Biofeedback is a learning process like learning to play a musical instrument
or a videogame. An individual acts (breathes effortlessly), observes the results (heart rate
variability increases), and repeats this action throughout the day while working in an office. We can think of biofeedback as a "psychophysiological
mirror" that teaches individuals to monitor, understand, and change their physiology (Peper, Shumay, &
Moss, 2012).
Biofeedback teaches clients to listen to their bodies.
Although they initially use equipment to track their physiology, biofeedback training progressively replaces external with internal cues. Graphic by Dani S@unclebelang adapted from Erik Peper.
The goal of biofeedback training is to teach self-regulation, which is control of behavior without feedback.
Mindfulness provides a foundation for biofeedback.
Biofeedback training may be more effective when training promotes mindfulness. Mindfulness involves "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" (Kabat-Zinn, 1994).
A mindfulness approach
teaches clients to focus on their immediate feelings, cognitions, and sensations in an accepting and nonjudgmental way, to distinguish between what can and cannot
be changed, and to change the things they can (Khazan, 2013).
Clients can become stuck when they
focus on outcomes they cannot immediately control. Dr. Khazan (2019) uses a quicksand metaphor to advise clients not to struggle with difficult emotions, since this can make them chronic.
Scott Adams (2006), the author of the Dilbert comic strip, struggled
with spasmodic dysphonia, in which he could not speak in person using a normal voice.
This disorder involves abnormal laryngeal muscle contraction, its cause is unknown, and spontaneous
remission is rare. Conventional treatment, including Botox injections, speech therapy, and surgical attempts
to reduce symptom severity, but not cure, this disorder (Bliznikas & Baredes, 2005).
Adams used multiple strategies to regain social speech, including visualization, affirmation, hypnosis, speech
therapy exercises, changing pitch, singing words, and speaking in foreign accents (self-regulation). He adjusted
his strategy based on its results (feedback) and actively searched for patterns (self-monitoring) to explain why
some strategies were more helpful than others. He achieved a breakthrough when he discovered that he could speak
in rhyme and repeatedly practiced this strategy for several days until he largely regained normal speech.
Biofeedback can involve basic technology, high technology, or no technology, as in the case of Scott Adams. Biofeedback is defined by the
learning process and not by the hardware. The table below is organized by the body system monitored and
may help you explain biofeedback to your clients and colleagues.
BCIA Blueprint Coverage
This unit addresses Definitions of biofeedback (I-A), Concepts
of feedback and control in biological systems(I-C), and
Overview of principles of human learning as they apply to biofeedback(I-D).
This unit
covers Definitions of Biofeedback, Physiological Monitoring and Modulation Are Not Biofeedback, Major Biofeedback Modalities, An Explosion of Personal Biofeedback Devices and Apps, Quantum Biofeedback, Memory, Associative Learning, Six Influential Biofeedback Models, The Training Process, and Biofeedback Training Should Teach Voluntary Control.
Please click on the podcast icon below to hear a full-length lecture.
Definitions of Biofeedback
Biofeedback Alliance and Nomenclature Task Force (2008)
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.
International Society for Neurofeedback and Research (2010) definition of
neurofeedback
Like other forms of biofeedback, NFT uses monitoring devices to provide moment-to-moment information to an
individual on the state of their physiological functioning. The characteristic that distinguishes NFT from other
biofeedback is a focus on the central nervous system and the brain. Neurofeedback training (NFT) has its
foundations in basic and applied neuroscience as well as data-based clinical practice. It takes into account
behavioral, cognitive, and subjective aspects as well as brain activity.
NFT is preceded by an objective assessment of brain activity and psychological status. During training,
sensors are placed on the scalp and then connected to sensitive electronics and computer software that detect,
amplify, and record specific brain activity. Resulting information is fed back to the trainee virtually
instantaneously with the conceptual understanding that changes in the feedback signal indicate whether or not the
trainee's brain activity is within the designated range. Based on this feedback, various principles of learning,
and practitioner guidance, changes in brain patterns occur and are associated with positive changes in physical,
emotional, and cognitive states. Often the trainee is not consciously aware of the mechanisms by which such
changes are accomplished although people routinely acquire a "felt sense" of these positive changes and often
are able to access these states outside the feedback session.
NFT does not involve either surgery or medication and is neither painful nor embarrassing. When provided by a
licensed professional with appropriate training, generally trainees do not experience negative side-effects.
Typically, trainees find NFT to be an interesting experience. Neurofeedback operates at a brain functional level
and transcends the need to classify using existing diagnostic categories. It modulates the brain activity at the
level of the neuronal dynamics of excitation and inhibition which underlie the characteristic effects that
are reported.
Research demonstrates that neurofeedback is an effective intervention for ADHD and Epilepsy. Ongoing research
is investigating the effectiveness of neurofeedback for other disorders such as Autism, headaches, insomnia,
anxiety, substance abuse, TBI and other pain disorders, and is promising.
Being a self-regulation method, NFT differs from other accepted research-consistent neuro-modulatory
approaches such as audio-visual entrainment (AVE) and repetitive transcranial magnetic stimulation (rTMS) that
provoke an automatic brain response by presenting a specific signal. Nor is NFT based on deliberate changes
in breathing patterns such as respiratory sinus arrhythmia (RSA) that can result in changes in brain waves. At
a neuronal level, NFT teaches the brain to modulate excitatory and inhibitory patterns of specific neuronal
assemblies and pathways based upon the details of the sensor placement and the feedback algorithms used thereby
increasing flexibility and self-regulation of relaxation and activation patterns.
This definition was ratified by the ISNR Board of Directors on January 10, 2009 and edited on June 11, 2010.
This definition emphasizes that neurofeedback is a "self-regulation method" that teaches clients to
voluntarily change central nervous system activity. It draws a sharp distinction between neurofeedback and
neuromodulatory approaches like audio-visual entrainment (AVE) that alter the brain by exposing it to a stimulus.
While these are potentially valuable adjunctive procedures, they do not provide feedback of brain activity nor
teach self-regulation.
Core Elements of Biofeedback
The client-practitioner relationship is the foundation of BFT and NFT. Biofeedback is most effective when clients and providers are mindful because this promotes self-awareness and a sense of agency. Biofeedback promotes self-regulation when a practitioner provides effective coaching (Khazan, 2019).
Physiological Monitoring and Modulation Are Not Biofeedback
Biofeedback combines physiological monitoring, client feedback, and self-regulation training guided by feedback (Khazan, 2019). Biofeedback training may be most effective when performed mindfully.
