We would rather be ruined than changed;
We would rather die in our dread
Than climb the cross of the moment
And let our illusions die.
                                               -W. H. Auden

The topic of this booklet focuses on relaxation techniques. The techniques oulined below are adapted from the Association For Advanced Training In The Behavioral Sciences. The information in this booklet is intended to provide the reader with information about three techniques. Those techniques are 1) relaxation through the utilization of guided imagery contained in the “relaxation scene”, 2) Deep Muscle Relaxation (DMR), 3) Systematic Desensitization. These techniques can be utilized to lower stress by training yourself how to relax your body, reduce levels of stress through the use of guided imagery, and reduce anxiety through the use of Systematic Desensitization. If you are currently doing psychotherapy with a therapist, I highly recommend that you consult with your therapist prior to using the techniques outlined in this booklet.

Reducing Anxiety and Stress

The effects of fear, anxiety, and stress are unfortunately familiar to many of us. For example, fear may interfere with you getting involved in an activity that you’ve always wanted to try. The presence of stress may be sapping you of your vitality to experience the many joys and wonders of life.

One method which has consistently proven to be effective in the lessening of fear and anxiety is called systematic desensitization. Although originally developed by Joseph Wolpe to be administered by a therapist, research has shown that self-administered systematic desensitization is also effective.

Self-Administered Systematic Desensitization

The following method, self-administered systematic desensitization, will help you free yourself from some of the anxiety that you experience in your life. The procedure is similar to the one used by Wolpe, with minor modifications which make it possible for you to learn systematic desensitization at your convenience and without the aid of a therapist.

Before practicing desensitization, familiarize yourself with the instructions I provide by reading each step once or twice. Make note of the recommended time requirements where relevant and arrange your schedule to accommodate these periods of time. Also note any materials you may need for each step and have these available before starting.

The three steps included in the self-administered systematic desensitization procedure include: 1) deep muscle relaxation, 2) constructing your hierarchy, and 3) pairing relaxation with the situations described in your hierarchy.

 1) Step One: Deep Muscle Relaxation: The following describes the relaxation procedure and the use of cue-controlled relaxation and a relaxation scene. Appendix A presents a suggested schedule for learning deep muscle relaxation.

 Overview of Deep Muscle Relaxation

The relaxation procedure will teach you to relax voluntary muscles by a process of first tensing certain muscle groups and then relaxing them. This will enable you to recognize the difference between tension and relaxation and allow muscle tension to become a cue for you to relax. After learning deep muscle relaxation, you’ll be able to induce relaxation at the first signs of the tension that accompanies anxiety. (Be sure to consult with your physician before practicing DMR if you have a history of back problems, muscle spasms, or related problems).

The muscle groups you’ll learn to relax are: Group #1 hands and wrists; group #2-biceps and triceps; group #3-shoulders; group #4-neck; group #5 tongue and mouth; group #6-eyes, nose and forehead; group #7-back group; group #8-abdominal region (stomach); #9-thighs; group #10-calves and feet; and group #11-toes.

When you tense one muscle group it may feel natural to you to also tense other muscle groups. Therefore, when practicing DMR, be careful to tense only those muscle groups which you are learning to relax.

You may choose to practice all muscle groups during your first relaxation session or you may decide to divide the muscle groups into four areas (arms and shoulders; neck and face; midsection; legs) and to learn one area during each of four sessions (repeating the area two or three times during the session). If you choose the latter method, you will not practice all muscle groups until the fifth session (See appendix A). It’s recommended that you practice DMR at least twice a day for two weeks or, if it’s more convenient   for your schedule, once a day for four weeks.

After practicing the full procedure for the recommended time, you’ll then use a shortened form of DMR which requires no more than five to ten minutes of practice daily. Instructions for the shortened form of DMR follow the full length DMR instructions. This shortened form can be practiced at any time-for example, while riding the bus or waiting in the dentist’s office. To maintain your relaxation skills at an optimum level, it’s recommended that you practice the full DMR procedure at least once during week four. When you are ready to start using the shortened form of DMR, you should begin to construct your anxiety hierarchy.

