Progressive muscle relaxation

1. Introduction

Version followed: Bernstein & Borkovec's abbreviated Progressive Relaxation Training (PRT; 1973 manual, revised as Bernstein, Borkovec & Hazlett-Stevens, 2000): 16 muscle groups, then 7, then 4, then recall, recall with counting, and counting alone, over about 10 sessions. Jacobson's original method, Wolpe's shortening and the gentler German variants (Krampen, 2012) are described where they differ.

Progressive muscle relaxation (PMR) is a learned self-regulation skill, not a therapy for one disorder. The client tenses a muscle group, releases it, and attends to the contrast between the sensations of tension and of letting go. Edmund Jacobson, a physician, developed the method from about 1908 and set it out in Progressive Relaxation (1929; 2nd ed. 1938). Joseph Wolpe shortened it so it could serve as the anxiety-competing response in systematic desensitisation. Bernstein and Borkovec then standardised a short form that most clinicians now use. [source: Wikipedia PMR; Poppen 2005]

How change happens: the client learns to notice muscular tension they had stopped registering and to release it on purpose. Bernstein and Borkovec liken the process to a pendulum: a firm contraction makes the release, and so the relaxation, deeper. Jacobson saw tensing only as a way to teach the client what tension feels like, and he relied on the client ceasing effort. With practice the client needs less and less tension, and in the end only a recalled sensation, a count or a cue word, to relax quickly in daily life. [source: Spanish textbook chapter summarising Bernstein & Borkovec 1973 (Unizar reading); Poppen 2005] Relaxation is used either on its own (stress, tension, insomnia, pain) or as a component of a larger protocol (systematic desensitisation, applied relaxation, CBT for GAD or insomnia). [source: Poppen 2005; Div. 12 applied relaxation page]

2. Framework

The Bernstein & Borkovec programme reduces training in steps: 16 separate muscle groups are combined into 7 and then into 4 body areas in a fixed order, over about 10 sessions. [source: Poppen 2005] Tensing is then dropped (relaxation via recall), a count is added, and finally counting alone is used. Each stage depends on mastering the one before. [source: Unizar reading summarising Bernstein & Borkovec 1973]

Format. Individual training is the reference format. A reclining chair with full support for head, arms and legs is used, with the eyes closed. [source: Unizar reading] Sessions are usually weekly [uncertain: weekly spacing inferred from common practice]. Group courses are common in Germany; Krampen (2012) ran 7 group sessions of about 15 people, once or twice weekly. Typical totals there were 6–10 sessions of 30–60 min for the 16-group form and 5–7 for an 11-group form. [source: Krampen 2012]

Home practice. Two sessions a day of 15–20 min are treated as essential. Practise when not under time pressure. [source: Unizar reading] Pressure of time and low motivation are the usual barriers. [source: Krampen 2012]

Criteria for moving on [uncertain: the exact criteria are in Bernstein & Borkovec 1973 and Bernstein et al. 2000; the following reflects the mastery principle the sources describe, operationalised as synthesis]:

• The client reaches deep relaxation in every group in session, without signalling residual tension, or only after one extra cycle.
• Home practice is regular (most days, ideally twice) and the client reports reaching relaxation at home.
• If either fails, stay at the current stage for another session rather than moving on to the next step. If recall fails for a group, go back to tension-release for that group only. [synthesis]

Jacobson's original structure (for contrast). Jacobson isolated single muscle actions (for example bending back one hand) and worked through scores of muscle groups. The client lay down, tension was faint, and the client simply stopped the effort. Training ran to dozens of sessions over many months, with daily practice. [source: Poppen 2005; Wikipedia PMR] Wolpe combined groups (for example all five fingers at once), which cut training to a few sessions, and added suggestion. [source: Poppen 2005; Krampen 2012]

