Common Factors in Biofeedback Administered by Psychotherapists

Common factors are nonspecific therapeutic elements common across different varieties of psychotherapy. In a recent study, 68 expert psychotherapy researchers with a variety of allegiances collectively rated biofeedback as being negatively associated with many common factors (Tschacher et al. in Clin Psychol Psychother 21(1):82–96, 2014), including the therapeutic alliance. However, it seems implausible that biofeedback could benefit so many people while being incompatible with the therapeutic alliance and other common factors. The present study investigated the experiences of biofeedback clients who participated in a brief heart rate variability biofeedback protocol in order to explore the potential roles of common factors in biofeedback. The results of this study offer preliminary evidence that many common factors—including therapeutic alliance, self-efficacy expectation, mastery experiences, provision of explanatory scheme, mindfulness, and even cognitive restructuring—may play a role in biofeedback outcomes. Future research on this topic should include mediation and moderation models investigating the role of specific common factors on outcome and process studies to help determine what clinician behaviors are most helpful. Deeper investigation of common factors in biofeedback may benefit future biofeedback research and practice and address the concerns of colleagues outside of the biofeedback community who believe that biofeedback is at odds with common factors.

     

Interpersonal stress and style as predictors of biofeedback/relaxation training outcome: preliminary findings

Although the data base describing clinical outcome following biofeedback/relaxation training is accumulating, there have been relatively few attempts to predict short-term outcome, and even fewer for long-term outcome. Significant short-term outcome predictors have been identified, and they often allude to the level of psychological distress as a major factor affecting outcome. To investigate further the role of psychological variables in outcome prediction, this project presents preliminary findings that demonstrate the relationship involving interpersonal psychological stress, interpersonal style of behavior, and outcome. With a very heterogeneous group of patients (N = 39), measures of interpersonal style of behavior were used to discriminate correctly 80% of cases by outcome at the 3-month postadmission evaluation. With a more homogeneous group having somatic disorders alone (headache, Raynaud's, etc.), the accuracy of prediction at 3 months was 90%. No measures were capable of predicting long-term outcome with accuracies even moderately greater than chance. The results indicate that style of interpersonal behavior (e.g., managerial, dependent) and, to a lesser extent, interpersonal stress is predictive of short-term outcome following biofeedback/relaxation training. Individuals who tend to like responsibility and who are more executive and independent generally benefited more than doubtful, obedient, and depressed individuals. While the resulting prediction rates were only slightly more accurate than MMPI D and Pt subscales alone, the procedures provide additional information regarding the personality characteristics of successful and unsuccessful biofeedback clients, and may also provide the clinician with information regarding treatment choice if biofeedback is provided as an adjunct to psychotherapy.     

Interpersonal stress and style as predictors of biofeedback/relaxation training outcome: Preliminary findings

Although the data base describing clinical outcome following biofeedback/relaxation training is accumulating, there have been relatively few attempts to predict short-term outcome, and even fewer for long-term outcome. Significant short-term outcome predictors have been identified, and they often allude to the level of psychological distress as a major factor affecting outcome. To investigate further the role of psychological variables in outcome prediction, this project presents preliminary findings that demonstrate the relationship involving interpersonal psychological stress, interpersonal style of behavior, and outcome. With a very heterogenous group of patients (N=39), measures of interpersonal style of behavior were used to discriminate correctly 80% of cases by outcome at the 3-month postadmission evaluation. With a more homogeneous group having somatic disorders alone (headache, Raynaud's, etc.), the accuracy of prediction at 3 months was 90%. No measures were capable of predicting long-term outcome with accuracies even moderately greater than chance. The results indicate that style of interpersonal behavior (e.g., managerial, dependent) and, to a lesser extent, interpersonal stress is predictive of short-term outcome following biofeedback/relaxation training. Individuals who tend to like responsibility and who are more executive and independent generally benefited more than doubtful, obedient, and depressed individuals. While the resulting prediction rates were only slightly more accurate than MMPI D and Pt subscales alone, the procedures provide additional information regarding the personality characteristics of successful and unsuccessful biofeedback clients, and may also provide the clinician with information regarding treatment choice if biofeedback is provided as an adjunct to psychotherapy.     

Biofeedback treatment of dysmenorrhea

Nine dysmenorrheic women were run in EMG and thermal biofeedback procedures with concurrent autogenic relaxation practice. Significant reductions in subjective estimates of symptomology associated with dysmenorrhea were noted in all subjects. EMG levels correlated positively with the reductions in symptoms. Thermal levels did not correlate with EMG. In fact no consistent patterns in thermal measures were noted. However, thermal biofeedback cannot be ruled out as an effective treatment for dysmenorrhea since reductions in symptoms occurred during thermal biofeedback training. Another significant aspect of the present study is the effectiveness of long treatment procedures. A six month period was employed and significant reductions in symptoms were noted following two months of biofeedback treatment. Finally, the importance of beginning biofeedback treatment prior to onset of menstrual symptoms is indicated.     

