13a) Other CBT techniques

Question 1

What happens to our breathing when our alarm systems are turned on?

Answer 1

• increased breathing because body wants to ready itself for high level of motor activity (fight or flight)
• Floow brain and body with oxygen through blood flow

Question 2

When automatic down-regulation is dysfunctional or persistent high stress can result in:

Answer 2

• High resting levels of breathing (a la stuck gear)
• As a result of false alarm (PD) or true alarm (PTSD)

Question 3

Describe breathing physiology

Answer 3

• Need both O2 and CO2
• If alarm is accompanied by motor activity – balance is preserved

Question 4

What happens when we over-breathe?

Answer 4

• leads to low levels of CO2 in blood -> many symptoms
  o Dizziness, light-headedness, shortness of breath, belching, dry mouth, weakness, confusion, numbness and tingling, muscle spasms in hand and feet, chest pain and palpitations, sleep disturbances

Question 5

How do we solve having low levels of CO2 in blood (e.g., due to overbreathing) (3; 1)

Answer 5

Take in less O2 by
* Slowing down breathing OR
* Breathe through one nostril/straw
* Breathing through nose – take in less air than taking from mouth

Breathe in more CO2
* e.g., breathe into brown paper bag

Question 6

Why do we do breathing retraining?

Answer 6

• Most systems are not under voluntary control – but breathing is
• Because systems are inter-linked, upward/downward regulation often affects other systems

Question 7

Describe a calming breathing technique.

Answer 7

o Ensure that you are sitting on a comfortable chair
o Take a breath in for 3 seconds (through your nose if possible)
o Hold the breath for 1 seconds
o Release the breath taking 4 seconds (through your mouth if possible)
7.5 bpm = breaths per min

Question 8

What is a normal breathing rate?

Answer 8

10-12 breaths per minute

Question 9

What would a daily record of breathing rate look like?

Answer 9

• Monitor breathing at the times shown (10am, 2pm, 7pm)
• try to be sitting or standing quietly when you count your breathing. don’t alter breathing when youre counting
• breathing exercise: one hand on tummy, one hand on chest. breathe through nose and out through mouth. jaw relaxed, breathe low and slow. Do for approx 5 mins, 3 times a day
  1) monitor breathing rate
  2) practice the breathing exercise
  3) monitor your breathing rate again

Question 10

List applications for breathing retraining. (4)

Answer 10

o Conditions a/w high resting levels of arousal
 Anxiety
 Sleep management and sleep hygiene
 Anger (see textbook)

Question 11

Provide rationale for relaxation training (6)

Answer 11

• Mechanisms and effects: grounded in ANS physiology
  o Tries to reduce tonic arousal to basal levels
  o Phasic arousal: specific shifts from basal levels
   Threat cue (thoughts/image)
• Widely researched, especially through psychophysiology (EDA, HR, EMG, EEG)
• ANS activation akin to a gear in car
  o Low to high
• Evidence that high levels of tonic arousal in many anxiety disorders (exception spec phobias)
• Prolonged high arousal levels
  o Can increase likelihood of panic attacks
  o Secondary problems on concentration, sleep, mood, judgment, fatigue levels, etc.

Question 12

Describe relaxation procedure (9)

Answer 12

What it is not
* An SOS medication (Not a short-term strategy)
* Quick strategy and immediate effects

What it is
* Relaxation is a skill
 Relaxation grabs a hold of the gear and drops it down for a period of time
 Tonic arousal WILL go back up after inducing relaxation, but it takes time to increase
* Requires time/practice for effects to accrue
* Relaxation is a long term preventative coping strategy

If you teach a person to relax really well, gives them to skill to drop gears and take control of their tonic arousal
* The brain learns – over time, the gear stays low, and might stabilise at a low level

People respond differently to different types of relaxation

Question 13

What are the different types of relaxation procedures? (6)

Answer 13

o Progressive muscle relaxation
o Imaginal relaxation
o Sound relaxation
o Tactile relaxation
o Breathing retraining
o Body scanning

Question 14

Indications of relaxation procedure. (4)

