Grounding for anxiety: evidence based practice and practice-based evidence
Clients can, and often do, present for counselling in a mildly, or even highly anxious state and counsellors frequently use ‘grounding techniques’ for the alleviation of both acute and chronic anxiety. Here, we explore the techniques seen as most effective from an evidence-based point of view but additionally consider the thoughts of counsellors in practice i.e., practice-based evidence.
Progressive muscle relaxation (PMR) is a popular grounding technique with research suggesting that a significant reduction in anxiety levels occurs in participants practising PMR, for example in a study of trainee nurses suffering anxiety prior to an exam and using PMR versus a control group (who were instructed to ‘sit quietly’), found that anxiety was significantly reduced in the PMR participants versus the controls, Carver & O’Malley, (2015). Although the sample size for this work was relatively small (15 people) PMR has also been tried with larger samples (Cougle et al, 2020) and with specific populations; for example, patients suffering from Covid 19 (Liu et al, 2020) and people with schizophrenia (Chen et al, 2009), with results again suggesting reductions in both acute and chronic anxiety and additionally in Liu et al’s study improvements to sleep quality.
So, what about people presenting specifically for counselling or psychotherapy? In one study conducted by Mander et al, (2019) although participants clearly lowered their anxiety levels using PMR, this was not different to using ‘treatment as usual’ (proceeding with therapy without using any grounding technique) or to using mindfulness, as, in essence all three approaches resulted in lowered anxiety levels. Even though overall anxiety seems to lower after a counselling session (understandably if empathic listening and non-judgmental reflection have been going on) a key question might be, can I help a client feel less anxious in the first few minutes before we move on with the session? This seems like a useful idea for those of us meeting clients in an agitated or dissociated state.
In a study comparing four techniques for anxiety reduction (PMR, deep breathing, an adapted dive reflex technique and a condition where a weighted object is placed in the lap of participants) all four interventions were shown to reduce anxiety (Keptner, et al, 2021). In a recent study Steffen et al (2021) investigated the use of breathing techniques as a useful adjunct to psychotherapy, heart rate variability and blood pressure were measured and clear beneficial physiological effects were found in subjects using controlled breathing rates (essentially attempting to breathe only 6 times per minute) and similarly positive results in those subjects using soothing rhythm breathing when compared to control participants (who watched a calm nature video) and although the participants in the 6 breaths per minute arm of the study were unable to achieve 6 breaths per minute they did slow their breathing (from 17.8 breaths per minute to 12.2) and both groups had marked physiological benefits compared to the controls (Steffen, et al, 2021). So ‘grounding’ in some guise or other appears to be effective in helping change our immediate anxious state.
Aside from deep or relaxed breathing, carrying out a body scan, using your senses to see, hear, feel, and smell things in your immediate environment are also popular techniques, but perhaps before choosing a grounding technique the most important step is to teach clients to be aware of their thoughts. If you have had some contact with the approach of Acceptance and Commitment Therapy (ACT), you will probably be aware of the notion of defusion i.e., the process of becoming aware of your thoughts rather than just thinking them. Clients learn to separate themselves from their thoughts so they might better regulate the negative affect their thoughts are having on them (Harris, 2022). Just to illustrate the potential benefit to clients of practising defusion a 2017 study (Schumacher, Kemps and Tiggemann, 2017) found that ‘cognitive defusion lowered intrusiveness of thoughts, vividness of imagery and craving intensity’ this was in a sample of people seeking help for chocolate cravings.
How do grounding techniques work for anxiety?
In accordance with polyvagal theory (Porges, 2018) an explanation is that controlled breathing, muscle relaxation exercises are sending a signal via the parasympathetic nervous system to tell the body everything is ok, i.e., you are breathing at this controlled, calm rate, or else purposefully relaxing (even in the face of seemingly menacing situations/thoughts) and as you are breathing/relaxing in this way everything must be ok… A key element of these controlled breathing exercises is simply to spend longer doing something else than breathing in, i.e., breathe in for four, hold for four and breathe our for four means you are spending twice as long holding/breathing out than you do breathing in, the net result will of course be that you increase co2 levels and reduce o2 levels in the blood stream- in essence this is the opposite of what you would do in fight, flight freeze (as naturally for fighting and fleeing you are going to need extra oxygen). Another great controlled breathing exercise is to breathe in whilst making a tight fist and then as you breathe out very slowly unfurl your fingers in time with the release of the breath, the relaxing hand providing a visual support to the cadence of your breath.
