{"id":4045,"date":"2016-12-19T19:19:22","date_gmt":"2016-12-19T19:19:22","guid":{"rendered":"https:\/\/treatmentmaps.net\/?page_id=4045"},"modified":"2018-07-11T01:36:55","modified_gmt":"2018-07-11T01:36:55","slug":"sleep-section-24","status":"publish","type":"page","link":"https:\/\/treatmentmaps.net\/?page_id=4045","title":{"rendered":"Sleep Section 24"},"content":{"rendered":"<p><strong>24:\u00a0 RELAXATION\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong><em>[Rev 11-12-2017]<\/em><\/p>\n<p style=\"padding-left: 60px;\"><em>This appears on Step D1 (<a href=\"https:\/\/treatmentmaps.net\/?page_id=4067\">Section 44<\/a> and <a href=\"https:\/\/treatmentmaps.net\/?page_id=4065\">Section 45<\/a>) as one set of techniques for helping people who are agitated or anxious and obsessing at bedtime. It can be of special help when combined with a buffer period (<a href=\"https:\/\/treatmentmaps.net\/?page_id=4039\">Section 18<\/a>).<\/em><\/p>\n<p>There are many ways to relax. A therapist\u2019s job includes helping the patient find a way that is comfortable, meaningful, helpful and easy to do. As with a new exercise program, the method needs to be started in a way that the person will actually do it and continue doing it outside of the treatment setting. The general notion is for the patient to be able to create moments of calm as a matter of choice or plan, and then be able to use them to get to sleep.<\/p>\n<p>For a listing of many forms and techniques of relaxation see the article \u201c<a href=\"https:\/\/en.wikipedia.org\/wiki\/Relaxation_technique\">Relaxation Technique<\/a>\u201d in Wikipedia. This article also has links to articles on specific techniques. However, they are not necessarily relevant to the problem of falling asleep.<\/p>\n<p>This section includes several parts<\/p>\n<p>24a. General principles for selecting a technique<\/p>\n<p>24b. The patient\u2019s repertoire of relaxation techniques<\/p>\n<p>24c. Specific techniques<\/p>\n<p>24d. Choosing among techniques for a particular person<\/p>\n<p><a href=\"#relax_appx\">Appendix<\/a> \u2013 notes on some techniques<\/p>\n<p>&nbsp;<\/p>\n<p><strong>24a. General Principles for Selecting a Technique<\/strong><\/p>\n<p>Whatever method or technique is chosen, it needs to<\/p>\n<ul>\n<li>Be consistent with the person\u2019s issues<\/li>\n<li>Be something that the person can use in the time just before going to bed, that will help prepare him\/her for sleep.<\/li>\n<li>In most instances, it should be something that the person can do alone. Sex might be an exception, except that most people can\u2019t count on using sex as a relaxation technique every night.<\/li>\n<\/ul>\n<p>Different relaxation techniques target different kinds of issues \u2013 physical tension, emotional tension and cognitive activity. If the mind is racing, a physical relaxation technique may not be effective. However, sometimes combinations can be more effective, as when a hot bath is combined with observation and fantasy.<\/p>\n<p>We also want the chosen technique to provide some kind of rapid results.<\/p>\n<ul>\n<li>Chronic sleep loss can be debilitating, and the person wants relief as soon as possible.<\/li>\n<li>The person may be discouraged from many unsuccessful attempts to sleep.<\/li>\n<li>Even a small amount of success can be rewarding.<\/li>\n<\/ul>\n<p>A person\u2019s preferred style of relaxing can suggest a kind of technique. If he\/she is able to be passive and drift away, deep breathing or meditation might help get to sleep. More active people may need engagement and distraction, as in guided imagery or progressive muscle relaxation. People who are more obsessive may need a distraction, such as a boring television program or a dull book.<\/p>\n<p>A number of possible techniques for relaxation might not be useful for getting to sleep, or might have to be adapted. A relaxation technique can be problematic if it\u2026<\/p>\n<ul>\n<li>involves activity that could be relaxing and energizing at the same time. (e.g.: practicing basketball shots or self-defense moves might be anxiety-reducing but physically energizing.)<\/li>\n<li>is limited to a particular time of day or season of the year (e.g.: gardening).<\/li>\n<li>requires special preparations or cleaning up afterwards (e.g.: biofeedback or flotation therapy)<\/li>\n<li>relies on others (e.g.: massage. Your partner might not find it relaxing.)<\/li>\n<li>increases alertness (e.g.: playing video poker or watching a comedy program on television).<\/li>\n<li>requires special training, unless the training can take place during the day and the patient can then use what was learned at bedtime.<\/li>\n<\/ul>\n<p>Relaxation techniques differ in their purpose<\/p>\n<ul>\n<li>To allow a person to relax in preparation for sleep<\/li>\n<li>To allow a person to relax in general, especially if the person is tense, stressed or anxious.