3. Guiding principles

• Relaxation is a skill, not a treatment done to the client. Present it as something the client learns and practises, like a sport. Progress depends on practice, not on the therapist's voice. [source: Unizar reading; Poppen 2005]
• The core learning is discrimination. Every cycle is there to sharpen the client's ability to notice tension and its absence. Keep directing attention to the sensations. [source: Unizar reading; Wikipedia PMR]
• Tension serves contrast; it should never hurt. Bernstein & Borkovec ask for firm, all-at-once contraction. Jacobson used minimal tension. German guidance (DG-E, via Krampen) now advises against intense tensing because it can leave lasting tension or pain. In practice, ask for firm but not maximal tension, and less for any painful or injured area. [source: Unizar reading; Krampen 2012; Wikipedia PMR]
• Release all at once. The release is sudden, not gradual. Gradual letting go is a different, later skill. [source: Unizar reading]
• Relaxation phases are much longer than tension phases. Use 5–7 s of tension and 30–40 s of relaxation (Bernstein & Borkovec). Krampen gives a ratio of 1:3–4. [source: Unizar reading; Krampen 2012]
• Patter is indirect and descriptive, not hypnotic. Describe sensations and invite the client to notice them. Do not command states. Jacobson rejected suggestion altogether. [source: Unizar reading]
• Voice matches the phase. Use a crisper, firmer voice for tension instructions and a slower, softer one during release. [source: Unizar reading]
• The client stays in control. Agree a non-verbal signal, let the client open their eyes or stop at any time, and adapt any instruction that hurts. [synthesis; consistent with Wikipedia PMR safety note]
• Keep the standard sequence and timing. Keep the order fixed so the routine becomes automatic and practice can be checked. [source: Poppen 2005]
• Progress by mastery, not by session number. Each reduction step (16→7→4→recall→counting) depends on success at the one before. [source: Unizar reading]
• Daily home practice is part of the treatment. Without it, training is unlikely to work. Plan when, where and how practice will happen. [source: Unizar reading; Krampen 2012]
• The aim is portability. The end goal is fast relaxation used in daily life (counting, differential relaxation, cue words, applied use), not only a 20-minute ritual. [source: Unizar reading; Freidenberg & Blanchard 2005]
• Live training first, recordings as a supplement. Live training lets you adjust timing and troubleshoot. Use recordings to support home practice, not to replace training. [uncertain: research comparing live with taped training (Borkovec & Sides 1979)]

4. Intervention inventory

Sources for this section: the core procedure (tension and release timings, signal words, voice, the 16/7/4 sequence, the count-out, home practice) comes from a Spanish textbook chapter that summarises Bernstein & Borkovec (1973) (Unizar reading), checked against Poppen (2005) and Krampen (2012). The Bernstein manuals themselves (1973; 2000) are not drawn on here. Details that rest only on general knowledge of those manuals are marked [uncertain]. All example wording is illustrative.

4.1 Assessment and suitability check

• Purpose / when: Before training, decide whether PMR fits the target problem and whether any body areas need adapting. [synthesis]
• Steps:
  1. Clarify the target, for example general tension, worry, sleep onset, tension headache, or a coping skill inside a wider CBT plan. [synthesis]
  2. Ask about injuries, pain, recent surgery, arthritis, cramps, pregnancy, and cardiovascular or respiratory problems. Anyone with an injury should get medical advice first. Plan to skip or soften the tension step for affected areas. [source: Wikipedia PMR; Krampen 2012]
  3. Ask about past reactions to relaxation, meditation or hypnosis, including feeling anxious, unreal or out of control while relaxing. Ask about trauma cues linked to closing the eyes, lying back or body focus. [synthesis; see 5.6]
  4. Agree how progress will be measured, for example a 0–100 tension rating before and after each practice, a practice log, or a symptom diary. [synthesis]
• Example language (illustrative): "Before we start, are there any parts of your body that are injured, painful or easily cramped? We'll go gently there, or skip tensing altogether."
• Watch for: Unrealistic expectations, for example that relaxation will remove all anxiety. Medical symptoms presented as tension that have not been assessed. [synthesis]

4.2 Presenting the rationale

• Purpose / when: Session 1, before any exercise. Builds credibility and frames the method as skill learning.
• Steps:
  1. Explain that many people carry muscle tension they no longer notice, and that tension and anxious arousal feed each other. [source: Wikipedia PMR; Unizar reading]
  2. Explain the procedure: tense a group firmly, hold briefly, release all at once, and attend to the contrast. The pendulum image helps: a firm contraction lets the release swing further into relaxation. [source: Unizar reading]
  3. Stress that this is a learned skill: it needs daily practice, and later it will become quicker and need no tensing. [source: Unizar reading; Poppen 2005]
  4. Tell the client that the therapist does not do the relaxing. The client does it, and is in charge throughout. [synthesis]
  5. Invite questions and doubts. [synthesis]
• Example language (illustrative): "What you'll learn here is a skill, a bit like learning to swim. First you learn to notice tension clearly. Then you learn to let it go. Over a few weeks you'll be able to do it faster, without tensing at all."
• Watch for: The client hearing "you're doing it wrong if you're tense"; scepticism ("I already know how to relax"); fear of losing control. Address these before starting. [synthesis]

