Biofeedback, Mind-Body Medicine, and the Higher Limits of Human Nature
Donald Moss, Ph.D.
A chapter included in: D. Moss (Ed.). (1998). Humanistic and Transpersonal Psychology: A Historical and Biographical Sourcebook. Westport, CT: Greenwood Publishing. Reprinted with permission of Greenwood Publishing Group. This book is available from AAPB's Bookstore or from Greenwood at http://info.greenwood,com/books/o313291/0313291586.html
Abstract : Chapter Ten summarizes the Biofeedback movement, which serves as the arena where "high tech" meets the higher states of consciousness. The concept of biofeedback was introduced at a conference in Santa Monica in 1969. The image of electronic equipment guiding human beings to a greater awareness and control over their own physiology and consciousness appealed to both white coated experimental scientists and the white robed gurus of the higher consciousness movement. Biofeedback encourages the humanistic dream that the human being can become creator of his or her own ever perfecting health and nature.
The Birth of Biofeedback: 1969
A new interdisciplinary paradigm emerged throughout the late 1960's, unifying developments from the diverse fields of psychology, neurophysiology, cybernetics, and medicine, culminating in a number of key publications in the final year of the decade: In 1969 Neal Miller published an article in Science on the “Learning of Visceral and Glandular Responses.” Elmer Green was senior author for two classic articles in the same year -- “Self-Regulation of Internal States” (in Proceedings of the International Congress of Cybernetics ), and “Feedback Technique for Deep Relaxation” (in Psychophysiology ). Charles Tart also published his edited compendium Altered States of Consciousness (Tart, 1969), including several articles on feedback techniques or operant conditioning modifying neuro-physiological processes.
In the same year key publications in systems theory and cybernetics gave wider dissemination to new concepts of feedback within systems, which were to be so critical in understanding self-regulatory phenomena. Ludwig Van Bertalanffy contributed a chapter to General Systems Theory and Psychiatry (1969); and Herbert Simon published The Science of the Artificial (1969).
"Biofeedback" as a model and technique was ready to be born: A scientist applies sensitive electronic instruments to provide meaningful information about physiologic processes to an animal or human subject. In turn, the subject gains greater awareness and control over the physiology and self-regulates more effectively. Bio-feedback, the providing of information back to a subject about life processes, contributes a powerful new tool for self-mastery, research, and clinical intervention.
In October 1969 the Biofeedback Research Society was formed, held its first meeting in Santa Monica, at the Surfrider Inn, and the phenomenon of biofeedback officially received its name. We will return to this institutional history of biofeedback as a profession, after reviewing several of the research and clinical foundations of biofeedback.
The Origins of Biofeedback
The contributions of many earlier researchers and practitioners can be cited as forerunners of biofeedback: Edmund Jacobsen commenced research at Harvard in 1908, and throughout the 1920's and 1930's worked to develop progressive muscle relaxation as an effective behavioral technique for the alleviation of neurotic tensions and many functional medical disorders (Jacobsen, 1938). He used crude electromyographic equipment to monitor the levels of muscle tension in his patients during the course of treatment. The German Johann Schultz contributed autogenic training in the 1930's, a discipline for creating a deep low-arousal condition, with a pervasive quieting effect on the autonomic nervous system (Schultz and Luthe, 1959). B. F. Skinner, Albert Bandura, Joseph Wolpe, and others extended the operant training principles of the animal laboratory into a refined science of behavior therapy and behavior modification through instrumental learning (Skinner, 1969; Bandura, 1969; Wolpe and Lazarus, 1966). The building blocks were in place for a science of self-regulation by the 1960's.
The scientific emergence of biofeedback is a good example of synchronicity. A number of independent areas of scientific work converged and overlapped, until a community of researchers recognized their common ground. Kenneth Gaarder points out that biofeedback was not so much a discovery, as it was "an awareness which emerged from the Zeitgeist" (Gaarder, 1979). Many researchers of the 1950's and 1960's can be cited as independent founders of biofeedback. I will highlight here the early work on EEG, visceral learning, electromyography, and incontinence.
Operant Control of EEG and the Pursuit of Alpha States
In the late 1950's, Joe Kamiya studied the phenomenon of internal perception or the awareness of private internal experiencing. Seredipitously, he discovered that a subject could learn through feedback to reliably discriminate between alpha and beta dominant cortical states, and then further demonstrated that a subject could learn to produce such alpha or beta brain states on demand (Kamiya, 1969, 1994; Gaarder & Montgomery, 1977, p. 4). Kamiya's continuing work on voluntary production of alpha states coincided with the dawning counter-cultural interest in altered states of consciousness, and the emergence of a new interest in Eastern religions, the psychology of consciousness, and in transpersonal psychology (Moss & Keen, 1981; deSilva, 1981).
This was the era in which Timothy Leary was attracting media attention, by encouraging youth to use LSD to discover new levels of human consciousness. In August 1969 the renowned social psychologist, Dr. Richard Alpert, renamed as Ram Dass, gave a presentation to the annual meeting of the Association for Humanistic Psychology on “The Transformation of a Man from Scientist to Mystic.”
