The Clinical Handbook of Biofeedback

A Step-by-Step Guide for Training and Practice with Mindfulness

Inna Z. Khazan

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118485323
• Edition: 1
• Topic: Medicine
• Subtopic: Biotechnology in Medicine

A practical guide to the clinical use of biofeedback, integrating powerful mindfulness techniques.

• A definitive desk reference for the use of peripheral biofeedback techniques in psychotherapeutic settings, backed by a wealth of clinical research
• Introduces mindfulness and acceptance techniques and shows how these methods can be incorporated into biofeedback practice
• Step-by-step instructions provide everything a clinician needs to integrate biofeedback and mindfulness including protocols, exemplar logs for tracking symptoms, and sample scripts for mindfulness exercises
• Includes scientifically robust treatment protocols for a range of common problems including headaches, hypertension and chronic pain

Part I

Foundations

1

Mindfulness and Acceptance Approach to Biofeedback

“Why can’t I get control of my anxiety?” “Why won’t the pain go away?” “What’s wrong with me, why can’t I do this right?” Does any of that sound familiar? Have you heard questions like these from your clients? If your answer is yes, then this book is for you. Let us talk about how it might be useful.

Sam’s Fight for Control

Sam is an accomplished professional woman in her early thirties, who is used to being able to do things she sets out to do. She has a business degree from a prestigious university, and is doing well in her career. About two years ago she started having episodes of anxiety that were difficult to handle. At first, they occurred only when she needed to give presentations to larger audiences at work, but have gradually started creeping into situations that had previously been completely comfortable, like team meetings and phone conferences. Because of how distressing this anxiety felt, Sam started trying to avoid big presentations, spoke up as little as possible at team meetings, and dreaded phone conferences. When the issue came up in her annual review with the manager, Sam realized that anxiety might really get in the way of her career, so she did what she usually does when faced with a challenge – she took the bull by the horns.

Sam came to treatment with the goal of getting control of her anxiety and she wanted to try biofeedback. She learned that dysfunctional breathing had a lot to do with her physical symptoms and with intensifying her anxiety. She became determined to learn and use the new breathing skills. However, Sam found breathing practices to be difficult and uncomfortable, and when she tried to use them when she was anxious, it made the anxiety worse. She worked hard to control her breathing in order to control her anxiety and it was not working. She became frustrated and was ready to give up on treatment.

I suggested a new approach. Since trying to get control was not helping, what if she were to give up trying to get control and change her goals for breathing practices and for her treatment? Sam was slightly skeptical at first, but was also open to a new approach. She was willing to let go of trying to control her anxiety and just practice breathing for the sake of breathing, attend meetings and conferences for the sake of meetings and conferences, and so on, and not for the purpose of controlling anxiety. She learned how to attend mindfully to her breath and how to make space for all of her experience, including anxious thoughts, feelings, and physical symptoms. She made it her goal to be present at her meetings and phone conferences instead of figuring out ways to control anxiety. The result? Sam’s anxiety did not go away. She gets some anxiety before most presentations, and many meetings and phone conferences. So what has changed? She is now making presentations to large audiences and speaking up in her team meetings and not getting stuck in dread of phone conferences. Her attitude toward her anxiety has changed since she has allowed it to be. Her use of breathing skills has changed too. She is using biofeedback breathing in order to restore her blood chemistry and because it is helpful in bringing peace and allowing her to focus on the presentation she is about to give. Her focus changed from controlling anxiety to making choices over her actions when speaking opportunities came around. She has given up control over her anxiety and has regained control of her career.

Jack’s Struggle with the Present Moment

Jack is a 50-year-old software engineer who came to me for treatment of chronic back pain that remained after a serious car accident 10 years ago. He has been through many medical treatments, has had acupuncture and massage treatments, and has seen two previous therapists. Jack spent a lot of time sitting because of his job and prolonged periods of sitting made the pain worse. Only opioid medication and lying down made the pain tolerable. He reported that his pain was constant and he spent a lot of time wishing he had not been on the road the day of the accident and wishing for the pain to go away. Jack felt trapped in the pain because he could not get away from it.

Jack came to me seeking biofeedback treatment because it was the only thing he has not yet tried. We did a biofeedback assessment and found very high levels of muscle tension and breathing dysfunction. He was somewhat frustrated with me when I suggested starting with mindfulness training before proceeding to biofeedback training. He was concerned that accepting the present moment meant giving in to the pain and giving up on ever getting better. However, eventually he understood that acceptance was about making room for all of his experience in the present moment instead of keeping a narrow focus on stopping the pain and about learning to live a life worth living, instead of giving up on life.

Jack practiced mindful breathing, body awareness, and mindfulness of thoughts, feelings, and physiological sensations. He noticed that his pain was not constant, but rather coming and going. He noticed that he could attend to other parts of his experience while having pain. At that point, we began biofeedback training. He learned to recognize what it felt like when his muscles tensed up. He kept a log of his muscle tension and pain, and learned the triggers for muscle tension and for increases in pain. With surface electromyography (sEMG) biofeedback, he learned to release the tension in his muscles when he noticed it, and he learned to soften his muscles instead of bracing when his pain increased. With breathing biofeedback, he learned to change his breathing to bring balance to his blood chemistry. He learned that pain is not the same thing as suffering. Applying his biofeedback skills mindfully allowed Jack to greatly alleviate his suffering and to become a more active participant in the rest of his life. He still has some pain, which is sometimes dull, and sometimes intense, and sometimes barely there. He has learned to apply biofeedback skills to increase his openness instead of narrowing his focus in the face of pain.