4.3 Preparing the setting, posture and signals

• Purpose / when: Every in-session training.
• Steps:
  1. Use a quiet, dim room and a reclining armchair that supports the head, arms and legs. If none is available, use a high-backed chair with armrests. [source: Unizar reading] Jacobson used a lying position. [source: Poppen 2005]
  2. Ask the client to loosen tight clothing, remove glasses or contact lenses if wished, and settle into a comfortable position. [uncertain: standard in the manual]
  3. Agree a non-verbal signal, for example raising a finger of one hand, for "I still feel tension here" or "I am relaxed". Then you can check without the client having to talk. [uncertain: the exact signal convention of the manual was not verified]
  4. Tell the client to keep movement and talking to a minimum. They may change position, open their eyes or stop at any time. [synthesis]
  5. Ask the client to close their eyes when ready. Closing the eyes is optional for anyone uncomfortable with it (see 5.6). [source: Unizar reading; synthesis]
• Example language (illustrative): "If you still notice tension in an area when I ask, just lift a finger of your right hand. You don't need to speak."
• Watch for: Unsupported limbs (they create tension of their own); a cold room; interruptions. [synthesis]

4.4 Demonstration and practice of tensing actions

• Purpose / when: Session 1 (and whenever a new grouping is introduced). Make sure the client can tense each group without involving others.
• Steps:
  1. Describe and demonstrate the tensing action for each group, then have the client try it briefly with eyes open. [source: Unizar reading]
  2. Correct actions that spread tension to other groups, cause pain, or are too weak to notice. [synthesis]
  3. Agree an adapted action, or a no-tension recall approach (4.14), for injured areas. [synthesis]
• Example language (illustrative): "Let me show you how to tense the forehead: raise your eyebrows high. Try it now… good. Notice you can do it without clenching your jaw."
• Watch for: Cramp-prone groups (feet, calves). Use less tension or a shorter hold there. [synthesis]

4.5 The tension-release cycle (core unit)

• Purpose / when: The building block of the 16-, 7- and 4-group procedures.
• Steps [source: Unizar reading summarising Bernstein & Borkovec 1973]:
  1. Direct attention to the muscle group.
  2. Give a pre-arranged signal word (for example "now") for the client to tense the group, all at once rather than gradually.
  3. The client holds the tension for about 5–7 s and attends to the sensations. Meanwhile, describe them briefly in a firmer voice.
  4. Give the release word (for example "relax" or "let go"). The client releases all at once.
  5. Allow 30–40 s of relaxation while you give indirect, descriptive patter in a softer voice (4.7).
  6. Repeat the whole cycle once more for the same group.
  7. Check: ask the client to signal if any tension remains. If so, give another cycle for that group. [uncertain: the exact criterion for extra cycles was not verified]
• Example language (illustrative): "Focus on your right hand and forearm… and now, make a tight fist. Feel the tightness across the knuckles and up the forearm… and relax. Let it go all at once. Notice how the hand feels now, compared with a moment ago."
• Watch for: Gradual release (it will be less clear). Tensing other groups at the same time. Holding the breath for long periods (see 5.10). Pain means less tension. [synthesis]

4.6 The 16-muscle-group procedure

• Purpose / when: Sessions 1 to about 3. The most differentiated learning stage.
• Steps: Run the tension-release cycle (4.5) twice per group, in this fixed order. [source: Unizar reading; Krampen 2012; the tensing actions below follow the commonly published Bernstein & Borkovec list; foot/calf actions vary across secondary reports, so treat them as uncertain]
  1. Dominant hand and forearm: make a fist.
  2. Dominant upper arm: press the elbow down into the chair arm (biceps).
  3. Non-dominant hand and forearm: as 1.
  4. Non-dominant upper arm: as 2.
  5. Forehead: raise the eyebrows.
  6. Upper cheeks and nose: squeeze the eyes shut and wrinkle the nose.
  7. Lower cheeks and jaw: clench the teeth (gently) and pull back the corners of the mouth.
  8. Neck and throat: pull the chin down while pressing the head back against the support, so opposing muscles work against each other.
  9. Chest, shoulders and upper back: pull the shoulders back (shoulder blades together), optionally with a held breath [uncertain].
  10. Abdomen: make the stomach hard.
  11. Dominant thigh: tense the upper-leg muscles against each other.
  12. Dominant calf: pull the toes up toward the face [uncertain].
  13. Dominant foot: point the foot and curl the toes, gently because of the risk of cramp [uncertain]. 14–16. Non-dominant thigh, calf and foot: as 11–13. After the last group, review all groups (4.8), allow a quiet period, then do the count-out (4.9). The whole procedure takes about 20–30 min. [source: Unizar reading]
• Example language (illustrative): "Now move your attention to your forehead… and now, raise your eyebrows as high as they'll go… notice the tightness across the forehead… and relax."
• Watch for: Groups the client cannot tense in isolation (often the shoulders or neck). Groups that stay tense on review. Note these for the home-practice plan. [synthesis]

