I'm devoting this article to a case study that represents the work I've been involved in for the past several years. This study illustrates how advanced mind/body training and research can reveal deeply ingrained psychophysiological patterns and shows that these patterns can be changed, leading to corresponding changes in the client's psychophysiology and quality of life. In this study, the client not only learned how to self-regulate multiple body systems by recognizing and working with these patterns, she began the process of making more "appropriate choices" that have led to an increased satisfaction with life.
When biofeedback came upon the scene in the early 1970s, many people were excited by its potential for facilitating developmental changes in people, but the simple instrumentation and clinical technique then available stood in the way of this potential being realized. In the meantime, partly due to the economic necessity of translating biofeedback into a practical therapeutic model, many practitioners lost sight of biofeedback's deeper applications and instead emphasized its usefulness as part of the established medical paradigm.
This paradigm, based as it is on a fractionated, mechanistic view of the human being, channeled biofeedback into a limited application geared toward "treating" malfunctioning body systems without examining how these systems interrelate--we began to separate psyche from physiology, and bill accordingly. The work I have been pursuing over the past several years at the Bio Research Institute has been an attempt to explore and develop biofeedback's developmental potential.
Due to space limitations, I will not attempt to fully explain the many aspects of the training and research model presented here or of the psychological process experienced by the client as she moved toward greater development. I will provide an overview that challenges current practices in biofeedback training and the education of practitioners. I have chosen to present the following information in a research study format, but I encourage the reader to examine the effects of advanced mind/body training in the context of the changes in the client's life.
The charts (charts will be coming to this web site at a later date) presented here represent 53 sessions of advanced mind/body training in five modalities. Learning how to create and interpret this kind of longitudinal data has been a challenge and has yielded powerful implications for the way biofeedback is taught and practiced.
Most biofeedback training series (including personal training undergone by practitioners) extend for eight to twelve sessions and are limited to one or two modalities, typically temperature and EMG. The reasons for this include:
Long-term advanced mind/body training and research conducted at BRI has revealed a physiological periodicity in individuals that suggests practice and reinforcement of problematic behaviors on a cellular level. This implies that the physiology of the individual, as well as his or her cognitive patterns, may help to generate and maintain behavior. The following study illustrates how advanced mind/body training provides a larger perspective that reveals cyclical patterns which surface at different levels within physiological systems and across modalities. A client's specific problem may not be what it seems--that is, the presenting complaint may be an indicator of a deeper psychological process in motion, a struggle between the self attempting to actualize and the older psychophysiological shell resisting this development. The physical pain produced by this struggle is often what leads the client to seek help and may lead the clinician away from the larger issue at hand.
The client was a forty eight-year-old divorced women with five adult children who presented with debilitating migraine/tension headaches. She worked for the postal service but frequently worked only three days a week due to her condition. She also experienced substantial anxiety and distress in public situations such as shopping malls and grocery stores. She came to BRI at the recommendation of a friend, and because she was not insured, assumed full responsibility for payment.
This woman's psychological background provides some insight into the physiological manifestation of her stress. She was born to a strict Catholic family, attended parochial school and was brought up in the tradition that says if you are not physically busy, you aren't doing anything valuable--"idle hands are the devil's workshop". Her mother's technique for dealing with stressful issues, particularly interpersonal ones, was to become very talkative, to the point that resolution on any but the most superficial levels was impossible. The client accepted this modeled behavior as the natural way of being and utilized the same strategies for survival in her own life. In so doing, she learned to gain her sense of approval from sources outside herself, particularly her spouse, and to distance herself from her own real feelings.
At the beginning of training, the client reported feeling very guilty about spending time in this pursuit, and her feelings of guilt and uselessness increased when she elected to quit her job due to physical and emotional stress.
Instrumentation
Data analyzed and stored in two- and three-dimensional spread sheets along with custom-written programs for data manipulation. A typical data set for a client with this number of sessions is composed of:
Meaningful mind/body training involves an important educational component, in which clients learn that they have developed psychophysiological strategies for survival that involve specialized patterns of chronic tensing. We have learned these patterns in response to various life situations. Through mind/body training, we can unlearn them, to reverse many of their negative effects and develop more positive strategies for survival and self-development. This is done in part through a training process that involves achieving or reestablishing global homeostasis as reflected in the following psychophysiological levels. These levels are appropriate for the modalities and placements used in this protocol, and reflect appropriate activity for clients in a restful seated position from upright to reclining.
Different psychophysiological conditions may call for variations on the protocol. The training ranges stated above apply to those individuals who exhibit system-wide sympathetic outflow.