The electroencephalograph, feedback thermometer, photoplethysmograph, and surface electromyograph are probably the
most widely-used modalities in clinical biofeedback. In addition, both casual and elite athletes increasingly use
electrocardiographic and photoplethysmographic sensors built into activity trackers, clothing, and exercise equipment to guide their workouts. Check out the Mind Media YouTube video What is Biofeedback and Neurofeedback?
An electrocardiograph (ECG/EKG) measures the heart's electrical activity and provides information about cardiac conduction, heart rate, and heart rate variability (HRV).
An electrodermograph (EDA, GSR, SC, SP) measures skin electrical activity
that is generated by eccrine sweat glands.
An electroencephalograph (EEG) measures brain electrical activity, called
postsynaptic potentials, generated by cortical neurons. EEG biofeedback is also called
neurofeedback.
A surface electromyograph (SEMG) measures the muscle action potentials
that initiate skeletal muscle contraction.
A feedback thermometer (TEMP) measures relative peripheral blood flow and the
temperature of the fingers and toes.
A photoplethysmograph (PPG) measures relative peripheral blood flow and
heart rate, and HRV. Clinicians who monitor HRV may prefer the PPG to the ECG due to the ease of sensor placement
(clients don't have to undress).
Arespirometer (RESP) measures the movement of the abdomen and/or chest and
provides information about breathing mechanics and respiration rate.
The table below summarizes the primary biofeedback modalities used in clinical and optimal performance practice.
An Explosion of Personal Biofeedback Devices and Apps
Technology has provided us with the power of self-quantification, which tracks data about our inputs (sleep), states (mood), and performance (HRV) to improve lifestyle choices.
Activity trackers can measure exercise type, speed, distance, duration, intensity, calories consumed and burned, heart rate, and respiration rate. They can monitor sleep duration, stages, and disruption. They can also nag us when we have been inactive for too long.
Recent examples include the Apple Watch and Fitbit Sense.
;
Specialized applications like Elite HRV can wirelessly monitor heart rate variability using a finger sensor or chest strap.
You can attach sensors to your smartphone to measure heart rate variability (Institute of HeartMath Inner Balance), skin conductance (Mindfield's eSense Skin Response), and skin temperature (Mindfield's eSense Temperature).
The Upright
Posture Trainer can teach you to avoid slouching and resulting back and neck pain.
Software like Zukor's Grind 3.0 can interface with biofeedback and neurofeedback equipment to provide younger clients with an engaging skateboarding game.
Quantum Biofeedback and LenyosisTM
Slawecki (2009) cautioned consumers in "How to Distinguish Legitimate Biofeedback/Neurofeedback Devices."
Appending biofeedback to a product's name does not make it biofeedback. Exposing clients to electromagnetic fields is modulation. Since biofeedback provides clients with real-time performance information to guide self-regulation, Quantum Biofeedback and LenyosysTM devices fall outside of this definition.
Quantum Biofeedback
Quantum Biofeedback (EPFX / SCIO / XRROID / QXCI) devices do not provide individuals with
immediate information regarding their performance. Marketers advertise that these instruments monitor, diagnose, and correct
cellular abnormalities at a quantum level without providing peer-reviewed data. Critics claim that treatment with these
devices may result in false diagnoses and delay effective treatment for medical disorders.
The following information was retrieved from the Empowering Change in You site on December 27, 2009. Note the
disclaimer about "curing" medical conditions and explanation that it produces changes through stress
management:
The function of the Quantum Biofeedback/EPFX is similar to a virus scan on a computer. It focuses on your
energetic body, which offers a more complete view of each facet of your health. Based on Quantum Physics, it
runs a comprehensive test that measures the body’s frequencies. The system then contributes frequencies
designed to resonate within the body, thus creating balance.
The human body is composed of a biochemical structure and an electromagnetic field. It performs best when these
functions are balanced with one another and in complete harmony. Unfortunately, the daily stresses of life that
confront each and every one of us takes its toll on the human body. Stress reduction is essential for wellness.
This energy work is non-invasive.
It is important to remember that energetic medicine does not "cure" health problems. It addresses them
specifically by making energetic corrections and rebalancing the system through stress management.
LenyosysTM
LenyosysTM
describes its pulsed electromagnetic technology as a "body-biofeedback modality":
Ideal as a complement to neurofeedback and biofeedback therapy, BRT is a body-biofeedback modality that helps to address the physical and somatic symptoms of both simple and complex health issues including digestive problems, systemic inflammation, muscle and joint aches, drug and alcohol addiction, allergies and hypersensitivities, stress, trauma and chronic illness. Whether used before, right after or in between sessions, BRT works in tandem with neurofeedback and biofeedback to create synergies that relax the client, enhance the therapy session and improve end results.
Pulsed electromagnetic treatment is modulation--not biofeedback.
Instead of providing double-blind studies of their product's effectiveness, the marketers provide references for the application of Pulsed Electromagnetic Field Therapy (PEMF) and magnetism for specific applications.
Learning and Memory
Learning is how we acquire new information, patterns of behavior, or skills. Memory is the capacity to store and retrieve this information (Breedlove & Watson, 2023). Memory differs in its duration and content.
Long-Term Memory
Long-term memory, which can last from days to years, can be declarative or nondeclarative.
Declarative Memory
Declarative memory is what we usually consider memory. It is the "what" of memory and consists of the facts and information we have learned (and that we know we have learned). We are aware when we access declarative memory and share it with others.
Declarative memory allows us to associate stimuli that occur at the same time consciously. Each memory we create contains actors, sequences of events, and the locations where the events occurred. Through a relational learning process, we connect new memories with existing ones (Carlson & Birkett, 2021).
Declarative memory can be episodic and semantic.
Episodic memories provide contextual information: when, where, and in which order did the events that comprised an episode occur? They are highly specific and must be learned at once since each event is unique and only happens once.
In contrast, semantic memories, which concern facts, are more general and slowly acquired over time. A declarative memory of meditation might simultaneously associate a person's breathing
pattern, repeated phrase, and somatosensory feedback (like reduced muscle tone and the slowing of the heart).
Biofeedback Examples
During a stressful meeting, a client may intentionally retrieve an episodic memory of how they calmed themself during a biofeedback session to reduce anxiety.
Therapists can teach clients to increase their mindfulness through discrimination
training. For example, a clinician could ask a client to guess their heart rate and display the
actual value. Through repeated practice, they can increase the accuracy of their estimates. Discrimination training
is a crucial element of SEMG biofeedback for chronic pain patients since they are often unaware of their resting
muscle tension.
Peper uses this strategy to teach clients to estimate their inhalation volumes (the amount of air they can inhale). Clients inhale a volume of
air, estimate the volume, and then look at the actual measurement on an incentive
inspirometer. This increases client awareness of the depth of their inhalation.
