Although clients have social scripts that define their roles and actions during a medical check-up or therapeutic massage, few understand what neurofeedback is or their role in training. Client preparation delivers the "Setting Up for Success" component of Michael and Lynda's training model (Thompson & Thompson, 2015, p. 467) by guiding clients through this new experience. It allows clinicians to address client misconceptions about neurofeedback, define clinician and client roles, and explain the rules of this new partnership (e.g., 30 minutes of practice twice a day).
Client preparation also teaches the skills required for successful neurofeedback training. For example, the Thompsons recommend that clients develop an external and diffuse focus, resembling Fehmi's open focus or satori. They suggest that clients link this state with an enjoyable scene, feelings of empowerment, and encouraging self-statements. Finally, they emphasize the importance of healthy breathing, around six breaths per minute (bpm), to increase heart rate variability (HRV) and restore vagal (parasympathetic) tone.
Caption: Michael and Lynda Thompson
BCIA Blueprint Coverage
This unit covers VIII. Treatment Implementation - A. Client Preparation for Neurofeedback.
We will cover client preparation in four sections: Orientation for Neurofeedback, Client Preparation with Relaxation Training, Client Preparation with Respiration Training, and Client Preparation with Heart Rate Variability Biofeedback.
Please click on the podcast icon below to hear a full-length lecture.
Orientation for Neurofeedback and Procedures
Orientation will address Neurofeedback Myths, Client/Patient Orientation, Major Stages of the Neurofeedback Training Process, Client's Role and Responsibilities, The Initial EEG Assessment Session, and Mentoring for Neurofeedback Certification.
Neurofeedback Myths
Clients may approach neurofeedback with several misconceptions. These may include:
1. Neurofeedback electrodes transmit energy into my brain. 2. Neurofeedback equipment can read my mind.
3. Neurofeedback will change me.
4. My role is to relax while the neurofeedback equipment treats me.
Neurofeedback Electrodes Transmit Energy Into My Brain
Explain that EEG sensors resemble ECG electrodes that detect the heart's electrical activity. EEG sensors monitor electrical changes in the brain; they don't conduct current into the body.
Neurofeedback Equipment Can Read My Mind
Explain that the EEG cannot read their mind. While the EEG can reveal whether a client is distracted or focussed, it cannot reveal feelings or thoughts.
Neurofeedback Will Change Me
Swingle (2008) observed: "One element of neurotherapy that unsettles parents and older people in general is the notion of changing the way the brain functions" (p. 15).
Explain that we change how our brains function whenever we learn new skills like using FaceTime or Zoom. Neurofeedback teaches specialized skills to help improve your performance and quality of life.
My Role is to Relax While the Neurofeedback Equipment Treats Me
Explain that an electroencephalograph can no more treat a client than a stopwatch can coach a runner. Neurofeedback resembles coaching an athlete and involves skill training and practice inside and outside the clinic. Clients play an active role in their training to master self-regulation skills and transfer them to everyday life like an elite athlete.
Because both medicine and psychology tend to use the term treatment, patients/clients and clinicians have come to view most interventions as the clinician treating, i.e., applying an intervention that produces a result in the client/patient.
Neurofeedback, like all biofeedback, is a training process. It involves the client/patient and is based upon assessment, education, practice, trial and error, re-assessment, and continued refinement of the training experience based on the progress (learning, level of mastery) that client demonstrates.
Client/Patient Orientation
Patient orientation begins with an explanation of neurofeedback, self-regulation concepts, and operant conditioning. Adjust the level of your explanation to your client's education and experience.
Some clients want an in-depth explanation of the neurophysiological mechanisms of how and why neurofeedback works. Clinicians need to be prepared to respond to client requests for information and discuss in detail what is happening during neurofeedback training. This has the benefit of the client becoming a partner in the design and implementation of the training. The more the client understands what is being done, the more likely they will offer helpful feedback to the clinician, thereby facilitating the learning process.
Neurofeedback
Neurofeedback training (NFT) involves the same learning processes used to develop motor skills or master a videogame. For example, a child uses a strategy (instructs the body to remain still), observes the results (SMR increases and high beta decreases), and repeats this action throughout the day. Clients actively learn to regulate their psychophysiology (Thompson & Thompson, 2015).
Neurofeedback is also a psychophysiological mirror that teaches individuals to monitor, understand, and change their physiology (Peper, Shumay, & Moss, 2012).
From the International Society for Neuroregulation & Research's (ISNR) Guidelines for Practice:
Neurofeedback developed as a multidisciplinary treatment modality and is now practiced by a wide variety of providers who may or may not be licensed healthcare professionals who treat mental or other illnesses. Its range of practice includes assessment and treatment for conditions diagnosed by licensed healthcare providers, training for optimal performance (e.g., among athletes, executives, students, performing artists, and other healthy individuals), and both clinical and applied scientific research.
In general, neurofeedback involves placing sensors on the scalp of the individual and connecting the sensors to an amplifier and computer. Through these connections, the electrical activity of the brain is recorded and then presented back to the individual on the computer screen in the form of a video game or soundtrack that changes depending on what state the brain is in. This is the “feedback” aspect of neurofeedback that enables the individual to change their brain function and keep the game or sound on more.
Neurofeedback is the process of interacting with an electronic device that measures and feeds back information about brain electrical activity. Neurofeedback provides accurate, timely, and useful information to the client. This information is displayed using visual, auditory, or tactile feedback corresponding to meaningful changes in the monitored systems. Neurofeedback training encourages flexibility, resilience, and choice.
Self-Regulation Concepts
Biofeedback training aims to teach self-regulation, which is control of behavior without feedback. In light of the previous discussion of client orientation to the training process, the ultimate goal is for the skills learned during training and self-practice to become automatic responses. Ideally, the client will automatically attend in class, feel calm in stressful situations, shift away from physiological responses that produce migraine episodes, and more.
This transition's four critical ideas are mindfulness, neuroplasticity, operant conditioning, and passive volition.
Neuroplasticity, the ability of neurons and their networks to
remodel themselves in response to experience, makes neurofeedback training possible (Breedlove & Watson, 2020). The learning mechanisms that underlie neurofeedback training depend on interrelated structural and functional changes. Neuroplasticity involves alterations in transmitter release and binding, modulation of transmitter release by interneurons, the formation and elimination of synapses, selecting among competing neural pathways, and strengthening and weakening the connectivity between brain regions.
Operant Conditioning
Operant conditioning is a method of learning that uses rewards and punishments. The likelihood of a specific behavior is increased through positive or negative reinforcement each time the behavior is exhibited. The client comes to associate the pleasure of the reinforcement with the behavior.
Neurofeedback can target any number of responses. For example, slowing breathing can increase focus. Improved attention may serve as a negative reinforcer for slower breathing, motivating the client to adjust breathing more frequently. Over time, the client learns to reduce their respiration rate without the need for a computerized biofeedback device. They can sharpen their attention outside the clinic.
Passive Volition
Neurofeedback training succeeds when clients learn to create a state of calm alertness. Attempts to force physiological change fail because they activate the sympathetic nervous system, which is concerned with "fight-or-flight." Instead, we want to activate the parasympathetic nervous system, promoting self-regulation. Therapists should encourage their clients to use passive volition to visualize the desired change and then allow their bodies to make the change at their own pace.
For clients who have difficulty with visualization, a simple discussion of goals at the beginning of each training session can have a similar result. With these concepts fresh in mind, the client can attend to the feedback and observe movement in the desired direction.
Major Stages of the Neurofeedback Training Process
Describe the stages of neurofeedback training from intake to graduation and follow-up sessions. Your explanation should answer the following questions:
(1)
What will we do during this stage?
(2) What is my role during this stage?
(3) How will this stage address my concerns?
(4)
How long will it take?
Also, address more general training questions:
(1) How will you assess my progress?
(2) What will training cost?
(3) What are the risks of training?
(4) What are the limits of confidentiality?
Where the evidence for an intervention is weak (Evidence-Based Practice level 1 or 2), explain that the proposed training is experimental, why you believe it is appropriate for this client, and how you will monitor progress and adjust training if progress is not satisfactory. From ISNR's Guidelines for Practice:
Accurately represent the degree of scientific support reported in peer-reviewed publications for assessment and training methods for the various problems to which neurofeedback training may be applied.
The written informed consent document should explicitly designate the treatment as experimental and summarize your explanation covering the eight questions listed above, along with clinic policies. Following ISNR's Guidelines for Practice:
Document their client’s consent to the specifics of training, including where and how the client will be touched, acknowledgment of training benefits, risks, and costs. Document their client’s acknowledgement of the limits of confidentiality.
Document their client’s acknowledgment that training will not necessarily achieve agreed-upon goals, either completely or at all.
Further document the client’s acknowledgment that unexpected changes in the client’s experience or behavior may occur during the course of training which may or may not be related to the training itself, and that in those cases, it is important for the client to inform the neurofeedback provider so that the training methods can be either adjusted or discontinued, if necessary, and the unexpected changes can be appropriately addressed.
Collaborate with their clients to develop measurable training goals, a clear plan for training, and methods for measuring progress toward those goals. This collaboration includes regular review of progress with the client with the objective of asking for their decision regarding whether the benefit of continuing training merits the cost.
Client's Role and Responsibilities
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 Blanchard and Epstein's self-regulation model and Shellenberger and Green's mastery model, may produce better clinical outcomes than those that place clients in a passive role.
Blanchard and Epstein's 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 a desired state (practicing
healthy breathing to lower arousal).
Self-reinforcement is the use of
internal (self-praise) or external rewards (clothing) for the use of a skill.
Finally, self-maintenance involves the long-term practice of self-regulation
skills informed by
regular review.
Shellenberger and Green's (1986) Mastery Model
Shellenberger and Green's mastery model compares biofeedback training to coaching an athletic skill. This training process is social since you work with another person and possibly a partner or group.
Assignments and Logs
Practice assignments and daily logs reinforce a client's role as an active collaborator in neurofeedback. Assignments are vital for skill acquisition and the transfer of self-regulation from the clinic to everyday life. Daily logs are a valuable source of information regarding client practice and progress toward their training goals.
Clinicians should explain how each assignment addresses client goals, demonstrate the activity within the clinic, and ensure that the client is able and willing to practice the skill. In the next session, the clinician should review the log with the client to reinforce the importance of practice and logging and invite the client to help improve the assignment.
The Initial EEG Assessment Session
During the initial EEG assessment session, revisit the concept of neurofeedback and discuss how the equipment works. Summarize the purpose and steps involved in skin preparation. Explain how the sensors work and reassure your client about their safety. You may also reassure them regarding clinic procedures to prevent infection transmission in a pandemic environment. This is an excellent time to encourage questions to correct the equipment and training process misconceptions.
Screens will be meaningless to your client until you explain terms like amplitude, frequency, and z-scores and show how software displays them. As your client performs activities, show how visual and auditory feedback change, and encourage the client to tune in to how these changes feel.
Finally, explain how the display will change when your client succeeds, and describe how you will record sessions and monitor progress during and across sessions.
During training sessions, the clinician’s role is to encourage the type of passive attention and observation of change that has been discussed previously. The level of this intervention will depend upon the client’s need for re-direction. Ideally, the client will become self-directed and may even provide the clinician with evidence of learning and success.
