Behavioral Interventions 265
clinical trials of GAD. In a variety of outcome studies AR produced significant post-
treatment effects for GAD and maintenance of gains over follow-up that equalled cog-
nitive therapy (Arntz, 2003; Borkovec & Costello, 1993; Borkovec, Newman, Lytle, &
Pincus, 2002; Öst & Breitholz, 2000). However, Butler, Fennell, Robson, and Gelder
(1991) found that standard PMR was less effective than cognitive therapy for GAD and
barely more effective than a wait-list control. Moreover D. M. Clark and colleagues
found that cognitive therapy was somewhat superior to AR in the treatment of panic
disorder (D. M. Clark et al., 1994) and clearly superior to AR plus exposure in the
treatment of social anxiety (D. M. Clark, Ehlers, Hackmann, McManus, Fennell et
al., 2006). Öst and Westling (1995), on the other hand, found that CBT and AR were
equally effective in treatment of panic disorder. In summary, it would appear that AR
is an alternative treatment for GAD that can produce results equivalent to cognitive
therapy, but its effectiveness for the other anxiety disorders remains less certain.
table 7.6. applied relaxation treatment protocol
Sessions Intervention Instructions
Session 1 Psychoeducation Explain nature of anxiety, rationale for AR, graduated
homework in identifying and recording symptoms of
an x iet y.
Sessions 1–4 14-muscle PMR Complete body relaxation based on the 14-muscle
PMR protocol of Wolpe & Lazarus (1966). Twice daily
homework practice assigned.
Sessions 5–6 Release-only relaxation Teach relaxation of muscle groups directly without
tension instructions. Reduce relaxation induction time to
5–7 minutes. Takes 1 or 2 sessions with daily homework
practice.
Sessions 6–7 Cue-controlled relaxation Purpose is to create conditioned association between word
“relax” and the relaxation state. Focus is on controlled
breathing, relaxation induced via release-only method, and
repeated pairing of subvocalization of word “relax” with
every exhale. Homework practice assigned for 1–2 weeks.
Sessions 8–9 Differential relaxation Purpose is to teach individuals to relax in other situations
such as seating at a desk or walking and to remove tension
from muscles not in use for an activity.
Sessions 10 Rapid relaxation Teach client to relax in 20–30 seconds in multiple
nonstressful daily situations by controlled breathing,
think “relax,” and scan body for tension and release by
relaxation.
Sessions 11–13 Application training Brief exposure (10–15 minutes) to wide range of in vivo
anxiety-arousing situations, physical sensations (i.e.,
hyperventilation, physical exercise), or imagery in order to
practice applying relaxation as coping response to anxiety.
Sessions 14–15 Maintenance program Client encouraged to scan body at least daily and use rapid
relaxation to get rid of any tension. Differential and rapid
relaxation to be practiced twice a week on a regular basis.