Nondeclarative Memory
Nondeclarative (procedural) memory is the "how" of memory and consists of memories regarding perceptual (e.g., mirror reading) or motor skills (e.g., mirror tracing) you acquire through action. We demonstrate nondeclarative memory by doing since it is often non-verbal.
Nondeclarative memory encompasses skill learning, priming, and associative learning. Skill learning involves mastery of tasks like paced breathing, which depends on motor coordination. Priming (repetition priming) changes in your response to a stimulus, like a word, following exposure to an identical or related stimulus. For example, you are more likely to answer a question with a word you recently read in a list. Finally, associative learning connects two stimuli or a stimulus and a response. Classical and operant conditioning, which can modify our psychophysiological responses, are two forms of conditioning.
Classical conditioning is an
unconscious associative learning process that modifies
reflexive (elicited) behavior and prepares us to respond quickly to future
situations.
A previously neutral stimulus gains the ability to predict an event. Classical conditioning underlies
conditioned emotional responses, like anxiety when you see a
Highway Patrol vehicle, and the
placebo response, where client expectancies promote
healing.
An unconditioned stimulus (food) elicits an unconditioned response
(salivation) without conscious learning.
Extinction occurs when the failure of an
unconditioned stimulus (food) to follow the conditioned stimulus
(bell) weakens or eliminates a conditioned response
(salivation).
Spontaneous recovery
occurs when the conditioned response (salivation) reappears
after some time without exposure to the conditioned stimulus
(bell).
Stimulus generalization and discrimination are mirror images of each other. In stimulus
generalization, the conditioned response is elicited by stimuli (sounds) that resemble the
conditioned stimulus (bell). In contrast, in stimulus discrimination,
the conditioned response (salivation) is prompted by one
stimulus (high-pitched bell) but not another (low-pitched bell).
Operant Conditioning
Operant conditioning is an
unconscious associative learning process that modifies the form and occurrence of
an operant behavior (emitted behavior)
by manipulating its
consequences.
Operant conditioning occurs with a situational context. The identifying characteristics of a situation are called
its
discriminative stimuli and can include
the physical environment and physical, cognitive, and emotional cues. Discriminative stimuli teach us when to
perform operant behaviors.
In positive reinforcement, behavior (breathing practice) is followed
by a positive consequence (feeling good) that increases the likelihood
that your client will use the behavior in situations with similar discriminative
stimuli (distress cues).
In negative reinforcement, behavior (breathing practice) allows your client to escape or avoid an aversive state (distress), thereby increasing
the likelihood that your client will use the behavior in situations with
similar discriminative stimuli (distress cues). Don't confuse negative reinforcement with aversive
punishment, where an action that yields an unpleasant consequence becomes less likely in the future.
Current research is exploring the optimal reinforcement criteria for neurofeedback training.
Client skill acquisition is markedly affected by changing parameters like reinforcement schedule, frequency of reward, reinforcement delay, conflicting reinforcements, conflicting expectations, and environment alteration.
While continuous reinforcement, reinforcement of every desired behavior, is helpful during the early stage of skill acquisition, it is impractical as clients attempt to transfer the skill to real-world settings. Since reinforcement outside of the clinic is intermittent, partial reinforcement schedules, where the desired behavior is only reinforced sometimes, are important as training progresses. This reduces the risk of extinction, where failure to reinforce the desired behavior reduces the frequency of that behavior.
For neurofeedback, variable reinforcement schedules, where reinforcement occurs after a variable number of responses (variable ratio) or following a variable duration of time (variable interval) produce superior response rates than their fixed counterparts.
Shaping
In operant generalization,
your client performs an operant behavior (slow-paced breathing) with a new
discriminative stimulus (anger instead of anxiety). In contrast, in
operant discrimination,
your client performs an operant behavior (slow-paced breathing) when one
discriminative stimulus (anxiety) is present
but not during another (calm).
In aversive punishment(positive punishment), an operant
behavior (slow-paced breathing) is weakened when followed by an aversive
stimulus (frustration).
In response cost(negative punishment), an operant
behavior (slow-paced breathing) is weakened when followed by the removal of
a rewarding stimulus (client loses attention from others for symptoms). In
operant extinction, the frequency of behavior (slow-paced breathing) declines when it is not reinforced (client is
unable to achieve calm).
Shaping is an operant procedure that teaches a client to perform new
behaviors.
For example, a clinician rewards (provides praise and auditory and visual feedback) successive
approximations of a target behavior (trapezius muscle relaxation).
Six Influential Biofeedback Models
Six models have greatly influenced therapist and researcher conceptions
of biofeedback. These include the cybernetic, operant conditioning, drug,
placebo, relaxation, and skill-development models.
The components of
a thermostat system include a setpoint or goal (75°
F/ 23.9° C),
system
variable or what is controlled (room temperature),
negative feedback or
corrective instructions (commands to change furnace output), and
positive
feedback or instructions to continue action (commands to continue furnace
output).
The internal environment fluctuates around a setpoint and is never
stationary. This allows rapid adaptation to changing activity levels and
environmental conditions. Homeostasis is
a state of dynamic constancy achieved by stabilizing
conditions above and below a setpoint, which may change over time. From
the perspective of the cybernetic model, biofeedback training supplements
a client's proprioception to bring a malfunctioning biological system
variable (blood pressure) under better control (Fox & Rompolski, 2022).
Homeostasis depends on sensory systems (networks that monitor system
variables) to detect an actual or anticipated
change in physiological processes (temperature), an
integrating center,
which receives input from many sensors, and multiple effector systems
(control systems) to
adjust physiological processes.
The body maintains dynamic constancy through continuous negative feedback
loops amplified by positive feedback and antagonistic effectors.
Negative feedback loops produce corrective changes when a physiological
variable is outside an acceptable range. For example, we initiate
clotting to stop blood loss from a wound.
Positive feedback loops amplify the changes produced by negative feedback.
For example, activating a clotting factor activates others to create
a blood clot.
Push-pull control by effectors that produce antagonistic effects achieves
more precise control than turning a single effector on or off. For
example, a sympathetic nerve accelerates the heart while the
parasympathetic vagus nerve slows the heart.
Operant Conditioning Model
The operant conditioning model proposes that "biofeedback is the operant
conditioning of physiological processes." From this perspective, voluntary changes (muscle relaxation) are
strengthened by reinforcing consequences (feedback display). This model implies that awareness of which change is
being reinforced is unnecessary and disregards the instructional elements critical to training success.
The graphic below is courtesy of Wikimedia Commons.