During session 5, when you are familiar with DMR, you’ll begin practicing cue-controlled relaxation. Cue-controlled relaxation involves the following: While relaxing each muscle group after tensing it, focus on your breathing. Each time you exhale while you are relaxed, say the word “relax” (or another word you choose) to yourself. By associating the cue word with a state of relaxation, the cue word itself will eventually produce a relaxed state. You will find that cue-controlled relaxation is useful for inducing relaxation not only during the desensitization procedure, but also during times of tension in your daily life.

It is useful to use a “relaxation scene” during desensitization to facilitate relaxation. Like cue-controlled relaxation, the relaxation scene can also be used at other times to reduce your tension. When developing your scene, describe it in enough detail to provide a clear image. It should include descriptions of related visual, auditory and tactile sensations and should induce in you feelings of complete calm and relaxation. It’s recommended that you write your scene on index cards and that you have this written description available during relaxation sessions, or that you tape record the scene. After several “rehearsals,” you’ll have memorized the scene in sufficient detail so that you will no longer need the cards or tape recording. Practice imagining your relaxation scene for at least one to two minutes at the end of each relaxation session.

An example of a relaxation scene is given below. You may choose to use this scene or you may create a similar scene of your own.

 Relaxation Scene

You are in a forest. It’s not a dark, threatening forest, but instead, it’s inviting. You aren’t lost, but you’re alone because you wanted to take a long, calming walk. The air around you is cool and refreshing. Trees hang over your head and make the forest cool and shadowy, but there are bright spots of sunshine on the ground where the sun has filtered down through the leaves. You are walking barefoot and the leaves and moss feel soothing and soft on your feet, like a thick rug. The birds are singing soft, sweet songs in the trees and the sound makes you content and comfortable. You’ve been walking for a long time and your muscles feel very loose and relaxed from the exercise. The leaves feel so soft and pleasant beneath your feet that you want to fall down and just close your eyes and rest. You can barely keep your eyes open when you come to a small stream. It’s making a soft, bubbling noise that makes you even more relaxed. Next to the stream is the most beautiful place that you have ever seen. It’s a little patch of tall soft grass protected all around by the tall tress. It’s lit and warmed by sunlight. You see that it would be the perfect place to rest. You are so relaxed and loose that you can barely walk over to the grassy place. But you do walk over and you sink down to your knees and then fall gently into the soft, warm grass. Your eyes close immediately and you realize you have never laid in a softer place in your life. Even your bed is not as soft. You have never been so relaxed. Your eyes are closed and you hear the soft pleasant bubbling of the stream and the singing of the birds. You are completely comfortable and no tightness is left anywhere  in your body, from your toes to the top of your head, is completely loose and limp and very comfortable.

You may want to rehearse the instructions at least once with your friend before beginning a session or before tape recording them. During the sessions, you should tense muscles for at least eight seconds and relax for at least 15 to 30 seconds; therefore, at the end of each tensing and relaxing instruction, you or your friend should pause in order to provide this required amount of time.

If you choose to read the instructions to yourself each session, rather than taping them or having a friend read them, we suggest that you practice reading them for each muscle group prior to beginning your sessions. After several sessions, you’ll probably have memorized the instructions and be able to use prompts rather than the full instructions. These prompts can be written on index cards and you can refer to them when you need to. Prompts should include the name of the muscle group and a short phrase describing the exercise-for example: “hands and wrists; tighten fists.”

Always practice DMR in a moderately lit and quiet room. Eliminate as many distractions as possible (e.g., no radio or TV, ask friends and family not to enter the room). Also loosen any tight clothing, remove your shoes and refrain from smoking, eating or drinking during a session. Sit in a comfortable chair which supports your entire body. If   you have one available, a reclining lounge chair is best. Before beginning a session, always position  yourself comfortably in the chair and take several breaths.

 Instructions for Full Deep Muscle Relaxation

Group #1-Hands and Wrists. Make your hands into tight fists. Squeeze hard until your knuckles turn white and hold for at least eight seconds (remember if you’re recording or having a friend read the instructions, to pause at this point for at least eight seconds). Now let go. Let all the tightness and pain flow through your fingertips. Feel your fingers and wrists relax and become loose and limp. Notice the difference: when you let go, you began to relax. Stay relaxed for at least 15 seconds. Now clench your fists again; feel the tension. Now relax. Notice the difference between the two feelings.