Reinforce client orientation by providing brochures or links to
educational videos. ISNR provides a Neurofeedback Overview video.
Mentoring for Neurofeedback Certification
BCIA developed a 25-contact-hour mentoring requirement to promote "the development of skills, knowledge, responsibility, and ethical standards in the practice of neurofeedback." See Mentoring for neurofeedback certification on the BCIA website.
Certification candidates can learn from one or several mentors after demonstrating basic instrumentation competence. Your mentor can provide examples of how they orient clients to neurofeedback. This could include explaining neurofeedback, countering misconceptions, defining the client's role, selecting and adjusting practice assignments, conducting training, and providing feedback regarding client progress. In addition, your mentor can provide you with sample forms (e.g., informed consent and practice logs), clinic policies, and procedures you can adapt for your own practice.
Client Preparation with Relaxation Training
Biofeedback is not relaxation; it is information about your body and its performance.
Although consumers and clinicians sometimes conflate biofeedback with relaxation, they can be completely separate.
In biofeedback-assisted relaxation training (BART), clinicians combine biofeedback with relaxation exercises to teach clients to relax. BART can use individual or combined biofeedback modalities to reinforce relaxation exercises like Autogenics, guided imagery, mindfulness meditation, paced breathing, and Progressive Relaxation (Moss, 2020).
"a high percentage of biofeedback treatment follows a stress-relaxation model, in which the purpose of biofeedback training is to cultivate a relaxed state and counteract the effects of chronic situational and personal stress (Moss, 2020)."
Relaxation practices are diverse and vary in their degree of structure. Discover the relaxing activities your client already enjoys and build on them.
This section covers Relaxation Myths, Two Road Maps for Self-Relaxation, Procedures That Produce Deep and Moderate Relaxation, Autogenic Training, Progressive Relaxation, Visualization, Meditation, Hypnosis, the Quieting Response, and Physical Exercise.
Relaxation/Meditation/Mindfulness
Smith (2021) views relaxation as a component of a more expansive relaxation/meditation/mindfulness (RMM) construct. Relaxation, meditation, and mindfulness overlap.
There is a bit of relaxation in all of meditation and mindfulness. There is a bit of meditation and mindfulness in all of relaxation. Nearly all texts and training programs teach blends of RMM. Although different techniques clearly have a different pattern of effects, all can be placed on the same psychological map. All can evoke experiences from the same lexicon (Smith, 2017, 2019; pp. 39-40).
He states, "My definition is based on popular use; relaxation is what most professionals call relaxation" (p. 39). Examples of relaxation exercises are autogenic training, paced breathing, progressive muscle relaxation, tai chi, visualization, and yoga (Smith, 1985, 1986, 1990, 1999, 2001, 2005, 2017, 2019).
For Smith, the core element of meditation is "sustaining quiet, simple focus (Smith, 2017, 2019)" (p. 39). Focused attention (FA) meditation (Lutz et al., 2015) concentrates on one stimulus (e.g., breathing sensations). Mindfulness meditation "involves quietly attending to the flow of all stimuli (or restricted domain of stimuli, such as sounds) as a neutral observer" (p. 39).
BCIA Blueprint Coverage
This unit addresses Relaxation methods: Procedures, indications and contraindications (VII-B), and The effects of exercise on mood, physiological functioning, and presenting symptoms (VII-F).
This unit covers Relaxation Myths, Two Road Maps for Self-Relaxation, Procedures That Produce Deep and Moderate Relaxation, Autogenic Training, Progressive Relaxation, Visualization, Meditation, Hypnosis, the Quieting Response, Nutrition, and Physical Exercise.
Relaxation Myths
Both clients and therapists share misconceptions about relaxation. These include:
1. Relaxation is like being deeply asleep,
2. All relaxation procedures produce the same relaxed state,
3. You must make yourself relax.
4. We've administered "autogenic training"
Correcting these misconceptions is crucial for effective treatment.
Relaxation training should teach clients to achieve a state of
calm
alertness instead of drowsiness. Relaxation practice should improve your performance when
driving, presenting a talk, or hitting a golf ball.
All Relaxation Procedures Produce the Same Relaxed State
When we administer a psychophysiological profile to a new client, we
often see some systems within normal limits and others one or more
standard deviations outside clinical norms. Each client has a
personalized response stereotypy (unique psychophysiological response
pattern): blood pressure and heart rate might be elevated while skin
conductance level and upper trapezius muscle contraction are normal.
Mild and moderate stressors do not produce unidimensional physiological
changes. Stressors will trigger changes in some systems but not others:
blood pressure and heart rate may rise while skin conductance and upper
trapezius EMG do not change. This illustrates the concept of response
fractionation in which body systems react independently to stressors. Stress responses are
multidimensional.
If your client's response to stressors is unique and multidimensional, their response to a relaxation procedure will also be unique
and multidimensional. For example, a progressive relaxation exercise
(focus on the tension in your forearm and then let it go) may lower blood
pressure and heart rate and not change skin conductance and upper
trapezius EMG. In contrast, a visualization exercise ("imagine yourself
lying on warm sand") may lower state anxiety and not change blood
pressure, heart rate, skin conductance, or upper trapezius EMG.
Relaxation procedures produce complex changes in each client; there is
no generic relaxed state.
You Must Make Yourself Relax
A client's strategy during relaxation practice can result in clinical
success or failure. When we introduce a relaxation exercise to lower
blood pressure, clients should not practice it in a way that
triggers vagal withdrawal, paradoxically raising their blood pressure.
Although active
volition instructing muscles to contract can play a valuable role in progressive muscle relaxation procedures, excessive effort can backfire. Shaffer et al. (2002) reported that high effort in
autogenic training (AT) and progressive muscle relaxation (PMR) procedures caused unwanted
physiological changes. Effort can produce overbreathing and suppress the parasympathetic branch producing the phenomenon of vagal withdrawal (Khazan, 2019).
Therapists should remind their clients that relaxation is a state of calm alertness and that you cannot be calm when you force yourself to relax. Instead, therapists should encourage their clients to use passive volition to visualize the desired change and then allow their bodies to make the change at their own pace.
We've Administered "Autogenic Training"
Researchers often administer abbreviated versions of AT and PMR and then draw
conclusions about the effectiveness of these techniques. They may leave out crucial elements of the original
procedure, provide significantly less training time in session length and the number of sessions, lack
expertise in teaching the method, and play recorded relaxation instructions instead of offering live
interactive training.
There are three issues. First, they should not be surprised when "crippled" versions of procedures originally taught over months or years do not produce the profound changes reported by their developers. Second, relaxation training success is greatly influenced by trainer skill and personality
(Taub's "person effect"), just like athletic coaching success. Don't blame the tools. Third, recorded
instructions have less impact than live instructions and cannot be adjusted to help clients overcome difficulties
during a training session.
TWO ROAD MAPS FOR SELF-RELAXATION
Smith (2016) proposed two self-relaxation road maps, self-stressing theory and psychological relaxation theory.
Self-Stressing Theory
Self-stressing theory proposes that we initiate and perpetuate a "fight-or-flight" response in six ways: stressed posture and position, skeletal muscles, breathing, body focus (rapid breathing), emotion (anxiety), and attention (worrying about a threat).
Smith (2016) argued that the diverse self-relaxation strategies attempt to remedy these forms of self-stressing. A single family group may address more than one self-stressing mechanism.
The table below is reproduced from Smith (2016).
Psychological Relaxation Theory
Based on 31 published factor analytic studies and surveys of over 40 RMM techniques,
Smith (2021) grouped 25 relaxation states
(RMM states) into 6 levels. Several RMM exercises may produce the same subjective state. We recommend that professionals purchase Lehrer and Woolfolk's authoritative Principles and Practice of Stress Management (4th ed.) and read Smith's Overview of Stress and Stress Management in its entirety.
Smith
characterized RMM theory this way:
My approach is not narrow-spectrum; it does not focus on a homogenous, static outcome state or trait (e.g., the relaxation response, focused awareness, or nonjudgmental acceptance). Instead, my approach is broad-spectrum and based on four ideas: (1) RMM has many defining effects, (2) these effects inform and influence each other, (3) they change over time, and (4) this change is not random or circular but evolves in a direction that is decreasingly self-referential and increasingly deep and encompassing. Simply, my broad-spectrum model is multidimensional, interactive, dynamic, and directional (for an elaboration, see Smith, 2017, 2019) (pp. 40-41).
The table below is reproduced from Smith (2021).
Smith (2021) argued that RMM states powerfully reinforce the initiation and maintenance of relaxation practice and are
crucial to positive relaxation experiences. They enable clients to communicate their relaxation goals and experiences and incorporate relaxation into their daily lives.
Procedures That Produce Deep and Moderate Relaxation
Relaxation training combines deep relaxation and abbreviated relaxation
procedures. We can categorize relaxation procedures in terms
of subjective and physiological change, degree of sensory restriction,
and length of practice.
Autogenic
training (AT), progressive muscle relaxation (PMR), visualization, transcendental meditation (TM), clinically
standardized meditation (CSM), and hypnosis can help clients achieve deep relaxation since they
produce moderate-to-strong subjective and physiological changes, involve moderate-to-high sensory restriction, and are practiced for intermediate-to-long periods.
Abbreviated relaxation procedures like the Quieting Response (QR) produce mild-to-moderate subjective and physiological change, involve minimal sensory restriction, and are practiced for very brief periods.
Deep relaxation exercises
may help counter allostatic load and reset
body setpoints for blood pressure, muscle contraction, and stress hormone
levels. Finally, the belief that relaxation practice has been successful
may increase your clients' perception of self-efficacy (personal
effectiveness) and result in an internal shift in their locus of control
(perceived cause of individual outcomes like health and illness).
These exercises may create a relaxation template, help clients develop an automatic relaxation response, help clients counter changes produced by distress and reset body setpoints, and increase perceived self-efficacy and internally shift their locus of control.
Abbreviated relaxation procedures help clients transfer relaxation
skills to their environment by making relaxation automatic. A stress
response is a habit that has become automatic after months to decades of
practice.
A relaxation skill is also a habit, but it is so new that its practice initially requires conscious supervision. The more clients
practice a relaxation skill, the stronger this habit becomes. After about
6 months, clients may automatically replace a fight-or-flight response
with relaxation when they encounter stressors (traffic slowdown).
Abbreviated relaxation exercises may complement deep relaxation exercises
in countering cumulative changes produced by distress. These exercises
may also help reset body setpoints, increase perceived self-efficacy, and shift your clients' locus of control
internally.
To summarize, abbreviated relaxation exercises may help clients transfer relaxation skills to their environment, develop an automatic relaxation response, counter changes produced by distress and reset body setpoints, and increase perceived self-efficacy and shift their locus of control internally.
The Relationship of Biofeedback to Relaxation Training
There can be a remarkable synergy between biofeedback and relaxation
training. In BART, biofeedback helps clients refine their relaxation skills by
guiding their practice with knowledge of results. Feedback immediately
shows clients when relaxation strategies succeed or fail. Biofeedback
provides objective, quantifiable evidence of
performance success. Clients often trust physiological measurements more than
their perception of improvement. Measurements in microvolts seem more
real to them. This information can reassure clients that they have made
progress, increase their motivation to practice, and help them
continuously refine their relaxation skills.