The operant model has several problems. First, operant conditioning is only one of several learning processes
involved in self-regulation training. Classical conditioning, motor learning, and relational learning may also be
involved.
Second, reinforcement without systematic instruction is an inefficient way to teach a skill. This would be
like a track coach who announced a sprinter's time but never modeled good technique or corrected their form.
Drug Model
The drug model asserts that "biofeedback treatment treats symptoms as if
it were a prescription drug." This model is implied when a client receives only three sessions of temperature
biofeedback regardless of whether they can warm their hands to 95° F (35° C) on command.
The drug model is counterproductive because it places the client in a passive role (analogous to taking aspirin)
and emphasizes dosage (the number of sessions) over skill mastery. If you believe that skill mastery affects
treatment outcome, clients should be trained to criterion and not be limited to an arbitrary number of
sessions.
The relaxation model views biofeedback as inherently relaxing. Based on this
model, therapists may administer biofeedback without relaxation instructions, and researchers may compare
biofeedback to relaxation procedures like Progressive Relaxation.
This approach suffers from several misconceptions about biofeedback.
First, feedback about your physiology is
not always relaxing. For example, clients told that their blood pressure is high are likely to experience
distress.
Second, whether biofeedback training produces lowered arousal depends on relaxation instructions and a
client's learning strategy. For example, a client learning to lower blood pressure could worsen stress
symptoms by competing against the blood pressure monitor.
Finally, clients can experience distressing side effects when practicing techniques like imagery or Autogenic
exercises. Relaxation-induced anxiety has been reported in up to 40% of
clients receiving relaxation training.
Blanchard and Epstein's (1978) Self-Regulation Model
Blanchard and Epstein (1978) proposed that self-regulation consists of
five components.
Self-monitoring is scanning yourself in a situation
(checking your breathing during a job interview).
Discrimination means
identifying when self-regulation skills should be used based on
situational (stressful confrontation) and internal (rapid heart rate)
cues.
Self-control is using a skill to achieve the desired state (practicing
healthy breathing to lower arousal).
Self-reinforcement is the use of
internal (self-praise) or external rewards (clothing) forthe use of a skill.
Finally, self-maintenance involves the long-term practice of self-regulation
skills informed by
regular review.
After 6 months of practice, cues like red traffic lights and cold hands
can automatically trigger self-regulation responses. They become habits. Now, a healthy lifestyle becomes rewarding, and cheating
becomes aversive.
Shellenberger and Green's (1986) Mastery Model
Shellenberger and Green's mastery model compares biofeedback training to
athletic skill coaching. This training process is social since you work with another person and
possibly a partner or group.
The Training Process
Context is crucial. Mere exposure to information about our physiological performance produces no dependable
effects. For example, viewing a stopwatch does not reliably improve a runner's form.
Please click on the podcast icon below to hear a lecture over the first half of this unit.
The effect of information depends on the context in which it is provided. When biofeedback is combined with
physical therapy, it becomes biofeedback-assisted rehabilitation. When combined with relaxation training,
it becomes biofeedback-assisted relaxation. Without rehabilitation or relaxation coaching, the
information is neither rehabilitating nor relaxing.
Sources of Performance Information
Don't assume that biofeedback requires hardware. Information about your performance can be detected with or
without hardware. Somatosensation (perception of pain, touch, and temperature)
and proprioception (perception of body position, movement, and muscle length)
are your client's primary sources of information. Examples: your client can touch their finger to the wrist to detect
pulse rate or touch their cheek to perceive hand temperature.
During training, you can supplement proprioception with high-technology or low-technology instruments that
monitor performance. Watch a BioGraph ® Infiniti heart rate variability (HRV) display with 6-breaths-per-minute respiratory pacing.
Don't confine your concept of biofeedback to the traditional modalities like EEG (brain electrical activity),
SEMG (skeletal muscle electrical activity), skin conductance (sweat gland activity), and temperature. While
these modalities may prove invaluable in many clinical applications, your client may benefit from simpler devices.
Peper and Shambaugh (1979) have suggested that ordinary devices
provide valuable performance feedback. For example, clients can correct their facial expressions during public
speaking by practicing with a mirror. They can improve their balance by training with a pair of bathroom scales.
They can reduce hand tremors by using a graduated series of bells. Finally, athletes can refine their tennis serve
using a camcorder for video feedback.
Taub and School (1978) reported a person
effect when teaching hand-warming. An "informal and friendly" trainer successfully taught 19
of 21 participants (90.5%) to raise their finger temperature. In contrast, a more formal and "impersonal" trainer
only succeeded with 2 of 22 participants (9.1%) (p. 617). The interpersonal dynamics that make psychotherapy successful are
crucial in biofeedback training.
Further evidence suggests that synchrony strengthens emotional bonds and improves cognitive flexibility. When neural coupling occurs, it facilitates better communication between brain regions associated with decision-making, problem-solving, and emotional processing. This may explain why clients who engage in therapy with high levels of synchrony often experience deeper insights, improved emotional resilience, and greater capacity for behavioral change. Understanding and intentionally fostering this synchrony can, therefore, be a powerful tool in therapeutic practice, enhancing the overall efficacy of interventions.
For therapists, these findings underscore the importance of fostering therapeutic synchrony as an active component of treatment. Beyond verbal communication, nonverbal cues such as body language, tone of voice, and paced responsiveness contribute significantly to inter-brain synchrony. Therapists who practice mindfulness, attunement, and embodied presence may enhance their ability to facilitate neural synchrony with clients, potentially amplifying the effectiveness of therapy.
Moreover, this perspective encourages therapists to view relational healing not only as a psychological process but also as a neurobiological one. Clients who struggle with attachment issues, social difficulties, or trauma may particularly benefit from interventions that emphasize relational presence, attunement, and co-regulation.
Relational presence refers to the therapist's capacity to fully engage with the client, establishing an environment of genuine connection and trust where the client feels seen and valued. Attunement is the process by which the therapist accurately perceives and sensitively responds to the client's emotional signals, thereby fostering a therapeutic interaction that validates the client's internal experience. Co-regulation involves a collaborative dynamic in which the therapist supports the client in managing and modulating their emotional states, ultimately aiding the client in developing effective self-regulation skills. Collectively, these processes help create a secure relational framework essential for healing and developing adaptive emotional responses.
Therapists Should Be Credible Models
Unlike stereotypical "out-of-shape" coaches with "beer guts," biofeedback therapists have to
develop and practice the skills they teach. Peper (1994) strongly argued that
therapists must be "self-experienced." If you sought treatment for anxiety, how confident would you be
if your therapist looked "stressed out" and offered you an ice-cold handshake?