<\/li>\n<\/ul>\n<p>They also differ in execution<\/p>\n<ul>\n<li>Only used at bedtime<\/li>\n<li>Used during the day, with anticipated carry-over effect<\/li>\n<li>Practiced during the day in preparation for execution at bedtime<\/li>\n<\/ul>\n<p><strong>24b The Patient\u2019s Repertoire<\/strong><\/p>\n<p>A patient may already have some methods for relaxing in his\/her repertoire. They can be discussed and possibly expanded or refined. They might incluce<\/p>\n<ul>\n<li>Hot bath<\/li>\n<li>Reading a mindless novel or magazine<\/li>\n<li>Watching a boring or mindless television program<\/li>\n<li>Playing solitaire<\/li>\n<\/ul>\n<p>The person may already have tried other techniques, which can be refreshed or refined.<\/p>\n<p>Some techniques already in the person\u2019s repertoire may provide a basis for more effective ones. For example, a patient who drinks to unwind at the end of every day may not realize that drinking can lead to restless sleep and awakenings in the middle of the night (See Section 8). However once that is clear, he\/she might be willing to explore the other components of unwinding, such as sitting in a favorite chair and remembering a calmer time. Such a person might also be willing to try it regularly at other times of day.<\/p>\n<p>Another patient may enjoy listening to music. He\/she might be willing to set aside part of each day to listen to his\/her favorite music, without doing anything else.<\/p>\n<p><strong>24c. Specific Techniques<\/strong><\/p>\n<p>In using any of these techniques, a first issue is for the person to find an environment that is quiet and without distractions. This is especially true when relaxation is preliminary to sleep. However, most techniques require practice, often daily practice, and it is also important for the practice setting to be quiet and free of distractions.<\/p>\n<p>Some possibilities include:<\/p>\n<ul>\n<li>Self-hypnosis<\/li>\n<li>Deep breathing<\/li>\n<li>Guided imagery<\/li>\n<li>Progressive muscle relaxation<\/li>\n<li>Meditation<\/li>\n<li>Autogenic training<\/li>\n<li>Yoga<\/li>\n<li>Biofeedback<\/li>\n<li>Mindfulness<\/li>\n<li>Calming music<\/li>\n<\/ul>\n<p>A second issue is to find a comfortable location and\/or position. At bedtime this would most likely be the person\u2019s bed, to facilitate falling asleep immediately after relaxing \u2013 possibly even <em>while<\/em> relaxing. However, practice time should probably not lead to sleep, because for people with insomnia, napping is generally not recommended (<a href=\"https:\/\/treatmentmaps.net\/?page_id=4053\">Section 32<\/a>).<\/p>\n<p>Techniques will differ according to the focus of attention, but they all work to take the person away from issues of daily life, whether present, past or anticipated in the future. A technique may be effective for a particular patient because of the object of focus and the patient\u2019s ability to stay with it.<\/p>\n<p>Techniques may also differ according to how they encourage a passive attitude.<\/p>\n<p><u>PROGRESSIVE MUSCLE RELAXATION<\/u><\/p>\n<p>This procedure works by having the person work progressively from head to toe or toe to head, and first tightening then releasing the various muscle groups along the way: toes, then feet, then calves, thighs, and so on. As they release, the muscles feel like they are relaxing, and they may relax to a greater degree than when they started. The person gains a sense of success in being able to relax that is increased with each new muscle group. A brief definition appears in <a href=\"https:\/\/en.wikipedia.org\/wiki\/Progressive_muscle_relaxation\">Wikipedia<\/a>. <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_bourne01\">Bourne<\/a> (pp. 79-83) goes over general guidelines and a specific relaxation protocol. For more here, see the <a href=\"#relax_musclerelax\">appendix<\/a> to this section.<\/p>\n<p><u>DEEP BREATHING<\/u><\/p>\n<p>Also called \u201cbelly breathing\u2019, \u201cdiaphragmatic breathing\u201d, and \u201cabdominal breathing\u201d, this involves techniques to help a person breathe more slowly and deeply. The process is calming and relaxing by forcing the person to be physically still, focusing attention on the breath and away from muscles of interaction with the world, and stimulating the parasympathetic nervous system (which is connected to calming activities).<\/p>\n<p>The thoracic diaphragm stretches across the body under the rib cage and separated the thoracic cavity (which holds the lungs and heart) from the abdominal cavity. On inhalation, it moves downward, increasing the lung volume and drawing air inward. At the same time, it pushes the abdominal cavity downward and the abdomen outward. On exhalation, the diaphragm moves upward, squeezing the lungs and allowing the abdomen to contract.<\/p>\n<p>Normally breathing is effected primarily by the diaphragm, but also by the muscles between ribs, that raise and expand the chest on inhalation, and by abdominal muscles, that contract during exhalation. Wikipedia has a helpful article on <a href=\"https:\/\/en.wikipedia.org\/wiki\/Breathing\">breathing<\/a>.