Blood & Tension: November Research Snippet

Blood & Tension

Applied Tension in Treating Blood Phobia

Donald Robertson, NCH Research Director

This month’s research snippet deviates once again from the usual format.  This is an issue I’ve been talking to some hypnotherapists about recently and it’s of interest because it highlights the possible limitations of relaxation-based therapies in treating certain common anxieties. 

Virtually all contemporary researchers have rejected the idea that hypnosis can be equated with any form of relaxation, or that relaxation is a necessary component of hypnotherapy.  However, the notion that hypnosis involves mental or physical relaxation is still very popular, even among many hypnotherapists.  It is also widely-assumed that relaxation serves well as a method of managing anxiety, including in most phobias.  However, the value of relaxation in treating certain forms of anxiety has been questioned over recent decades for a number of reasons.

In particular, the treatment of choice for blood-injection-injury (BII) type phobias is currently the “Applied Tension” method developed by Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden.  Basically, Öst has produced a series of research studies which provide evidence that training in a special tension “coping skill” combined with exposure to feared situations or events appears to be more effective than exposure alone or accompanied by relaxation training (termed “Applied Relaxation”).  The rationale for Applied Tension is that BII phobia, unlike most other forms of anxiety, is often accompanied by actual fainting or feelings of faintness caused by the vasovagal response.  The response to blood among phobics has been found to be unusual in that it consists of a “biphasic” reaction during which blood pressure and heart rate first rise (as in normal anxiety) and then rapidly drop, leading to fainting.  

The tension coping skill learned in Applied Tension involves tensing one’s arms, chest, and legs until a feeling of warmth occurs in the face, usually taking about 10-20 seconds.  This is repeated five times in a row, with 20-30 second pauses between.  Relaxation more than normal is deliberately avoided.  Doing so has been found to increase blood pressure and, in particular, cerebral blood flow, and to do so sufficiently to prevent the drop in blood pressure associated with fainting and the associated sensations of faintness.  This coping skill is then repeated for sessions of five repetitions, five times per day, over the space of five weeks.  It is combined with systematic exposure to the feared situations, which in the research conducted by Öst, includes a visit to the blood donor clinic, where the phobic provides a blood sample, and ultimately to an operating theatre to observe thoracic surgery taking place in person.  90% of blood phobics have been found to have improved to a clinically-significant degree following this brief intensive treatment, compared to only 60% of those trained in relaxation methods.

Most of the (highly-regarded) research on Applied Tension for blood phobia comes from the same research group and has, unfortunately, tended to employ relatively small sample sizes.  Recently, the findings have been questioned somewhat by one team of reviewers (Ayala, Meuret & Ritz, 2009).  On the other hand, a recent large-scale study of 614 blood donors found that those who expressed fears of fainting were more likely to continue donating blood if trained in Applied Tension (Ditto, France & Holly, 2010).

So if tension may be more beneficial than relaxation in the treatment of blood phobia, how can this be incorporated into hypnotherapy?  Well hypnotherapy certainly doesn’t seem to require relaxation and so “active alert” approaches to hypnotic induction might be better indicated for this client group.  James Braid, the founder of hypnotherapy, definitely used to induce either tense (“cataleptic”) or relaxed states depending on the individual needs of his clients.  Modern active-alert hypnotic procedures can be combined with suggestions for confidence-building (or ego-strength) which seems important with this client group, and used in conjunction with Applied Tension training.  Let us know what you think, though, by posting your comments below.


Öst, Fellenius & Sterner   (1991).  ‘Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia’, Behav. Res. Ther., vol. 29, no. 6, pp. 561-574.

Öst, Sterner & Fellenius  (1989).  ‘Applied tension, appplied relaxation, and the combination in the treatment of blood phobia’, Behav. Res. Ther., 27, 109-121.

Öst & Sterner (1986).  ‘A specific behavioral method for treatment of blood phobia’, Behav. Res. Ther., vol. 25, no. 1, pp. 25-29.

Ditto B.;  France CR.;  Holly C. (2010).  ‘Applied tension may help retain donors who are ambivalent about needles’, Vox Sanguinis.  98(3 Pt 1):e225-30

Ayala ES.;  Meuret AE.;  Ritz T.  (2009).  ‘Treatments for blood-injury-injection phobia: a critical review of current evidence’, Journal of Psychiatric Research.  43(15):1235-42