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Biofeedback ÓAssociation for Applied & Volume 46, Issue 1, pp. 15–20 www.aapb.org DOI: 10.5298/1081-5937-46.1.06 SPECIAL ISSUE ‘‘Watch the Screen’’: Biofeedback Can Improve for Chronic

Saul Rosenthal, PhD, BCB

Newton, MA

Keywords: , mindfulness, acceptance, biofeedback

Chronic pain has a significant impact on the quality of , , family, school, work, and culture are lives for millions of people. Because it is resistant to some of the factors that interact to have an impact on the traditional medical intervention, the optimal approach to chronic pain experience (American Psychological Associa- chronic relies on a biopsychosocial tion, Interprofessional Seminar on Integrated Primary Care understanding of and treatment. To date, cognitive Work Group, 2016; Engel, 1977). It is important to point behavioral (CBT) has been the treatment of choice. out that far from rejecting the biomedical model, a However, CBT’s emphasis on active control can prove biopsychosocial perspective integrates it into a more counterproductive because the , behaviors, and complete understanding of health. related to pain are difficult to directly confront. Practicing from a biopsychosocial model raises many More recently, CBT has begun to integrate mindfulness, challenges, not least of which is patient (and fellow shifting toward paradigms of accepting sensations rather practitioner) buy-in. While it is relatively easy to agree than trying to change them. This is difficult for individuals with the notion that psychosocial interventions can help with chronic pain, who frequently spend significant manage pain, in the midst of a severe most people resources avoiding and trying to minimize sensations. understandably want to just take a pill that fixes the Biofeedback can be a useful tool for mindfulness problem. As biopsychosocial clinicians, our job is to shift because it allows a focus on an external signal that in fact the patient’s perspective away from fixing pain and towards reflects the internal process. Over time, individuals can integrating pain into their ongoing experiences. We want learn to integrate mindfulness techniques in their daily life our patients to reduce the relative impact of pain by that minimize the influence of pain, allowing them to focus on other aspects of their broader lives. on other aspects of their lives. The Role of Cognitive-Behavioral Therapy in Introduction: Chronic Pain and the Pain Management Biopsychosocial Model In general, cognitive-behavioral therapy (CBT) is consid- Chronicpainisamongthemostcommonreasons ered the nonbiomedical approach of choice for chronic pain, individuals visit their physicians (Sauver et al., 2013). Both with significant evidence of effectiveness across a variety of patients and physicians typically focus on medical inter- conditions (Ehde, Dillworth, & Turner, 2014; Murphy et ventions for chronic pain, although it often does not have a al., 2014). CBT expands on the biomedical model by clear physical cause, is frequently subjective in nature, may focusing on the interactive relationships among cognitions, occur in the absence of measurable body damage, and does behaviors, and emotional experience, even for ‘‘medical’’ not respond well to typical medical intervention (Interna- conditions. Underlying the therapeutic value of CBT is the tional for the Study of Pain, 1994/2012). This is hypothesis that the experience of pain is based on how frustrating to a healthcare system that traditionally relies individuals understand it within the context of their own on a biomedical model positing linear causal pathways from lives. For example, an individual waking with a Biofeedback pathogen to symptom and through to treatment. Unfortu- might think with certainty, ‘‘The day is ruined!’’ This nately, chronic pain rarely plays by the rules. catastrophic worsens mood, demotivates the A better approach to understanding chronic pain is the individual, and can lead to spending the day in bed. In | biopsychosocial model. This perspective emphasizes the other words, the patient’s response to pain allows it to take 2018 Spring interactive and nonlinear role of multiple factors. Behavior, on a more commanding role in his or her life (Murphy et

