Relaxation response and mind-body medicine (Benson)

1. Introduction

Version followed: (a) the single-practice relaxation response (RR) technique from Herbert Benson's The Relaxation Response (Benson with Miriam Z. Klipper, William Morrow, 1975; later HarperCollins editions), as reproduced in secondary sources and in the simplified two-step form the Benson-Henry Institute (BHI) promotes; and (b) the BHI group programme Stress Management and Resiliency Training (SMART), also called SMART-3RP (Relaxation Response Resiliency Program), in the session structure of the BHI "SMART content overview" (1 individual intake + 8 weekly 2-hour group sessions + 2 brief provider sessions). Where adapted versions differ (e.g. the 9-session cancer-survivorship version), this is named. [source: SMART content overview; Mass General Brigham SMART-3RP page; Psychology Today, Mitchell 2013; Harvard Health]

Source status (October 2026). Based on: a Benson-Henry Institute (BHI) mini-relaxation handout (4.6, 4.7); BHI's SMART certification page and 2026 application form (Section 2 "Who delivers it", 5.13); the abstract record of the 3RP development paper (Park et al., 2013) and an MGH 3RP-Lymphoma trial protocol (evidence status, format); the Heide & Borkovec 1983 and 1984 records (5.1); and, for the core sequence in 4.2, secondary reproductions of the 1975 book checked against a Harvard Health description and a BHI-hosted article. Still [uncertain]: the exact wording of the 1975 book's steps and of BHI's current full written sequence (BHI publishes its instruction as a recorded practice); the content of the 1984 "Relaxation and depersonalisation" letter.

What it is. The relaxation response is Benson's name for a physiological state he described as the opposite of the fight-or-flight (stress) response: in the original laboratory work, oxygen consumption, carbon dioxide production and respiratory rate fell during practice of a simple technique, which the authors interpreted as an integrated hypothalamic response with reduced sympathetic activity. [source: Beary, Benson & Klemchuk 1974, abstract] The technique grew out of Benson's Harvard studies of Transcendental Meditation practitioners from 1968; he stripped the method of its religious or cultural frame and proposed that any practice containing a few common elements can elicit the same response. [source: HandWiki, The Relaxation Response] For the meditation traditions the method drew on (mantra meditation, contemplative prayer, yoga), see Domain XIII.

Mind-body medicine as practised at BHI is a framework and programme rather than a single therapy: SMART-3RP combines (1) education about the biological stress response, (2) daily elicitation of the RR by several routes (single-pointed focus meditation, breathing, body scan, progressive muscle relaxation, mindfulness, yoga or tai chi, guided imagery), and (3) resiliency-building through stress awareness and adaptive strategies drawn from cognitive behavioural therapy and positive psychology (cognitive restructuring, problem-solving, acceptance, social support, appreciation, self-compassion, humour). [source: SMART content overview; OHSU SMART-3RP page]

Core idea of change. Chronic activation of the stress response is held to drive distress; regular, repeated elicitation of its physiological opposite, combined with noticing stress early and responding to it adaptively, is held to build resilience, "control in the uncontrollable" in the words of one programme page. [source: Mass General Brigham SMART-3RP page] Benson's claims that the RR helps stress-related physical conditions (he listed hypertension, headache, insomnia, irritable bowel syndrome, back pain, heart disease and others) are his attributed claims. [source: HandWiki; Harvard Health] In this guide the RR and SMART-3RP are used only as psychological care: for stress, worry, coping and quality of life, alongside (never instead of) medical treatment. They are not a treatment for hypertension, cancer or any other physical disease. Programme pages for people with cancer present the group as coping and resiliency support and do not describe it as a cancer treatment. [source: Mass General Brigham SMART-3RP page]

Evidence status (brief). The original physiological findings come from small laboratory studies. [source: Beary et al. 1974] The 3RP development paper (Park, Traeger, Vranceanu, Scult, Lerner, Benson, Denninger & Fricchione, Psychosomatics, 2013) describes the 3RP as an 8-session, multimodal, patient-centred programme for coping with chronic stress, for people with a range of psychological and medical conditions. It has three core targets: eliciting the RR, stress appraisal and coping, and growth enhancement. It draws on stress management, CBT and positive psychology, and links the RR to resiliency and allostatic load. [source: Park et al. 2013, abstract record] Adapted versions have been piloted. One example is an 8-session 3RP for lymphoma survivors delivered by videoconference: about 90 minutes per session, groups of about 6, each session repeating stress, distress and coping ratings, a goal check-in, an RR practice and a mini, plus daily 10–20 minute home practice recorded in weekly logs. [source: NCT03212261 protocol] One institutional page reports pre-post improvements in burnout and perceived stress in a small group of physicians and some patient groups, without study details. [source: OHSU] Trial outcomes are not reviewed here, because the spec excludes evidence reviews.

2. Framework

Two ways to use it. [synthesis]

• Stand-alone RR training within individual therapy: screen, teach one RR method in session, assign daily home practice, review and troubleshoot over the next few sessions, then add other RR routes if needed. Typically woven into 2–4 sessions of ongoing therapy. [synthesis]
• SMART-3RP group programme, delivered as manualised by BHI (a "manualized, copyrighted curriculum"). [source: SMART content overview] Use the BHI manual and participant materials; this guide names session contents and paraphrases them, and does not replace the manual.

SMART-3RP structure (BHI overview version). [source: SMART content overview]

The grouping into phases A–C is a reading aid [synthesis]; the session contents are from the overview.

Format and delivery. Eight consecutive weekly 2-hour group sessions, plus intake and two 30-minute provider sessions; participants practise between sessions and track which techniques reduce their stress most. [source: SMART content overview] BHI adaptations exist for children, older adults and military personnel. [source: SMART content overview]

Named variants.

