J. Behav. Ther. & Exp. Psychm. Vol. II, PP. 95-99. Pergamon Pre>\ Ltd., 1980. Printed in Great Britain

GENERALIZATION OF RELAXATION SKILLS

JOHN N. MARQUIS

Veterans Administration Hospital, Palo Alto, California and

Stanford University Medical School

JAMES M. FERGUSON

University of California, San Diego, Medical School

and

Veterans Administration Hospital, San Diego, California

and

C. BARR TAYLOR

Stanford University Medical School, Stanford, California

Summary-A previous publication describes a script for teaching deep muscle relaxation. The present paper describes means of teaching differential relaxation and generalization by instruction and practice in reducing residual tension, relaxing more quickly in various postures, during various activities, and in various places. Then these components are combined in a program to decondition tensions in progressively more difficult situations and to maintain levels of arousal optimal for the activity engaged in.

IMPORTANCE OF GENERALIZATION

TRAINING

Many methods of stress reduction (e.g. Jacob- son, 1928) leave generalization largely to chance. This is not entirely unjustified because Goldfried and Trier (1971) report that 67% of their speech phobic subjects who were taught to relax, but were not instructed to relax before and during speeches, did so on their own initiative. Never- theless, careful shaping of the increasing ap- plication of relaxation responses to everyday situations should greatly improve the effective- ness of training as Goldfried and Trier (1971), Chang-Liang and Denny (1976), and Zeisset (1968) have shown.

RESIDUAL TENSION

To eliminate all residual tension may require considerable effort from therapist and patient.

However, residual tension can function like an ember which if left burning can re-ignite the flames of tension. Once patients have become skilled at relaxation with taped or direct re- laxation instructions, the next step is to teach them to eliminate residual tension without ex- ternal instruction. Often patients can learn to identify and relax tense muscles simply by listen- ing to the instructions five or ten times. When patients are satisfied that they can eliminate all residual tension, the therapist can check their state of relaxation using the following procedure:

First, he observes the patient for any visible signs of tension such as tightened jaw or tense forehead muscles. The patient’s pulse should be slow and regular, and respiration as well. The

patient’s voice should be tension free. Secondly, the therapist tests various muscle

groups: The abdomen is gently prodded with a finger. It should be soft and yielding. With one hand under the patient’s elbow, and the other

Requests for reprints should be addressed to James M. Ferguson, Department of Psychiatry, University of California, San Diego Medical School, San Diego, CA 92093.

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96 JOHN N. MARQUIS, JAMES M. FERGUSON and C. BARR TAYLOR

just short of the wrist, the therapist lifts the patient’s arm, shakes the hand, hinges the elbow, and moves both hands together to rotate the ball and socket joint in the shoulder. This pro- cedure will reveal even a very small level of tension anywhere in the pectoral girdle. Similarly with one hand under the knee, the foot is shaken, the knee hinged, and the ball and socket joint of the hip rotated. If the patient is suspected of moving with the therapist, unexpected changes of direction will detect helping efforts. This is

particularly likely when the head is moved around to check neck muscles because people are used to helping barbers and hairdressers. Individual muscles can be palpated to pinpoint residual tensions. If tension is detected, feedback about muscle tension, and reinforcement often help eliminate it.

INDIVIDUALIZING THE PROGRAM

When the patient has demonstrated that he

can relax completely without the use of tape or instruction, he can then be trained to apply his relaxation skills. If he is a generally relaxed person, tense only in a few specific situations, it may by sufficient to instruct him to try to relax before, during, and after the specific anxiety-arousing situation. Other patients need more detailed instructions and the relaxation generalization program needs to be carefully tailored to their needs. Response to relaxation training is idiosyncratic. Some patients may need many small steps and elaborate programs of repetition, while others master great blocks of the material and dramatically shorten the length of time required to acquire generalization

skills.

INCREASING SPEED AND FREQUENCY

Relaxation, like any motor skill, can be

mastered more rapidly with repetition. Initially this is practiced under the easiest circumstances of low external stimulation and a comfortable position. Later, the technique of massed practice is one way of teaching rapid relaxation. With

this technique the patient alternates relaxation with a non-stressful pursuit such as household chores so that he or she can feel free to stop and relax completely. The patient relaxes deeply, and after a few minutes goes back to an ordinary level of tension, and a few minutes later practices relaxing again. Each time the number of seconds needed to achieve a relaxed state is recorded, and blocks of five or ten trials are averaged. The client can graph these to provide himself feedback and reinforcement about progress.