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al., 2014). CBT interventions focus on confronting and started with a focus on chronic pain management. What modifying unhealthy and behaviors to have a Kabat-Zinn and a multitude of clinicians afterwards found more realistic relationship with the situation. For example, was that individuals who learn to nonjudgmentally observe, the individual with the headache might think something reduce automatic reactions, and respond thoughtfully to like, ‘‘I’m hurting now and that might affect my day. internal sensations report less pain and less interference However, I don’t necessarily know what the future brings. from pain (Jensen & Turk, 2014; Murphy et al., 2014). CBT If I get up and try some stretching I might feel better and be itself is now embracing an acceptance stance both in general able to get my day started.’’ A more thoughtful response to (e.g., Barlow et al., 2004) and more specifically for chronic pain can improve quality of life. pain management (Jensen & Turk, 2014). Although CBT posits something of a biopsychosocial perspective, it has been criticized (including by the Mindfulness and Acceptance in Chronic biofeedback community) for a reductionistic approach, Pain Management focusing too narrowly on actively changing maladaptive Chronic pain patients benefit from accepting three funda- thoughts and behaviors (e.g., Hayes, 2016). Any interven- mental truths about effective pain management. First, tion that is not focused on overt change, or for which there chronic pain is a function of interactive biopsychosocial is not sufficient empirical evidence of efficacy, is rejected as factors unique to the patient’s life. Therefore, patients need ineffective at best and as avoidance of the ‘‘real work’’ of to be actively involved in their own care. Even if medications at worst. Hayes (2016) and others argued and procedures have positive effects, a proactive approach to that this mindset excludes approaches that are both effective health improves quality of life. Second, to help themselves, and theoretically consistent with CBT. patients must develop, integrate, and practice skills that might at first seem useless or feel uncomfortable. Mindful- The Influence of Mindfulness on Emergent ness is like riding a bicycle. We can teach our patients the basic skills, but until they get on and wobble around for a This critical examination of CBT has fueled an evolution of while, they are not riding the bike. Finally, patients have to CBT interventions that more strongly emphasize the learn the subtle but vital difference between not doing integration of biology, cognition, social systems, psychol- anything (what they often initially think mindfulness is ogy, culture, and other factors. Therapeutic systems like about) and actively doing nothing (which is often what acceptance and commitment therapy (Hayes, Strosahl, & mindfulness is actually about). Wilson, 2012), dialectical behavior therapy (Linehan, 1993, Although there are countless strategies to help patients 2015), mindfulness-based (e.g., Segal, develop mindfulness, psychotherapeutically useful ap- Williams, & Teasdale, 2013), and Barlow’s unified treat- proaches should encompass three characteristics defined ment for emotional disorders (Barlow, Allen, & Choate, by Germer (2005): ‘‘(1) awareness, (2) of present experi- 2004) are examples of approaches that attempt a more ence, (3) with acceptance’’ (p. 7, emphasis in original). For complex and holistic understanding of health. chronic pain, the point of mindfulness is to shift the A common element to these newer approaches is fundamental relationship an individual has with her or his mindfulness. Both as a philosophy and an intervention, body and mind. Instead of hypervigilance, , mindfulness reflects a fundamental shift from traditional reactivity, and escape, patients can hopefully accept all CBT’s active, change-focused, symptom-based approach aspects of their physical, cognitive, and emotional experi- (Hayes,2016).Formindfulness,theproblemisnot ences (Siegel, 2005). symptoms and conditions per se, but the resources Practically speaking, patients are encouraged to maintain individuals utilize to avoid, plan their lives around, and their focus on, rather than react to, whatever sensations work to get rid of symptoms and conditions. Mindfulness- arise, even if they are painful. They are reminded that based approaches teach individuals to first differentiate distractions, reactions, and judgments are normal and between what is changeable and what is acceptable and then expected. When these occur, patients are asked to notice make thoughtful choices about what to do next. Sometimes them, allow for them, and shift their focus back to the it is worth taking the pill and sometimes it is worth sitting actual sensations themselves. with pain. For example, one of the most common mindfulness