Therapists are models. Their personal self-regulation training can increase their awareness of their psychophysiological
responses like cold hands, breath-holding, and incomplete muscle relaxation. Unless a therapist becomes aware of
these behaviors, they might inadvertently teach them to their clients.
Personal training enables therapists to develop the skills they intend to teach, increases their confidence in
the effectiveness of their training methods, and helps them better understand their clients' inevitable
frustrations. Gandhi said, "Be the change you want to see in the world."
Due to secondary gains (reinforcement of symptoms), adjustment to their
symptoms, identification with their symptoms ("I'm a low back pain patient"), and uncertainty about the
consequences of change, clients enter biofeedback training with the same approach-avoidance and avoidance-avoidance
conflicts seen in psychotherapy.
A client has an approach-avoidance conflict when unpleasant symptoms are
reinforced (professional and family attention, control over relationships, access to narcotic medication, and/or
financial compensation).
An avoidance-avoidance conflict exists when symptoms are unpleasant and
the client negatively perceives biofeedback training (financial cost, time investment, and/or fear of
failure).
Finally, as in psychotherapy, significant others who benefit from a patient's persistent symptoms may
sabotage training. This is particularly a problem in co-dependent relationships.
Assess and Modify Your Client's Motivation
Assess and modify your clients' motivation by focusing on the symptoms that concern them. Ask clients during the intake interview to select three symptoms
that they want to improve. Ask them to daily chart these symptoms throughout biofeedback
training. The criterion for success is a 25% to 35% decrease in symptom frequency and severity.
This strategy increases client motivation because it:
1. increases their commitment or "buy-in"
2. places them in an active role, increasing their perceived self-efficacy
3. shows them persuasive evidence of their improvement
Clients Should Be Active Participants
Successful clients should be active participants in this learning process. A therapist can modify clients' expectations about their role in biofeedback training through educational literature, assessment, and initial training sessions.
Models that emphasize active skill learning, like Shellenberger and Green's mastery model, may produce better
clinical outcomes than those that place clients in a passive role.
Practice Builds Client Success
Therapists routinely assign clients skill practice outside of their training sessions.
These assignments often
include lifestyle modification, biofeedback practice, abbreviated relaxation exercises, deep relaxation
exercises, and self-monitoring.
Lifestyle modification involves changes in routine behavior to help
achieve treatment goals. For example, a client treated for anxiety may reduce caffeine intake from 4 cups of
caffeinated coffee to 1 cup of decaffeinated tea.
Biofeedback practice may involve continuing biofeedback training with portable
monitors. This is designed to increase a client's proficiency in self-regulation and generalize it to settings
outside of the clinic. For example, a client with hypertension may practice increasing heart rate variability at
home using a smartphone application like the Garmin Connect App below.
Abbreviated relaxation exercises like Stroebel's Quieting Response
(QR) often require less than a minute and may be repeated many times a day to accelerate their
acquisition and generalization. They are designed to replace symptoms like anxiety with more adaptive behaviors
like mindfulness and increased parasympathetic activation. Unlike deep relaxation exercises, clients can efficiently
perform them during routine activities like commuting.
Procedures that can produce deep relaxation, like Autogenic Training, meditation, and
Progressive Relaxation, require 15 minutes to several hours and involve a break from routine activity. For example,
you could not safely meditate as you drove your car on an interstate highway. These exercises may profoundly
reduce physiological arousal and reset physiological activity to healthier values. As your client more readily
experiences lowered arousal, this may reinforce biofeedback training and increase the effectiveness of abbreviated
relaxation exercises.
Self-monitoring means checking symptoms and performance. Therapists ask
clients to chart this information to develop mindfulness. This can help your clients identify causal patterns, teach them when to use an
abbreviated relaxation exercise to disrupt an escalating symptom, and measure their improvement.
Research indicates that clients succeed if they occasionally practice self-regulation skills. Why is practice
crucial to client success? Practice helps a client acquire skills through more time on task. If a client trains
1 hour a week in the clinic (red), this leaves 167 hours outside the clinic (blue) to refine skills
learned during the training session.
Practice helps clients transfer self-regulation skills to environmental settings. Hand-warming in the clinic
does not automatically generalize to driving in rush hour traffic. Unless clients practice these skills in the
locations where they need them, they might only be symptom-free in the clinic.
Practice makes self-regulation automatic. When you learn to drive a manual transmission,
you start out concentrating intensely on shifting, afraid that you will "strip the gears." After
months of practice and several gear boxes, you shift without attention.
Finally, clients practicing Stroebel's
Quieting Response may only automatically perform this skill after about 6 months.
Biofeedback Training Should Teach Voluntary Control
Successful biofeedback training teaches voluntary control. Voluntary
control is shown when a person can produce a requested physical change
(warm your hand to 95° F/35° C) on command
without external feedback.
Voluntary control can be achieved through the appropriate use of passive and active volition. Passive
volition means encouraging your body to produce change. Passive volition engages the parasympathetic branch of the autonomic nervous system. This division conserves energy and supports relaxation. You can promote passive volition with words like "allow" and "imagine," and through acceptance of your immediate without judgment.
Active volition means giving orders to your body to produce change. This process may be triggered by
words like "make" or "try" and by competing and judging yourself. Active volition can activate the sympathetic branch of the autonomic nervous system. This division consumes energy to prepare us to fight or flee.
You cannot "try to relax" because the sympathetic activation produced by active volition disrupts the parasympathetic activation required for relaxation. Khazan (2013) considers the phrase, "try to relax," an oxymoron. This is the reason that forcing yourself interferes with urinating during halftime, achieving an erection, or performing Zen archery.
In two studies, Wegner and colleagues (1987, 1997) documented this physiological paradox. In the first study, subjects told to block specific thoughts (e.g., a white bear) increased the frequency of these thoughts compared to subjects instructed to think about them actively. In the second study, participants asked to relax during difficult cognitive tasks showed higher sweat gland activity (a sign of sympathetic activation) than controls who received no relaxation instructions when performing the identical tasks.
When training clients to increase self-awareness and control muscle contraction, clinicians can instruct them to follow an active volition exercise with a passive volition exercise. For example, in modern versions of Jacobson's Progressive Relaxation, clinicians guide clients to intentionally contract (active volition) and relax (passive volition) muscle
groups to detect and reduce residual muscle tension. Since clients perform these exercises sequentially, they complement each other.
As you can see, despite associating biofeedback training with passive volition,
voluntary control involves shifting flexibly between these modes
as required.
Clients Should Use Strategies That Work for Them
Schultz, who developed Autogenic Training,
believed that imagery is the
language the body best understands. He contended that an image serves as
a blueprint for physiological change.