Bethany’s Failure

Bethany is a stay-at-home mom to two active boys. She is in her forties and has had periodic incapacitating migraines since she was a teenager. She came to see me when she thought that her migraines were getting more frequent and affecting her ability to be a good mother. When a migraine came, Bethany felt she could do nothing else except lie down in a quiet dark room, but spent much of that time beating up on herself for not being able to “get a hold of” herself.

Bethany was interested in both mindfulness and biofeedback treatment, and her neurologist recommended biofeedback. We started with a stress profile, which revealed that her finger temperature was low at baseline and got lower with each stressor with no recovery. Her breathing was also fast and shallow and her heart rate variability (HRV) was low. Bethany liked the idea of mindfulness training before proceeding to biofeedback skills. She was willing to observe her breathing and make space for her pain. She enjoyed the meditations I taught her and listened to the recordings every day.

When we started biofeedback, she learned to increase her HRV with her breathing nicely in my office. She was able to use mindful awareness to let her breathing fall in sync with her heart rate. She started practicing resonance frequency breathing at home. She was also keeping a log of her breathing practices and finger temperature. After the first week of home practice of her biofeedback skills, Bethany came back and said that she did not do so well on her own. She felt that she failed to achieve her goals. It sounded to me like she was spending a lot of time virtually beating up on herself, and Bethany agreed that being hard on herself felt like the way to motivate herself to do and be better.

I asked Bethany whether she was interested in learning how to be kinder to herself and how to let go of impossible-to-reach goals. She agreed. We talked about self-compassion and about setting achievable goals. Perhaps being able to stick to resonance frequency breathing rate and increase her finger temperature after one session of actual biofeedback training was unnecessary and as unrealistic as being able to power through a severe migraine. Bethany learned the loving kindness meditation. She learned to not only allow her biofeedback skills to happen at the moment she practiced them, but also to be kind to herself no matter what the outcome of her practice. Sometimes she felt she was in the zone with her breathing and her finger temperature increased. There were also times when her finger temperature did not budge. She was able to allow “a failure” to happen and move on with her day. Bethany learned to be kind to herself when she had migraines, and allowed herself to ask for help and to take care of herself by letting go of whatever self-judgments automatically came with the need to ask for help. Practicing biofeedback skills became easier when she was no longer trying to evaluate whether she was doing them right, and having her migraines, which became less frequent and less severe, became easier too.

With these three examples, I hope to introduce you to the main ways in which mindfulness may be helpful to you and to your clients. To summarize, mindfulness is useful for at least three reasons:

1. Sometimes we work really hard to control what is out of our control, the way Sam tried to control her anxiety. Mindfulness can teach you to tell the difference between what is and is not controllable, and choose to direct your resources toward creating the behavioral changes that are within your control.

2. Sometimes we struggle to make the present moment be different, the way Jack tried to stop the pain. Mindfulness gives us the freedom to choose our responses, rather than following with automatic struggle and to attend fully to our experience instead of narrowly focusing on the object of the struggle.

3. Sometimes we judge ourselves for failing to reach our goals, the way Bethany judged herself as a failure for failing to power through migraines and learn her skills in one week. With mindfulness, we learn to give ourselves a break, to be kinder to ourselves, which then allows us to turn toward our experiences with curiosity and interest, and gives us an opportunity to create change.

In this chapter, I give an introduction to mindfulness and acceptance approach, discuss its relevance to biofeedback, and give a brief overview of research demonstrating effectiveness of the mindfulness and acceptance approach in producing desirable physiological and neurological changes. I then focus on implementing mindfulness into your biofeedback practice, including a step-by-step guide.

What Are Mindfulness and Acceptance?

Let us begin with talking about what mindfulness is and how it is helpful. There are many definitions, each touching on slightly different aspects of mindfulness. As described by Christopher Germer, its literal translation from Pali, the language of earliest Buddhist writings, is “awareness, remembering.” Awareness is most relevant to the modern definitions of mindfulness, often described as simply moment-to-moment awareness. Guy Armstrong defines mindfulness as “Knowing what you are experiencing while you are experiencing it.” Finally, a definition similar to Jon Kabat Zinn’s is “being in the present moment, accepting, letting go of judgment.”

Ruth Baer and colleagues (2004) identified five facets of mindfulness, reflecting all the major components of mindfulness practice and mindfulness interventions. These components are:

• Observing – attending to internal and external stimuli
• Describing – labeling one’s experience with words
• Acting with awareness – choosing action, instead of behaving automatically
• Nonjudgmental stance – letting go of evaluation of one’s internal experience
• Nonreactivity to internal experience – allowing thoughts and feeling to come and go, without getting caught up in them.

I will continue referring to every one of these components throughout this chapter and the rest of the book...