<\/p>\n<p>Shallow breathing is effected primarily by use of the chest muscles. It is often more rapid than deep breathing, because a smaller volume of air moves in and out with each breath. It is common in anxious people and people who have never learned to breathe deeply.<\/p>\n<p>Deep breathing exercises are designed to teach a person to use his\/her diaphragm and abdominal muscles more actively in breathing. They typically involve<\/p>\n<ul>\n<li>Setting aside time<\/li>\n<li>Taking a relaxed position, usually lying on one\u2019s back or sitting comfortably<\/li>\n<li>Placing one hand on the abdomen and one on the chest<\/li>\n<li>Breathing deeply<\/li>\n<li>Noticing the movement<\/li>\n<li>Some kind of pattern \u2013 eg: breathe in, hold, breathe out, hold, and repeat<\/li>\n<li>Some kind of counting \u2013 inhaling for a count of four, hold for a count of four, etc.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>In the process of learning to breathe deeply, the person needs to focus on a physical activity that is not usually central to thinking. This occupies attention, forces physical quiet, and distracts from other stimulating thoughts. Once the person has learned the technique, other activities can be appended, and the focus on relaxation \u00a0can remain central while the person falls asleep.<\/p>\n<p>Specific plans for deep breathing can be found in many books, usually in chapters on anxiety treatment. For examples, see <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_bourne01\">Bourne<\/a>, pp. 75-79, <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_wehnrnberg01\">Wehrenberg<\/a>, pp. 50-61, <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_daitch01\">Daitch<\/a>, pp. 58-60, and <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_hirshkowitz01\">Hirshcowitz and Smith<\/a>, pp. 129-130. Internet versions appear in many places, including <a href=\"https:\/\/psychcentral.com\/blog\/archives\/2013\/07\/22\/reduce-your-anxiety-this-minute-3-different-types-of-deep-breathing\/\">Psych Central<\/a>, <a href=\"https:\/\/www.webmd.com\/balance\/stress-management\/stress-management-breathing-exercises-for-relaxation\">WebMD<\/a>, and <a href=\"https:\/\/www.verywell.com\/how-to-reduce-stress-by-deep-breathing-2797585\">VeryWell<\/a>.<\/p>\n<p><u>BIOFEEDBACK<\/u><\/p>\n<p>Biofeedback uses feedback from technological devices to provide information about physiological activity. Armed with that information, the person has an opportunity to focus on the process and learn to manage it.<\/p>\n<p>For some additional information, see the <a href=\"#relax_biofeed\">appendix<\/a> to this section.<\/p>\n<p><u>SELF-HYPNOSIS<\/u><\/p>\n<p>Hypnosis commonly includes relaxation, focus, and suggestion. When you are relaxed, it is easier to focus on something you choose \u2013 an image, a process, your own body. When you are focused, you are more open to suggestions, and the suggestions can include the idea of further relaxation.<\/p>\n<p>Relaxation often includes a focus on breathing or systematic relaxation of muscle groups. This helps escape the thoughts that keep a person awake. Images can take the person away from daily life and its anxiety and arousal. The conscious mind is unhooked by concentration away from practical or interpersonal matters. Language is minimized, and the stage is set for sleep.<\/p>\n<p>This is not a place to explore hypnosis, but many other places treat it well. For example, <a href=\"https:\/\/en.wikipedia.org\/wiki\/Self-hypnosis\">Wikipedia<\/a> has an article on self-hypnosis. <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_bryant01\">Bryant and Mabbutt<\/a> include a chapter on \u201cOvercoming Insomnia\u201d with self-hypnosis, and a two-page self-hypnosis script for insomnia (pp. 204-205).<\/p>\n<p><u>VISUAL IMAGERY<\/u><\/p>\n<p>Many people can think of relaxing images \u2013 of places they have been or would like to be, scenes they have seen in the movies or on television, etc. See if the person can generate that image in the treatment setting, and if so, return to it at will during the day.<\/p>\n<p>You can suggest relaxing scenes to get the person started, such as<\/p>\n<ul>\n<li>Lying on the beach in the warm sun, listening to the waves or the children playing and watching the clouds go by overhead.<\/li>\n<li>Walking through the woods on a spring day, smelling the trees and hearing the birds.<\/li>\n<li>Sitting on the roof of an apartment building and watching the sun set over the city.<\/li>\n<\/ul>\n<p>There are many forms of this approach, often combined with instructions to relax the body at the same time. One appears in <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_jacobs01\">Jacobs<\/a>, pp. 140-143. Several appear in <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_bourne01\">Bourne<\/a> , pp. 83-85 and 226-235 .