Alpha brain states are most closely associated with a creative, open awareness, or with a receptive, meditative state. Kamiya's research gave birth to a new humanistic dream, of human beings learning to cultivate a spiritually awakened state, within a relatively short time frame, and through the guidance of electronic monitoring. Now human beings could explore higher states of consciousness without psychedelic drugs.
A host of EEG studies and optimistic clinical reports followed. In 1967 Les Fehmi undertook a series of experiments on producing brain synchrony in humans, in hopes of enhancing the clarity and scope of information processing. In another example of serendipity, Fehmi discovered that he dramatically increased his own alpha production, after he "gave up on the task," out of frustration at being unable to increase alpha. Further study of voluntary enhancement of alpha brain states, including studies of relaxation and imagery, led Fehmi to highlight a broadened, diffuse state of awareness. Fehmi contends that this non-focused, non-goal oriented attentional state serves to release physiological tensions, soften interpersonal relating, and optimize physiological functioning and health. Out of this program of research Fehmi developed his Open Focus model, for training individuals in a learned, meditative attentional style (Fehmi & Fritz, 1980; Fehmi & Selzer, 1980; Fehmi, in press). On a more philosophical level, Fehmi characterizes the human being as Homo qui attendit quomodo attendit , or the species which can attend to and choose its own style of attention (in press).
The research on alpha brain wave production and meditative spirutual awareness found a ready audience in the popular press. A new industry emerged, offering "alpha training units," primitive biofeedback instruments, to assist the meditatively oriented individual in enhancing alpha states.
The scientifically minded community became increasingly skeptical. Ancoli and Kamiya (1978) critiqued the methodological weaknesses and inconsistencies of many of the early studies on alpha feedback training. They found the quality and length of training inadequate in many studies, and criticized researchers for neglecting to monitor such critical variables as the social interactions between experimenter and subject, and instructional set (1978, pp. 179-180). In 1979 Basmajian declared that "Alpha feedback is still a mystery but it is not an acceptable treatment method" (1979, p. 1).
The basic principle that brain processes can be brought under voluntary control remains exciting, and the scientific evidence for this principle continues to mount four decades later. Further, the interest never entirely faded in pursuing meditative, alpha dominant states of mind conducive to some kind of spiritual integration. Today's EEG feedback or neurofeedback movement, however, has also been encouraged by additional pragmatic applications of brain wave control.
Eugene Peniston's impressive 1989 report on successful outcomes in treating alcoholics with a program based on enhancing alpha/theta range cortical activity sparked a flood of interest, that altered states of consciousness could, after all, have benefit for personal growth and recovery (Peniston & Kukolsi, 1989). Similarly, a series of methodologically cautious reports by Joel Lubar suggested that schoolchildren diagnosed with Attention Deficit and Hyperactivity Disorder could enhance their attentional capacities through selective EEG training in theta suppression and enhancement of beta range cortical activity (Lubar, 1989, 1991; Lubar and Shouse, 1977).
The neurofeedback movement of the late 1980's and 1990's continues some of the evangelistic fervor and methodological carelessness of the 1960's alpha movement. The advances in instrumentation and computer signal processing in three decades, however, make possible an impressive degree of precision in electro-encephelographic measurement and real time feedback.
Visceral Learning and the Dream of Controlling One's Own Health
Neal Miller, Leo DeCara, and their colleagues carried out a series of dramatic animal experiments in the 1960's, demonstrating the operant conditioning of a variety of internal autonomically regulated physiologic processes, including blood pressure, cardiac function, and intestinal activity (Miller & DeCara, 1967; Miller, 1969; Miller, 1978). Prior to their research physiologists generally assumed that organisms have control over bodily functions governed by the central nervous system (or "voluntary nervous system"). The internal physiological processes controlled by the autonomic (or "involuntary") nervous system were regarded as operating beyond conscious awareness or control.
Miller and DeCara used animals paralyzed by curare so that the animals could not produce the desired visceral changes through voluntary activity mediated by the central nervous system. In this paralyzed state their animal subjects were still able to change their visceral functions. A group of thirsty dogs were trained to salivate more (or to salivate less) to obtain water. Curarized rats were even able to change their EEG.
Many of Neal Miller's experiments on curarized animals have not been successfully replicated, yet his animal studies spurred further investigations extending the same operant model of visceral learning to human subjects (Miller & Dworkin, 1974). More importantly, Miller's research inspired the hope that biofeedback can enable a human being to take a more active role in recovering and maintaining health. Further, it encouraged the dream that human beings can aspire to previously unimagined levels of personal control over bodily states, reaching unprecedented states of wellness and self-control.
