The Role of Relaxation in Anxiety Treatment

So often people who are feeling anxious are told to “just relax.” Often simply being told to relax does very little to help someone who is feeling anxious. In fact sometimes being told to relax can make matters worse, as it can highlight just how UN-relaxed a person may be feeling. But does that mean that we should throw away the idea of relaxation as a therapy for anxiety? Since relaxation techniques are so often talked about in relation to anxiety, I thought it would be a good idea to find out if research supports the use of relaxation therapy in treating anxiety.

In Brief:

There are lots of ways to do relaxation and it appears at least somewhat helpful:

  • It’s more effective if you practice one style of relaxation rather than bounce from one to the other or combine different types.
  • Applied relaxation, progressive muscle relaxation, and meditation seem best
  • In the short-term it reduces anxiety comparable to other treatments
  • It works for most people and can be learned individually or in group settings
  • More seems to be better, but most studies don’t involve more than 30-60 minutes per day
  • It can be a good complement to treatment, but it can also interfere with treatment
  • It is primarily hypothesized to work by reducing physiological arousal, which has calming effects upon thinking and behavior
  • It can also work by teaching someone to notice when they first get anxious so they can intervene early, and by developing mindfulness
  • You should avoid trying to use relaxation during an exposure because it may interfere with treatment.

 

Written by Ashley Sedlacek, currently completing her Master’s degree in Child and Adolescent Psychology.

Anxiety is very common and can range from helpful to debilitating. For over 100 years people have tried to better manage anxiety when it gets out of control. To this end medication has long been used, even though the research shows that when used alone it has limited long-term efficacy. This means that we need to find other treatments that can be used alone or in combination with medication. This is where relaxation therapy could come in to play. In the field of psychology, relaxation is very commonly used as a complimentary part of CBT and even as a stand-alone treatment. It’s efficacy as a stand-alone treatment is the purpose of this article. Let’s take a look at the literature and understand if relaxation by itself is an effective treatment for anxiety.

To evaluate this I turned to a meta-analysis/review conducted in 2008. This paper looked at 27 studies to evaluate if different types of relaxation training would reduce overall anxiety levels. This was an interesting study because it looked at the effect of several different of the most common types of relaxation therapies including progressive muscle relaxation and meditation. It also compared how volunteers/students (who did not have severe anxiety ratings), patients with psychological disorders and patients with medical disorders responded to relaxation trainings. This is great because we can draw conclusions as to how the results apply to these different groups of people.

Here’s the reference:

Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E. (2008). Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC psychiatry8(1), 41.

 

What Did They Find?

Overall relaxation training had a medium effect size, meaning that it resulted in a pretty large decrease in anxiety following treatment. This means it is likely effective in helping people to at least manage anxiety.

What Kinds of Relaxation Methods Were Most Useful?

Applied Relaxation (AR), Progressive Muscle Relaxation (PMR) and meditation were shown to be the most effective in reducing anxiety symptoms.  Later on in the article I will be explaining more of how AR and PMR work. However, the most important finding was that combining different types of relaxation is the least effective method. This means that using just one relaxation technique at a time will probably yield better results than switching around from technique to technique, or picking and choosing pieces you like from each different technique.

Group vs. Individual Relaxation

The authors found no differences between group and individual trainings. People who did relaxation training in a group were just as well off as those who practiced in individual sessions.

How Much Should I Be Doing?

They showed that when people had either longer relaxation sessions or simply more sessions, the anxiety decreased the most. This intuitively makes sense, but its still good to know for sure that practicing relaxation at home can really help. That being said, from a practical standpoint, spending more than 60 minutes a day probably wont be necessary to get benefits as most studies show improvements using much shorter durations. Most studies looked at around 30 minutes of relaxation.

Who Does Relaxation Work For?

Interestingly, younger people seemed to benefit the most. It’s unclear why. They also found that medical patients benefited the least, but they argue that this is likely because this group used relaxation for pain management and anxiety reduction is just a beneficial side effect.

