Atlas›Domain XVI · Historical, discredited & harmful›Guide 096
Guide XVI-096

Relaxation training for panic-prone patients

A 24 · L 69 · M 720 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: relaxation training for panic-prone patients as it appears on Lilienfeld's (2007) provisional list of potentially harmful therapies; the relaxation-induced anxiety literature (Heide and Borkovec 1983, 1984; Adler, Craske and Barlow 1987; Wells 1990) as the evidence of harm; applied-relaxation trials (Öst 1988; Öst and Westling 1995; Tarrier and Main 1986; Beck et al. 1994; McCarthy et al. 2018), the APA Division 12 listing and NICE CG113 (2011, updated 2020) as the counter-evidence and current guidance. This guide covers the psychotherapist's own work around the risk; how to deliver progressive muscle relaxation and applied relaxation is in Domain II 066 and 067, and panic-focused CBT with interoceptive exposure is in the Domain II panic CBT guide.

"Relaxation training for panic-prone patients" is not a separate therapy. It names a risk: that teaching relaxation methods (progressive muscle relaxation, meditation, autogenic training and similar) to people who are prone to panic can, in some of them, provoke anxiety or a panic attack instead of calm. Lilienfeld (2007), in Psychological Treatments That Cause Harm (Perspectives on Psychological Science, 2(1), March 2007), offered a provisional list of potentially harmful therapies; secondary accounts report that relaxation for panic-prone clients is on that list, on the grounds that a heightened focus on bodily sensations can trigger panic in some clients [source: APS journal page; Therapist Aid, Schuldt] [uncertain: the list's exact wording and evidence level for this item not verified in the article itself].

The phenomenon is called relaxation-induced anxiety (RIA) or relaxation-induced panic. Heide and Borkovec (1983) found that, in a small sample of adults with general tension, about 31% reported increased tension after progressive relaxation and about 54% after a mantra-focused method [source: Heide and Borkovec 1983, Penn State record]. Heide and Borkovec (1984) set the phenomenon in a framework emphasising fear of somatic anxiety cues and fear of loss of control [source: Heide and Borkovec 1984, Penn State record]. Adler, Craske and Barlow (1987) wrote on "relaxation induced panic" in panic patients [source: Craske publication list] [uncertain: content not verified].

The position is contested. Applied relaxation, a coping-skill method developed by Öst, has been tested against other treatments for panic disorder and is rated by APA Division 12 as having "Modest Research Support" for panic disorder [source: Div12]. NICE CG113 recommends applied relaxation as a high-intensity option for generalised anxiety disorder, while its psychological recommendations for panic disorder name CBT [source: NICE CG113].

Core idea of how change happens in the psychotherapist's work here: the risk is managed, not by abandoning relaxation for everyone, but by recognising who is likely to react badly (fear of bodily sensations and of losing control), obtaining informed consent, monitoring closely, and offering or switching to treatments with a stronger evidence base for panic when a client reacts [synthesis, from the sources above].

2. Framework

The psychotherapist's work has five phases [synthesis, structure drawn from the sources cited in each phase].

Phase 1. Recognition and assessment. Goal: identify panic proneness, prior adverse reactions to relaxation or meditation, and fear of bodily sensations or loss of control (the factors Heide and Borkovec 1984 emphasise) [source: Heide and Borkovec 1984]. Move on when diagnosis and risk factors are documented.

Phase 2. Treatment choice and consent. Goal: agree a treatment the client understands. For panic disorder, NICE names CBT, delivered by suitably trained and supervised practitioners who adhere to empirically grounded protocols, in the optimal range of 7 to 14 hours in total, usually in weekly sessions of 1 to 2 hours completed within 4 months [source: NICE CG113 1.3.13-1.3.16]. For GAD, NICE offers CBT or applied relaxation; applied relaxation should follow the trial manuals, be delivered by trained and competent practitioners and usually consist of 12 to 15 weekly one-hour sessions [source: NICE CG113 1.2.18, 1.2.20]. Move on when the client has given informed consent to a named approach, including what to do if relaxation provokes anxiety.