4.7 Relaxation patter

• Purpose / when: During every release phase and the quiet period. It helps attention stay on the sensations of relaxation.
• Steps:
  1. Use indirect, descriptive phrases ("notice how the muscles feel as they loosen more and more"), not direct hypnotic suggestions. [source: Unizar reading]
  2. Talk about sensations clients commonly report: warmth, heaviness, looseness, smoothness. Offer these as possibilities, not as instructions. [synthesis]
  3. Leave silences. Slow your pace and lower your voice in release phases. Speak more crisply in tension phases. [source: Unizar reading]
• Example language (illustrative): "Just notice what happens in those muscles as they keep letting go… perhaps a sense of looseness, or warmth… whatever you notice is fine."
• Watch for: Talking too much. Telling the client what they must feel ("your arm is now heavy"). Jacobson rejected all suggestion. [source: Unizar reading]

4.8 Checking for residual tension and the review

• Purpose / when: After the sequence (and after any group where you suspect tension remains).
• Steps:
  1. Name each group or area in order and ask the client to signal any remaining tension. [uncertain: the manual's exact review wording was not verified]
  2. Give one more tension-release cycle (or a recall for that area) for any group signalled. [synthesis]
  3. Allow a quiet period (about a minute or two) of enjoying the relaxed state, optionally attending to slow, easy breathing. [uncertain]
  4. Optionally ask for a silent 0–100 relaxation rating, to be reported after the count-out. [synthesis]
• Example language (illustrative): "I'm going to name the areas we've relaxed. If you notice any tension left in an area, lift your finger… hands and arms… face… neck…"
• Watch for: Clients who never signal because they want to please. Check this in the post-session inquiry. [synthesis]

4.9 Termination (count-out)

• Purpose / when: End of every relaxation session. Brings the client back to alertness gradually.
• Steps [source: Unizar reading summarising Bernstein & Borkovec 1973]:
  1. Tell the client you will count backwards from four to one.
  2. Four: move the legs and feet. Three: move the arms and hands. Two: move the head and neck. One: open the eyes, feeling calm and relaxed.
  3. Ask the client to sit for a moment before standing (risk of light-headedness). [synthesis]
• Example language (illustrative): "In a moment I'll count backwards from four to one… Four, gently move your legs and feet… three, your arms and hands… two, your head and neck… one, open your eyes when you're ready."
• Watch for: Dizziness on standing, grogginess, or still feeling drowsy before driving. [synthesis]

4.10 Post-session inquiry

• Purpose / when: Straight after every relaxation run.
• Steps [synthesis; the manual includes a post-relaxation discussion, but its content was not verified]:
  1. Ask how relaxed the client feels overall (rating 0–100) and which areas were easiest and hardest.
  2. Ask about any unusual sensations (tingling, floating, twitches, heaviness) and normalise them.
  3. Ask about intrusive thoughts, sleepiness, discomfort, cramps or anxiety, and plan adjustments (Section 5).
  4. Agree the home-practice plan for the week.
• Example language (illustrative): "What did you notice? Which areas let go easily, and which seemed to hold on?"
• Watch for: Reports of rising anxiety while relaxing (see 5.5). [synthesis]

4.11 Home practice and monitoring

• Purpose / when: After session 1 and throughout. Skill comes from repetition.
• Steps:
  1. Prescribe two practices a day of 15–20 min, at times without pressure. [source: Unizar reading]
  2. Agree the specific times and place: not straight after a large meal, not in bed if the aim is daytime skill, a supported chair. [synthesis; the meal advice also appears on secondary sites]
  3. Give a written list of the groups and actions. Give a log to record date, time, before and after tension ratings, problem areas and comments. [synthesis]
  4. Recordings: one of the therapist's in-session voice can support early home practice. Fade it once the client knows the sequence, so that the client can relax without a voice guiding them. [uncertain: the evidence on live versus taped training (Borkovec & Sides 1979)]
  5. Review the log at the start of every session, problem-solving any missed practice (5.8).
• Example language (illustrative): "When in your day could you guarantee 15 minutes twice where no one will interrupt you?"
• Watch for: Practising only in bed and falling asleep. This can help sleep, but it does not build the skill of relaxing while awake. [synthesis]

4.12 The 7-muscle-group procedure

• Purpose / when: Sessions 4–5 or so, once the 16-group procedure reliably produces deep relaxation. Shortens the procedure while keeping the same depth.
• Steps:
  1. Explain that groups are now combined, and that the client already knows each component.
  2. Use the same cycle as before (4.5): two cycles per group, then the review, quiet period and count-out.
  3. Groups [source: Unizar reading; Poppen 2005; exact boundaries uncertain, because secondary reports differ on whether the neck goes with the face or the shoulders]:
     • dominant arm (fist, with the elbow bent and pressed down);
     • non-dominant arm;
     • face (all facial actions at once);
     • neck and throat;
     • chest, shoulders, upper back and abdomen;
     • dominant leg (thigh, calf and foot);
     • non-dominant leg.
• Example language (illustrative): "This time we'll tense the whole right arm at once: make a fist, bend the elbow slightly and press it down… now…"
• Watch for: Loss of depth compared with 16 groups. If one combined group stays tense, split it out again for a session. [synthesis]

