Copyright © Donald Robertson, 2012.  All rights reserved.

Edmund Jacobson was a professor of physiology who developed the technique of Progressive Relaxation in the 1920s based on his research on muscular tension and relaxation.  This article looks in more detail at how the general skill of Progressive Relaxation was originally applied to the treatment of phobic anxiety and worry.  Jacobson studied the activity of muscles directly in his physiology laboratory, using a device specially designed for the purpose.  He taught patients to systematically release tension by first learning to observe it more closely, a process known as “cultivation of the muscle sense.”  Jacobson recommended that patients should try to become aware of how they unconsciously tense muscles in anxious situations or when worried and learn to respond by doing the opposite and selectively releasing all the tension from those parts of the body.  Writing of pathological phobias, Jacobson says:

It is not considered sufficient in treating such a condition through relaxation for the patient to learn to be relaxed merely when lying down. Rather, it seems necessary for the patient to learn to recognise when and where he is tense during the experience of fear and to relax the localities involved. This is differential relaxation. (Jacobson, 1976: 56)

A similar strategy is employed in the treatment of more abstract fears:

In training nervous persons to relax, the patients are directed, as previously indicated, in methods of observing what they do subjectively when they worry. They note tensions of which, as they assert, they have previously been unconscious. (Jacobson, 1976: 57)

According to Jacobson, when asked to monitor the location of bodily tensions during worry, subjects typically report faint sensations in the muscles around the eyes, as though looking at an image of the problem being worried about, or in the muscles involved in speech, as if they were saying the verbal thoughts that constitute part of the process of worry.

Jacobson found that when asked to monitor their physical sensations carefully during mental activity, his subjects almost always reported faint tension sensations around the eyes when picturing mental images and in their tongue, lips and throat when thinking in words, e.g., mentally reciting a poem. While these muscles were completely relaxed, mental images disappeared and verbal thoughts could not be continued. He claimed that all thinking, in words or images, entails muscular action normally so slight as to be invisible. He and his colleagues collected scientific evidence that appeared to demonstrate that thinking is accompanied by minute muscular tensions and movements, a miniature physical version of talking aloud and looking around.

When you think or worry or are excited, you see things in imagination or say things to yourself. According to numerous observations, by finding what region is tense and relaxing it promptly you mechanically remove the disturbing activity. (Jacobson, 1976: 124-125)

This is a remarkable claim and others have disputed the notion that muscles are always involved in thinking. However, it’s easy to observe that when engrossed in thought, e.g., when worrying intensely, certain people often tend to make slight hand gestures, change their facial expression, or even mutter under their breath, as if engaged in a “muted” version of normal speech and action in response to some imagined situation. It’s also true that people often report their thoughts diminishing as they relax their body deeply, particularly the muscles of the face. Note that when people merely relax superficially their thoughts often become more vivid or rapid. However, deep muscle relaxation of the face, neck, and head, tends to be experienced differently and people often feel as if they are falling asleep. Jacobson reputedly said, “It might be naïve to say that we think with our muscles, but it would be inaccurate to say that we think without them” (McGuigan & Lehrer, 2007: 58).

‘Try it now’: Relaxing the Jaw and Internal Speech

It’s possible to relax your jaw and the muscles of speech and still engage in internal dialogue, if you do so superficially, but what happens if you really relax these muscles much deeper than normal, trying to make them completely limp and slack?

1. Tense your jaw by clenching your teeth moderately for about ten seconds.
2. Then take a deep breath, hold it for a moment, and relax your jaw and face completely. Let your jaw hang slack as though you’ve been knocked unconscious, which should mean your teeth part, and perhaps that your lips part slightly. Let go completely for about 30-60 seconds.
3. Repeat this about three times in total, trying to release the jaw muscles, and relax the rest of the face, and all the muscles used during speech, more completely each time.
4. Now continue to let go of the muscles completely but try to spell the (arbitrary) word “RHINOCEROS” in your mind.

Notice if this seems more difficult than normal, or if it takes longer to get started or to complete the word. If so, consider the implications that this specific type of physical relaxation might have for controlling negative thoughts, particularly unnecessary worry.

Releasing Tension & Worry

Tension control is therefore intended as a form of mental self-control, by controlling the muscles involved in speech and vision, and other subtle tensions associated with mental processes. Stopping thinking, in this sense, resembles stopping talking aloud, only it involves letting go of tension and activity in the muscles more deeply.   Jacobson’s primary solution to “mental” problems, such as worry, is therefore to carefully pay attention to the subtle muscular tensions occurring during the process, especially around the region of the eyes and forehead, and the apparatus of speech, and to “let go” of those tensions completely, which he was confident would eliminate the associated thoughts and emotions.

Observation on worried patients suggests that their moments of concern involve particularly often the knitting of the brows, although this tension occurs commonly in most persons when they are thinking actively or facing relatively bright light. It may be of interest for you to note how often this tension occurs in persons you meet. Darwin considered tension in this region significant, noting that the animal which frowns or contracts his brows is meeting difficulty. Under this assumption, if a worrisome patient reports or seems to show such tension more or less habitually, he is drilled particularly in relaxing this region. (Jacobson, 1976: 58)

In other words, Darwin had observed that knitting the brows is a long-standing evolutionary response to encountering problems, shared with many of our animal ancestors. Even in relation to quite abstract thoughts, such as contemplating the idea of “infinity”, Jacobson claimed that measurable tension occurred in the muscles associated with speech, as if words were being spoken.

‘Try it now’: Relaxing the Eyes & Mental Imagery

You’re going to mentally picture (“visualise”) your finger moving horizontally, from right to left across your field of vision, while closely observing the movements in your eyes and even the faintest sensations in the muscles.

1. Start by actually moving your index finger before your eyes a few times, slowly, observing the changing sensations in the muscles around your eyes as you track your finger with your gaze.
2. Now close your eyes and just visualise your finger moving slowly across your field of vision several times, paying close attention to the muscles around the eyes to detect any slight tension or movement.
3. Now picture your finger being held stationary in the centre of your field of vision and notice any slight sensations in the muscles again.
4. Now picture your finger moving horizontally, as before, but much more quickly, notice how your eye muscles are involved.
5. Now wrinkle your nose and squeeze your eyes tightly shut for about 10 seconds. Take a deep breath and let go of the tension completely. Keep letting go more deeply on each exhalation of breath, for about 30-45 seconds. Repeat this cycle 2-3 times, progressively letting go of tension in the eye muscles more deeply and completely each time.
6. Once your eye muscles feel completely relaxed, keep letting go and avoid tensing them, while you try to picture your finger moving slowly across your visual field once again.

You should find that it’s difficult to picture the image while the muscles are completely relaxed and hence that by relaxing your eye muscles you can eliminate mental imagery, or by controlling your eye muscles, influence the speed of imagery, etc. (McGuigan F. J., 1981, pp. 182-188)

A Manual for Evidence-Based Clinical Hypnosis

Copyright © Donald Robertson, 2012.  All rights reserved.

ISBN: 9781855755307

Due for publication in 2012.  Available for pre-order now.

The Practice of Cognitive-Behavioural Hypnotherapy is a major new clinical textbook on evidence-based practice in clinical hypnosis, written by psychotherapist and hypnotherapist Donald Robertson and published by Karnac, the UK’s leading specialist psychotherapy publishing house.  Based on extensive background research, it contains references to almost 250 different scientific journal articles and clinical textbooks on hypnosis and CBT.

