Biofeedback ÓAssociation for Applied Psychophysiology & Biofeedback 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 Mindfulness for Chronic Pain Saul Rosenthal, PhD, BCB Newton, MA Keywords: chronic pain, mindfulness, acceptance, biofeedback Chronic pain has a significant impact on the quality of cognition, emotion, 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 pain management relies on a biopsychosocial tion, Interprofessional Seminar on Integrated Primary Care understanding of health and treatment. To date, cognitive Work Group, 2016; Engel, 1977). It is important to point behavioral therapy (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 cognitions, behaviors, and complete understanding of health. emotions 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 migraine 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 shaping 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 focusing 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 Association 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 headache 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 thought 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 Spring 2018 interactive and nonlinear role of multiple factors. Behavior, on a more commanding role in his or her life (Murphy et 15 Watch the Screen al., 2014). CBT interventions focus on confronting and started with a focus on chronic pain management. What modifying unhealthy thoughts 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 psychotherapy 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 Psychotherapies 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 cognitive therapy (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, anxiety, 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 stress 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.