RELAXATION TRAINING

The primary goal of relaxation training is to alleviate autonomic arousal, which includes
symptoms like tense muscles, rapid heart rate, cold hands, and fast breathing, commonly
experienced during periods of fear and anxiety.

2. Techniques Used: Individuals engage in specific relaxation techniques designed to induce

bodily responses that counteract autonomic arousal. These techniques aim to elicit physical
changes that are opposite to the symptoms of arousal, such as reducing muscle tension,
slowing heart rate, decreasing breathing rate, and warming hands.

3. Reported Benefits: When individuals successfully achieve these contrasting bodily

responses through relaxation techniques, they often report a reduction in anxiety levels.
This indicates the effectiveness of relaxation training in managing anxiety and promoting a
sense of calmness.

4. Common Approaches: The passage mentions four common approaches to relaxation

training:
- Progressive Muscle Relaxation: Involves systematically tensing and then relaxing
different muscle groups to reduce overall muscle tension.
- Diaphragmatic Breathing: Focuses on deep, slow breathing from the diaphragm to
promote relaxation and reduce the rapid breathing associated with anxiety.
- Attention-Focusing Exercises: Described by Davis, Eshelman, & McKay (1988), these
exercises involve directing attention to specific sensations or thoughts to distract from
anxiety-provoking stimuli.
- Behavioral Relaxation Training: Described by Poppen (1988), this approach involves
incorporating relaxation techniques into daily activities and routines to promote long-term
stress reduction.

JPMR
 ● Muscle relaxation techniques have a long history of use, with some rooted in the methods
developed by nurse Annie Payson Call in 1891. Call's approach integrated muscle
relaxation, rest, and mental training to promote relaxation.

● Among the most renowned contemporary exercises are those devised by E. Jacobson in
1938 and Rippon and Fletcher in 1940.

● D. H. Yates in 1946 and Neufeld in 1951 outlined sets of exercises designed to help
individuals attain voluntary control over tension. These exercises offer a means for
individuals to actively manage their levels of tension.

Theoretical Framework:
The theoretical framework of JPMR is based on the idea that there is a close relationship
between physical tension and mental tension.
According to this theory, chronic stress and anxiety can lead to increased muscle tension, which
in turn can exacerbate feelings of stress and anxiety.
By learning to systematically tense and relax specific muscle groups in the body, individuals can
reduce muscle tension and break the cycle of stress and anxiety.
JPMR is often used as a complementary approach to medical treatment, and has been found to be
effective in reducing symptoms of a variety of medical conditions.
For example, a study published in the Journal of Psychosomatic Research found that JPMR was
effective in reducing pain and improving overall well-being in individuals with chronic pain.
JPMR EXPLANATION
The Jacobson's Progressive Muscle Relaxation (JPMR) technique is a relaxation method
developed by Dr. Edmund Jacobson in the early 1920s.
The technique involves the systematic tensing and relaxing of specific muscle groups in the
body, with the aim of reducing muscle tension and inducing a state of relaxation.
REQUIREMENTS OF JPMR
Conductive environment: The setting for relaxation is quiet and of distraction noises. The client
will be kept physically comfortable in a position.
General Instructions (Before and During Muscle Relaxation Exercise)

a) To sit on a chair as comfortably as possible. Keep your body loose... light...and free.

b) Be calm and comfortable.

c) Keep your eyes closed.

d) Avoid stray thoughts.

e) Avoid extra movements of the body.

f) Try to keep all other muscles relaxed as you exercise specific muscle group.

g) As you exercise from head to toe...observe changes like tightness and the development of light
and soothing sensations.

h) Relax by taking 3 deep breaths inhaling through nose and exhaling mouth after each step.

i) Make your body completely loose... light...and free.

BENEFITS OF JPMR
Reducing muscle tension: JPMR can help to reduce muscle tension in the body, which can be
beneficial for individuals who experience chronic muscle tension or pain.
Reducing anxiety and stress: JPMR has been shown to be effective in reducing anxiety and stress
levels in individuals who practice it regularly.
Improving sleep quality: JPMR has also been found to be effective in promoting better sleep by
reducing tension and promoting relaxation before bedtime.
Enhancing mood: JPMR has been shown to have positive effects on mood, including reducing
symptoms of depression and improving overall well-being.
CONTRAINDICATIONS OF JPMR
• Muscle or joint injury: JPMR may not be appropriate for individuals with muscle or joint
injuries, as it involves tensing and relaxing specific muscle groups in the body.
• Cardiovascular conditions: JPMR may not be appropriate for individuals with cardiovascular
conditions, as the technique can increase heart rate and blood pressure.
• Chronic pain conditions: While JPMR can be helpful in reducing muscle tension and pain, it
may not be appropriate for individuals with certain chronic pain conditions, as it may exacerbate
their symptoms.
• Cognitive impairment: Individuals with cognitive impairments may find it difficult to
understand and follow the instructions for JPMR.
• Severe mental health conditions: JPMR may not be appropriate for individuals with severe
mental health conditions, such as schizophrenia or bipolar disorder, as it may exacerbate their
symptoms.
Claustrophobia: JPMR may involve lying down in a relaxed position with eyes closed, which
may be uncomfortable or triggering for individuals with claustrophobia or anxiety related to
enclosed spaces.
Limited mobility: Individuals with limited mobility or who use mobility aids may find it difficult
to perform the muscle tensing and relaxing exercises involved in JPMR.
Individuals with OCD and other vigilance-related disorders may experience a heightened sense
of tension and vigilance, which can be exacerbated by the muscle tensing involved in JPMR.
Additionally, these individuals may be more likely to experience
intrusive thoughts or other anxiety-related symptoms during relaxation exercises, which can be
distressing and counterproductive.

AUTOGENIC TRAINING
• Autogenic training is a relaxation technique that involves focusing on physical sensations in the
body to promote relaxation and reduce stress.
• It was developed by German psychiatrist Johannes Heinrich Schultz in the 1920s.
• The technique involves focusing on sensations such as warmth, heaviness, and tingling in
different parts of the body, with the goal of inducing a state of deep relaxation.
• Autogenic training typically involves a series of exercises or visualizations designed to promote
relaxation and reduce stress, which can be practiced regularly to help manage stress and improve
overall well-being.
NEED
Autogenic training is based on the idea that the body and mind are connected, and that by
inducing physical relaxation, it is possible to promote mental and emotional relaxation as well.
• While autogenic training is often used as a relaxation technique, it has also been used in
the treatment of certain medical and mental health conditions, including anxiety, depression, and
chronic pain.

● Get set up. Before you begin, make sure to find a quiet, comfortable place to relax.
Ideally, this should be the same place you use each time you practice relaxation
techniques. You can do these exercises lying down or sitting up. Make sure to remove
your glasses and loosen any tight clothing.
● Begin with your breathing. The first step is to slow down your breathing. Make sure you
are in a comfortable position and start with slow, even breaths. Once you have controlled
breath, tell yourself, “I am completely calm.” Saying this to yourself may even be enough
to put you in a state of relaxation.
● Focus attention on different areas of your body. Start with your right arm and repeat the
phrase, “My right arm is heavy, I am completely calm,” while breathing slowly and
controlled. Do this again with your other arm and legs, always going back to “I am
completely calm.”
● Shift attention to your heartbeat. While breathing deeply, repeat to yourself six times,
“My heartbeat is calm and regular,” and then say, “I am completely calm.” This
continues on for different areas of your body, including the abdomen, your chest, and
forehead. In addition to these steps, you may also want to follow along with a voice
recording with directions. This allows you to fully relax and focus on the technique.

STAGES
There are six stages of autogenic training, each of which focuses on a different physical
sensation:
• Heaviness: The first phase involves focusing on sensations of heaviness in the arms and legs,
which can promote relaxation and reduce tension.
• Warmth: The second phase involves focusing on sensations of warmth in different parts of the
body, which can help to promote relaxation and reduce stress.
• Heartbeat: The third phase involves focusing on the heartbeat and other bodily sensations,
which can promote a sense of calm and relaxation.
• Breathing: The fourth phase involves focusing on the breath, which can help to reduce stress
and promote relaxation.
Abdominal warmth: The fifth phase involves focusing on sensations of warmth in the abdomen,
which can promote relaxation and reduce stress.
• Coolness: The final phase involves focusing on sensations of coolness in different parts of the
body, which can promote relaxation and reduce tension.

PREREQUISITES
• Before beginning autogenic training, it is important to ensure that you are in a comfortable,
quiet environment where you will not be interrupted.
• It is also important to be patient and persistent, as it can take time to learn the techniques and to
see the full benefits of the practice.
• In addition, autogenic training may not be suitable for everyone.
• It is important to consult with a healthcare provider before beginning any new relaxation
technique, especially if you have any underlying medical or mental health conditions.
• Individuals with certain conditions, such as epilepsy or schizophrenia, may need to avoid or
modify certain aspects of autogenic training to ensure their safety and well-being.

BENEFITS
• Stress Reduction: Autogenic training can help to reduce stress and promote relaxation by
inducing a state of physical and mental calm.
• Improved Sleep: Regular practice of autogenic training has been shown to improve sleep
quality, which can help to reduce stress and improve overall well-being.
• Reduced Anxiety and Depression: Autogenic training has been found to be helpful in reducing
symptoms of anxiety and depression, which can improve mental health and well-being.
• Improved Physical Health: Regular practice of autogenic training may have positive effects on
physical health, including reducing blood pressure, improving immune function, and reducing
symptoms of certain medical conditions.
LIMITATIONS
• Not Suitable for Everyone: Autogenic training may not be suitable for everyone, especially
those with certain medical or mental health conditions. It is important to consult with a
healthcare provider before beginning any new relaxation technique.
• Time and Effort: Learning and practicing autogenic training requires time and effort, and may
not be suitable for those who are unable or unwilling to commit to regular practice.
• Individual Variability: The effectiveness of autogenic training may vary depending on
individual differences in physiology, personality, and other factors.
• Not a Substitute for Medical Treatment: Autogenic training should not be used as a substitute
for medical treatment or advice. While it can be helpful as a complementary approach to health
and wellness, it is not a replacement for medical care when needed.
YOGA & MEDITATION

YOGA

HISTORY OF YOGA

Introduction:

Yoga is essentially a spiritual discipline based on an extremely subtle science, which focuses on
bringing harmony between mind and body. It is an art and science of healthy living. The word
‘Yoga’ is derived from the Sanskrit root ‘Yuj’, meaning ‘to join’ or ‘to yoke’ or ‘to unite’. As
per Yogic scriptures the practice of Yoga leads to the union of individual consciousness with that
of the Universal Consciousness, indicating a perfect harmony between the mind and body, Man
& Nature. According to modern scientists, everything in the universe is just a manifestation of
the same quantum firmament. One who experiences this oneness of existence is said to be in
yoga, and is termed as a yogi, having attained to a state of freedom referred to as mukti, nirvana
or moksha. Thus the aim of Yoga is Self-realization, to overcome all kinds of sufferings leading
to 'the state of liberation' (Moksha) or ‘freedom’ (Kaivalya). Living with freedom in all walks of
life, health and harmony shall be the main objectives of Yoga practice."Yoga” also refers to an
inner science comprising of a variety of methods through which human beings can realize this
union and achieve mastery over their destiny.Yoga, being widely considered as an ‘immortal
cultural outcome’ of Indus Saraswati Valley civilization – dating back to 2700 B.C., has proved
itself catering to both material and spiritual upliftment of humanity.Basic humane values are the
very identity of Yoga Sadhana.
History:

The practice of Yoga is believed to have started with the very dawn of civilization. The science
of yoga has its origin thousands of years ago, long before the first religions or belief systems
were born. In the yogic lore, Shiva is seen as the first yogi or Adiyogi, and the first Guru or Adi
Guru. Several Thousand years ago, on the banks of the lake Kantisarovar in the Himalayas,
Adiyogi poured his profound knowledge into the legendary Saptarishis or "seven sages”. The
sages carried this powerful yogic science to different parts of the world, including Asia, the
Middle East, Northern Africa and South America. Interestingly, modern scholars have noted and
marvelled at the close parallels found between ancient cultures across the globe. However, it was
in India that the yogic system found its fullest expression. Agastya, the Saptarishi who travelled
across the Indian subcontinent, crafted this culture around a core yogic way Of life

Conclusion:

Yoga works on the level of one’s body, mind, emotion and energy. This has given rise to four
broad classifications of Yoga: karma yoga, where we utilize the body; bhakti yoga, where we
utilize the emotions; gyana yoga, where we utilize the mind and intellect and,
kriya yoga, where we utilize the energy. Each system of Yoga we practice would fall within the
gamut of one or more of these categories. Every individual is a unique combination of these four
factors. "All the ancient commentaries on Yoga have stressed that it is essential to work under
the direction of a Guru.” The reason being that only a Guru can mix the appropriate combination
of the four fundamental paths, as is necessary for each seeker.Yoga Education:Traditionally,
Yoga Education was imparted by knowledgeable, experienced, and wise persons in the families
(comparable with the education imparted in convents in the west) and then by the Seers
(Rishis/Munis/Acharyas) in Ashramas (compared with monastries). Yoga Education, on the
other hand, aims at taking care of the individual, the 'Being'. It is presumed that a good,
balanced, integrated, truthful, clean, transparent person will be more useful to oneself, family,
society, nation, nature and humanity at large. Yoga education is 'Being oriented'. Details of
working with 'being oriented' aspect have been outlined in various living traditions and texts and
the method contributing to this important field is known as 'Yoga'.
WHAT IS YOGA ?