Phase 3. Monitored delivery or referral. Goal: if a relaxation component is used (by the psychotherapist trained in it, or by another service), watch for paradoxical anxiety from the first practice; if the psychotherapist is not trained in the chosen protocol, refer. NICE advises regular supervision to monitor fidelity [source: NICE CG113 1.2.21]. Move on when the client is practising without adverse reactions, or when an adverse reaction has occurred (go to phase 4).

Phase 4. Response to relaxation-induced anxiety. Goal: stop, stabilise, make sense of the reaction with the client, and decide together whether to modify, switch or continue. Wells (1990) reports a single case in which autogenic training increased panic frequency and an external attention-training procedure reduced panic [source: Wells 1990]. Move on when a revised plan is agreed.

Phase 5. Repair and follow-up. Goal: address any loss of trust, avoidance of relaxation, meditation or body-based practices, and track outcome and dropout. In one trial, applied relaxation had a high active-phase dropout rate (41%), which the authors suggested reflected lower tolerability, although gains were maintained among those who improved [source: McCarthy et al. 2018].

Historical phases in outline: relaxation methods were widely used for anxiety from the mid-20th century; in the 1980s reports of relaxation-induced anxiety and panic appeared (Heide and Borkovec 1983, 1984; Adler, Craske and Barlow 1987); in the same period Öst developed applied relaxation as a coping technique and tested it in panic disorder (Öst 1987, 1988; Öst and Westling 1995) [source: Div12; Penn State records; Craske publication list]; Lilienfeld (2007) included relaxation for panic-prone patients among potentially harmful therapies [source: Therapist Aid] [uncertain: secondary, unverified]; current guidance (NICE CG113) prefers CBT for panic disorder [source: NICE CG113].

3. Guiding principles

  • First, do no harm. Lilienfeld frames the field's credo as "primum non nocere" [source: APS journal page]. Practical meaning: ask before every relaxation-based exercise whether this client could react badly.
  • The risk is individual, not universal. RIA occurred in a minority in Heide and Borkovec (1983), and relaxation-based treatments outperformed controls in several trials (Tarrier and Main 1986; Beck et al. 1994) [source: Penn State record; Cambridge abstract; Memphis record]. Practical meaning: screen and monitor rather than assume either safety or harm.
  • Fear of bodily sensations and of losing control is the warning sign. Heide and Borkovec (1984) emphasise these fears [source: Penn State record]. Practical meaning: ask about them directly before inward-focused exercises.
  • Method matters. Heide and Borkovec (1983) found more increased tension after the mantra-focused method than after progressive relaxation; Wells (1990) found autogenic training increased panic in one case [source: Penn State record; Manchester record]. Practical meaning: do not treat all relaxation and meditation methods as equivalent.
  • Guideline first for panic disorder. NICE names CBT for panic disorder [source: NICE CG113]. Practical meaning: offer panic-focused CBT, or refer to it, as the default for diagnosed panic disorder.
  • Applied relaxation has its own evidence base. It is rated "Modest Research Support" for panic disorder by APA Division 12 and recommended for GAD by NICE [source: Div12; NICE CG113]. Practical meaning: do not describe it to clients as discredited.
  • Informed consent includes the possibility of paradoxical anxiety. [synthesis] Practical meaning: name the risk before the first practice, and agree a stop signal.
  • The client may stop at any time. [synthesis] Practical meaning: stopping is a valued signal, not a failure.
  • Competence and fidelity. NICE asks for trained practitioners following trial manuals, with supervision [source: NICE CG113 1.2.20-1.2.21, 1.3.14]. Practical meaning: deliver only methods you are trained in; otherwise refer.
  • Watch dropout as a harm signal. [source: McCarthy et al. 2018] Practical meaning: a client who drifts away after relaxation sessions should be contacted and asked about adverse reactions.
  • No medical or medication decisions. [synthesis] Practical meaning: new physical symptoms are routed to medical assessment; never advise starting, stopping or changing a medicine.
  • Even-handedness. [synthesis] Practical meaning: present clients and colleagues with both the harm reports and the supportive trials, attributed.