Relaxation training, in turn, helps clients transfer self-regulation
skills learned through biofeedback to their environment. Forty minutes a
week of biofeedback training cannot change client stress responses by
itself. These 40 minutes must counter the stressors encountered during
about 10,000 waking minutes each week. Biofeedback training does not have
a chance of changing clients' stress responses without weekly relaxation
practice. Biofeedback research has consistently shown that successful
clinical and performance outcomes require regular—but not daily—relaxation practice.
Autogenic Training
Johannes Schultz (1884-1970), a German neurologist and Nazi, developed AT during the 1920s based on clinical hypnosis research (Schaefgen,
1984). Schultz described clinical applications of AT to
the Medical Society in 1926 and published his first book, Das Autogene
Training, in 1932.
Wolfgang Luthe, a German-born psychiatrist who was
Schultz's student and collaborator, introduced AT to
English-speaking professionals. Luthe translated Das Autogene Training
into English in 1959 and co-authored a six-volume English series on
AT from 1969 to 1973 (Suter, 1986).
Schultz observed that deep relaxation and falling asleep are associated with limb heaviness and warmth sensations. AT assumes that this process is bidirectional. Passively imagining
heaviness and warmth can produce a deeply relaxed state. AT requires passive concentration, free of effort or
goal direction.
Luthe believed that visualization is crucial to achieving self-regulation in AT.
From Luthe's perspective, passive concentration reduces cortical
interference with maintaining homeostasis by subcortical structures.
The transition to a passive, pre-sleep, hypnagogic autogenic state is
called autogenic shift. The challenge is to maintain the autogenic state
without falling asleep. A client walks a tightrope between active
attention and sleep (Luthe, 1979). Check BodyMindPower video Autogenic Training - A Guided Relaxation for a Deep and Restful Sleep.
Autogenic Therapy
AT is a sequence of six standard
exercises, autogenic modification, and autogenic meditation. Therapists
often use complete or abbreviated versions of the standard exercises. They frequently dispense with autogenic modification and autogenic meditation. Training
can be individual or in a group setting. The environment should be
comfortable with minimal distraction. A client should sit or lie
comfortably with good neck and leg support. The ideal position is
lying supine on a couch since this minimizes muscle tension and promotes
drowsiness. The room should be slightly darkened (Linden, 1990).
Six Standard Exercises
The six standard exercises focus on physiological changes. A therapist
prepares the client for the first exercise by reviewing its rationale,
the learning process, common experiences, and the mechanics of autogenic
training. Each standard exercise consists of a relaxation theme
("heaviness") a client subvocally repeats while visualizing that they are lying or sitting in a comfortable environment like a beach or a
meadow (Schultz & Luthe, 1969). A passive attitude is the most crucial
element. A relaxed position, conducive environment, and visualization are
also important.
AT consists of six relaxation themes.
AT's heaviness and warmth standard exercises (themes 1-2) are divided
into
seven parts.
The remaining standard exercises (themes 3-6) consist of only one relaxation
component. In total, the six standard exercises consist of 18
components. The European practice of 1-2 sessions per component requires
almost 6 months to complete these exercises (Lichstein, 1988). American
clinicians sharply abbreviate autogenic exercises (Pikoff, 1984), often
providing less than one hour of training.
Each training session starts with the formula, "I am at peace." The initial
practice may be as brief as 30 seconds per relaxation component (for a
total of 9 minutes for one standard exercise). A client may extend
performing a component to over 30 minutes as their skill increases.
Standard exercises end with taking back procedures: vigorously flexing
the arms, deep breathing, and opening the eyes: "Arms firm, breathe
deeply, open eyes" (Linden, 1990).
Autogenic Modification
Autogenic modificationprocedures are used when a
symptom like low back
pain does not respond to the practice of the six standard exercises.
Following a client's mastery of the standard exercises, a therapist may
introduce organ-specific formulae or intentional formulae.
Organ-specific
formulae modify standard exercise themes (heaviness, warmth, calm and
regular heartbeat, and coolness) to treat client symptoms ("My back is
warm"). Intentional formulae, which may be reinforcing or neutralizing,
increase or decrease behaviors. Reinforcing formulae motivate
action ("I am energetic and will practice harder"). Neutralizing formulae
reduce self-defeating statements ("My job frustration does not matter").
Autogenic Meditation
Seven autogenic meditation exercises improve visual imagery
skills after a client has mastered the six standard exercises. These
exercises are designed to assist clients who find visualization hard.
The exercise sequence is arranged in increasing difficulty. The client
should follow the established order and only advance after
mastering an exercise.
A client's visualization skills determine their rate of mastery.
Moderate-ability clients may master all seven exercises in one or two
sessions; others may require a month per exercise (Lichstein, 1988).
Physiological Effects
Eighty studies have demonstrated that autogenic training increases skin temperature and peripheral blood flow.
Vasodilation becomes apparent during the "heaviness" phrases and
increases during the "warmth" exercises. The temperature increases often followed the anatomical focus
of the "warmth" exercises (Lichstein, 1988).
These studies challenged Freedman and colleagues' (1983) conclusion
that AT does not produce hand-warming. The authors assigned Raynaud's clients to listen to 3
minutes of tape-recorded instructions followed by the repetition of the phrase, "My hands are warm and heavy"
for 13 minutes over 10 biweekly sessions. These clients did not increase their hand temperature.
Freedman and colleagues' conclusion was indefensible for two reasons. First, they did not use traditional
AT. Instead, they used a crippled version that had failed to produce hand-warming in a previous
study by Surwit and colleagues (1978). Second, their findings can't be generalized to all individuals since they
were based on Raynaud's clients, who suffered from compromised peripheral blood flow.
AT Efficacy
Quantitative, meta-analytic findings indicated that AT was associated with medium-sized pre-to posttreatment effects ranging from d = –0.43 for biological indices of change to d = –0.58 for psychological indices in the Linden (1994) review, and d = –0.68 (biological indices) and d = –0.75 (psychological outcomes) in the Stetter and Kupper review (2002). The pooled effect size estimates hide considerable variability in behavioral/psychological effects for individual target problems; moderately sized improvements were reported for tension headache and migraine, hypertension, coronary heart disease rehabilitation, asthma, somatoform pain disorder, Raynaud’s disease, and anxiety and sleep disorders (Linden, 2021, p. 546).
Progressive Relaxation
Edmund Jacobson (1888-1973) received training as a research
physiologist and physician. Jacobson started using PMR
in clinical cases about 1918 and published case histories in two 1920s
articles (Jacobson, 1920, 1924). His most significant research productivity was
between 1925 and 1940, when he studied the psychophysiology of progressive
relaxation. During this period, he published the classic texts Progressive
Relaxation (Jacobson, 1929) and You Must Relax (Jacobson, 1934).
PMR was not widely used until Wolpe incorporated an
abbreviated version of this procedure in systematic desensitization. Wolpe
designed this behavior therapy procedure to treat phobic disorders. Wolpe
(1958) and Goldfried (1971) condensed Jacobson's standard
procedure, which covered 50 muscle groups in 3-6 months of training. Wolpe's version trains about 15 muscle groups
in 20 minutes (Lichstein,
1988).
Jacobson observed that clients maintain tension not required to perform
a task (clenching teeth when writing a check) and are often
unaware of that tension. He also discovered using electromyography that
muscles usually do not relax even when we lie down. Jacobson theorized that
unconscious muscle bracing wastes energy, disrupts performance, and
produces stress disorders (Jacobson, 1929). He also asserted that anxiety
is correlated with muscle tension, so muscle relaxation reduces
anxiety.
Research has shown that the relationship between muscle tension and
stress disorders, and anxiety is complex. Muscle tension may be a
byproduct of an underlying disease instead of the cause (Suter, 1984).
Jacobson's original procedure trained clients to relax 2 or 3 muscle
groups each session until 50 groups were trained. Several sessions might
focus on a single difficult muscle group before moving to successive
groups. Jacobson's approach was time-intensive, requiring 50-60 sessions
in the clinic and 1-2 daily one-hour practice sessions (Suter, 1984).
Studies do not show a difference in outcome between Jacobson's original
PMR protocol and modern condensed versions (Snow,
1977; Turner, 1978).
In contrast to current protocols in which clients tense and relax muscle
groups, Jacobson only asked clients to produce minimal muscle tension
early in training. Jacobson's clients mainly employed passive relaxation
in which they simply focused on muscle sensations (Lichstein, 1988). For
Jacobson, the objectives of progressive relaxation were the development of
muscle sense (awareness of muscle tension) and reducing useless
residual tension. After eliminating residual tension, Jacobson encouraged his clients to develop differential relaxation skills, inhibiting unneeded muscle groups during routine activities. Check out the YouTube video Progressive Muscle Relaxation.
Popular PMR protocols are no more standardized than
their autogenic counterparts. There are significant procedural differences (Lichstein, 1988). Watch the University of Toledo video Progressive Muscle Relaxation.
As in AT, clients may be trained individually or in
groups. Also, a client reclines or sits in a slightly darkened room
with eyes closed. For a conventional protocol covering 16 muscle groups,
a client might tense for 7 seconds and relax for 45 seconds. The
training sequence may be revised to accommodate a client's needs. Before training, a therapist should question each client to exclude already relaxed muscle groups and identify problem groups. Spastic or strained
muscle groups may be skipped, or the tension level may be passively
observed (without additional tensing). A therapist may repeat the
tense-relax cycle two or three times for difficult muscle groups
(Lichstein, 1988).
PMR Efficacy
Jacobson’s clinical applications of progressive relaxation are impressive indeed. However, there apparently are no experimental (vs. clinical) data that validate the method, probably because of the extensive methodological difficulties in conducting an experiment...Although the literature on various forms of relaxation therapy is impressive, descriptions of the length and nature of training indicate either that the research has not used Jacobson’s progressive relaxation procedure or that this procedure has been confounded with other methods (McGuigan & Lehrer, 2021).
Visualization
Kenneth Pelletier's (1977) classic text Mind as Healer, Mind as Slayer proposed that mental imagery can produce harmful or beneficial physiological changes. Negative imagery can increase blood
pressure, heart rate, muscle contraction, and pain.
Visualization, in which a client
generates mental imagery that can be somatosensory and visual, is a common element in interventions ranging
from autogenic training to behavior therapy. The vivid images created during visualization can help relaxation (standard autogenic exercises), prepare an individual to cope with stressful situations (mental rehearsal), and reduce anxiety, back pain, headache, hypertension, and ulcers. There are marked individual
differences in visualization ability, and this capacity may overlap with
hypnotic susceptibility. High-hypnotizable individuals who are gifted visualizers may achieve the best results using this strategy (Moss,
2004). Watch the University of Houston at Clear Lake White Cloud Visualization video.
Transcendental meditation (TM) is a
form of mantric meditation in which an individual repeats Sanskrit
syllables that have been assigned by an instructor based on age or
personality.
Benson (1975)
identified four components that TM shares with other deep relaxation
procedures: a "quiet environment, mental device, passive attitude, and
comfortable position" (pp. 112-113). Benson developed a secularized
version of TM, called the Relaxation Response, that incorporated these four
elements and recommended that
clients practice 1-2 times daily for 10-20 minutes. Watch the Relaxation Response: Dr. Herbert Benson Teaches You The Basics video.