Answer 14

• To drop heightened arousal levels for a short period, on a regular basis
• Prevent, in long term, adverse consequences of sustained arousal (eg. Panic, stress- related problems)
• Teach skills to recognize early signs of anxiety and reduce unhealthy response pattern before it escalates
• As the first step towards developing a portable technique that can be used in anxiety provoking situations

Question 15

What does the research say about relaxation? (4)

Answer 15

• Proven efficacy in a wide variety of conditions, relative to placebo controls
  o Anxiety conditions
  o Anger control
  o Stress
  o Sleep problems
  o Pain conditions
  o Psychosomatic conditions where anticipatory anxiety is an important factor
• Relaxation does more than reduce muscle tension:
  o Decreases HR, BP, etc.
• Therapist-aided relaxation better than tape in a few studies.
• Some clients are unlikely to benefit from standard relaxation procedures.
  o E.g., PTSD

Question 16

What does the research say about meditation? (4)

Answer 16

• Experienced meditators are “healthier” than nonmeditators.
• Four to ten weeks of meditation improve performance on a wide range of tests.
• Regular meditation is associated with greater decrements in psychopathology relative to a control group of nonmeditators.
• Relieves symptoms (not necessarily a complete cure) in a wide variety of conditions including pain, sleep, anxiety, phobic, drug and alcohol conditions.

Question 17

What is involved in preparation for relaxation procedure? (2; 2)

Answer 17

Assessing client suitability.
* Rule out physical problems that might be affected by procedure.
E.g., Breathing problems, Emphysema, Surgeries, Pain problems
* Clarify previous experience with hypnosis.

Other issues
* Use of touch: ethical and client preparedness issues
* Choice of posture, venue, time

Question 18

Identify variants of relaxation procedures. (6)

Answer 18

• audiotapes
• Most-researched in past is JPMR (tense-relax) and variants (e.g., Ost’s Applied Relaxation)
• More recently: meditation techniques and mindfulness- based relaxation procedures have become popular and show positive effects
• Mental realxations (Comparative efficacy of mental vs. physical relaxations (equivocal results))
• Physical relaxations
• Varying lengths: can be long –> short methods (make it more portable)

Question 19

What does tailoring relaxation procedures to individual need?

Answer 19

Research on response specificity.

Question 20

What needs to be considered when utilising audiotapes for relaxation procedures? (4)

Answer 20

o Important to let subject know to keep own pace of breathing
o Varied tastes among subjects concerning voice quality, music, associations, so best that tapes are tailored for individuals, especially those:
 specific needs (e.g,,tension headaches)
 Finicky and meticulous persons
o Record a tape if necessary

Question 21

What does client need to do for relaxation procedures? (4)

Answer 21

• Differentiate between tense-relax
• Differentiate between muscle groups and selectively exercise one group at a time
• To enhance awareness/mindfulness, client needs to “Watch” the muscle wind up and relax
• So pace of “relax” component should be slow enough for ct to notice the difference

Question 22

Identify types of applied relaxation. (7)

Answer 22

o Progressive Relaxation
o Relax Only Stage
o Cue-controlled relaxation
o Differential relaxation (generalise when conducting other activities
o Rapid relaxation
o Application training
o Maintenance program

Question 23

Outline the procedure for applied relaxation. (5; 3; 4; 3; 3; 4; 3)