With another technique, spaced practice, the patient relaxes at set times throughout the day and continually attempts to reduce the amount of time it takes to relax completely. To facilitate this progress, the patient may be given a diary or a three by five card with columns of days and rows of odd or even numbered waking hours. Beginning with the first day the patient notes the amount of time it takes to relax at each hour. He or she is instructed to continue practice until able to relax in less than one minute. Most individuals can learn with these methods to relax on cue in less than one minute.

DIFFERENTIAL RELAXATION

When patients can relax reclining in less than one minute, they can begin to learn to relax some muscles while continuing to use others. To learn differential relaxation, the patient first relaxes deeply in a reclining position. Then he changes to a sitting position and assesses the muscles needed to maintain this posture. He carefully uses the minimal muscle tension needed to sit upright. Then the eyes are opened while continuing to relax. If this creates tension it can be attenuated by opening the eyes for gradual increasing periods of time. The entire procedure is repeated for learning to relax while standing. People are used to having tension in their back and neck muscles to maintain erect posture, and con- sequently most find it difficult to know when these muscles are relaxed or barely tense

GENERALIZATION OF RELAXATION SKILLS 97

enough to maintain their posture. Excess tension can be assessed by relaxing the muscles of the abdominal wall and the front of the neck. After sitting and standing relaxation with eyes open are mastered, the clients practice starting their relaxation in these positions.

At this point the patient is instructed to begin practicing relaxation in a wide variety of places: various rooms, outdoors, at work, public places, etc. Once they can relax in a variety of settings, differential relaxation is practiced during various activities. First the patient passes an object from hand to hand relaxing differentially during actions and deeply between muscular activities. When he can do this, other activities are practiced. An important step is learning to stay relaxed while walking. Once this is mastered, the patient can be instructed to relax while walking throughout the day. Routine daily motor activities are examined for unnecessary tension and these are practiced using the differential relaxation paradigm. This should include frequent activities and those which are components of the patient’s work. For example, a secretary should practice relaxing while typing, a cab driver while driving, a real estate salesman while talking on the phone, etc. At first the relaxation process

may be slow and incomplete. However, as the pattern of differential relaxation is established, the speed can be increased markedly. Since the feeling of hurrying or pressure to move faster often causes tension, the patient is encouraged to participate in relaxing in conditions that include various degrees of pressure.

GENERALIZATION TO DIFFICULT SETTINGS AND ACTIVITIES

Once the patient has learned to relax rapidly, frequently, and differentially, these components of relaxation can be combined in an attempt to help the patient stay relaxed most of the time. Haugen, Dickson and Dickel (1958) devised a method of arranging a patient’s life in an anxiety hierachy for the purpose of desensitizing recurring anxieties by differential

relaxation. The patient is asked to review a typical week, and make a list of various kinds of activities and situations related to tension levels, with a description of their effect on tension level. For example, one patient may indicate that he feels tense when the children are not in bed, when his boss is in the immediate working area, when he is driving to and from work, before going out to dinner, etc. The activities and situations the patient lists are ranked according to how tense he reports feeling in these situations. They are then classified into five or ten anxiety levels. One group of these anxiety provoking situations is approached each week. For example, the first week might involve relaxing while driving and while watching television. The patient will be taught to check his muscles for tension and relax during every commercial on tele- vision, or on the car radio. If he is able to relax during these previously anxiety-provoking situ- ations, the following week another group of activities is added to his “desensitization hierachy”. If he still feels uncomfortable with his original target activities, the goal of relaxing during their presence may be repeated for an additional week or two.

When desensitizing the client to any type of activity, the therapist looks for recurring stimuli in the environment which can be used to cue a relaxation response: a ringing telephone, a striking clock, dogs barking, slamming doors, or mannerisms which are associated with anxiety, such as nail biting, finger tapping, forehead wrinkling, or rapid speech. A very useful variant of this cueing procedure for patients who smoke is to insert a three by five card saying RELAX into their cigarette pack. When they light up a cigarette they are asked to read the word, relax completely, and then

reward themselves by smoking their cigarette. Once the clients have learned to relax using these techniques, it is often easier to help them stop smoking if this is one of their treatment objectives.

