Cognitive behavioral therapy (CBT)

Related Terms

Abbreviated progressive muscle relaxation therapy, APRT, autogenic training, behavioral techniques, Benson's "relaxation response", biofeedback-assisted relaxation, breath therapy, chosen relaxation, cognitive behavioral therapy (CBT), conscious relaxation, functional relaxation, guided relaxation, hypnotic music, imagery, J. H. Schultz, Jacobson's progressive, Laura Mitchell approach, meditation passive relaxation, mind-body medicine, muscle relaxation techniques, musical relaxation therapy, progressive muscle relaxation, progressive relaxation, psychomotor therapy programs, Qi gong, relaxation coping, relaxation exercises, self-hypnosis, Soong (Mandarin), visualization.

Background

Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually nondirected relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), using a passive attitude towards intruding thoughts, and return to the focus.
Deep and brief methods exist. Deep methods include autogenic training, progressive muscle relaxation (PMR), and meditation (although meditation is sometimes distinguished from relaxation based on the state of "thoughtless awareness" that is said to occur during meditation). Brief methods include self-control relaxation, paced respiration, and deep breathing. Brief methods generally require less time and often represent an abbreviated form of a deep method. Other relaxation techniques include guided imagery, deep breathing, breathing control, passive muscle relaxation, and refocusing. Applied relaxation involves imagination of relaxing situations with the intention of inducing muscular and mental relaxation. Another popular technique is progressive relaxation, in which the individual is taught what it feels like to relax by comparing relaxation with muscle tension. Progressive muscle relaxation (PMR) is said to require several months of practice at least three times per week in order to be able to evoke the relaxation response within seconds. Relaxation technique instruction is available in many hospitals, in the community, in books, or on audiotapes or videotapes.
The term "relaxation response" was coined by Harvard professor and cardiologist Herbert Benson, MD in the early 1970s to describe the physiologic reaction that is the opposite of the stress response. The relaxation response is proposed to involve decreased stimulation of the nervous system, as well as increased parasympathetic activity (urination, digestion, and other activities that occur when the body is at rest) characterized by lowered heartbeat, muscle, and skeletal function, and altered interactions between the nervous and endocrine systems.
Relaxation techniques may be taught by complementary practitioners, physicians, psychotherapists, hypnotherapists, nurses, clinical psychologists, or sports therapists. There is no formal credentialing for relaxation therapies.
Clinical studies suggest that relaxation techniques may be beneficial in patients with anxiety, although these approaches do not appear to be as effective as psychotherapy. For conditions with a strong psychosomatic element, relaxation may be beneficial, although it is not clear if the effects are long-term. Relaxation techniques may be used for stress management using self-regulation (self-control). There is not enough evidence to form firm conclusions about the effectiveness of relaxation for any condition. However, relaxation has been studied with respect to depression, pain, behavior, blood pressure lowering, etc. It has also been studied in patients with irritable bowel syndrome. Relaxation techniques are sometimes used by people with insomnia or other sleep disorders.

Theory

In situations of stress, there is increased activity of the sympathetic nervous system, which leads to the "fight or flight" response. Physiologic changes include increased heart rate, blood pressure, rate of breathing, blood supply to the muscles, and dilation of the pupils. It has been proposed that frequent stressful situations may lead to negative effects on health, such as high blood pressure, raised cholesterol levels, gastrointestinal distress, or depression of the immune system.
In contrast to the stress response, relaxation is characterized by decreased stimulation of the nervous system, as well as increased parasympathetic activity (urination, digestion, and other activities that occur when the body is at rest). This may include decreased metabolism, blood pressure, oxygen consumption, and heart rate, as well as a feeling of calmness. Increased brain wave slow-wave activity (measured on EEG) has been reported. Alterations in the immune system may also play a role.
It has been theorized that by learning how to self-initiate the relaxation response, the negative effects of chronic stress may be counterbalanced. There are some reports that, with practice, states of relaxation can be achieved after several seconds. Massage, deep meditative states, mind-body interactive techniques, and certain types of music and sounds have been suggested as means of establishing a state of relaxation. Rhythmic, deep, visualized, or diaphragmatic breathing may be practiced. Mental imagery, biofeedback, desensitization, cognitive restructuring, and adaptive self-statements may also be included in such techniques.
Jacobson muscle relaxation, or "progressive relaxation," involves flexing specific muscles, holding that position, then relaxing the muscles. This technique often involves progressing through the muscle groups of the body one at a time, beginning with the feet, spending approximately one minute on each area. Progressive relaxation may be practiced while lying down or sitting. This approach has been suggested for psychosomatic disorders, for pain relief, to ease physical tension, or to relieve "inner unrest."
The Laura Mitchell approach involves reciprocal relaxation, moving one part of the body in the opposite direction from an area of tension, and then letting it go.
No formal credentialing or licensure exists for these relaxation techniques. Courses are offered at institutions such as the National Institute for Clinical Applications of Behavioral Medicine (NICBM), the American Holistic Medical Association (AHMA), and the Center for Mind-Body Medicine (CMBM).
According to Dr. Herbert Benson, who coined the term "the relaxation response," relaxation has been shown to decrease oxygen consumption and carbon dioxide output, to decrease the rate of breathing, to slightly increase oxygen levels in the blood, to decrease blood lactate levels (an indicator of stress), and to increase oxygen consumption during sleep.