Top 5 Grounding techniques
Breathing This can be mindfulness meditation breathing as in focussing carefully on the breath as you breathe in and expand your lungs etc or else timed breathing such as square breathing: four in, hold for four, four out and so on.
PMR, can be done body part by body part by tensing and holding a contraction then releasing it- often done as a relaxation exercise in workout classes, it can also be paired with your breathing- starting at one end of the body contract a muscle group and beath in and hold, then breathe out and relax the muscle at the same time and move up/down the body from head to toe.
Mindfulness exercise- focus on three things you can see, hear in the room, something you can smell, something you can taste… or simply look around the room and notice the most popular colour being worn by the people around you
Adapted dive response… this technique is based on the response to people diving into cold water… except you can do this using a basin filled with cool water and add ice from the freezer- ideally the bowl or basin will necessitate you bending forward to reach it- hold your breath and immerse yourself for as long as you comfortably can. (check with your doctor if you have any doubts whatsoever about doing this).
Body scan- wherever you are sat or standing try closing your eyes and focussing on the physical sensations you have from head to toe, slowly where your feet meet the ground, your bum and legs meet the chair, what do you feel in your neck, your shoulders? Scan slowly form top bottom then up again from bottom to top.
Carver, M. L., & O’Malley, M. (2015). Progressive muscle relaxation to decrease anxiety in clinical simulations. Teaching and Learning in Nursing, 10(2), 57-62.
Chen, W. C., Chu, H., Lu, R. B., Chou, Y. H., Chen, C. H., Chang, Y. C., … & Chou, K. R. (2009). Efficacy of progressive muscle relaxation training in reducing anxiety in patients with acute schizophrenia. Journal of clinical Nursing, 18(15), 2187-2196.
Cougle, J. R., Wilver, N. L., Day, T. N., Summers, B. J., Okey, S. A., & Carlton, C. N. (2020). Interpretation bias modification versus progressive muscle relaxation for social anxiety disorder: a web-based controlled trial. Behavior Therapy, 51(1), 99-112.
Harris, R. (2022). The happiness trap: How to stop struggling and start living. Shambhala Publications.
Keptner, K. M., Fitzgibbon, C., & O’Sullivan, J. (2021). Effectiveness of anxiety reduction interventions on test anxiety: a comparison of four techniques incorporating sensory modulation. British Journal of Occupational Therapy, 84(5), 289-297.
Liu, K., Chen, Y., Wu, D., Lin, R., Wang, Z., & Pan, L. (2020). Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complementary therapies in clinical practice, 39, 101132.
Mander, J., Blanck, P., Neubauer, A. B., Kröger, P., Flückiger, C., Lutz, W., … & Heidenreich, T. (2019). Mindfulness and progressive muscle relaxation as standardized session‐introduction in individual therapy: A randomized controlled trial. Journal of clinical psychology, 75(1), 21-45.
Porges, S. W. (2018). Polyvagal theory: A primer. Clinical applications of the polyvagal theory: The emergence of polyvagal-informed therapies, 50, 69.
Riyanto, D., Sulistiowati, N. M. D., & Imelisa, R. (2021, December). THE EFFECT OF GROUNDING TECHNIQUE THERAPY TOWARDS Reducing THE Anxiety LEVEL OF STUDENTS IN THE FINAL LEVEL OF MASTER OF NURSING JENDERAL ACHMAD YANI UNIVERSITY CIMAHI. In International Seminar on Global Health (Vol. 4, No. 1, pp. 27-40).
Steffen, P. R., Bartlett, D., Channell, R. M., Jackman, K., Cressman, M., Bills, J., & Pescatello, M. (2021). Integrating breathing techniques into psychotherapy to improve HRV: Which approach is best?. Frontiers in Psychology, 12, 624254.