Conclusions

Based on this study, it is safe to say that we shouldn’t throw relaxation out the door as a tool for anxiety. It seems to have merit as a stand-alone and non-pharmacological way to reduce anxiety in some cases. Although it is not helpful when someone is told simply to “relax”, finding ways to incorporate relaxation in a more guided and structured manner may benefit a lot of people.

With all of this in mind, lets take a look at one type of structured relaxation and understand how it works.

Applied Relaxation

Applied Relaxation (AR) has been used to reduce anxiety for around 50 years. At its essence, it is really an adaptation of Progressive Muscle Relaxation (PMR) and Systematic Desensitization. PMR involves tensing and then releasing different muscle groups all over the body, with the goal of learning to feel the difference between a tense and a relaxed muscle. Over time PMR can help you learn to relax muscles more easily, and this can in turn help reduce anxiety. Systematic Desensitization is a practice where you engage in some kind of relaxation exercise (could be PMR for example) and then are gradually exposed to an anxiety-provoking stimulus (e.g. a spider). You keep practicing this until you can stay relaxed while imagining the scary thing.

However, applying PMR and systematic desensitization in the real world can be challenging, and this is where AR comes in. The goal of AR is to be able to relax in 20-30 seconds and to use this practice at the very earliest signs of anxiety, to keep the anxiety cycle from accelerating. Let’s take a look at how you can learn AR.

Step 1: Learn about anxiety and AR. Our body, brain and behavior are all linked and by changing one we can change the others. So, by practicing body relaxation, we can influence our thoughts and behaviors.

Step 2:  Develop awareness of your own anxiety. This involves monitoring and recording how your anxiety shows up, what it feels like, what comes before it, and what you do in response to it. The main goal here, is to learn to recognize the very earliest signs of anxiety so that you can stop it before it gets bad.

Step 3: Progressive Muscle Relaxation. Tense one muscle group for at least 10-20 seconds (e.g. lower leg), then tense it 50%, then completely relax it. Move through your entire body step by step. This is the first relaxation strategy learned. It can take up to 30 minutes at first, but over time you can learn to do it more quickly. Once you find it working, start grouping multiple muscle groups together and it will become faster (see step 6).

Step 4: Cue-controlled Relaxation. This next step of relaxation training involves getting into a relaxed state (through PMR) and then saying the word “relaxing” each time you exhale so that you start to make an association between the word “relaxing” and the sensation of being relaxed.

Step 5: Differential Relaxation. This relaxation technique involves relaxing muscles that are not used for certain activities. For example, you may practice sitting at a chair and typing while relaxing your neck and shoulders.

Step 6: Rapid Relaxation. This last step combines aspects of all the steps and focuses on shortening the time it takes to get relaxed. By practicing the above steps (relaxing muscles, saying “relax”, only using necessary muscles) you will be able to relax your body in 20-30 seconds.

Once you have this down then you use the strategies of AR as soon as you feel anxious.

 

How Effective Is This Compared To An Actual Treatment Like Cognitive-Behavioral Therapy?

In general, AR and other relaxation methods can show decreases in anxiety similar to Cognitive-Behavioral Therapy (CBT) intervention, which is considered the gold standard. However, improvements from CBT last longer than relaxation (Hayes-Skelton, Roemer, Orsillo, & Borkovec, 2013). Thus CBT should be the treatment of choice. This makes sense, because if you stop doing relaxation then anxiety will likely return, whereas CBT is designed to manage and then prevent future anxiety by helping you not be as triggered by anxiety-producing cues. As such, it’s more of an anxiety management tool than a stand-alone treatment.

Relaxation, especially AR, is often used in anxiety treatment. There is conflicting evidence on whether it should be. On the one hand, it reduces anxiety as well as most therapies during treatment. On the other hand, more and more research shows that exposure therapy for anxiety disorders is the active ingredient in treatment. I can see it having some benefit. For example, it can provide some short-term relief. It also helps a person to simply observe their mental and psychological state in an unattached manner.  Finally, it can allow people to engage in fearful situations, and thus it may facilitate exposure therapy itself.