Group #2-Biceps and Triceps. Put your right hand around your left wrist. Now try to pull your left arm in towards your body, but at the same time, push outward with your right arm. Focus on your lower arms. Feel how tight they are getting. Now relax your arms and feel the difference. Feel the tension flow out through your fingers and disappear. Now repeat the exercise. Notice the difference between the feeling of tension and the feeling of relaxation. Repeat the exercise with your left hand on your right wrist. Again, focus on the tension as you pull your right arm toward your body and push outward with your left arm. Then relax. Feel the tension disappear. Repeat. Now wrap your arms around  yourself, as though you were hugging yourself, but instead of hugging, squeeze yourself very hard using your upper arms. Feel the tension. Now relax and let go. Feel the warmth flow through your arms. Repeat the exercise, first tensing, then relaxing.

Group #3-Shoulders. Reach above yourself; stretch your arms as far as they will go while you stay seated. Feel your shoulder muscles tighten. Then relax, let your arms fall to your sides. Let your shoulders and arms relax. Make them loose and comfortable. Now repeat the exercise. Notice the difference between tension and relaxation.

Group #4-Neck. Bend your head downward so that your chin points into your chest. Push your chin hard against your chest. Then return your head to the headrest. Focus on the tension at the front of the neck (the pull on the back of the neck is strain and should be ignored). Now relax. Feel the tension disappear from the front of your neck. Now bend your neck backwards as though you were trying to see the wall behind you. Push the base of your head downward into your back. Feel the tension in the back of your neck (again, ignore the strain in the front of your neck). Now return your head to an upright position. Feel the difference between the tension in the back of your neck and the feeling of relaxation. Now bend your head downwards toward your right shoulder (don’t raise your shoulder); push your right ear downwards to your shoulder. Feel the tension on the left side of your neck. Relax. Repeat all four positions: front, back, right, left. Notice the difference between tension and relaxation in your neck muscles.

Group #5-Tongue and Mouth. Put the tip of your tongue on the roof of your mouth right behind your front teeth. Push hard, until your tongue feels solid, tight and hard. Let your tongue rest naturally in a comfortable position. Once again push your tongue against the roof of your mouth and then relax. Open your mouth as wide as you can. Feel the tension in your jaw. Now relax. Feel the tension disappear. Repeat this exercise. Now purse your lips together. Tighten your lips together as hard as you can. Then relax. Feel the tension around your mouth disappear. Repeat.

Group #6-Eyes, Nose, and Forehead. Close your eyes as tightly as possible. Squeeze your eyelids together so that your nose wrinkles up. Keep squeezing. Now relax your eyes and nose. You don’t have to open your eyes all the way; just let your eyelids relax until all the tightness is gone and they feel very comfortable. Tightly close your eyes again. Then relax. Notice the difference between tension and relaxation. Focus on your forehead and tense the muscles until you are frowning and your forehead is wrinkled. Now relax. Feel your forehead becoming smooth. Allow the relaxation to spread from your forehead to your scalp. Now frown again and then relax.

Group #7-Back. Straighten your arms out from your sides and stretch them backwards as far as they will go. Press your shoulder blades toward the back of your chair and push the center of your body forward. Feel the muscles in your upper back tense. Now let your arms fall to your sides and your shoulders hunch forward. Feel the tension and tightness disappear. Repeat. Notice the difference between tension and relaxation.

Group #8. Take in a deep breath and suck in your stomach as hard as you can. Try to continue breathing while you hold in your stomach. Try to touch your backbone with the front wall of your stomach. Now let go and relax until all the tightness is gone. Feel the difference between tension and relaxation in your stomach region. Now take a deep breath and push your stomach forward as though you were preparing  for a punch in your abdomen. Then relax. Breathe deeply and exhale slowly. Repeat both exercises: pulling in your stomach and then relaxing, and pushing out your stomach and relaxing.