Early TM
hypertension studies lacked control groups, involved single-group
pre-test-post-test designs, and yielded mixed results. Controlled trials
of Benson's meditative procedure have not demonstrated
clinically significant blood pressure changes in hypertensive
individuals (Lichstein, 1988). Check out the 5 min Mantra Meditation for Beginners - Easy Guided Meditation.
Clinically Standardized Meditation (CSM)
Clinically standardized meditation (CSM) is a systematic secular meditative procedure that incorporates meditative techniques like TM components. A meditator selects or
creates a mantra (soothing sound), repeats it aloud with the instructor
and then alone, whispers it, and then mentally (silently) repeats it
with eyes closed. Both the instructor and trainee meditate seated with
eyes closed for 10 minutes, after which the trainee gradually returns to ordinary consciousness over 1-2 minutes. An instructor answers the
student's questions about using this meditative technique and then
instructs them to meditate alone for a specified period
(10-20 minutes) after the instructor leaves the room. The student
completes a questionnaire following meditation which is reviewed with
the instructor. Then the instructor teaches the following week's
meditative exercise and reviews how to control negative side effects.
Meditation practice is prescribed twice daily for about 20 minutes and
may be shortened if the student experiences adverse side effects
(Lehrer & Carrington, 2003).
Mantric Meditation Efficacy
Several meta-analyses of the data have been reported (Ooi, Giovino, & Pak, 2017;
Park & Han, 2017; Shi et al., 2017), and these reviews generally confirm the earlier findings that mantra meditation is of decided value for health and emotional stability. These studies frequently call for more rigor in the design of studies and ask for larger samples. This is sound advice, except for the fact that funding for research on meditation is not easy to come by due to its seemingly esoteric nature, which still marks it as somewhat outside of the commonly accepted parameters. For this reason, research funds for more elaborate studies may not be readily obtainable. Hopefully, adequate support will bring forth such larger studies in the future.
PTSD is a notoriously difficult area to study due to the difficulties in pinning down the diagnosis and acquiring a suitable population for study, for follow-up, and for obtaining reliable outcome measures. Despite such difficulties, however, the general conclusion that mantra meditation can be highly effective in the treatment of many components of PTSD has been repeatedly confirmed (Kang et al., 2018; Metcalf et al, 2016; Cushing & Braun, 2018; Lang et al., 2012; Park & Han, 2017; Harne & Hiwale, 2018), and anxiety remains a major area in which mantra meditation seems to offer considerable clinical help (Cooney Roxbury, 2018; Travis et al., 2018) (Carrington & Lehrer, 2021, p. 403).
Mindfulness Interventions
Mindfulness is "preverbal awareness of the present moment with acceptance" (Germer, 2009). Clinicians have developed a family of mindfulness interventions over four decades, including Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Stress Reduction (Khazan, 2019). These interventions teach clients to be in the moment without action or judgment. Mindfulness is not relaxation but can enhance relaxation training as clients nonjudgmentally experience emotions, physical sensations, and thoughts. Check out the Comfort Care Mindfulness Meditation video.
Physical Changes
Lazar and colleagues (2005) used magnetic resonance imaging (MRI) to compare the thickness of the prefrontal cortex and right anterior insula in Buddhist Insight meditators and matched nonmeditators. They found that meditators had greater prefrontal cortical gray matter volume than the controls. This difference was greatest for older meditators and suggested that meditation may protect aging brains from apoptosis. Prefrontal cortex and right anterior insula volumes were positively correlated with years of meditation.
A systematic review (Gard et al., 2014) of 12 studies, including 6 randomized controlled trials, concluded that various types of meditation might protect against age-related cognitive decline.
Hölzel and colleagues' (2009) used MRI to measure gray matter changes in the amygdala. The investigators randomized participants to an 8-week mindfulness-based stress reduction (MBSR) intervention or a wait-list control condition. They measured amygdala volume and perceived stress scale (PSS) scores before and after the intervention. Participants who received MBSR training reported significant stress reductions correlated positively with decreased right basolateral amygdala gray matter volume.
However, Kral et al. (2022) conducted an RCT that failed to replicate whole-brain or region-of-interest structural changes previously reported for an 8-week mindfulness-based stress reduction (MBSR) course in 218 meditation-naive participants. The authors highlighted the low statistical power of previous studies with sample sizes of 20 or less.
Mindfulness-Based Intervention (MBI) Efficacy
By mid-2013, a meta-analysis of MBIs drew on 209 studies (Khoury, Lecomte, Fortin, et al., 2013), showing comparable effects of MBIs to CBT and psychopharmacology and greater effects in comparison to other control conditions. Other meta-analyses are now showing effects for stress reduction in healthy individuals (Khoury, Sharma, Rush, & Fournier, 2015), in primary care (Demarzo et al., 2015), in older adults (Hazlett-Stevens, Singer, & Chong, 2018), and in the prison population (Shonin, Van Gordon, Slade, & Griffiths, 2013). An inclusive meta-analysis of psychiatric disorders (Goldberg, Tucker, Greene, Davidson, et al., 2018) examined efficacy by five types of control groups (from wait-list to evidence-based intervention), finding significant improved value both immediately after intervention and at follow-up for most comparisons, with MBIs being comparable to evidence-based alternatives. There are now enough meta-analyses in core areas for a meta-analysis of the meta-analytic studies (Gotink et al., 2015). With the focus primarily on MBSR and MBCT, results show significant improvement in depressive symptoms, anxiety, stress, quality of life, and general physical functioning (Kristeller, 2021, p. 423).
Hypnosis
The American Psychological Association's Division of Psychological
Hypnosis cautions that hypnosis "is not a type of therapy" but instead
"a procedure that can be used to facilitate therapy" (Kirsch et al.,
1999, p. 3). Instead of hypnotherapy,
which connotes an independent treatment like cognitive behavior therapy
(CBT), we should use the term "hypnotically-assisted psychotherapy"
(Moss, 2004, p. 37).
Researchers disagree on the clinical efficacy and nature of
hypnosis.
Barber (1996) views hypnosis as an altered state of
consciousness and contends that analgesia involves
negative hallucination where normal perception is
suppressed. Hilgard (1978)
hypothesized that the process of hypnotic
induction produces an altered state of consciousness in
susceptible individuals that allows them to create physiological
changes. Barber (1982)
conceptualizes hypnosis as a trait or relatively permanent
predisposition to respond to suggestion and believes that the hypnotic
process is not simply relaxation. He challenges the need for
hypnotic induction (promotion of a hypnotic state) and argues that individuals respond equally well
to suggestions without a trance state. Most hypnotherapists agree that
all hypnotic procedures involve
self-hypnosis (self-suggestion).
Hypnotic suggestibility
(responsiveness to suggestion) was measured originally by instruments like the
Stanford Hypnotic Susceptibility Scale and the Harvard Group Scale of Hypnotic Susceptibility. Clinicians can administer the recent Elkins Hypnotizability Scale more briefly than the hour required for the Stanford and Harvard scales while achieving relatively strong concurrent validity
with the older scales (Kekecs et al., 2016).
Moss and Willmarth (2019) described hypnotic ability as a relatively stable trait when measured over a lifetime. A study of monozygotic and dizygotic twins estimated that hypnotic susceptibility has a heritability index of 0.64 (Morgan, 1973). A heritability index estimates the percentage of variation due to genetic influences. Values close to 1.0 indicate strong genetic influence.
A 25-year longitudinal study (Piccione et al., 1989) reported test/re-test correlations of 0.64, 0.82, and 0.71 for measurements at 10, 15, and 25 years, respectively.
The distribution of this trait in the population is relatively normal, which means that there are individuals with very low and very high hypnotic ability. Moss and Willmarth (2019) caution that about 20% of patients may be poor candidates for medical hypnosis applications due to low hypnotic ability. Interventions to increase suggestibility do not help most of these individuals (Lynn et al., 2015). For this reason, therapists should measure client
suggestibility to determine whether to use a hypnotic procedure.
The Role for Biofeedback
Hypnosis can be effectively combined with biofeedback/neurotherapy (Moss, 2004). Wickramasekera (2003) proposed different roles for biofeedback with highly hypnotizable and medium-to-low hypnotizable individuals. He argued that highly hypnotizable clients will best respond to hypnotic procedures and that biofeedback can help illustrate the connection between mind and body. In contrast, medium-to-low hypnotizable clients are often better candidates for more intensive biofeedback training, which may increase their hypnotic susceptibility.
The Promise of Hypnosis in Integrative Healthcare
Most patients show moderate-to-high hypnotic ability and achieve comparable outcomes to validated medical interventions. Moss and Willmarth (2019) advocate including adjunctive hypnosis in integrative healthcare programs where its addition enhances treatment outcomes.
For this to happen, it is critical that the patient’s complaint be one for which there is a strong research base supporting the value of hypnotic treatment. There is good research support for the application of hypnosis for anxiety disorders, depression (including major depression), post-traumatic stress disorder, stress management, sleep disorders, smoking cessation, weight management and eating disorders, and the addictions. There is also strong research support for the use of hypnosis for acute and chronic pain, IBS, colitis, diabetes mellitus, hypertension, skin conditions including psoriasis, chemotherapy induced nausea, and pediatric problems such as anxiety, school phobia, and recurrent abdominal pain (Elkins, 2017; Nash & Barnier, 2008). (p. 500)
A meta-analysis
(Montgomery et al., 2000) revealed that analgesic suggestions
reduced pain in about 75% of subjects and comparably reduced clinical
and experimental pain. Hypnotic procedures have been successfully used
in burn pain, cancer pain in children, childbirth discomfort, dental
pain, headache, low back pain, pain from sickle cell disease, and
surgical pain. These techniques are underutilized due to misconceptions
such as "hypnotized clients are unaware of their surroundings" (Brannon, Feist, & Updegraff,
2022).
Moss and Willmarth (2019) summarized
Patterson's review of hypnosis for chronic pain:
Similar to his table related to acute pain, Patterson (2010) presented a table related to chronic pain that included 14 controlled studies of hypnosis (12 randomized), in chronic conditions including fibromyalgia, headaches, cancer-related pain, back pain, and irritable bowel syndrome (IBS)-related pain. Again, all studies found that hypnosis was equal to or better than standard care treatments which included group support, biofeedback, medication, relaxation, Autogenic training, attention control and CBT. (p. 499)
Hypnosis for Surgical Patients
Moss and Willmarth summarized meta-analyses by Montgomery et al. (2002, 2007) on surgical applications of hypnosis. Surgery graphic MAD.vertise/shutterstock.com.
Montgomery et al. reviewed 20 well-controlled research studies, using meta analytic techniques, and concluded that hypnosis is an effective adjunctive treatment for patients undergoing surgery.
The meta-analysis showed a broad beneficial impact of hypnosis with surgical patients, across outcome categories. Subjective measures such as anxiety and pain, objective measures such as analgesia use, physiological measures, recovery time, and treatment time, all showed comparable beneficial outcomes for patients in the groups receiving hypnosis. The patients in the hypnosis groups showed better medical and psychological outcomes than 89% of the patients who did not receive hypnosis. Later research by Montgomery et al. (2007) showed that not only could hypnosis reduce patients suffering, enhance healing, and optimize recovery time, but that the savings to the hospital were substantial, mainly in reduced time in surgery. (pp. 499-500)
Hypnosis as an Adjunct to CBT for Stress
Clinicians do not have to choose between CBT and hypnosis. Kirsch et al. (1995) reported compelling evidence that hypnosis can improve CBT efficacy.