• Cancer survivorship SMART-3RP (Mass General Brigham Cancer Institute): nine 90-minute skills-based group sessions on Zoom, led by a licensed psychologist or psychiatrist; session 1 sets goals and a plan; adds health-behaviour promotion, managing treatment-related symptoms and late effects; for adults after cancer treatment or living with cancer as a chronic illness; not generally recommended for the newly diagnosed; an 8-week virtual version exists for adolescent and young adult survivors aged 18–39; participants buy a programme manual; billed in the US as group psychotherapy. [source: Mass General Brigham SMART-3RP page]
• Clinician wellbeing SMART-3RP (Oregon Health & Science University): group course for faculty, led in pairs by physicians described as trained and certified in the programme; framed as complementary to, not a replacement for, individual counselling. [source: OHSU SMART-3RP page]

Who delivers it. BHI certifies licensed healthcare practitioners to deliver SMART. As of October 2026, certification has five requirements, completed in order: (1) the BHI/Harvard CME course, or three online BHI/MGH Psychiatry Academy courses ("Stress and the Relaxation Response", "Using Mind Body Techniques in Clinical Practice", "Building Resiliency through Cognitive Reappraisal"), within the past three years; (2) taking an 8-session SMART programme as a participant and attending at least seven of the eight sessions; (3) a 2-day SMART Implementation Training taught by BHI clinicians, in person or by video conference; (4) mentorship by a BHI clinician while leading one's first SMART group (nine 1-hour sessions); (5) a competency exam. Certified clinicians may deliver the BHI SMART programme, order SMART manuals and recordings directly from BHI, and are recognised by BHI as certified. Certification lasts three years. Renewal requires ongoing delivery of the curriculum and BHI recertification activities, which the page lists as still to be determined. Listed fees total about US$8,700–9,200 (effective October 2024, subject to change). Applicants send a form to BHI. [source: BHI "Apply for certification" page; BHI certification application 2026] Programme pages and trial protocols name the following group leaders: licensed psychologists or psychiatrists, doctoral-level clinical psychologists with 3RP experience, and certified physician facilitators. [source: Mass General Brigham; OHSU; NCT03212261 protocol]

Criteria for moving on. The sources describe a fixed weekly sequence, not mastery criteria. [source: SMART content overview] Practical criteria [synthesis]: move from RR-foundation sessions to cognitive work once the client can name at least one RR method that works for them and is practising most days; move to consolidation once the client can identify personal stress warning signals and pick an adaptive strategy in the moment; end with a written resiliency plan. If RR practice repeatedly increases anxiety, pause and reassess (Section 5) rather than proceeding.

3. Guiding principles

• The response is a learned skill that needs practice. Expect regular, usually daily, practice; it gets easier over time. [source: Psychology Today/Mitchell; OSU handout] Practice: schedule the practice time with the client and review it every session.
• Two elements matter most: repetition and a passive attitude. Benson's original list had four elements (a mental device, a passive attitude, reduced muscle tone/comfortable position, a quiet environment); later only the repetitive mental focus and passive disregard of intruding thoughts were treated as essential. [source: Beary et al. 1974; HandWiki] Practice: adapt setting and posture freely; protect the repetition and the non-striving stance.
• Many routes to one response. Repetition can be a word, sound, phrase, prayer or movement; jogging, yoga and prayer were all described as qualifying. [source: Boston Globe 2015; Harvard Health] Practice: let the client pick a method and focus that fits their beliefs and body.
• Do not judge success. Benson advised letting relaxation occur at its own pace; worrying about whether one is "doing it right" interferes. [source: Psychology Today/Mitchell; Boston Globe] Practice: treat wandering attention as part of the exercise, never as failure.
• Belief and meaning are respected. The focus may be a short prayer or a phrase from the client's own tradition. [source: Harvard Health] Practice: ask about faith and values before suggesting a focus word; never impose a religious or secular frame.
• Self-care and self-monitoring. SMART-3RP asks participants to track which techniques work best for them. [source: SMART content overview] Practice: use a simple practice log and review it together.
• Combine physiology with appraisal and action. RR practice is paired with stress awareness and CBT-based adaptive strategies. [source: SMART content overview; OHSU] Practice: do not stop at relaxation; link it to what the client does when stressed.
• Build positive resources, not only reduce distress. Appreciation, positivity, self-compassion and humour are core components. [source: SMART content overview] Practice: include at least one positive-resource exercise each week.
• Complement, not substitute. The programme is complementary to individual counselling and to medical care. [source: OHSU; Mass General Brigham] Practice: keep medical symptoms with the medical team; never present RR as treating physical disease.
• Medical check where relevant. One handout advises consulting a doctor before starting if the person has medical problems. [source: OSU handout] Practice: ask about medical conditions at intake; encourage the client to tell their physician.
• Safety first with inward-focused practice. Relaxation can paradoxically increase anxiety in some people, more often with focused (mantra-type) practice than with progressive muscle relaxation. [source: Heide & Borkovec 1983] Practice: screen, start short, offer eyes-open and movement-based options, and have a plan if anxiety rises.
• Group as support. SMART-3RP groups are supportive and apply skills to each person's identified stressors. [source: Mass General Brigham] Practice: keep discussion skills-focused; manage disclosure so the group stays safe.
• Collaborative care. [synthesis] Practice: with consent, inform the client's physician or medical team that the client is practising RR and passes on any new or worsening physical symptoms.