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis]. None of them is a relaxation or breathing procedure: for how to deliver progressive muscle relaxation or applied relaxation, see Domain II 066 and 067; for interoceptive exposure, see the Domain II panic CBT guide.

4.1 Evidence literacy for yourself and your team

  • Purpose / when: before offering any relaxation-based component to anxious clients, and when a colleague asks whether relaxation is "harmful" or "safe".
  • Steps: (1) Know the harm evidence: Heide and Borkovec (1983) on increased tension after relaxation and meditation in tense adults; Heide and Borkovec (1984) on fear of somatic cues and loss of control; Wells (1990) on autogenic training increasing panic in one case; Lilienfeld (2007) listing [source: Penn State records; Manchester record; Therapist Aid]. (2) Know the counter-evidence: applied relaxation trials in panic (Öst 1988; Öst and Westling 1995), Div12 "Modest Research Support", Beck et al. (1994) relaxation training superior to minimal contact, Tarrier and Main (1986), McCarthy et al. (2018) maintained gains but 41% dropout [source: Div12; Memphis record; Cambridge abstract; JCP]. (3) Know the guidance: NICE CG113 names CBT for panic disorder and CBT or applied relaxation for GAD [source: NICE CG113]. (4) Summarise both sides when discussing with colleagues [synthesis].
  • Example language (illustrative): "The research shows relaxation helps many anxious people, but a minority, especially those frightened of body sensations, can feel more anxious or panic during it. So we screen and monitor."
  • Watch for: overstatement in either direction ("relaxation is dangerous" or "relaxation is always safe"). Working: team members can state both positions with sources.

4.2 Screening for a history of relaxation-induced anxiety

  • Purpose / when: at intake for any anxious client, and before the first relaxation, meditation, imagery or body-scan exercise.
  • Steps: (1) Ask whether the client has ever felt worse, panicky, unreal or out of control while relaxing, meditating, falling asleep, lying still or doing yoga or guided audio [synthesis]. (2) Ask about the context, what happened and how they coped [synthesis]. (3) Record the answers and flag a positive history in the plan [synthesis].
  • Example language (illustrative): "Some people find that when they try to relax, their body sensations become louder and that feels alarming. Has anything like that ever happened to you?"
  • Watch for: reports of panic on letting go, of depersonalisation, or of avoiding rest or stillness. Working: you can say before starting whether this client is at higher risk.

4.3 Assessing fear of bodily sensations and fear of loss of control

  • Purpose / when: when panic proneness or a positive screen is present; these are the fears Heide and Borkovec (1984) emphasise [source: Penn State record].
  • Steps: (1) Ask which body sensations frighten the client and what they fear those sensations mean [synthesis]. (2) Ask how the client feels about "letting go" or being less vigilant [synthesis]. (3) Where a standardised measure of anxiety sensitivity is used, administer and score it as its licence permits, without adapting items [synthesis]. Relaxation-induced anxiety and anxiety sensitivity have been studied together, for example by Gómez Pérez and colleagues (2004, Revista de psicopatología y psicología clínica) [source: UNED portal record] [uncertain: findings not verified].
  • Example language (illustrative): "When your heart speeds up or you feel light-headed, what goes through your mind? And how do you feel about the idea of switching off and letting your guard down?"
  • Watch for: catastrophic beliefs about sensations ("I'll faint", "I'm losing my mind") and a strong need for vigilance. Working: the case formulation names these fears and the plan addresses them.

4.4 Diagnostic clarification before choosing a method

  • Purpose / when: NICE gives different pathways for GAD and panic disorder, so the diagnosis shapes the choice [source: NICE CG113].
  • Steps: (1) Establish whether the presentation is panic disorder, GAD, another anxiety condition or general tension [synthesis]. (2) Note comorbidity and physical health concerns; route new or unexplained physical symptoms to medical assessment [synthesis]. (3) Record the diagnosis and its implications for treatment choice [synthesis].
  • Example language (illustrative): "Before we choose an approach, I want to be sure we understand which kind of anxiety is driving this, because the recommended treatments differ."
  • Watch for: unrecognised panic disorder in a client referred "for relaxation". Working: the choice of method follows the diagnosis.