The procedures used in this study, and with all clients at BRI, have been consciously designed to foster a feeling of partnership between trainer and client. This involves a process of education that begins when the client enters the door of the institute and continues throughout each session.
A series of color charts displaying the process of different individuals through a number of biofeedback training sessions is on display in the waiting room of the institute. The purpose of this is to provide clients with an aesthetically interesting source of information regarding what they will be doing and to give some idea of the time involved in gaining control over psychophysiological systems. The monitoring and training room is informal and nonclinical. During each session and over all the sessions, I deliberately repeat information about the monitoring techniques and different psychophysiological systems to reinforce the client's growing body of knowledge.
The application of seventeen sensors has the potential of creating anxiety in some clients, so I have over the years developed a relatively elegant and gentle protocol for sensor application. To check the sensors are transmitting information accurately and reliably, I turn on the biosystem and the audio amplifier to make a raw audio and oscilloscopic check of the appropriate signals. I make a third check by observing the numeric data displayed on the biosystem screen.
The initial session is composed of a comprehensive psychophysiological evaluation and a thorough intake. The psychophysiological evaluation is composed of four baselines: five minutes eyes closed, no talking; five minutes eyes open, no talking; fifteen minutes discussing stress-related issues; and seven minutes eyes closed, no talking, self-soothing response.
Training prioritization depends on three factors: (1) the presenting complaint, which suggests one or more physiologies to be prioritized; (2) the results of the comprehensive evaluation; and (3) the ability of the client to learn to control specific psychophysiological systems. At this point, the multimodality approach to training is particularly significant, in that the client usually exhibits inappropriate activity in multiple systems, and it is important to recognize that successful training involves regulation of the organism as a whole.
Speed of training depends on (1) the client's ability to overcome the philosophical belief that "trying" (expending conscious or unconscious sympathetic nervous system effort) is the only path to achievement; (2) how long the physiological condition has existed, which corresponds with how much practice the client has had reinforcing the condition on the psychocellular level; and (3) client motivation. This last factor can depend significantly on how well the trainer has educated the client, how many sessions the client has had (how familiar the client is with what can be done through biofeedback training), and how willing the client is to practice at home and integrate his or her learning into everyday life.
To demonstrate the client's potential for psychophysiological change, I provide an on-screen review of other clients' longitudinal mind/body charts drawn from the BRI library at some point during the early sessions. These charts powerfully demonstrate the effect of training over time and encourage clients to persist in training when they have reached apparent plateaus in ability to control various systems.
One of the procedural goals of training is for the client to develop sufficient skill in understanding the feedback process so that he or she can work with increasing independence, resulting in reduced verbal interaction during actual training. A research benefit of this protocol is that the data tend to reflect the client's general levels without the physiological responses and artifacts produced by active verbal interaction.
The data presented here reflect the psychophysiological changes recorded over 53 sessions. With the exception of the first session, all means in all modalities represent an average of 30 minutes of physiological data.
As will be shown, this kind of advanced mine/body training and research can provide crucial information regarding the potential for self-regulation and psychophysiological patterns that is not available to the practitioner/researcher who monitors and trains in only one or two modalities for eight or twelve sessions.
Since this client's presenting complaint was migraine/tension headaches, a traditional biofeedback practitioner might have trained her in one or two channels of temperature and EMG. In this study, she was trained in two channels EMG, two channels temperature, one channel heart rate and RSA, one channel (two variables) EDA, two channels (multiple variables) EEG and respiration.
In examining the following charts (charts will be coming to this web site at a later date), I would like to draw the reader's attention to overall level changes and repeating patterns within specific physiologies and across physiologies.
Chart 1 indicates the mean measurement of EMG activity of the anterior temporalis, a.k.a. scalp and jaw (solid line) and right and left trapezius (dashed line) for each of the sessions. Note that the overall levels in EMG may be higher than are ordinarily seen due to the size of the sensors used, bandwidth of the EMG amplifier (90-400 Hz) and sensor placement. This may result in readings that are 50% greater than those EMGs at 100-200 Hz with one centimeter sensors.
When the client began training, the mean reading for the first session for the scalp and jaw was just under 11 microvolts; the mean for the right and left trapezius was approximately 24 microvolts. During the second session, the client was able to achieve mean readings of 7.8 and 8.8, closer to the ideal range of 2.5-3.5 microvolts but still grossly elevated. The third session yielded a smaller decrease in EMG activity at both sides. In the fourth session, the mean reading for scalp and jaw EMG followed this lowering pattern, but the mean reading for trapezius EMG rose sharply from 8.5 to 9.5 microvolts.
