Chapter 15

Arousal Reduction

Matthew McKay, PhD

The Wright Institute, Berkeley, CA

Background

The arousal reduction processes covered in this chapter target sympathetic nervous system arousal (Selye, 1955) and can be distinguished from arousal reduction targeting cognitive processes (Beck, 1976), attentional control (Wells, 2011), and decentering/distancing/defusion (Hayes, Strosahl, & Wilson, 2012), which are covered elsewhere in this volume. The history of modern arousal reduction strategies starts in the 1920s, when Jacobson (1929) introduced progressive muscle relaxation (PMR). Since that time, various breathing, muscle release, and visualization exercises have been added for a now complex armamentarium generally termed relaxation training.

In the 1930s, autogenics (Schultz & Luthe, 1959) provided a new form of arousal reduction that relied on autosuggestion: those seeking stress relief via autogenics repeat phrases using themes of warmth, heaviness, and other suggestions. Autogenics was practiced for years in Germany, and Kenneth Pelletier (1977) popularized it in the United States.

Mindfulness as a stress reduction technique was introduced in the West in the 1960s by Maharishi Mahesh Yogi (2001) as transcendental meditation, a secular form of which Benson (1997) later popularized and labeled the relaxation response. More recently, mindfulness-based stress reduction was introduced (Kabat-Zinn, 1990); it incorporates meditation and yoga into a stress reduction program taught in six-to-twelve-week classes around the world.

Applications

Targets for arousal reduction processes include health problems and chronic pain; anger disorders; emotion dysregulation; and the majority of anxiety disorders, such as generalized anxiety disorder (GAD), specific phobia, social anxiety disorder, and post-traumatic stress disorder (PTSD).

Health

A number of specific health problems associated with high levels of stress, such as hypertension, gastrointestinal disorders, cardiovascular problems, tension headaches, certain immune disorders, and the susceptibility to infection, appear to improve with either mindfulness or relaxation training (e.g., Huguet, McGrath, Stinson, Tougas, & Doucette, 2014; Krantz & McGeney, 2002). Autogenics has been found to reduce symptoms of asthma, gastrointestinal disorders, arrhythmias, hypertension, and tension headaches (e.g., Linden, 1990). In addition, chronic pain associated with lower back injury, fibromyalgia, cancer, irritable bowel syndrome, nerve damage, and other disorders has been treated with mindfulness (Kabat-Zinn, 1990, 2006), relaxation training (Kwekkeboom & Gretarsdottir, 2006), and autogenics (Sadigh, 2001).

Emotion Disorders

Relaxation strategies are used in dialectical behavior therapy (Linehan, 1993) to target emotion dysregulation and enhance coping efficacy. Relaxation is also a core component of anger management protocols (e.g., Deffenbacher & McKay, 2000).

Perhaps the most extensive applications for relaxation and arousal reduction are for anxiety disorders. Craske and Barlow (2006) include relaxation training in their protocol for GAD, but Barlow (Allen, McHugh, & Barlow, 2008) has since dropped relaxation in his unified protocol for emotional disorders, arguing that it promotes unhealthy affect avoidance. Similarly, relaxation was commonly used in the exposure protocols for phobia (e.g., Bourne, 1998) but has since been found to reduce the extinction effects of exposure treatments (Craske et al., 2008).

Relaxation training for PTSD has had mixed results. Again, although relaxation appears to reduce the effectiveness of both brief and prolonged exposure treatments, it continues to have utility in managing PTSD symptoms, such as emotional volatility and flashbacks (Smyth, 1999).

All in all, while arousal reduction is no longer recommended for exposure—with the possible exception of anger exposure (Deffenbacher & McKay, 2000)—it continues to show utility for emotion regulation (Linehan, 1993) and stress-related health problems.

Techniques

I recommend the six arousal reduction processes listed below for their research-supported effectiveness as well as the ease with which they can be taught or learned (Davis, Eshelman, & McKay, 2008). Step-by-step methods for teaching them follow:

Breathing Techniques

Diaphragmatic breathing. During periods of stress the diaphragm tightens to prepare for fight or flight (Cannon, 1915), sending a “danger” message to the brain. The object of diaphragmatic breathing is to stretch and relax the diaphragm, thus sending a signal to the brain that all is safe. Diaphragmatic breathing also tends to slow the breath rate, enhancing vagal tone (Hirsch & Bishop, 1981).