4. Intervention inventory

Interventions 4.1–4.3 are the core RR method; 4.4–4.28 follow the SMART-3RP sequence; 4.29–4.30 are the psychotherapist's collaborative-care and group-leading tasks. Where the BHI curriculum names a component but its detailed steps are in the copyrighted manual, the steps below are written as [synthesis] in standard clinical form and should be checked against the manual.

4.1 Intake: screening, goals and consent

• Purpose / when: before any RR teaching or group entry. SMART-3RP begins with a one-hour individual intake to introduce resiliency and the RR, orient the person and set personal goals. [source: SMART content overview]
• Steps: [synthesis except where cited]
  1. Ask what stressors bring the person and what they hope to change; turn this into 1–3 concrete personal goals. [source: SMART content overview for goal-setting]
  2. Ask about medical conditions and current medical care; suggest they tell their doctor they are starting, as one RR handout advises for people with medical problems. [source: OSU handout]
  3. Screen for risk factors for adverse reactions to inward-focused practice: panic disorder or fear of bodily sensations, prior anxiety on relaxing or meditating, trauma history with intrusions or dissociation, current or past psychosis or mania, severe depression with suicidality. [synthesis; relaxation-induced anxiety: source Heide & Borkovec 1983]
  4. Explain what practice involves, that some people feel more tense at first, and that they can stop at any time; agree what they will do if that happens.
  5. Explain clearly that the programme supports coping and wellbeing and does not treat physical illness.
  6. For a group, check fit (e.g. the cancer version is not generally recommended for the newly diagnosed). [source: Mass General Brigham]
• Example language (illustrative): "This is training in a calming skill and in ways of handling stress. It works alongside your medical care, not instead of it. Some people find that slowing down makes them more aware of tension at first. If that happens, tell me and we'll adjust."
• Watch for: expectations that relaxation will cure a physical condition (correct gently); history suggesting high risk (see Section 5); the client agreeing out of politeness. Working: the client can state their own goals and what to do if practice feels unpleasant.

4.2 Eliciting the relaxation response (Benson's focus-word method)

• Purpose / when: the core daily practice; first taught in SMART session 1 as single-pointed focus meditation with body awareness. [source: SMART content overview]
• Steps (the book's steps as reproduced in secondary sources, paraphrased): [source: Psychology Today/Mitchell 2013; OSU handout] [uncertain: secondary reproductions of the 1975 book; the core of the sequence matches Harvard Health 2017 and a BHI-hosted article]
  1. Choose a quiet place, free of interruptions, especially while learning.
  2. Sit quietly in a comfortable position; sitting rather than lying down helps avoid falling asleep. [OSU]
  3. Close the eyes.
  4. Relax the muscles progressively from the feet up to the face and keep them relaxed.
  5. Breathe through the nose, easily and naturally, noticing the breath.
  6. On each out-breath, silently repeat the chosen focus. The book used the word "one"; any calming word, sound, phrase or short prayer of the person's choosing may be used. [source: Psychology Today; Harvard Health]
  7. When thoughts intrude, let them pass without concern and return to the focus. Benson's advice: "maintain a passive attitude and permit relaxation to occur at its own pace". [source: Boston Globe, quoting Benson's website]
  8. The book's sequence is described as lasting about 10–20 minutes, with the time checked by opening the eyes rather than by an alarm. [source: Psychology Today; OSU]
  9. At the end, sit quietly for a few minutes, first with eyes closed, then open, and wait a few minutes before standing. [source: Psychology Today]
  10. The book is described as suggesting practice once or twice a day and not soon after a meal, as digestion seemed to interfere. [source: Psychology Today; OSU] Agree any routine with the client rather than prescribing one [synthesis].
• Version note: the original book gave a short numbered sequence; an updated edition is described as expanding it to nine steps as taught at BHI [source: HandWiki] [uncertain: secondary, unverified]. BHI's public pages give its instruction as a recorded practice ("Eliciting the Relaxation Response with Herbert Benson, MD") and an introductory audio covering breath awareness, body scan relaxation and use of a focus word, not as a written step list [source: BHI Guided Relaxation Exercises page]. A BHI-hosted article confirms the two basic steps (repetition, and setting aside intruding thoughts), practice once a day for about 10–20 minutes, and Benson's advice not to worry about whether a deep level of relaxation is reached [source: Boston Globe 2015, BHI-hosted copy]. Harvard Health gives the same core sequence: sit in a quiet place with eyes closed, breathe deeply and relax the muscles, silently repeat a word, phrase, sound or short prayer of one's choosing, let stray thoughts come and go, and return to the focus [source: Harvard Health 2017].
• Teaching in session [synthesis]: explain the four elements; help the client pick a focus; guide a first practice of 5–10 minutes with the clinician speaking sparsely; debrief; agree when and where home practice will happen.
• Example language (illustrative): "Let your eyes close if that's comfortable. Each time you breathe out, silently say your word... When you notice you've drifted into thoughts, that's fine. Simply come back to the word. There's nothing to achieve." Debrief: "What did you notice? Where did your attention go, and what was it like to come back?"
• Watch for: rising anxiety, a sense of losing control, unusual bodily sensations, dissociation or unwanted memories (stop, open eyes, ground: see 5.1); striving or self-criticism; falling asleep, which ends the RR rather than deepening it. [source: OSU for sleep] Working: easier settling over weeks, the client reporting calmer baseline, and spontaneous use at stressful moments.

