Groups 2 and 3 had obtained the same treatment
as group 1 between post-test and follow-up assessment. l * = Waiting-list group had obtained treatment.

Treatment time
There are very large variations regarding the treatment time and number of sessions used in the
outcome studies. The shortest time has the Scott et al. (1985) study on tinnitus where inpatients
were given one session a day for 2 weeks and outpatients the same 10 sessions over 3 weeks. Tlne
longest treatment time has the panic disorder study (t)st, 1987) with 14 weeks. In terms of treatment
sessions there is also a large variation; 6-15.

Variations of the original method

Most of the studies in Table 1 used AR as outlined above. There are, however, some variations
that should be noted. None of the studies by Larsson et al. on headache in adolescents and Scott
et al. (1985) on tinnitus have included differential relaxation. Larsson and Melin (1986) also seem
to have excluded the rapid relaxation training from their program. The Dahl et al. (1985, 1986)
studies on epilepsy have rather meager descriptions in this respect, but the differential relaxation
is probably deleted. Whether this has any detrimental effect on the outcome cannot be ascertained,
as a component analysis study has not yet been undertaken. Another variation of AR is the
self-help AR in which the patients practice relaxation by following the instructions on cassette tapes
delivered by the school nurse. In this condition the contact with a professional therapist is reduced
to a minimum.

Combination treatments
Researchers working in other areas besides anxiety disorders have often combined AR with other
behavioral procedures. Examples of this are the studies by Linton and Gotestam (1984), Linton
et al. (1985), and Dahl et al. (1985, 1986) in which operant programs have been used concurrently
with AR. Of these, the study by Linton and Gotestam (1984) used a design in which the added
effect of the operant program to AR could be assessed. In the Linton and Melin (1983) and Linton
et al. (1985) studies there are, due to clinical reasons no pure AR-condition. Instead AR is added
to the regular treatment used at the somatic rehabilitation clinic. Finally, in the Scott et al. (1985)
study AR is combined with distraction training in order for the patients to relocate their attention
from the tinnitus to something unrelated to this phenomenon.

Outcome of the controlled studies

No-treatment comparisons. AR (or a combination).has been compared to a waiting-list condition
in 10 of the 18 studies. In all of these AR yielded significantly better results than the no-treatment
condition.
 Applied relaxation 401

(cont.)
Drop- Percent F- P-t
out % Results improvement UP ReWlts improvement

l-3:0 l-2=3 1:48, 2:25, 3:8 1yr 1-2~3 1:31, 2: -325, 3: -62
1=2=3 1:92, 2:0, 3:0 1=2x3 1:87, 2:0, 3: -97
1>2-3 1:96, 2:50, 3:2 1~2-3 1:95. 2:-150, 3:-188
1:17 1>2>3 1:47,2:-50, 3:-11 13m 1=2-3. 1:87, 2:88, 3:70
2:17
3:o
1:17 2>1 I: -2, 2:4 9m 1=2** I+ 2~9
2:o 2>1 I: -2, 2:17 1-t 2~26
2>1 1: -2, 2:35 1+2:6
1=2 I: -5, 2:22 I +2:3
I:11 I=2 1:84, 2: 100 19m 2>1 1:76, 2:toO
2:ll I=2 1:68, 2:84 2r1 1:73, 2:loo
221 1:54, 2~75 221 1:69, 2:86
2>1 1:33, 2:57 2>1 1:43, 2:70
I=2 1:51, 2:65 221 1:59, 2~79
I=2 1:38. 2:75 2>1 1:25. 2:lOO

Non-specific treatment comparisons. In 6 studies AR was compared to some kind of attention

control condition or regular treatment, containing more or less non-specific components. In 5 of
the 6 studies AR was significantly better, and in the sixth (Linton and Melin, 1983) there was a
trend in the same direction.
Active treatment comparisons. In 9 studies (7 on phobias, 1 on panic disorder, and 1 on mixed
headache) AR was compared to some other active behavioral treatment, i.e. exposure in uivo,
self-instructional training, social skills training, applied tension and progressive relaxation. In 6 of
these studies AR yielded as good results as the comparison treatment. However, in two studies,
AR was significantly better than social skills training or exposure in viuo for physiological reactors,
while the opposite was true for behavioral reactors in the bst et al. (198 1, 1982) studies on social
phobia and claustrophobia, respectively. Finally, in the study on panic disorder (bst, 1987) AR
was significantly better than progressive relaxation.

Maintenance of the treatment effects

Twelve of the studies have included follow-up assessments on the average 11 months (range 5-19)
after the end of treatment. These studies are shown in Table 2, which gives percent improvement
from pre-post and pre-follow-up assessments. This shows that not only are the treatment effects
obtained by AR maintained at the follow-up assessment, but there is a further improvement in 9
of the studies. This is also reflected by the mean percent improvement across the studies, which
at follow-up is 12 percentage points higher compared to the post value.

Table 2. Percent improvement for the AR-condition on the main measure in studies having
follow-up assessment
Study Measure Pm-post Pre-F-up
&t er (I/. (1982) Behavioral test 61 86.
c)st et 01. (1984a) Behavioral test 58 72
bt er al. (1984b) Behavioral test 70 86
Sterner er al. (1986) Behavioral test 73 86
Larsson & Melin (1986) Headache sum 67 41
Larsson er ol. (1986a) Headache sum 29 59
Larsson er 01. (1986b) Headache sum 41 56
Linton & GBtestam (1984) Pain intensity 31 35
Dahl er 01. (1985) Seizure index 96 95
Dahl er 01. (1986) Seizure frequency 47 a7
Scott er 01. (1985) Tinnitus discomfort 17 26
&t (1987) Panic frequency 100 100
- -
Mean 57.4 69.1
*Based on two similar, but not exactly the same, test situations as the one used in the pre- and
post-test.
408 hRS-G&UN t)ST

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 this 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 the low attrition rate. AR also has
a wide applicability, both regarding type of disorder, and the age range for which this method is
suitable.
The results of AR in controlled outcome studies 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.
The effects of AR are also durable, at least in follow-up 5-19 months after the end of treatment.
The assessments not only showed a maintained effect, but a further sizable improvement in 9 out
of 12 studies.
There are, of course, still a large number of questions concerning AR that need to be addressed
in future research, and below follows a few. A component analysis should be made using a
dismantling strategy (Kazdin, 1980) to study the importance of the different components. The
self-help version of AR that has been found effective for headache in adolescents should be tested
in other disorders to find out how far a reduction of professional time can go. Finally, the
AR-studies need to be replicated by therapists/researchers outside our group in Uppsala. Such a
study is underway in Oxford by Dr. David M. Clark and colleagues regarding panic disorder.

Acknowledgements-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
reprint should be addressed to L-G. &t.

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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. . . 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. . . 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.