Evidence Table

These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. GRADE *
These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. GRADE *


One study failed to demonstrate any effects of relaxation therapy on aggression. More well-designed trials are needed.

 C


One study failed to demonstrate any effects of relaxation therapy on aggression. More well-designed trials are needed.

 C


Early research in patients with angina has reported that relaxation may reduce anxiety, depression, the frequency of angina episodes, the need for medication, and physical limitations. Large, well-designed studies are needed to confirm these results.

 C


Early research in patients with angina has reported that relaxation may reduce anxiety, depression, the frequency of angina episodes, the need for medication, and physical limitations. Large, well-designed studies are needed to confirm these results.

 C


Numerous human studies have reported that relaxation techniques (for example, using audiotapes or group therapy) may moderately reduce anxiety, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias (such as agoraphobia), panic disorders, work-related stress, and anxiety (due to serious illnesses, prior to medical procedures, or during pregnancy). However, because there are many types of relaxation techniques used in studies, and because many trials do not clearly describe design or results, a strong recommendation cannot be made without better human evidence.

 C


Numerous human studies have reported that relaxation techniques (for example, using audiotapes or group therapy) may moderately reduce anxiety, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias (such as agoraphobia), panic disorders, work-related stress, and anxiety (due to serious illnesses, prior to medical procedures, or during pregnancy). However, because there are many types of relaxation techniques used in studies, and because many trials do not clearly describe design or results, a strong recommendation cannot be made without better human evidence.

 C


Preliminary studies of relaxation techniques in individuals with asthma have reported a significant decrease in asthma symptoms, anxiety, and depression, along with improvements in quality of life and measures of lung function. Further large trials in humans are needed to confirm these results.

 C


Preliminary studies of relaxation techniques in individuals with asthma have reported a significant decrease in asthma symptoms, anxiety, and depression, along with improvements in quality of life and measures of lung function. Further large trials in humans are needed to confirm these results.

 C


One study failed to demonstrate any effect of relaxation therapy on attention-deficit hyperactivity disorder. More well-designed trials are needed.

 C


One study failed to demonstrate any effect of relaxation therapy on attention-deficit hyperactivity disorder. More well-designed trials are needed.

 C


Early research of relaxation techniques in people who have had a heart attack suggests that fewer future heart attacks may occur when relaxation is regularly practiced. Relaxation techniques have been associated with reduced pulse rate, systolic blood pressure, and diastolic blood pressure; lower perception of stress; and enhanced perception of health. Further research is needed to confirm these results.

 C


Early research of relaxation techniques in people who have had a heart attack suggests that fewer future heart attacks may occur when relaxation is regularly practiced. Relaxation techniques have been associated with reduced pulse rate, systolic blood pressure, and diastolic blood pressure; lower perception of stress; and enhanced perception of health. Further research is needed to confirm these results.

 C


One study failed to show that relaxation techniques may be helpful in treating chronic fatigue syndrome. More research is necessary before a firm conclusion can be drawn.

 C


One study failed to show that relaxation techniques may be helpful in treating chronic fatigue syndrome. More research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating chronic obstructive pulmonary disease. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating chronic obstructive pulmonary disease. Better-quality research is necessary before a firm conclusion can be drawn.

 C


There is conflicting evidence from human trials supporting the use of relaxation to reduce symptoms of depression. Better-quality research is necessary before a firm conclusion can be drawn.