The 18 studies that were analyzed in the Kirsch et al. (1995) report comprised 20
comparisons of hypnotic with nonhypnotic CBT groups, with a total of 90 effects and 577 participants. Larger positive effects tended to occur in larger samples. The average weighted effect was 0.66, so the average person receiving CBT in a hypnotic context did as well as the person at the 75th percentile or so of those receiving CBT without hypnosis.
Of these studies, Kirsch et al. (1995) identified 14 in which the only difference
between hypnotic and nonhypnotic conditions was the use of the word hypnosis during relaxation instructions and training. The average weighted effect size for interventions labeled hypnotic, compared with the same intervention without the label hypnosis, for these 14 studies was d = 0.63. Thus labeling an intervention as hypnotic increases its efficacy by more than half a standard deviation (Karlin, p. 560).
The Quieting Response
Stroebel developed the
Quieting Response (QR) abbreviated relaxation
exercise to counteract the fight-or-flight response.
The 6-second fight-or-flight response consists of four stages.
The 6-second QR consists of four corrective stages.
Stroebel recommended that clients learn the QR in eight
learning sessions scheduled about one week apart. The activities for each
session were described in QR: The Quieting Reflex (Stroebel, 1982). He
advised clients to initially practice the QR whenever
they experience annoyances, as many as 50-100 times a day. He cautioned
that it would take about six months for the QR to become
automatic. While 100-times-a-day practice might seem excessive, it only
involves 600 seconds or 10 minutes per day. Stroebel estimated that 80%
of clients practicing the QR achieve this level of
proficiency and continue using this technique after two years.
Stroebel explained that the 80% compliance rate was due to the minimal time
commitment required by the QR and the fact that clients
do not have to disrupt daily activities to perform this 6-second
exercise. "They controlled the technique; the technique did not control
them." (p. 82)
Relaxation Training Issues
Causes of Deep Relaxation Training Failures
No one knows the average quality of instruction in AT and
PMR when delivered as part of biofeedback
training. There are many reasons that deep relaxation training fails.
Recorded Relaxation Exercises
The professional can benefit from recorded relaxation exercises because
they conserve training time, increase flexibility regarding when and
where the client can practice, reduce the professional's burnout from
the repeated presentation of relaxation scripts, and standardize relaxation
script language.
There are many practical benefits of recorded exercises. The cost of
therapy may be lower due to fewer sessions. The therapist may schedule more clients.
Therapist credibility and client enthusiasm may increase as the exercises
produce desired results. Finally, client practice shortens the time to achieve mastery.
From a client's perspective, recorded exercises are desirable because
they increase comprehension and retention, improve client satisfaction,
motivation, and compliance, provide more consistent instructions and
standardize exercises, provide information that family members can
understand, allow for practice with fewer distractions, and help the
client learn to pace relaxation exercises.
Schwartz (2003) recommended several steps when recording relaxation
instruction.
Therapists should consider teaching clients to record exercises in their
voices to increase client skills and promote an internal locus of
control. We want clients to perceive relaxation as a skill they can
refine through practice. We don't want them to use recordings as
substitutes for medication. In Wickramasekera's language, we want to
promote "skills, not pills."
Research suggests that live instructions may be more effective than taped
instructions. A therapist's physical presence may produce more motivating demand
characteristics than a recording. The
advantage of live instructions may also be due to a therapist's ability
to adjust relaxation training to the client's immediate experience and
progress. For example, a therapist might suggest changes in sitting
position or reduced effort during practice, observing psychophysiological
measurements. Finally, a therapist can adjust pacing to an individual
client's performance.
Negative Side Effects of Relaxation Training
Striefel (2004) cautioned that
BART could produce negative reactions in any
client.
Most negative reactions to BART are due to its relaxation component.
While Budzynski (1994)
suggested that a thorough psychological history can identify clients with
an elevated risk of adverse reaction, therapists must be prepared to
respond to problems in clients without diagnosed disorders.
Schwartz, Schwartz, and Monastra (2016) advised that while significant severe adverse reactions are rare, mild-to-moderate adverse responses can interfere with training, possibly end promising therapy, and reduce client practice of assigned relaxation exercises.
Caption: Mark Schwartz
When clients experience adverse reactions like anxiety, muscle spasms,
tics, and increased sympathetic activation, a biofeedback
therapist can reassure the individual and adjust biofeedback therapy and
home practice assignments. In the rare case of a severe adverse
reaction that exceeds the therapist’s expertise, they may need to
consult with or obtain supervision from a more experienced professional. If they cannot effectively
treat their client, they may
refer them to another clinician. Nash
and colleagues (2001) contend that biofeedback therapists who
are not licensed mental health professionals should not treat clients
with a DSM diagnosis without licensed supervision.
Deep relaxation procedures like autogenic training and progressive
relaxation can result in negative experiences.
Intrusive thoughts are among the most common adverse reactions to BART or relaxation exercises by themselves.
A survey by
Edinger and
Jacobsen (1982) of 116 psychologists who used a relaxation procedure
revealed that relaxation side effects are common. For example, 15% reported intrusive thoughts and 9% fear of losing control.
The adverse reactions experienced during relaxation training can be
grouped as follows.
Adverse reactions can interfere with or lead to the termination of
relaxation training. Based on 17,542 clients seen by 116 clinicians,
3.5% experienced adverse reactions that interfered with relaxation
therapy, and 3.8% experienced negative side effects that confounded
therapy, requiring discontinuation of relaxation. In all, 7.3%
experienced significant adverse reactions.
An experienced therapist can reduce client distress through reassurance,
positive reframing (reconceptualizing) these experiences, and slowing training
pace. These sensations often fade in weeks or become more
pleasant (Lichstein, 1988).
During relaxation training, relaxation-induced negative reactions (RINRs) may be characterized by increased anxiety, including increased perspiration, shivering, trembling, pounding heart,
and rapid breathing (Carrington, 1977). Relaxation training, and not
biofeedback, appears to cause these reactions.
Diverse causes produce RINRs.
Schwartz, Schwartz, and Monastra (2016) recommended several preventative strategies.
Finally, they cataloged common problems and practical strategies for dealing with them.
A biofeedback therapist should obtain their client’s agreement to consult with the healthcare
provider before reducing dosage or discontinuing a drug (Schwartz,
2003).
Nutrition
Acute and chronic stress disorders may deplete B-complex vitamins (50-100
mg/day), calcium (1,000 mg/day), and magnesium (400 mg/day), requiring
their increased intake through dietary sources or supplements (University
of Maryland Medical Center Complementary Medicine Program, 2005).
Clients should avoid or minimize caffeine consumption due to its
activation of the sympathetic nervous system and potential to disrupt
sleep. They should also restrict alcohol intake due to the risk of abuse and physical dependency,
interaction with prescription medication, and potential interference with
sleep. Check out the YouTube video Bill Nye The Science Guy & Nutrition.
Physical exercise is crucial to psychophysiological health. While an hour
of exercise per day may be optimal, physicians often recommend at least
30 minutes of moderate-intensity activity (brisk walking) at least 5 days
per week or 20 minutes of high-intensity training (running) at least 3
days a week. The American College of Sports Medicine recommendations for four age groups are below (USDHHS, 2018). The table below was adapted from Brannon et al. (2022).
Exercise Health Benefits
Dozens of more recent studies have examined the relationship between physical activity and cardiovascular mortality. A systematic review of these studies shows that physical activity confers a 35% reduction in risk of death due to cardiovascular causes (Nocon et al., 2008). The same review concludes that physical activity confers a 33% reduction in risk of death due to all causes. Furthermore, both men and women benefit from physical activity, but risk reductions may be larger for women than for men (Nocon et al., 2008). More recent reviews confirm this link (Lavie et al. 2019; PAGAC, 2018). A dose–response relationship exists between levels of vigorous physical activity and reduced risk of all-cause mortality (Samitz et al., 2011), and a large reduction in risk appeared when comparing people who reported no activity to those who reported low levels of light-to-moderate physical activity (PAGAC, 2018; Woodcock et al., 2011). Thus, some activity is far better than none, but there are still benefits adding more activity to some activity (Brannon et al., 2022, p. 405.)
Physical exercise reduces mortality, increases life
expectancy an average of 2 years, and is associated with a lower risk of
specific cancers (breast, colon, lung, prostate, and rectum), Type 2
diabetes, osteoporosis (decreased
bone density), hypertension, cardiovascular disease, and stroke. Moderate
physical activity can increase basal metabolism and help clients control
their weight, reduce low-density lipoproteins
(LDL), increase protective
high-density lipoproteins (HDL), and possibly lower
triglycerides. Watch the 10 Benefits Of Exercise On The Brain And Body video.
7,000 Steps
The 10,000-steps guideline originated in a Japanese pedometer marketing campaign. A prospective cohort study that followed 2100 adults on average for 10.8 years found that 7,000 steps were a mortality-risk dividing line. Participants who logged at least 7,000 steps experienced a 50-70% lower mortality risk than those who achieved less than 7,000 steps, regardless of step intensity (Paluch et al., 2021).
Exercise Effects on the Brain
Animal research has shown that exercise affects brain-derived neurotrophic factor, irisin, glial-derived neurotrophic factor, and microglia. Human studies demonstrate positive effects on paralysis and dementia.
Animal research has shown that exercise affects brain-derived neurotrophic factor, irisin, glial-derived neurotrophic factor, and microglia. Human studies demonstrate positive effects on paralysis and dementia.
Studies with mice and rats have shown that exercise increases expression of brain-derived neurotrophic factor (BNDF),
which increases the number of new neurons and neural connectivity, and aids learning to navigate the Morris water
maze (Gomez-Pinilla et al., 2001; Van Praag et al., 1999). Exercise also expresses the gene that codes for the hormone irisin, which may mediate some of the cognitive benefits of physical activity. Exercise increased spatial learning and memory in wild-type mice but not in irisin-deficient mice (Islam et al., 2021).
In mice predisposed to accumulate beta-amyloid plaques and develop Alzheimer's-like symptoms, mice with running
wheels (runners) performed better in the Morris water maze and showed half the beta-amyloid buildup of sedentary
mice (Adlard et al., 2005; Berchtold et al., 2005).
Rats who exercised daily on a treadmill for one week or were sedentary were subsequently injected with
6-hydroxy-dopamine, which selectively destroys dopaminergic (DA) neurons in the nigrostriatal pathway. Parkinson's
disease also involves the loss of DA neurons in this pathway. The rats that exercised lost fewer DA neurons than their
sedentary counterparts. Exercise may have increased expression of another neurotrophic factor, glial cell-derived neurotrophic factor. This is a small protein that promotes the survival of
dopaminergic and motoneurons (Zigmond & Cotman, 2005).
Microglia, the central nervous system's primary immune cells, centrally modulate neuroinflammation. Exercise may reprogram
microglia to increase their energy efficiency and resist neuroinflammation that can compromise cognitive functions like memory (Mee-Inta et al., 2019).