Research on successful self-regulators has shown that they use diverse
strategies, including pictures, sounds, bodily sensations, feelings, and
abstract concepts. You should encourage your clients to experiment with
different techniques and then use the ones that work. This communicates
respect for them as collaborators and increases their perceived self-efficacy,
which is their perceived ability to achieve desired outcomes.
Luria (1968) described S.'s remarkable self-regulatory abilities in his classic The Mind of a Mnemonist. In May 1934, long before the birth of biofeedback, he quoted S. as stating: "If I want something to happen, I simply picture it in my mind. I don't have to exert any effort to accomplish it -- it just happens" (p. 139).
After S. accelerated his heart rate to 100 and slowed it down to between 64 to 66, he described his strategy to Luria: "What do you find so strange about it? I simply see myself running after a train that has just begun to pull out. I have to catch up with the last car if I'm to make it. Is it any wonder then my heartbeat increases? After that, I saw myself lying in
bed, perfectly still, trying to fall asleep . . . I could see myself begin to drop off . . . my breathing became regular, my heart started to beat more slowly and evenly . . ." (p. 140).
Treatment Protocols Should Incorporate Current Research Findings
The clinical literature should guide your conceptualization of a disorder and treatment design. This can be frustrating for a
clinician when research findings contradict the conventional wisdom about a
disorder. Evidence-Based Practice in Biofeedback and
Neurofeedback (4th ed.) published by the Association for Applied Psychophysiology
and Biofeedback, summarizes clinical efficacy studies for diverse biofeedback/neurofeedback applications and
should often be consulted first when designing treatment plans.
The discredited sympathetic arousal model of Raynaud's disease
provides an excellent example. The sympathetic arousal model asserts that
stressors are potent
triggers for Raynaud's attacks and that interventions that lower
sympathetic arousal will reduce symptom severity. Therapists who
subscribe to this model usually provide biofeedback to lower sympathetic
tone and teach stress management skills.
Research by Freedman and colleagues has challenged the sympathetic
arousal model's assumptions. Raynaud's disease appears to be due to a
"local fault" in peripheral blood vessels. Cold and cold-related stimuli
are more likely to trigger hand-cooling than stressors. Temperature
biofeedback does not prevent attacks by reducing sympathetic arousal.
Finally, bidirectional temperature biofeedback with cold challenge produces
greater symptom reduction than stress management techniques. In this strategy, clinicians teach clients to warm and cool their extremities alternatively in a cold room or while wearing a suit cooled by circulating cold water.
Failure to revise our models and treatment strategies may seriously
reduce our clinical effectiveness.
Treatment Protocols Should Be Personalized
Clients reporting a symptom like hypertension may have very different
psychophysiological profiles. Treatment should be personalized to correct
abnormalities: values that are too high, low, show excessive or
insufficient variability, or recover too slowly.
Biofeedback training of astronauts and pilots to reduce motion sickness illustrates this approach. A therapist
monitors an individual's
autonomic responses during stress testing in a Barany chair that tilts and rotates or in a centrifuge and
identifies
the abnormally responding systems. Biofeedback-assisted relaxation to correct abnormal responses can prevent or
moderate motion sickness (Cowings et al., 1986; Cowings & Toscano, 1982).
Personalizing treatment also means training clients to mastery criteria.
For example, you might provide temperature training until your client
can achieve 95° F (35° C) without
feedback. This is more flexible than
limiting training to five sessions of temperature biofeedback whether the
client has succeeded or not. Clients have different learning curves and
learning styles.
Length and Number of Training Sessions
The length and number of sessions should reflect research findings concerning
biofeedback training for specific modalities (e.g., temperature) and applications (e.g., migraine).
Khazan (2019) recommends a maximum biofeedback practice time of 20 minutes.
Professionals should optimize training protocols for each client's learning curve, availability, and ability to pay for
training.
Bidirectional Training May Produce the Best Outcomes
Bidirectional training teaches clients to increase and decrease a
physiological response. This strategy may be more effective than training in a single direction. This advantage
may result from increased training time, higher proficiency standards, and learning to control more than one
physiological mechanism.
Bidirectional training has been advocated in both temperature and neurofeedback. When teaching clients to
hand-warm to prevent Raynaud's episodes, you might teach hand-warming and cooling in the same or successive
sessions. In neurofeedback training for addiction, you might teach a client to increase and decrease
theta amplitude (signal strength).
Training Sessions Should Be Spaced
Wherever feasible outside of neuromuscular rehabilitation, biofeedback training should be spaced instead of
massed. Training sessions are scheduled over an extended period in spaced practice to produce greater skill acquisition and generalization. A 15-session training protocol might
involve 2 weekly sessions for 5 weeks and then 1 session a week for the remaining 5 weeks.
In massed practice, training sessions are compressed into a shorter period. A client might receive 5 sessions a week for 3 weeks. This training schedule might be necessary when a
client is hospitalized (constraint-induced movement therapy for stroke) or treated as an out-client in another
city.
Generalization to Life Situations
Biofeedback therapists use multiple treatment strategies to aid
generalization of self-regulation skills to everyday situations:
teaching self-monitoring to increase mindfulness
emphasizing "skills" instead of "pills,"" thereby fostering
self-efficacy
assigning daily self-regulation skill practice
teaching clients how to modify their environments
fading of feedback
during training
incorporating discrimination training
training
clients using realistic simulations (virtual reality) or real-life
settings
encouraging clients to create and record their own training
scripts
Consider the 70-30 Rule in Adjusting Performance Goals
Olton and Noonberg (1980) advised that performance goals should be raised
when a client succeeds more than 70% of the time and lowered when a
client succeeds less than 30% of the time. Computer-based biofeedback
systems incorporate algorithms like the 70-30 rule and automatically
revise goals based on a client's performance during the previous 15-
or 30-second trial.
This approach helps maintain client motivation and ensure sufficient
challenge. Training success can increase the client's perception of
self-efficacy, positively affecting a
client's symptoms.
How You Explain Biofeedback Matters
How do you explain biofeedback to your clients? Biofeedback metaphors
help define your client's role in the training process. I recommend two
metaphors that portray biofeedback as a process that teaches the client
skills using information about personal performance.
"Biofeedback is like coaching a runner using a stopwatch." This metaphor
emphasizes the importance of coaching in improving client performance.
"Biofeedback is like teaching carpentry, not hammering." This metaphor
communicates that the purpose of biofeedback training is to teach
self-regulation instead of mastery of a particular technique.
