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Adding Biofeedback to your Practice

Both biofeedback and neurofeedback are additions to an eating disorders practice.

Adding Biofeedback to your Practice

     Biofeedback is well accepted as a safe method of stress reduction and is very easy to incorporate into a practice. Biofeedback instruments can be simple, flexible and powerful ways to bring calm to those with nervous disorders by training the nervous system in self-regulation. Biofeedback results can be charted precisely and can answer the call for evidence based practice. It may also help generate new revenue streams for your practice. Biofeedback of brainwaves (neurofeedback) has developed with advancing technology and has demonstrated broad clinical success.

     Neurofeedback clinicians report excellent outcomes with eating disorders and there is increasing research to back them up.

     A biofeedback loop occurs when a person is engaged in interactive learning with a display of information from a biological signal generated by the nervous system. Learning to calm and stretch the nervous system enhances resilience and flexibility. Biofeedback offers patients improved anxiety management, an increased sense of physiological self-awareness, self-control and an improved level of hope that they can escape uncomfortable feelings in a healthy, non-destructive way.

     The three professional organizations that promote biofeedback research and practice are the Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Certification Institute of America (BCIA) and the International Society for Neurofeedback and Research (ISNR). They have defined biofeedback this way:

"Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information often in conjunction with changes in thinking, emotions, and behavior supports desired physiological changes. Over time, these changes can endure without continued use of an instrument."

     Biofeedback is an intervention technique that emerged from operant and respondent conditioning procedures in the 1960s (Schwartz & Olson, 1995). To date, considerable empirical evidence has shown that through operant learning, humans can gain moderate to strong volitional control over numerous internal physiological functions and the principal means of developing this control has been with consequences delivered via biofeedback (Allen, 2007).

     Biofeedback is nothing mysterious. Biofeedback systems make unconscious behavior conscious. Once neurophysiology is visible and quantifiable it can be shaped and rewarded. In this age of evidence-based practices, biofeedback offers objective evidence of change, since numbers and graphs can be produced during each session. You can see improvement within and between sessions, e.g., reduced muscle tension, improved heart rate variability, increasing skin temperature and/or lower skin conductance (less sweaty hands). Biofeedback has long been recognized as a useful form of stress reduction (Lehrer, 2007) and has growing efficacy for a host of psychological problems (Oubr, 2002), (Masterpasqua, Healey, 2003). Yucha, C. & Gilbert, C. 2004 list efficacy ratings for numerous disorders including anxiety, attention deficit disorder, incontinence, headache, hypertension, alcoholism/substance abuse, arthritis, chronic pain, epilepsy, migraines, insomnia, traumatic brain injury, asthma, depressive disorders, fibromyalgia, irritable bowel syndrome, post traumatic stress disorder, Raynaud's disease, tinnitus and eating disorders. In addition, biofeedback can enhance sports performance, personal growth and creativity in patients and non-patients alike.

     There are a variety of ways to get training in biofeedback. Membership in the relevant professional organizations is an excellent way to learn more. Certification will be an eventual goal for some professionals. Licensed health care professionals may want to check with their professional organizations and boards about the scope of practice issue. The web sites of professional societies, manufacturers, and practitioners are rich sources of information. There are a dozen yahoo newsgroups devoted to biofeedback and neurofeedback. There are several paths of entry into biofeedback. The simplest is to start with "peripheral" biofeedback devices available to consumers, e.g., of muscle tension ("surface electromyography or sEMG), skin temperature, galvanic skin response (GSR) or skin conductance level (SCL) and/or heart rate variability (HRV). The cheapest way to begin is with a "stress thermometer" available on the internet for $20. It is a digital thermometer with a sensor at the end of a wire. You hold or tape the sensor on a finger tip, then relax. Within a few minutes most people will begin to see the temperature climb and this will be accompanied by a noticeable sense of relaxation. Fully relaxed, the skin temperature measured this way will be about 94 degrees. You can validate just how relaxing imagery, meditation, pleasant music or massage actually is by seeing this type of direct physiological evidence of the relaxation response (Benson 2000).