John Basmajian and the Control of a Single Motor Unit
The skeletal muscles have long been known to be under the human being's conscious control, through the central nervous system. Human locomotion is based on this conscious control. The individual carelessly pictures the destination, and begins to move. In that same moment his or her central nervous system fluidly organizes multiple components of muscular activity into a "kinetic melody," which effectively carries the individual to the goal. Hundreds and even thousands of "motor units" (each motor unit comprised of many muscle fibers) are recruited into one such activity or movement. A variety of diseases, injuries, and pathological conditions undermine this muscular integration, and rehabilitation of muscle pain and functional motor deficits is challenging at best. In many cases injury destroys the sensory-motor pathway linking brain and muscle, while the muscle fibers themselves remain structurally intact, but without coordination. Even the healthy individual shows little precise awareness of, or control over, individual motor units in the muscles. There is no proprioceptive sensation to guide the acquisition of control of such microscopic areas of muscle function.
John V. Basmajian began a program of research in the 1950's to test the outer limits of voluntary control over the skeletal muscles. Basmajian utilized surface electrodes over the muscle, and visual (oscilloscope) and auditory feedback to the subject (Basmajian, 1967). Ultimately he demonstrated that almost any subject could establish conscious control and training of a single motor unit within a muscle, within a brief time. On one occasion he monitored the muscle functions of a television interviewer. This interviewer insisted that he would learn the motor control, while simultaneously conducting the interview for television cameras. Basmajian discouraged this bravado, yet the interviewer persisted and mastered the motor control with feedback, while carrying out the half hour interview (Brown, 1980).
Basmajian's research, and the thousands of investigations which have followed, have established the powerful role which surface electromyography can play in physical therapy, neuromuscular re-education, and pain treatment (Moss, Kasman, & Fogel, 1996). The applications range from relieving a tension headache to rehabilitating foot drop after a stroke. Further, Basmajian's work provides convincing support for the basic biofeedback model. If an external device is able to provide the human subject with precise information about physiological processes, then the individual's control over these bodily processes can be increased. Even those muscles (or other organ functions) that have been damaged by injury or disease process may be brought under some form of compensatory control, once electronic feedback is provided to the individual. The biofeedback instrument creates a functional substitute (an external feedback loop), replacing the body's original internal feedback and self-regulatory process.
Arnold Kegel, O. H. Mowrer, and Incontinence
One less glamorous area of clinical biofeedback practice antedates the rest of the biofeedback movement by at least two decades. In 1947 California gynecologist Arnold Kegel invented the perineometer, to assist his gynecological patients in controlling urinary leakage. John Perry and Leslie Talcott (1988, 1989) point out that the perineometer meets all of the definitions of a biofeedback device, including the 10 point definition of biofeedback proposed by Mark Schwartz (Schwartz & Associates, 1987). The perineometer is an instrument inserted into the vagina, which measures muscle contraction and provides the patient with immediate feedback, to guide her enhanced control of urine. The use of this device enhances self-regulation, and avoids personal embarrassment, social stigma, and costly and often ineffective surgical procedures. Dr. Kegel also introduced the now widely used Kegel exercises, but it is noteworthy that the Kegel exercises are more effective when their use is accompanied by perineometric feedback. John Perry points out that the only book on biofeedback ever to reach the New York Times Bestseller List was The G Spot and Other Recent Discoveries about Human Sexuality (Ladad, Whipple, & Perry, 1981), which includes discussion of the Kegel exercises and the perineometer.
The field of incontinence treatment also produced another contender for the earliest biofeedback device. O. Hobart Mowrer, the respected psychological researcher, described the use of a bedwetting alarm in a 1938 article. The simple device detected wetting, sounded an alarm, and awakened the child and parents (Mowrer & Mowrer, 1938). This immediate feedback triggered awakening, reflex sphincter contraction, and detrusor muscle relaxation. Through a process of classical conditioning, the internal cues presented by the filling bladder take over to stimulate the same response sequence (Collins, 1973). Many children rapidly learn to self-monitor and self-regulate. The process becomes automatic for most children, to the extent that they sleep through the night without incident.
These early innovations in daytime and nighttime incontinence treatment have born fruit with dramatic personal consequences for many individuals. The United States Agency for Health Care Policy and Research published practice guidelines for adult urinary incontinence in 1992, recommending biofeedback as the first choice of treatment (Whitehead, 1995). Research reports show a similar efficacy for biofeedback with fecal incontinence (Whitehead & Drossman, 1996). These procedures produce a tremendous boon in personal esteem, because the individual can once again to lead an active life without shame or fear. Further, incontinence is one of the most frequent reasons many older adults are placed prematurely in nursing home care, and effective treatment preserves the personal dignity of independent living.
The Rapid Application of Biofeedback Techniques
The work of the above pioneers in biofeedback was not alone. Reports of biofeedback applications to a variety of medical and emotional disorders proliferated rapidly in the 1960's and 1970's. I will cite just a few of these investigations: Barry Sterman (1986) demonstrated that EEG guided training of a specific sensori-motor rhythm over the sensori-motor cortex could suppress some epileptic seizures. Bernard Engel (1973) reported operant control of cardiac arrhythmias. Chandra Patel (1975) reported on the use of both yoga and biofeedback in hypertension. Elmer Green, Dale Walters, and Joseph Sargent reported on the use of self-regulation training for migraine headache (Sargent, Walters, & Green, 1972). Thomas Budzynski, Johann Stoyva, and Charles Adler (1970) reported on the effects of feedback induced muscle relaxation on tension headaches.