About the Book

Hypnotherapy is arguably the oldest modality of psychological therapy, at least in the modern sense.  Psychologists have long attempted to conceptualize hypnosis in terms of cognitive and behavioural processes and the term cognitive-behavioural approach to hypnosis was first coined in 1974 by Theodore Barber, and his colleagues, one of the most prolific and influential researchers in the field of hypnosis.  Since then cognitive research on hypnosis has continued to evolve alongside the assimilation of modern cognitive-behavioral therapy (CBT) techniques within the framework of hypnotherapy and vice versa.  This book explores the historical and conceptual relationship between hypnotherapy and cognitive-behavioral therapies (CBT).

It proceeds to offer a modern cognitive conceptualization of hypnosis, based on the writings of James Braid the founder of hypnotherapy and drawing upon modern cognitive-behavioral research on hypnosis.  The author carefully explores the combination of hypnosis with both cognitive and behavioural interventions and ways in which methods can be adapted in the light of therapeutic principles derived from both fields.  The book aims to provide a comprehensive core text for the practice of cognitive-behavioural hypnotherapy and to facilitate further dialogue between practitioners of hypnosis and CBT.

Available for Pre-order Online

• Karnac, the publisher
• Amazon UK
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Table of Contents

Part I: The Cognitive-Behavioural Approach to Hypnosis
Chapter 1: Introduction to Cognitive-Behavioural Hypnotherapy
Chapter 2: James Braid & the Original Hypnotherapy
Chapter 3: Cognitive-Behavioural Theories of Hypnosis

Part II: Assessment, Conceptualisation, & Hypnotic Skills
Chapter 4: Assessment in Cognitive-Behavioural Hypnotherapy
Chapter 5: Case Formulation in Cognitive-Behavioural Hypnotherapy
Chapter 6: Socialisation & Hypnotic Skills Training

Part III: Cognitive-Behavioural Hypnotherapy
Chapter 7: Applied Self-Hypnosis & Coping Skills
Chapter 8: Affect: Hypnotic Exposure Therapy
Chapter 9: Behaviour: Problem-Solving Hypnotherapy (PSH)
Chapter 10: Cognition: Cognitive Hypnotherapy
Chapter 11: Conclusion & Summary

Copyright © Donald Robertson, 2010.  All rights reserved.

In 2006, Steven Jay Lynn collaborated with the Buddhist teacher Lama Surya Das, and two other researchers, in an attempt to explore the possibility of combining elements of Buddhist mindfulness meditation practice, cognitive therapy, and hypnosis, drawing on recent research in cognitive psychology.

Mindfulness versus Thought Suppression

Over the past couple of decades, enthusiasm for mindfulness meditation techniques derived from Buddhism has flourished among cognitive-behavioural therapists, inspired by the early success of Jon Kabat-Zinn’s meditation programme for stress management. Meditation and acceptance strategies have been used to counteract the tendency of many clients to try to suppress, control, or “fight” distressing thoughts. Lynn et al. refer to the recent study by Wegner and his colleagues, which found that when people tried to deliberately suppress a thought there was evidence of a “rebound effect” in which they subsequently experienced more intrusions of the thought than a control group who were simply asked to think freely about the same thing. Other studies have found evidence that emotional suppression can inhibit memory and problem-solving and increase physiological signs of nervous arousal. Lynn and his colleagues report that of nearly a hundred subjects who were asked to keep their minds blank while listening to hypnotic suggestions, only one reported any success.

Where thought-control strategies backfire, mindfulness and acceptance have been seen as offering an alternative way of responding to distressing experiences. Lynn et al. follow other contemporary cognitive-behavioural therapists in contrasting non-judgemental mindfulness and acceptance with the unhealthy suppression of thoughts and feelings. (However, they fail to mention that experimental studies on this “rebound” effect in thought suppression have produced some mixed results – q.v. Clark & Beck, 2010, for a more detailed review.) Lynn et al. also cite a 2003 meta-analysis of mindfulness-based cognitive therapy and stress reduction approaches by Baer, which found a mean effect size of 0.59 (a medium-sized treatment effect) for this approach across various emotional problems and medical conditions. In other words, it probably works, but the effects are comparable to those of other therapies and not dramatically superior to them.

Mindfulness & Metacognition

Lynn et al. appeal to a cognitive model combining elements of Adrian Wells’ influential metacognitive theory and Lynn and Kirsch’s own “response set” theory to explain the mechanism underlying mindfulness meditation and its relationship with hypnosis. Contrary to Beck’s earlier cognitive therapy model, Wells introduced a focus on the notion of “metacognition”, thinking about thinking, or beliefs about beliefs. According to this model, negative automatic thoughts aren’t particularly unhealthy in themselves, but rather they become so because of our attitude toward them. In plain English, whereas Beck’s original cognitive therapy assumed that negative thoughts play a central role in the development of emotional disturbance, Wells points to the fact that many people experience lots of negative thoughts without becoming upset by them, whereas patients with severe emotional disorders appear to be unusually disturbed by individual negative thoughts and worries. Mindfulness meditation, likewise, can be seen as an attempt to adopt a more detached attitude toward our stream of consciousness, and thereby to modify our thinking about thinking, i.e., to see automatic (spontaneous) thoughts as relatively transient and harmless, rather than important and dangerous. Indeed, Beck has recently assimilated many aspects of Wells’ metacognitive approach into his revised cognitive therapy for anxiety (Clark & Beck, 2010).

Curiously, Lynn et al. don’t mention the fact that Wells’ metacognitive model raises serious problems for hypnotherapy because it suggests that the assumptions often made by hypnotherapists about the “power of thought” risk reinforcing maladaptive (metacognitive) assumptions held by many clients, i.e., the assumption that thoughts (including suggestions) are inherently powerful, whereas Wells teaches his clients that ideas are only as powerful as we believe them to be and we can learn to dismiss them as “mere thoughts”, lacking any real power or significance. Likewise, Lynn et al. cite the recent research by Twohig (2004), which found that by repeating a negative thought to oneself one hundred times, like a mantra or autosuggestion, subjects made it seem less believable rather than more so, as some hypnotists might assume. To borrow Wells’ terminology, hypnotism itself can be seen as a set of metacognitive beliefs rather than an altered state of consciousness or “hypnotic trance”. The belief that autosuggestions are powerful when phrased in certain ways and the strategy of attending to their meaning for a prolonged period, to the exclusion of distractions, are ways of “thinking about thinking” (metacognition), which it’s the aim of most “hypnotic inductions” to instantiate. In a sense, mindfulness meditation can be seen as a kind of “de-hypnosis” or “counter-hypnosis”, which aims to develop a metacognitive mind-set that weakens the hold of certain thoughts or suggestions, e.g., “Imagine that you are transparent, and disturbing thoughts and emotions cannot penetrate you or have any power to control your actions” (Lynn et al.), which contrasts sharply with typical preliminary hypnotic suggestions to experience certain ideas (suggestions) as powerful, controlling, and deeply penetrating into the mind, etc.

Combining Hypnosis & Meditation

Lynn et al. summarise the relevance of hypnosis to mindfulness training as follows,

1. Suggestions can be used to motivate clients to persevere with meditation practice on a regular basis.
2. Suggestions can be used to generate a patient mind-set, so that when the attention naturally wanders this is seen as normal and accepted.
3. Suggestions can be given about acceptance of things that cannot be changed.
4. Hypnosis can be used to help people avoid identification with thoughts and feelings.
5. Hypnosis can help clients to become more tolerant of unpleasant feelings.
6. Clients can be hypnotised to perceive negative thoughts as transient and unimportant.

They specifically recommend the use of the following hypnotherapy techniques in conjunction with mindfulness meditation, which generally involves exposure to aversive feelings and events in CBT,

1. Mental (“covert behavioural”) rehearsal of previously avoided situations.
2. Cue-controlled relaxation to help facilitate exposure to feared situations.
3. The use of hypnotic desensitisation to facilitate mental (“imaginal”) exposure .
4. The use of hypnotic regression or reliving as a form of imaginal exposure to traumatic memories (as in PTSD treatment).
5. The use of suggestion to help clients tolerate the discomfort and repetition of exposure therapy.

