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
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,
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
"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
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,
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 (Oubré, 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.
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.
Maintenance of preferred weight direction was better for anorexics
(p>.05) than for bulimics (p>.08), and third for overweight.
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 brain’s 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
Oubré 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 Practitioner’s 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 email@example.com.