A Science of Self-Regulation
By 1975 the field of biofeedback had established a number of effective treatment protocols, for tension headache, migraine, lower back pain, temporo-mandibular disorders, hypertension, Raynaud's syndrome, incontinence, and a number of other functional disorders. The basic instrumentation triad of the EMG, thermal feedback, and the GSR had emerged as the "workhorses" of the biofeedback clinic. The electromyograph (or EMG) measures the electrical potential of muscle fibers, and proved to be useful for general relaxation training, the treatment of headaches and muscular pain, and neuromuscular education. Thermal feedback measures skin temperature, especially finger temperature, and proved useful as an indirect measure of vaso-constriction or vaso-dilation and blood flow. Thermal feedback proved useful for migraine headache, Raynaud's disease, hypertension, and general autonomic relaxation. The Galvanic Skin Response meter (GSR, also referred to as a Skin Conductance or Electrodermal Activity meter) measures electrical changes in the skin, associated with sympathetic nervous arousal. The GSR proved useful as an adjunct to psychotherapy and behavior therapy, measuring anxiety and cognitive/emotional threat reactions (Fuller, 1977). A variety of additional feedback modalities proved useful for special applications: the feedback EEG (electroencephalograph), measuring electrical activity on the cortex of the brain; the pneumograph, measuring respiration rate and pattern; the photo-plethysmograph, measuring heart rate and blood pulse volume; the perineometer, discussed above; and a variety of other devices (Schwartz and Associates, 1995).
This same time period of the 1960's and 1970's also saw the articulation of a number of concepts framing a new approach to health, wellness, and the actualization of higher human potential.
Humanistic psychology dramatically emphasized the unity of body and mind. Fritz Perls introduced a number of body awareness exercises into Gestalt therapy, as did the Reichian and other body therapy schools. Biofeedback took this emphasis on a mind-body unity to a new level and created a mind-body medicine. The "psycho-physiological principle" was formulated in a variety of ways; Elmer Green and his associates expressed it as follows: "Every change in the physiological state is accompanied by an appropriate change in the mental-emotional state, conscious or unconscious, and conversely, every change in the mental-emotional state, conscious or unconscious, is accompanied by an appropriate change in the physiological state" (Green, Green, & Walters, 1970, p. 3). Body and mind are one, and the pursuit of health requires a holistic, biopsychosocial approach (Green & Shellenberger, 1991).
Ian Wickramasekera and colleagues have proposed that current applied psychophysiological methods can serve as a bridge between the traditional biomedical model and the biopsychosocial model in family medicine and primary care (Wickramasekera, Davies, & Davies, 1996). Over 75 % of patients visiting a primary care physician present with physical symptoms related to psychosocial and behavioral factors. Engel (1977) called for a biopsychosocial model for medicine almost two decades ago, but this challenge remains unfulfilled. Wickramasekera cites a variety of interrelated mind-body techniques -- biofeedback, hypnosis, and cognitive behavior therapy -- as effective tools for addressing a variety of stress related disorders and somatization disorders. Psychophysiological assessment and psychophysiological monitoring using sophisticated electronic biofeedback instruments can play a critical role in effective interventions with medical patients (Wickramasekera, Davies, & Davies, 1996, pp. 223-229).
George Whatmore and Daniel B. Kohli (1974) used EMG feedback to teach patients to relax muscle groups and developed the concept of dysponesis, misplaced effort, as a common neurophysiological factor in many functional disorders. Many individuals facing stressful situations respond by dramatically increasing efforts in the same old directions, and drawing on the same old strategies and habits. The result is a misplaced waste of effort and energy. The concept of dysponesis takes this problem of "doing more of the same" to a neuro-physiological level. In the face of stress the individual engages in maladaptive muscular efforts, breathing patterns, and autonomic arousal, producing only illness and fatigue. The promise of biofeedback is to increase awareness of such dysponetic habits, and to provide an avenue to new more healthful behavioral and physiological habits.
The Stress Response and the Relaxation Response
Hans Selye's (1956) groundbreaking research on stress demonstrated that the human response to stress is an adaptive biological response with impact on the entire organismic system. Cognitive attention to an approaching threat triggers an alarm and mobilization response preparing the body for emergency action. The stress response activates the limbic or emotional brain, and the hypothalamus, which then stimulate large portions of the sympathetic nervous system and the endocrine system. The result is a flood of stress hormones (including ACTH), elevated blood sugar, and hyper arousal of many internal organs and functions. The individual will notice elevated heart rate, tense musculature, rapid respiration, and a variety of intense emotional states. This adaptive response prepares the individual to flee or fight the threat. In ideal circumstances the threat passes and the individual can return to a more relaxed psycho-physiological state.