4.5 Informed-consent conversation that names paradoxical anxiety

  • Purpose / when: before any relaxation-based component, whether delivered by you or another service.
  • Steps: (1) Describe what the method involves in plain terms [synthesis]. (2) Say that some people, particularly those prone to panic, can feel more anxious at first [source: Heide and Borkovec 1983; Therapist Aid]. (3) Describe the alternatives (4.6) [source: NICE CG113]. (4) Confirm the client's right to stop at any time, and record consent [synthesis].
  • Example language (illustrative): "Most people find this calming, but a few feel more anxious, especially at first. If that happens, it's useful information, not a failure, and you can stop at any point."
  • Watch for: a client agreeing only to please you. Working: the client can say in their own words what might happen and what they will do.

4.6 Offering choice and supported alternatives

  • Purpose / when: for every panic-prone client, and especially after a positive screen.
  • Steps: (1) For diagnosed panic disorder, explain that NICE recommends CBT delivered by trained, supervised practitioners following empirically grounded protocols [source: NICE CG113 1.3.13-1.3.14]. (2) Mention that applied relaxation has been tested in panic disorder (Div12 "Modest Research Support") and that cognitive therapy outperformed relaxation training on responder rates in Beck et al. (1994) [source: Div12; Memphis record]. (3) For mild to moderate panic disorder, NICE also lists individual self-help, facilitated or not [source: NICE CG113 1.3.9]. (4) Agree a choice with the client [synthesis].
  • Example language (illustrative): "There are a few options with good evidence. The one most recommended for panic disorder is a form of CBT that helps you relearn how to respond to body sensations. Relaxation-based coping has some evidence too. Which feels right for you?"
  • Watch for: steering a client into the method you happen to prefer. Working: the client's choice is informed and recorded.

4.7 Psychoeducation on why relaxation can feel alarming

  • Purpose / when: after a positive screen, or after an episode, to reduce shame and catastrophic interpretation.
  • Steps: (1) Explain, in plain terms, that turning attention inward can make normal body sensations more noticeable, and that a person who fears those sensations or fears losing control may react with alarm [source: Heide and Borkovec 1984; Therapist Aid]. (2) Link this to the client's own formulation (4.3) [synthesis]. (3) Check understanding [synthesis].
  • Example language (illustrative): "When you slow down and tune in, your body doesn't change much, but you notice it more. If part of you is on guard for danger, that noticing can set off an alarm."
  • Watch for: the explanation increasing fear ("so relaxing is dangerous for me"). Working: the client can reframe the episode as understandable, not as evidence of damage.

4.8 Agreeing a monitoring plan and stop signal

  • Purpose / when: before any first practice of a relaxation-based method by a client with risk factors.
  • Steps: (1) Agree a simple verbal or hand signal for "stop" [synthesis]. (2) Agree that you will check in briefly during and immediately after any exercise [synthesis]. (3) Agree what the client will do if it happens during home practice: stop, open eyes, orient to the room, note what happened, and bring it to the next session [synthesis]. (4) Note the plan in the record [synthesis].
  • Example language (illustrative): "If at any point it starts to feel worse, just raise your hand or say 'stop', and we'll stop straight away and talk about it."
  • Watch for: clients pushing through distress because they think they should. Working: the client uses the signal when needed, and episodes are reported rather than hidden.

4.9 Responding in session to an episode of relaxation-induced anxiety

  • Purpose / when: a client becomes more anxious, panicky or unreal during a relaxation-based exercise, in your session or another clinician's.
  • Steps: (1) Stop the exercise at once [synthesis]. (2) Speak calmly, invite the client to open their eyes, sit up and look around the room [synthesis]. (3) Name what happened without alarm and reassure the client that the reaction is known and passes [source: Heide and Borkovec 1983, 1984, on the reaction being known] [synthesis for wording]. (4) Do not introduce a new breathing or body technique to "fix" it [synthesis]. (5) When settled, ask what sensations and thoughts came up [synthesis]. (6) If symptoms suggest a medical problem, route to urgent medical assessment [synthesis].
  • Example language (illustrative): "Let's stop here. Open your eyes and have a look around the room. What you're feeling is a known reaction, and it will pass. You're safe here with me."
  • Watch for: escalation, dissociation, or the client's wish to leave. Working: the client settles, can describe the episode, and is willing to discuss next steps.