In addition to these benefits, Hayes-Skelton and colleagues (2013) argue that relaxation training and specifically the Applied Relaxation procedure described above can play a critical role in helping individuals detect anxious thoughts/feelings early. Sort of like fine tuning an alarm system to go off before a flame becomes a fire. In this way it can help regulate anxious states early and prevent further increases.

Is Relaxation A Stand-alone Treatment For Anxiety?

Let’s step back and understand the difference between treatment and management. To treat something means to address the mechanism causing the problem and thereby eliminate the symptoms of a disorder. On the other hand, to manage something means to be able to handle the level of symptoms that are present on a temporary basis. Basically, treatment is something that gets rid of symptoms while management is something that helps you deal better with symptoms while you have them. Management can be really important, even though it is not getting rid of whatever you are dealing with. I have no idea why I get a headache sometimes, but I take something for the pain and eventually it goes away! Sometimes management is necessary in order to engage in treatment. Sometimes management is necessary in order to keep functioning when symptoms get really bad. It’s great to learn management techniques, but we should not think that they alone will cure us.

Based on the existing research, and the general proposed mechanism of action of relaxation, it appears that relaxation is more of a management strategy than a treatment. Why? Because there is little evidence from these studies that the reduction in anxiety symptoms remains over time. There is little follow up data showing that people who participate in relaxation alone treatment studies continue to experience reduced anxiety 6 months or a year after the studies concluded. This is one clue that relaxation acts more as a management tool than as a treatment for anxiety. Additionally, there is evidence that when head-to-head against CBT, although the initially perform equally, relaxation fails to keep up the gains. This suggests that once relaxation stops being used, anxiety will come back. And that is very close to the definition of a management strategy!

Putting This All Together

So, what does this all mean? It means that learning relaxation skills can be really useful in order to reduce anxiety in the moment, but it likely won’t make anxiety go away long-term, unless you continue to use relaxation strategies all the time. It can be helpful to learn relaxation skills to recognize anxiety, to prevent further increases and to manage more intense anxiety symptoms. In order to really treat anxiety, it still appears that CBT, particularly exposure therapy is the most effective method.

What Are The Best Ways To Use Relaxation In Dealing With Anxiety?

It is critically important to remember that relaxation should be used to help treatment, which is likely CBT if you’re treating anxiety. This means that we don’t want to use relaxation to avoid doing exposures or reduce their intensity. For example, let’s say you are afraid of spiders and you are going to start doing exposure by watching a film scene with a giant spider (like the second Harry Potter movie for instance). If you start watching it, feel your anxiety rising, and then immediately close your eyes and start doing relaxation then you will likely not habituate to this experience and you will continue to feel anxious next time you watch it. Put another way, relaxation could interfere with treatment by calming you down and distracting you from the treatment itself. In this way, it can become what we call a “safety behavior”. There is a lot of evidence that in order to effectively treat anxiety, we need to produce the feeling of anxiety, which too much relaxation could interfere with. Although it is uncomfortable, the goal of the exposure is to actually experience the anxiety of spiders (or whatever else) so you can learn to tolerate it and over time experience a decrease in anxiety in those situations. As such, it’s not recommended that you do relaxation during an exposure.

When Is Relaxation Recommended?

It is sometimes necessary to just calm yourself down. Perhaps anxiety is so high that you cannot tolerate it. Many people experience a continuously high level of anxiety throughout the day (i.e. generalized anxiety disorder) and would benefit from being able to relax their body. Or perhaps you are in a situation you need to just get through, like a job interview, a difficult conversation, or completing an assignment. These are situations when using relaxation skills could be really useful and would not get in the way of anxiety treatment.

Summary

I hope this helps give a good understanding of the latest research involving relaxation for anxiety disorders. While it’s more of a management strategy, there do seem to be times where it can be helpful. This article described how it can help, ways to use it, and gave a guide for actually implementing the strategies.

Thank you for reading! Look out for my upcoming guide on strategies to help teach children breathing and relaxation strategies.

 

 

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