Biofeedback Jon Kabat-Zinn’s mindfulness-based reduction, exercises used for individuals with chronic pain is the body | generally considered the first systematic integration of scan. There are many variations of this practice. Typically, mindfulness and psychotherapy (e.g., Kabat-Zinn, 1990) patients are guided through a mental tour of the sensations Spring 2018 16 Rosenthal they carry around with them all the time but frequently resources to reflect internal processes while biofeedback ignore or react to negatively. They start by sitting or lying uses sensors to do the same thing. Biofeedback has been comfortably so that they are fully supported and do not have utilized effectively for multiple chronic pain conditions to work to maintain their position. The body scan then including (Hassett et al., 2007; Kayıran, typically starts with a general focus on the body as a whole: Dursun, Dursun, Ermutlu, & Karamursel,¨ 2010), chronic how it feels, the physical sensation of lying or sitting on back pain (Sielski, Rief, & Glombiewski, 2017), orofacial something, the sensation of breath. Focus is then guided pain (Crider & Glaros, 1999), from body part to body part. The individual is asked to (Dobbin, Dobbin, Ross, Graham, & Ford, 2013; Skardoon, observe sensations with a sense of curiosity, rather than in a Khera, Emmanuel, & Burgell, 2017; Stern, Guiles, & mindset to change them. Is this body part warm or cold? Gevirts, 2014), and headache (Nestoriuc, Martin, Rief, & Tight or loose? Is there even any sensation noticeable? As Andrasik, 2008). they mentally observe, patients might try to imagine they Biofeedback also integrates into CBT as a reflection of are ‘‘breathing through’’ the body part. If they are distracted emotional reaction and a way to support changing behavior (this can be boring) or react to pain, they are asked to (Hamiel & Rolnick, 2016; Rosenthal & McGinnis, 2011). acknowledge the reaction or the distracting thoughts, but Khazan (2013) was among the first to explicitly argue that then to allow their focus to go back to the body part. At the biofeedback does not need to focus primarily on change, but end of the exercise, the individual might again observe the can be enhanced by integrating mindfulness and acceptance. overall body and the breath. Traditional body scans often Rolnick, Oren, and Bassett (2016) extended this idea, laying take 45 minutes, although there are briefer versions. out how biofeedback can help enhance the development of This is only one of many such exercises. Others include mindfulness in the service of managing emotional distress. mindful breathing, mindful eating, mindful walking, and, of Likewise, biofeedback can serve as a venue for the course, mindful . The point is not that one or individual to develop mindfulness skills to help manage another exercise is the ‘‘best’’ path to mindfulness and pain the negative effects of chronic pain. management. In fact, clinicians often mix and match, based Mindfulness is about observing rather than reacting. In on patient response and pragmatics. A 45-minute body scan the best of circumstances, it is difficult to separate the is not practical in a busy primary care service where the observing self from the reacting self. It is even harder when standard session is 30 minutes every 2 weeks. It is important there is a significant history of escaping and avoiding to keep in mind that the therapeutic goal of mindfulness is to internal sensations. Just as this is the case for many develop a new relationship with the body, with pain, and individuals with emotional disorders (Barlow et al., 2004; with all experiences. With less energy devoted to trying to Rolnick et al., 2016), it is certainly the case for individuals control and eliminate pain, patients can choose to focus more with chronic pain. As an external reflection of the internal on improving the quality of their lives. state, biofeedback can serve as a scaffold to support Teaching mindfulness to individuals with chronic pain is separating the observer from the reactor. particularly challenging because they typically want to escape from and control the experience. Individuals wince, The Case of Joan tightening muscles in a way that leads to fatigue or further To illustrate this approach, consider ‘‘Joan,’’ a young stimulation of pain neural pathways. They about the woman in her mid-20s. Joan presented with a history of future, creating a reality influenced by negative expecta- chronic medical and psychiatric issues, meeting diagnostic tions and emotions. They strike out at others. They overuse criteria for generalized . Medically, she medications. They act in multiple ways to attempt reported years of gastrointestinal-related problems, includ- immediate reductions in pain, regardless of longer term ing shortened muscles, multiple urinary tract consequences and often without considering whether it is infections, gastrointestinal (GI) distress, and irritable bowel necessary. Mindfulness is the opposite. Working to shift syndrome. Joan was able to articulate the ways that her GI patients from their automatic reactions to more mindful and anxiety symptoms interact. She felt physically worse Biofeedback responses can stymie even highly skilled clinicians. when she worried and she worried more when her pain flared. When pain worsened, she tended to physically Biofeedback as a Tool to Enhance retreat, cancelling activities, and spending the day in bed. Mindfulness She also engaged in a significant amount of planning in an | Biofeedback may help ease the effort of teaching mindful- attempt to prevent or avoid all imaginable negative 2018 Spring ness in such situations. Mindfulness uses cognitive outcomes. For example, she came up with multiple plans