Definition:

Yoga is a holistic discipline originating from ancient Indian philosophy which encompassing a
variety of Physical, Mental, and Spiritual practices.

It typically involves Physical postures (asanas), Breathing techniques (pranayama), and

Meditation, with the aim of achieving harmony between Mind, Body, and Spirit.

While yoga is often associated with physical fitness and flexibility, its deeper principles include
Self-awareness, Mindfulness, and the Cultivation of inner peace.

BENEFITS OF YOGA

According to 2012 survey, 94% of adults who practice yoga do so for wellness reasons.

Yoga has many physical and mental benefits including:

 Attainment of perfect equilibrium and harmony.

 Promotes self- healing
 Removes negative blocks from the mind and toxins from the body.
 Enhances personal power.
 Increases self-awareness
 Helps in Attention, Focus and Concentration,
 Reduces stress and tension in the physical body by activating the parasympathetic nervous
system.
 Improves Sleep,Enhancing Overall well being and Quality of life
TWO FUNDAMENTAL CONCEPTS OF YOGA

1) YAMAS

2) NIYAMAS

Yamas and Niyamas are two fundamental concepts in yoga philosophy that provide guidelines
for ethical and moral conduct, both towards oneself and towards others.

1) Yamas: The Yamas are ethical guidelines or restraints that are often described as the "don'ts"
of yoga. There are five Yamas:

 Ahimsa – ‘Non violence’

 Satya – ‘Truthfulness’
 Asteya – ‘Non-stealing’
 Brahmacharya – ‘Continence’ or ‘Right use of energy’
 Aparigraha – ‘Non Greed’ or ‘Non-attachment‘

a.Ahimsa (Non-violence): Ahimsa encourages practitioners to cultivate compassion and kindness

towards all beings, avoiding harm in thought, speech, and action.

b. Satya (Truthfulness): Satya emphasizes honesty and integrity in one's thoughts, words, and
actions, encouraging practitioners to speak and act truthfully.

c. Asteya (Non-stealing): Asteya discourages stealing in all its forms, whether it be material
possessions, time, or energy, and promotes the practice of generosity and contentment.

d. Brahmacharya (Moderation): Brahmacharya encourages moderation and balance in all aspects

of life, including the control of one's senses and the conservation of energy.
e. Aparigraha (Non-attachment): Aparigraha teaches non-attachment to material possessions and
desires, fostering contentment and detachment from worldly attachments.

2)Niyamas: The Niyamas are personal observances or practices that are often described as the
"dos" of yoga. There are also five Niyamas:

 Saucha- ‘Cleanliness’
 Santosha- ‘Contentment’
 Tapas -’Discipline’
 Svadhyaya -’Self-study’
 Ishvara Pranidhana-’Surrender to a Higher Power’

a. Saucha (Cleanliness): Saucha emphasizes cleanliness and purity, both externally and
internally, including cleanliness of the body, environment, and mind.

b. Santosha (Contentment): Santosha promotes contentment and gratitude for what one has,
regardless of external circumstances, cultivating a sense of inner peace and fulfillment.

c. Tapas (Discipline): Tapas encourages self-discipline, perseverance, and dedication to one's

spiritual practices, enabling personal growth and transformation.

d. Svadhyaya (Self-study): Svadhyaya involves self-reflection, study of sacred texts, and

continuous learning, fostering self-awareness, wisdom, and spiritual growth.

e. Ishvara Pranidhana (Surrender to a Higher Power): Ishvara Pranidhana encourages

surrendering to a higher power or divine presence, acknowledging that there is something greater
than oneself and aligning one's actions with the divine will.

By practicing the Yamas and Niyamas, individuals aim to cultivate ethical conduct, self-
discipline, and spiritual growth, ultimately leading towards greater harmony and balance in life.
MEDITATION

Definition:

According to APA,Meditation is defined as a profound and extended contemplation or reflection

in order to achieve focused attention or an otherwise altered state of consciousness and to gain
insight into oneself and the world. (APA, .2018)

Meditation is a practice that involves training the mind to achieve a state of mental clarity,
emotional calmness, and increased focus. It has been practiced for thousands of years in various
cultures and religious traditions, including Hinduism, Buddhism, Taoism, and Christianity,
among others.

There are numerous techniques and styles of meditation, but most involve focusing the mind on a
particular object, thought, or activity to achieve a state of mindfulness or heightened awareness.
Common meditation practices include mindfulness meditation, where one focuses on the present
moment and observes thoughts and sensations without judgment; concentration meditation,
where attention is focused on a single point such as the breath or a mantra; and loving-kindness
meditation, where one cultivates feelings of compassion and goodwill towards oneself and
others.

Research has shown that regular meditation practice can have numerous benefits for mental and
physical health, including reducing stress, anxiety, and depression, improving concentration and
attention, enhancing emotional well-being, and even boosting the immune system.

Many people find meditation to be a valuable tool for promoting relaxation, self-awareness, and
overall well-being. It can be practiced individually or in group settings, and there are many
resources available, including books, apps, and guided meditation recordings, to help beginners
get started and deepen their practice.
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窗体底端

Types of Meditation

1) Mindfulness meditation:

Mindfulness meditation is a mental training practice that teaches to slow down racing thoughts,
let go of negativity, and calm both your mind and body. It combines meditation with the practice
of mindfulness, which can be defined as a mental state that involves being fully focused on "the
now" and thus can acknowledge and accept our thoughts, feelings, and sensations without
judgment.
Techniques can vary, but in general, mindfulness meditation involves deep
breathing and awareness of body and mind. Practicing mindfulness meditation doesn't require
props or preparation (no need for candles, essential oils, or mantras, unless you enjoy them). To
get started, all you need is a comfortable place to sit, three to five minutes of free time, and a
judgment-free mindset.
2)Spiritual Meditation
Spiritual meditation is a form of meditation that focuses on connecting with a higher power, the
divine, or one's inner spirit. It often involves practices that aim to deepen one's relationship with
the sacred or transcendental aspects of existence. While different spiritual traditions may have
their unique approaches, the essence of spiritual meditation typically involves seeking inner
peace, insight, and a sense of unity with the universe or a higher power.
 Focused meditation, also known as concentration meditation, is a mindfulness practice that
involves directing one's attention to a single point of focus. By concentrating on this focal point,
practitioners aim to quiet the mind, increase awareness, and develop mental clarity. This type of
meditation cultivates the ability to sustain attention and build concentration skills, which can
have numerous benefits for mental well-being.

3)Focused Meditation

Here are some common focal points used in focused meditation:

.
Breath: Observing the natural rhythm of the breath as it enters and leaves the body. This is one
of the most common focal points in meditation practices and is known for its calming effects on
the mind.
.
.
Mantra: Repetition of a word, phrase, or sound (mantra) to anchor the mind and prevent it from
wandering. Mantras can be traditional Sanskrit phrases, affirmations in any language, or simple
sounds like "om."
.
.
Visualizations: Imagining a specific object, scene, or symbol in vivid detail. This could be a
candle flame, a serene natural setting, or a geometric shape.
.
.
Body Sensations: Bringing awareness to physical sensations in the body, such as the feeling of
sitting or the sensation of the breath moving through the nostrils.
.
.
External Objects: Focusing on an external object in the environment, such as a candle flame, a
flower, or a piece of artwork.
.
.
Sound: Concentrating on a particular sound, such as the ticking of a clock, the chirping of birds,
or the sound of flowing water.

3) Movement meditation

It is also known as mindful movement or moving meditation, is a practice that combines

meditation with physical movement. Unlike traditional seated meditation where the body
remains still, movement meditation involves engaging the body in deliberate, mindful
movements to cultivate awareness, presence, and inner peace.

There are various forms of movement meditation, each emphasizing different types of movement
and mindfulness techniques. Some common practices include:

.
Tai Chi: An ancient Chinese martial art characterized by slow, flowing movements coordinated
with deep breathing and mindfulness. Tai Chi promotes relaxation, balance, and flexibility while
cultivating a meditative state of mind.
.
.
Qi Gong: Similar to Tai Chi, Qi Gong is a Chinese practice that involves gentle movements,
breathing exercises, and visualization techniques to cultivate qi (life energy) and promote
physical, mental, and spiritual well-being.
.
.
Yoga: While yoga encompasses a wide range of practices, many yoga styles incorporate
elements of movement meditation. Vinyasa, Hatha, and Kundalini yoga, among others,
emphasize synchronized movement with breath awareness to promote mindfulness and inner
harmony.
.
.
 Walking Meditation: Walking can be a form of meditation when practiced mindfully. In walking
meditation, practitioners focus their attention on the sensations of walking, such as the
movement of the feet, the rhythm of the breath, and the surrounding environment.
.
.
Dance Meditation: Dance can be a powerful form of self-expression and meditation. Dance
meditation involves moving the body freely and spontaneously, allowing emotions, thoughts, and
energy to flow without judgment
.
Mantra meditation is a form of meditation that involves the repetition of a specific word, phrase,
or sound, known as a mantra, to focus the mind and induce a meditative state. Mantra meditation
has roots in various spiritual and religious traditions, including Hinduism, Buddhism, and
Sikhism, but it is also practiced independently of any particular religious affiliation.

Here's how mantra meditation typically works:

.
Choosing a Mantra: Practitioners select a mantra that resonates with them personally or one that
holds significance in their tradition. Mantras can be traditional Sanskrit phrases, such as "Om,"
"So Hum" (I am), or "Om Mani Padme Hum," or they can be simple words or affirmations in
any language.
.
.
Repetition: Sitting comfortably in a quiet space, practitioners repeat the chosen mantra silently or
aloud with focused attention. The repetition of the mantra helps to anchor the mind and prevent it
from wandering.
.
.
Focusing the Mind: As the practitioner continues to repeat the mantra, they gently redirect their
attention back to the mantra whenever the mind starts to wander or thoughts arise. The goal is to
maintain concentration on the sound and vibration of the mantra.
.
.
Deepening Awareness: With consistent practice, mantra meditation can lead to a deepening
sense of inner peace, stillness, and heightened awareness. Some practitioners may also
experience insights, emotional release, or states of profound tranquility.
.
.
Integration: Mantra meditation can be practiced for a specific duration, such as 10 or 20 minutes,
or integrated into daily life as a way to center oneself and cultivate mindfulness in everyday
activities.
.

Process of Meditation

Meditation is a practice that involves focusing the mind and eliminating distractions to achieve a
state of deep relaxation and heightened awareness.
Prepare Your Space: Find a quiet and comfortable place where you can sit or lie down without
being disturbed. You may choose to sit on a cushion or chair with your back straight, or lie down
in a comfortable position. Ensure that the temperature and lighting in the room are conducive to
relaxation.

 Get Comfortable: Close your eyes and take a few deep breaths to relax your body and mind.
Allow your muscles to loosen and release any tension you may be holding. Find a posture
that feels comfortable and sustainable for the duration of your meditation session.

 Focus Your Attention: Choose a focal point for your attention, such as your breath, a mantra,
a visual object, or the sensations in your body. Direct your attention to this focal point and
gently bring your mind back to it whenever you notice it wandering.
 Breathe Mindfully: If you're using your breath as your focal point, observe the Natural
rhythm of your breathing without trying to control it. Notice the sensations of the breath as it
enters and leaves your body, focusing on the rise and fall of your abdomen or the sensation
of air passing through your nostrils.

 Cultivate Awareness: As you continue to focus on your chosen focal point, be aware of any
thoughts, emotions, or sensations that arise in your mind and body. Instead of getting caught
up in these distractions, simply observe them with curiosity and Non-judgmental awareness,
allowing them to come and go without attachment.

 Return to Your Focal Point: Whenever you notice your mind wandering or becoming
distracted, gently guide your attention back to your focal point. This process of returning to
the present moment is an essential aspect of meditation practice and helps to train the mind
to remain focused and attentive.

 Practice Patience and Persistence: Meditation is a skill that requires practice and patience.
Be gentle with yourself and understand that it's natural for the mind to wander. Whenever
you find yourself becoming frustrated or discouraged, gently bring your focus back to your
chosen focal point and continue with your practice.

 End Mindfully: When you're ready to end your meditation session, gradually bring your
awareness back to your surroundings. Take a few deep breaths and slowly open your eyes.
Take a moment to Reflect on your experience and notice how you feel mentally,
emotionally, and physically.

Meditation is a practice, and it's normal for our mind to wander or for distractions to arise. Be
patient with ourself and approach meditation with an attitude of openness, curiosity, and self-
compassion. With regular practice, gradually we can develop greater focus, clarity, and also
inner peace.