4.13 The 4-muscle-group procedure

• Purpose / when: Sessions 6–7 or so, after mastery of the 7-group form.
• Steps:
  1. Same cycle (4.5) with four areas: both arms together; face and neck; chest, shoulders, back and abdomen; both legs and feet. Some clients need the legs done one at a time. [source: Unizar reading]
  2. Review, quiet period, count-out as before.
• Example language (illustrative): "Now both arms together: make two fists, bend the elbows and press them down… now… and relax."
• Watch for: Rushing the release phases now that the procedure is shorter. Keep the 30–40 s of relaxation. [source: Unizar reading for timing; synthesis]

4.14 Relaxation via recall

• Purpose / when: About session 8, after the 4-group form is mastered. Removes the tensing step so relaxation can be done anywhere unobtrusively. [source: Unizar reading; Wikipedia PMR (recall as a Bernstein & Borkovec variant via McCallie 2006)]
• Steps [uncertain: the manual's chapter on recall (described in Spanish chapter 7); steps reconstructed from the described principle]:
  1. Ask the client to focus on the first of the four areas and notice any tension present.
  2. Ask them to recall what the release felt like in earlier sessions, and to let the muscles go in the same way, without tensing first.
  3. Allow 30–45 s with descriptive patter.
  4. Ask the client to signal if the area is not relaxed. If so, go back to one tension-release cycle for that area, then continue with recall.
  5. Repeat for the other areas, then do the quiet period and count-out.
• Example language (illustrative): "Focus on your arms and hands… notice any tightness there… and now remember how they felt when you released them after tensing… and let them go in just that way."
• Watch for: Clients who tense a little first out of habit. Gently remind them that recall involves no effort. [synthesis]

4.15 Recall with counting

• Purpose / when: About session 9. Links a simple count to deepening relaxation, preparing for counting alone.
• Steps [uncertain: reconstructed from the described stage; exact wording and pacing not verified]:
  1. Do relaxation via recall for the four areas (4.14).
  2. Count slowly from one to ten, timing each count to an exhalation. Invite the client to relax a little more with each number.
  3. Quiet period, count-out.
• Example language (illustrative): "As I count from one to ten, let each number go with a breath out, and let yourself relax a little further with each one… one… two…"
• Watch for: Counting so fast that the breathing becomes forced. Follow the client's natural breathing rate. [synthesis]

4.16 Counting alone

• Purpose / when: About session 10. The final portable form, after recall with counting works. [source: Unizar reading]
• Steps [uncertain: reconstructed]:
  1. Ask the client to settle and close their eyes.
  2. Count one to ten on exhalations, inviting relaxation to spread through the whole body with each number.
  3. Check for areas still tense, using recall for any area signalled.
  4. Have the client practise counting silently on their own: at first in quiet settings, then in daily life before stressors.
• Example language (illustrative): "This time you won't go through the areas at all. Just let the count do the work… one… letting go… two…"
• Watch for: A drop in depth compared with recall. If so, go back to recall with counting for another week. [synthesis]

4.17 Differential relaxation

• Purpose / when: Alongside or after the counting stages, to bring relaxation into everyday activity. The client keeps only the tension an activity needs and relaxes everything else. [source: Unizar reading (cross-reference to a chapter on differential relaxation); Krampen 2012 notes the differentiated origin in Jacobson]
• Steps [uncertain: the manual's graded sequence was not verified; the gradient below is synthesis built on the described principle]:
  1. Explain the idea: most activities need only a few muscles, yet people tense many more.
  2. Start sitting, eyes open, in a quiet room. Have the client keep the muscles needed for sitting upright and relax all others (face, shoulders, hands, abdomen).
  3. Add a simple activity (writing, typing, holding a cup). Ask the client to scan for tension the task does not need, and release it with recall or a count.
  4. Progress to standing, walking, then noisy and busy real settings (a queue, a meeting, driving at a standstill).
  5. Set brief daily "tension checks" during routine activities.
• Example language (illustrative): "Keep holding the pen, but notice whether your shoulders and jaw are involved too. Let them go while your hand keeps writing."
• Watch for: Clients trying to become fully limp in active situations. The aim is minimum necessary tension, not sleepiness. [synthesis]