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to make up for any classes she might miss due to pain. a focus on pain or anxious thoughts, in turn triggering her Although she identified her overplanning as a escape and avoidance strategies. Now she was getting better mechanism, she also recognized that it was in reality a at noticing her thoughts and feelings without getting maladaptive avoidance strategy. She spent so much time entangled with them. Instead, she learned to mentally shift and energy reacting to pain and planning for imagined her attention to her breathing, checking that it was calm and problems that she was exhausted much of the time and rhythmic. Joan described how this approach allowed her to missed out on much of her own life. recognize that some sensations were not ‘‘important’’ Joan had tried some mindfulness exercises with a enough to try to change. She reported a consistent decrease psychotherapist, but found herself unable to maintain her in her baseline GI discomfort as well as more frequent drops focus or tolerate the anxiety related to sitting with her own in acute discomfort when engaging in mindful breathing. sensations. She was referred for biofeedback training to Joan’s ability to observe her ongoing experience rather help with pain management. During the evaluation, she than reacting to it also made it easier to incorporate reported a desire to calm her mind and body. She wanted to traditional CBT. She started to recognize patterns of reduce both her pain and her constant anxiety about catastrophic thinking related to pain and was able to possible future difficulties. tolerate the process of considering those thoughts without A biofeedback stress evaluation indicated slower respi- acting on them. Mindfulness allowed her to ‘‘catch’’ those ration rate during stressors and variability that thoughts, evaluate their value and then decide what to do. was generally reduced across the entire evaluation. These She continued to experience GI discomfort, but it bothered findings suggested physiologic bracing during times of her less. She was able to put more resources into improving stress but also sympathetic hyper-reactivity (i.e., once the the quality of her life—for example, engaging more sympathetic system was activated, it did not easily frequently in social activities and focusing more efforts on deactivate). Joan agreed to try breathing exercises while developing her career. focusing on physiologic feedback. For the first session, respiration and heart rate were displayed without any Conclusion: ‘‘Watch the Screen’’ training goal. She was talked through a mindful breath Utilizing biofeedback can be thought of as a method of exercise and encouraged to keep her focus on the feedback shaping mindfulness. Learning to observe the external screen. Afterwards she reported that monitoring the signals biofeedback signal and allowing change rather than trying made it easier to pay attention to her breathing. When to force change are steps along the path toward an ability to discussing home practice, she agreed to engage in mindful have a more accepting relationship with internal sensations, breathing for at least five minutes a day, expecting that she thoughts, and emotions. could return herself to the calm feeling experienced during Often, when an individual stops trying so hard to change the training session. the signal, it in fact changes: Temperature goes up, Over the next few sessions, the therapeutic focus goes down, remained on mindful breathing and encouraging Joan to improves. This serves to illustrate a primary point about maintain her focus on the feedback screen. Paced respiration mindfulness. Disengaging from overt attempts to change added another level of challenge. She was asked to breathe experience can lead to change, often in desirable ways. It is at a series of specified frequencies, even if it became easy to misunderstand this as ‘‘not doing anything.’’ In fact, uncomfortable. This can be a challenging exercise for maintaining a focus on something without trying to change individuals not used to slow, rhythmic breathing. Joan was it and resisting distraction takes a lot of effort. This is where guided to breathe for three-minute periods, at paces ranging it is worth distinguishing ‘‘not doing anything’’ from the from 8.0 to 5.5 breaths per minute. During the exercise, more proactive ‘‘do nothing.’’ Joan’s average heart rate dropped over 10 beats per minute Biofeedback can help patients develop this skill because, and very low frequency waves dropped below 1%. She also simply put, it is easier to ‘‘do nothing’’ when there is described a sensation of strong awareness of her something outside of the self on which to focus. The power along with a deep physical and mental calmness. of biofeedback lies in the external signal’s direct connection Joan started using a breathing pacer app for home practice, to the internal state. High reactions in muscle and utilizing it for 10 minutes a day. She started shifting her electrodermal activity reflect high reactivity to internal