     Heart rate variability biofeedback devices cost $160 - $300. HRV is a powerful way to balance the autonomic nervous system by synchronizing breathing with respiratory sinus arrhythmia. At a persons resonant breathing frequency the fastest heart rate will be at full inhalation and the slowest heart rate will at the full exhalation (Leher, 2006). Muscle tension devices start at about $475. With very little training, most anyone can teach their clients very quickly (6 sessions or less) how to find a relaxed posture sitting and standing, how to let go of chronic sympathetic activation of the "fight or flight" response and how to initiate the relaxation response of the parasympathetic "rest and digest" system.


     Neurofeedback (sometimes called EEG biofeedback or neurotherapy) is a form of biofeedback that monitors and feeds back neurological information usually in a multimedia display. The ISNR publishes the Journal of Neurotherapy, which focuses exclusively on research with neurofeedback and quantitative EEG. There is a comprehensive bibliography of disorders treated by neurofeedback on the www.ISNR.org website. With 2 or 3 lines per citation and 45 categories the document is currently running to 30 pages (Hammond, 2008).

     Not published is a controlled outcome study at a residential treatment center where 120 patients were administered psychological and EEG tests (Smith, Sams, Sherlin, ISNR Annual Conference, 2006). A variety of neurofeedback approaches were added to the standard treatment regimen for 21 anorexic and 54 bulimic patients. All neurofeedback approaches were successful compared to a traditional treatment control group.


1.      Significant decrease in Beck Depression Inventory-2 scores, neuroticism scores, and all Eating Disorders Inventory-2 scores.
2.      Significant increase in extroversion scores.
3.      MMPI-2 changes reveal a reduction in symptoms associated with distress.
4.      Reduction in dosage of psychiatric medications ranged between 25% and 65%.
5.      Anorexics gained weight significantly. Bulimics lost 3 lbs/month during treatment.


1.      63 of the original 75 subjects responded to 6-month follow-up.
2.      80-100% reduction in depression on Beck Depression Inventory.
3.      Depression reduction was the key factor in sustained success.
4.      Weight changes continued in the proper direction. Anorexics gained about 1 lb per week. Overweight bulimics lost about 3 lbs per month.
5.      65% are doing well in recovery. 80% have had some resurgence of symptoms.
6.      Maintenance of preferred weight direction was better for anorexics (p>.05) than for bulimics (p>.08), and third for overweight.
7.      Overall, outcomes for neurofeedback group were twice as strong as the traditional treatment controls.

    There is not just one way to do neurofeedback. Instead there are several camps that have each developed diverse yet successful approaches. Neurofeedback is done by some in a training model with the goal to optimize neurological functioning in people with or without symptoms. Others prefer a practice model that uses subjective and/or objective assessments such as a QEEG brain map to "target" neurofeedback training. For example, people with high anxiety, physical tension and incessant thinking frequently have excessive high frequency "beta" brainwave activity over the central sensorimotor and parietal association cortices. And there are several other approaches to the same case such as focusing on inter-site coherence, reducing turbulence of the EEG or training up regional cerebral blood flow with hemoencephalography (HEG). Other popular approaches to training will boost alertness, e.g., less frontal/central theta with more mid-range beta power or training will aim for a more relaxed state, e.g., more sensorimotor rhythm or more posterior alpha rhythm eyes closed. Neurofeedback equipment is generally more powerful, complex and expensive than peripheral biofeedback. Neurofeedback equipment can cost $1100 - $5000+. Most manufacturers have a version of their systems for clients to train at home under clinical supervision.

Take Home Points

     With careful observation of what is really going on psychophysiologically, you can help people take charge of themselves. With this comes an increasing sense of self-efficacy and a belief in the controllability of previously uncontrollable emotional states. As this happens, much of the out-of-control panic feelings patients have will dissipate. Depression begins to lift rapidly and enduringly as patients realize there is actually something they personally can do to improve the way they feel and the way they operate their nervous system.