4.18 Conditioned (cue-controlled) relaxation

• Purpose / when: After the client can reliably relax deeply. Gives a quick self-produced cue (a word paired with breathing out) to use when anxiety rises. [source: Freidenberg & Blanchard 2005]
• Steps [source: Freidenberg & Blanchard 2005]:
  1. Start the session with the usual muscle relaxation.
  2. When the client is relaxed, have them breathe slowly from the diaphragm.
  3. The client chooses a cue word (for example "relax" or "calm") and says it silently on each exhalation. Say it aloud in time with the first five exhalations.
  4. The client continues pairing for about 15 more breaths.
  5. Allow about 60 s of attending to the general feeling of relaxation.
  6. Do about 20 more pairings.
  7. Repeat over four to five further sessions. At home, practise about 20 pairings a day: first when calm, later in mildly stressful situations.
  8. Optional: in session, have the client imagine a feared situation until mildly anxious, then use the cue. Pair it also with everyday reminders (keys, traffic lights) to help it carry into daily life.
• Example language (illustrative): "Each time you breathe out, say your word silently… I'll say it with you for the first few breaths… 'calm'…"
• Watch for: Using the cue only at peak anxiety before it is well practised. Build it up when calm first. [source: Freidenberg & Blanchard 2005]

4.19 Jacobson's original method (minimal-tension, cultivated awareness)

• Purpose / when: With clients who find strong tensing painful or unhelpful, or when the aim is fine-grained awareness of tension rather than quick relief. A slower and more demanding training. [source: Poppen 2005; Krampen 2012]
• Steps [source: Poppen 2005 for the procedure; details of positions, practice periods and sequence come from Jacobson 1938, so they are uncertain]:
  1. The client lies on their back, eyes closed.
  2. The client makes one small, isolated action, for example extending one finger or bending the hand back. They attend to the faint sensation of tension (for example in the forearm) rather than the movement itself.
  3. The client then simply stops the action and lets the part rest, noting the sensations as the tension goes. Then continue ceasing effort beyond that point, with no further instruction.
  4. The same action is repeated, then the next isolated action is introduced, working gradually through the limbs, trunk, neck and face. Jacobson extended this to the eyes and speech muscles, linking them to thinking and imagery [uncertain: not verified in a primary text here].
  5. Use progressively fainter tensions so the client learns to detect very slight tension.
  6. Practise daily at home. Over weeks to months, extend from lying to sitting and to daily activities (differential relaxation).
  7. Avoid suggestion: give no descriptions of what the client should feel. [source: Unizar reading]
• Example language (illustrative): "Bend your hand back slightly… notice the faint feeling in the upper forearm… that is tension. Now just stop doing it. Don't do anything else."
• Watch for: Clients waiting for a pleasant feeling, or trying to "make" relaxation. In this method, relaxation is the absence of effort. [source: Unizar reading for no-suggestion stance; synthesis]

4.20 Gentle and bilateral variants (German practice)

• Purpose / when: Group courses, clients with pain or limited time, or when strong tensing causes discomfort. [source: Krampen 2012]
• Steps [source: Krampen 2012]:
  1. Use brief, light but noticeable tension and a longer, deeper relaxation phase. Krampen's estimates assume two cycles per group, and the relaxation phase is 3–4 times longer than the tension phase.
  2. 11-group bilateral form: both hands and forearms, biceps, triceps, shoulders, neck, face, back, abdomen, thighs and buttocks, calves, and shins, each done on both sides at once. It takes about 10–11 min, up to 15–20 min.
  3. 5-group short form: arms and hands, shoulders, face, trunk, legs and feet. It takes 2–4 min.
  4. Mental short form: the 5-group sequence done in imagination, sitting with eyes open and gaze on a nearby point. It takes 1–2 min and is for use in everyday settings. Krampen reports that many participants rated this form ineffective at course end. Introduce it last, and only after the physical forms are well established.
  5. If clients struggle at first, demonstrate one side at a time (hands, forearms, upper arms).
• Example language (illustrative): "Just a light tension this time, enough to notice it, not more… and let go, and give yourself a good long time to feel the difference."
• Watch for: Dropout in group courses (about 40% in Krampen's study) and low home practice. Plan for both from the first session. [source: Krampen 2012]

4.21 Relaxation as the competing response in systematic desensitisation

• Purpose / when: When PMR is taught as one part of Wolpe's systematic desensitisation. The client relaxes while imagining items from a graded fear hierarchy. [source: Poppen 2005]
• Steps: Teach a short form of PMR first (4.12–4.16), then follow the desensitisation protocol (a separate guide). The relaxation skill should be reliable before hierarchy work starts. [synthesis]
• Watch for: See the systematic desensitisation guide for exposure-specific consent and safety steps.