<\/p>\n<p>Sometimes a little humor can be helpful. \u201cI knew a guy who was very good at dealing with tension. He would imagine himself lying on a recliner in a small boat in the middle of Nantucket Sound, the land far away, the boat rocking gently, and he would be at peace. Unfortunately, he was a salesman of marine supplies, and he would often generate this image when dealing with customers. The bad thing was that he angered some customers and lost some sales. The good thing was that he worked for his brother, and didn\u2019t get fired &#8211; he only got yelled at from time to time. And he only got a little anxious when his brother yelled at him.\u201d<\/p>\n<p><u>GUIDED IMAGERY<\/u><\/p>\n<p>Here the therapist takes the patient through a set of images designed to be relaxing, with the suggestion that the series is working.<\/p>\n<p>For example, \u201cYou are standing on an escalator that is going down to the subway. You watch the walls go by on both sides. As you go down you are getting more and more calm and relaxed. More and more relaxed. Then you arrive at the platform, fully relaxed.\u201d (This is the very brief version.)<\/p>\n<p>If the image is one that the patient has selected, a therapist can guide him\/her to explore the details of the scene \u2013 including sounds, smells, etc.<\/p>\n<p>There is still the issue of how the patient can make use of the process at bedtime. The suggestion could be made that the person will be able to do so, or specific instructions can be given for carrying out the process at home. If the patient has selected the scene, transfer to home may be easier.<\/p>\n<p>There are other examples of these images in books on hypnotic induction techniques. Some imagery also appears on relaxation tapes.<\/p>\n<p><u>HOT BATH<\/u><\/p>\n<p>Taken an hour or two before bedtime, a hot bath can be relaxing to some people. It can become part of a person\u2019s bedtime rituals (Section 37), marking the end of the person\u2019s active day, providing a signal that sleep is coming soon. It can be combined with some form of observation and fantasy (Section 41) to put a person in a dream-like mode.<\/p>\n<p>A person may need to experiment with timing. For some people, it can be somewhat energizing, and shouldn\u2019t be done too close to bedtime. It also has to be coordinated with the person\u2019s daily activities, such as cleaning the residence or putting children to bed. And if it is followed by more daytime activities, such as preparation for the next day, it may be ineffective.<\/p>\n<p><u>MEDITATION<\/u><\/p>\n<p>There are many forms of meditation, some of which can be very helpful in regulating and reducing anxiety. Effective components of meditation include [1] getting away from everyday demands and pressures; [2] relaxing; and [2] focusing the attention on something other than the person\u2019s anxiety-producing thoughts. For a little more, see the <a href=\"#relax_meditate\">Appendix<\/a> to this section.<\/p>\n<p><u>CALMING STIMULI<\/u><\/p>\n<p>There are many relaxation audio recordings available. Even music that is not specifically labeled as sleep-inducing can be calming and help a person prepare for sleep.<\/p>\n<p>If the person can be lulled to sleep by the sound of a human voice, books on tape may be a good choice. It depends on the book, of course. Some books, like some videos, may be more stimulating than relaxing.<\/p>\n<p>It is also possible that some people may be put to sleep by videos or television programs that are played without the sound.<\/p>\n<p>An online meditation supplement called \u201cBinaural Beats\u201d appears at<\/p>\n<p><a href=\"https:\/\/www.google.com\/webhp?sourceid=chrome-instant&amp;ion=1&amp;espv=2&amp;ie=UTF-8#q=binaural%20beats%20youtube\">https:\/\/www.google.com\/webhp?sourceid=chrome-instant&amp;ion=1&amp;espv=2&amp;ie=UTF-8#q=binaural%20beats%20youtube<\/a><\/p>\n<p><u>AUTOGENIC TRAINING<\/u><\/p>\n<p>Autogenic training can be thought of as a method of self-regulation of the autonomic nervous system. Most often it is used as a method of relaxation. [Linden and Lenz, 118]\n<p>Patients are trained to repeat certain phrases sub-vocally, that are thought to regulate the sympathetic nervous system. The patient becomes more balanced as the training takes effect. For more, see the <a href=\"relax_autogenic\">Appendix<\/a> to this section.<\/p>\n<p><u>YOGA<\/u><\/p>\n<p>Yoga can be useful both as a practice that has a general effect on the person and his\/her life style, which makes insomnia less likely. Specific yoga techniques have also been recommended as preparation for bedtime. These applications are discussed in <a href=\"https:\/\/treatmentmaps.net\/?page_id=4057\">Section 39<\/a>.