Exercise Effects on Paralysis and Dementia
MacDonald studied the effects of exercise on clients who had been paralyzed for an average of 5 years. Twenty-four
clients were assigned to exercise three times a week with bikes equipped with electrodes to stimulate pedaling, and
24 clients were assigned to stretching. At the end of 2 years, 40 percent of the exercisers and only 4 percent of
the stretchers increased motor function (McDonald et al., 2002).
A 6-year study of 1,740 participants over 65
associated moderate exercise with a reduced incidence of dementia (Brownlee, 2006).
Client Preparation with Respiration Training
Breathing assessment provides a roadmap for training clients to replace dysfunctional breathing with healthy breathing. Correcting breathing fundamentals is critical for heart rate variability biofeedback (HRVB) using paced breathing at the resonance frequency (RF) or 6 bpm. Most clients must learn to rely more on their diaphragm to ventilate the lungs, slow their respiration rate (RR), and breathe consistently to produce robust resonance effects.
This section covers Common Breathing Misconceptions, Healthy Breathing Roadmap, Medical Cautions, Breathing Basics, Physiological Effects of Healthy Breathing, Modalities for Teaching Healthy Breathing, Healthy Breathing Training, and Breathing Practice.
Appreciation
This section draws heavily on Dr. Inna Khazan's clinical experience and extensive writing and presentations on healthy breathing.
We only use one-fourth of inhaled oxygen and don't need more. We need to conserve CO2 by retaining 85-88% of its volume (Khazan, 2021).
Healthy Breathing Roadmap
Evaluate breathing during a psychophysiological assessment, correct breathing fundamentals, and then teach RF breathing to exercise the baroreflex.
If we don’t correct dysfunctional breathing patterns like overbreathing, they could compromise the effectiveness of HRVB training.
For example, overbreathing is associated with RRs far above the RF range of 4.5-7.5 bpm. Also, breathing is irregular--not sinusoidal. Together, these characteristics preclude strong resonance effects.
Before HRVB, respiration and the baroreflex are usually out of phase resulting in weak resonance effects. Graphic adapted from Elite Academy.
HRVB training slows breathing to the baroreflex’s rhythm aligning these processes and significantly increasing resonance effects. Graphic adapted from Elite Academy.
Slowing breathing to rates between 4.5-6.5 bpm for adults and 6.5-9.5 bpm for children increases RSA (Lehrer & Gevirtz, 2014). Graphic adapted from Elite Academy.
Increased RSA immediately “exercises” the baroreflex without changing vagal tone or tightening BP regulation. Those changes require weeks of practice. HRVB can increase RSA 4-10 times compared to resting (Lehrer et al., 2020b; Vaschillo et al., 2002).
Caption: The red waveform shows HR oscillations while resting without breathing instructions or feedback. The blue waveform shows HR oscillations with HRV biofeedback and breathing from 4.5-6.5 bpm.
Successful clients learn to breathe near their RF and achieve ocean-like breathing cycles without pacing or feedback.
Effortless breathing could be hazardous if your client suffers from diseases that produce metabolic acidoses like
diabetes and kidney disease. In these cases, overbreathing is an attempt to compensate for abnormal acid-base
balance, and slow-paced breathing could endanger health.
Clients diagnosed
with low blood pressure should be careful since slow-paced breathing might further lower blood pressure.
Finally, slow-paced breathing might produce a functional overdose if your client takes anti-hypertensive medication, insulin, or a thyroid supplement. If medication adjustment appears
necessary, your client should consult the supervising physician before reducing dosage (Fried & Grimaldi, 1993).
Breathing Basics
Healthy breathing achieves a match between metabolic needs, production of CO2, and breath depth and rate. We should maintain optimal breathing chemistry for each activity level and breathing rate.
Although rapid breathing does not always signal overbreathing and slow breathing does not always indicate health, there are correlations (Khazan, 2021).
Breathing should be mindful with focus on the abdomen, effortless, between 5-7 breaths per minute, supported by loose clothing, posture, and ergonomics that promote healthy breathing.
They should breathe at
a comfortable depth (like smelling a flower), exhaling longer than inhaling. Breathing will calm your client when its depth and rate satisfy their resting body’s metabolic needs (Khazan, 2021). Elena Sherengovskaya/Shutterstock.com.
Discourage typical deep breathing, where a client inhales a massive breath and inevitably exhales too quickly because this promotes overbreathing and expels too much CO2 (Khazan, 2021).
Relaxed breathing increases the carbon dioxide concentration of arterial blood compared to thoracic breathing. At rest, we only excrete 12-15% of blood CO2. Conserving CO2 lowers blood pH, weakens the bond between hemoglobin and oxygen, and increases oxygen delivery to body tissues. This phenomenon is called the Bohr effect. Check out MEDCRAMvideos YouTube lecture Oxygen Hemoglobin Dissociation Curve Explained Clearly!
Slow-paced breathing in the resonance frequency (RF) range (e.g., 4.5 to 7.5 bpm for adults) conserves CO2, reduces pH, releases NO and O2, and better distributes glucose and oxygen to more active tissues. Graphic adapted from Inna Khazan.
Healthy breathing can increase peripheral blood flow when the RR slows to the RF range of 4.6 to 7.5 bpm, and end-tidal CO2 normalizes to 5% or 36 mmHg. Peripheral vasodilation can increase perfusion and delivery of oxygen and glucose to the brain, reduce peripheral resistance, and promote hand-warming. These changes are crucial for executive functioning and treating hypertension, vascular headache, and Raynaud's disease. Breathing in the RF range can slow HR and increase vagal tone and HRV.
Healthy Breathing Training
You can teach healthy breathing as a component of weekly HRVB training sessions. Provide three or more 3-minute segments (some without feedback and pacing), each followed by coaching. Don’t progress to HRVB until your client has corrected dysfunctional breathing.
The red heart rate and blue respirometer tracings are synchronous with an almost 0-degree phase relationship in the screen below.
Robert Fried (1987)
recommends shifting breathing to the abdomen and slowing its rate. Clients should take normal-sized inhalations and not emphasize breath depth or volume. They should exhale slowly through the nostrils or pursed lips.
Encourage clients to wear nonrestrictive clothing, loosen their clothing to allow the diaphragm to move freely, and assume a comfortable position like reclining. Invite them to place one hand on the abdomen and the other on the chest for feedback (Khazan, 2021).
Some clients may find the image of a balloon helpful in shifting from thoracic to
abdominal breathing and remembering when the stomach should expand and contract.
Inhale -- the stomach expands, inflating the balloon.
Exhale -- the stomach contracts, delating the balloon.
Encourage mindful effortless breathing to prevent larger tidal volumes and faster exhalation that result in overbreathing.
Engage passive volition by using words like "allow," "let," and "permit," and avoiding "correct," "effort," "try," and "work."
Demonstrate low-and-slow breathing and allow clients several minutes practice in your clinic.
Click on the Read More button for sample instructions from Inna Khazan.
"Let's practice low-and-slow breathing. Allow your breath to shift lower towards your abdomen and to slow down gently . To help guide your breath lower, imagine that there is a balloon in your belly. What color is it? …. Now, with every inhalation, imagine that you are gently inflating the balloon and with every exhalation, you are allowing the balloon to deflate."
"Do not push your stomach out, do not pull it back in. In fact, do not apply any effort at all.
Provide your body with some guidance, and then let your body breathe for you.
This is all about letting your breathing happen as opposed to making it happen."
"Keep in mind that your body knows exactly how to breathe low and slow. When you were a baby and a young child, you were breathing this way all the time. You have a few years of practice. This is kind of like riding a bike; you don’t forget how to do it. You just need to let your body do what it knows how to do. Watch me doing this first, and then join in whenever you are ready.”
"Let’s shift the breath down from the chest to the belly, take a normal-sized comfortable breath in, and exhale slowly, perhaps blowing air out through pursed lips, as if you are blowing out a candle.
Allow yourself to exhale fully, do not rush the next inhalation
Again, take a normal-sized comfortable breath in, exhale slowly and fully."
Repeat for 5 or 6 breaths (Khazan, 2021).
Help Clients Recover Their Breathing Reflex
The Breathing Reflex
The breathing reflex is a physiological drive to inhale in response to rising CO2 levels. Clients may override the breathing reflex during overbreathing. They inhale too early before CO2 levels rise to the level that triggers the next breath, lowering blood CO2 levels.
This “hijacking” of the breathing reflex may represent an attempt to catch one’s breath due to fear of insufficient oxygen or to reduce anxiety (Khazan, 2021).
Several "red flags" can signal effortful breathing. First, accessory muscle (e.g., trapezius and scalene) SEMG increases. A trapezius-scalene placement is sensitive to breathing effort.
A
BioGraph ®
Infiniti accessory muscle training screen used to correct clavicular breathing is shown below.
Third, the respirometer waveform may lose its smoothness when clients try harder.
Breathing Practice
Breathing practice can help generalize breathing skills to everyday life. Clients may benefit from breathing apps and pacers. Encourage them to practice an exercise 20 minutes twice a day, log the activity, and discuss it at the start of the next training session. Also, encourage mindful low-and-slow breathing. Invite your client to observe their breathing several times a day in different settings. When they find themselves overbreathing, they can remind themselves to breathe with less effort.
Encourage Practice with Breathing Apps and Breathing Pacers
You may use a computer, pad, and smartphone apps that provide auditory or visual pacing. Try them out to find the apps that offer the adjustability and ease of use best for your clients. Click on the Read More button for computer software and smartphone breathing apps, and breathing pacers.
Consider
Coherence Coach and EZ-Air Plus for computers.
Popular apps are available for both Android and Apple platforms.
Assign practice with breathing pacers and then gradually fade them. Click on the Alliant link to download these free tracks.
Healthy Breathing Tips
Erik Peper (1994) and Inna Khazan (2021) have proposed several invaluable breathing suggestions.
The BioGraph ® Infiniti display below shows healthy inhalation and exhalation in which the abdomen gradually
expands and then contracts.
The BioTrace+/NeXus-10 training screen below was designed to teach effortless breathing. The balloon's inflation and deflation mirror the respiration sensor's rhythmic expansion and contraction.
Client Preparation with Heart Rate Variability Biofeedback
Clinicians may prepare clients for neurofeedback with HRVB. HRVB aims to exercise the baroreceptor
reflex and the vascular tone rhythm to enhance homeostatic regulation, regulatory reserve, and executive functions (Gevirtz, 2021). In addition, HRVB training can correct dysfunctional breathing, increase attention, and teach mindfulness and passive volition strategies.
Lehrer and colleagues (2000, 2013) have published two descriptions of their HRVB RF protocol that detail their approaches to assessment and training.
The client-practitioner relationship is the foundation of BFT and NFT. HRV biofeedback is most effective when clients and providers are mindful because this promotes self-awareness and a sense of agency. HRV biofeedback promotes self-regulation when a practitioner provides effective coaching (Khazan, 2019).
Mindfulness guides the trial-and-error process underlying self-regulation by helping clients draw connections
between their actions, internal feedback, and results. Graphic retrieved from Pinterest.
Slow-paced breathing involves healthy breathing near an
individual's unique resonance frequency (RF) or 6 breaths per minute (bpm) to exercise the
baroreceptor reflex and vascular tone rhythm, increasing vagal tone and HRV.