In modern human society, however, the individual is exposed to chronically stressful work and family environments, the individual perseverates in thinking about the problems, and neither mind nor body return to the original resting state. This is the basis for many functional medical and psychiatric disorders. The body and mind enter a state of fatigue, exhaustion, and loss of adaptability. Many of specific components in the stress response have a temporary adaptive effect, but a debilitating effect over time. Under stress, for example, the pituitary releases vasopressin, which contracts the walls of the arteries, raising blood pressure. Over time this vasoconstriction contributes to chronic and life threatening hypertension. The immune system also can become depleted and unable to protect one from disease.
More recent research has shown that the so-called stress response is really more complex than first recognized. The autonomic nervous system does not respond as one single unit; rather a variety of divergent patterns occur in different individuals, some for example, affecting the cardio-vascular system in various ways, others affecting the upper or lower gastrointestinal tract, and others the musculoskeletal system. Both sympathetic and parasympathetic nervous system activation patterns play a role in the multiple forms of the human stress response (Gevirtz, 1996).
Herbert Benson (1975) established that just as there is a human stress response , with negative effects on the body, there is also a relaxation response with a healing or restorative impact on the human physiology and mind. Benson began by investigating transcendental meditation, and its effects on physiology. The effects were the exact opposite of the stress response: a decrease in sympathetic activation, a reduction in stress hormone levels, lowered heart rate and blood pressure, relaxed musculature, and emotional calm. Benson reviewed the literature on Eastern meditation, Christian mysticism, and relaxation practices, and found that most approaches shared a common formula with three elements: a quiet environment, cultivation of a passive mental attitude ("letting go"), and the use of a mental device to focus attention. Benson then developed a non-religious form of meditation based on these three elements, and discovered similar effects on quieting physiological arousal. Benson hypothesized that this "relaxation response" (as he calls the psycho-physiological state), appears to underlie the beneficial effects of many schools of Eastern and Western meditation, yoga, and relaxation skills training.
Benson's research showed the clinical benefits of cultivating the relaxation response: in lowered blood pressure, reduced anxiety, smoke cessation, and reduced drug and alcohol dependence. The relaxation response provides a conceptual framework for one of the major contributions of biofeedback. Providing immediate physiological feedback enhances the acquisition of a relaxation response, with immediate benefits for a number of functional medical disorders.
The Institutional History of Biofeedback
Academic departments of neurophysiology, physiological psychology, and sleep research, and a few medical institutions such as the Veterans Administration and the Menninger Foundation supported much of the new research on feedback mechanisms controlling physiological processes. Kenneth Gaarder identifies two critical meetings that preceded the Santa Monica Conference and supported the networking that culminated in the Biofeedback Research Society. First, an annual Veteran's Administration research meeting took place in Denver in 1968, and several feedback researchers were in attendance: Thomas Budzynski, Kenneth Gaarder, Thomas Mulholland, Barry Sterman, and Johann Stoyva. Then in April 1969 the American Association for Humanistic Psychology and the Menninger Foundation co-sponsored a Conference on Altered States of Consciousness in Council Grove, Kansas, bringing together researchers working on many aspects of consciousness in relation to health. The work reported at Council Grove reflected the mood of the 1960's, including research on meditation, psychedelic drugs, mysticism and extra-sensory perception. Elmer Green was one of the prime movers for the conference, and Barbara Brown, Kenneth Gaarder, Joe Kamiya, Gardner Murphy, and Johann Stoyva were in attendance.
The Santa Monica Conference and the Biofeedback Research Society
In 1969 a triad of Kenneth Gaarder, Gardner Murphy, and Barbara Brown formed a core committee to organize a single unifying conference to focus the growing interest in the concept of feedback. Several colleagues encouraged and supported the concept of a larger conference and the establishment of a new scientific society. Barbara Brown did most of the logistical work for the conference, set up the scientific program and later was elected as the first President. The Conference ran from October 20-22, 1969, at the Surfrider Inn in Santa Monica.
The Conference program was organized into a series of research reports and panels on the following issues: "Conditioning and the Control of Autonomic Functions, Muscle Feedback, EEG Feedback, Feedback and States of Consciousness, Methodologies of Feedback, Feedback--Theory and the Future, Feedback Techniques in Experimental Animals, and Clinical Applications of Feedback Concepts."
The word biofeedback was not listed anywhere in the program and one of the controversial issues of the program was the debate over what to call this new research/treatment technique as well as what to call the organization. The terms self-regulation, auto-regulation, and feedback were all proposed. Finally the technique of "biofeedback" was named and the Biofeedback Research Society was formed.