Controlled group designs in biofeedback research: Ask, “what does the control group control for?”

The extant literature on the specific role of biofeedback in promoting skeletal muscular relaxation is reviewed and found deficient with respect to the use of properly controlled group outcome research. The review emphasizes the failure of commonly used control procedures to adequately control a number of potentially confounding variables. Strengths and weaknesses of three types of controlled group design (attention placebo, pseudofeedback, and altered contingency) are discussed with respect to their relative usefulness in controlling certain nonspecific or placebo effects in biofeedback research. Many published biofeedback studies failed to measure the credibility of control procedures or the subject's ability to discriminate different feedback contingencies. The studies reviewed suggest that the various control procedures used are not inert and are not equivalent with respect to their effects on control group behavior. The suggestion is made that the controlled group outcome design be accepted as the minimum requirement for testing the specific effects of biofeedback, and possible methods for improving control procedures are discussed.     

Biofeedback theory and application in allied health

The implementation of biofeedback procedures represents a new approach to clinical management of speech disorders. Thus far, results of experiments utilizing biofeedback techniques have suggested positive effects in the remediation of speech disorders. The purpose of this paper is to provide the reader with the principles of biofeedback; to survey areas of clinical application including voice, fluency, and other clinical disorders; and to explore potential applications of biofeedback procedures for the speech and language pathologist.     

Electromyographic (EMG) Biofeedback in the Comprehensive Treatment of Central Pain and Ataxic Tremor Following Thalamic Stroke

Peripheral pain and ataxic tremor can appear suddenly following thalamic stroke and can significantly alter a patient's psychological, social, and physical functioning. The present paper reports the case of a 70-year-old Caucasian female who sustained an acute left posterior cerebral artery infarction involving the thalamus and left mesiotemporal regions. She subsequently developed Central Poststroke Pain and ataxic movement of her right arm and hand in addition to a significant right-side claudication. She was treated over 16 weeks (6 weeks of EMG biofeedback and 10 weeks of psychotherapy) with a combination of EMG biofeedback, progressive muscle relaxation, behavioral pain coping skills training, Forced Use Therapy, and Cognitive Behavioral Therap 7 years after her initial cerebral accident. The case demonstrates the utility of biofeedback when combined as part of a comprehensive treatment program to address the multiple complications associated with thalamic stroke.     

Biofeedback training: offerings, plans, and some attitudes in graduate schools and internships

Graduate schools and APA-approved internships in North America were surveyed to determine the type and extent of biofeedback training, additional biofeedback training planned, requirements considered to be a minimum necessary before beginning clinical practice of biofeedback, when biofeedback is considered an appropriate application, and whether biofeedback is considered a "passing fad" in clinical practice. Questionnaires were returned by 56% of the graduate schools and 54% of the internships, and revealed training in 58% and 67% respectively. Training in biofeedback procedures appears to be growing, and most graduate schools and internships think that biofeedback is not a passing fad in clinical practice. Training emphases vary considerably across graduate schools and internships, with some schools and internships excluding theory and/or practice and/or research from their instruction. The results are discussed in relation to the question of determining which procedures to include in future instruction.     

Single-case designs and clinical biofeedback experimentation

Rigorous evaluation of the effects of biofeedback with clinical populations is necessary, but practical problems often preclude utilization of between-groups experimental designs involving large numbers of clients with clinically relevant problems. Single-case experimental designs provide a viable alternative for answering most research questions. In addition, single-case designs possess several distinct advantages for biofeedback research, including a focus on clinical significance, the use of variability as data not error, unique procedures for establishing generality of findings, and an ability to deal with ethical concerns in clinical research. Basic procedures in the use of single-case experimental designs are described and illustrations in clinical biofeedback research are provided.     

Biofeedback as an adjunct to psychotherapy in the treatment of vaginismus

This exploratory study examines the use of biofeedback as an adjunct to psychotherapy in the treatment of vaginismus. A set of six Sims-type graded EMG probes was constructed to provide biofeedback from the vaginal sphincter and was tested on a pilot sample of nulliparous women prior to this study. Five sequential cases of vaginismus from a clinic waiting list participated in the program. All five couples completed the program and all reported successful intercourse at its conclusion. The number of sessions devoted to biofeedback probe insertion was almost halved in comparison to previous experience with Sims dilators. Overall treatment duration was not shortened. At follow-up 6 months later, two couples reported pregnancy, one couple was having regular intercourse, and two couples had ceased intercourse. The authors conclude that biofeedback is an effective aid to learning muscle control, is acceptable to patients, and may increase the success rate by minimizing dropouts. The importance of follow-up is stressed.We wish to thank Mr. John Conboy, senior technician, Department of Psychiatry, University College, Dublin, for his help in setting up and running this experiment.     