They add that the most basic use of hypnosis in combination with mindfulness-based CBT would be in the use of suggestion to directly develop an ongoing state of mindfulness. As Lynn et al. emphasise, virtually all modern researchers now take it for granted (following several well-known studies) that hypnosis does not necessarily entail any form of relaxation, although it is frequently accompanied by it. The same applies to meditation and Lynn et al. refer to a recent EEG brain imaging study in which subjects trained in relaxation showed markedly different brain activity from those trained in mindfulness meditation.

Negative Reactions

As an aside, Lynn et al. also note that a considerable body of research demonstrates the existence of transient, relatively superficial, negative reactions following standard hypnosis, i.e., things like headaches, feelings of nausea, anxiety, etc., in up to 29% of subjects. This is comparable to the rates of negative responses reported by control groups who are simply asked to sit with their eyes shut, without being hypnotised, for the same amount of time. However, similar negative reactions are also reported following meditation training, and may even be more frequent, being reported in up to 63% of subjects. Hence, we might say that although negative reactions can occur following hypnosis it may be as harmless (generally speaking) as common meditation or relaxation techniques.

References

Lynn, Steven Jay; Das, Lama Surya; Hallquist, Michael N.; Williams John C. (2006). Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives. IJCEH, 54(2), 143-166.

Clark, David A.; Beck, Aaron T. (2010). Cognitive Therapy of Anxiety Disorders: Science and Practice.

Teach Yourself How to Survive and Thrive in Any Situation

by Donald Robertson

Scheduled for publication May 2012

ISBN: 1444168711

Resilience: How to Thrive and Survive in Any Situation helps you to break negative thought patterns and find healthier ways of thinking and behaving, by drawing on a series of effective strategies and therapeutic techniques. It uses recent innovations in cognitive-behavioural therapy (CBT) combined with elements of positive psychology, and traditional psychological therapies to help you build a complete toolkit for dealing with challenging times. The book also draws upon classical Socratic philosophy to provide a wider context for resilience-building.

This book is a complete course in resilience training, covering everything from building resilience to specific problems to developing long-term strengths from mindfulness and valued action. Each chapter contains an assessment test, case studies, practical exercises and reminder boxes and concludes with a reminder of the key points of the chapter (Focus Points) and a round-up of what to expect in the next (Next Step), which will whet your appetite for what’s coming and how it relates to what you’ve just read.

About the Author

Donald Robertson is a psychotherapist with a private practice in Harley Street. He is a CBT practitioner specialising in treating anxiety and building resilience and director of a leading therapy training organisation. He is the author of many journal articles and three books on therapy, The Philosophy of CBT, The Discovery of Hypnosis, and The Practice of Cognitive-Behavioural Hypnotherapy, and blogs regularly from his website www.londoncognitive.com.

Pre-Order Online

Available for pre-order online from….

• Amazon
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• Blackwells

(Some of the material for this post is derived from the forthcoming book The Practice of Cognitive-Behavioural Hypnotherapy. Copyright (c) Donald Robertson, 2011. All rights reserved.)

A well-known example of an evidence-based approach to relaxation skills training is the “Applied Relaxation” protocol developed in Sweden by the psychologist Lars-Goran Öst, currently a professor at the University of Stockholm, and his colleagues (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987). It developed out of Edmund Jacobson’s Progressive Muscle Relaxation, Wolpe’s Systematic Desensitisation, and a variety of “coping skills” approaches to anxiety management that evolved in the 1970s. The following account is based on Öst’s original protocol and the self-help version published by Davis et al. (Davis, et al., 1995 pp. 65-74; Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987). Although essentially a form of modern behaviour therapy, Applied Relaxation has also been used in combination with cognitive restructuring as part of a cognitive-behavioural therapy (CBT) approach.

Applied Relaxation consists of a very simple treatment protocol employing relaxation coping skills, which has been adapted for use with a range of problems, and supported by a number of well-designed research studies. It has met critical appraisal criteria for being classed as an Empirically-Supported Treatment (EST) for panic disorder and research has also supported its efficacy in the treatment of generalised anxiety disorder (GAD) and, to some extent, for specific phobias, headache, pain, epilepsy, tinnitus, and other conditions. It’s also been recommended for general management of worry and stress, i.e., for subclinical problems.

Overview of the Applied Relaxation (AR) Protocol

The full text of a journal original article by Prof. Öst describing the method in detail is currently available online at this link.

Components of Applied Relaxation

In brief, Applied Relaxation begins with training in Progressive Muscle Relaxation, which is gradually developed into a cue-controlled relaxation coping skill, and systematically applied during in vivo exposure to feared situations. The original protocol takes about 10-12 sessions, following assessment, and the specific stages of treatment are as follows,

1. Assessment, formulation, and self-monitoring, which Öst seems to imply takes 2-3 sessions prior to training
2. Progressive Muscle Relaxation, lasting 2-3 weeks/sessions
3. Release-only relaxation, lasting 1-2 weeks/sessions
4. Cue-controlled relaxation, lasting 1-2 weeks/sessions
5. Differential relaxation, lasting 1-2 weeks/sessions
6. Rapid relaxation, lasting 1-2 weeks/sessions
7. Applied relaxation (application training), lasting 2-3 weeks/sessions
8. Maintenance

1. Assessment & Formulation Phase

The full protocol begins with behavioural analysis and self-monitoring, usually carried out over three weeks. Clients are asked to begin during the first week by recording their experiences on a very simple self-monitoring form that contains the following three headings: Date, Situation, and Intensity (rated 0-10). In the second week, a column is added headed “Reaction (What did you feel?)”, and finally, in the third week, a column is included headed “Action (What did you do?”). The final self-monitoring form, therefore contains headings as follows,

• Date/Time
• Situation
• Reaction (What did you feel? Focus on the earliest signs.)
• Intensity (0-100%)
• Action (What did you do?)

Öst introduces clients to a three-system conceptualisation model of anxiety (or stress) that distinguishes between physiological sensations, behaviour, and cognitive (subjective) responses. The emphasis of assessment and conceptualisation is on helping the client spot the signs of stress, especially the earliest stages of the response developing. This tends to particularly involve identifying common physiological sensations, such as muscles tensing or heart rate increasing, and environmental antecedents such as typical events or situations that are associated with elevated stress. Öst recommends presenting the treatment rationale to clients as follows,

One good way of breaking this development [of anxiety] is to focus on the physiological reactions and learn not to react so strongly. The method we are going to use to achieve this is called applied relaxation. The aim of this technique is to learn a skill of relaxation, which can be applied very rapidly and in practically any situation. This skill can be compared to any other skill, e.g. learning to swim, ride a bike, or drive a car, in that it takes time and practice to learn, but once you have mastered it you can use it anywhere. You are not restricted to the calm and non-stressful situation in my office or your own home. The goal is to be able to relax in 20-30 sec and to use this skill to counteract, and eventually get rid of, the physiological reactions you usually experience in phobic situations. To achieve this we are going through a gradual process starting with tensing and relaxing different muscle groups. This takes about 15 min, and you are to practice it twice a day. Then we start to reduce it by taking the tension part away, just relaxing, which takes 5-7 min. The next step teaches you to connect the self-instruction “Relax” to the bodily state of relaxation. Then we teach you to do different things while still being relaxed in the rest of your body, and also relaxing while standing and walking. After that it is time for the rapid relaxation, which you practice many times a day in non-stressful situations. Finally, you reach the stage of applying the skill in phobic situations, and I will take you to different anxiety arousing situations coaching you how to apply the relaxation at the first signs of anxiety in these situations. Applied relaxation is thus a skill that most people can acquire with the right instructions and a lot of practice. It is a “portable” skill that can be used in almost any situation and is not restricted to phobias, but can be used in other situations, e.g. when having problems in falling asleep. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987)