Glossary
70-30 rule: Olton and Noonberg's guide that training thresholds should be
raised when a client succeeds more than 70% of the time and lowered when a client succeeds less than 30% of the
time.
abbreviated relaxation exercises: procedures like Stroebel's Quieting
Response (QR) that produce low-to-moderate subjective and physiological change involve minimal sensory
restriction, and are practiced for very brief periods. They are designed to replace symptoms like anxiety
with more adaptive behaviors like cultivated low arousal or mindfulness.
active volition: a process where you direct yourself to act
(clenching a fist) triggered by words like make or try.
approach-avoidance conflict: a client perceives their symptoms as both
aversive (discomfort and disability) and advantageous (gaining professional and family attention, control over
relationships, and financial compensation).
attunement: the process by which a therapist accurately perceives and responds to a clients emotional state.
Autogenic Training: a deep relaxation procedure developed by Schultz and
Luthe that involves a sequence of three procedures: six standard exercises, autogenic modification, and autogenic
meditation.
aversive punishment (positive punishment): the weakening of an operant
behavior when followed by an aversive stimulus (a client reduces relaxation practice when lack of progress
frustrates them).
avoidance-avoidance conflict: the client perceives both their symptoms (low
back pain) and training (SEMG biofeedback) as aversive.
bidirectional temperature biofeedback with cold challenge: biofeedback
training to increase and decrease peripheral temperature in a cold room or while wearing a cold suit
or glove.
bidirectional training: teaching a client to increase and
decrease a physiological response (increase and decrease masseter SEMG).
biofeedback: a learning process that teaches an individual to control their
physiological activity, (2) the aim of biofeedback training is to improve health and performance, (3) instruments
rapidly monitor an individual's performance and display it back to them, (4) the individual uses this feedback to
produce physiological changes, (5) changes in thinking, emotions, and behavior often accompany and reinforce
physiological changes, and (6) these changes become independent of external feedback from instruments.
classical conditioning: an unconscious associative learning process that
modifies reflexive behavior and prepares us to rapidly respond to future situations.
conditioned response (CR): in classical conditioning, a response (blood
pressure rise) that is elicited by a conditioned stimulus (criticism).
conditioned stimulus (CS): in classical conditioning, a stimulus
(dentist's office), that in association with an unconditioned stimulus (pain), elicits a conditioned response
(anxiety) like the original unconditioned response.
conditioning: a subtype of nondeclarative memory that connects two stimuli or a stimulus and a response.
co-regulation: the process through which one person helps another regulate their emotional state through interaction and connection.
cultivated low arousal: the reduced activation of the central nervous system
(EEG) and peripheral nervous system (autonomic and somatic).
cybernetic model: an explanation that biofeedback is like a thermostat system
with a setpoint, system variable, and negative and positive feedback.
declarative memory: facts or information that you can consciously recollect and share with others.
deep relaxation exercises: procedures like Autogenic Training, meditation,
and Progressive Relaxation that may require 15 minutes to several hours, involve a break from routine activity,
and profoundly reduce physiological arousal and reset physiological activity to healthier values.
discrimination: the perception of changes in physiological activity (0.5
microvolt versus 1 microvolt of SEMG activity) which is a crucial component of self-regulation.
discriminative stimuli: in operant conditioning, the identifying
characteristics of a situation (the physical environment and physical, cognitive, and emotional cues) teach
us when to perform operant behaviors. For example, a traffic slowdown could signal a client to practice healthy breathing.
drug model: an explanation that biofeedback can be administered like doses of
a drug, which ignores the role of skill mastery and the need to train clients to criteria.
electrocardiograph (ECG/EKG): an instrument that measures the heart's electrical activity.
electrodermograph (EDA, GSR, SC, SP): an instrument that measures skin
electrical activity generated by eccrine sweat glands.
electroencephalograph (EEG): an instrument that measures brain electrical
activity.
electromyograph (EMG/SEMG): an instrument that measures the muscle action
potentials that initiate skeletal muscle contraction; called a surface electromyograph (SEMG) when sensors are
placed on the skin surface.
endoscope: a medical device to visualize the interior body.
episodic memory: a subtype of declarative memory that provides contextual information (when, where, and sequencing) about events.
extinction (classical conditioning): the weakening and disappearance of a
conditioned response (CR) when it is repeatedly presented without the unconditioned stimulus (UCS). For example, a
client's blood pressure rise (CR) decreases and then disappears after several painless dental visits (UCS).
extinction (operant conditioning): the weakening and disappearance of an
operant behavior when it is no longer reinforced. For example, a client reduces and then stops practicing the
Quieting Response after they cease to feel calm during this exercise.
feedback thermometer (TEMP): an instrument that measures relative peripheral
blood flow and the temperature of the fingers and toes.
generalization: in operant conditioning, performing behavior
when a new discriminative stimulus is present. For example, a client learns to breathe effortlessly when anxious
or experiencing pain.
heart rate variability (HRV): the beat-to-beat changes in the time interval
between consecutive heartbeats.
homeostasis: a state of dynamic constancy, achieved by stabilizing
conditions about a setpoint, whose value may change over time.
integrating center: in cybernetic theory, the site that receives sensory
input. For example, the hypothalamus is the primary integrating center in the human body.
inter-brain plasticity: the capacity of the brain to adapt and change based on repeated neural synchrony with another person.
interoception: the perception of the body's interior (pain and pressure).
learning: the process by which we acquire new information, patterns of behavior, or skills.
lifestyle modification: changes in routine behavior like diet, exercise,
and sleep to help achieve treatment goals.
long-term memory: memory, which can be declarative or nondeclarative, that lasts from days to years.
massed practice: the compression of training sessions into a brief period like 10 sessions in 2 weeks.
mastery model: Shellenberger and Green's (1986) explanation compares
biofeedback training to coaching an athletic skill.
memory: the capacity to store and retrieve new information.
mindfulness: accepting and nonjudgmental focus of attention on the present on a
moment-to-moment basis.
multiple effector systems: in cybernetic theory, multiple control systems.
For example, the hypothalamus regulates homeostasis by controlling the autonomic nervous system,
endocrine system, immune system, and somatic nervous system.
negative feedback: a signal that a physiological variable is outside a
target range.
negative reinforcement: in operant conditioning, the strengthening of an
operant behavior (healthy breathing) when it is followed by the avoidance or removal of an aversive stimulus
(pain).
neural coupling: the synchronization of brain activity between two individuals during social or therapeutic interactions.
neurofeedback: information about EEG activity that is obtained by
noninvasive monitoring and used to help individuals achieve self-regulation through a learning process that
resembles motor skill learning.
neutral stimulus (NS): in classical conditioning, a stimulus (the sight of a
street light) that does not trigger a conditioned response (CR).
nondeclarative (procedural) memory: memories regarding perceptual (e.g., mirror reading) or motor procedures (e.g., mirror tracing) you acquire through action.