The presenters listed in the program include John Basmajian, Barbara Brown, Thomas Budzynski, Leo Di Cara, Les Fehmi, Elmer Green, Joe Kamiya, Thomas Mulholland, Gardner Murphy, Barry Sterman, Johann Stoyva, Charles Tart, and George Whatmore, among others. Joe Kamiya observes that the group that gathered in Santa Monica was fascinating in its diversity, ranging from "the hardest nosed operant conditioners to those in white robes." The Eastern spiritual influences were strong, as was the humanistic emphasis on the unfolding of new levels of human potential. The pursuit of Alpha cortical states as a pathway to spiritual awareness especially drew the interests of transpersonal psychologists and meditators. Yet methodology and rigorous psychophysiological research received equal emphasis. Biofeedback seemed to be a meeting point where high technology and the higher levels of consciousness could meet.
After Santa Monica the broadly focused new Biofeedback Research Society continued to evolve, becoming the Biofeedback Society of America in 1976, and the Association for Applied Psychophysiology and Biofeedback in 1988. The development of a panoply of clinical techniques for a variety of health problems increased the clinical emphasis of the Society. A greater emphasis developed on research documenting clinical efficacy of biofeedback techniques with a variety of clinical problems.
Biofeedback and Applied Psychophysiology Today
Today the Association for Applied Psychophysiology and Biofeedback, headquartered in Wheat Ridge, Colorado, supports a peer reviewed journal publishing scientific articles, and a newsmagazine, and fosters basic scientific work by recognizing outstanding research papers at the annual conference. A variety of sections and interest groups have developed within the Association for individuals pursuing special interests in: EEG feedback (“neurofeedback”), surface EMG applications, technology, education, nursing, pediatric applications, respiratory physiology, and applied psychophysiology in family medicine.
Diversity continues to characterize the organization, which remains multi-disciplinary and continues to combine the poetic and the empirical in its annual programs. The 1996 annual meeting in Albuquerque, New Mexico featured keynote speakers on: 1) the frontiers of brain imaging technology, 2) transpersonal medicine, 3) the psychophysiology and behavioral treatment of hypertension, 4) the development and control of childhood asthma, 5) recent advances in spinal cord rehabilitation, and 6) "Why do African Americans suffer illness and die at a higher rate than other Americans?"
As this list of speakers illustrates, both the scientific foundations and the clinical breadth of the biofeedback movement has grown steadily since 1969. The term biofeedback is frequently criticized as too narrow, since biofeedback practitioners also engage in a variety of other treatment interventions, drawing on psychophysiological principles, but without specific use of a biofeedback instrument. The concepts of applied psychophysiology, clinical psychophysiology, and behavioral health may more broadly capture the spirit of the field today.
The majority of biofeedback practitioners today are health care providers involved in a daily clinical practice; this includes physicians, psychologists, nurses, social workers, physical and occupational therapists, and several other disciplines. Clinical biofeedback today offers a diversity of clinical procedures and protocols, with applications to a wide range of disorders.
Today's vigorous EEG biofeedback movement, or neurotherapy movement, provides examples of the diversity of today's clinical biofeedback: Many substance abuse therapists apply Eugene Peniston's treatment protocol for training recovering alcoholics to produce higher magnitudes of alpha and theta brain activity, while utilizing imagery techniques for self-transformation and rehabilitation (Peniston & Kulkoski, 1989). Other neurotherapist's follow Joel Lubar's or Michael Tansey's protocols for training children with attention deficits to alter dominant brain rhythms and enhance academic attention (Lubar, 1991). Others apply Barry Sterman's (1986) EEG protocols to suppress convulsive neural activity and control epilepsy. Additional EEG applications and treatment protocols emerge regularly for disorders ranging from multiple personality to closed head injury.
According to an AAPB publication (Shellenberger, Amar, Schneider, & Turner, 1994, pp. 2-3), the clinical efficacy of biofeedback has been demonstrated for the following disorders: anxiety disorders, attention deficit and hyperactivity, cerebral palsy, chronic pain, enuresis, epilepsy, essential hypertension, headache (migraine, mixed and tension types), incontinence (fecal and urinary), insomnia, irritable bowel syndrome, motion sickness, myofascial pain syndrome, neuromuscular disorders, rectal pain and rectal ulcer, Raynaud's disease, rheumatoid arthritis pain, stroke, and TMJ disorders.
In a recent publication Schwartz and Associates categorized biofeedback applications according to the quality of outcome research supporting each application. Schwartz and Associates (1995, pp. 108-109) report that abundant empirical research has demonstrated biofeedback's efficacy for the following disorders: tension-type headache, migraine headache, Raynaud's disease, urinary and fecal incontinence, essential hypertension, nocturnal enuresis, and dyschezia. At least some research supports good outcomes with: insomnia, anxiety disorders, chronic pain, ADD and ADHD, functional nausea and vomiting, irritable bowel syndrome, motion sickness, asthma, bruxism and TMD, tinnitus, phantom limb pain, and secondary Raynaud's symptoms. Additionally, there are case reports of positive outcomes for biofeedback with: writer's cramp, esophogeal spasm, occupational cramps, blepharospasm, dysmennorhea, visual disorders, some dermatologic disorders, diabetes mellitus, fibromyalgia, and menopausal hot flashes.