2. Coping Skills Training Phase

2.1 Progressive Muscle Relaxation

The first phase of actual Applied Relaxation training consists of Jacobson’s Progressive Muscle Relaxation technique, which Öst derives directly from the abbreviated approach introduced by Wolpe and Lazarus as part of Systematic Desensitisation (Wolpe, et al., 1966; Jacobson, 1938). This training is divided across the first 2-3 sessions, the first of which focuses on relaxing the head and arms (hands, arms, face, neck, and shoulders), to which are added, in the second session, relaxation of the torso and lower body (back, chest, stomach, breathing, hips, legs, and feet). In Öst’s version, each muscle group is tensed for only five seconds, much abbreviated from Jacobson’s original method, followed by 10-15 seconds of relaxation. In Jacobson’s original approach, the aim is to learn to keep relaxing the rest of the body while tensing individual muscle groups, i.e., to only tense the muscles you’re deliberately using, which helps create a bridge to the “differential relaxation” stage (Jacobson, 1938). At the end of the procedure, the client rates their level of tension on scale (0-100%), similar to a traditional SUD scale, where zero means absolute relaxation and 100% means maximum tension – the same self-rating scale used during homework. Although people do normally find it easier to relax when lying down, training begins in a seated upright position, as the purpose is to develop a coping skill that will generalise to situations where the client is physically active. The same relaxation routine is to be practised twice daily for homework, sessions typically lasting about 15-20 minutes, with each recorded on a homework form for review during sessions.  The headings of a “Relaxation Homework Record” include,

• Date/Time
• Component (Technique)
• Tension Before (0-100%)
• Tension After (0-100%)
• Duration (Minutes)
• Comments (Any difficulties?)

2.2 Release-only Relaxation

The next phase of Applied Relaxation, like the original Progressive Muscle Relaxation approach, focuses on “release-only relaxation” training for an additional 1-2 weeks. In this phase, the initial tensing of muscles is omitted, some basic skill having been acquired in closely studying the contrasting sensations of tension and relaxation. This also means a reduction in the time taken to induce relaxation from 15-20 minutes to 5-7 minutes. The therapist verbally prompts the client to “Breathe with calm, regular breaths and feel how you relax more and more for every breath… Just let go… Relax your forehead… eyebrows… eyelids… jaws… tongue and throat… lips… your entire face…”, etc. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987). The client then scans their body for any remaining tension and tries to relax completely. However, if the client does find tension creeping back into a muscle group during release-only relaxation they are to revert to the original tension-release technique, for that part of the body alone.

2.3 Cue-controlled Relaxation

The next phase, cue-controlled relaxation, involves training in a “verbal cue” or “self-instruction” to induce relaxation more quickly, usually in around 2-3 minutes, by using the word “RELAX”, which is practised for another 1-2 weeks. This is apparently conceptualised by Öst as a process of conditioning the relaxation response to the verbal stimulus (“RELAX”). During the session the client relaxes as deeply as possible using the release-only approach, signalling when they have done so by raising a finger. The client then focuses on their breathing, while the therapist repeatedly says the words “INHALE”, just before each inhalation, and “EXHALE”, before each exhalation, five times in a row. The therapist then fades this verbal prompt and the client takes over using her own self-instruction by saying “INHALE” and “RELAX” internally (covertly), in a similar manner. After about a minute, the therapist begins repeating the words again, about five times, and the client takes over again, repeating the process above, and once more after a break of about fifteen minutes. The therapist should ask the client to estimate how long it took them to relax completely, and feedback the correct answer, because, as Öst points out, clients typically over-estimate the duration. This routine should also be practised about twice per day, to help condition an association between the verbal cue “RELAX” and rapid release-only relaxation.

2.4 Differential Relaxation

The next phase involves “differential relaxation, again derived from Jacobson’s approach, which consists of learning to relax while using some muscles. The client is asked to induce cue-controlled relaxation while seated in a hard chair or standing, and to remain relaxed while moving their head or arms, or legs, etc., and finally while walking. Emphasis is placed on further reducing the time taken to induce relaxation, which typically comes down to 60-90 seconds, according to Öst.

2.5. Rapid Relaxation

This is followed by a “rapid relaxation” training phase, which aims to help the client relax in vivo, in naturally stressful situations, while further reducing the time taken for relaxation to 20-30 seconds. The client is asked to relax 15-20 times each day for homework. Obviously, this means the technique is used very frequently throughout the day, and so cues are identified to act as reminders, such as each time the client checks the time on a watch or clock, or opens a door, etc. Sticky notes or other reminders can be used in the work or home environment to act as additional reminders. The rapid form of cue-controlled relaxation consists in taking three deep breaths, saying “RELAX” internally after each one, before exhaling slowly. The body is then scanned for any remaining tension, and the client tries to maintain maximum relaxation in the real-world situation.

3. Application & Maintenance Phase

3.1 Application

The “application” phase usually begins after roughly 8-10 sessions of preceding training, and involves brief exposure to a wide variety of anxiety-provoking stimuli and situations. The client is encouraged to use their cue-controlled relaxation coping skill immediately prior to exposure, and to continue to use the technique during exposure, in response to any initial signs of escalating tension. Exposure using Applied Relaxation typically takes 10-15 minutes, much briefer than normal prolonged exposure sessions, which can last 1-2 hours. However, the aim is not to extinguish anxiety completely but rather to learn to cope with it by using cue-controlled relaxation as a coping strategy. The client may be exposed in vivo to feared objects or events, or through interoceptive exposure to panic sensations, or using imaginal exposure, especially for feared catastrophes in worry and GAD.

3.2 Maintenance

Training is followed by a “maintenance” programme to help ensure that the coping skill further generalises to different situations in the future and is not simply forgotten. To help maintain the skill, clients are asked to scan their body at least once each day and use their rapid relaxation method to dispel any tension identified, and to practice either differential or rapid relaxation at least twice per week. The client may also keep the therapist updated by posting them records of their progress, e.g., for a period of six months after treatment.

The Role of Awareness Training in Relaxation Therapy

Copyright © Donald Robertson, 2011.  All rights reserved.

Training in Applied Relaxation can be divided into three broad stages (see diagram).

1. Assessment

Where information is gathered on the problem and its background.  At this stage self-monitoring also begins, which tends to involve increasing awareness of automatic thoughts, actions, and feelings across different situations.  This can often be seen as a form of “awareness training”, which potentially overlaps with everyday mindfulness of the kind acquired through Buddhist meditation practices.  An important goal of this stage is to identify the range of trigger (“high risk”) situations in which the problem tends to occur, modulating factors that make those situations either easier or harder to cope with, and any “early warning signs” that tension or anxiety are beginning to develop. 

2. Skills Training

A variety of coping skills can be learned in therapy and different CBT approaches tend to emphasise different ones, including a variety of different types and methods of relaxation.  However, Applied Relaxation mainly employs a special technique of muscle relaxation known as “Progressive Relaxation” (PR), developed at the start of the 20th century by the physiologist, Prof. Edmund Jacobson.  (See www.progressiverelaxation.org for an excellent sketch of his life and work.)  Progressive relaxation was originally intended as a method of systematically training people to become more aware of the way they use their muscles, leading to greater relaxation.  It therefore complements the goals of awareness training through self-monitoring.

3. Application & Maintenance

During this stage, the coping skills or relaxation techniques learned are systematically applied to the problem situations identified during the initial assessment and self-monitoring stage.  This may be done first in role-play, through mental rehearsal, using the imagination, and, most importantly, through gradually more demanding tasks or situations related to the problem in the real world.  Once the main problem has been dealt with adequately, emphasis may shift on to learning to cope with a wider range of situations.  Finally, treatment ends by focusing on the prevention of relapse and maintaining positive gains over the longer-term.