4.22 Applied relaxation (Öst) as a downstream use

• Purpose / when: When relaxation is to become a coping skill used at the first signs of anxiety or panic. [source: Div. 12 applied relaxation page]
• Steps (outline only): identify early warning cues; learn PMR and then faster forms; apply relaxation when the cues appear; practise in real situations. Öst's sequence moves through progressively quicker forms (release-only, cue-controlled, differential and rapid relaxation, then application training). [source: Div. 12 page; Öst 1987, uncertain] Treat applied relaxation as its own manualised protocol, with its own guide.
• Watch for: Using relaxation to escape or avoid feared situations, rather than to cope while staying in them (see 5.9). [synthesis]

5. Handling problems

Bernstein & Borkovec (1973) devote a chapter to problems in training (cited in the Unizar reading), but its content is not drawn on here. Most responses below are therefore marked [synthesis]. Source-backed points are tagged.

5.1 Falling asleep.

• Common in early sessions and evening practice.
• In session, use a slightly louder voice or a gentle check ("just lift a finger if you can hear me").
• Have the client practise sitting, not in bed, and at a time of day when they are not tired.
• Reframe: the skill being learned is relaxing while awake. Falling asleep is fine only when sleep is the goal. [synthesis]

5.2 Intrusive thoughts and wandering attention.

• Normalise them.
• Ask the client to notice the thought and bring attention back to the muscle sensations.
• Increase the density of patter, or shorten the silences, until attention steadies.
• For persistent worry, relaxation via counting or a cue word gives the mind a focus. [synthesis]

5.3 Laughing, giggling or embarrassment.

• Common in session 1.
• Acknowledge it lightly, pause, and continue.
• Demonstrate the actions yourself, so that the client is not the only one pulling faces. [synthesis]

5.4 Cramps, pain and injury.

• Reduce the strength and length of tension, especially in the feet and calves.
• For painful or injured areas, skip tensing and use recall only, or leave the area out.
• Strong contraction can produce lasting muscle tension and pain. German guidance advises against intense tensing. [source: Krampen 2012]
• Anyone with injuries should seek medical advice before starting. [source: Wikipedia PMR]
• If cramp occurs: stop, stretch gently, and resume with milder tension. [synthesis]

5.5 Relaxation-induced anxiety (RIA) and fear of losing control.

• Some clients become more anxious as they relax. They may feel alarmed by body sensations (heaviness, tingling, a racing heart they now notice), by losing vigilance, or by feeling "out of control". Heide and Borkovec described this phenomenon. [uncertain: their papers (1983, 1984)] Occasional relaxation-induced anxiety is also listed as a known risk. Responses:
  • Before training, predict that unusual sensations may occur and that they are harmless.
  • Give more control: eyes open, sitting upright, shorter sessions, client-paced release, permission to stop.
  • Focus on the muscles, not the breath, for clients alarmed by breathing.
  • Treat the sensations as information. For panic-prone clients, the alarm reaction can itself be addressed with interoceptive exposure in a CBT plan.
  • If RIA persists despite these steps, consider an active alternative (stretching-based relaxation, Carlson et al. 1990, or exercise) rather than pushing on. [synthesis]

5.6 Trauma history, dissociation and eyes-closed discomfort.

• Offer eyes open with gaze lowered, an upright chair, and a clear view of the door.
• Avoid touch, and avoid sudden loud changes in voice.
• Check in more often.
• If the client becomes detached or unreal, stop. Ground with eyes open, naming objects in the room and feet on the floor, then resume with shorter cycles.
• Defer body-focused work until the client's trauma treatment plan supports it. [synthesis]

5.7 Unusual sensations, twitches, jerks, coughing, sneezing, movement, noise.

• Explain in advance that muscle twitches and odd sensations are common as muscles release.
• If the client coughs, sneezes or needs to move, they do so and then return to the last group.
• For outside noise, include it in the patter ("sounds may come and go") rather than stopping. [synthesis]

5.8 Non-adherence to home practice.

• Home practice is often blocked by motivation and lack of time. [source: Krampen 2012]
• Two daily sessions are treated as essential. [source: Unizar reading]
• Responses [synthesis]:
  • Review the log first thing every session.
  • Problem-solve specific barriers: when, where, interruptions, family members.
  • Shorten practice temporarily (the 4-group form) rather than accepting none.
  • Link practice to an existing routine.
  • Use a recording early on.
  • Do not advance a stage without adequate practice, and explain why.

5.9 Relaxation used as avoidance or a safety behaviour.

• In anxiety disorders, clients may use relaxation to escape feared situations or sensations. This can maintain fear.
• If PMR is part of exposure-based treatment, frame relaxation as a way to stay in the situation, not to leave or prevent anxiety. Watch for rituals ("I can't go out unless I've relaxed first").
• Where exposure is the main treatment, consider whether relaxation is needed at all. [synthesis]

5.10 Medical cautions with tensing and breath-holding.

• For clients with cardiovascular conditions, uncontrolled hypertension, glaucoma, recent surgery or pregnancy:
  • avoid long breath-holds and maximal straining during tension;
  • use light tension or recall only;
  • leave out abdominal tensing in pregnancy and after abdominal surgery;
  • check with the treating physician. [synthesis; general caution consistent with Wikipedia PMR and Krampen 2012]
• Do not alter any medication. Refer medication questions to the prescriber.