Answer 23

• Stage 1: Progressive Relaxation
  o 20 minutes, 3-4 sessions
  o i) Hands, Arms, Face, Neck, Shoulders
  o ii) Back, Chest, Stomach, Breathing, Hips, Legs, Feet
  o Posture: Seated on comfortable chair
  o Practice 2 x daily, monitor efficacy
• Stage 2: Relax only stage
  o 7 minutes; 1-2 weeks
  o Release only: all muscles in sequence
  o Tense-relax …particular muscle groups if needed
• Stage 3: Cue-controlled relaxation
  o Couple of minutes, 1-2 weeks
  o Watch breathing pattern
  o Prompts: inhale …relax (few times)
  o Client prompts, thinks it. Repeat steps
• Stage 4: Differential Relaxation
  o 1-2 Sessions, 60-90 seconds
  o Begin with Stage 3 while client is seated
  o Initiate movements while client maintains relaxation
• Stage 5: Rapid Relaxation
  o Relax in natural, non-stressful situations
  o 15-20 times daily (1-2 weeks)..20-30 seconds
  o Stimulus cue to prompt relaxation (clock, telephone, etc)
• Stage 6: Application training
  o Relaxing in stressful situations
  o Brief exposure (10-15 minutes)
  o Large array of anxiety arousing situations
  o Less ambitious goals as exposure therapy (coping)
• Stage 7: Maintenance program
  o As preventative measure
  o Rapid relaxation daily
  o Differential relaxation twice weekly

Question 24

What are the 2 main stages when it comes to utilising applied relaxation as an intervention?

Answer 24

Client to first learn how to do it, and check if it’s effective
Then, need to learn to be more efficient at achieving relaxation

Question 25

How to terminate a relaxation session? (6)

Answer 25

• Draw clients awareness to where the person is.
• Draw client’s awareness to specific stimuli (weight on chair, voice) .
• Get the client to do a specific thing (stretch, wiggle fingers, count backwards etc.).
• Instruct client to open eyes.
• What to do if client appears non-responsive.
• End with a positive suggestion.

Question 26

How to enhance a good response with relaxation? (4)

Answer 26

• Procedures to enhance relaxation
  o Use of imagery (multi-sensory imagery)
• Briefer relaxation procedures
• Procedures to generalize effects to real-life situations
  o Differential & isometric relaxation
• Modify procedures to fit individual’s anxiety experience

Question 27

What are some possible problems when utilising relaxation procedures? (10)\

Identify solutions where possible

Answer 27

• Physical (Medical problems, pain)
  o Use an alternative method
• Poor outcomes in past
  o Assess - consider alternative relaxation method
  o Good initial response –> poor generalisation –> Relaxation becomes a “safety behaviour”
• Cognitive (Beliefs)
  o Unhelpful assumptions about relaxation or its consequences
  o Control is the problem not the solution (ACT)
   Use cognitive therapy to identify barriers and reduce resistance
• Compliance
• Misconceptions
  o Not a magical procedure where details need to be accurate
• Anxiety sensitivity and misappraisal
  o Relaxation induced anxiety & panic
• Reinforcing need to control emotions and negative affect when control is the problem!
• Induces sleep
  o Positive: reducing ANS arousal
  o Negative: inadequate skills-acquisition
• Personality Issues (e.g., OCPD, BPD)
  o Standard relaxation might not be as effective with these personalities
• State Issues
  o Hypervigilance (PTSD, other severe conditions)
  o Agitation, restlessness (OCD, BPD)

**Solutions:
 Shape behaviour to ensure pre-requisites of relaxations are met
 Some meds may help **

• Distractions
  o Distracting thoughts are not the problem
  o Client’s appraisal and response is key
   Anxiety sensitivity and catastrophic thinking
   Self-disparagement

**o Solution: interoceptive exposure, mindfulness, cognitive therapy **

• Are we too obsessed with relaxation training and correct procedures?
• Are we encouraging “control” when control may actually be the problem?
   Sometimes control is an underlying problem
   Sometimes it is not (e.g., pain, ANS physiology)

Possible solutions
* Shorter form
* Breathing retraining
* Different type of relaxation

Question 28

Summarise relaxation.

Answer 28

• Be clear about rationale of and outcomes you want from relaxation
• Relaxation is a skill
• Be aware of triggers that raise or reduce anxiety /relaxation for Client and tailor procedure for the individual
• Be clear about indications for relaxation programs vs. technique
• Identify barriers/constraints; work around them
• Problems: Analyse, assess, resolve
• Be alert to relaxation becoming an avoidance strategy/safety behaviour
• In general
  o Concerns about details often unwarranted
  o Use time efficient strategies first (e.g., group, self- taught procedures)
  o Use valuable therapy time only if necessary