Benefits of meditation
1)Physical benefits of meditation
Decrease the physical tension
Delete disorders caused by tension
Lowers blood pressure
Relax again stress
Strengthens the immune system
Slows the aging process
Recharge our batteries
2)Psychological benefits of meditation
Calm
Soothes
Helps to be tolerant and sensitive
Helps to control our anger
Energizes
Helps to be confident
It helps personal growth

MEDITATION AND AUTONOMIC SYSTEM

Meditation has been shown to have profound effects on the autonomic nervous system (ANS),
which regulates many involuntary bodily functions, such as heart rate, blood pressure, digestion,
and respiratory rate. Here's how meditation influences the autonomic nervous system:
Activating the Parasympathetic Nervous System (PNS): The parasympathetic nervous system is
responsible for the body's "rest and digest" response, promoting relaxation, digestion, and
recovery. During meditation, especially practices focused on slow, deep breathing and
relaxation, such as mindfulness meditation or progressive muscle relaxation, the PNS becomes
more active. This leads to a decrease in heart rate, blood pressure, and respiratory rate, inducing
a state of deep relaxation and calmness.

Reducing Sympathetic Activity: The sympathetic nervous system is responsible for the body's
"fight or flight" response, preparing the body to respond to stress or danger by increasing heart
rate, blood pressure, and releasing stress hormones like cortisol. Chronic activation of the
sympathetic nervous system can contribute to stress-related health issues. Meditation practices,
particularly those emphasizing mindfulness and breath awareness, have been shown to reduce
sympathetic activity. By calming the mind and body, meditation helps to counteract the effects of
chronic stress and promote overall well-being.
Improving Heart Rate Variability (HRV): Heart rate variability refers to the variation in time
intervals between heartbeats and is an indicator of the body's ability to adapt to stress. Higher
HRV is associated with better cardiovascular health and overall resilience. Meditation practices
have been found to increase HRV, indicating improved autonomic function and increased
resilience to stress.

Regulating the HPA Axis:

What is HPA axis?
The hypothalamic-pituitary-adrenal (HPA) axis involves the central nervous system and the
endocrine system adjusting the balance of hormones in response to stress
The hypothalamic-pituitary-adrenal (HPA) axis is a key neuroendocrine system involved in the
body's response to stress. Chronic activation of the HPA axis can lead to dysregulation of stress
hormones like cortisol, which can have negative effects on physical and mental health.
Meditation has been shown to modulate the HPA axis, reducing cortisol levels and promoting a
more balanced stress response.
STRENGTHS /ADVANTAGES OF MEDITATION
 Reduces stress and anxiety: Regular meditation practice has been shown to reduce
symptoms of stress and anxiety by decreasing the activity of the stress hormone cortisol and
increasing activity in the parts of the brain responsible for regulating emotions.

 Improves focus and concentration: Meditation may help improve focus and concentration by
training the mind to stay present and not be easily distracted. This can be especially
beneficial for those who struggle with attention disorders such as ADHD.

 Promotes emotional well-being: Meditation can have a positive effect on overall emotional
well-being by increasing feelings of happiness and reducing symptoms of depression and
anxiety.
 Lowers blood pressure: Research has shown that meditation can lower blood pressure by
reducing stress and promoting relaxation.

 Enhances the immune system: Meditation can help boost the immune system by decreasing
inflammation and increasing the activity of immune cells.
LIMITATIONS OF MEDITATION
Takes time and effort to learn: To meditate is a skill that takes time and effort to master. It may
take weeks or even months before one begins to see the full benefits of meditation.
 Can be difficult for some people to quiet the mind: For some individuals, it can be
challenging to quiet the mind and focus on the present moment. This can lead to feelings of
frustration or disappointment if progress is not seen quickly.
 Can cause feelings of frustration or disappointment: If individuals have unrealistic
expectations about the benefits of mindfulness meditation or if they are not seeing progress
as quickly as they would like, it can lead to feelings of disappointment or frustration.

 Can cause physical discomfort: Sitting in one position for an extended period of time can
cause discomfort, especially for those with physical limitations or injuries.
 Can cause dissociation or depersonalization: In rare cases, meditation can lead to
dissociation or depersonalization, which can be disorienting and cause feelings of
detachment or disconnection.

Prerequisites for MEDITATION

Openness: Approach meditation with an open mind and heart. Be willing to explore your inner
experiences without judgment or preconceptions.
Commitment: Consistency is key to developing a meditation practice. Set aside regular time for
meditation, even if it's just a few minutes each day.
Comfortable Environment: Find a quiet and comfortable place where you can meditate without
distractions. It could be a dedicated meditation space or simply a quiet corner in your home.
Patience: Understand that meditation is a skill that takes time to develop. Be patient with
yourself and don't expect immediate results.
Posture: While not absolutely necessary, sitting with an upright and relaxed posture can help
promote alertness and focus during meditation. You can sit on a cushion, chair, or even lie down
if that's more comfortable for you.
Breath Awareness: Many meditation practices involve focusing on the breath as a point of
concentration. Having some awareness of your breath can be helpful, although it's not essential.

Guidance: While not strictly necessary, beginners may find it helpful to start with guided
meditation sessions led by experienced teachers. There are plenty of resources available online or
in-person classes you can attend.
Intention: Set a clear intention for your meditation practice. Whether it's stress reduction,
cultivating mindfulness, or exploring spiritual growth, having a clear purpose can help guide
your practice.

The Psychological effects of meditation: A meta-analysis.

Journal ArticleDatabase: APA PsycArticles
This meta-analysis provides a detailed examination of the effects of meditation on various
psychological factors, focusing particularly on nonclinical groups of adult meditators. However,
due to methodological limitations, a significant portion of the initially identified studies had to be
excluded from the analysis. Many of these studies seemed to lack a solid theoretical foundation.
To better understand the results, the analysis briefly outlines major theoretical approaches to
meditation from both Eastern and Western perspectives. Among the 163 studies that were
included and allowed for the calculation of effect sizes, the average effects were moderate. These
effects were not solely attributable to relaxation or cognitive restructuring, suggesting that
meditation has unique impacts.

The results indicate that meditation tends to have stronger effects on emotional and relational
aspects, moderate effects on attention, and relatively weaker effects on cognitive measures.
However, the specific findings varied depending on the type of meditation practiced (e.g.,
transcendental meditation, mindfulness meditation).
Interestingly, the level of meditation experience only partially correlated with the long-term
impact on the psychological variables examined. This suggests that factors other than mere
experience influence the outcomes of meditation practice.

Overall, the analysis suggests that existing theories about meditation lack precision in predicting
its effects on various psychological factors. To gain a more comprehensive understanding of
meditation's mechanisms and outcomes, there is a need for the development of more precise
theories and measurement tools.
References
 APA Dictionary of Psychology. (n.d.) https://dictionary.apa.org/meditation
 https://www.medicalnewstoday.com/articles/286745#risks-and-side-effects
 Ganguly, A., Hulke, S. M., Bharshanakar, R., Parashar, R., & Wakode, S. (2020). Effect of
meditation on autonomic function in healthy individuals: A longitudinal study. Journal of
Family Medicine and Primary Care, 9(8), 3944. https://doi.org/10.4103/jfmpc.jfmpc_460_20
 Vacayou. (2023, December 5). How to meditate in 7 simple steps. Vacayou Travel.
https://vacayou.com/magazine/meditate-7-simple-steps/
 Meditation: Process and effects. (2015). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles
Yoga is a mind and body practice that can build strength and flexibility. It may also help manage
pain and reduce stress. Various styles of yoga combine physical postures, breathing techniques,
and meditation

Patanjali is known as the father of modern yoga. In some parts of India, Tirumalai
Krishnamacharya is also considered as the father of modern yoga.

Yoga is a holistic discipline originating from ancient Indian philosophy which encompassing a
variety of physical, mental, and spiritual practices. It typically involves physical postures
(asanas), breathing techniques (pranayama), and meditation, with the aim of achieving harmony
between mind, body, and spirit. While yoga is often associated with physical fitness and
flexibility, its deeper principles include self-awareness, mindfulness, and the cultivation of inner
peace. Over the years, numerous styles and variations of yoga have emerged, ranging from
vigorous and dynamic practices like Ashtanga and Vinyasa to more gentle and meditative
approaches such as Hatha and Yin yoga. Across cultures and societies, yoga has gained
popularity as a means of promoting overall well-being, stress reduction, and spiritual growth.

Remember to adapt this definition to suit the specific context and purpose of your writing, and
always consult the latest APA guidelines for formatting and citation requirements.

Yoga is an ancient practice that may have originated in India. It involves movement, meditation,
and breathing techniques to promote mental and physical well-being.

History

The first mention of the word “yoga” appears in Rig Veda, a collection of ancient texts. Yoga
comes from the Sanskrit word “yuj,” which means “union” or “to join.

What is the main purpose of yoga?

Yoga brings the body and mind together and is built on three main elements – movement,
breathing and meditation. Yoga has many physical and mental health benefits including
improved posture, flexibility, strength, balance and body awareness.

Benefits of yoga

According to 2012 survey, 94% of adults who practice yoga do so for wellness reasons.

Yoga has many physical and mental benefits including:

 building muscle strength

 enhancing flexibility

 promoting better breathing

  supporting heart health

 helping with treatment for addiction

 reducing stress, anxiety, depression, and chronic pain

 improving sleep

 enhancing overall well-being and quality of life

Summary

Yoga is an ancient practice that has changed over time.

Modern yoga focuses on poses designed to stimulate inner peace and physical energy. Ancient
yoga did not place as much emphasis on fitness. Instead, it revolved around cultivating mental
focus and expanding spiritual energy.

There are many different types of yoga available. The style a person chooses will depend on their
expectations and level of physical agility.

People with certain health conditions, such as sciatica, should approach yoga slowly and with
caution.

Yoga can help support a balanced, active lifestyle

‘Yoga indeed lead to behaviour modification in individuals through various mechanisms.

They are,’

Mind-Body Connection: Yoga emphasizes the connection between the mind and body through
breath control, meditation, and physical postures (asanas). By practicing yoga regularly,
individuals become more aware of their bodies and emotions. This heightened awareness can
lead to better self-regulation and control over behaviors.
 ‘With a regular Yoga practice, adolescents with emotional and behavioral problems can manage
and develop a greater body awareness, Emotional balance and concentration - increasing their
capacity for schoolwork and creative play. This can also, in turn, aid their self-esteem.’
.
Stress Reduction: One of the primary benefits of yoga is its ability to reduce stress levels.
Through deep breathing exercises and mindful movement, yoga activates the parasympathetic
nervous system, which promotes relaxation and decreases the production of stress hormones like
cortisol. As stress levels decrease, individuals may find themselves less prone to reactive or
impulsive behaviors.
.
.
Emotional Regulation: Yoga encourages the cultivation of mindfulness and emotional resilience.
Through practices such as meditation and pranayama (breath control), individuals learn to
observe their thoughts and emotions without judgment. This awareness allows them to respond
more thoughtfully to challenging situations rather than reacting impulsively.
.
.
Improved Self-Discipline: Committing to a regular yoga practice requires discipline and
dedication. Over time, individuals develop a sense of accountability to themselves and their
practice, which can spill over into other areas of their lives. This improved self-discipline may
lead to positive behavior changes, such as better time management, goal-setting, and follow-
through.
.
.
Increased Self-Awareness: Yoga encourages introspection and self-reflection. As individuals
delve deeper into their practice, they may uncover underlying patterns or habits that no longer
serve them. This heightened self-awareness allows them to consciously choose alternative
behaviors that align with their values and goals.
.
.
Enhanced Well-Being: Yoga is associated with numerous physical and mental health benefits,
including improved mood, increased energy levels, and enhanced overall well-being. When
individuals feel better physically and mentally, they are more likely to engage in behaviors that
support their health and happiness.
.
.
Cultivation of Compassion and Empathy: Many forms of yoga emphasize the principles of
compassion, kindness, and non-violence (ahimsa). Through yoga philosophy and ethical
guidelines, individuals learn to cultivate empathy and understanding towards themselves and
others. This shift in perspective can lead to more compassionate and considerate behaviors in
daily interactions.
.

Overall, the holistic nature of yoga - addressing physical, mental, and spiritual aspects of well-
being - can foster profound behavior modification in individuals, leading to greater self-
awareness, emotional regulation, and overall personal growth.

How can we change our Behaviour through yoga?

It brings emotional stability. It helps to control negative emotions. Yogic practices such as yama,
niyama, asana, pranayama, pratyahara and meditation help in emotional management.
Yama and niyama under lu varunna..

The very first – and often thought of as the most important – Yama, is ‘Ahimsa’, which means
‘Non-violence’ or ‘non-harming’. (‘Himsa’ = ‘hurt’ and ‘a’ = ‘not’) In this sense, we’re talking
about non-violence in all aspects of life. When we act with ‘Ahimsa’ in mind, this means not
physically harming others, ourselves, or nature; not thinking negative thoughts about others or
ourselves; and making sure that what we do and how we do it is done in harmony, rather than
harm. Sutra 2:35 reveals;
The word ‘sat’ literally translates as ‘true essence’ or ‘true nature’. Sanskrit is a vibrational
language and so each word is so much more than a label – it literally holds the very essence of
the word. Because of this, ‘sat’ also holds the meanings; ‘unchangeable’, ‘that which has no
distortion’, ‘that which is beyond distinctions of time, space and person’, and ‘reality’. Many
Sanskrit words use the prefix ‘sat’ such as ‘satsang’ meaning ‘true company’ and ‘sattva’
meaning ‘pure’, which leads us to understand that ‘sat’ really means more than ‘truth’, it’s
something that is unchanged and pure.