To practice this technique, have clients perform these steps:

  1. Place one hand on the abdomen just above the belt line, and the other hand on the chest. Press down with the hand on the abdomen.
  2. Inhale slowly in such a way that (1) the hand on the abdomen is pushed out, while (2) the hand on the chest remains still. (You should model diaphragmatic breathing while also monitoring the individual’s ability to expand the diaphragm.)

If clients have difficulty (e.g., both hands move or the chest hand rises in a herky-jerky movement), you can suggest the following:

Diaphragmatic breathing should be practiced five or ten minutes at a time a minimum of three times daily to acquire the skill. Thereafter, in addition to daily practice, encourage clients to use diaphragmatic breathing whenever they notice anxiety or physical tension.

A word of caution: Diaphragmatic breathing has been known to induce hypocapnia, paradoxically increasing anxiety for individuals with anxiety disorders, especially panic. Should this occur, capnometer-assisted breathing retraining (to measure carbon dioxide levels and help slow breath rate) is a viable alternative (Meuret, Rosenfield, Seidel, Bhaskara, & Hofmann, 2010).

Breath control training. This technique (Masi, 1993) has been used to slow breathing for relaxation purposes, as well as to manage hyperventilation in panic disorder. Encourage individuals to master the following steps:
  1. Exhale deeply.
  2. Inhale through the nose for three beats.
  3. Exhale through the nose for four beats.
  4. Once the pace is comfortably established, breathing can be slowed further: inhale for four beats; exhale for five beats.
  5. Practice three times daily for five minutes; once mastered, use the method during stressful situations.

Progressive Muscle Relaxation and Passive Relaxation

Progressive muscle relaxation. After Edmond Jacobson developed PMR in the 1920s, Joseph Wolpe (1958) subsequently borrowed the technique as a component of systematic desensitization, and other behavior therapists used it as an effective arousal reduction strategy. The process targets sympathetic nervous system arousal by reducing tension in motor muscles typically activated in the fight-or-flight stress response. Below is an instructional sequence for basic PMR, adapted from Davis, Eshelman, and McKay (2008).

Tighten each muscle group for five to seven seconds.

Begin to relax as you take a few slow, deep breaths… Now as you let the rest of your body relax, clench your fists and bend them back at the wrist…feel the tension in your fists and forearms… Now relax… Feel the looseness in your hands and forearms… Notice the contrast with the tension… Repeat this, and all succeeding procedures, at least one more time. Now bend your elbows and tense your biceps… Observe the feeling of tautness… Let your hands drop down and relax… Feel that difference… Turn your attention to your head and wrinkle your forehead as tight as you can… Feel the tension in your forehead and scalp. Now relax and smooth it out. Now frown and notice the strain spreading throughout your forehead… Let go. Allow your brow to become smooth again… Squeeze your eyes closed…tighter… Relax your eyes. Now, open your mouth wide and feel the tension in your jaw… Relax your jaw. Notice the contrast between tension and relaxation… Now press your tongue against the roof of your mouth. Experience the strain in the back of your mouth… Relax… Press your lips now, purse them into an O… Relax your lips… Feel the relaxation in your forehead, scalp, eyes, jaw, tongue, and lips… Let go more and more…

Now roll your head slowly around on your neck, feeling the point of tension shifting as your head moves…and then slowly roll your head the other way. Relax, allowing your head to return to a comfortable upright position… Now shrug your shoulders; bring your shoulders up toward your ears…hold it… Drop your shoulders back down and feel the relaxation spreading through your neck, throat, and shoulders.

Now, tighten your stomach and hold. Feel the tension… Relax… Now place your hand on your stomach. Breathe deeply into your stomach, pushing your hand up. Hold… and relax… Feel the sensations of relaxation as the air rushes out… Now arch your back, without straining. Keep the rest of your body as relaxed as possible. Focus on the tension in your lower back… Now relax… Let the tension dissolve away.

Tighten your buttocks and thighs… Relax and feel the difference… Now straighten and tense your legs and curl your toes downward. Experience the tension… Relax… Straighten and tense your legs and bend your toes toward your face. Relax.

Feel the warmth and heaviness of deep relaxation throughout your entire body as you continue to breathe slowly and deeply.

During PMR training, it’s important to inquire what relaxation feels like for each muscle group. Do the muscles feel heavy, tingly, warm, and so forth? Requiring clients to observe the relaxation experience will help them differentiate between tense and relaxed states. It will also facilitate the passive relaxation procedure explained later in this section.

Some individuals resist the above instructional sequence, finding it overly long and burdensome. If that’s the case, introduce them to this shorthand version that takes less than five minutes.