 C


There is conflicting evidence from human trials supporting the use of relaxation to reduce symptoms of depression. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating dyspepsia. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating dyspepsia. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating epilepsy. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Early human trials report that relaxation techniques may be helpful in treating epilepsy. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Relaxation therapy has been investigated as a treatment for radiation-induced fatigue and for aviation-induced fatigue. More well-designed trials are needed.

 C


Relaxation therapy has been investigated as a treatment for radiation-induced fatigue and for aviation-induced fatigue. More well-designed trials are needed.

 C


Relaxation has been reported to reduce fibromyalgia pain. However, results from studies are conflicting, and therefore further research is needed before a clear recommendation can be made.

 C


Relaxation has been reported to reduce fibromyalgia pain. However, results from studies are conflicting, and therefore further research is needed before a clear recommendation can be made.

 C


Preliminary evidence suggests that relaxation techniques may be helpful for the reduction of migraine headache symptoms in adults. Many adults reportedly supplement traditional treatments with relaxation therapy. Research on relaxation in children with headaches has yielded unclear results. Relaxation therapy has been suggested as being helpful in special populations (children, the elderly, pregnant or nursing women) where more traditional migraine prevention medications may not be appropriate. Additional research is necessary before a firm conclusion can be drawn.

 C


Preliminary evidence suggests that relaxation techniques may be helpful for the reduction of migraine headache symptoms in adults. Many adults reportedly supplement traditional treatments with relaxation therapy. Research on relaxation in children with headaches has yielded unclear results. Relaxation therapy has been suggested as being helpful in special populations (children, the elderly, pregnant or nursing women) where more traditional migraine prevention medications may not be appropriate. Additional research is necessary before a firm conclusion can be drawn.

 C


Mental health and quality-of-life improvements have been seen in preliminary studies of HIV/AIDS patients. These findings suggest the need for further, well-controlled research.

 C


Mental health and quality-of-life improvements have been seen in preliminary studies of HIV/AIDS patients. These findings suggest the need for further, well-controlled research.

 C


Preliminary research in patients with Huntington's disease has evaluated the effects of either multisensory stimulation, using relaxation activities as a control. Results were unclear. Further research is necessary before a conclusion can be drawn.

 C


Preliminary research in patients with Huntington's disease has evaluated the effects of either multisensory stimulation, using relaxation activities as a control. Results were unclear. Further research is necessary before a conclusion can be drawn.

 C


Several human trials suggest that relaxation techniques may be beneficial in people with insomnia, although the effects appear to be short-lived. Research suggests that relaxation techniques may produce improvements in some aspects of sleep, such as sleep latency and time awake after sleep onset. Cognitive forms of relaxation, such as meditation, are reported as being slightly better than somatic forms of relaxation, such as progressive muscle relaxation (PMR). Well-conducted research is necessary before a firm conclusion can be drawn.

 C


Several human trials suggest that relaxation techniques may be beneficial in people with insomnia, although the effects appear to be short-lived. Research suggests that relaxation techniques may produce improvements in some aspects of sleep, such as sleep latency and time awake after sleep onset. Cognitive forms of relaxation, such as meditation, are reported as being slightly better than somatic forms of relaxation, such as progressive muscle relaxation (PMR). Well-conducted research is necessary before a firm conclusion can be drawn.

 C


Early research in humans suggests that relaxation may aid in the prevention and relief of irritable bowel disease symptoms. Large, well-designed trials are needed to confirm these results.

 C


Early research in humans suggests that relaxation may aid in the prevention and relief of irritable bowel disease symptoms. Large, well-designed trials are needed to confirm these results.

 C


There is promising early evidence from human trials supporting the use of relaxation techniques to reduce menopausal symptoms,although the effects appear to be short-lived. Better-quality research is necessary before a firm conclusion can be drawn.

 C


There is promising early evidence from human trials supporting the use of relaxation techniques to reduce menopausal symptoms,although the effects appear to be short-lived. Better-quality research is necessary before a firm conclusion can be drawn.

 C


Limited numbers of well-designed trials have examined the effects of relaxation on myocardial infarction outcomes, and the results are mixed. More research is needed.

 C


Limited numbers of well-designed trials have examined the effects of relaxation on myocardial infarction outcomes, and the results are mixed. More research is needed.

 C


A small number of studies on psychotherapy-related approaches, e.g., relaxation therapy, have failed to demonstrate any decisive positive outcomes. Additional research is needed.

 C


A small number of studies on psychotherapy-related approaches, e.g., relaxation therapy, have failed to demonstrate any decisive positive outcomes. Additional research is needed.