Biofeedback training: Offerings,plans, and some attitudes in graduate schools and internships

Graduate schools and APA-approved internships in North America were surveyed to determine the type and extent of biofeedback training, additional biofeedback training planned, requirements considered to be a minimum necessary before beginning clinical practice of biofeedback, when biofeedback is considered an appropriate application, and whether biofeedback is considered a passing fad in clinical practice. Questionnaires were returned by 56% of the graduate schools and 54% of the internships, and revealed training in 58% and 67% respectively. Training in biofeedback procedures appears to be growing, and most graduate schools and internships think that biofeedback is not a passing fad in clinical practice. Training emphases vary considerably across graduate schools and internships, with some schools and internships excluding theory and/or practice and/or research from their instruction. The results are discussed in relation to the question of determining which procedures to include in future instruction.     

Self-regulation of respiratory sinus arrhythmia.

Respiratory sinus arrhythmia (RSA)--the peak-to-peak variations in heart rate caused by respiration--can be used as a noninvasive measure of parasympathetic cardiac control. In the present study four strategies to increase RSA amplitude are investigated: (1) biofeedback of RSA amplitude, (2) biofeedback of RSA amplitude plus respiratory instructions, (3) respiratory biofeedback, and (4) respiratory instructions only. All four procedures produce a significant increase of RSA amplitude from the first physiological control trial compared to baseline. This increase is faster for the groups that received respiratory biofeedback and respiratory instructions only than for the two groups that received biofeedback of RSA amplitude, the increases being equivalent for the four groups in the third session. All subjects of the group that received biofeedback of RSA amplitude only reported respiratory strategies in order to achieve the increase in RSA. Possible clinical implications of these results for parasympathetic cardiac control and cardiovascular disorders are discussed.     

Self-directed EMG training for the control of pain and spasticity in paraplegia: a case study

A 25-year-old paraplegic woman was able to gain control of her debilitating leg and bladder spasms and abdominal pain using self-directed EMG biofeedback. The case is significant in that she previously had only cursory exposure to biofeedback as an undergraduate student and received only minimal support and direction from an instructor. She proceeded through daily home practice using a borrowed EMG unit and audiotapes from Lester Fehmi's Open Focus series. Records were kept of the frequency and intensity of her pain and spasms, as well as the frequency and procedures of her home practice. She also maintained a record of specific psychosocial events in her life, which, over time, showed a strong, consistent pattern of influence on the recurrence and severity of her symptoms. The woman's physician declared her medical progress remarkable and encouraged her biofeedback work. At 2-year follow-up, she remains virtually symptom- and medication-free. Her successful biofeedback training program provides support for the value of client-directed biofeedback in selected cases.     

Detection of noncontingent feedback in EMG biofeedback

Noncontingent feedback is frequently used as a placebo control procedure in biofeedback research. Researchers, however, have criticized this procedure for lacking credibility because of easy detection. The present study examined detection of false feedback in biofeedback with EMG. Contingent feedback (CF), truly random false feedback (FF), and controlled false feedback (CFF) groups were compared for changes in EMG levels, report of inaccurate feedback, and report of learning muscle activity reduction. The results indicated that FF procedures are easily detected; therefore, differences found between the FF and CF groups may be influenced by extraneous variables. The CFF group did not detect false feedback, but subjects reported some suspicions in later trials. With more trials, CFF may have also been detected. These results indicate a need for more attention to appropriate placebo control procedures in evaluating the parameters and efficacy of biofeedback.     

Detection of noncontingent feedback in EMG biofeedback

Noncontingent feedback is frequently used as a placebo control procedure in biofeedback research. Researchers, however, have criticized this procedure for lacking credibility because of easy detection. The present study examined detection of false feedback in biofeedback with EMG. Contingent feedback (CF), truly random false feedback (FF), and controlled false feedback (CFF) groups were compared for changes in EMG levels, report of inaccurate feedback, and report of learning muscle activity reduction. The results indicated that FF procedures are easily detected; therefore, difference found between the FF and CF groups may be influenced by extraneous variables. The CFF group did not detect false feedback, but subjects reported some suspicions in later trials. With more trials, CFF may have also been detected. These results indicate a need for more attention to appropriate placebo control procedures in evaluating the parameters and efficacy of biofeedback.     