Group #9-Thighs. Put your right hand on your left knee. Push your knee upwards and at the same time push down with your hand. Focus on the thigh muscle and push harder with that muscle. Feel the tension in your thigh (you will also feel tension in your arm). Now relax. Repeat the exercise using your left hand and right leg. Feel the tension in your right thigh. Relax. Notice the difference between tension and relaxation. Repeat the exercise for both legs.

Group #10-Calves and Feet. With your legs supported (use a footstool if you are not seated in a reclining lounge chair), allow your thighs to remain relaxed while you draw your toes of both feet upward toward your head and tense the calf muscles. If you feel any cramping during this exercise, relax immediately and “shake out” your legs. Now relax. Feel the difference between tension and relaxation. Now point both feet downwards and feel the tension on the front of your legs and ankles. Then relax. Once again point the feet upwards and relax. Then point the feet downwards and relax.

Group #11. Now sit straight in your chair with your feet flat on the floor. Curl your toes downward. Push them into the floor. Now relax. Repeat.

Once you have tensed and relaxed all muscle groups, close your eyes and relax all the muscle groups. When you are ready to get up, open your eyes, stretch your body and slowly rise from the chair.

 Instructions for Shortened Form of DMR

The shortened form of DMR reduces the eleven muscle groups to four groups: arms, shoulders and neck; face; back and stomach; lower limbs. Perform each exercise twice.

 Step 1 for Shortened DMR

Group #1-Arms, Shoulders and Neck. Move your arms toward the center of your body and bend both arms at the elbow. Tighten your hands into fists and at the same time tense the muscles in your upper arms and shoulders. Hold for ten seconds and then relax for fifteen to twenty seconds.

Group #2-Face. Tense your facial muscles by wrinkling your forehead and pursing your lips. Hold for ten seconds. Then relax for fifteen to twenty seconds.

Group #3-Back and Stomach. Take a deep breath and suck in your stomach as hard as possible for eight to ten seconds. Then exhale and relax for fifteen to twenty seconds.

Group #4-Lower Limbs.  With your legs supported on a footrest, straighten both legs. Tense the muscles of your entire leg and pull your toes toward your head (keeping your feet on the stool). Hold for eight to ten seconds and then relax for fifteen to twenty seconds.

 Always repeat your cue word to yourself when you exhale during relaxation. Also, end each shortened form practice session by imagining your relaxation scene for one or two minutes.

Step Two: Constructing the Anxiety Hierarchy

Overview of the anxiety hierarchy. In explaining the anxiety hierarchy, I will use the example of test anxiety. Items included in an anxiety hierarchy describe situations which produce varying levels of anxiety. The hierarchy you construct will contain situations or scenes related to test taking. The situations you choose can include ones you have actually experienced, as well as ones you only fear experiencing. For example, you may want to include the item “time is almost up and I have not finished the exam” because you fear this may happen, even if you have never had trouble finishing a test within the time limit.

The items you include on your hierarchy should be described in enough detail so that you can vividly imagine each one. For example, a brief phrase such as “sitting in the testing room waiting for the examination” should be imagined vividly. When you imagine a situation, make sure you are not merely acting as an observer, watching yourself in the scene, but that you are instead actually “experiencing” yourself in the situation.

Constructing your anxiety hierarchy. Your final hierarchy will contain 10 to 15 items. However, since some items may be eliminated in the ordering or grading process, it is suggested that you begin with 16 or 17 situations. Write each situation on a separate index card so that you can easily rearrange and/or eliminate some of them.

The situations or scenes included in your hierarchy should represent an evenly spaced progression in terms of the level of anxiety each produces. Use Wolpe’s Subjective Anxiety Scale (“SUDS”) to provide a basis for ordering your situations. Begin by assigning the SUDS value of 100 to the highest level of anxiety you can remember experiencing  and the SUDS value of 0 to the most relaxed state you can remember experiencing. Then, assign values to your hierarchy situations in terms of a scale where 100 is the highest level of anxiety and 0 is a state of relaxation.