Self-Monitoring and Awareness Training

This article will focus on the “self-monitoring” stage, as a means of increasing awareness, as this often leads to a reduction in the problem itself, just through mindful observation, without any specific coping skills necessarily having to be learned or used.  People are generally quite unaware of the way they tense their bodies and becoming more mindful and self-aware can sometimes break the habit.  Indeed, people generally complain of “being tense”, phrasing the problem in the passive voice (“I am tense”), rather than talking about “tensing” specific muscles (“I tense my neck”), using the active voice.  Of course, this tension is usually automatic and happens without deliberate effort or conscious awareness most of the time.  By simply becoming more aware of the process of tension, in everyday life, we can reduce its frequency and intensity, replacing mindless automatic tension with mindfulness.  Becoming more aware of your bodily sensations, thoughts, feelings and actions, can be likened to learning to “listen” more closely to the wisdom embodied in your emotions.  For example, Charles Darwin observed that we humans, like our animal ancestors, tend to automatically frown, by tensing the muscles of the forehead, when we meet with some difficulty or frustration.

“Subtle (“low-intensity”) early warning signs are to be treated as “cues to cope”, like a green traffic light, acting as a signal to immediately respond with the coping skills learned in the next stage, so that the problem can be repeatedly “nipped in the bud” at the earliest stage. The development of tension or anxiety can be seen as a sequence of steps, each one representing a “choice point” or opportunity to stop and think, or to engage in alternative behaviour.  A good “socialisation” exercise, to help you understand the concept of spotting early warning signs and begin applying it to your own life, is as follows,

1. “How do you know when other people are tense?” Brainstorm a list of observable signs that other people are becoming tense, e.g., in their mannerisms, facial expression, voice, etc. Try to make your list as exhaustive as possible. Common themes include frowning, staring, anxious speech, rigid posture or movements, etc.
2. “How does that work?” Make notes on what physically causes the changes you’ve listed. For example, if you mentioned people speaking more rapidly, carefully consider how that might be caused by changes in their breathing or muscle use. When people frown, what muscles are they using? What other changes are associated with that? For example, when people frown do they also move their head and body differently, change their gaze, or speak differently?
3. “When do you do that?” Notice where and when you do similar things with your body and behaviour. What does that feel like inside? What thoughts and sensations are you experiencing at the time? For example, notice where you are and who you’re with when you frown and what you’re feeling and thinking as you do so.

Think in terms of shifting your overall “orientation” or attitude toward your body, adopting a more mindful and body-centred way of life.  If you like, you can treat this as a kind of behavioural experiment, taking a “trial-and-error” approach to body-focused mindfulness for a few weeks.  It can be helpful to keep a personal journal, recording what happens and your reflections on the wider significance of what you observe for your individual problems and the rest of your life in general.

Keeping a Tally

One of the simplest methods of self-monitoring is to keep a running tally for a week or more of certain events.  For example, you might simply tick a page in your diary to keep count of how many times you notice tension creeping into your muscles each day.  You might also focus on counting the number of times you tense specific groups of muscles, such as your forehead, neck, jaw, or shoulders, etc.  Doing this will help you keep a very simple measure of your progress as you’ll be able to see whether the habit of tensing muscles decreases in response to learning relaxation coping skills.  It will also help you to become increasingly aware of the typical trigger situations and times of day when tension is most common.  Finally, it usually leads to increased self-awareness of the “early warning signs” of tension, which you will inevitably find yourself on the lookout for.  This will tend to make you more aware of your muscle use in general, throughout the day, as long as you continue to deliberately monitor your automatic behaviour or keep a tally.

Frequent Self-Rating & Running Log

Another good initial strategy involves self-rating your level of tension (or anxiety, anger, etc.) from 0-100% and then noting down in a running log what specific signs of tension you observed that led you to give yourself that specific number as a rating. This should be done carefully, and treated as an opportunity to patiently reflect on your thoughts and feelings, etc. To put it another way, you might pose the question to yourself: “Why didn’t I rate my tension as 0%?” and note down the signs (“cues”) that your self-rating was based upon. How often should you do this? Initially, it’s a good idea to do it frequently throughout the day, but particularly at times when you notice tension or other problems occurring. You might get into a routine of rating your tension every other hour throughout the day, or place post-it notes around your home or workplace as a reminder to self-rate whenever you notice them.

Self-Monitoring Record Sheet

A slightly more elaborate method, used in standard Applied Relaxation, involves keeping a simple self-monitoring record sheet with the following information,

1. The date and time when the tension occurred
2. The situation where the tension occurred
3. The intensity of the tension or anxiety, rated on a simple 0-100% scale
4. The earliest reactions spotted, i.e., early warning signs of tension such as starting to hunch your shoulders, or fidget with your hands or feet, sensations of pain in specific areas, anxious thoughts, etc.

A special effort is made to spot early warning signs of tension and record them, so that the habit can be interrupted at the earliest possible stage.  Eventually another column can be added to record what was done in response to the early warning signs of tension, i.e., what specific coping skills were used, followed by a re-rating the level of tension 0-100%.  In other words, you should eventually begin to record your level of tension immediately before and after using relaxation techniques, so that you have a record of how effective your coping has been.

Mental Imagery Rehearsal

Mental imagery techniques, which make good use of the imagination, can also be powerful ways of heightening self-awareness.  In therapy, it’s common during assessment to ask the client to close their eyes and relive a recent event, describing their responses in detail, with the aid of prompts from the therapist, and perhaps in slow motion.  Sometimes the client might be asked to imagine themselves at the point when tension or anxiety was first noticed, then to go back a few minutes and relive in detail the events, and their reactions, immediately preceding the full problem.  This helps to raise awareness of the sequence of reactions, including early warning signs, and to take away the “automatic” feel of events.  Likewise, the client may be asked to deliberately, in slow motion, make themselves tense or anxious, in the way they normally do automatically, and then to remove the feeling again several times in a row, in order to help them study the sequence of their reactions: thoughts, actions, and feelings.  In a sense, tension-release exercises, such as Jacobson’s “progressive relaxation”, perform a similar function by allowing people to tense muscles systematically and study the sensations in detail – the goal being to raise awareness of their “muscle sense” and reduce automatic tension in daily life.

Copyright ©Donald Robertson, 2011.  All rights reserved.

Workshops on Evidence-Based Relaxation Skills Training

Relaxation has been described as the “aspirin” of stress management.  However, in recent decades relaxation techniques have declined in popularity.  Nevertheless, a long-standing and robust evidence-base supports the use of well-designed relaxation therapy approaches for a wide range of problems.  Among the most effective relaxation techniques are those which promote awareness of muscular tension and the progressive relaxation of muscles beyond their normal resting level, something which appears to have greatest benefit when applied systematically to counteract tension in response to “early warning signs” of tension, to nip stress responses in the bud. 

Aaron T. Beck, the founder of cognitive therapy, the main alternative to relaxation training, has recently published a radically-revised treatment manual for anxiety disorders.  Following a review of the outcome research on Applied Relaxation for Generalised Anxiety Disorder (GAD), Beck concludes that it “is an alternative treatment for GAD that can produce results equivalent to cognitive therapy.”  Elsewhere he elaborates,

The role of relaxation training in treatment of anxiety disorders continues to generate considerable debate. The long-established tradition of teaching progressive relaxation to relieve anxiety may still have some efficacy for the treatment of GAD and possibly panic disorder, especially when the more systematic and intense applied relaxation protocol is employed.  However, relaxation training for OCD and social phobia is unwarranted, although it may still have some value in PTSD for those with heightened generalised anxiety. (Clark & Beck, 2010, p. 267)

In fact, historically, relaxation techniques, such as Systematic Desensitisation, have frequently been used in the treatment of specific phobias and social anxiety, as well as subclinical stress management.  Beck himself still recommends the use of relaxation techniques in cognitive therapy for general stress management.