4.3 Simplified two-step and alternative-repetition forms

• Purpose / when: when the full sequence feels too formal, or the client prefers prayer, movement or another repetitive focus. BHI's simplified description: repeat a word, sound, phrase, prayer or movement, and passively set aside intruding thoughts, returning to the repetition. [source: Boston Globe; Harvard Health]
• Steps:
  1. Step one: choose a repetitive focus (word, phrase, short prayer, sound, or rhythmic movement such as walking, jogging or swimming strokes). [source: Boston Globe]
  2. Step two: when other thoughts come, notice them, let them go, return to the focus.
  3. Practise about 10–20 minutes, ideally daily (Harvard Health cites BHI's twice-daily recommendation). [source: Harvard Health]
• Example language (illustrative): "The essentials are just two: something you repeat, and an easy-going attitude to the thoughts that interrupt. If sitting still doesn't suit you, the repetition can be your footsteps on a walk."
• Watch for: a prayer focus that brings up guilt or religious distress (switch to a neutral focus); movement versions done competitively (keep it gentle). Working: the client finds a version they actually do.

4.4 Psychoeducation: the stress response and its opposite

• Purpose / when: SMART intake and session 1, to give the rationale for practice. [source: SMART content overview; OHSU]
• Steps [synthesis]: describe the fight-or-flight response (heart rate, breathing, muscle tension, alertness) as useful in short bursts and wearing when chronic; describe the RR as the body's opposite state that can be practised; invite the client to map their own stress responses (body, thoughts, feelings, behaviour); link to the rationale for daily practice.
• Example language (illustrative): "Your body has an alarm system that's great in emergencies. When it keeps going off, you feel it everywhere. We're going to practise switching on the opposite system on purpose, every day, so it becomes easier to reach."
• Watch for: the client hearing "your illness is caused by stress" (avoid this; it can produce blame); health anxiety heightened by talk of bodily effects. Working: the client can explain the rationale in their own words.

4.5 Body awareness / body scan

• Purpose / when: an RR route in sessions 1–2; builds interoceptive awareness and noticing early tension. [source: SMART content overview]
• Steps [synthesis]: seated or lying, attention moves slowly through the body region by region (feet to head or the reverse), noticing sensations without trying to change them; when the mind wanders, return to the current region; finish with whole-body awareness and a few breaths before opening eyes.
• Example language (illustrative): "Bring attention to your feet... just noticing whatever's there: warmth, pressure, nothing much. Now move up to the ankles..."
• Watch for: distress at particular body areas (trauma, pain, body-image concerns; allow skipping areas or keeping eyes open); health-anxious scanning for symptoms. Working: the client notices tension earlier in daily life.

4.6 Diaphragmatic breathing

• Purpose / when: session 2; a portable RR route and basis for minis. [source: SMART content overview]
• Steps [synthesis]: one hand on chest, one on abdomen (the BHI mini-relaxation handout instead places one hand just below the navel; the breath goes in through the nose and out through the mouth, the belly rises and falls about an inch, and the stomach muscles stay relaxed; if the pattern is hard to feel, lie on the back or front [source: BHI mini-relaxation handout via UT Southwestern]); breathe in gently through the nose so the lower hand rises more than the upper; breathe out slowly and fully; keep the breath unforced, without deliberately deep or fast breathing; practise a few minutes, then without hands.
• Example language (illustrative): "Let the breath drop down toward your belly, as if the lower hand is gently lifted... no need to breathe bigger, just lower and slower."
• Watch for: over-breathing (light-headedness, tingling) from trying too hard; panic-prone clients misreading breath awareness as danger. Slow down, normalise, shorten. Working: smooth breathing that the client can find in stressful moments.

4.7 "Mini" relaxation exercises

• Purpose / when: session 2 onward; brief RR practices for use during the day. [source: SMART content overview] The steps below paraphrase a BHI handout, "mini relaxation exercises", credited to the Benson-Henry Institute and reproduced in 2009 UT Southwestern lifestyle-medicine teaching materials. BHI's current version may differ [uncertain]. [source: BHI mini-relaxation handout via UT Southwestern]
• Steps (paraphrased from the handout):
  1. Basic breath: place a hand just below the navel. Breathe in slowly through the nose and out through the mouth, letting the belly rise about an inch on the in-breath and fall on the out-breath (diaphragmatic breathing). Keep the stomach muscles relaxed. If the pattern is hard to feel, practise lying on the back or front first.
  2. Version 1, countdown: count slowly down from 10 to 0, one number per breath. Slow the counting if light-headed or dizzy. At zero, check how you feel, and repeat if still tense.
  3. Version 2, matched counting: count slowly up to four on the in-breath and back down to one on the out-breath. Repeat several times.
  4. Version 3, pauses: pause for a few seconds after each in-breath and again after each out-breath, for several breaths.
  5. Use in everyday moments the handout lists: waiting (on hold, in a queue, in a doctor's or dentist's waiting room, in traffic), after an upsetting remark, when overwhelmed by tasks, or when in pain. Eyes may be open or closed; when driving, keep them open.
  6. In therapy [synthesis]: choose one version in session, practise it twice together, then tie it to two or three daily cues the client names.
• Example language (illustrative): "Pick three moments tomorrow when you'd usually tense up, like waiting on hold. At each one, do a countdown: ten slow belly breaths, one number per breath, down to zero."
• Watch for: light-headedness (slow the count, as the handout advises); using minis only to avoid feelings or situations (link to 4.19 acceptance and 4.18 problem-solving) [synthesis]; closing the eyes while driving (never). The handout says minis work best for people who also practise the RR regularly, so keep up daily practice alongside them. Working: the client reports catching stress earlier and recovering faster.