 C


In an early study, Jacobson relaxation was reported to lower the level of subjective pain and reduce the need for pain medication in osteoarthritic patients. Further well-designed research is needed to confirm these results.

 C


In an early study, Jacobson relaxation was reported to lower the level of subjective pain and reduce the need for pain medication in osteoarthritic patients. Further well-designed research is needed to confirm these results.

 C


Early research suggests that massage is more effective than relaxation therapy for pain, including postoperative pain and low back pain. Also, the quality of most studies in this field is poor. Better research is necessary before relaxation techniques can be recommended either alone, or as an addition to other treatments, for acute or chronic pain.

 C


Early research suggests that massage is more effective than relaxation therapy for pain, including postoperative pain and low back pain. Also, the quality of most studies in this field is poor. Better research is necessary before relaxation techniques can be recommended either alone, or as an addition to other treatments, for acute or chronic pain.

 C


Limited studies have examined the effects of relaxation for post-traumatic stress disorder. More research is needed.

 C


Limited studies have examined the effects of relaxation for post-traumatic stress disorder. More research is needed.

 C


There is early evidence that progressive muscle relaxation (PMR) training may improve physical and emotional symptoms associated with PMS. Further research is necessary before a conclusion can be drawn.

 C


There is early evidence that progressive muscle relaxation (PMR) training may improve physical and emotional symptoms associated with PMS. Further research is necessary before a conclusion can be drawn.

 C


Studies suggest that relaxation therapy may have positive effects on preventing premature labor and hypertension. More well-designed trials are needed.

 C


Studies suggest that relaxation therapy may have positive effects on preventing premature labor and hypertension. More well-designed trials are needed.

 C


Limited preliminary research reports that muscle relaxation training may improve function and well-being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached.

 C


Limited preliminary research reports that muscle relaxation training may improve function and well-being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached.

 C


Limited research has been conducted examining the effects of relaxation therapy alone in improving skin conditions. Well-designed trials are needed.

 C


Limited research has been conducted examining the effects of relaxation therapy alone in improving skin conditions. Well-designed trials are needed.

 C


Early research suggests that use of an occlusal appliance is more effective than relaxation therapy for relief from temporomandibular disorders. More well-designed trials are needed.

 C


Early research suggests that use of an occlusal appliance is more effective than relaxation therapy for relief from temporomandibular disorders. More well-designed trials are needed.

 C


Relaxation therapy has been associated with benefits in preliminary studies of tinnitus patients. Further research is needed to confirm these results.

 C


Relaxation therapy has been associated with benefits in preliminary studies of tinnitus patients. Further research is needed to confirm these results.

 C


Limited evidence suggests a lack of benefit for relaxation therapy in Tourette's syndrome. More well-designed trials are needed.

 C


Limited evidence suggests a lack of benefit for relaxation therapy in Tourette's syndrome. More well-designed trials are needed.

 C


There is a lack of evidence reporting the effects of relaxation therapy on upper respiratory tract infections in children. Well-designed trials are needed.

 C


There is a lack of evidence reporting the effects of relaxation therapy on upper respiratory tract infections in children. Well-designed trials are needed.

 C


Studies assessing relaxation to improve psychological well-being and "calm" in patients have reported positive results, although the results of most trials have not been statistically significant. Although this research is suggestive, additional work is merited in this area before a firm conclusion can be drawn.

 C


Studies assessing relaxation to improve psychological well-being and "calm" in patients have reported positive results, although the results of most trials have not been statistically significant. Although this research is suggestive, additional work is merited in this area before a firm conclusion can be drawn.

 C
* Key to grades

A: Strong scientific evidence for this use
B: Good scientific evidence for this use
C: Unclear scientific evidence for this use
D: Fair scientific evidence for this use (it may not work)
F: Strong scientific evidence against this use (it likley does not work)
* Key to grades

A: Strong scientific evidence for this use
B: Good scientific evidence for this use
C: Unclear scientific evidence for this use
D: Fair scientific evidence for this use (it may not work)
F: Strong scientific evidence against this use (it likley does not work)

Tradition / Theory

The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.

Safety

Many complementary techniques are practiced by healthcare professionals with formal training, in accordance with the standards of national organizations. However, this is not universally the case, and adverse effects are possible. Due to limited research, in some cases only limited safety information is available.

Attribution

This information is based on a systematic review of scientific literature edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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