A wide variety of stimuli can elicit anxiety. Although Haugen, Dixon and Dickel (1958)

98 JOHN N. MARQUIS, JAMES M. FERGUSON and C. BARR TAYLOR

pointed out many types of environmental In such a case it may be useful to teach the stimuli that have anxiety-provoking qualities, flexing of some unaccustomed muscle rather cognitive processes also can cue, or lead to than one incorporated into a usual anxiety tension. For example, some patients sub- response pattern, so that this response becomes vocalize anxiety-producing thoughts, or re- voluntary and controllable, and terminable hearse angry, worried, depressed, or anxious when no longer needed. At the other end of “Walter Mitty” fantasies. If these patients the spectrum, when an individual is engaged learn to relax when they experience these in a sedentary task for a long period of time, thoughts, and to include relaxation of their the arousal level may drop below an optimal

vocal apparatus with their general relaxation, level for the task at hand. In this case the they can sometimes reduce their general level arousal level must be increased to provide of tension, and eliminate the sub-vocalized optimal learning conditions, and optimal res- thought patterns. At this point, they need not ponse patterns. They can knead a ball in spend more than a few minutes in a bad mood. their hand or do some other simple exercise

to correct this, or in some cases engage in a strenuous exercise for a few minutes to

AROUSAL MANAGEMENT produce a longer lasting physiological arousal pattern.

Patients often express the fear that they will become too relaxed following these exercises and not be able to respond alerty to important MAINTENANCE OF RELAXATION

stimuli. In practice this is rarely a problem. EFFECTS

The relationship between arousal and responsive- Despite the beneficial effects which seem ness was described by Yerkes and Dodson to occur with continued practice of relaxation (1908). They demonstrated in a variety of exercises, many patients begin to decrease the organisms that as physiological arousal increases, frequency of their practice when they begin the cue value of stimuli rapidly increases. to feel better or when their therapist no longer The saliency of the cue slowly reaches a maxi- reminds them to pracice. It is often necessary mum, and begins to decrease as the individual to develop environmental cues which remind becomes tense, and drops to virtually zero when them to relax, for example, circling dates on the patient is panicked. When a person is the calendar, setting their alarm clock to ring frightened or puzzled, he responds by tightening in the evening to remind them to do their muscles to increase arousal. For example, a exercises, booster relaxation therapy on a regular person may grip the steering wheel in response basis from the therapist, or other procedures to seeing a brake light in front on the freeway to encourage continued practice. or wrinkle the brow when something is puzzling.

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more easily once he is freed from some feeling Arousal of tension. His life becomes more pleasant.

Fig. 1. Relationship between arousal and cue value of stimuli. As patients gain the ability to see their problems

RESULTS

If the patient is successful in learning to relax and if he is able to generalize his skill, he often notices a marked change in the quality of his life. Obsessions may decrease in intensity, he becomes more observant of the world around him, and begins to interact

GENERALIZATION OF RELAXATION SKILLS 99

more objectively and calmly, they may find it increasingly easy to solve problems. They may find themselves with increased energy levels, and a heightened sense of competence and well being.

REFERENCES Chang-Liang R. and Denny D. (1976) Applied relaxation

as training in self-control, J. COWIS. Psycho/. 23, 183-189.

Ferguson J. M., Marquis J. N. and Taylor C. Barr (1977) A script for deep muscle relaxation, Dis. Nerv. Cyst. 38.703-708.

Goldfried M. F. and Trier C. S. (1971) Effectiveness of relaxation as an active coping skill, J. Abnorm Psycho/. 83,348-355.

Haugen G. B., Dixon H. H. and Dickel H. A. (1958) A Therapy for Anxiety-Tension Reaction. Macmillan, New York.

Jacobson E. (1928) Progressive Relaxafion. University of Chicago Press.

Yerkes R. M. and Dodson J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation, J. Comp. Neurol. Psycho!. l&459-482.

Zeisset R. (1968) Desensitization and relaxation in the modification of psychiatric patients’ interview behavior, J. Abnorm. Psychol. 23, 18-24.