When looking at the word ‘truth’ from this perspective, it’s easy to then understand how so much
of our time is spent not actually seeing the truth or reality in any of our life situations….

Our thoughts, emotions and moods are extremely interchangeable, yet these are the things that
create our own truth and our whole life experience. If ‘sat’ means ‘unchangeable’, then this can
make us aware that much of our experience of life is brought about by paying more attention to
that which changes, rather than the unchanging truth.

Asteya is mentioned throughout many Indian texts, including the Sutras, the Mahabarata (which
the Bhagavad Gita is part of), the Upanishads and the Vedas. Gandhi also saw how important the
practice of ‘non-stealing’ was and considered it one of his ’11 Vows’, in which he expanded
beyond the physical act of stealing – importantly – that ‘mankind’s greed and craving for
artificial needs are also stealing’.

The fourth of the Yamas, Brahmacharya, is often translated as ‘celibacy’ or ‘chastity’, which
doesn’t always make for a very popular Yama…! Traditionally, ‘Brahmacharya’ was meant to
encourage those involved in the practice of yoga to conserve their sexual energy, in favour of
using that energy to further progress along the Yogic path.

However, the practice of Brahmacharya or ‘right use of energy’ as it is widely translated, is more
prevalent now than ever.

Contemplation

The word Brahmacharya actually translates as ‘behaviour which leads to Brahman’. Brahman is
thought of as ‘the creator’ in Hinduism and Yogic terms, so what we’re basically talking about
here is behaviour which leads us towards ‘the divine’ or ‘higher power’.

Regarding Brahmacharya as ‘right use of energy’ leads us to consider how we actually use and
direct our energy. Brahmacharya also evokes a sense of directing our energy away from external
desires – you know, those pleasures which seem great at the time but are ultimately fleeting –
and instead, towards finding peace and happiness within ourselve

Aparigraha is the last Yama in Patanjali’s Eight Limbs of Yoga. It often translates to non-greed
and non-attachment.

The Niyamas

The word ‘Niyama’ often translates as ‘positive duties’ or ‘observances’, and are thought of as
recommended habits for healthy living and ‘spiritual existence’. They’re traditionally thought of
as practices concerned with ourselves, although of course we can think of them as affecting the
outside world too. Patanjali lists a total of five Niyamas, but again there are other traditions and
texts that list more:

Saucha (cleanliness)

Santosha (contentment)

Tapas (discipline, austerity or ‘burning enthusiasm)

Svadhyaya (study of the self and of the texts)

Isvara Pranidhana (surrender to a higher being, or contemplation of a higher power)

MEDITATION

Meditation is a practice that involves focusing the mind and eliminating distractions to achieve a
state of deep relaxation and heightened awareness

Last..

By following these steps and making meditation a regular part of your routine, you can cultivate
greater mindfulness, relaxation, and inner peace in your life. Remember that there's no right or
wrong way to meditate, so feel free to experiment with different techniques and find what works
best for you.
 . The HPA axis is a term used to represent the interaction between the hypothalamus, pituitary
gland, and adrenal glands; it plays an important role in the stress response.

Exposure therapies - systematic desensitization

Exposure Therapy:

What is Exposure Therapy?

- Psychological treatment developed to confront fears and break avoidance patterns.

- Provides a safe environment for individuals to face feared objects, activities, or situations.

Rationale for using this therapy.

-The rationale for exposure therapies originates from conditioning models of fear acquisition,
notably O. H. Mowrer's two-factor model proposed in 1960. This model suggests that fears are
acquired through classical conditioning and maintained via operant conditioning, particularly
negative reinforcement. Later research highlighted the role of beliefs and expectations in
conditioning processes, leading to more complex fear theories. One prominent contemporary theory
is E. B. Foa and M. J. Kozak's emotional processing model (1986), which posits that fears are
stored in networks in long-term memory. These networks comprise representations of feared
stimuli, responses, and meanings, with activation evoking fear and motivating avoidance.
According to this model, fears can be diminished by modifying fear structures through exposure
interventions, which provide corrective information. While more intricate than the two-factor
model, both theories support the efficacy of exposure interventions in reducing fears and phobias.

Theoretical Basis for Exposure Therapy:

1. Emotional Processing Theory:

Emotional Processing Theory (EPT) is a prominent model in explaining improvement during

Exposure and Response Prevention (ERP) therapy. It suggests that therapeutic exposure activates
a "fear structure" in memory, which is then challenged with incompatible information to promote
corrective learning. This process aims to replace or compete with fear-based associations,
leading to fear reduction. Habituation, a decrease in response to repeated stimulation, is
considered a crucial index of change in ERP therapy, indicating that learning is occurring. Fear
reactions are measured through verbal, behavioral, and physiological symptoms. Foa and
colleagues proposed three indicators of emotional processing predicting successful outcomes:
initial fear activation, within-session habituation, and between-session habituation. Therapists are
guided to explain exposure rationale, terminate exposures upon habituation, and progress
gradually through fear-provoking stimuli. Treatment effectiveness is closely linked to
habituation. Overall, EPT underscores the importance of activating fear structures and promoting
corrective learning through exposure therapy for anxiety disorders.

Summary of emotional processing theory:

1. Background and Influences:

- Developed by Foa and Kozak in 1986.

 - Influenced by Rachman (1980) and Lang (1977, 1979).

- Aimed to elucidate the mechanisms of exposure therapy.

2. Fear Network Representation:

- Fear stored in memory as a network.

- Comprising stimulus, response, and meaning propositions.

- Pathological fear results from errors in this network.

3. Exposure Therapy as Reprogramming:

- Exposure therapy aims to reprogram the fear network.

- Diminishes clinical pathology by providing incompatible information.

4. Phenomena of Emotional Processing:

- Activation of fear network (physiological reactivity, self-reported fear).

- Within-session habituation (decrease in fear indices).

- Between-session habituation (gradual decline in fear responses).

5. Variables Vital for Emotional Processing:

- Input information should match elements in the fear network.

- Patient attention to relevant input is crucial.

- Cognitive avoidance impedes activation and incorporation of new information.

6. Changes During Emotional Processing:

- Habituation weakens associations between feared stimuli and responses.

- Meaning propositions change (exaggerated estimates diminish).

- Negative valence of feared consequences diminishes.

- Decline in fear refutes the expectation of its indefinite persistence.

The Learning Model

The Inhibitory Learning Theory, influenced by Bjork and Bjork's New Theory of Disuse,
suggests that learned associations, particularly fear-based ones, persist in memory even
with disuse. While this process is generally adaptive, individuals with fear-based
disorders like OCD are at risk of relapse due to the persistence of these associations. In
the context of exposure therapy, there's a misconception that performance during
exposure trials, primarily habituation, reflects long-term learning. Consequently,
therapists may prioritize techniques that enhance immediate performance, such as
systematic and gradual exposure to foster habituation, over methods that promote long-
term encoding and generalization of learning from exposure sessions.

Bjork and Bjork argue that the focus on habituation during exposure therapy might overlook
the importance of encoding and generalizing learning for long-term efficacy. Instead of
solely aiming for habituation within sessions, therapists should consider strategies that
maximize the retention and application of learning beyond the immediate exposure
context. This perspective highlights the need to balance short-term symptom reduction
with long-term therapeutic goals, emphasizing techniques that facilitate enduring changes
in fear associations and behaviors. Ultimately, understanding the dynamics of memory
retention and applying this knowledge to exposure therapy can enhance its effectiveness
in treating fear-based disorders by addressing both immediate symptoms and long-term
resilience against relapse.

Fear extinction, a key process in exposure therapy, involves associative learning where a person
confronts fear-inducing stimuli (conditioned stimuli, CS) without the aversive unconditioned
stimulus (US), leading to altered expectancies and behavior changes. Unlike habituation, which
involves non-associative learning and refers to a reduction in fear response with repeated
stimulus exposure, extinction specifically targets conditioned fear responses. In this process,
individuals gradually learn that feared stimuli are not as threatening as expected through repeated
exposure without aversive outcomes.
For instance, in the case of a patient with OCD fearing contracting herpes from doorknobs,
exposure therapy involves confronting doorknobs without experiencing the feared outcome,
resulting in extinction of conditioned fear responses. However, according to Inhibitory Learning
Theory (ILT), the original threat association learned during fear acquisition isn't replaced by new
non-threat associations formed during extinction. Instead, the CS retains both excitatory
(associated with fear acquisition) and inhibitory (acquired during extinction) meanings, leading
to competition for retrieval.

This dual representation of fear associations explains why fear can return even after successful
exposure therapy. Despite the extinction of conditioned responses, the original fear-based
associations persist in memory, leaving individuals vulnerable to relapse. ILT underscores the
importance of understanding the nuanced dynamics of fear extinction and highlights the need for
strategies to strengthen inhibitory associations and mitigate the risk of fear resurgence in
exposure therapy.

Return of Fear (ROF) in exposure therapy refers to the reappearance of fear responses that have
undergone partial or complete extinction, which can lead to a clinical relapse of symptoms and
impairment. ROF occurs when the original fear associations resurface, often at a higher level
than before extinction. Three main processes contribute to ROF: spontaneous recovery, context
renewal, and reinstatement.

Spontaneous recovery involves the return of fear simply with the passage of time, as new
learning becomes less accessible while the original fear associations gradually resurface. Context
renewal occurs when the conditioned fear response returns in a different context than where
extinction took place, highlighting the context-dependency of extinction learning. This poses a
challenge as fear associations easily generalize to new contexts, whereas extinction learning is
context-specific. Reinstatement involves the unexpected presentation of the aversive
unconditioned stimulus (US), reigniting fear responses to previously extinguished conditioned
stimuli (CS).

These processes reveal that fear-based associations persist even after successful exposure
therapy, and they compete with newly learned non-threat associations. The goal of exposure
therapy, from an Inhibitory Learning Theory (ILT) perspective, is to maximize the likelihood
that newly learned non-threat associations will inhibit the retrieval of older threat associations.
While exposure therapy is highly efficacious, there are opportunities to enhance its long-term
effects to better protect against later return of fear. Strategies focusing on maximizing inhibitory
learning and generalization across contexts can strengthen exposure therapy's efficacy in treating
fear-based disorders like OCD.

The Summary of learning model:

- Inhibitory Learning Theory (ILT) Overview:

- Influenced by Bjork and Bjork's New Theory of Disuse.

- Suggests that learned associations, including fear-based ones, persist in memory even with
disuse.

- Individuals with fear-based disorders like OCD are at risk of relapse due to the persistence of
these associations.

- Importance of Encoding and Generalization:

- Bjork and Bjork argue for considering strategies maximizing retention and application of
learning beyond immediate exposure context.

- Emphasizes the need to balance short-term symptom reduction with long-term therapeutic
goals.

- Highlights techniques facilitating enduring changes in fear associations and behaviors.

- Fear Extinction in Exposure Therapy:

- Involves associative learning where individuals confront fear-inducing stimuli (CS) without
the aversive unconditioned stimulus (US).

- Targets conditioned fear responses, unlike habituation which involves non-associative

learning.
 - Gradual exposure to feared stimuli leads to altered expectancies and behavior changes.

- Inhibitory Learning Theory (ILT) Perspective:

- Original threat associations learned during fear acquisition persist alongside newly formed
inhibitory associations during extinction.

- Competition between excitatory and inhibitory associations explains potential return of fear
even after successful exposure therapy.

- Emphasizes the need to strengthen inhibitory associations and mitigate risk of fear resurgence.

- Return of Fear (ROF) in Exposure Therapy:

- Refers to reappearance of fear responses that underwent partial or complete extinction, leading
to clinical relapse.

- Occurs due to spontaneous recovery, context renewal, and reinstatement.

- Fear-based associations persist in memory, competing with newly learned non-threat

associations.

- Enhancing Exposure Therapy:

- Strategies focusing on maximizing inhibitory learning and generalization across contexts can
strengthen exposure therapy's long-term efficacy in treating fear-based disorders like OCD.

The inhibitory learning model

The Inhibitory Learning Model, rooted in research on fear extinction, learning, and memory, is a
framework used in exposure therapy for anxiety disorders. It emphasizes the creation of new
inhibitory associations to extinguish fear responses. Unlike traditional Pavlovian conditioning,
where stimuli predict negative outcomes leading to excitatory associations, exposure therapy
 aims to establish inhibitory associations between feared stimuli and non-occurrence or reduced
intensity of feared outcomes. However, the challenge lies in strengthening these inhibitory
associations to compete effectively with the original excitatory ones.

An important aspect to note is that while exposure therapy may successfully weaken fear
responses, the original excitatory associations are not erased from memory. This can lead to the
return of fear, observed in various forms such as reinstatement, spontaneous recovery, context
renewal, and rapid reacquisition. For instance, a patient who underwent exposure therapy for
panic disorder with agoraphobia might experience reinstatement if they have an unexpected
panic attack. Similarly, spontaneous recovery may occur if the patient avoids elevators for some
time after therapy.

To mitigate the likelihood of return of fear, proponents of the inhibitory learning model suggest
various techniques. These include both common techniques applicable across exposures and
specific techniques tailored to particular situations within a treatment course. Examples of
common techniques include enhancing safety learning and inhibitory learning during exposures,
while specific techniques may involve exposure in multiple contexts or incorporating variable
stimulus presentation. These strategies aim to strengthen inhibitory associations and minimize
the resurgence of fear responses following exposure therapy.