It may be easier for you to order situations if you initially grade them in terms of the following anxiety categories (i.e., divide the items into five groups according to the descriptions in the left-hand column):

SUDS VALUE

·       Intense Anxiety                           (80-100)

·       Moderate High Anxiety              (60-79)

·       Moderate Anxiety                       (40-59)

·       Mild Anxiety                               (20-39)

·       Weak Anxiety                             (1-19)

After you have separated your items into these five categories, you should have at least two situations in each category. If you don’t, create new items or modify an existing item from an adjacent category so that it can be placed into the deficient category. For instance, let me use the example of test taking anxiety. You might have the following three items in the Intense Anxiety category: reading over the questions on the examination paper; the instructor is passing out the examinations; standing in the corridor in front of the testing room minutes before the examination begins. Your Moderately High Anxiety category may have only one item: talking to friends about the exam   over breakfast an hour before the exam begins.

In this case you need to delete one item from your Intense Anxiety category and add one to your Moderately High Anxiety category. To do this, first consider the three items in the Intense Anxiety category and determine which of the items produces the least anxiety. This is the item which you’ll delete. Now try modifying this item so that it produces a slightly lower level of anxiety and then place it into your Moderately High Anxiety category. If you choose to modify rather than eliminate an item, the item can be changed by altering its temporal and spatial elements. For example, “standing in the corridor in front of the testing room minutes before the examination begins” can be changed to “entering the building where the test is to be held twenty minutes before the examination begins.” Since you can have up to three items in any category, rather than eliminating an item from your Intense Anxiety category, you may decide to develop an additional item for your Moderately Intense Anxiety category.

When you have at least two situations in each category, order the items within each category by assigning appropriate values to each one. Write these values on the back of each index card. For example, if you have three items in the Moderately High Anxiety category, each item should be assigned a SUDS value between 60 and 79. When you have labeled each index card with an appropriate SUDS value, arrange all cards in order from the lowest level of anxiety to the highest level of anxiety produced by the situations.

The differences in value between items should be approximately equal. In other words, if you have assigned item 10 a SUDS value of 92 and item 9 a value of 82, then item 8 should have a value of approximately 72. As before, you may find that you need to eliminate or modify some items (if their SUDS value are identical or only one or two points apart) or that you need to develop new items in order to achieve approximately equal intervals. Remember, SUDS values are subjective; therefore, a truly equal  difference between all items is unnecessary. It is important, however, that your hierarchy represent a relatively smooth progression from a lower level of anxiety to a high level of anxiety.

To check the accuracy of your ordering, shuffle the index cards a few days after you have ordered them and then reorder them. Check the values on the back of your cards to see if your second ordering is the same as your first. If not, you may need to make some additional revisions.

 Sample Anxiety Hierarchy for Test Anxiety

To help you get started, I am including a sample hierarchy that was created by Joseph Wolpe for a university student suffering from test-taking anxiety.

·       Item #1:    A month before an exam

·       Item #2:    Two weeks before an exam

·       Item #3:    A week before an exam

·       Item #4:    Five days before an exam

·       Item #5:    Four days before an exam

·       Item #6:    Three days before an exam

·       Item #7:    Two days before an exam

·       Item #8:    The night before an exam

·       Item #9:    The night before an exam

·       Item #10: The exam paper lies face down before her

·       Item #11: Awaiting the distribution of papers

·       Item #12: Standing before the unopened doors of the exam room

·       Item #13: In the process of answering an exam paper

·       Item #14: On the way to the university on the day of an exam

 Step Three: Pairing Relaxation
with the Situations in Your Anxiety Hierarchy-Systematic Desensitization:

     Overview of the pairing procedure: The aim of the systematic desensitization process is to desensitize you to all aspects of the anxiety situation, thereby depriving anxiety-related situations of their power to arouse your anxiety. This is accomplished by confronting each situation while you are in a state of relaxation.

Before attempting to confront these situations, you should be able to easily put yourself in a state of deep muscle relaxation using the shortened form of DMR, cue-controlled relaxation, and your relaxation scene. In addition, you need to have constructed your anxiety hierarchy.