A recent survey of the evidence-base for relaxation entitled “relaxation training for anxiety: a ten-years systematic review with meta-analysis” was published in 2008 by Manzoni et al.  Four researchers from psychology departments in Italian universities identified 27 studies on relaxation techniques used in the treatment of anxiety, which met their inclusion criteria for statistical analysis.  On average, meta-analysis showed that relaxation training had a “medium to large” effect on symptoms of anxiety.  The authors conclude: “The results show consistent and significant efficacy of relaxation training in reducing anxiety.”  Comparison of different techniques of relaxation showed that methods based on Jacobson’s Progressive Muscle Relaxation, including “Applied Relaxation”, had the largest effect size, and were superior to meditation and other approaches.  However, the authors conclude that in general, Progressive Relaxation and Applied Relaxation (muscle relaxation), Autogenic Training (autosuggestion), and meditation were more effective than other methods, especially those combining several techniques,

Progressive relaxation, applied relaxation, autogenic training and meditation show great efficacy in decreasing anxiety against the combination of more than one methods and the other techniques.  The “other techniques” treatment type shows the lowest score. (Manzoni et al., 2008)

Edmund Jacobson’s approach to muscle relaxation formed the basis of early behaviour therapy, particularly the “Systematic Desensitisation” method of Joseph Wolpe.  However, this has led to the development of a number of other behaviour therapy and CBT approaches, particularly the Applied Relaxation approach of Ost and Borkovec.  The table below gives a summary of some of the main variants of Progressive Relaxation,

Some Common Variants of Progressive Relaxation used in CBT

1. Jacobson’s Progressive Relaxation (PR) and Differential Relaxation (DR)

(Jacobson, Progressive Relaxation: A Physical and Clinical Investigation of Muscular States and Their Significance in Psychology and Medical Practice, 1938; Jacobson, You Must Relax, 1977; McGuigan & Lerher, 2007).

2. Systematic Desensitisation (SD) – An abbreviated version of Jacobson’s method, employing repeated imaginal exposure.

(Wolpe, Psychotherapy by Reciprocal Inhibition, 1958; Wolpe, The Practice of Behavior Therapy (Fourth Edition), 1990; Wolpe & Lazarus, Behavior Therapy Techniques: A Guide to the Treatment of Neuroses, 1966)

3. Abbreviated Progressive Relaxation Training (APRT) – Modern hybrid of Jacobson and Wolpe’s approaches.

(Bernstein, Borkovec, & Hazlett-Stevens, New Directions in Progressive Relaxation Training: A Guidebook for Helping Professionals, 2000; Bernstein, Progressive Relaxation: Abbreviated Methods, 2007)

4. Self-Control Desensitisation & Stress Inoculation Training (SIT) – “Coping skills” variations of Wolpe’s method based more on operant conditioning principles.

Relaxation is an optional coping skill in SIT but in practice it has been emphasised in most studies on anxiety or pain.

(Goldfried & Davison, Clinical Behaviour Therapy, 1976; Bernstein, Borkovec, & Hazlett-Stevens, 2000; Meichenbaum, Cognitive-Behavior Modification: An Integrative Approach, 1977; Meichenbaum, Stress Inoculation Training, 1985; Meichenbaum, Stress Inoculation Training: A Preventative and Treatment Approach, 2007; Goldfried, Systematic desensitization as training in self-control, 1971)

5. Applied Relaxation (AR) – Modified version of systematic desensitisation, with more emphasis on in vivo exposure, associated with Öst and Borkovec.

(Öst, 1987; Bernstein, Borkovec, & Hazlett-Stevens, 2000; Borkovec, Applied Relaxation and Cognitive Therapy for Pathological Worry and Generalized Anxiety Disorder, 2006; Borkovec & Sharpless, Generalized Anxiety Disorder: Bringing Cognitive-Behavioural Therapy into the Valued Present, 2004)

Workshops on Evidence-Based Relaxation Skills Training

What Works and What Doesn’t

Copyright © Donald Robertson, 2002-2011.  All rights reserved.

• See the UK College website for details of our two-day certificate workshop on cognitive-behavioural hypnotherapy for smoking cessation, approved by the National Council for Hypnotherapy (NCH) for CPD.

Numerous research studies show hypnotherapy to be effective as a means of stopping smoking.  However, results are highly variable; more so perhaps than for any other problem.  Some approaches to hypnotherapy appear inadequate, such as direct/scripted suggestion or regression, whereas others have been found to work much better, usually by integrating hypnosis with elements of established cognitive and/or behavioural therapy.

Nevertheless, many hypnotherapists employ simple direct suggestion scripts for smoking cessation.  I’ve heard several times of clients being treated by hypnotherapists who read a script to them from a sheet of paper or leave the room while they play a recorded script.  (That’s clearly not very professional, of course!)  By contrast, most modern researchers and evidence-based practitioners agree that direct verbal suggestion, of the kind found in most CDs and scripted approaches, is the bedrock of hypnotherapy for smoking cessation but totally inadequate by itself to achieve significant outcomes,

The most basic procedure, one on which you can build your own approach, involves a hypnotic induction and deepening routine, followed by suggestions that from now on the client will be a non-smoker and have no desire to smoke ever again. This approach is unlikely to yield an abstention rate (continuous over, say, 1 year) that is much above the 5-7% rate achieved by those smokers who spontaneously decide to quit. (Heap & Aravind, 2002: 299)

A more detailed review of the research on smoking cessation (and weight loss) hypnotherapy concluded that direct suggestion hypnosis was not particularly effective when used alone (Waddon & Anderton, 1982). Hence, hypnotherapy methods for smoking cessation which are based on simple direct suggestion scripts are unlikely to be anywhere near as effective as more sophisticated multi-component treatments.  The most effective treatments for smoking cessation, across the board, are “multi-component” in nature and tend to involve several cognitive-behavioural strategies used in conjunction.  In the case of hypnotherapy, the most effective approaches tend also to be highly multi-component and to incorporate elements of cognitive-behavioural therapy (CBT).

Multi-Component / Cognitive-Behavioural Hypnotherapy

As no single (“uni-modal”) therapy intervention has been found to be particularly effective for smoking cessation when used in isolation, the general consensus is that a package or combination of techniques specially tailored for the problem is indicated, i.e., a multi-component or “multi-modal” approach.

Cognitive-behavioural approaches to smoking cessation typically include a range of different interventions designed to tackle the problem at different levels, and can therefore also be designated “broad spectrum” or “multimodal.” The combination of hypnotherapy and CBT called “cognitive-behavioural hypnotherapy” (CBH) is even more broad spectrum in nature, as it combines a wide range of different, evidence-based, interventions. As Marks, a specialist in this area, observes, “CBT methods can improve the results of any treatment programme.” (2005, 16). The inclusion of hypnosis also seems to generally improve outcomes, so it is not surprising that the combination of a tailored CBT and hypnosis package might be considered the treatment of choice for smoking cessation.