<\/p>\n<p><u>MINDFULNESS<\/u><\/p>\n<p>Mindfulness is a state in which a person works to be aware of the present in a focused, nonjudgmental way. Each thought or perception that one becomes aware of is acknowledged and accepted. It is a form of meditation that involves noticing what one is thinking and feeling without attempting to alter or direct it. More formal and structured forms lead to meditation. Less formal versions can simply involve paying attention to what is happening as it happens.<\/p>\n<p>As a sleep aid, a person can be mindfully aware of what he\/she is experiencing at the point of preparing to sleep \u2013 what thoughts pass through his\/her head, what sensations are experienced, and so on, without trying to control them. It can also involve considering each night is a new night, that sleep can\u2019t be forced, and that the process of staying awake or becoming sleep is open to observation.<\/p>\n<p>There are many resources describing a mindful approach. You can find an article on mindfulness meditation in <a href=\"https:\/\/www.psychologytoday.com\/blog\/the-courage-be-present\/201001\/how-practice-mindfulness-meditation\">Psycholo gy Today<\/a>. Some other articles on mindfulness appear in the <a href=\"http:\/\/www.mindful.org\/meditation\/mindfulness-getting-started\/\">mindful.org<\/a> web site. <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_wehrenberg01\">Wehrenberg<\/a> (pp.62-69) describes a technique for learning mindfulness in the context of treating anxiety.<\/p>\n<p><strong>24d. Choice Among Techniques<\/strong><\/p>\n<p>If there is a neuromuscular component to a person\u2019s symptoms (as in tension headaches, hypertension, irritable bowel syndrome, asthma), progressive relaxation can be helpful. (<u><a href=\"https:\/\/treatmentmaps.net\/?page_id=1015\/#anxietyref_lehrer01\">Lehrer \u00a0and Carr<\/a><\/u>, 1997, p.84)<\/p>\n<p>Progressive relaxation can also help with specific symptoms such as worry, insomnia and obsessive ruminations (<u><a href=\"https:\/\/treatmentmaps.net\/?page_id=1015\/#anxietyref_lehrer01\">Lehrer and Carr<\/a><\/u>, 1997, p.84).<\/p>\n<p>For stress reduction, autogenic training can be helpful.<\/p>\n<p><u>CHOICE BASED ON CURRENT ACTIVITIES<\/u><\/p>\n<p>If the patient is currently using some way to relax, you may want to expand on it. This solution is already available to the patient, and it could involve very little additional commitment.<\/p>\n<p>For example, a patient with chronic pain likes to sit on his deck and watch the birds. Maybe he could do that regularly, watch them for a while each time, and really \u201cget into\u201d their movement and patterns. The result, if pursued, might end up as a form of meditation.<\/p>\n<p><u>CHOICE BASED ON PATIENT LIMITATIONS<\/u><\/p>\n<p>Choose biofeedback over progressive relaxation when a person can\u2019t isolate feelings of tension in habitually tense muscles (Lehrer and Carr, 1997, p.85).<\/p>\n<p>If a patient reacts badly to suggestion, choose progressive relaxation over hypnotic techniques or autogenic training (Lehrer and Carr, 1997, p.92).<\/p>\n<p>Where the person needs to maintain conscious control, the passive nature of autogenic training and progressive relaxation may be both difficult and rewarding. Here a question might be whether to avoid pressing the person to be more passive or work on training him\/her to be better at it.<\/p>\n<p><u>CHOICE BASED ON THERAPY GOALS<\/u><\/p>\n<p>Choose progressive relaxation training over procedures that quickly train the whole body in one session by tension-relaxation of muscle groups, if you want the training to lead to better control and greater usefulness (Lehrer and Carr, 1997, p.86).<\/p>\n<p>Autogenic training and progressive relaxation sensitize the person to physical sensations, whereas meditation doesn\u2019t (Linden and Lenz, 1997, p.121).<\/p>\n<p>Biofeedback helps people gain greater awareness of involuntary processes through use of technical equipment (Linden and Lenz, 1997, p.121).<\/p>\n<p>Where there is a need for rapid results or where the person is only concerned with outcomes, progressive relaxation and autogenic training may not be focused enough or rapid enough for the person to maintain motivation sufficiently to obtain beneficial results<\/p>\n<p><u>CHOICE BASED ON SIDE EFFECTS<\/u><\/p>\n<p>Progressive relaxation is less likely than autogenic training or meditation to induce a re-experiencing of a traumatic event (Lehrer and Carr, 1997, p. 90).<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>24e. Appendix to Section 24<\/strong><\/p>\n<p>Here are some additional discussions of specific techniques.<\/p>\n<p><u>PROGRESSIVE MUSCLE RELAXATION<\/u><\/p>\n<p>Progressive relaxation was developed by Edmund Jacobson and elaborated into an extensive program of exercises. Most people today use it as a treatment for anxiety, in highly abbreviated forms. It can also be used as a hypnosis induction technique.