This elevation was echoed in the next session in the scalp and jaw mean reading which rose from 7 to 9.2 microvolts. However, while the scalp and jaw rose, the trapezius fell from 9.5 to 6.8 and in the sixth session, both fell again. In the seventh session, both rose again; and in the eighth session, the two measurements again diverged--scalp and jaw dropping from 9 to 8.6 microvolts, right and left trapezius rising from 7 to 8.5 microvolts. This pattern continued over the ninth session; but in the tenth session, the measures from the two sites switched directions, and scalp and jaw rose while left and right trapezius dropped to create an inverse pattern, i.e., the tension level was essentially the same but shifted between EMG channels.
The results of EMG training for this client, based on averages taken over the first ten sessions, are mixed at best. Certainly, the readings at both sites were lower than they were when she started training, but they did not approach the desirable range, and they did not show any clear pattern of tension reduction.
However, viewed in light of the following 43 sessions, these readings reveal a pattern that not only repeats at consistently lower levels but shifts physiological location by appearing first in the scalp and jaw readings, then reappearing 20 weeks later in the right and left trapezius readings (this pattern is circled in Chart 1). Through session 39, every data point represents a weekly session; from session 40 on, visits were made every two weeks.
This switching of activity patterns between jaw and scalp and trapezius EMG activity was also revealed in the readings taken during individual sessions. These patterns indicate that the client has a particular psychophysiological mechanism that is activated periodically and that lasts for minutes and for weeks. Over 53 sessions, the client learned to reduce system-wide activation to desirable levels but not without experiencing repeating patterns of elevation at progressively lower levels.
Throughout the training, this client worked with each physiology and was able to gain a more comprehensive understanding of her psychophysiology by comparing activity levels in each system, noticing patterns, similarities and differences. I include charts in other modalities here so the reader may observe the changes that occurred in terms of both achieving homeostasis and periodicity of patterns exhibited. I will not attempt to describe each chart in detail, but I encourage readers to spend some time seeing patterns and noticing what is possible beyond the standard extent of training.
Chart 2 is a record of the mean readings of the client's left and right hand temperatures for 53 sessions. The goal of training was to reach temperatures in the mid-90s with symmetrical site activity, and for the first 16 sessions, it appeared that the training was actually counterproductive; although greater symmetry was achieved, the mean temperatures decreased from an initial reading of 82 degrees (left hand) and 89 degrees (right hand) to 73 and 74 degrees respectively. However, the 19th session echoes the dramatic rise in mean temperatures between the sixth and seventh sessions, revealing a pattern that is repeated in lesser degree over the next 30 sessions until the client achieves nearly ideal symmetry and temperature.
Chart 3 illustrates how skin conductance level over the period studied began with an elevated reading of 2.35 mhos and dropped to 1.1; GMAX began at 125 and dropped to 25 at the end of training. GMAX is defined as maximum phasic electrodermal level achieved in any period.
Heart rate, illustrated in Chart 4, was not measured for the first 20 sessions, but between sessions 21 and session 53, it stabilized to a desirable region between 54 and 59 beats per minute. The client showed a wide mean range of beats per minute over the 30 sessions, including mean readings as high as 75 and as low as 48.2. You may find it interesting to observe how the low mean readings gradually edged upwards.
Brain wave measurements of left and right hemisphere activity in the beta and gamma band widths (Chart 5) showed a significant decrease in activity from the beginning of training, when both were off the chart, to the final readings of approximately 115 microvolts per second. In EEG, the power measure known as amplitude density is the favored feedback and analysis measure; units are in microvolts per second. In consideration of chart clarity, I have omitted alpha and theta line graphs (sorry).
The client's psychological condition showed changes corresponding to those exhibited in her psychophysiological systems over the training period. For a few months after leaving her job, she focused primarily on training and included more pleasurable activities such as visiting with friends and reconnecting with family. After approximately ten sessions of training, she reported reduction in the frequency and intensity of headaches, and by the twentieth she reported being virtually headache free. Her anxiety at being in public situations also gradually disappeared.
As she became more adept at psychophysiological self-regulation, she summoned the courage to attempt a number of pursuits including joining a women's group, studying Aikido, participating in a week-long, self-exploration workshop and taking courses at the community college (this in spite of her previous belief that she would never be able to function in a college setting). In addition, she enrolled in and completed massage school and began seeing clients.
In her interpersonal relationships, she became much less dependent on others for approval and redirected her investment of energy away from the men in her life and towards herself. She removed herself from a problematic living situation with a man and decided to live alone for the first time in her life.