4.10 Debriefing and reformulating after an episode

  • Purpose / when: in the same or the next session after relaxation-induced anxiety.
  • Steps: (1) Review what happened, in sequence: sensations, thoughts, feelings, actions [synthesis]. (2) Link the episode to the fears identified in 4.3, as the Heide and Borkovec (1984) framework suggests [source: Penn State record]. (3) Update the case formulation and record the adverse reaction [synthesis]. (4) Ask what the client now wants to do (4.11) [synthesis].
  • Example language (illustrative): "Let's piece together what happened. What did you notice first, and what did your mind tell you it meant?"
  • Watch for: self-blame ("I can't even relax properly") and new avoidance. Working: the client sees the episode as understandable and informative.

4.11 Joint decision to modify, switch or continue

  • Purpose / when: after any adverse reaction, or when a client reports repeated distress in home practice.
  • Steps: (1) Lay out the options: pause the relaxation component; switch to a method the client tolerates better; or move to the guideline treatment for panic disorder (CBT) [source: NICE CG113]. (2) Note that methods differ in risk (more increased tension after a mantra-focused method than after progressive relaxation in Heide and Borkovec 1983; autogenic training increased panic in Wells 1990) [source: Penn State record; Manchester record]. (3) Agree and record the decision [synthesis].
  • Example language (illustrative): "We have choices. We can set relaxation aside for now, try a different approach, or move to the treatment that has the strongest evidence for panic. What feels right to you?"
  • Watch for: continuing an exercise unchanged after repeated adverse reactions. Working: the plan changes in response to the client's experience.

4.12 Switching to an externally focused or exposure-based approach

  • Purpose / when: when inward-focused relaxation provokes panic and a supported alternative is chosen.
  • Steps: (1) Explain the rationale: Wells (1990) reported a single case in which an external attention-training procedure reduced panic and aided tension reduction, whereas autogenic training increased panic [source: Manchester record]. (2) Deliver the alternative only if trained in it, following its own guide (attention training; panic-focused CBT with interoceptive exposure, Domain II), including its contraindications, safety and consent steps [synthesis]. (3) Otherwise refer (4.16) [synthesis].
  • Example language (illustrative): "Focusing inward seems to turn up the alarm for you. There are approaches that work differently, by changing where your attention goes or by helping your body's alarm system relearn. I'd like to explain them."
  • Watch for: a single case is weak evidence for attention training in this use; present it as such. Working: panic frequency and distress fall on the new approach.

4.13 Distinguishing helpful coping from avoidance [synthesis]

  • Purpose / when: when a client uses relaxation mainly to prevent feared sensations, or abandons all relaxation after a bad reaction.
  • Steps: (1) Ask what the client believes would happen if they did not relax at the first sign of anxiety [synthesis]. (2) Ask whether they now avoid rest, stillness, meditation, yoga or sleep routines [synthesis]. (3) Bring the pattern into the formulation and the treatment plan, coordinating with the panic CBT guide in Domain II [synthesis].
  • Example language (illustrative): "Sometimes relaxing becomes a way of keeping feared sensations at bay, and sometimes a bad experience makes people avoid rest altogether. Does either fit you?"
  • Watch for: rigid, compulsive relaxation rituals or new avoidance of rest. Working: the client can tolerate sensations without either fighting them or fleeing stillness.