Electromyographic biofeedback for relief of tension in the facial and throat muscles of a woodwind musician

Electromyographic(EMG) biofeedback, for the relaxation of specific throat and facial muscles, was given to a woodwind musician. The patient had a nineteen-year history of tics and high levels of tension in his throat and facial muscles. Eventually these problems progressed to a point that interfered with his ability to perform as a professional woodwind musician. Following detoxification from alcohol and Dexamyl, and after a period of psychotherapy, EMG biofeedback relaxation training was started for the muscles specifically showing chronically high tension levels. The EMG training consisted of four phases designed to help the patient progressively lower tension and generalize these newly learned techniques to his professional life. He had a total of twenty treatments of approximately 45 minutes each. This procedure resulted in dramatic reductions in tension levels of the specific throat and facial muscles along with increased proficiency as a muscician and in psychological functioning.     

Self-directed EMG training for the control of pain and spasticity in paraplegia: A case study

A 25-year-old paraplegic woman was able to gain control of her debilitating leg and bladder spasms and abdominal pain using self-directed EMG biofeedback. The case is significant in that she previously had only cursory exposure to biofeedback as an undergraduate student and received only minimal support and direction from an instructor. She proceeded through daily home practice using a borrowed EMG unit and audiotapes from Lester Fehmi'sOpen Focus series. Records were kept of the frequency and intensity of her pain and spasms, as well as the frequency and procedures of her home practice. She also maintained a record of specific psychosocial events in her life, which, over time, showed a strong, consistent pattern of influence on the recurrence and severity of her symptoms. The woman's physician declared her medical progress remarkable and encouraged her biofeedback work. At 2-year follow-up, she remains virtually symptom- and medication-free. Her successful biofeedback training program provides support for the value of client-directed biofeedback in selected cases.     

Biofeedback treatment for headaches,Raynaud's disease,essential hypertension,and irritable bowel syndrome: A review of the long-term follow-up literature

Long-term follow-up evidence for biofeedback treatment of headaches, Raynaud's disease, essential hypertension, and the irritable bowel syndrome was reviewed. Acknowledging the difficulties with cross-study comparisons, the following general success rate were determined: primary idiopathic Raynaud's disease—70%, or better; vascular headache—70%, or better; mixed headache—about 60%; and muscle contraction headache—50%, or less. With relatively fewer patients, successful outcomes with the irritable bowel syndrome and secondary Raynaud's phenomenon were roughly 60% and 40%, respectively. Few cases of clinically significant long-term decreases in diastolic blood pressure were demonstrated; however, the need for medication was reduced or eliminated in some patients. There were indications that biofeedback combined with psychotherapy resulted in highest success rates. No differences were found in effectiveness between biofeedback, other relaxation techniques, and biofeedback in combination with relaxation techniques—all had essentially comparable rates of success. No correlations between physiological and psychological measures of condition at follow-up were reported. Implications and interpretations of these findings are discussed.     

Self-regulation of respiratory sinus arrhythmia

Respiratory sinus arrhythmia (RSA) — the peak-to-peak variations in heart rate caused by respiration — can be used as a noninvasive measure of parasympathetic cardiac control. In the present study four strategies to increase RSA amplitude are investigated: (1) biofeedback of RSA amplitude, (2) biofeedback of RSA amplitude plus respiratory instructions, (3) respiratory biofeedback, and (4) respiratory instructions only. All four procedures produce a significant increase of RSA amplitude from the first physiological control trial compared to baseline. This increase is faster for the groups that received respiratory biofeedback and respiratory instructions only than for the two groups that received biofeedback of RSA amplitude, the increases being equivalent for the four groups in the third session. All subjects of the group that received biofeedback of RSA amplitude only reported respiratory strategies in order to achieve the increase in RSA. Possible clinical implications of these results for parasympathetic cardiac control and cardiovascular disorders are discussed.This research was supported by a grant to the first author from the University of Granada (Spain).     

The use of biofeedback in a behavioral program designed to teach an anxious child self-catheterization

This paper presents a case study of a 7-year-old girl with a noncompliant bladder who was trained to self-catheterize using biofeedback and behavior therapy techniques. Initial attempts to train her to self-catheterize were unsuccessful owing to excessive amounts of fear, muscle tension, and refusal. After seven treatment sessions in which she was instructed in proper self-catheterization technique by a urology nurse clinician and coached in biofeedback-assisted relaxation by a clinical psychologist, the child successfully learned to self-catheterize. EMG readings showed a decrease in quadriceps muscle tension levels across sessions. Eight additional sessions were held in order to train the child's parents in proper technique and coaching procedures. Through the use of portable biofeedback equipment during actual training sessions, the biofeedback served as a cue--first to the child and coach, and later to the child and parents--for when the child needed to stop and relax. This case illustrates the usefulness of biofeedback in a comprehensive behavioral program designed to teach self-catheterization to fearful children.