Passive relaxation. This procedure, also known as passive tensing or relaxation without tension, follows the same sequence and relaxes the same muscle groups as the shorthand PMR. Instruct individuals to observe each target muscle group, noticing any areas of tension. Then have them take a deep, diaphragmatic breath. Just as they begin to exhale, they should say to themselves, “Relax,” and proceed to relax away any tension in the target area. Each step should be repeated once, and individuals should be encouraged to seek the feeling of relaxation they achieved in PMR.

While most people are understandably reluctant to do the longer version of PMR in any public place, passive relaxation has the advantage that it can be done without anyone noticing, so it can be used anywhere. Furthermore, a client can streamline the procedure to focus on a single muscle group that habitually holds tension.

Applied Relaxation Training

Öst (1987) developed applied relaxation training to rapidly relax severely phobic individuals, as well as people suffering from nonspecific stress disorders and sleep onset insomnia. The greatest advantage of Öst’s method is that it provides fast stress relief. While applied relaxation takes several weeks of practice to learn, the technique itself can significantly reduce arousal in a minute or two.

Öst’s relaxation procedure offers a versatile intervention to clinicians because it can be used anytime, anywhere—no matter what the current activity might be.

Mindfulness Techniques

Mindfulness is a component of many newer behavior therapies (mindfulness-based stress reduction, acceptance and commitment therapy, dialectical behavior therapy, mindfulness-based cognitive therapy, and others). The common goal is to increasingly free individuals from a focus on the past and future—the source of rumination and worry—and anchor their awareness in the present moment (Kabat-Zinn, 1990, 2006). In essence, mindfulness processes initiate attention reallocation, from future threats or past losses and failures to present-moment sensory experience, and from cognitive processes to specific sensations.

Body scan meditation. This simple, present-moment exercise encourages individuals to nonjudgmentally observe inner sensations in the body—from toe to head. The following script, adapted from Davis, Eshelman, and McKay (2008), typifies the body scan process:
  1. Begin by becoming aware of the rising and falling of your breath in your chest and belly. You can ride the waves of your breath and let it begin to anchor you to the present moment.
  2. Bring your attention to the soles of your feet. Notice any sensation that is present there. Without judging or trying to make it different, simply observe the sensation. After a few moments imagine that your breath is flowing into the soles of your feet. As you breathe in and out you might experience an opening or softening and a release of tension. Just simply observe.
  3. Now bring your attention to the rest of your feet, up to your ankles. Become aware of any sensation in this part of your body. After a few moments imagine that your breath flows all the way down to your feet. Breathe into and out of your feet, simply noticing the sensations.
  4. Proceed up your body in this manner—lower legs, knees, thighs, pelvis, hips, buttocks, lower back, upper back, chest and belly, upper shoulders, neck, head, and face. Take your time to really feel each body part and notice whatever sensations are present, without forcing them or trying to make them be different. Breathe into each body area and let go of it as you move on to the next area.
  5. Notice any part of your body that has pain, tension, or discomfort. Simply be with the sensations in a nonjudgmental way. As you breathe, imagine your breath opening up any tight muscles or painful areas and creating more spaciousness. As you breathe out, imagine the tension or pain flowing out of that part of your body.
  6. When you reach the top of your head, scan your body one last time for any areas of tension or discomfort. Then imagine that you have a breath hole at the top of your head, much like the blowholes that whales or dolphins use to breathe. Breathe in from the top of your head, bringing your breath all the way down to the soles of your feet and then back up again through your whole body. Allow your breath to wash away any tension or uncomfortable sensations.
Breath counting meditation. This classic vipassana meditation has three components:
  1. Observe the breath. This can be done either by sensing or watching the breathing process (cool air down the back of the throat, ribs and diaphragm expanding, etc.) or focusing attention on the moving diaphragm itself.
  2. Count the breath. Each out-breath is counted, up to either four or ten, and the process is repeated for a set period of time. Thich Nhat Hahn (1989) suggests a simple alternative: just noting “in” on the in-breath and “out” on the out-breath.
  3. As a thought arises, simply note the thought—perhaps saying to oneself, “thought”—and return to observing the breath.

When teaching this process, emphasize that thoughts will inevitably arise; this isn’t a failure or mistake because the mind doesn’t like to be empty. The object of this meditation is to notice thoughts as soon as possible, and then return attention to the breath.