Systematic desensitization should be conducted in an environment free from distractions, under the conditions I described for DMR. Prior to beginning each desensitization session, assemble the following materials so that they will be readily available during your desensitization  sessions: your anxiety hierarchy, your relaxation scene, instructions for the shortened form of DMR and instructions for systematic desensitization.

Desensitization sessions should not exceed 30 minutes. It’s recommended that you do not attempt more than three of your anxiety hierarchy items during a session. The sessions (after the first one) should begin with the last item you successfully completed during the previous session (i.e., the last item presented without producing anxiety). For a ten item hierarchy, a suggested schedule of sessions would be:

Session                                                  Item Numbers

1                                                             1-3

2                                                             3-5

3                                                             5-7

4                                                             7-9

5                                                             9-10

Using a schedule of two sessions per week, the desensitization procedure can be completed in 2-1/2 weeks.

Self-Administered Systematic
Desensitization Procedure

Step 1. Induce relaxation using the shortened form of DMR, cue-controlled relaxation and/or your relaxation scene. Although you’ll use additional techniques later in the session, at the beginning of each session, use the shortened form of DMR to initially establish a state of relaxation.

Step 2. Read the appropriate situation on your hierarchy. In the first session this will be the first item. In later sessions, the first item you read will be the last one you successfully completed in the previous session.

Step 3. Stop imagining the situation and determine the amount of anxiety you are experiencing in terms of a SUDS value. If any anxiety has been produced by the situation, re-establish a state of relaxation using the shortened form of DMR, cue-controlled relaxation or the relaxation scene (whichever you prefer) and relax
for 20-30 seconds.

Step 4. Re-read the description of the situation. Imagine yourself in the scene for 30 seconds.

Steps 5.  Stop and determine your level of anxiety in terms of SUDS value. If anxiety is present, repeat steps 3 and 4 until the situation can be imagined without producing anxiety. If no anxiety has been produced, go to step 6.

Step 6. Once a scene has been introduced without producing anxiety, you are ready to introduce the next scene on the hierarchy. Repeat steps 1 through 5 for the next item.

Remember to end each of your sessions in a state of relaxation. Whenever possible, end your sessions when an item has been presented without producing anxiety. You may also want to end your sessions by imagining your relaxation scene for one or two minutes.

To facilitate their use during desensitization sessions, transfer the desensitization instructions to index cards in a shortened form. Write one instruction per card. A suggested shortened form is:

·       Relax

·       Read anxiety situation. Imagine for 10 seconds.

·       Stop. Determine anxiety level. If anxiety is present, re-establish

     relaxation.

·       Read situation. Imagine for 30 seconds.

·       Stop. Determine anxiety level. If anxiety is present, repeat steps

     three and four. If no anxiety, go to step 6.

·       Repeat steps 1-5 for next anxiety situation.

Remember that for the first presentation of each item you should imagine yourself in the situation for 30 seconds. When you reach items on the hierarchy which produce high levels of anxiety (e.g., items 7-10 on a 10 item hierarchy), you may want to reduce the length of time you imagine yourself in the scene on the second and subsequent presentations. For example, on the second presentation of item 8, and extremely high level of anxiety may occur after imagining the scene for only 15 seconds. Stop imagining the scene at this point and re-establish relaxation. Slowly increase the amount of time you imagine the situation in subsequent presentations until you are able to imagine the situation for 30 seconds with a moderate or mild amount of anxiety; then repeat desensitization until the situation produces no anxiety. Also, with an item which initially produces a high level of anxiety, repeat presentation of the item one time after it has been presented without producing anxiety in order to reinforce your ability to relax in that situation.

As noted, you should end each session in a state of relaxation, preferably when you have successfully completed a hierarchy item, and the next session should begin with the last item successfully completed in the previous session.

G.B.U.

Steve

Dr. Steve Frisch, Psy.D. is a clinical psychologist in private practice in Chicago, Illinois and Northfield, Illinois. You can contact Dr. Frisch, Psy.D. at drfrisch@aliveandwellnews.com  or at (847) 498-5622. Recover from chemical dependency and its toxic impact on family members. Raise your children to choose to be alcohol and other drugs free. Learn how to in Dr. Frisch’s, Psy.D. Recovery book series.