ON-OFF-ON: training paradigm in which a client performs a target behavior
(increases alpha amplitude), suppresses it (reduces alpha amplitude), and then produces it again (increases alpha
amplitude).
operant behavior: behavior that operates on the environment and is under
voluntary control (e.g., writing in a personal journal).
operant conditioning: an unconscious associative learning process that
modifies the form and occurrence of voluntary behavior by manipulating its consequences.
operant conditioning model: an explanation that "biofeedback is the
operant conditioning of physiological processes," which downplays the importance of client awareness of
physiological changes and instruction in training.
parasympathetic division: the autonomic nervous system subdivision that
regulates activities that increase the body's energy reserves, including salivation, gastric (stomach) and
intestinal motility, gastric juice secretion, and increased blood flow to the gastrointestinal system.
passive volition: a process where you invite yourself to perform an action
like dropping your arm in your lap that is triggered by words like "allow" or "permit."
person effect: Taub and School's (1978) observation that biofeedback
training is a social situation and that a client's relationship with the therapist is a critical aspect of
training.
photoplethysmograph (PPG): an instrument that measures relative peripheral
blood flow, heart rate, and HRV.
physiological monitoring: the detection of biological activity like blood pressure.
placebo: physiologically-inactive interventions (e.g., sugar pills) that appear to be active treatments and produce improvement through expectancy and classical and operant conditioning.
placebo model: an explanation that "biofeedback produces nonspecific
effects, like a drug, due to client beliefs."
pneumograph (respirometer, RESP): an instrument that measures the abdomen or chest movement and provides information about breathing mechanics and respiration rate.
positive feedback (feedforward): in cybernetic theory, commands to
continue current action (slow breathing). Positive feedback can amplify the effects of negative feedback (tone
when breathing is too rapid).
positive reinforcement: in operant conditioning, the strengthening of an
operant behavior (aerobic exercise) when it is followed by a reward (praise).
priming: a subtype of nondeclarative memory in which your response to a stimulus, like a word, changes following exposure to an identical or related stimulus.
Progressive Relaxation: Jacobson's deep relaxation procedure that
originally trained patients to relax 2 or 3 muscle groups each session until 50 groups were trained during 50-60
sessions in the clinic and 1-2 daily one-hour practice sessions.
proprioception: the perception of body position, movement, and muscle
length.
push-pull control: the regulation by effectors that produce antagonistic
effects and achieves more precise control than turning a single effector on or off. For example, parasympathetic
and sympathetic motor neurons jointly adjust the heart rhythm.
Quieting Response (QR): Stroebel's 6-second exercise instructs a
client to focus on a stress cue, smile inwardly, take an easy deep breath, and let the jaw, tongue, and shoulders
go limp as they exhale.
relational learning: the conscious learning process that associates stimuli
that occur simultaneously and underlies working memory and declarative memory (learning how to warm your hands
using a biofeedback display).
relational presence: a therapist's ability to be fully engaged and attuned to a client in a way that fosters connection and trust.
relaxation-induced anxiety: increased anxiety during relaxation training
may include increased perspiration, shivering, trembling, pounding heart, and rapid breathing.
relaxation model: the explanation that biofeedback is inherently relaxing,
which could lead therapists to administer biofeedback without relaxation instructions.
response cost (negative punishment): the weakening of an operant behavior
(pain complaints) when it is followed by the removal of a rewarding consequence (attention from a spouse).
secondary gains: the rewards of symptomatic behavior (e.g., reduced
housecleaning responsibilities following the display of pain behaviors).
self-control: using a skill to achieve the desired state (e.g., running on a
treadmill to reduce weight).
self-efficacy: one's perceived ability to achieve desired outcomes. For example,
your belief that you can learn to lower your blood pressure.
self-maintenance: the process of long-term skill practice, like periodically
reviewing your success with healthy breathing and fine-tuning this skill.
self-monitoring: observing yourself in a situation, like taking your pulse
after a run.
self-quantification: a process that tracks data about our inputs (sleep), states (mood), and performance (heart rate variability) to improve lifestyle choices.
self-regulation: the control of your behavior (e.g., good posture) without feedback.
self-reinforcement: using internal or external rewards to increase the
performance of a behavior. For example, praising yourself for using healthy breathing during an argument.
semantic memory: a subtype of declarative memory that is generalized and consists of facts.
sensory systems: networks that detect actual or anticipated changes in
system variables.
setpoint: goals like a core body temperature of 98.6° F (37° C).
skill learning: a subtype of nondeclarative memory in which you master a task which depends on neuromuscular coordination.
social learning (observational learning): learning process in which
observation of the consequences of a model's behavior can influence an individual's operant behavior. For example,
exposure to a therapist's slow breathing increases a client's practice of healthy breathing.
somatosensation: the perception of pain, touch, and temperature.
spaced practice: scheduling training sessions over an extended period like 15 sessions over 8 weeks.
spasmodic dysphonia: the inability to speak using a normal voice due to
abnormal laryngeal muscle contraction.
spontaneous recovery: in classical conditioning, the reappearance of an
extinguished conditioned response (CR) following a rest period. For example, your blood pressure increase returns
after 6 months away from the dentist's office.
stimulus discrimination: in classical conditioning, when a conditioned
response (CR) is elicited by one conditioned stimulus (CS), but not by another. For example, your blood pressure
increases during a painful dental procedure but not during an uncomfortable blood draw.
stimulus generalization: in classical conditioning, stimuli that
resemble a conditioned stimulus (CS) elicit the same conditioned response (CR). For example, your blood
pressure increases during painful dental procedures and an uncomfortable blood draw.
sympathetic arousal model of Raynaud's: poorly-supported model that
asserts that stressors are powerful triggers for Raynaud's attacks and that interventions that lower sympathetic
arousal will reduce symptom severity.
system variable: in cybernetic theory, the variable that is controlled,
like room temperature.
therapeutic synchrony: the alignment of emotional and cognitive processes between therapist and client that enhances the therapeutic process.
unconditioned response (UCR): an innate response that is elicited by an
unconditioned stimulus (UCS) without prior learning (elevated blood pressure in response to physical pain).
unconditioned stimulus (UCS): a stimulus (physical pain) that elicits an
innate response (increased blood pressure) without prior learning.
voluntary control: the intentional production of physiological change without feedback.
working memory: a short-term conscious memory system called "blackboard
memory."
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Assignment
Now that you have completed this unit, how would you explain biofeedback training to a client? Evaluate yourself
as a client model for behaviors like breathing and hand-warming. Which are your strengths? Where do you need work?
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