4.8 Progressive muscle relaxation (PMR)

• Purpose / when: session 2; an active RR route useful for people who find mental focus difficult. PMR produced less relaxation-induced anxiety than focused (mantra) relaxation in one study, which makes it a useful alternative for anxious clients. [source: SMART content overview; Heide & Borkovec 1983]
• Steps [synthesis]: work through muscle groups in order (hands, arms, face, neck, shoulders, back, abdomen, legs, feet); tense each moderately for a few seconds, then release and attend to the contrast for longer; then a whole-body release; gradually shorten to release-only.
• Example language (illustrative): "Make a fist with your right hand, firmly but not painfully... hold... and let it go. Notice how the hand feels now, compared with a moment ago."
• Watch for: pain, injury or medical conditions where tensing is unwise (skip that group or use release only; check with the medical team); cramps. Working: faster, deeper release and lower reported tension.

4.9 Appreciations (recording positive moments)

• Purpose / when: from session 1; homework of at least one recorded appreciation a day, to counter the stress-driven narrowing of attention. [source: SMART content overview]
• Steps [synthesis]: each day, notice one moment that was pleasant, meaningful or kind; write a line about what happened and how it felt; review entries at the next session.
• Example language (illustrative): "Before bed, jot down one moment from today that you appreciated, however small: a cup of tea, a message from a friend. Write what you noticed in your body as you remember it."
• Watch for: forced positivity or guilt ("I should be grateful"); in grief or depression, allow very small entries and validate difficulty. Working: entries come more easily; mood lifts slightly at review.

4.10 Sleep hygiene and stress-related sleep problems

• Purpose / when: session 2. [source: SMART content overview]
• Steps [synthesis]: review sleep pattern and habits; discuss regular timing, a wind-down routine, a bedroom kept for sleep, limiting late caffeine and screens; use an RR method as part of the wind-down while noting that falling asleep ends the RR, so daytime practice stays separate. [source: OSU for falling asleep]
• Example language (illustrative): "Let's keep your main practice for the daytime, sitting up. At night, a few minutes of slow breathing can be part of winding down; if you drift off, that's fine."
• Watch for: possible sleep disorders (loud snoring, gasping, severe insomnia, unusual night behaviours): suggest a medical or sleep-specialist review; in bipolar disorder, marked sleep reduction can be a warning sign to pass on to the treating team. [synthesis] Working: more regular sleep, less bedtime rumination.

4.11 Mindful awareness of breath, external stimuli and sensations

• Purpose / when: session 3; broadens attention training beyond a single focus. [source: SMART content overview] For mindfulness traditions in depth, see Domain XIII.
• Steps [synthesis]: a few minutes on the breath; then open to sounds, noticing them come and go without naming or judging; then bodily sensations; then return to the breath; finish with eyes open and a brief note of what was observed.
• Example language (illustrative): "Now let your attention widen to sounds... the near ones, the far ones... letting each sound arrive and leave on its own."
• Watch for: sound or sensation cues linked to trauma; restlessness. Working: the client describes noticing experience with less immediate reaction.

4.12 Mindful eating

• Purpose / when: session 3, as an everyday mindfulness practice. [source: SMART content overview]
• Steps [synthesis]: with a small piece of food, look, smell and feel it; eat slowly, noticing taste and texture and the urge to swallow; reflect on what was noticed; later apply to part of a daily meal.
• Example language (illustrative): "Take a moment just to look at it, as if you'd never seen one before... notice what happens in your mouth before you even bite."
• Watch for: eating disorders, restrictive eating or strong body-image distress: adapt or omit, and do not set any eating or weight goals; respect dietary, religious or allergy needs. [synthesis] Working: curiosity, slowing down.

4.13 Recognising stress warning signals

• Purpose / when: session 3; early detection so a skill can be used before stress escalates. The overview names physiological, cognitive, affective and behavioural signals. [source: SMART content overview]
• Steps [synthesis]: list personal signals in each of the four domains; rate a recent stressful episode on when each signal appeared; choose one early signal as a cue for a mini (4.7); track for a week.
• Example language (illustrative): "What's the very first thing you notice when stress starts building: in your body, your thoughts, your mood, what you do?"
• Watch for: new or unexplained physical symptoms being labelled "just stress": encourage medical review instead of assuming. [synthesis] Working: the client catches stress earlier.

4.14 Social support

• Purpose / when: session 3; social connectedness as an adaptive strategy. [source: SMART content overview; OHSU]
• Steps [synthesis]: map current supports (practical, emotional, informational); identify one connection to strengthen and a concrete step; plan how to ask for help.
• Example language (illustrative): "Who are the people you can lean on, even a little? Is there one person you'd like to be in touch with more this week?"
• Watch for: isolation, abusive relationships (safety comes first), social anxiety. Working: at least one supportive contact made.

4.15 Mindful movement (yoga, tai chi)

• Purpose / when: session 4; RR through movement. [source: SMART content overview; OHSU names yoga and tai chi]
• Steps [synthesis]: if not trained to teach movement, refer to a qualified teacher or use programme materials; emphasise slow, gentle movement with attention on breath and sensation, staying within comfortable range; seated or chair versions for limited mobility.
• Example language (illustrative): "Move only as far as is comfortable today. The point isn't the stretch; it's noticing your body as it moves."
• Watch for: pain, injury, pregnancy, balance problems, recent surgery or other medical conditions: advise checking with their physician first; competitive pushing. [synthesis] Working: the client finds a movement form they enjoy.

4.16 Identifying negative thought patterns and cognitive errors

• Purpose / when: session 4; homework to log negative thoughts and their links to emotions and physical reactions. [source: SMART content overview]
• Steps [synthesis]: introduce the link between situation, automatic thought, emotion, body reaction and behaviour; describe common thinking errors (e.g. catastrophising, all-or-nothing, mind-reading, should-statements); give a log with columns for situation, thought, emotion, body reaction; review in session.
• Example language (illustrative): "When you noticed your shoulders tense, what was going through your mind just before?"
• Watch for: self-blame ("my thoughts are making me ill"); depressive rumination; realistic worries in illness that are not errors. Working: the client spots thoughts in real time.