In 2000, Green and Lynn conducted a careful systematic review of the research on hypnotherapy for smoking cessation which concluded that hypnotherapy was a promising treatment for smoking but that it probably achieved its results mainly by the incorporation of cognitive and behavioural strategies rather than because of the inherent power of hypnotic suggestion alone,

This article reviews 56 studies of hypnosis and smoking cessation as to whether the research empirically supports hypnosis as a treatment. Whereas hypnotic procedures generally yield higher rates of abstinence relative to wait list and no treatment conditions, hypnotic interventions are generally comparable to a variety of nonhypnotic treatments. […] Furthermore, in many cases, it is impossible to rule out cognitive/behavioral and educational interventions as the source of positive treatment gains associated with hypnotic treatments. Hypnosis cannot, as yet, be regarded as a well-established treatment for smoking cessation. Nevertheless, it seems justified to classify hypnosis as a “possibly efficacious” treatment [according to APA criteria for empirically-validated treatments] for smoking cessation. (Green & Lynn, 2000)

In short, hypnosis may work well as a means of enhancing a combination of cognitive-behavioural interventions, and may even be superior to standard CBT in some cases, but direct hypnotic suggestion used alone is unlikely to be effective.  Individuals seeking hypnotherapy to stop smoking would therefore be well-advised to check whether their therapist intends to employ a scripted or direct suggestion approach alone or whether they plan to work according to an evidence-based “multi-component” model, incorporating a number of cognitive-behavioural strategies supported by the clinical research literature.

Addendum: Dave Elman & Regression Hypnotherapy

We still hear, albeit very rarely, of therapists employing regression as their primary technique in smoking cessation.  (Despite the fact that Sigmund Freud, the originator of the hypnotic regression approach died from mouth cancer due to a cigar-smoking habit he was unable to extinguish.)  Regression therapy has never been widely employed as a treatment for smoking cessation and is not supported by any credible research evidence in this area. As Spiegel, an authority on hypnotherapy for smoking cessation, writes,

To delve into the reasons they started to smoke is irrelevant, because at the time most adults of today [1978] started smoking it was not known to be harmful. No matter what reasons are uncovered, the critical information is not there. Smoking was not known with any certainty to be malignant until 1964. The reasons for stopping the habit were then based on information not available when the smoking started. This specific habit became a fair starting point to study habit change without taking the time to explore the [historical] reasons behind the habit. (Spiegel & Spiegel, 1978: 210)

In other words, after the US Surgeon General’s report condemning smoking was published in 1964 a strong motivation to stop smoking was introduced which people were not widely aware of when they initially developed the habit. This suggested that “regression to cause” might be irrelevant in treating these clients and so the cognitive-behavioural treatment of smoking, focused on the here and now, became common practice.

Dave Elman, one of the most popular and influential advocates of regression hypnotherapy, emphasised his failure with smoking cessation, in the following exchange,

Doctor: What can we do about the cigarette habit?

Elman: Hypnosis is of as little value in permanently correcting the cigarette habit as superficial suggestion is in correcting alcoholism. I have succeeded in giving hypnotic suggestions to people who declared sincerely that they wanted to stop smoking or stop drinking, and I have managed to make the suggestions hold for as long as a month, sometimes for two or three months or even longer. But if you follow up these same cases six months or a year after the hypnotic suggestions have been given, you find that the patients are smoking or drinking as much as ever; the hypnotic suggestions have had no permanent effect. […] Moreover, since the smoking habit isn’t usually based on any very serious emotional disturbance, even hypnoanalysis is of little value. You cannot unearth and correct a traumatic event when there is no trauma. (Elman, Hypnotherapy, 1964: 324-325)

Of course, Elman was himself a smoker and apparently smoked in front of his class when hypnotising patients. However, Elman was also unfamiliar with the principles of cognitive-behavioural therapy, such as relapse prevention, cognitive restructuring, etc. His limited set of tools, even in the hands of an acknowledged master of his art, were deeply unsuited to the task of smoking cessation. However, subsequent researchers reported considerably more success employing hypnosis in conjunction with simple cognitive-behavioural methods. Consequently, even advocates of hypnoanalysis have tended to favour the combination of hypnosis with elements of CBT or behaviour therapy.

• See the UK College website for details of our two-day certificate workshop on cognitive-behavioural hypnotherapy for smoking cessation, approved by the National Council for Hypnotherapy (NCH) for CPD.

Copyright © Donald Robertson, 2010.  All rights reserved.

This is an excerpt from the book The Philosophy of Cognitive-Behavioural Therapy (CBT).  Find out more about the book at www.philosophy-of-cbt.com

The “reserve clause” (exceptio) is perhaps one of the most basic underlying concepts of Stoicism. In a sense, it merely formulates from a different perspective what I have termed the “Stoic Fork”, the distinction between that which is under one’s control and that which is not. It is a verbal clause added to the end of each sentence concerning one’s own actions or intentions. Or rather, it is the concept which would be implied by adding such a clause, the idea that it expresses, because I would assume that the Stoic went from learning to merely say the reserve clause to actually experiencing it. The clause itself can take several forms, e.g., “God willing”, “fate willing”, “nature permitting”, “if nothing prevents me”, etc. In each case, however, the underlying idea is basically the same. A common proverb expresses it thus: “Do what you must; let happen what may.”

Seneca writes that the Stoic Sage undertakes every action with the reserve clause: “If nothing shall occur to the contrary”’ (Seneca, 2009, p. 116).

The wise man considers both sides: he knows how great is the power of errors, how uncertain human affairs are, how many obstacles there are to the success of plans. Without committing himself, he awaits the doubtful and capricious issue of events, and weighs certainty of purpose against uncertainty of result. Here also, however, he is protected by that reserve clause, without which he decides upon nothing, and begins nothing. (Seneca, 2009, p. 116, modified)

He defines the reserve clause by the following formula,

I want to do such and such, as long as nothing happens which may present an obstacle to my decision. (Seneca, in Hadot, 1998, p. 193, modified)

He gives the example, “I will sail across the ocean, if nothing prevents me,” and elaborates,

Nothing happens to the Sage contrary to his expectations, for he foresees that something may intervene which prevents that which he has planned from being carried out. […]

What he thinks above all is that something can always oppose his plans. But the pain caused by failure must be lighter for one who has not promised success to himself beforehand. (Seneca, in Hadot, 1998, p. 205)

The Stoic therefore makes a point of qualifying the expression of every intention, by introducing a distinction between his will and external factors beyond his control. The Sage thereby holds two complementary propositions in mind simultaneously, viz.,

1. I will do my very best to succeed.

2. While simultaneously accepting that the ultimate outcome is beyond my direct control.

It implies, “I will try to succeed, but am prepared to accept both success and failure with equanimity”, and thereby recognises human fallibility. Centuries later, Christian theologians would signify the same notion by appending the letters “D.V.” or Deo Volente (“God Willing”) to their correspondence.

The concept of goal-directed behaviour was traditionally illustrated in classical philosophy by the metaphor of an archer. (Apollo, the patron god of philosophy, was also the god of archery.) The archer can notch his arrow and draw his bow to the best of his ability, but once the arrow has flown he can only wait to see if it hits the target: an unexpected gust of wind could blow it off course. The intention is under his control, as is the act of setting the arrow in motion, but the result is outside his sphere of direct influence and, at least in part, down to “fate” – by which is meant merely external variables. In the third book of De Finibus, Cicero uses the analogy of the archer shooting an arrow at a target. His ultimate wish is to hit the target, but he can only do everything within his power to shoot his arrow straight, and so shooting straight, as opposed to actually hitting the target, must be his primary concern, and so it is with life in general. Nowadays, we say, “All that anyone can ask is that you try your best.” Marcus Aurelius writes, ‘Thanks to action “with a reserve clause” […] there can be no obstacle to my intention’ (Meditations, 5.20).