This client began making more "appropriate choices" in her life after learning that she was able to make significant and beneficial changes in her psychophysiological patterns and freeing herself from the discomfort caused by chronic system overactivation. These choices were "right" in the sense that they were congruent with her intuitive self-knowledge, which emerged as chronic sympathetic outflow began to subside as a result of training.
These five charts illustrate the potential of long-term psychophysiological training to create dramatic and lasting changes. Not only do these changes occur in more than one system, they reflect patterns in the client's psychophysiological strategies for survival that appear both within and between systems and occur over a matter of minutes and months.
Conclusions about this client based on the traditional eight or twelve sessions of training would be startlingly different from those implied by advanced training. For example, the first 16 sessions of temperature training not only failed to increase hand temperature, they appeared to reflect a lessening of the relaxation response. Yet over the course of training, the client was able to achieve highly desirable levels of hand temperature and symmetry. In the same way, EMG activity decreased over the first 10 sessions but by no means as significantly as it did over the following 43 sessions. The fact that patterns of increasing and decreasing activity appeared first in one channel, then weeks later in another suggests that such patterns serve to preserve an enduring personal strategy for survival that exists on a cellular level. Although these patterns are clearly ingrained and capable of switching location when the client begins working on them, this study demonstrates that with sufficient training they can be changed, to the lasting benefit of the client.
The common misunderstanding of biofeedback's potential for making profound and enduring changes in chronic conditions has been shaped by the accepted practice of limiting training to eight or twelve hours and expecting clients to be able to take what they learn in those sessions and apply it to the rest of their lives. As this study demonstrates, much of what a client can achieve is never even approached in the first 10 to 15 sessions, and the client may not receive more than a hint of what he or she can gain in terms of multi-system self-regulation.
In the August 1990 issue of the Harvard Medical School Health Letter, Dr. Bruce Masek states, "The crucial point about biofeedback training is that it is a way of teaching skills that must be applied throughout the day . . . . However, treatment should be relatively short in duration--a matter of six to ten sessions. Then you go away and work on the skills. From time to time after that, a check-up and a few refresher sessions may be useful--or may become unnecessary." This perspective on biofeedback short-changes clients by treating a potentially powerful means of self-regulation and self-knowledge as a "band-aid" that may serve to reduce symptoms but does little to reveal their sources or uncover deeply ingrained psychophysiological patterns that affect the client's entire life.
The current practice of limiting biofeedback training to eight or twelve sessions exemplifies a thin application of a very powerful discipline. We know that short-term training can be useful in symptom and pain reduction, which is valuable in itself. But to stop because the discomfort is alleviated or for other reasons may mean missing a chance to do far more than this, to make lasting changes that involve the whole person.
However, using biofeedback to make these changes requires a philosophic shift from seeing the human being as a collection of discrete physiologies to an understanding that the whole is greater than the sum of its parts. This process has implications that extend beyond symptom relief to the reorganization of personality.
Unfortunately, current biofeedback practice virtually ignores this potential, partly because of financial concerns, but also because practitioners themselves have not been exposed to the kind of research and education that would help to change the way biofeedback is popularly understood.
Practitioners who have received only ten hours of training before certification develop a limited personal understanding of the discipline. In addition, when they are unfamiliar with the possibilities and rewards of long-term training, they are less able to promote lasting and far-reaching change in clients. Advanced mind/body training is more than simply extending training beyond the usual number of sessions. It involves a new attitude toward training and research, and the design of more powerful data sets and graphics, so that the information can be presented meaningfully to clients and other researchers.
Advanced mind/body training is more likely to be effective in alleviating symptoms, in that its results tend to be enduring. But it is important to note that the results endure because the client has had time to reduce the patterns that caused the symptoms and is empowered through self-awareness that is unavailable through standard training involving fewer sessions and modalities. This self-awareness extends beyond symptom relief and implies a human capacity for changing aspects of the self that have previously been seen as permanent.
A client who has observed the interaction of body systems and the correlation between body states and life events over a long period gains a deeper understanding of the psychophysiological strategies at work. Very often, these strategies are no longer necessary.
Using multi-system advanced mind/body training gives such clients a chance to make lasting changes that not only relieve pain but free them to make new decisions about the ways in which they live their lives. Success in achieving psychophysiological global homeostasis encourages the client to take more control of other aspects of life and makes this process easier by eliminating the discomfort of chronic system overactivation. Perhaps more important, the ability to reduce system activation gives the client "breathing room" that he or she may never have experienced before and clears the way for making more "appropriate choices".
References Masek, Bruce. (1990). Biofeedback. Harvard Medical School Health Letter. August 15, 1-4.