Today AAPB has a sister organization, the Biofeedback Certification Institute of America (BCIA), also headquartered in Wheat Ridge, Colorado, which serves to assure the standards of care in the clinical practice of biofeedback. BCIA has established a basic blueprint of knowledge and skills regarded as essential to the practice of clinical biofeedback. BCIA now grants certification in three areas -- biofeedback, stress management, and eeg biofeedback -- based on didactic educational pre-requisites, supervised personal training, supervised clinical practice, and a comprehensive exam.
Biofeedback Today and the Search for Human Potential
Several figures in the field have expressed a concern that biofeedback's transformation into a health profession treating sick individuals has led the field astray from the original dream of a human being guided by technology into a higher realization of human potential (Kamiya, 1994; Kall, 1994; Peper, 1996). According to Rob Kall, the vision of biofeedback involves recreating wholeness, balance and health, rather than merely eliminating symptoms. At its best, biofeedback "... opens people's vision, dissolves inner barriers, illuminates paths to greater potential, opportunity, capacity for happiness, and ability to share with and contribute to others" (1994, p. 30).
The excitement of enhancing personal control and self-direction is never entirely lost even in the most mundane clinical procedures. Clinicians frequently report that patient's utilizing biofeedback instruments have repeated "Eureka" experiences: "You mean that when I change my thoughts, my heart slows down and my heart rate and breathing come into balance," or "I can do it! I can warm my own hands with my own mind. And I don't ever have to have headaches again."
Nevertheless, the critics remain justified in their concerns. The original visionaries never intended biofeedback to be an entirely practical affair. Barbara Brown, a founder and first president of the Biofeedback Research Society, proclaimed that biofeedback could give to the human being a New Mind and a New Body (1975). Later she imaged this new mind as a Supermind , with expanded consciousness and unlimited potential (Brown, 1980). Kenneth Pelletier showed that the mind can slay human health, but with the guidance of biofeedback, autogenic training, and meditative practices this same human mind can become the basis for a new holistic and creative adaptation for the healthy individual (1977).
If we are to be faithful to this original vision of Barbara Brown, Kenneth Pelletier, Elmer Green, and so many others, it is essential that the approach, concepts, and techniques of biofeedback remain available for education, spiritual discovery, self-awareness, and personal growth, and never become entirely medical. The biofeedback research tradition remains a part of the humanistic quest for human freedom, self-regulation, and personal and spiritual renewal.
References to Chapter Ten
- (The author is grateful to Joe Kamiya, Kenneth Gaarder, and Francine Butler for assistance in drafting the historical overview.)
- Ancoli, , & Kamiya, J. (1978). Methodological issues in alpha biofeedback training. Biofeedback and Self-Regulation , 3 (2), 159-183.
- Bandura, A. (1969). Principles of behavior modification . NY: Holt, Rhinehart, and Winston.
- Basmajian, J. V. (1967). Muscles alive: Their functions revealed by electromyography. Baltimore: Williams and Wilkins.
- Basmajian, J. V. (1979). Biofeedback: Principles and practice for clinicians . Baltimore: Williams and Wilkins.
- Benson, H. (1975). The relaxation response . NY: William Morrow.
- Brown, B. (1974). New mind, new body . NY: Harper & Row.
- Brown, B. (1977). Stress and the art of biofeedback . NY: Harper & Row.
- Brown, B. (1980). Supermind: The ultimate energy . NY: Harper & Row.
- Budzynski, T. H., Stoyva, J. M., & Adler, C. (1970). Feedback induced muscle relaxation: Applications to tension headache. Journal of Behavior Therapy and Experimental Psychiatry , 1 , 1-14.
- Butler, F. (1993, June). Personal correspondence.
- Collins, R. W. (1973). Importance of the bladder-cue buzzer contingency in the conditioning treatment for enuresis. Journal of Abnormal Psychology , 82 (2), 299-308.
- DeSilva, P. (1981). Two paradigmatic strands in the Buddhist theory of consciousness. In R. S. Valle & R. von Eckartsberg (Eds.), The metaphors of consciousness (pp. 275-285). NY: Plenum.
- Engel, B. T. (1973). Clinical applications of operant conditioning in the control of cardiac arrhythmias. Seminars in Psychiatry , 5 (4), 433-438.
- Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine, Science , 196, 129-136.
- Fehmi, L. G., & Fritz, G. (1980, Spring). Open focus: The attentional foundation of health and well being. Somatics , 24-30.
- Fehmi, L. G., & Selzer, F. (1980). Attention and biofeedback training in psychotherapy and transpersonal growth. In S. Boorstein & K. Speeth (Eds.), Explorations in transpersonal psychotherapy (pp. 314-337). NY: Jason Aronson.
- Fehmi, L. G. (in press). Attention to attention. In R. Kall (Ed.), Applied neurophysiology and brain biofeedback . Trevose, PA: FUTUREHEALTH, Inc.
- Fuller, G. D. (1977). Biofeedback: Methods and procedures in clinical practice . San Francisco: Biofeedback Press.