To summarize the inhibitory learning model:

Inhibitory Learning Model and techniques for enhancing exposure therapy:

1. Basic Principles:

- Draws on research in fear extinction, learning, and memory.

- Anxiety disorders involve fear stimuli associated with negative outcomes.

- Exposure therapy aims to create new inhibitory associations to extinguish fear.

2. Excitatory and Inhibitory Associations:

- Excitatory associations: CS predicts US, leading to fear.

 - Inhibitory associations: CS associated with non-occurrence or lower intensity of feared
outcome.

- Extinguished stimulus has both excitatory and inhibitory meanings, context-dependent.

3. Challenges in Exposure Therapy:

- Strengthening inhibitory association to compete with excitatory one is crucial.

- Original excitatory association remains in memory post-extinction, leading to potential

return of fear.

4. Return of Fear Phenomena:

- Reinstatement: Fear returns when US (feared outcome) is presented alone.

- Spontaneous Recovery: Fear re-emerges with time, even after successful extinction.

- Context Renewal: Fear returns in new contexts different from extinction setting.

- Rapid Reacquisition: Fear quickly reappears if CS paired with US again post-extinction.

Enhancing Exposure Therapy Techniques:

1. Common Techniques:

- Apply to all exposures under the inhibitory learning model.

- Aim to reduce likelihood of return of fear.

2. Specific Techniques:

- Relevant for particular exposures in treatment.

- Tailored to address specific challenges or contexts.

 Overall, the Inhibitory Learning Model highlights the importance of creating new inhibitory
associations to counteract fear responses. Techniques for enhancing exposure therapy aim
to address challenges such as the return of fear by strengthening inhibitory associations
and adapting interventions to specific contexts.

Scientifically Demonstrated Effectiveness:

- Effective for treating various problems including phobias, panic disorder, social anxiety disorder,
OCD, PTSD, and generalized anxiety disorder.

1- According to a study done on exposure therapy, it demonstrates effectiveness in reducing health

anxiety symptoms, as evidenced by significant decreases posttreatment and at follow-up.
Additionally, improvements were noted in depressiveness, somatic symptoms, and psychological
distress. The findings suggest that exposure therapy is efficacious and sustainable in treating health
anxiety, even within routine outpatient care settings, albeit with lower response and remission rates
compared to randomized controlled trials (RCTs) (Kindermann et al., 2020).

2- In a study investigating the median effective dose of prolonged exposure (PE) therapy for
veterans with posttraumatic stress disorder (PTSD), it was found that the probability of
experiencing clinically meaningful improvement in PTSD symptoms from PE was 50% after just
four sessions. This suggests that meaningful change can be achieved in half the number of sessions
typically considered adequate in both research and clinical settings. These findings underscore the
potential efficiency and efficacy of PE therapy in treating PTSD symptoms among veterans (Gutner
et al., 2020).
3- According to the study, systematic reviews and meta-analyses of the long-term efficacy of
narrative exposure therapy (NET) for adults, children (KIDNET), and perpetrators (FORNET)
indicate that these interventions yield beneficial and sustainable treatment results for severely
traumatized individuals living in adverse circumstances. However, there is a need for further
research, particularly in highly developed health care systems, to compare NET with other
evidence-based trauma-focused interventions (Neuner et al., 2020).

4- According to the study on the Effectiveness of Self-Guided Virtual-Reality Exposure Therapy

for Public-Speaking Anxiety found that Increased self-exposure to virtual social threats from self-
guided virtual-reality exposure therapy (VRET) relieves anxiety and shows immediate reductions
in subjective and physiological arousal during application, but also yields sustained improvement in
public speaking anxiety (Segal et al., 2021).

Variations of Exposure Therapy:

1. The paradigm of exposure. There are two fundamental exposure therapy paradigms. In
brief/graduated exposure treatment, the client is exposed to dangerous events (a) for a brief
duration (few seconds to minutes) and (b) progressively, starting with parts of the events that cause
them to feel less anxious and working their way up to more anxiety-inducing parts. Graduated
exposure is a prime example of the stepwise progression that characterizes many behavior therapy
procedures.

Prolonged/intense exposure therapy, on the other hand, exposes the client to frightening events (a)
at a high intensity right away and (b) for a considerable amount of time (typically 10 to 15 minutes
at a minimum, occasionally longer than an hour). While many exposure therapy applications neatly
fall into one of the two paradigms, this is not always the case. For example, a client may be exposed
to anxiety-inducing stimuli for a long time, but the stimuli are introduced gradually; this is referred
to as hybrid exposure, or prolonged/graduated exposure.

2. Mode of exposure. In all paradigms, there exist four fundamental modes of exposure that are
arranged in a continuum.
- in vivo exposure—actually encountering the event (such as taking a flight, in the case of fear of
flying).

- imaginal exposure—vividly imagining the event, as one does in a daydream (for example,
visualizing taking a flight).

- virtual reality exposure —technology allows clients to be exposed to anxiety-evoking events

through interactional computer simulations that appear almost real.

3. Additional procedures. - Exposure therapy may involve one or more additional procedures,
with the three most prevalent being:

- Competing response: During exposure, the client performs an action that opposes their fear, like
tensing their muscles while picturing an unpleasant situation.

-Response prevention refers to preventing the client from engaging in maladaptive avoidance or
escape behaviors that are usually used to decrease anxiety. Examples of these behaviors include
constantly washing hands after touching something that may contain germs.

- Exaggerated scenes: The portrayal of an event may be overdone in order to increase the intensity
or vividness of the imagined exposure.

A therapist might, for instance, ask a client who is terrified of snakes to picture themselves in a pit
full of hundreds of snakes.

4. Administration of exposure: The exposure can be delivered by the therapist during therapy
sessions or self-managed by the client outside of sessions. Alternatively, both approaches can be
applied, beginning with the exposure given by the therapist.

If the range of paradigms, modes, and other processes that comprise exposure therapy seems
overwhelming, don't worry. You will progressively be exposed to examples of mixed-variable
exposure therapy procedures, and their application will become evident. Examining the actual
implementation of exposure therapy. Since the brief/graduated paradigm was the first to be created,
we start with it and incorporate both systematic desensitization and in vivo desensitization.
Exposure In Vivo Therapy

Exposure in vivo therapy is a fundamental behavioral procedure employed in the treatment of

various psychological disorders, primarily aimed at reducing avoidance behaviors and subjective
anxiety. Traditionally limited to external stimuli like specific phobias, exposure therapy has evolved
to encompass both external and internal (interoceptive) stimuli. Interoceptive stimuli, such as bodily
sensations associated with panic disorder or social anxiety, are also targeted through exposure. The
selection of exposure stimuli is tailored to the individual's specific concerns and avoided situations,
ensuring relevance and efficacy.

Exposure sessions can be conducted using various schedules, ranging from massed to spaced or
expanding-spaced exposure sessions. The duration of exposure to the phobic stimulus during a
session is crucial, typically recommended to continue until a marked reduction in fear is observed.
Repeated exposures or re-exposures may be necessary for situations where prolonged exposure is
challenging. Escape during exposure is discouraged, as it can reinforce avoidance behaviors, but the
level of control patients experience during exposure plays a significant role in fear reduction.

Exposure techniques can vary from gradual to steep, with flooding being more intense but
potentially leading to noncompliance. Graded exposure, utilizing a hierarchy of progressively more
anxiety-provoking situations, is commonly employed. Distraction during exposure is generally
avoided, as it can impede long-term fear reduction, although it may provide short-term relief.
Exposure therapy can be conducted with the assistance of a therapist, partner (spouse-aided
therapy), or self-directed, utilizing various mediums like self-help manuals, computer programs, or
group sessions. Overall, exposure in vivo therapy remains a cornerstone of treatment for anxiety
disorders, offering effective strategies for confronting and overcoming fears.

Benefits of Exposure Therapy:

1. Habituation: Reactions to feared objects or situations decrease over time.

2. Extinction: Weakens associations between feared objects and bad outcomes.

3. Self-efficacy: Demonstrates capability of confronting fears and managing anxiety.

4. Emotional processing: Allows for attachment of new, realistic beliefs about feared objects or
situations, increasing comfort with fear.

- Exposure therapy offers a structured approach to overcoming fears and reducing avoidance, with
demonstrated effectiveness in treating various anxiety-related disorders.

Systematic Desensitization

-Purpose:

The purpose of systematic desensitization is to alleviate fear and anxiety by gradually

exposing individuals to feared stimuli while they remain deeply relaxed. This therapy
was developed as a behavioral technique for treating various phobias and anxiety
disorders.

-History:

The history behind systematic desensitization dates back to Joseph Wolpe's work in the
1950s. Wolpe proposed that fear could be reduced through the learned inhibition of
anxiety, based on parasympathetic inhibition of sympathetic activation.

Systematic desensitization involves creating a hierarchy of fear-inducing situations or stimuli

and then systematically exposing individuals to these stimuli in a relaxed state until their
 fear diminishes. Over time, individuals become desensitized to the feared stimuli, leading
to a reduction in anxiety.

Despite the emergence of exposure therapy as the treatment of choice for phobic complaints,
systematic desensitization remains a valuable option, especially when in vivo exposure is
not feasible or initially refused. Numerous case studies and clinical series have
demonstrated the effectiveness of systematic desensitization in treating various phobias
and anxiety disorders, supporting its continued use in clinical practice.

Systematic Desensitization Overview:

1. Development: Created by Joseph Wolpe over 50 years ago, systematic desensitization was the
pioneering exposure therapy and behavior therapy technique.

2. Objective: To alleviate anxiety by gradually exposing individuals to progressively more anxiety-

inducing situations while engaging in a competing response, such as skeletal muscle relaxation.

3. Three Steps:

a. Therapist teaches client a response that competes with anxiety.

b. Anxiety-provoking events are ordered based on their level of anxiety induction.

c. Client repeatedly visualizes anxiety-evoking events while performing the competing response,
systematically progressing through the hierarchy.

Historical Context:

1. Origins: Watson's idea of pairing a feared stimulus with a non-fearful stimulus was endorsed in
1924 by Jones in his work with a 3-year-old boy, Peter, who feared rabbits.

2. Jones' Experiment: Detailed steps involved in Peter's desensitization process demonstrated the
gradual exposure to rabbits, starting from distant encounters to eventual close contact.
3. Wolpe's Advancements: In 1958, Wolpe refined the technique into systematic desensitization,
emphasizing counter-conditioning as the core principle, aiming to substitute relaxation for anxiety.

1. Counter-Conditioning: Systematic desensitization aims to replace anxiety with relaxation through

repeated exposure to feared stimuli.

2. Behavioral Maladaptation: Wolpe views maladaptive behavior as learned and neurotic, resulting
from over-excitation of the nervous system.

3. Alternative Response: Therapists present fear-inducing stimuli while evoking alternative

responses to fear, resembling the concept of transference in psychoanalytic approaches.

Theoretical basis of SD

The Reciprocal Inhibition Theory

The reciprocal inhibition theory, proposed by Joseph Wolpe, forms the basis of systematic
desensitization (SD) therapy. Wolpe expanded upon Charles Sherrington's concept of reciprocal
inhibition, which originally referred to the suppression of one spinal reflex by another. In the
context of clinical conditions, Wolpe applied this concept to anxiety-provoking stimuli, suggesting
that if a response antagonistic to anxiety could occur in the presence of such stimuli, accompanied
by a partial or complete suppression of anxiety responses, the bond between the stimuli and anxiety
would weaken.

Wolpe believed that many neurotic patterns are conditioned anxiety responses and sought to train
individuals to remain calm and relaxed in situations that previously elicited anxiety. By inducing
relaxation responses that are incompatible with anxiety, individuals can experience a reduction in
neurotic responses. Wolpe conducted experiments with cats, inducing neurotic responses through
shock in conjunction with the presence of food, and then gradually reducing these responses
through exposure to similar environments where relaxation and feeding occurred.

In human subjects, the relaxation component of systematic desensitization promotes muscular

relaxation, which is incompatible with the anxiety triggered by fear-provoking stimuli. The
reinforcement of relaxation through reciprocal inhibition leads to conditioned inhibition of anxiety
responses. Through systematic exposure to anxiety-provoking stimuli paired with relaxation,
individuals can experience a reduction in anxiety and ultimately overcome their neurotic responses.
Thus, the reciprocal inhibition theory provides a theoretical framework for understanding and
implementing systematic desensitization therapy in the treatment of anxiety disorders.

The Habituation Theory

The habituation theory, as elucidated by Lader, Wing, and later by Lader and Mathew, provides a
theoretical framework for understanding the response decrement observed in systematic
desensitization (SD) therapy. Habituation refers to the waning of a response to a stimulus due to its
repeated presentation, particularly applicable to unconditional responses. This decremental process
of anxiety in desensitization resembles habituation, as both novel stimuli eliciting orienting
responses and anxiety-arousing stimuli activate the behavioral inhibition system, particularly active
in neurotic introverts.

The 'maximal habituation theory' postulated by Lader and Mathew suggests that the reduction in
fear or anxiety response to aversive stimuli is a habituation process maximized by aspects of the
procedure, notably relaxation, which lowers central arousal. Relaxation, instrumental in lowering
central arousal, excites the parasympathetic nervous system, which inhibits the sympathetic nervous
system involved in anxiety responses. Consequently, relaxation becomes conditioned to each step
of the hierarchy scenes in a graded manner, promoting a state of anxiety inhibition through counter-
conditioning.