5.11 "It doesn't work" or "I can't feel the difference".

• Check the timing: release phases that are too short are a common reason.
• Check the strength of tension: enough to notice clearly, without pain.
• Check the stage: the client may have been moved on too quickly. Go back to the previous stage.
• Increase the focus on noticing sensations, and use a 0–100 rating to show small changes.
• Some clients respond better to Jacobson-style minimal tension (4.19) or the gentle variants (4.20). [synthesis]

5.12 Trying too hard and perfectionism.

• Some clients strain to relax. Explain that relaxation is the absence of effort, which is the core of Jacobson's approach.
• Remove performance targets, and praise noticing rather than outcome. [source: Poppen 2005 for the Jacobson principle; synthesis for the response]

5.13 Ruptures: the client feels patronised, bored or that the method is trivial.

• Acknowledge the reaction.
• Explain the rationale again, linking it to the client's own goals.
• Invite the client to adapt the method with you: the pace, the wording, and whether patter is used at all.
• Explain how the method moves from a long ritual to short, portable forms.
• If PMR does not fit, agree to drop it rather than push on. [synthesis]

5.14 Over-reliance on the therapist's voice or recording.

• Fade recordings: alternate guided practice with practice from memory.
• Have the client lead a run in session while you observe.
• Move on to recall, counting and cue words, which need no external guide. [synthesis]

5.15 Group delivery problems.

• In groups, expect high dropout (about 40% in one German study) and uneven progress. [source: Krampen 2012]
• Responses [synthesis]:
  • Hold brief individual check-ins.
  • Offer an alternative action for anyone who cannot do a group's tensing.
  • Keep the faster learners on the current stage until most of the group has mastered it.

Sources

Sources

• Progressive muscle relaxation – Wikipedia
• Poppen, R. (2005). Relaxation strategies. Encyclopedia of Behavior Modification and Cognitive Behavior Therapy (SAGE)
• Freidenberg, B. M., & Blanchard, E. B. (2005). Cue-controlled relaxation. Encyclopedia of Behavior Modification and Cognitive Behavior Therapy (SAGE)
• Krampen, G. (2012). Entspannungsverfahren: Progressive Relaxation course study (Universität Trier PDF)
• Spanish textbook chapter on Progressive Relaxation Training summarising Bernstein & Borkovec (1973) (Universidad de Zaragoza OCW reading; referred to above as "Unizar reading")
• Society of Clinical Psychology (Div. 12): Applied Relaxation for Panic Disorder
• McCallie, Blum & Hood (2006). Progressive muscle relaxation. J Human Behavior in the Social Environment (abstract only)
• UKnowledge record: Bernstein & Carlson (1992), Progressive relaxation: Abbreviated methods
• UKnowledge record: Bernstein, Carlson & Schmidt (2007), Progressive relaxation: Abbreviated methods
• UKnowledge record: Carlson et al. (1990), Muscle stretching as an alternative relaxation training procedure
• BMC Complementary Medicine and Therapies: 8-session group PMR protocol table (example of a 16→7→4→recall schedule)

Further reading (not drawn on; content via the secondary sources above)

• Jacobson, E. (1929; 2nd ed. 1938). Progressive Relaxation. University of Chicago Press.
• Jacobson, E. (1934). You Must Relax. McGraw-Hill.
• Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford University Press.
• Bernstein, D. A., & Borkovec, T. D. (1973). Progressive Relaxation Training: A Manual for the Helping Professions. Research Press.
• Bernstein, D. A., Borkovec, T. D., & Hazlett-Stevens, H. (2000). New Directions in Progressive Relaxation Training: A Guidebook for Helping Professionals. Praeger.
• Bernstein, D. A., Carlson, C. R., & Schmidt, J. E. (2007). Progressive relaxation: Abbreviated methods. In P. M. Lehrer, R. L. Woolfolk & W. E. Sime (Eds.), Principles and Practice of Stress Management (3rd ed.). Guilford.
• Öst, L.-G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397–409.
• Heide, F. J., & Borkovec, T. D. (1983; 1984). Papers on relaxation-induced anxiety. [uncertain]
• Borkovec, T. D., & Sides, J. K. (1979). Review of controlled research on progressive relaxation (live vs taped training). [uncertain]

Further reading (not drawn on): BBC News (2015) "The man who invented relaxation", progressiverelaxation.org, the VA Whole Health PMR handout, PubMed and PubMed Central pages.