<\/p>\n<p>The approach involves teaching patients awareness of their own muscle tension and how to eliminate it. Emotional tension is consistently associated with muscle tension, so that by eliminating muscle tension, one is able to partly reduce emotional tension as well. [Lehrer and Carr, 83-84] The patient is actively engaged in doing something and in focusing his\/her attention.<\/p>\n<p>A common theme is that relaxation of any muscle can better be accomplished if the muscle is first tightened. Then, even if the person only returns to the prior tension level, that return can be experienced as relaxing. However, it is often possible to relax to a place of less tension than before, and that is the purpose of the treatment.<\/p>\n<p><u>A suggested protocol<\/u><\/p>\n<p>In one form of the basic procedure, the person is taught to relax his\/her muscles, group-by-group. Training can occur once, with the patient expected to continue at home; or it can be repeated as many times in session as needed.<\/p>\n<p>It is often difficult for anxious people just to relax. In fact, they probably have tried that many times. So you can present it as a somewhat paradoxical task: \u201cIn order to relax effectively, you have to tighten-up first. It gives you control over the relaxation process, and it helps you relax more completely.\u201d<\/p>\n<p>Begin by having the person sit or lie comfortably, so when he\/she is fully relaxed, the chair or floor will fully support him\/her.<\/p>\n<p>Then begin with a specific group of muscles. For this example, start with the person\u2019s right foot. Ask the person to tighten the foot muscles, really tight, and hold that for a few &#8211; say, five &#8211; seconds. Try not to tighten any other muscles, if possible. Then relax those muscles, and feel them relax.\u00a0 Feel them get more relaxed than they were before starting. This part should take longer \u2013 20 to 30 seconds.<\/p>\n<p>Take a few seconds to ask how it went: Was the person able to hold it? Does the right foot feel more relaxed? Then repeat the same procedure, with the right foot again. All the while, the rest of the person\u2019s body should remain as relaxed as possible.<\/p>\n<p>Then, take other muscle groups in order, in each case first tightening and then relaxing the muscles, and repeating the process twice:<\/p>\n<ul>\n<li>Right calf and foot<\/li>\n<li>Right leg. Here, it may be helpful to raise the entire leg and hold it out stiffly.<\/li>\n<li>Left foot<\/li>\n<li>Left calf and foot<\/li>\n<li>Left leg<\/li>\n<li>Buttocks and groin<\/li>\n<li>Stomach or abdomen. It may help to exhale here, or to imagine the abdominal muscles to be stiff and board-like.<\/li>\n<li>Taking in a breath and holding it can be helpful. The relaxation phase includes letting the breath come in and go out slowly and easily.<\/li>\n<li>Right hand<\/li>\n<li>Right hand and forearm<\/li>\n<li>Right arm. The arm can be held up and out.<\/li>\n<li>Left hand<\/li>\n<li>Left hand and forearm<\/li>\n<li>Left arm<\/li>\n<li>Shoulders<\/li>\n<li>Neck and head<\/li>\n<li>Here, it can be helpful to squeeze the eyes shut and pinch the facial muscles together.<\/li>\n<\/ul>\n<p>At the end, ask how the person feels.<\/p>\n<p>Two other issues are worth noting. One is that the techniques force a focus on the person\u2019s muscles, which interferes with thinking anxious thoughts. Another point is that thoughts are often expressed in muscles, so when the muscles are relaxed, the thoughts tend to relax also.<\/p>\n<p>There is general agreement that training and practice are important to learning to use any form of the approach well.<\/p>\n<p><a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_wehnrnberg01\">Wehrenberg<\/a> (2008, 72-74) gives clear instructions for carrying out this process, as does <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_bourne01\">Bourne<\/a> (2005, 81-83). Many other treatments \u2013 including lists of steps \u2013 can be found in the literature and online.<\/p>\n<p>For other scripts, see Robertson, or Guidetopsychology.com or rci.rutgers.edu<\/p>\n<p><a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_lehrerreite01\">Lehrer and Carr<\/a> (1997) offer a plan for treatment of anxiety that works with specific muscle groups \u2013 different groups on successive weeks, for a total of eight sessions. It involves the basic tense-relax approach but also works to increase the person\u2019s awareness of muscle tension by training in partial tensing of muscles.<\/p>\n<p><u>BIOFEEDBACK<\/u><\/p>\n<p>Steps involve\u2026<\/p>\n<ul>\n<li>Identify a physiological process that reflects levels of anxiety, can be displayed electronically, and is capable of being altered through concentration. Many processes fit these criteria, including respiration rate, galvanic skin response, brain waves, heart rate, etc.