Biofeedback attention to her internal physical, mental, and emotional sensations. Calmer signals reflect a calmer internal state. | states, while also engaged in the breathing exercise. Prior, No guided mindfulness exercise can provide that direct paying ‘‘too much’’ attention to her internal processes led to information about the internal process. Spring 2018 18 Rosenthal

As challenging as it is to engage in the hard work of Seattle, WA: IASP Press. Available at https://www.iasp-pain. mindfulness, it can help. The more an individual is able to org/PublicationsNews/Content.aspx?ItemNumber¼1673 keep a focus on the pain sensation and away from the Jensen, M. P., & Turk, D. C. (2014). Contributions of reaction to that sensation, the more pain’s influence fades. to the understanding and treatment of people with chronic Pain may never disappear. It may always have an impact on pain: Why it matters to ALL psychologists. American Psychologist, 69, 105–118. multiple areas of life. But by limiting pain’s influence, an Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom individual can integrate it as only one feature of the many of your body and mind to face stress, pain, and illness. New that make up a more complete and gratifying life. York: Dell Publishing. ı References Kay ran, S., Dursun, E., Dursun, N., Ermutlu, N., & Karamursel,¨ S. (2010). intervention in fibromyalgia syn- American Psychological Association, Interprofessional Seminar on drome; A randomized, controlled, rater blind clinical trial. Integrated Primary Care Work Group. (2016). A curriculum Applied Psychophysiology and Biofeedback, 35, 293–302. for an interprofessional seminar on integrated primary care. Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step- Retrieved from http://www.apa.org/education/grad/ by-step guide for training and practice with mindfulness. West curriculum-seminar.aspx Sussex, UK: Wiley-Blackwell. Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a Linehan, M. M. (1993). Cognitive-behavioral treatment of unified treatment for emotional disorders. Behavior Therapy, borderline personality disorder. New York: . 35, 205–230. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New Crider, A. B., & Glaros, A. G. (1999). A meta-analysis of EMG York: Guilford Press. biofeedback treatment of temporomandibular disorders. Jour- Murphy, J. L., McKellar, J. D., Raffa, S. D., Clark, M. E., Kerns, R. nal of Orofacial Pain, 13, 29–37. D., & Karlin, B. E. (2014). Cognitive behavioral therapy for Dobbin, A., Dobbin, J., Ross, S. C., Graham, C., & Ford, M. J. chronic pain among veterans: Therapist manual. Washington, (2013) Randomised controlled trial of brief intervention with DC: U.S. Department of Veterans Affairs. biofeedback and in patients with refractory Nestoriuc, Y., Martin, A., Rief, W., & Andrasik, F. (2008). irritable bowel syndrome. The Journal of the Royal College of Biofeedback treatment for headache disorders: A comprehen-

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Saul Rosenthal

Correspondence: Saul Rosenthal, PhD, 134 Rumford Avenue, Suite 205, Newton, MA 02466, email: [email protected]

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