Mindfulness in daily life. Attending to the present moment is a practice that individuals can develop by focusing on sensations associated with a particular daily experience:

Visualization

Visualization processes induce attention reallocation, from fight or flight sensations and related cognitive processes to nonthreatening images that signal the parasympathetic nervous system to release tension. The most common imagery-based relaxation exercise is the special (or safe) place visualization (Achterberg, Dossey, & Kolkmeier, 1994; Siegel, 1990). It has been used extensively for arousal reduction, as well as for the management of extreme stress reactions following PTSD exposure trials.

Encourage individuals to select a place where they have felt safe and peaceful. It could be a beautiful beach, a mountain meadow, or a childhood bedroom where they were happy. If no such real place exists, encourage them to create a fictional but safe and relaxed environment. Some people, particularly those with an abuse history, may create images with extraordinary built-in protections. One sexually abused woman, for example, developed a safe place at the beach—but with thirty-foot walls, topped with glass shards, extending far out into the ocean.

Once the visualization has been selected, encourage individuals to fill in the details, including visual (shapes, colors, objects), auditory (voices, ambient sounds), and kinesthetic (sense of temperature, texture, weight, pressure) imagery. It’s crucial to use the three sensory modalities noted above so the image will be rich enough to impact arousal level. Now lead several rehearsals of the special place visualization, taking stress readings (zero to ten) before and after to verify effectiveness. Encourage twice-daily practice sessions for the next week to achieve mastery.

The special place visualization can be combined with other relaxation exercises for an additive effect. Augmenting techniques can include diaphragmatic breathing, passive relaxation (focused on a particular tense muscle group), cue controlled relaxation, and others. For example, while conjuring a peaceful meadow, individuals may also be taking deep breaths or relaxing tension in the shoulder region.

Autogenics

The autogenic technique targets the sympathetic adrenal system and vagal tone using autosuggestion to create deep relaxation. The following autogenic verbal formulas were developed and combined into five sets to reduce stress and normalize key body functions.

Set 1

Set 2

Set 3

Set 4

Set 5

Individuals should learn one set at a time. The sets can be either recorded or memorized. It’s generally recommended that clients practice twice daily and to give them a week to master each set. Because each set includes themes from previous sets, there’s no need to repeat previous sets—the set an individual is working on can be his or her entire focus. (Other autogenic formulas for calming the mind and specific physical conditions are available; see Davis et al., 2008).

The guidelines for practicing autogenics are as follows:

Choosing a Relaxation Protocol

People inevitably prefer some arousal reduction techniques over others, so it’s advisable to teach four to five so they can decide what works best. For nonspecific stress, start with breathing techniques, including the breath counting meditation, and proceed to muscle relaxation and (to increase choices) visualization.

If an individual suffers significant health problems that are influenced by stress, begin with relaxation processes that directly target muscle tension—PMR, autogenics, or the body scan. For chronic pain and problems with specific muscle groups, try PMR (if tolerated) and, ultimately, passive relaxation, as well as the body scan meditation. If rumination or worry are part of the clinical picture, you could include mindfulness exercises to quiet mental activity.

Individuals who are beset with stress at work or in other public places are best served with applied relaxation training because it can be used in virtually any circumstance and quickly impacts arousal levels. Problems with emotion dysregulation, including GAD, can be treated with breathing techniques (diaphragmatic breathing, applied relaxation, and the breath counting meditation). Start by having the client use the breath counting meditation at regular intervals throughout the day to reduce baseline arousal. Then introduce either diaphragmatic breathing or applied relaxation for use during acute upsurges in emotion. The special place visualization can be used adjunctively for virtually any target problem, but it can be especially helpful with anxiety-based stress.

Dose Considerations

Most relaxation techniques require two or three daily practice sessions—for at least a week—for mastery. Techniques designed to reduce general arousal (PMR, mindfulness, autogenics, special place visualization) should be scheduled at regular intervals throughout the day (tied to events like use of the restroom, or signaled by a smartphone alarm). Once mastered, techniques designed to address unpredictable surges in stress (diaphragmatic breathing, applied relaxation, and passive relaxation) can be used whenever the stress symptoms arise.

Paradoxical Reactions

Some individuals, particularly people with trauma histories, will paradoxically respond to relaxation training with anxiety and hypervigilance. This is particularly true with PMR and some breathing exercises. When this happens, the best approach is to switch to a different arousal reduction strategy (autogenics and mindfulness are sometimes better tolerated), or titrate the relaxation dose, starting with ten to twenty seconds and increasing in small increments.

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