<\/li>\n<li>Find a way to measure that activity and display it for the person to monitor. A large meter is ideal, where the patient can watch the reading on the meter. Alternatively, a beeper may go off or a light may flash, and the patient may attempt to modify the rate of the signal light or sound.<\/li>\n<li>Ask patient to alter the displayed activity level using any possible thought or emotion.<\/li>\n<\/ul>\n<p>At least two things are happening here.<\/p>\n<ul>\n<li>To the extent that the process being monitored reflects anxiety, any increased control over that process has the potential for interrupting the anxiety response. Ideally, after a number of sessions, the person also learns to identify the physiological states that go along with a high meter reading and the way to lower that reading after the meter is discontinued.<\/li>\n<li>To the extent that the task is engaging and the patient is able to focus, he\/she is learning about focus of attention. This in itself interferes with the patient\u2019s ongoing anxious mood. Here also, learning to focus attention can have long-lasting benefits.<\/li>\n<\/ul>\n<p>Biofeedback work requires special training and equipment. Typically a therapist refers out to a specialist for this phase of treatment, after gathering preliminary information about the patient\u2019s sources of anxiety.<\/p>\n<p><u>Biofeedback &#8211;\u00a0 Tools<\/u><\/p>\n<p>A number of different instruments are possible sources of information for biofeedback training, including\u2026<\/p>\n<ul>\n<li>thermistor \u2013 registers skin temperature<\/li>\n<li>electromyograph \u2013 registers muscle tension from skin readings<\/li>\n<li>electrodermograph \u2013 electric conductance\/ resistance of skin<\/li>\n<li>electroencephalograph [EEG] registers brain waves based on skin activity<\/li>\n<li>electrocardiograph \u2013 electrical activity of the heart<\/li>\n<li>pneumograph \u2013 depth and rate of breathing<\/li>\n<\/ul>\n<p>More on these can be found in the <u>Wikipedia<\/u> article on biofeedback.<\/p>\n<p><u>Biofeedback &#8211; Treatment<\/u><\/p>\n<p>A therapist attaches and adjusts the equipment and helps the patient learn to control the signal. This begins the process of self-management of the physiological process that the equipment monitors<\/p>\n<p><u>Biofeedback &#8211; Rationale<\/u><\/p>\n<p>Many physiological reactions to stress prepare the body to react to physical dangers. When the danger passes, the reaction diminishes. However, in modern life, the danger [financial worries, chronic illness in a close relative, work stress] may be chronic not relieved by physical action. After a time, the stress reaction is itself chronic, leaving the person with an ongoing sense of preparation for unspoken and endless danger. The body needs to be de-programmed from its ongoing preparation for attack <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_perlis01\">Perlis, M., Aloia, M., and Kuhn<\/a>, B. 51<\/p>\n<p>An extended article on biofeedback can be found in <a href=\"https:\/\/en.wikipedia.org\/wiki\/Biofeedback\">Wikipedia<\/a><\/p>\n<p><u>MEDITATION<\/u><\/p>\n<p>There are many forms of meditation, some of which can be very helpful in regulating and reducing anxiety. Effective components of meditation include [1] getting away from everyday demands and pressures; [2] relaxing; and [2] focusing the attention on something other than the person\u2019s anxiety-producing thoughts.<\/p>\n<p><u>Time Away<\/u><\/p>\n<p>One goal is to find time that is not connected to the person\u2019s anxiety-producing issues. The time should be set aside, with no interruptions, and no incentive to work on daily life or the person\u2019s issues or fears. Meditation is not for problem-solving; there is plenty of other time in the day for that. The place for meditation is also best away from daily life \u2013 a place not used for practical activities, with as few distractions as possible.<\/p>\n<p><u>Meditation and relaxation<\/u><\/p>\n<p>When the body is relaxed, it helps the mind relax and reduces anxiety. The goal here is to relax as much as possible without falling asleep; so a common procedure is to sit in as relaxed a position as possible, perhaps in a comfortable chair. Sometimes specific relaxation techniques can be used to help the person prepare for meditation.<\/p>\n<p><u>Focus of attention<\/u><\/p>\n<p>A common goal is to be aware without being logical, judgmental or practical. Meditation involves self-regulation away from dealing with thoughts or objects and toward just observing.<\/p>\n<p>Many things can be attended-to. The problem is to find something that works for the patient, something that leads to relaxation and increased comfort. The person can focus on\u2026<\/p>\n<ul>\n<li>his\/her own breath, possibly counting breaths as they go in and out.<\/li>\n<li>a particular object, such as a flower, a clock, an animal, clouds overhead, etc. Try to experience it as fully as possible.<\/li>\n<li>a sound, either a sound heard from outside or a sound that he\/she creates vocally.