4.14 Working with a client previously harmed by relaxation or meditation

  • Purpose / when: a client arrives distrustful of therapy after panic in a relaxation, meditation or yoga setting.
  • Steps: (1) Validate the experience and say that the reaction is documented in the research literature [source: Heide and Borkovec 1983, 1984; Wells 1990]. (2) Ask what would help them trust the process now (control, explanation, stop signal) [synthesis]. (3) Offer a plan that does not begin with inward-focused relaxation (4.6, 4.12) [synthesis]. (4) If the earlier provider acted without consent or ignored distress, discuss the client's options (4.19) [synthesis].
  • Example language (illustrative): "What happened to you is a known reaction, and it makes sense that you're wary. We'll go at your pace, and nothing will happen without your agreement."
  • Watch for: shame, anger at the earlier provider, generalised avoidance of body-based care. Working: the client re-engages and trust grows.

4.15 Working with a panic-prone client drawn to relaxation apps, recordings or meditation classes

  • Purpose / when: a client plans to use self-guided relaxation or meditation outside therapy.
  • Steps: (1) Respect the client's choice [synthesis]. (2) Share, without alarm, that some people feel more anxious with inward-focused methods, and that a mantra-focused method produced more increased tension than progressive relaxation in one small study [source: Heide and Borkovec 1983]. (3) Agree warning signs and a plan to stop and report (4.8) [synthesis]. (4) Note that NICE lists structured self-help for mild to moderate panic disorder, which is not the same as general relaxation material [source: NICE CG113 1.3.9].
  • Example language (illustrative): "That app might suit you. If you notice it making you more on edge, stop and tell me, and we'll find something that fits better."
  • Watch for: escalating panic linked to practice; hiding episodes. Working: the client reports reactions and adjusts.

4.16 Referral to a trained panic-treatment practitioner

  • Purpose / when: when the chosen guideline treatment is outside your competence.
  • Steps: (1) Identify a practitioner trained and supervised in empirically grounded CBT for panic disorder [source: NICE CG113 1.3.14]. (2) With consent, share the screening results and any adverse reaction to relaxation [synthesis]. (3) Arrange continuity during the handover [synthesis].
  • Example language (illustrative): "I'd like you to see a colleague who specialises in panic treatment. With your permission, I'll let them know what happened when we tried relaxation so they can plan around it."
  • Watch for: the client feeling rejected. Working: the client attends and the receiving clinician has the information needed.

4.17 Supervision, fidelity and competence

  • Purpose / when: whenever you deliver applied relaxation or another relaxation-based method.
  • Steps: (1) Use the trial-based manual for the method [source: NICE CG113 1.2.20]. (2) Arrange regular supervision that monitors fidelity [source: NICE CG113 1.2.21]. (3) Bring every adverse reaction to supervision [synthesis].
  • Example language (illustrative, to a supervisor): "A client with panic became more anxious in our first relaxation practice. I'd like to review my screening and whether to switch approaches."
  • Watch for: practising a method you were never trained in. Working: supervision records show adverse reactions were reviewed.

4.18 Outcome and dropout monitoring

  • Purpose / when: throughout any relaxation-based treatment.
  • Steps: (1) Track panic frequency, distress and practice experiences session by session using a measure your service is licensed to use [synthesis]. (2) Treat missed sessions or sudden withdrawal as a possible sign of an adverse reaction; McCarthy et al. (2018) report 41% active-phase dropout in applied relaxation and suggest lower tolerability [source: JCP]. (3) Contact clients who drop out and ask about adverse experiences [synthesis].
  • Example language (illustrative, on follow-up): "I noticed you haven't been back since we started the relaxation work. Sometimes that's because it didn't feel good. I'd like to hear how it went."
  • Watch for: rising panic scores during the relaxation phase. Working: adverse reactions are caught early.

4.19 Duties when a colleague or service uses relaxation unsafely

  • Purpose / when: a colleague or service gives relaxation to panic-prone clients without screening or consent, or presses clients to continue through panic.
  • Steps: (1) Raise the concern with the colleague directly, sharing the evidence in 4.1 [synthesis]. (2) If unresolved, raise it through supervision, clinical governance or your service's complaints route [synthesis]. (3) Where a client has been harmed and wants to complain, inform them of the provider's complaints process and the relevant licensing or registration body as those bodies publish them [synthesis]. (4) Follow your professional code; the APA Ethics Code is at https://www.apa.org/ethics/code [synthesis for its application here].
  • Example language (illustrative, to a colleague): "I've had a couple of clients with panic who felt worse after the relaxation group. There's research on relaxation-induced anxiety; could we add a screen and a stop option?"
  • Watch for: framing a contested, evidence-based method as misconduct. Working: screening and consent are added and adverse reactions are reported.