4.17 Cognitive restructuring

• Purpose / when: session 5, once thoughts can be identified. [source: SMART content overview]
• Steps [synthesis]: pick a logged thought; examine evidence for and against; consider other views and what one would say to a friend; form a balanced alternative; re-rate emotion.
• Example language (illustrative): "If a friend in your situation said this to you, what might you say back?"
• Watch for: invalidating real threats, e.g. a medical prognosis (use acceptance or problem-solving instead). Working: lower emotional intensity after reframing.

4.18 Problem-solving

• Purpose / when: sessions 5 and 7, for controllable stressors. [source: SMART content overview]
• Steps [synthesis]: define the problem specifically; brainstorm options without judging; weigh pros and cons; choose and plan steps; act; review.
• Example language (illustrative): "Of this stressor, what part is in your hands? Let's list every option, even silly ones, before choosing."
• Watch for: problems outside the client's control (switch to acceptance); overwhelm (break into small steps). Working: a step taken and reviewed.

4.19 Acceptance

• Purpose / when: sessions 5 and 7, for stressors that cannot be changed; the overview stresses learning when each of restructuring, problem-solving and acceptance fits. [source: SMART content overview]
• Steps [synthesis]: sort a stressor into changeable and unchangeable parts; for the unchangeable, practise noticing and allowing the feeling (with breath or RR), naming it, and turning toward what matters; distinguish acceptance from resignation or approval.
• Example language (illustrative): "This part we can't change. Can we make some room for how hard that is, and still choose what you want to do today?"
• Watch for: acceptance used to tolerate abuse or injustice (it shouldn't be); grief needing more time. Working: less struggle, more valued action.

4.20 Guided imagery

• Purpose / when: session 5, to deepen the RR. [source: SMART content overview]
• Steps [synthesis]: after a few minutes of RR, guide the client to imagine a calm, safe place they choose, using all senses; allow them to stay; return gradually, counting back and opening eyes; debrief.
• Example language (illustrative): "Picture a place where you feel at ease, real or imagined... What do you see there? What can you hear?"
• Watch for: imagery turning distressing (trauma intrusions, dissociation): open eyes, ground, switch to an external or movement focus; let the client choose content; avoid imposing scenes such as water or beaches. Working: vivid, calming imagery that the client can call up briefly in daily life.

4.21 Physical activity for coping

• Purpose / when: session 5. [source: SMART content overview]
• Steps [synthesis]: explore activities the client enjoys and can do safely; plan small, specific, enjoyable steps; link activity to mood and stress tracking; no numerical exercise or weight targets.
• Example language (illustrative): "What kind of movement have you enjoyed before? What's one small version you could try this week?"
• Watch for: medical limitations (check with physician); compulsive exercise or eating-disorder risk. Working: activity becomes a regular stress outlet.

4.22 Cultivating positivity

• Purpose / when: session 6, drawing on positive psychology. [source: SMART content overview]
• Steps [synthesis]: build on appreciations: plan small pleasant or meaningful activities, savour positive moments by lingering on them, and notice personal strengths; review effects.
• Example language (illustrative): "When something good happens this week, try staying with it for twenty or thirty seconds longer than usual."
• Watch for: toxic positivity; clients in acute grief or crisis (prioritise support). Working: more frequent positive moments noted.

4.23 Self-empathy and self-compassion

• Purpose / when: session 7. [source: SMART content overview]
• Steps [synthesis]: notice self-critical talk; acknowledge suffering, recognise it as shared human experience, and respond with kindness (a soothing phrase or gesture); practise in a short exercise and daily.
• Example language (illustrative): "What would you say to someone you care about who was going through this? Can you offer yourself even part of that?"
• Watch for: strong fear of self-compassion or grief responses in people with harsh histories (go slowly; process in therapy). Working: softer self-talk.

4.24 Creative expression

• Purpose / when: session 7; homework to engage in creative expression at least once. [source: SMART content overview]
• Steps [synthesis]: invite any creative activity (writing, drawing, music, crafts, cooking) done for its own sake; reflect on mood before and after.
• Example language (illustrative): "This isn't about being good at it. Spend a little time making something, anything, and notice how you feel during and after."
• Watch for: perfectionism; expressive writing that opens trauma material (bring to individual therapy). Working: absorption and enjoyment.

4.25 Humour and imagination

• Purpose / when: session 8, as coping resources. [source: SMART content overview]
• Steps [synthesis]: discuss what helps the client laugh or play; plan to include it; use imagination to rehearse coping with an upcoming stressor.
• Example language (illustrative): "What reliably makes you laugh? Where could a bit more of that fit into your week?"
• Watch for: humour used to deflect painful topics; humour that feels invalidating in serious illness. Working: lightness without avoidance.

4.26 Personal resiliency plan

• Purpose / when: session 8, to maintain gains. [source: SMART content overview]
• Steps [synthesis]: review goals set at intake and progress; list the RR methods and adaptive strategies that worked best (from tracking); identify personal warning signals and a plan for each; set a daily practice routine and a plan for lapses; note supports and when to seek further help.
• Example language (illustrative): "Let's write down your own toolkit: what works for you, when you'll use it, and what you'll do if you notice your old stress signs coming back."
• Watch for: plans that are too ambitious; no plan for lapses. Working: a short, realistic written plan the client owns.