Mindful low-and-slow breathing can amplify RSA.
A HRV Biofeedback Koan
While your clients practice slow-paced breathing near their RF, this will increase peak-to-trough heart rate (HR) differences, RMSSD, and low-frequency (LF) power. RMSSD is root mean square of successive differences between heartbeats, which is an important measure related to vagally-mediated HRV. Following weeks of practice, they should expand their peak-to-trough HR fluctuations, RMSSD, and high-frequency (HF) power when breathing at typical rates without feedback or pacing (Gevirtz, 2021).
This unit covers Clinical Tips When You Start HRV Biofeedback Training, HRV Biofeedback Training, and Practice Assignments.
Clinical Tips When You Start HRV Biofeedback Training
Critical elements of HRVB training include modeling, your relationship with your client, passive volition, monitoring HRV, selecting an effective display, teaching rhythmical skeletal muscle tension instead of paced breathing, monitoring excessive effort, engaging games, and apps, pacing displays, resting heart rate (HR), and emotional self-regulation.
Consider an ECG sensor on the wrists or a PPG sensor on an earlobe or finger for clinical work.
A PPG sensor trades accuracy for ease of application. An ECG sensor may be required if there is significant vasoconstriction due to outdoor temperature or stress, movement, or standing (Constant et al., 1999; Hemon & Phillips, 2016; Jan et al., 2019; Medeiros et al., 2011).
Selecting an Effective Display
Provide an HRV training screen with respirometer and instantaneous HR waveforms.
Analog displays can provide your client with incredibly detailed and intuitive information. Encourage your client to
increase the peak-to-trough swings in heart rate during each breathing cycle (Lehrer et al., 2013; Lehrer & Gevirtz, 2014).
While client preference and success should guide your selection of feedback displays, you might first try feedback of LF power and peak-to-trough differences.
The concentration of signal power around 0.1 Hz in the LF band corresponds to the Institute of HeartMath's concept of coherence, in which a client produces a "narrow, high-amplitude, easily visualized peak" from 0.09-0.14 Hz (Ginsberg, Berry, & Power, 2010, p. 54; McCraty et al., 2009).
The BioGraph ® Infiniti screen shown below is
designed to increase the percentage of power in the LF
band. This display shows the dynamic change in the
distribution of HRV amplitude as a client breathes effortlessly and
cultivates positive emotion.
Some clients may prefer a display of the synchrony (alignment of peaks and troughs) between respirometer and instantaneous HR signals. Synchrony is crucial because it amplifies the resonance effects produced by slow-paced breathing (Vaschillo et al., 2002). The NeXus-10 ® BioTrace+ screen below displays the degree of synchrony between respiration and heart rate. The
flower opens as synchrony increases.
Teaching Rhythmical Skeletal Muscle Tension Instead of Paced Breathing
Excessive effort (active volition) during HRVB training can increase SNS activation, reduce vagal tone, and promote overbreathing. Clinicians can detect effort by monitoring respirometer, HR and HRV, accessory muscle SEMG, and capnometer waveforms.
Respirometer
Breathing effort can disrupt a smooth breathing waveform and create inflection points.
HR and HRV
If training effort increases SNS tone, HR may increase with very-low-frequency (VLF) band power, and HRV may decrease.
This phenomenon is called vagal withdrawal. In the FFT spectral plot, VLF power is colored gray.
The BioGraph ® Infiniti screen below provides respiratory
and SEMG biofeedback to teach rhythmic breathing while maintaining
relaxed accessory muscles.
Note the overuse of accessory muscles during clavicular breathing.
Once your client has mastered slow-paced breathing, games can motivate practice and speed skill acquisition. Biofeedback software allows clients to challenge themselves with increasing game difficulty levels without triggering parasympathetic withdrawal. This is crucial for transferring self-regulation skills to everyday life.
Click on the Read More button to see screens from Zukor's Drive, Zukor's Sport, the Garden Game, BioGraph Infiniti, Inner Balance, Elite HRV, HRV4 Training, and Camera HRV.
Inner Balance, Elite HRV, HRV4 Training, and Camera HRV screens are shown below.
Pacing Displays
Pacers can guide breathing and RSMT using animation and sound. Software may integrate a pacer into an HRVB display, or it may be separate.
Assign practice with breathing pacers and then gradually fade them.
You may use a computer, tablet, and smartphone apps that provide auditory or visual pacing. Try them out to find the apps that offer the adjustability and ease of use that will be best for your clients.
Consider
Coherence Coach and EZ-Air Plus for computers.
These apps are available for both Android and Apple platforms.
Use a stopwatch app that continuously loops when teaching RSMT instead of slow-paced breathing. For 6 cpm, select 10 seconds with no pause and instruct your client to contract their hands and feet simultaneously for the first 3 seconds of each cycle.
Clients can increase RSA and HRV time- and frequency-domain measurements during their initial training session. After four 30-minute sessions, many clients correct dysfunctioning breathing and increase vagal tone and HRV. However, they may require extended training
and practice (e.g., 10 or more sessions) to achieve maximum health and performance gains (Lagos et
al., 2011).
This section covers session structure, resting pre- and post-baseline measurements,
how to select a starting respiration rate, training introduction, training success indicators, training difficulty indicators, training segment review, promote mindful breathing, session review, comparing pre- and post-session values, HRV biofeedback training elements, and how many sessions are required.
Session Structure
Resting Pre- and Post-Baseline Measurements
Resting baselines measure your clients’ psychophysiological activity without feedback or paced breathing. You might instruct your clients to “sit quietly and breathe normally for the next few minutes.” You might monitor HRV, breathing (depth, pattern, and rate), autonomic activity (skin conductance and temperature), BP, and end-tidal CO2 as appropriate.
Compare pre-baseline to post-baseline changes within a session to show within-session learning. Evaluate pre-baseline changes across sessions to see the combined effect of clinic training and home practice.
Since your clients will breathe at typical rates (~12-16 bpm) during pre- and post-baselines, do not expect increases in LF power. Instead, look for increased HF, HRV metrics (e.g., RMSSD), and hand temperature, and reduced skin conductance level.
We train clients to increase LF power during slow-paced breathing to increase HF power during baselines when they breathe at typical rates.
How to Select a Starting Respiration Rate
Based on your client's RF, select an initial respiration rate for an animated pacing display. Since shaping is crucial to ensuring client motivation and success, choose a respiration rate within 1 or 2 breaths per minute of their baseline mean.
Training Introduction
Click on the Read More button to see sample introductory instructions.
A healthy heart is not a metronome. As you inhale, your heart rate speeds, and as you exhale, your heart rate
slows. This rhythmic speeding and slowing of your heart produces heart rate variability, which is vital to your
health, performance, and resilience against stressors. The purpose of heart rate variability biofeedback training is
to teach you to increase the healthy speeding and slowing of your heart by breathing effortlessly at the rate that
is best for you and by increasing your ability to experience positive emotions like feelings of
appreciation and gratitude.
Adopt a passive attitude in which you trust your body to breathe itself. Allow your attention to settle on your waist. Let your exhalation continue until your body initiates your next breath. Your inhalations should be no deeper than as if you were smelling a flower. Allow your breathing to follow the yellow ball effortlessly.
Allow
your stomach to gradually plop out as you inhale and then slowly draw inward as you exhale. As you practice, we will
adjust the speed of the pacing display. Let it guide your inhalation and exhalation.
The computer can help you learn slow, effortless breathing. The pink tracing shows your heart rate, while the
violet tracing shows the movement of the sensor around your stomach. As you gradually learn low-and-slow,
the two tracings should resemble smooth, repeating ocean waves.
Start recording data for 3 minutes. At the end of the training segment ask: ”How was the speed of the pacing
display? Should we change it? Should we adjust the inhalation and exhalation lengths? What did you experience as you
practiced breathing effortlessly?"
Training Success Indicators
Training Difficulty Indicators
Training Segment Review
Fit an entire 3-minute segment on the screen to review it together. If your client succeeded, you might point out where
they succeeded.
Promote Mindful Breathing
Before starting the next segment, you might ask: "What were you doing when the display became wavelike and regular?
What happened when the display became more jagged and irregular?" If accessory SEMG exceeded 2 microvolts, point
this out on the display, ask them if they felt the heightened breathing effort, and encourage them to "let their
shoulders relax and allow themself to breathe."
Reassure them that it's normal for the
tracings to be choppy when people start training and that they will gradually become more wavelike as their breathing
becomes more rhythmic and regular.
Instead of overwhelming them with corrections, ask them to experiment with one or two changes at a time. For example,
"Effortless breathing is rhythmic like ocean waves. Allow your stomach to expand and contract gently as you follow
the pacing display."
Session Review
After your client has completed six 3-minute training segments, take a 3-minute post-baseline without feedback. After
the post-baseline, ask your client how they felt and what they learned during the training session. Display the entire
session on one screen and highlight where they succeeded and where they need more work.
Comparing Pre- and Post-Session Values
Without pacing or feedback, your client should breathe at typical rates during the pre- and post-baselines. HF power, RMSSD, and hand temperature may increase, while skin conductance level may decrease.
The graphic below shows HF power in blue during a pre-training baseline, HRVB training, and a post-training baseline. The y-axis shows power in each band. HF power increases from ~100 during the pre-training baseline to ~300 during the post-training baseline. This change is important because increased HF power can signal greater vagal tone.
Also, note the greater LF power concentration post-training compared with pre-training during which the client breathed at typical rates. Inna Khazan generously provided the spectral plots. Inna Khazan generously provided the spectral plots.
HRV Biofeedback Training Elements
How Many HRVB Sessions Are Required?
Many clients start to breathe more effortlessly and increase HRV during their initial training sessions. There can be a several-week lag between increased HRV and improved health or performance. Clients require this time to consolidate their learning and transfer enhanced skills to the diverse settings of their lives.
Practice is the bridge between the clinic and everyday life.
Increased RSA immediately “exercises” the baroreflex without changing vagal tone or tightening blood pressure regulation. Those changes require months of practice (Gevirtz, Lehrer, & Schwartz, 2016; Lagos et al., 2011).
Assign 20 minutes of practice twice a day with HRV monitoring. They can fill out a diary online after each practice session and send you their IBIs. Khazan (2013) provides an excellent selection of logs in The Clinical Handbook of Biofeedback that you can adapt.
How much will your clients actually practice? You may have to settle for 10 minutes once a day or
“as needed.” Lehrer et al. (2020a) concluded that the frequency of home practice length did not impact effect size. The practice of resonance frequency breathing as needed may have produced most of their gains (p. 125).
As recommended by Gevirtz, include starting and ending hand temperatures since successful HRVB practice may produce hand-warming.
Explain the purpose of the exercise, demonstrate the skill in the clinic, and confirm that they can correctly perform it
and agrees to practice it. To build a collaborative relationship and empower your client, encourage them to find ways to
improve the exercise or develop a different one.
Overview
This section addresses practice in diverse settings,
aerobic activity, monitor HR, monitor HRV, emotional self-regulation, home HRV practice, advanced HRV assessment, and monitor finger temperature.
Invite clients to monitor their HR during daily activities and emotional states to increase mindfulness of stressors and their physiological responses to these challenges.