Remember that your intention was always to act “with a reserve clause”, for you did not desire the impossible. What, then, did you desire? Nothing other than to have such an intention; and that you have achieved. (Meditations, 6.50)

Again, Epictetus puts it as follows,

For can you find me a single man who cares how he does what he does, and is interested, not in what he can get, but in the manner of his own actions? Who, when he is walking around, is interested in his own actions? Who, when he is deliberating, is interested in the deliberation itself, and not in getting what he is planning to get? (Discourses, 2.16.15)

This is a little like saying “It’s not what you do; it’s the way that you do it.” The Stoic Handbook of Epictetus likewise recommends that in addition to reminding oneself to avoid attaching emotive language to external things, we should undertake any action with this reservation: that we may always be thwarted by others, or by fortune. We should remind ourselves to view the future realistically, and to prepare to accept any obstacles calmly rather than feel frustration (Enchiridion, 4). The reserve clause can probably be correlated with the Serenity Prayer insofar as it makes a basic distinction between courageously doing what is under our control while Stoically and serenely accepting what is outside of our control, the outcome or consequences of our actions.

The Reserve Clause & REBT

We have seen that the Stoics acknowledge both irrational and rational forms of desire which could be translated in terms of the distinction between “craving” and “preference”. The reserve clause, which appears to typify the concept of rational preference (boulêsis) in Stoicism, bears a very obvious resemblance to the concept of “rational preference” in REBT. Ellis considered irrational demands, the major underlying source of most emotional disturbance, to be fundamentally exemplified by “must” and “should” statements

So REBT encourages your clients to feel strongly about succeeding at important tasks and relationships, but not to fall into the human propensity to raise their strong desires to absolutistic demands – “I must succeed or else I am worthless!” These produce dysfunctional negative feelings, especially panic and depression, that block their desires.(Ellis & MacLaren, 2005, p. 21)

The healthy alternative prescribed by Ellis is to adopt a philosophy of flexible preference which expresses a desire but also accepts the possibility of it being frustrated, e.g.,

“I must succeed, failure would be awful!”, becomes,

“I strongly prefer to succeed, but even if I fail I will accept myself fully.”

This is, of course, essentially the same “philosophical” attitude toward success or failure that the reserve clause embodied for the Stoics. Again, to put it another way, “I intend to act with wisdom and integrity, fate willing, but will accept the result of my actions with a philosophical attitude.”

We might call this philosophical stance the “take it or leave it” attitude of the Stoic Sage, who is willing to meet success or failure with equal composure. These are the Stoic qualities Marcus Aurelius appears to have deliberately sought to model from his adoptive father, the Emperor Antoninus Pius.

The way he handled the material comforts that fortune had supplied him in such abundance – without arrogance and without apology. If they were there, he took advantage of them. If not, he didn’t miss them.

This “take it or leave it” aspect of Stoicism was, of course, one of the themes in Kipling’s famous poem, If,

If you can meet with Triumph and Disaster

And treat those two impostors just the same; […]

Yours is the Earth and everything that’s in it,

And – which is more – you’ll be a Man, my son!(Kipling, 1994, p. 605)

This is sound wisdom and illustrates, once again, the extent to which Stoicism embodies a “perennial philosophy” which permeates the history of European civilisation, from philosophy and theology to poetry and the arts.

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Excerpt from The Philosophy of Cognitive-Behavioural Therapy

Copyright © Donald Robertson, 2010.  All rights reserved.

[The following excerpt comes from The Philosophy of Cognitive-Behavioural Therapy: Stoic Philosophy as Rational and Cognitive Psychotherapy by Donald Robertson, available from Amazon UK.]

Seneca provides a wonderful account of the “here and now” orientation based upon the saying of the Stoic philosopher Hecato that, ‘Cease to hope and you will cease to fear’(Seneca, 2004, p. 38).  Seneca interprets this with reference to the basic Stoic discipline of desire and aversion, which sees emotional disturbance as the result of over-attachment, or rather over-concern with external things. According to Seneca, hope and fear ‘march in unison like a prisoner and the escort he is handcuffed to’ and both embroil us in anticipated, and therefore imagined, events.

Fear keeps pace with hope. Nor does their so moving together surprise me; both belong to a mind in suspense, to a mind in a state of anxiety through looking into the future. Both are mainly due to projecting our thoughts far ahead of us instead of adapting ourselves to the present. Thus it is that foresight, the greatest blessing humanity has been given, is transformed into a curse. Wild animals run from the dangers they actually see, and once they have escaped them worry no more. We however are tormented alike by what is past and what is to come. A number of our blessings do us harm, for memory brings back the agony of fear while foresight brings it on prematurely. No one confines his unhappiness to the present. (Seneca, 2004, p. 38)

In this remarkable passage, Seneca makes observations which would not be out of place in modern psychotherapy, but in his uniquely powerful literary style. Indeed, Beck and his colleagues say something very similar with regard to the cognitive therapy of anxiety,

Anxiety is a result of projecting oneself into a dangerous situation in the future. As long as the person is in the present, there is no danger. (Beck, Emery, & Greenberg, 2005, p. 243)

The gift which allows us to contemplate the future and the past, and distinguishes us from other animals, becomes a curse when it allows us to dwell upon troubles that are not present, and may not even be real. When such projection of our thoughts across time runs amok, planning and problem-solving for the future easily become anxious worrying, whereas reflecting on what we can learn from the past may become depressive rumination. The only true reality is the present moment, where our ability to take action is centred. Elsewhere, Seneca quotes the Epicurean maxim, ‘The life of folly is empty of gratitude, full of anxiety: it is focused wholly on the future’ (Seneca, 2004, p. 62).

Another aspect of this “here and now” orientation is brought out beautifully by the Epicureans. When we find ourselves, for the first time, in the presence of something completely and utterly new, we are filled with wonder. We might imagine the world looking this way to a small child, or to a blind man who suddenly regains his sight. Over time, we become jaded and habituated to the world, though, and mundane things cease to excite us. However, by immersing ourselves more fully in the present moment, and thereby ceasing to compare it to the past, in a sense, we recapture something of its novelty. The great Latin poet Lucretius writes, ‘there is nothing so mighty or so marvellous that the wonder it evokes does not tend to diminish in time’,

Take first the pure and undimmed lustre of the sky and all that it enshrines: the stars that roam across its surface, the moon and the surpassing splendour of the sunlight. If all these sights were now displayed to mortal view for the first time by a swift unforeseen revelation, what miracle could be recounted greater than this? What would men before the revelation have been less prone to conceive as possible? (Lucretius, 1951, p. 90)

This contemplative technique also appears in Stoicism, e.g., when Seneca writes,

As for me, I usually spend a great deal of time in the contemplation of wisdom. I look at it with the same stupefaction, with which, on other occasions, I look at the world; this world that I quite often feel as though I were seeing for the first time. (Seneca, in Hadot, 1995, p. 257)

Philosophy, according to Socrates, begins with the sense of wonder, and wonder is therefore the hallmark of the philosopher (Plato, Theaetetus, 155d3). The sense of wonder, in this way, is intimately related to consciousness of the here and now.

However, the philosophical Sage is not merely wide-eyed, but also circumspect and self-possessed. The Chinese Daoist sage, Lao Tzu, said that the wise man was as cautious as someone crossing a winter stream. Epictetus says something virtually identical, when he writes that the Sage walks about cautiously, like a man wary of treading on a nail or twisting his ankle on rocky ground (Enchiridion, 38). Rather than literally being careful of every footstep, of course, Epictetus means that one should mind one’s own thinking. Elsewhere, he says that one who is making good progress in Stoicism keeps watch continually over himself, his thoughts and judgements, as he would his own deadliest enemy, ‘and one lying in wait for him’ (Enchiridion, 48). Hence, ‘you should turn all your attention to the care of your mind’ (Enchiridion, 41).

[This excerpt comes from The Philosophy of Cognitive-Behavioural Therapy: Stoic Philosophy as Rational and Cognitive Psychotherapy by Donald Robertson, available from Amazon UK.]