- Gaarder, K. R., & Montgomery, P. S. (1977). Clinical biofeedback: A procedural manual . Baltimore: Williams and Wilkins.
- Gaarder, K. (1979). Unpublished manuscript on the founding of the Biofeedback Society of America.
- Gevirtz, R. (Chair). (March, 1996). The stress response is not unidimensional . Symposium at the Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Albuquerque, New Mexico.
- Green, E. (1969). Feedback technique for deep relaxation. Psychophysiology , 6 (3), 371-377.
- Green, E., Green, A. M., & Walters, E. D. (1970). Self-regulation of internal states. In J. Rose (Ed.), Progress of cybernetics: Proceedings of the First International Congress of Cybernetics, London, September 1969 (pp. 1299-1318). London: Gordon and Breach Science Publishers.
- Green, E., Green, A. M., & Walters, E. D. (1970). Voluntary control of internal states: Psychological and physiological. Journal of Transpersonal Psychology , 2 , 1-26.
- Green, E., & Green, A. (1977). Beyond biofeedback . San Francisco: Delacorte Press.
- Green, J., & Shellenberger, R. (1991). The dynamics of health and wellness: A biopsychosocial approach . Fort Worth: Holt, Rhinehart, and Winston.
- Jacobsen, E. (1938). Progressive relaxation . Chicago: University of Chicago Press.
- Kall, R. (1994, Summer). Heart, spirit and human potential section proposed for AAPB. Biofeedback Newsmagazine , 22 (2), 30.
- Kamiya, J. (1994, February). Personal correspondence.
- Kamiya, J. (1969). Operant control of the EEG alpha rhythm. In C. Tart (Ed.), Altered states of consciousness. NY: Wiley.
- Ladad, A.; Whipple, B.; & Perry, J. D. (1981). The G spot and other recent discoveries about human sexuality . NY: Holt, Rhinehart, & Winston.
- Lazarus, R. S. (1990 a). Stress, coping, and illness. In H. S. Friedman (Ed.), Personality and disease . (pp. 97-120). NY: Wiley.
- Lazarus, R. S. (1991). Emotion and adaptation . NY: Oxford University Press.
- Lubar, J. F. (1989). Electroencephalographic biofeedback and neurological applications. In J. V. Basmajian (Ed.), Biofeedback: Principles and practice for clinicians (3rd ed.), pp. 67-90. Baltimore: Williams and Wilkins.
- Lubar, J. F. (1991). Discourse on the development of EEG diagnostics and biofeedback treatment for attention-deficit/hyperactivity disorders. Biofeedback and Self-regulation , 16 , 201-225.
- Lubar, J. F., & Shouse, M. N. (1977). Use of biofeedback in the treatment of seizure disorders and hyperactivity. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (pp. 203-265). NY: Plenum Press.
- Miller, N. E. (1969). Learning of visceral and glandular responses. Science , 163, 434-445.
- Miller, N. E. (1978). Biofeedback and visceral learning. Annual review of psychology , 29 , 373-404.
- Miller, N. E., & DiCara, L. (1967). Instrumental learning of heart rate changes in curarized rats: Shaping and specificity to discriminative stimulus. Journal of Comparative and Physiological Psychology , 63, 12-19.
- Miller, N. E., & Dworkin, B. (1974). Visceral learning: Recent difficulties with curarized rats and significant problems for human research. In P. A. Obrist; A. H. Black, J. Brener, & L. V. DiCara (Ed.), Cardiovascular psychophysiology (pp. 312-331). NY: Aldine.
- Moss, D. (1994, March). Twenty-five years of biofeedback and applied psychophysiology. In D. Moss (Ed.), Twenty-fifth anniversary yearbook (pp. 3-6). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
- Moss, D., & Keen, E. (1981). The nature of consciousness. In R. S. Valle & R. von Eckartsberg (Eds.), The metaphors of consciousness (pp. 107-120). NY: Plenum.
- Moss, D., Kasman, G., & Fogel, E. (Eds.). (1996). Physical medicine and rehabilitation (Special Issue). Biofeedback Newsmagazine , 24 (3).
- Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis: A method for its study and treatment. American Journal of Orthopsychiatry , 8, 436-459.
- Patel, C. (1975). 12 month follow up of yoga and biofeedback in the management of hypertension. Lancet, 1, 62-65.
- Pelletier, K. R. (1977). Mind as healer, mind as slayer . NY: Delta.
- Peniston, E. G., & Kukolski, P. J. (1989). Alpha-theta brainwave training and beta-endorphin levels in alcoholics. Alcoholism: Clinical and Experimental Research , 13 , 271-279.
- Peper, E. (1994, November). The future of applied psychophysiology. Panel discussion at the Midwestern Regional Conference on Behavioral Medicine and Biofeeedback, Grand Rapids, MI.
- Perry, J. D.; & Talcott, L. B. (1988, May). The bastardization of Dr. Kegel's exercises. Presentation to the Northeast Gerontological Society, New Brunswick, New Jersey.
- Perry, J. D., & Talcott, L. B. (1989, March).