Monitor HRV
Apps like Elite HRV allow you to take HRV snapshots with limited artifact correction.
Institute of HeartMath Lock-In ® Technique Instructions.
Try to focus your attention on the area around your heart. Maintain your heart focus and, while breathing,
imagine that your breath is flowing in and out through the heart area. Breathe casually, just a little deeper than
normal.
Now try to recall a positive emotion or feeling that makes you relaxed and comfortable. Find a positive
feeling like appreciation, care, joy, kindness, or compassion. You can recall a time you felt appreciation or care.
This could be the appreciation or care you feel towards a special person, a pet, a place you enjoy, or an activity
that was fun for you.
If you can’t feel anything, it’s ok. Just try to find a sincere attitude of appreciation or care.
Continue to think of this positive feeling or emotion.
Acceptance and Commitment Therapy (ACT) and compassion meditation may also aid emotional self-regulation.
Home HRV Practice
Portable HRV biofeedback devices like the Institute of HeartMath's Inner Balance allow personal training whenever your clients want.
Advanced HRV Assessment
The Institute of HeartMath's emWave Pro Plus provides HRV assessment using their automated deep breathing protocol. The software reports commonly-used HRV metrics referenced to age-related norms.
The emWave Pro Plus also reports resting metrics for training sessions that run from 1-99 minutes.
Monitor Finger Temperature
Encourage your clients to monitor their hand temperature using inexpensive alcohol thermometers to see whether their practice resulted in warming or cooling.
Glossary
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.
accessory muscles: sternocleidomastoid, pectoralis minor, scalene, and
trapezius muscles, which are used during forceful breathing, as well as during clavicular and thoracic
breathing.
active volition: a process where you direct yourself to act
like clenching a fist triggered by words like make or try.
analgesia: insensitivity to pain.
autogenic discharges: Luthe identified 53 categories of side effects like
tingling and muscle twitches in 100 novice clients.
autogenic meditation exercises: in autogenic training, these techniques teach visual imagery skills after mastering the six standard exercises.
autogenic modification procedures: in autogenic training, organ-specific formulae and intentional formulae are used when a client does not respond to the six standard exercises.
autogenic shift: in autogenic training, the transition to a passive,
pre-sleep, hypnagogic autogenic state.
autogenic training: deep relaxation procedure developed by Schultz and Luthe
that involves six standard exercises, autogenic modification, and autogenic
meditation.
baroreceptor reflex (baroreflex): a mechanism that provides negative feedback control of BP. Elevated BP activates the baroreflex to lower BP, and low BP suppresses
the baroreflex to raise blood pressure.
bicarbonates: salts of carbonic acid that contain HC03.
Bohr effect: the influence of carbon dioxide on hemoglobin release of nitric oxide and oxygen.
brain-derived neurotrophic factor (BDNF): a member of the neurotrophin family that increases the number of new neurons and neural connectivity, whose expression is increased by exercise.
clavicular breathing: breathing pattern that primarily relies on the external
intercostals and the accessory muscles to inflate the lungs, resulting in a more rapid RR, excessive
energy consumption, and incomplete ventilation of the lungs.
clinically standardized meditation (CSM): a systematic secular meditative procedure incorporating meditative techniques like TM components.
coherence: narrow peak in the BVP and ECG power spectrum between 0.09 and 0.14
Hz.
confidentiality: a client's right to keep personal information private.
deep relaxation procedures: 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.
diaphragm: dome-shaped muscle whose contraction enlarges the vertical diameter
of the chest cavity and accounts for about 75% of air movement into the lungs during relaxed breathing.
differential relaxation: in progressive relaxation, the inhibition of unneeded
muscle groups during routine activities.
discrimination: perception of changes in physiological activity (0.5
microvolt versus 1 microvolt of SEMG activity) which is a crucial component of self-regulation.
effortless breathing: Peper’s relaxed breathing method in
which the client uses about 70% of maximum effort, attention settles below the waist, and the volume of air moving through
the lungs increases. The subjective experience is that "my body breathes itself."
empirical approach: data-guided strategy in which a therapist presents several
procedures to a client, determines which procedure they prefer, and monitors subjective cognitive and
physiological changes.
end-tidal CO2: the percentage of CO2
in exhaled air at the end of exhalation.
frequency-domain measures of HRV: calculation of the absolute or relative power
of the HRV signal within four frequency bands.
functional overdose: overdose that can occur when biofeedback training
reduces a patient's requirement for a drug. For example, biofeedback training may lower a patient's blood pressure
to the extent that the prescribed dose may produce hypotension and fainting.
glial cell-derived neurotrophic factor: a small protein synthesized in response to exercise, that promotes dopaminergic and motoneuron survival.
habit: a behavior pattern often acquired through frequent repetition.
heaviness and warmth standard exercises: in autogenic training, exercises that
teach clients the first two relaxation themes, heaviness and warmth, which are divided into seven parts.
high-frequency (HF) band: HRV frequency range from 0.15-.40 Hz that represents the inhibition and
activation of the vagus nerve by breathing (respiratory sinus arrhythmia).
HR Max – HR Min: a HRV index that calculates the average difference between the
highest and lowest HRs during each respiratory cycle.
hypnosis: a procedure that can aid therapy, for example, hypnotically-assisted
psychotherapy.
hypnotherapy: a controversial term that
implies that hypnosis is a therapy like cognitive behavior therapy.
hypnotic induction: from Hilgard’s perspective, the promotion of an
altered state of consciousness which is termed a hypnotic state.
hypnotic suggestibility: responsiveness to suggestion, measured by
instruments like the Stanford Hypnotic Susceptibility Scales, appears to be distributed along a bell-shaped curve.
informed consent: written statement in which participants voluntarily confirm
their willingness to participate in a research study following disclosure of all aspects of the study relevant to
their decision to participate.
intentional formulae: in autogenic training, autogenic modification
procedures, which may be reinforcing or neutralizing, are used to increase or decrease behaviors.
interbeat interval (IBI): the time interval between the peaks of successive R-spikes (initial upward
deflections in the QRS complex). This is also called the NN (normal-to-normal) interval after artifact removal.
low-frequency (LF) band: HRV frequency range of 0.04-0.15 Hz that may represent the influence of PNS and baroreflex activity when breathing at the RF.
mastery model: Shellenberger and Green's (1986) explanation compares
biofeedback training to coaching an athletic skill.
metabolic acidosis: pH imbalance in which the body has accumulated excessive acid and has insufficient bicarbonate to neutralize its effects. In diabetes and kidney disease, hyperventilation attempts to compensate for abnormal acid-base balance and slower breathing could endanger health.
mindfulness: a nonjudgmental focus of attention on the present on a
moment-to-moment basis.
negative hallucination: hypnotic phenomenon where normal perception is
suppressed, for example, perceiving an audience as naked following a hypnotic suggestion.
operant conditioning: an unconscious associative learning process that
modifies the form and occurrence of voluntary behavior by manipulating its consequences.
organ-specific formulae: in autogenic training, autogenic modification
procedures that modify standard exercise themes. For example, “My back is warm” instead
of “My right arm is warm.”
osteoporosis: decreased bone density, is reduced by weight-bearing exercise
that remodels the skeleton's bones.
overbreathing: subtle breathing behaviors like sighs and yawns reduce
end-tidal CO2 below 5%, exceeding the body's need to eliminate CO2.
parasympathetic division: 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 attitude: in autogenic training, allowing is
the most crucial element of the six standard exercises.
passive concentration: in autogenic training, the absence of effort and
goal direction.
passive volition: in autogenic training, visualizing the desired change and then
allowing the body to make the change at its own pace.
Quieting Response (QR): Stroebel's (1982) 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.
random-dot stereograms: hidden three-dimensional images created by repeating
patterns within one image that can be perceived by allowing your eyes to defocus until you see double.
Relaxation state (R-state): positive psychological state experienced during
relaxation.
Relaxation-induced negative reactions (RINRs):
Anxiety experienced during relaxation training.
resonance frequency: the frequency at which a system, like the cardiovascular
system, can be activated or stimulated.
respiratory sinus arrhythmia (RSA):
respiration-driven heart rhythm that contributes to the high frequency (HF) component of heart rate variability.
Inhalation inhibits vagal nerve slowing of the heart (increasing HR), while exhalation restores vagal slowing
(decreasing HR).
response stereotypy: a person’s unique response pattern to stressors of
identical intensity.
rhythmical skeletal muscle tension (RSMT): the simultaneous contraction of the hands and feet near an individual's RF to increase RSA.
RMSSD: the square root of the mean squared difference of adjacent NN
intervals.
SDNN: the standard deviation of the normal (NN) sinus-initiated IBI measured in milliseconds.
self-control: using a skill to achieve a desired state (e.g., running on a
treadmill to reduce weight).
self-efficacy: perceived ability to achieve desired outcomes. For example,
your belief that you can learn to lower your blood pressure.
self-hypnosis: self-suggestion.
self-maintenance: ensuring 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.
six relaxation themes: in autogenic training, the themes include heaviness,
warmth, cardiac regulation, respiration, abdominal warmth, and forehead cooling.
six standard exercises: in autogenic training, exercises that focus on the
physiological changes of the six relaxation themes. While the heaviness and warmth exercises are divided into
seven parts, the remaining four exercises focus on only one body region (heart, lungs, abdomen, and forehead).
Stanford Hypnotic Susceptibility Scales: instruments that measure
hypnotizability.
synchrony: the phase relationship between two signals in which their peaks and
valleys are aligned (e.g., HR and respirometer expansion reach their maximum and minimum values simultaneously).
systematic desensitization: Wolpe’s behavior therapy technique
incorporates an abbreviated version of progressive relaxation.
taking back procedures: in autogenic training, standard exercises end with
vigorous flexing of the arms, deep breathing, and opening the eyes, and the suggestion, "Arms firm, breathe
deeply, open eyes.”
time-domain measures of HRV: indices like SDNN that measure the degree to which
the IBIs between successive heartbeats vary.
Transcendental meditation (TM): mantric meditation developed by Maharishi
Mahesh Yogi, in which an individual repeats Sanskrit syllables that have been assigned by an instructor based on
age or personality.
transfer of training: generalization from clinic to a client's
environment.
ultra-low-frequency (ULF) band: HRV frequency range below 0.003 Hz. Very slow
biological processes that include circadian rhythms, core body temperature, metabolism, the renin-angiotensin
system, and possible PNS and SNS contributions.
vagus nerve: the parasympathetic vagus (X) nerve decreases the rate of
spontaneous depolarization in the SA and AV nodes, and slows the HR. Heart rate increases often reflect
reduced vagal inhibition.
very-low-frequency (VLF): HRV frequency range of 0.003-0.04 Hz that may represent temperature regulation, plasma renin fluctuations, endothelial, and physical activity influences, and possible intrinsic cardiac, PNS, and SNS contributions.
visualization: generation of mental imagery, which can be somatosensory and visual, is a common element in interventions ranging from autogenic training to behavior therapy.
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Assignment
Now that you have completed this unit, think about why you incorporate specific relaxation exercises in
your practice. What do you expect each to accomplish? How do you encourage
client practice? How do you assess compliance?
References
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Benson, H. (1975). The relaxation response. Morrow.
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Carrington, P. (1999). Clinically standardized meditation (CSM)
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