4.27 Mid-point and one-month follow-up provider sessions

• Purpose / when: two 30-minute individual sessions, at the programme's mid-point and about one month after the group ends. [source: SMART content overview]
• Steps [synthesis]: review goals, practice log and difficulties; troubleshoot adverse reactions; at follow-up, review the resiliency plan and whether further therapy or referral is needed.
• Example language (illustrative): "We're halfway. Which practices are working for you, and which ones are you skipping? Anything that's felt uncomfortable?"
• Watch for: silent non-adherence, distress hidden in group. Working: practice maintained after the group.

4.28 Health-behaviour and symptom-coping module (illness-adapted versions)

• Purpose / when: the cancer-survivorship version adds health-behaviour promotion (e.g. eating well, exercise), managing treatment-related physical and emotional symptoms and late effects, and building a sense of control, optimism and acceptance. [source: Mass General Brigham]
• Steps [synthesis]: use RR and coping skills to manage distress around symptoms, appointments and scans; set general, self-chosen health-behaviour goals without numerical diet or exercise targets; encourage the client to report symptoms to their medical team; apply acceptance and problem-solving to uncertainty.
• Example language (illustrative): "This group won't treat the illness itself. It's about how you cope with what it brings: the waiting, the symptoms, the worry. Anything physical you notice, please take to your medical team."
• Watch for: belief that stress caused the illness or that relaxation can cure it (correct); symptoms that need medical attention (route to medical team). Working: greater sense of control and coping.

4.29 Collaborative care alongside medical treatment

• Purpose / when: whenever the client has a physical condition or is under medical care; the programme is presented as complementary support. [source: Mass General Brigham; OHSU] Steps are [synthesis].
• Steps:
  1. With consent, let the physician or medical team know the client is learning RR and coping skills.
  2. Make clear to the client that RR does not replace any medical treatment, test or medicine, and that any question about medicines goes to the prescriber.
  3. Pass on new, worsening or unexplained physical symptoms reported in sessions, and encourage the client to report them directly.
  4. Coordinate on distress linked to treatment (procedures, scans, side effects) and integrate RR before and after these events.
• Example language (illustrative): "Would it be all right if I let Dr X know you're practising this? If anything changes physically, that's one for your medical team. I'd rather you mention it than put it down to stress."
• Watch for: clients wishing to drop medical treatment in favour of relaxation (explore, do not endorse, encourage discussion with the physician); shared-care confidentiality agreements. Working: the medical team and therapist are aligned.

4.30 Leading the SMART-3RP group

• Purpose / when: for group delivery. Groups are supportive and focus on applying skills to identified stressors; participants are encouraged to attend all sessions and, if missing one, to tell the facilitator in advance and review the material. [source: Mass General Brigham]
• Steps [synthesis]: open each session with a brief RR practice; review home practice in rounds; teach the session's new skill with a live practice; small-group or pair application to members' stressors; assign home practice; close with a short practice. Keep personal disclosure brief and skills-linked; agree group confidentiality.
• Example language (illustrative): "Let's go round: what did you practise this week, and what got in the way? A sentence or two each."
• Watch for: members dominating or withdrawing; distress in a member during practice (have a co-facilitator able to step out with them); people for whom group is not right (refer to individual care). Working: high attendance, members using each other's ideas.

5. Handling problems

5.1 Relaxation-induced anxiety and panic

In a small study, 14 adults reporting general tension each had one session of progressive relaxation and one of mantra meditation ("focused relaxation"), in counterbalanced order. 30.8% reported increased tension after progressive relaxation and 53.8% after the focused method. Four participants, plus one who dropped out early, showed clinical signs of an anxiety reaction during a preliminary practice period. Progressive relaxation produced larger reductions on subjective and physiological measures and less relaxation-induced anxiety. [source: Heide & Borkovec 1983, Penn State record] A follow-up review by the same authors links the problem to fear of somatic anxiety cues and fear of losing control, within a model of generalised anxiety. It proposes ways round the problem in therapy, but the abstract does not list them. [source: Heide & Borkovec 1984, Penn State record] Response [synthesis]: normalise; keep eyes open; shorten practice to a minute or two; switch to PMR, movement or an external focus (sounds, a held object); stress that the client is in control and can stop; if the problem is fear of bodily sensations or of losing control, treat that directly (e.g. interoceptive work within a panic protocol) before resuming RR. Stop if anxiety escalates, and reassess.

5.2 Trauma, intrusions and dissociation

Response [synthesis]: inward-focused, eyes-closed practice can bring up intrusive memories, numbing or detachment. A British Journal of Psychiatry letter by W. D. Fewtrell (1984), "Relaxation and depersonalisation", responds to Heide & Borkovec. Its content is [uncertain]. Offer eyes-open practice, grounding via the five senses, short sessions, choice of focus and posture, and no imposed imagery; agree a stop signal; coordinate with trauma-focused treatment, and prioritise stabilisation over relaxation where dissociation is frequent.

5.3 Psychosis, mania and severe mental illness

No source in this guide addresses this directly [uncertain: not verified]. Response [synthesis]: in active psychosis or mania, avoid long eyes-closed or intensive meditation; use brief, concrete, grounding practices (PMR, slow breathing with eyes open, mindful movement) only if stable and in consultation with the treating team; pass on early warning signs (reduced sleep, unusual perceptions) to the team.

5.4 Depression and suicidality

Response [synthesis]: RR is not a treatment for moderate to severe depression; carry out standard risk assessment, safety planning and referral for evidence-based treatment; keep RR as an adjunct; watch for rumination during practice and prefer active forms (movement, PMR).

5.5 "I can't stop my thoughts" / striving

Sources stress that intrusions are normal and that one should not judge success. [source: Boston Globe; Psychology Today/Mitchell] Response: redefine success as returning to the focus; shorten sessions; anchor the focus to the out-breath; try movement repetition (4.3).