The 'dual-process habituation theory' proposed by some authors suggests that the observed response
decrement in SD therapy results from the summation of two processes: habituation and
sensitization. Watts further explains that during imagery and actual exposure phases of SD, initial
sensitization to specific phobic stimuli in the hierarchy is accompanied by habituation. The
combination of short presentation of low-intensity stimuli and relaxation can prevent the
development of sensitization, facilitating response decrement.

The Cognitive Theory

The cognitive theory offers insights into how systematic desensitization (SD) therapy affects
individuals' cognitive processes and beliefs regarding anxiety-provoking stimuli. Ellis highlighted
that SD discourages self-verbalizations that lead to anxiety, suggesting that the therapy aims to
modify maladaptive thought patterns. Conversely, Bandura observed that the reduction of
physiological arousal in the presence of anxiety-inducing stimuli enhances individuals' beliefs in
their ability to cope with phobic situations, indicating a cognitive shift towards self-efficacy.

Weitzman provided a reinterpretation of the SD process, suggesting that aversive scenes presented
during therapy are transformed and elaborated by clients into imaginal content that is less fearful or
anxiety-provoking, leading to newer forms of adaptive responses. This active cognitive
restructuring involves integrating associative material into the ego complex, resulting in changes in
perception and response to feared stimuli. However, research findings suggest that clients who
modify presented scenes to be less threatening or inadvertently introduce anxiety-provoking
elements may not benefit from desensitization therapy as effectively.
Furthermore, Strahley's experiments indicated that better outcomes were observed when SD therapy
was based on real-life exposures to aversive stimuli, suggesting the importance of genuine and
impactful exposure experiences. Overall, the cognitive theory emphasizes the role of cognitive
restructuring and belief modification in the success of systematic desensitization therapy,
highlighting the need for genuine exposure experiences and the avoidance of modifying exposure
scenes to ensure therapeutic effectiveness.

Overview:

Reciprocal Inhibition Theory and its application in treating anxiety:

1. Definition: Reciprocal inhibition, first introduced by Charles Sherrington in 1906, refers to the
inhibition of one response by the occurrence of another, antagonistic response.

2. Clinical Application: Joseph Wolpe extended the concept of reciprocal inhibition to clinical
conditions, particularly in treating anxiety disorders.

3. Principle: Wolpe's principle states that if an anxiety-provoking stimulus is paired with a response
antagonistic to anxiety, the bond between the stimulus and anxiety weakens.

4. Treatment Approach: Wolpe utilized systematic desensitization to treat anxiety. This approach
involves exposing individuals to anxiety-provoking stimuli while simultaneously inducing a
relaxation response.

5. Mechanism: By pairing relaxation with anxiety-inducing stimuli, the relaxation response inhibits
the anxiety response, leading to a reduction in anxiety over time.
6. Animal Studies: Wolpe conducted experiments on animals, inducing neurotic responses in cats
and then gradually reducing anxiety by feeding them in environments similar to where the anxiety
occurred.

7. Human Application: In humans, systematic desensitization induces muscular relaxation

incompatible with anxiety, leading to a conditioned inhibition of anxiety responses.

8. Process: The process involves gradually exposing individuals to anxiety-provoking stimuli while
helping them maintain relaxation until anxiety diminishes.

9. Successive Approximation: Individuals progress from less anxiety-provoking situations to more

challenging ones, gradually overcoming anxiety responses.

10. Outcome: Through systematic desensitization, individuals learn to remain calm and relaxed in
situations that once triggered anxiety, leading to a reduction or elimination of neurotic responses.

the Habituation Theory and its application in systematic desensitization:

1. Definition: Habituation is the waning of a response to a stimulus due to repeated presentation. It

primarily applies to unconditional responses.

2. Behavioral Inhibition System: Activated by novel stimuli and anxiety-inducing stimuli, it inhibits
ongoing behavior and increases arousal, particularly in neurotic introverts.

3. Maximal Habituation Theory: Proposed by Lader and Mathew, it suggests that the rate of
reduction in fear or anxiety response to aversive stimuli is a habituation process.

4. Relaxation: Central to the maximal habituation theory, relaxation lowers central arousal,
facilitating the habituation process.

5. Physiological Mechanism: Deep muscle relaxation activates the parasympathetic nervous

system,which inhibits the sympathetic nervous system involved in anxiety responses.

6. Counter-conditioning: Relaxation is conditioned to each step of the hierarchy in systematic

desensitization, replacing anxiety with relaxation.
7. Dual-Process Habituation Theory: Some authors propose that observed response decrement
involves both habituation and sensitization processes.

8. Initial Sensitization: During exposure to specific phobic stimuli, there may be initial sensitization
accompanied by habituation.

9. Combination Approach: Short presentations of low-intensity stimuli, combined with relaxation,

prevent sensitization and facilitate response decrement.

10. Application: This theory explains how systematic desensitization reduces anxiety by habituating
individuals to anxiety-inducing stimuli, replacing anxiety responses with relaxation responses.

the Cognitive Theory of systematic desensitization:

1. Ellis's Perspective: Systematic desensitization discourages self-verbalizations that lead to anxiety.

It aims to replace negative self-talk with more positive and adaptive thoughts.

2. Bandura's Observation: Lowering physiological arousal in the presence of anxiety-provoking

stimuli enhances the client's belief in their ability to cope with the situation.

3. Weitzman's Interpretation: During desensitization, aversive scenes presented by the therapist are
transformed by the client into less fearful or anxiety-provoking imagery, leading to adaptive
responses. This involves active cognitive restructuring.

4. Associative Material and Ego Complex: Changes in response to desensitization are derived from
associative material integrated into the ego complex, contributing to adaptive responses.

5. Cognitive Restructuring: Clients actively modify aversive scenes into less threatening events
during desensitization. However, research suggests that unintended anxiety-provoking elements
introduced during this process may hinder the effectiveness of desensitization.

6. Effectiveness of Real-Life Exposures: Experiments by Strahley indicate that desensitization

based on real-life exposures to aversive stimuli leads to better outcomes compared to purely
imaginal desensitization.
7. Failures of Desensitization: The cognitive process invoked by desensitization may better explain
failures of therapy rather than its success, suggesting the need for further exploration of its
mechanisms.

8. Clinical Implications: Understanding the cognitive aspects of desensitization can inform

therapeutic approaches, emphasizing the importance of addressing and modifying maladaptive
thought patterns during treatment.

METHOD

a. Relaxation Training

During relaxation training, the client is trained to learn to relax himself by using any of the
relaxation procedures. Various methods of relaxation training are used, depending on the suitability
for the client and expertise of the therapist. However, JPMR technique is generally used. The other
relaxation techniques include meditation, yoga, hypnosis and drugs (Bandura 1969; Brady 1967).
This is done in about the first six sessions

b. Construction of Hierarchy

In systematic desensitization therapy, relaxation training is combined with the creation of a

hierarchy of anxiety-inducing scenes or events. This hierarchy is prepared by the client, who
arranges the scenes in descending order based on the level of distress they evoke, known as the
subjective unit of distress (SUD). The scenes must be vivid and relevant to the client's experiences
or expectations, ensuring the hierarchy reflects their specific anxieties. The client typically prepares
index cards depicting each situation and arranges them based on levels of distress, with the
therapist's assistance to provide necessary details for visualization during relaxation.

Marquis and Morgan suggested that around 10 items are usually sufficient for the hierarchy, but
additional items may be introduced during therapy if needed. Possible inconsistencies in hierarchy
construction are addressed by allowing the client to independently re-rate anxiety-inducing events.
Furthermore, Paul distinguished between thematic and spatial-temporal hierarchies, allowing clients
to visualize themes of similar events to address common anxieties. Overall, the creation of a
tailored hierarchy is a crucial aspect of systematic desensitization therapy, facilitating gradual
exposure to anxiety-inducing stimuli in a controlled and manageable manner.

3. The Desensitization Procedure:

Desensitisation training is only given once the client has mastered the act of relaxation. The
therapist guides the client through a graded experience of each circumstance in a hierarchy, from
pleasant to anxiety-provoking, while they are fully relaxed in a comfortable chair or couch. The
therapist starts with the scene that is lowest on the hierarchy and works their way up to the next
thing if the client settles down nicely. When the client exhibits signs of anxiety, such as raising his
index finger, the treatment is stopped and the following thing below is used to resume. It goes on
until the customer is still at ease and can clearly picture the scene.

Systematic Desensitization

Systematic desensitization is a type of behavior therapy that is used to treat anxiety disorders,
particularly specific phobias. It is based on the principles of classical conditioning and involves
gradually exposing individuals to feared stimuli, while using relaxation techniques to reduce
anxiety and promote habituation.

The steps of systematic desensitization can be summarized as follows:

Relaxation training: The therapist teaches the individual a relaxation technique, such as deep
breathing, progressive muscle relaxation, or guided imagery, to help them reduce their anxiety
response.

Fear hierarchy: The therapist works with the individual to develop a fear hierarchy, which is a list
of feared stimuli or situations, ranked from least to most anxiety-provoking.

Exposure: The individual is exposed to each item on the fear hierarchy, starting with the least
anxiety-provoking item, while using the relaxation technique to reduce anxiety.

Gradual exposure: The individual progresses through the fear hierarchy, gradually increasing the
level of exposure to each feared stimulus or situation, while continuing to use the relaxation
technique to reduce anxiety.
 Maintenance and generalization: The individual is encouraged to practice the relaxation
technique and exposure exercises outside of therapy, to maintain their progress and generalize the
skills to real-world situations.

The underlying rationale of systematic desensitization is that anxiety and fear responses are learned
through classical conditioning, and can be unlearned through exposure to the feared stimulus or
situation, while pairing that exposure with relaxation. By pairing the relaxation response with the
feared stimulus or situation, the individual can learn to associate it with a more positive or neutral
response, rather than anxiety or fear.

Systematic desensitization has been found to be an effective treatment for a range of anxiety
disorders, particularly specific phobias, with high rates of success and relatively low rates of relapse
(Wolpe, 1958). It has also been found to be well-tolerated by individuals, with few side effects or
complications (Choy et al., 2007)

Subjective Units of Distress (SUDS)

SUDs stands for Subjective Units of Distress, which are used in systematic desensitization as a way
of measuring an individual's level of anxiety or distress in response to a feared stimulus or situation.
SUDs are typically rated on a scale of 0 to 100, with 0 indicating no distress and 100 indicating
extreme distress or panic. During the exposure phase of systematic desensitization, the individual is
gradually exposed to feared stimuli or situations, starting with the least anxiety-provoking item on
their fear hierarchy. As they are exposed to each item, they are asked to rate their level of distress or
anxiety using the SUDs scale.

The use of SUDs in systematic desensitization serves several purposes. First, it allows the therapist
to monitor the individual's progress and adjust the exposure exercises as needed. If the individual's
distress level is too high, for example, the therapist may need to slow down the exposure or provide
additional support. Second, SUDs ratings can be used to assess the effectiveness of the treatment. If
the individual's distress level decreases over time, this indicates that they are habituating to the
feared stimulus or situation, and that the treatment is having a positive effect. Finally, SUDs ratings
can be used as a way of promoting self-awareness and self-regulation in the individual. By
becoming more aware of their own anxiety responses, and learning to regulate their level of distress
using relaxation techniques or other coping strategies, the individual can develop greater control
over their anxiety in real-world situations.

Overall, the use of SUDs in systematic desensitization is an important tool for measuring and
monitoring an individual's level of distress or anxiety during exposure exercises, and for assessing
the effectiveness of the treatment. It also promotes self-awareness and selfregulation in the
individual, which can have positive effects beyond the therapy sessions.

In-Vitro and In-Vivo In systematic desensitization,

in vivo and in vitro are two different types of exposure techniques used during the exposure phase
of the treatment. In vivo exposure involves exposing the individual to real-life situations or stimuli
that provoke anxiety or fear, such as being in an elevator, driving a car, or encountering a spider.
The goal of in vivo exposure is to help the individual gradually habituate to the feared stimulus or
situation by exposing them to it in a controlled and supportive environment, while using relaxation
techniques to reduce anxiety and promote habituation.

In vitro exposure, also known as imaginal exposure, involves exposing the individual to imagined
or virtual representations of feared stimuli or situations. For example, the individual may be asked
to imagine themselves in a particular anxiety-provoking situation, or they may be exposed to virtual
reality simulations that mimic the feared stimulus or situation. The goal of in vitro exposure is
similar to in vivo exposure, but it may be particularly useful for situations that are difficult or
impossible to recreate in real life.

Both in vivo and in vitro exposure are effective techniques for reducing anxiety and fear responses,
and are commonly used in the treatment of anxiety disorders, particularly specific phobias. The
choice of which type of exposure to use may depend on a variety of factors, such as the nature of
the feared stimulus or situation, the individual's level of anxiety or avoidance, and their personal
preferences or limitations. Basically, in vivo and in vitro are two different types of exposure
techniques used in systematic desensitization. In vivo exposure involves real-life exposure to
anxiety-provoking situations or stimuli, while in vitro exposure involves imagined or virtual
exposure. Both techniques are effective in reducing anxiety and promoting habituation.
Theoretical framework

The theoretical framework of systematic desensitization is based on the principles of classical

conditioning. The treatment aims to replace the individual's fear response with a relaxation
response. By pairing the feared stimulus with relaxation, the individual learns to associate the
stimulus with a positive, calm state instead of a fearful one. This process is called
counterconditioning.

