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8. Tighten the muscles in the back of your neck by pulling your head way back, as if you were

going to touch your head to your back. Hold, then relax.

9. Take deep breaths and focus on the weight of your head sinking into whatever surface it is

resting on.

10. Tighten your shoulders as if you are going to touch your ears. Hold, then relax.

11. Tighten the muscles in your shoulder blades by pushing your shoulder blades back. Hold then

relax.

12. Tighten the muscles of your chest by taking in a deep breath. Hold, then relax.

13. Tighten your stomach muscles by sucking your stomach in. Hold, then relax.

14. Tighten your lower back by arching it up (dont do this if you have back pain). Hold, then

relax.

15. Tighten your buttocks by pulling them together. Hold, then relax.

16. Squeeze the muscles in your thighs. Hold, then relax.

17. Tighten your calf muscles by pulling your toes towards you. Hold, then relax.

18. Tighten your feet by curling them downwards. Hold, then relax.

19. Mentally scan your body for any left over tension. If any muscle group remains tense repeatthe exercise for those muscle groups.

20. Now imagine a wave of relaxation spreading over your body.

Controlled or abdominal breathing

When tense, a persons breathing is rapid and shallow, which can lead to hyperventilation or

panic attacks. Hyperventilation is a process where shallow breathing gets rid of too much carbon

dioxide which can lead to light-headedness, breathlessness, feeling of suffocation, blurred vision,

and numbness or tingling in hands or feet as well as a hot, flustered feeling. Mild

hyperventilation can lead to increased perpetual anxiety and apprehension.

When teaching clients breathing retraining, it is important they understand and feel the

difference between shallow, chest-level breathing and controlled, abdominal breathing. A good

way to do this is to ask clients to practice each type of breathing. However, it is important to

inform clients who are extremely anxious that they may experience trouble breathing deeply

and may need to try this when feeling less anxious (some clients may always have trouble with

this). Encourage clients to increase their breathing speed. Ask them to place their hand gently on

their abdomen and feel how shallow and rapid their breathing is, only the chest moves up and

down. Compare this with abdominal breathing based on the following instructions for the clientprovided by Lee et al.

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1. Rate your level of anxiety on a scale from 1 to 10.2. Sit as comfortably as possible in a chair with your head, back and arms supported, free

legs and close your eyes (if you like).

3. Place one hand on your abdomen right beneath your rib cage4. Inhale deeply and slowly, send the air as low and deep into your lungs as possible. If you

are breathing from your abdomen you should feel your hand rise, rather than your chest.

5. When you have taken a full breath, pause before exhaling. As you exhale imagine all ofthe tension draining out of your body.

6. Do 10 slow abdominal breaths. Breathe in slowly counting to four, before exhaling to thecount of four (four seconds in, four seconds out). Repeat this cycle 10 times. Hold final

breath for 10 seconds, then exhale.

7. Now re-rate your level of anxiety and see if it has changed.Controlled breathing techniques can help reduce overall levels of tension and are a useful

strategy to use when faced with high-anxiety or high-risk situations when relapse is likely. A

client worksheet for abdominal breathing is included in Appendix DD.

Calming response

This is a quick skill developed by Montgomery and Morris368

to reduce the discomfort of

unwanted feelings. The basic steps involve the client mentally detaching from the situation and

thinking clear head, calm body as they take one slow deep breath. As they exhale they relax.

Visualisation and imagery

This relaxation technique might be only useful for a select few clients and should not be used

where a client finds the process difficult or has unpleasant affects as a result367

.

1. Sit comfortably in a chair, close your eyes and breathe deeply. Clear your mind of allthoughts and images.

2. Imagine a place where you feel safe and relaxed; this could be a real or imaginary place.Think in as much detail as possible: What are the sounds? What are the smells? What do

you feel? What do you see?

3. Think about how your body feels in this place (e.g., are your muscles relaxed? Is itwarm? Is your breathing and heart rate slow or fast?).

4. Stay in this relaxed state for a moment and remember how it feels so you can return toit when you need to.

5. Slowly clear your mind again and return to the here and now and the sounds aroundyou. Stretch your arms and legs and when you are ready, open your eyes.

A client worksheet for visualisation in provided in Appendix EE.

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Grounding

For most clients suffering anxiety symptoms, most breathing and relaxation techniques are

effective; however, for sufferers of panic or trauma some relaxation and breathing strategies can

occasionally trigger flashbacks, intrusive memories, panic, fear and dissociation. AOD workers

can assist these clients and reduce traumatic and panic reactions by focusing the attention of

these clients on the outside world rather than the internal trauma. This process is known as

grounding (or distraction, centering, or healthy detachment)224

.

There are different forms of grounding outlined below; different strategies work best for

different clients and it is important to use a strategy appropriate to the individual. The examples

of grounding techniques provided below are adapted from Najavits224

.

Examples of mental grounding:

Describe objects in your environment in detail using all your senses.

Describe an every day activity, such as eating or driving to work, in detail.

Use a grounding statement. I am Jo, I am 23years old, I am safe here, today is ....

Say the alphabet slowly.

Counting backwards from 20.

Examples of physical grounding:

Run cool or warm water over your hands.

Press your heels into the floor.

Touch objects around you as you say their names. Jump up and down.

Change your posture to a more upright one.

Stretch.

As you inhale say in, and when you exhale say out or calm or easy or safe.

Examples of soothing grounding:

Rub nice smelling hand cream slowly into hands and armsand notice the feel and smell.

Say encouraging statements to yourself such as Youre okay, youll get through this.

Think of favourites of any kind of object (e.g., cars) or animal. Think of a place where you felt calm and peaceful, describe where you were, what was

around you and what you were doing.

Plan something nice for yourself such as a bath or a good meal.

Think of things you look forward to doing in the next few days.