5.6 Falling asleep

Falling asleep ends the RR; sit up and practise at a time of day when less drowsy. [source: OSU handout] Response [synthesis]: check for sleep debt or a sleep disorder (refer if suspected).

5.7 Non-adherence to daily practice

Response [synthesis]: problem-solve barriers; link practice to an existing routine (e.g. first thing in the morning, which Benson suggested to one writer [source: Boston Globe]); start with minis; use a log; review without criticism; ask about meaning (does practice feel self-indulgent, or clash with beliefs?).

5.8 Scepticism, religious or cultural concerns

Response [synthesis]: explain that the RR was described in secular, physiological terms and that a focus can be from the client's own faith or entirely neutral [source: Harvard Health; HandWiki for origins]; respect a client's wish to avoid practices with roots in other religious traditions (offer PMR, breathing or prayer from their own tradition).

5.9 Medical misunderstandings and physical problems

Response [synthesis]: correct beliefs that relaxation cures or that stress caused an illness; never suggest changing medical treatment or medicines; route physical symptoms to the medical team; for light-headedness on standing, rise slowly after practice, as the classic instructions suggest waiting a few minutes before standing [source: Psychology Today/Mitchell]; ask clients with medical conditions to tell their doctor before starting. [source: OSU handout]

5.10 Group-specific difficulties

Missed sessions: notify facilitator ahead and review the material. [source: Mass General Brigham] Other problems [synthesis]: a member overwhelmed in group practice (co-facilitator support, individual follow-up); over-disclosure (gently refocus on skills, offer individual time); conflict (restate group agreements).

5.11 Ruptures and disappointment

Response [synthesis]: if the client feels "it isn't working" or feels dismissed ("you're saying it's all stress"), acknowledge, ask what they hoped for, clarify the limits of the method, collaboratively revise goals, and consider other treatments.

5.12 Using relaxation to avoid

Response [synthesis]: when RR becomes a way to escape necessary action or feelings, pair it with problem-solving (4.18), acceptance (4.19) or exposure work; in anxiety disorders, avoid using relaxation as a safety behaviour during exposure unless the protocol includes it.

5.13 Competence and programme fidelity

Response: SMART-3RP is a manualised, copyrighted curriculum. [source: SMART content overview] BHI certification (see Section 2, "Who delivers it") is what allows a clinician to deliver the BHI SMART programme and to order its manuals and recordings. [source: BHI certification page] Without it, call your work relaxation and coping-skills training, not SMART-3RP. [synthesis] If you are not trained to teach movement practices, refer them to qualified teachers. [synthesis]

Sources

• SMART content overview (Benson-Henry Institute)
• Stress Management and Resiliency Training - Relaxation Response Resiliency Program (SMART-3RP), OHSU
• Stress management and resiliency (SMART-3RP for cancer survivors), Mass General Brigham
• A Simple Psychophysiologic Technique Which Elicits the Hypometabolic Changes of the Relaxation Response (abstract record)
• Meditation and a relaxation technique to lower blood pressure, Harvard Health Publishing
• Finding escape from daily grind in meditation, Boston Globe, 13 March 2015 (copy on the Benson-Henry Institute site)
• Medicine: The Relaxation Response, HandWiki
• Dr. Herbert Benson's Relaxation Response, Psychology Today (Mitchell, 2013)
• Relaxation Response, Wilce Student Health Center, Ohio State University
• Relaxation-induced anxiety: paradoxical anxiety enhancement due to relaxation training (Penn State record)
• The relaxation response, by Herbert Benson, with Miriam Z. Klipper (library record)

Added at verification (October 2026):

• mini relaxation exercises (Benson-Henry Institute handout, in UT Southwestern lifestyle-medicine materials)
• Training: Apply for certification, Benson-Henry Institute
• BHI SMART Certification Application 2026
• Park et al. 2013, The Development of a Patient-Centered Program Based on the Relaxation Response: the 3RP (abstract record, Qigong Institute database)
• Take steps to prevent or reverse stress-related health problems, Harvard Health Publishing, 14 February 2017
• Guided Relaxation Exercises, Benson-Henry Institute
• Promoting Resiliency Among Lymphoma Survivors: The 3RP-Lymphoma (NCT03212261 protocol)
• Relaxation-induced anxiety: mechanisms and theoretical implications (Penn State record)
• Relaxation and depersonalisation, British Journal of Psychiatry correspondence (Cambridge Core; title page only)
• Breathe away stress in 8 steps, Harvard Health (introduction only)

Books and papers:

• Benson, H., with Klipper, M. Z. (1975). The Relaxation Response. New York: William Morrow. (Later HarperCollins edition 2001.)
• Beary, J. F., Benson, H., & Klemchuk, H. P. (1974). A simple psychophysiologic technique which elicits the hypometabolic changes of the relaxation response. Psychosomatic Medicine, 36, 115–120.
• Heide, F. J., & Borkovec, T. D. (1983). Relaxation-induced anxiety: paradoxical anxiety enhancement due to relaxation training. Journal of Consulting and Clinical Psychology, 51(2), 171–182. https://doi.org/10.1037/0022-006X.51.2.171
• Park, E. R., Traeger, L., Vranceanu, A.-M., Scult, M., Lerner, J. A., Benson, H., Denninger, J., & Fricchione, G. L. (2013). The development of a patient-centered program based on the relaxation response: the Relaxation Response Resiliency Program (3RP). Psychosomatics, 54(2), 165–174. https://doi.org/10.1016/j.psym.2012.09.001 (abstract only)

For meditation traditions underlying the RR, see Domain XIII.