Limitations

There are some limitations to the use of systematic desensitization as a therapeutic technique.
Firstly, it may not be effective for all types of anxiety disorders. For example, it may not be suitable
for individuals with severe phobias or panic disorder, as exposure to the feared stimulus may be too
overwhelming for them. Additionally, the treatment requires the individual's active participation
and motivation, which can be difficult to achieve in some cases. Another limitation is that
systematic desensitization may not be a long-lasting solution. Some individuals may experience a
relapse of their anxiety symptoms after the treatment is complete. Additionally, the treatment may
not address the underlying causes of the anxiety disorder, such as past trauma or environmental
stressors. Overall, while systematic desensitization can be an effective treatment for some
individuals with anxiety disorders, it may not be suitable for everyone and may have limitations in
terms of its long-term effectiveness and ability to address underlying causes of anxiety.

References

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Kindermann, S., Lazarov, A., Grunert, V., Schumacher, S., & Hohagen, F. (2020). Exposure
therapy for health anxiety: Effectiveness and response rates in routine care of an outpatient clinic.
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Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2020). Narrative exposure
therapy for adults, children, and perpetrators. Journal of Aggression, Maltreatment & Trauma,
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Segal, J., Shiban, Y., Roth, J., Kolassa, I.-T., & Pauli, P. (2021). The effectiveness of self-guided
virtual-reality exposure therapy for public-speaking anxiety. Frontiers in Psychiatry, 12, 694610.
https://doi.org/10.3389/fpsyt.2021.694610

FLOODING

The term ‘flooding’ was first used by Polin (1959) while reporting on the effects of exposure to
anxiety-provoking stimuli and physical suppression of anxiety-motivated locomotor response on
avoidance behaviour in animals. The method is also called response prevention. It involves
therapist controlled prolonged exposure to anxiety-provoking conditioned stimuli (CS)
simultaneously blocking the individual’s chance of escape and avoidance. It helps him to
habituate to the anxiety provoking conditioned stimuli. In a natural setting, instrumental
responses such as running away from the situation help in relieving the individual from the
stress. The responses that occur prior to it may include instrumental and autonomic responses
such as crying, increased palpitation, sweating, fainting, repetitive washing, cleaning, checking
and so on. When these responses are frequently associated with a feeling of relief, they are
negatively reinforced. This is how many phobic, anxious, obsessive or compulsive responses are
maintained over time. Literally, ‘We are afraid as we run away from the situation.’ In order to
eliminate fear, we must encounter the fear-provoking stimulus. Lack of opportunity to do so
‘incubates’ the ‘neurotic’ response. The response continues to be negatively reinforced.

During flooding, the therapist presents a conditioned stimulus (e.g. dog) that usually
elicits a strongly conditioned emotional response (fear) without being followed by the
unconditional stimuli (e.g. physical injury or pain due to dog bite). Prolonged exposure to the
stimulus (dog) extinguishes the avoidance response (fear). By preventing avoidance behaviour in
presence of the anxiety-provoking stimulus, extinction is allowed to occur at a faster rate.
Flooding may involve actual exposure to the real-life situations (flooding in vivo) through films,
or computer-generated images (virtual reality therapy) or they could even be imaginary.

Flooding and Systematic Desensitisation

Although both systematic desensitisation and flooding procedures are classified under
exposurebased treatment methods (Kazdin 2001), in the former method, the client is trained to be
deeply relaxed, then the acquired relaxation is paired with the anxiety-provoking stimulus
gradually and step by step; whereas in flooding, the client is ‘flooded’ with the anxiety-
provoking stimulus until the avoidance response habituates. There is considerable evidence that
response blocking is an effective method of speeding up the extinction of avoidance response
(e.g. Baum 1966, 1970; Black 1958). Thus, slow extinction of avoidance response (as it is done
in systematic desensitisation), is not seen in flooding. However, reviewing a number of studies
comparing flooding and systematic desensitisation, Morganstern (1973) observed that both the
procedures are equally effective. Occasionally when systematic desensitisation is not effective,
flooding may successfully reduce avoidance response. Yule et al. (1974) demonstrated the case
of an 11-year-old boy who was afraid of a number of events such as loud noise of a balloon
bursting, guns, motorcycles and so on. Several weeks of systematic desensitisation could not
bring a change in the behaviour. At last, fl ooding was used.

The procedure was as follows:

In the first session, the child along with the therapist entered into a room full of balloons. The
mere sight of balloon made the child anxious and he started crying when the therapist started
breaking them one after another. He then persuaded the child, too, to break the balloons with his
legs, and then with his hands. Initially, the therapist covered his (child’s) ears with hands. Like
this, the child was made to burst several dozens of balloons. At the beginning of the second
session, he was still anxious, but after bursting another hundreds of balloons, he seemed to enjoy
it. Finally, he had no fear of loud noises. A 25-months follow-up study revealed complete
extinction of fear of loud noise. Meyer et al. (1975) reported the case of an obsessive woman
who used to engage in elaborate washing rituals after the death of her husband. She used to wash
all objects ‘contaminated’ with death. The in vivo flooding technique used to treat this case
included touching a dead body in the hospital mortuary in presence of the therapist. Turner et al.
(1994) successfully used a combination of in vivo flooding in treatment of social phobias. People
suffering from social phobia often report physiological symptoms like increased heartbeat,
trembling or sweating in social situations that others do not find disturbing.
The authors compared the effects of three treatment conditions:
flooding therapy, (ii) drug (atenol) therapy, and (iii) placebo (where the clients consumed tablets
thought to be atenol). All were exposed to three months each of these treatments. The clients
were assessed through psychological tests measuring anxiety and through verbal interaction,
where they were asked to speak to an audience of three persons.
Flooding was found to be more effective than drug or placebo conditions. The gain from the
treatment was maintained in six months follow-up.

Operationally, there is a subtle difference between in vivo flooding and in vivo exposure. They
are similar except that the in vivo exposure can be conducted on a graduated or hierarchical basis
and not desired to maximise the fear/anxiety reaction, whereas flooding always aims at
maximising these responses in order to extinguish them faster. Conducting a long series of
studies on confronting real life exposures in phobic and obsessive compulsive disorders, Marks
(1981) suggested that anxiety disorders are not necessarily caused by conditioning. Instead, he
described the fear situation as an ‘evoking stimulus’ (ES) and the avoidance behaviour that
follows (e.g. phobic or compulsive response) as ‘evoking response’ (ER). In flooding exposure
in vivo, the therapist’s task is to identify the ES and present it until the ER is reduced. Stronger
the evoking stimulus, longer would be the required duration of exposure to extinguish the
response.

The relationship between stimulus intensity and stimulus duration in flooding will
determine whether it will be sensitising or desensitising (Reiss, 1980). However, Yule and his
associates cautioned that if the flooding session is terminated prematurely, it might even increase
the phobic response. Indeed Staub (1968) reported some similar cases where fears worsened after
a short duration of flooding. Systematic desensitisation is considered as a rather pleasant
procedure; therefore, it is more popular. It does not allow the person to experience high degree of
anxiety/fear, whereas flooding does. Therefore, Mazur (1986) even stated that there is little
justification for using flooding. This may be an over generalised view of the technique. In many
situations, fl ooding is found to be more effective than imaginary desensitisation (Marshall et al.
1977). On the other hand, there are real life situations (e.g. natural disaster, accidents, rape or a
terrorist attack) that cannot be simulated to create a situation for fl ooding in vivo. Thus, there
are limitations and advantages of both the procedures. Regardless of which theory best explains
this phenomenon, fl ooding and exposure in vivo have been used by behaviour therapists
successfully for treatment of a number of disorders including phobias (Jones 1924; Kandel et al.
1977; Kolko 1984; Yule et al. 1974), anxiety disorders (Girodo 1974), obsessive-compulsive
disorder (Hackmann and McLean 1975; Levy and Meyer 1971; Meyer et al. 1975; Rachman et
al. 1873; Rainey 1972), children’s agitated depression (Hannie and Adams 1974); somatic
complaints (Stambaugh 1977) and psychogenic urinary retention (Glasgow 1975; Lamontagne
and Marks 1973). Flooding is not a fixed technique but there are different parameters involved it.
When a client is not able to tolerate extremely intense stimulation, the therapist is required to
present the stimuli in a graded manner. This method is called graded exposure. One has to
proceed in short hierarchies, depicting smaller level of anxiety (Borden 1992). Failure to modify
the procedure by downgrading the level of anxiety through limited or graded exposure may lead
the client to drop out. The therapist should also be careful to see that the threatening stimulus
(CS) is not accompanied by unpleasant stimuli (US) like pain or injury.
Flooding may also involve a wide range of allied procedures. Sinha and Jalan (2001)
successfully used a combined method that included relaxation, exposure and cognitive
restructuring in the treatment of social phobia. Recently, Abramowitz et al. (2002) treated
obsessive-compulsive disorders in 14 males and 14 females using exposure and ritual prevention.
The therapists were asked to rate the treatment compliance of these clients. Results showed that
understanding of the treatment rationale and compliance with in-session and homework exposure
instruction were more closely linked with the treatment outcome, than with ritual prevention and
self-monitoring

. Is flooding a safe method of response elimination?

This is an important question. For that matter, acceptability of any form of therapy depends on
the safety of the client under treatment. Exposure to the fearful situations in real life may have
serious side effects. This may perhaps even worsen the client’s condition. However, a survey
conducted by Shipley and Boudewyns (1980), negative outcomes were only in nine out of 3500
cases. Thus, most therapists consider the procedure to be quite safe. The second question, which
is often asked is that whether it is necessary for a therapist to accompany the client. Research
findings reveal that presence of the therapist during flooding does not enhance its effectiveness
(Al-Khubaisy et al. 1992). In spite of controversies, flooding has been used successfully in many
clinical conditions.

IMPLOSION

Implosion or implosive therapy is a variant of flooding but it takes place at the imaginary level.
The technique was developed by Thomas Stampfl (Hogan 1968; Stampfl 1966, 1970; Stampfl
and Levis 1967). It involves prolonged exposure of the client to relevant negative fantasies
connected with an anxiety-provoking event. The therapist’s task is to describe the scenes in an
involved and dramatic manner repeatedly with variation in order to arouse maximal anxiety,
maintaining it almost at an intolerable level, so that the stress/anxiety caused by it dissipates. The
scenes are usually unrealistic, exaggerated or physically damaging events, that are unlikely to
happen in real life (Morganstern 1973; Stampfl and Levis 1967). For instance, a snake phobic
client is asked to imagine a snake coiling around his body and starting to bite his finger. He is
trying to put his finger out, feeling the fangs going right down into the finger. The terrible pain is
spreading throughout the shoulder and the body, and blood dripping out of his finger. At the next
stage, the animal begins to attack his face and other vital organs of the body.The therapist may
also assist the client in doing so, instead of directly being engaged in description of the scenes. It
is based on the hypothesis that neurotic and avoidance responses are perpetuated because they
reduce anxiety. Stampfl theorised that the cues from early traumatic experiences caused by
punishment, rejection, deprivation, or humiliation are retained throughout the lifetime of an
individual. Everything associated with these events tends to elicit anxiety. These ‘neurotic’
behaviours can be treated by re-creating the original trauma, or something quite similar to it in
the absence of real punishment, deprivation or rejection. If intense emotional reactions are made
to occur in absence of primary reinforcement, extinction of neurotic behaviour perpetuated by
anxiety would occur (Hogan 1968). While explaining implosion, Stampfl combined
psychodynamic principles with behaviour therapy. The unique aspect of this therapy is that the
client avoids not only the real situations or objects but also the thoughts and ideas concerning the
event. Implosion is useful in changing the catastrophic ideas concerning an anxiety-provoking
stimulus directly. Implosion differs from flooding in that in flooding, the client is exposed to the
fear-provoking stimuli either in real life or in imagination, whereas in implosion these scenes are
presented verbally in an exaggerated and dramatic manner. The descriptions are rather
unrealistic. The length of imagining anxiety-provoking scenes may be upto two or more hours,
although 40 to 60 minutes sessions are more common (Marks 1972).

Research does not indicate that implosion therapy is better than systematic desensitisation
(Morganstern1973, 1974). Inclusion of implosion like material in flooding either has no effect or
the outcome of it is poor (Wilson 1982). Looking at these findings, some authors do not
recommend the use of implosive therapy in clinical practice (e.g. Martin and Pear 1992).
Biofeedback
Biofeedback is a technique in which an electromechanical device monitors the status or changes
of a person’s physiological processes, such as heart rate or muscle tension, and immediately
reports that information to that individual (Schwartz & Schwartz, 2003). This information allows
the person to gain voluntary control over these bodily processes through operant conditioning. If,
for instance, we were to use biofeedback to lower your blood pressure or heart rate and the
device reports that the pressure or rate has just decreased a bit, this information would reinforce
whatever you had done to achieve this decrease (Weems, 1998). The phrase ‘‘whatever you had
done’’ is more interesting than it may appear: People who learn to control a bodily process
through biofeedback often can’t describe the responses they make that affect it.