4.20 Suicide-risk awareness in panic presentations [synthesis]

  • Purpose / when: panic and severe anxiety can coexist with hopelessness; ask whenever distress is high, including after a frightening episode.
  • Steps: (1) Ask directly about suicidal thoughts using your service's standard risk assessment [synthesis]. (2) Follow safe-messaging principles [synthesis]. (3) Give crisis resources: 988 (US); Samaritans 116 123 (UK and Ireland) [synthesis].
  • Example language (illustrative): "When panic is this bad, some people feel like they can't go on. Have you had thoughts like that?"
  • Watch for: hopelessness after failed treatments. Working: risk is assessed, documented and acted on.

5. Handling problems

  • Client insists on relaxation despite past panic during it. Respect autonomy; review the consent conversation (4.5), agree a monitoring plan and stop signal (4.8), and keep CBT for panic on the table as the guideline option [source: NICE CG113] [synthesis for the approach].
  • Client now refuses anything calming or body-focused. Treat this as possible avoidance (4.13); validate the earlier experience (4.14) and offer an approach that does not start with inward focus (4.12) [synthesis].
  • Overwhelm or dissociation during an exercise. Stop at once and follow 4.9; do not add a breathing or body technique to counter it; route physical symptoms that may be medical to medical assessment [synthesis].
  • Repeated adverse reactions in home practice. Pause home practice, debrief (4.10) and revisit the plan (4.11); Heide and Borkovec (1983) and Wells (1990) both show that the method used can matter [source: Penn State record; Manchester record].
  • Non-adherence to home practice. Ask first whether practice is aversive before treating it as low motivation [synthesis]; dropout from applied relaxation was high in McCarthy et al. (2018) [source: JCP].
  • Stuck: relaxation helps a little but panic persists. Review the diagnosis (4.4) and consider moving to, or referring for, panic-focused CBT, which NICE names for panic disorder [source: NICE CG113]; in Beck et al. (1994), cognitive therapy had a higher responder rate than relaxation training [source: Memphis record].
  • Rupture after an episode ("you made it worse"). Acknowledge your part without defensiveness, explain what is known about the reaction (4.7), and give the client control over next steps [synthesis].
  • Client is told by another provider that relaxation is "harmful" or "always safe". Give both positions with sources (4.1): the harm reports and Lilienfeld's listing on one side; the applied-relaxation trials, the Div12 rating and NICE's GAD recommendation on the other [source: as in 4.1].
  • Group or class settings. Individual screening is harder in groups; ask the group leader to name the possibility of paradoxical anxiety, offer an opt-out and a quiet way to stop, and follow up individually [synthesis].
  • Client asks about medicines to make relaxation easier. Do not advise starting, stopping or changing any medicine; refer the question to the prescriber [synthesis].
  • Physical symptoms during or after practice. Do not interpret them as anxiety without medical review when they are new, severe or unexplained [synthesis].
  • Colleague resists adding screening. Use 4.19; share the evidence even-handedly, and escalate through governance only if clients are being harmed [synthesis].
  • Uncertainty about the evidence itself. Lilienfeld's exact grading for this item, the content of Adler, Craske and Barlow (1987), the findings of Öst (1988) and Öst and Westling (1995), and whether the Williams et al. (2021) reanalysis of the potentially harmful therapies list examined this item are [uncertain: not verified]. A 2021 reanalysis by Williams, Botanov, Kilshaw, Wong and Sakaluk in Clinical Psychology: Science and Practice is reported to have found harm likely for critical incident stress debriefing and Scared Straight and unlikely for DARE and grief counselling, with many items lacking enough data [source: KU News 2021].

Sources

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