<\/li>\n<li>a pleasant image or fantasy.<\/li>\n<li>his\/her own awareness. He\/she can simply pay attention to whatever he\/she is aware of from second to second. This is sometimes called \u201cmindfulness meditation.\u201d In Gestalt therapy, it is called the \u201cawareness continuum\u201d.<\/li>\n<\/ul>\n<p>Meditation is also discussed in <a href=\"https:\/\/en.wikipedia.org\/wiki\/Meditation\">Wikipedia<\/a><\/p>\n<p><u>AUTOGENIC TRAINING<\/u><\/p>\n<p><u>Theory of Autogenic Training<\/u><\/p>\n<p>Anxiety is accompanied by an imbalance between the sympathetic and parasympathetic nervous systems. When the individual brings the sympathetic system under control, homeostatic balance returns naturally. Linden and Lenz, 120]\n<p>Autogenic training can be thought of as a method of self-regulation of the autonomic nervous system. Most often it is used as a method of relaxation. [Linden and Lenz, 118]\n<p>It can be beneficial as an adjunct to other treatments, especially relative to interpretation of body sensations, management of worrisome thoughts, uncovering latent issues, etc. [Linden and Lenz, 140]\n<p><u>Technique<\/u><\/p>\n<p>Patients learn six different phrases to say subvocally. Each phrase targets a different function of the sympathetic nervous system: [Linden and Lenz, 118]\n<ul>\n<li>muscle relaxation.<\/li>\n<li>vascular control.<\/li>\n<li>heart function.<\/li>\n<li>regulation of breathing.<\/li>\n<li>regulation of visceral organs.<\/li>\n<li>regulation of blood flow in the head.<\/li>\n<\/ul>\n<p>Imagery exercises involving these six functions lead to physiological changes, increased physiological self-control and a consequent reduction in the person\u2019s stress level. [Linden and Lenz, 119-120]\n<p>Emphasis is on learning the techniques, rather than on the outcome of reduced anxiety [Linden and Lenz, 122]\n<p>The technique is essentially passive; according to Linden and Lenz [130, 134], attempts at more active control of the sympathetic nervous system will be ineffective.<\/p>\n<p><u>Risks<\/u><\/p>\n<p>Patients may on occasion experience sudden levels of high anxiety or panic with any relaxation technique. This is a reason for careful preparation before using the technique, and for not using it as the only treatment method for a patient. [Linden and Lenz, 135]\n<p>This is a form of relaxation and self-control with similarities to self-hypnosis and other relaxation techniques. The person assumes a relaxed position and repeats a set of prescribed phrases that describe physical sensations and emotional states, such as \u201cmy right arm is heavy;\u201d or \u201cMy legs are warm.\u201d<\/p>\n<p>At the conscious level, the statements may not be fully accurate. However, they are designed to be auto-suggestions directed to unconscious, autonomic processes. There is also plausibility to the idea that if they are repeated daily for a period of weeks, the images may have an effect on the person\u2019s self-awareness.<\/p>\n<p>Autogenic training might be helpful for overall calming of a person and indirectly have an effect on sleep. It could also be combined with other calming techniques. However, the effects on a person\u2019s sleep are not likely to be immediate.<\/p>\n<p>Another discussion can be found in the corresponding <a href=\"https:\/\/en.wikipedia.org\/wiki\/Autogenic_training\">Wikipedia<\/a> treatment. A more comprehensive treatment appears in <a href=\"https:\/\/treatmentmaps.net\/?page_id=4258\/#sleepref_linden01\">Linden and Lenz<\/a>. An example autogenic relaxation script appears online in a number of places \u2013 click here for one <a href=\"http:\/\/www.innerhealthstudio.com\/autogenic-relaxation.html\">example<\/a>.<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>24:\u00a0 RELAXATION\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 [Rev 11-12-2017] This appears on Step D1 (Section 44 and Section 45) as one set of techniques for helping people who are agitated or anxious and obsessing at bedtime. It can be of special help when combined with a buffer period (Section 18). There are many ways to relax. A therapist\u2019s job includes &#8230;<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":4020,"menu_order":24,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4045","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/pages\/4045","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=4045"}],"version-history":[{"count":18,"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/pages\/4045\/revisions"}],"predecessor-version":[{"id":4734,"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/pages\/4045\/revisions\/4734"}],"up":[{"embeddable":true,"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=\/wp\/v2\/pages\/4020"}],"wp:attachment":[{"href":"https:\/\/treatmentmaps.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=4045"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}