INSTRUMENTATION AND MEASUREMENT

Measuring blood pressure provides a clear and familiar example of how biofeedback devices
work. You’ve surely seen a physician or nurse apply the basic device, called a
sphygmomanometer, to measure a patient’s blood pressure. A cuff on the person’s arm is filled
with air until it is tight enough to stop the blood from flowing through the main artery in the arm
(AMA, 2003). The cuff is then slowly deflated so that the medical worker can hear through a
stethoscope the first beat forcing its way along the main artery as the blood flow overcomes the
pressure in the cuff. The cuff pressure at that first beat can be seen on a gauge and indicates the
person’s maximum (that is, systolic) blood pressure at that time, which occurs when the heart
contracts to pump the blood. The medical worker continues the procedure by deflating the cuff
until the beating sound has disappeared. The pressure shown on the gauge at this time reflects the
resting (diastolic) pressure in the artery while the heart chambers fill with blood between
contractions. Blood pressure biofeedback sessions can be conducted in several different ways
(Olson & Kroon, 1987).

In one approach, many sphygmomanometer readings are taken, and the person receives each
pressure reading. Some devices can inflate and deflate the cuff and take readings automatically
(Goldstein, Jamner, & Shapiro, 1992).
The information individuals receive in a biofeedback procedure can take many different forms.
For instance, the level of physiological functioning can be reflected by high or low numbers on a
gauge, pitches of tones produced by an audio speaker, degrees of loudness of a tone from a
speaker, or degrees of brightness of a light. Status and functioning can be measured for many
different physiological processes, enabling the use of biofeedback on each process (Olson, 1987;
Peek, 2003). For some body functions, such as heart rate or temperature, measurements can be
taken continuously without having to cycle through a complex procedure.

Specific names are given for biofeedback techniques for different physiological processes. Here
are the names and descriptions of some commonly used techniques:

• BP biofeedback. Gives feedback on the person’s blood pressure (BP) measured with a
sphygmomanometer.

• HR biofeedback. Measures and gives feedback on heart rate (HR), or heartbeats per minute
. • GSR biofeedback. The galvanic skin response (GSR—also called electrodermal activity,
EDA) is a measure of sweat gland activity assessed with a device that tests how readily the skin
conducts minute levels of electricity:
Sweaty skin conducts more readily than dry skin. GSR level is given as feedback.

• EEG biofeedback. An electroencephalograph (EEG) assesses electrical activity in the brain,

including certain types of brain waves. EEG level is given as feedback.

• EMG biofeedback. An electromyograph (EMG) measures muscle tension by assessing the

electrical activity of muscles when they contract. EMG level is given as feedback.

• Thermal biofeedback. Assessments of skin temperature in a region of the body measure the
flow of blood, which is warm, in that part of the body, such as a foot or hand. Temperature level
is given as feedback.
Note that all these measures are indirect. They are taken on the outside of the body or just below
the skin to reflect changes deeper in the body, such as brain or heart activity. And sometimes the
measure allows us only to infer internal changes, as when we assume that skin temperature
changes suggest that blood flow changes have occurred—the higher the temperature, the greater
the blood flow.

Biofeedback sessions typically begin after the target person has had a period of time to adapt to
the situation. The length of the adaptation period depends on the person and his or her familiarity
with the procedures and experiences in the preceding minutes (Arena & Schwartz, 2003). Two
examples show why adaptation can be important. First, the procedure involves having sensors
attached to various parts of the body, and people who are not familiar with this may feel uneasy,
thus arousing their physiological function. Second, some individuals may have rushed or climbed
stairs to make the appointment, and some of them may have arrived early and had time to adapt
physically in the waiting room. Each biofeedback session begins with a baseline assessment of
the physical system targeted for biofeedback; this baseline period should usually last at least 15
minutes (Arena & Schwartz, 2003). Once the system appears stabilized, biofeedback can begin.

THE IMPORTANCE OF TRAINING AND DEVELOPMENTAL LEVEL

Learning to regulate one’s own bodily processes with biofeedback usually requires training,
which is most effectively provided by an experienced professional. The training clients get
incorporates a shaping procedure in which tiny physiological changes in the desired direction are
reinforced initially; as the training progresses, larger and larger changes are required for
reinforcement. Clients are usually encouraged to practice biofeedback techniques at home when
they receive training. Home practice appears to enhance the success of biofeedback in certain
applications, such as in treating headache (Gauthier, Cˆot ́e, & French, 1994), but it may not help
people learn the methods better or faster during training (Blanchard et al., 1991).

Researchers have proposed that children may be especially good candidates for treatment with
biofeedback (Attanasio et al., 1985). Some evidence supports this view: A study combining data
from prior research found that biofeedback treatment for headache was more successful in
reducing headache pain with children than with adults (Sarafino & Goehring, 2000). Although
we aren’t sure why children would have greater success with biofeedback treatments, two
speculations have been offered (Attanasio et al., 1985). First, children seem to be more interested
in and enthusiastic about the equipment and procedure than adults are. Second, adults appear to

CERTIFICATION IN BIOFEEDBACK TREATMENT

The Biofeedback Certification Institute of America (BCIA) provides accreditation for non-
university based training programs in biofeedback and certification for practitioners (Schwartz &
Montgomery, 2003). The purpose of certification is to give the public some way to determine
that biofeedback individual practitioners are likely to be competent, having met basic
requirements for training and experience.

Application

TREATING HYPERTENSION
Hypertension is the medical condition of having blood pressure that is consistently high over
several weeks or more (AHA, 2011). Medical treatment for hypertension usually starts with
having the person make lifestyle changes,
such as by exercising and making dietary changes designed to lower weight, and often involves
taking prescription drugs. Biofeedback can be a useful supplement to medical treatment,
enabling people to control their blood pressure to some degree, achieve lower blood pressure
levels, and use less medication (McCaffrey & Blanchard, 1985; McGrady & Linden, 2003;
Olson & Kroon, 1987). Drugs used in treating hypertension can cause side effects, such as
increased blood sugar levels or feelings of weakness or confusion, that may be difficult for some
patients to tolerate. Using biofeedback, sometimes with relaxation techniques, may be especially
useful for these people in helping to reduce their blood pressures while minimizing the use of
drugs. Research has shown that biofeedback applied with or without relaxation is effective in
lowering blood pressure in people with hypertension (McGrady & Linden, 2003).
Some successful biofeedback treatments for hypertension apply BP biofeedback, using a
sphygmomanometer that measures blood pressure directly; but other approaches, such as
thermal, GSR, or EMG biofeedback, have had success, too (McGrady & Linden, 2003). Patients
learn the BP biofeedback method in about 3 months in supervised sessions and are generally
asked to practice the procedure at home, particularly at times of the day when their blood
pressure tends to be high.

TREATING SEIZURE DISORDERS: EPILEPSY

Epilepsy is a neurological condition marked by recurrent, sudden seizures that result from
electrical disturbances in the brain (AMA, 2003; EFA, 2011). Brain-wave examinations of
patients with epilepsy have revealed recurring patterns of excessive neuron firing in specific
regions of the brain, such as the temporal lobes located above the ears (Monastra, 2003). In the
most severe form of epileptic seizure, called a grand mal or tonic-clonic seizure, the person loses
consciousness and has muscle spasms. Biofeedback treatment of epilepsy was developed initially
for patients whose seizures were not adequately reduced by medication.

EEG biofeedback has been used successfully with many epilepsy patients in helping them learn
to control their brain electrical activity and reduce their seizures (Monastra, 2003; Sterman &
Egner, 2006; Strehl, 2003).

The general approach in using EEG biofeedback for people with epilepsy involves training them
to decrease certain kinds of brain-wave activities and increase others in specific areas of the
brain. If they can gain some measure of control over these brain waves in the areas of the brain
where the disturbances occur, seizures should diminish. Although not all patients benefit from
this approach, most show substantial reductions in the number of seizures. Because the treatment
is costly, researchers have examined factors that may predict which patients are likely to benefit
from this approach and which are not. Some evidence suggests that the sizes of certain brain
waves before beginning biofeedback treatment and the location of abnormal waves are related to
the treatment’s success (Strehl, 2003).
TREATING CHRONIC HEADACHE

Two biofeedback approaches have been used for treating patients who suffer from severe,
recurrent headaches (Andrasik, Blake, & McCarran, 1986). The biofeedback approach used
depends on the headache type:

• Tension-type (or ‘‘muscle-contraction’’) headache seems to result from the combined effects
of a central nervous system dysfunction and persistent contraction of the head and neck muscles
(AMA, 2003; Holroyd, 2002). Patients with tension-type headaches generally receive EMG
biofeedback training to control the tension in specific muscle groups, such as those in the
forehead.

• Migraine headache seems to result from the combination of dilation of blood vessels
surrounding the brain and a dysfunction in the nervous system (AMA, 2003; Holroyd, 2002).
Patients with migraine headaches generally receive thermal biofeedback training (usually
monitoring the hand) to help them control the constriction and dilation of arteries

. A large number of carefully conducted experiments have shown that biofeedback is an effective
treatment for tension-type and migraine headache (Nestoriuc, Martin, Rief, & Andrasik, 2008).
Studies have also shown that biofeedback methods and relaxation methods are about equally
effective in reducing chronic headache, and using both methods together can be more effective
than using either one alone, at least for some patients (Andrasik, Blake, & McCarran, 1986;
Holroyd & Penzien, 1985). What’s more, the results of many studies with follow-up periods
averaging 14 months have shown that treating chronic headache with relaxation techniques or
with relaxation and biofeedback methods together provides durable relief (Blanchard, 1987;
Nestoriuc, Martin, Rief, & Andrasik, 2008). The data from one study with five yearly follow-up
assessments are presented in Figure 23-1 (Blanchard et al., 1987). The success of biofeedback in
reducing headache has been demonstrated in adults and children (Hermann & Blanchard, 2002).
Children acquire skills in EMG and thermal

TREATING ANXIETY
Two biofeedback approaches have been tested as treatments for anxiety. One approach uses
EMG biofeedback. We’ve seen in earlier chapters that procedures that relax the muscles,
particularly progressive muscle relaxation techniques, can reduce anxiety and other conditioned
emotional responses. Because EMG biofeedback can help people learn to relax specific muscle
groups, studies have investigated and found support for the utility of this form of biofeedback in
treating anxiety. Most of these studies applied biofeedback to reduce tension in the frontalis
region of the head—where rectangular sheets of muscle span the forehead—because some
evidence suggested a link between frontalis relaxation and general body relaxation (Surwit &
Keefe, 1978). The second approach tested for treating anxiety uses EEG biofeedback, such as by
increasing the person’s alpha waves evidence of its effectiveness is not strong (Monastra, 2003).
Although EMG biofeedback appears to reduce anxiety, an important question is whether it is
more effective than more easily or cheaply administered methods, such as progressive muscle
relaxation.

TREATING ASTHMA

Two biofeedback approaches have been applied to reduce the frequency and intensity of asthma
episodes (Sarafino, 1997). One approach uses EMG biofeedback, typically for the frontalis
muscle, which is of questionable utility. We’ll focus on the other approach, respiratory
biofeedback, in which airflow is measured with an apparatus as the patient breathes and feedback
is given on respiratory function so that the person can learn to control airway diameter. One
respiratory biofeedback apparatus has the person breathe through a device that varies air pressure
and assesses airway resistance to these variations: The greater the resistance, the poorer the
airflow. The feedback informs the person when changes occur, such as with numbers on a gauge.
After several training sessions, the patient is able to make stronger and stronger airflow
improvements and can eventually increase airflow when an asthma episode begins. As an
addition to respiratory biofeedback, the person can be trained in relaxation to reduce the role of
emotion in initiating an episode or making it worse when one occurs. Studies have generally
found that respiratory biofeedback and relaxation are useful supplements to medical treatments
for asthma (Nickel et al., 2005; Sarafino, 1997).
TREATING NEUROMUSCULAR DISORDERS
Neuromuscular disorders are medical conditions that affect the muscles and the nerves that carry
information directing the muscles to move. Some neuromuscular disorders involve paralysis,
which may have resulted from a spinal cord injury or a stroke that damages the brain; other
disorders cause the muscles to become rigid or have spasms. Such conditions have been treated
successfully with EMG biofeedback (Brudny, 1982; Fogel, 1987; Krebs & Fagerson, 2003). This
procedure involves monitoring muscles in the affected body parts, such as the legs, with sensitive
electronic equipment to detect tiny changes in muscular function. In the case of patients
Woman’s leg with EMG biofeedback sensors attached to treat her neuromuscular disorder.
Biofeedback is being used to teach her to walk again after a car accident injury. with paralysis of
part of the body, the paralysis cannot be total—a condition that happens when the spinal cord is
completely severed. Incomplete paralysis can occur if nerves are damaged, but not severed. For
patients whose muscles are incompletely paralyzed, EMG biofeedback is conducted by showing
the patient that the muscle has tensed a bit and encouraging him or her to tense it more and more,
thereby gradually increasing its strength. For patients with rigid muscles, the feedback focuses
on relaxing the muscles. Patients with muscle spasms focus on trying to get the EMG pattern to
match that of normal muscle action.