     Your patients can benefit from learning to lower their anxiety and improve their ability to drop themselves at will into an emotionally and physically relaxed, but mentally alert and focused state. This is easy enough to promote with a variety of biofeedback methods, ranging from peripheral feedback of muscle tension and autonomic indicators to various aspects of the brains electrical activity. A final excellent reason to add biofeedback to your practice is that patients volunteer to stay in treatment longer when neurofeedback is offered to them (Scott et al. 2005).

     Historically, biofeedback efficacy has been recognized for some decades now, but it has been trivialized as relaxation training when in fact it offers a powerful pathway for enhanced self-regulatory status of the whole nervous system. This has particular import for conditions with a significant neurophysiological component that impedes recovery by conventional therapeutic methods. The role of biofeedback in recovery is particularly compelling when the dysregulation manifests in so many different systems, as is the case in eating disorders and in addictions, (Trocki, 2007).


Allen, K.D. (2006). Recurrent Pediatric Headaches: Behavioral Concepts and Interventions Journal of Early and Intensive Behavior Inetrevtion, 3 (2), 211-218.  Retrieved from www.behavior-analyst-online.org

Association for Applied Psychophysiology and Biofeedback: http://www.aapb.org

Benson, Herbert; Klipper, Miriam Z. 2000 Relaxation Response, New York: Harper Collins.

Biofeedback Certification Institute of American: http://www.bcia.org

International Society for Neurofeedback and Research: http://www.isnr.org

Leher, P. M, Woolfolk, M., Robert, L. & Sime, W. E. (Eds,) (2007). Principles and Practices of Stress Management. New York: Guilford Press.

Masterpasqua, F., Healey, F. & Source, K.N. (2003). Neurofeedback in Psychological Practice.. Professional Psychology: Research and Practice Vol. 34, No. 6, 652-656

Oubr A. (2002, July 1) EEG neurofeedback for treating psychiatric disorders. Psychiatric Times, 19.  Retrieved from http://www.psychiatrictimes.com/p020268.html.

Schwartz, M. & Olson, R. (1995). A historical perspective on the field of biofeedback and applied psychophysiology. In M.S. Schwartz (Ed). Biofeedback: A Practitioners Guide (2nd Ed). (pgs 3-18). New York: Guilford Press.

Scott, W.C., Kaiser, D., Othmer, S., and Sideroff, S.I. (2005).Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population, American Journal of Drug and Alcohol Abuse, 31(3), 455-469

Smith, P., Sams, M., Sherlin, L. (2006). The Neurological Basis of Eating Disorders. I: EEG Findings and the Clinical Outcome of Adding Symptom-Based, QEEG-Based, and Analog/QEEG-Based Remedial Neurofeedback Training to Traditional Treatment Plans. Paper Presented at 2006 ISNR conference, Atlanta, GA.

Trocki, K.F. (2006).Is there an Anti-Neurofeedback Conspiracy? Journal of Addictions Nursing, 17( 4) , 199 202

Yucha, C. & Gilbert, C. (2004) Evidence-Based Practice in Biofeedback and Neurofeedback. Colorado Springs, CO: Association for Applied Psychophysiology and Biofeedback

Gary Ames, M.A. is a licensed psychologist in private practice in Bala Cynwyd, PA near Philadelphia, see www.AlertFocus.com. He specializes in neurofeedback and advocates for greater acceptance of biofeedback in education, healthcare, criminal justice and executive training.   Email GaryAmes@AlertFocus.com Call 610.668-3223.

John K. Nash, Ph.D. is a Licensed Psychologist in Minnesota where he operates Behavioral Medicines Associates, Inc. (www.qeeg.com) in Edina, MN, near Minneapolis. He uses a wide range of biofeedback modalities, including EMG, HRV and neurofeedback, coupled with individual and family therapy using the cognitive behavioral and family systems approaches. He is currently President-elect of the International Society for Neurofeedback and Research. The author can be contacted at johnnash@qeeg.com.


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Copyright 2004, Gary Ames
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