Biofeedback and Cognitive Behavior Therapy: Open Marriage? Rumors says Biofeedback is flirting with dynamic psychotherapy ביופידבק וטיפול קוגניטיבי התנהגותי איזה סוג יחסים יש להם? נשואים פתוחים? ידועים בציבור? יש גם שמועות על יחסים עם טיפול דינמי

BF and CBT :common law marriage נשואים או ידועים בציבור? The concept of a common law marriage can be used figuratively to describe the relationship between biofeedback and CBT. A common law marriage is an informal or de facto relationship that is legally recognized as a marriage even though no legally recognized marriage ceremony has been performed. Similarly, these two interventions, CBT and biofeedback, “live together" de facto: both are short-term goal-directed interventions striving for evidence-based status. Early in their relationship, when CBT was simply behavior therapy, it was very clear that both approaches were related to learning theory and were heavily based on relaxation techniques and desensitization

Biofeedback and Cognitive Behavioral Interventions: Reciprocal Contributions Daniel Hamiel and Arnon Rolnick Discusses the integration of two major treatment approaches: cognitive behavioral therapy (CBT) and biofeedback. By integrating these two intervention approaches, we take advantage of and empower both of them. Accepted for publication in in. Schwartz MS and Andrasik F (Eds.), Biofeedback A Practitioner's Guide (4th ed.)

Two Questions How biofeedback practitioners can integrate cognitive behavioral elements into their practice   How Cognitive Behavioral Therapists can integrate biofeedback into their practice

BIOFEEDBACK WITHOUT COGNITIVE ELEMENTS – THE NEAL MILLER PARADIGM Through a process of trial and error, the subject learns autonomic regulation. Device and feedback

Biofeedback intervention was originally based on a learning theory model. Neal Miller's classical studies (Miller et al., 1978) did not include cognitive elements, not only because the subjects were animals, but mainly due to the understanding that biofeedback is a trial and error process only involving conditioning elements (Pavlovian and instrumental).

BIOFEEDBACK AIDED BY RELAXATION A coach teaches relaxation methods while using the physiological feedback to enhance motivation and application Device and feedback

Biofeedback and CBT Physiological screen Thought screen

The cognitive element in biofeedback This model incorporates the client’s thoughts during the session and the schemas (sometimes hidden) that affect the client’s views about his or her ability to self-regulate. Here, a metaphoric screen, the ‘‘cognitive/emotion screen,’’ is introduced. Clients share their thoughts with the therapist or voice ‘‘what went on in their mind,’’ and both the therapist and client observe this process in relation to the physiological data screen. Whereas working with the physiological screen involves repeated practice, working with the subjective experience requires a significant amount of discussion. Indeed, the focus within this model is on the relationship between subjective content (thought/ images) and objective measurement (physiology)

Why CBT clinicans rarely use biofeedback

Clark and Beck 2010 Barlow 2008

Clark and Beck 2010

Barlow on Physiological Measures Ongoing physiological measures are not very practical tools for clinicians, ?? but they can provide important information. In particular, the discrepancy described earlier between reports of symptoms and actual physiological arousal (i.e., report of heart rate acceleration in absence of actual heart rate acceleration) may serve as a therapeutic demonstration of the role of attention and cognition in symptom production.

Similarly, actual recordings provide data to disconfirm misappraisals such as “My heart feels like its going so fast that it will explode” Finally, baseline levels of physiological functioning, which are sometimes dysregulated in anxious individuals, may be sensitive measures of treatment outcome (e.g., Craske, Golinelli, et al., 2005).

So how to integrate CBT and BF?

The Dance between practicing to Talking

A time to talk and a time to Practice

The Contribution of Biofeedback in the Treatment of Anxiety Disorders   Accepted for publication in in. Schwartz MS and Andrasik F (Eds.), Biofeedback A Practitioner's Guide (4th ed. ) Arnon Rolnick, Udi Gal, Dana Bassett ,Anat Barnea

Why there was not a chapter on anxiety disorders in “Biofeedback A practitioner guide” in the three editions till now?

Wrong view On the Nature of Anxiety? Yuch and Gilbert (2004)…anxiety is less a disorder of physiology than of attention and cognition, and biofeedback monitors physiological changes (p.)".  Most theories of anxiety disorders contradict this assertion, proposing that reports of fear and anxiety reflect an underlying state of physiological hyperarousal (Lang & McTeague, 2009).

More recently Yucha and Montgomery (2008) omitted their assertion about the nature of anxiety, having reviewed several controlled studies where biofeedback was proved to efficacious (Bont, Castilla & Maranon, 2004; Coy, Cardenas, Cabrera, Zirot & Claros, 2005; Dong & Bao, 2005). Yucha and Montgomery (2008) concluded that biofeedback can be used in the treatment of anxiety disorders with a high degree of efficacy (Level 4 in a 5 point scale).

Arousal Reduction and Biofeedback Aided Relaxation as Tools for Alleviating Anxiety The use of biofeedback as an arousal reduction tool may be understood when considering the need to regulate the autonomic nervous system as an integral aspect of treating anxiety disorders. some anxiety disorders involve over activation of the sympathetic nervous system, while others involve an active avoidance of thoughts and behaviors that are likely to trigger this over activity.

Experiential Psycho-education In simple CBT, the therapist uses the cognition itself to demonstrate some cognitive distortions and relevant information. However, this remains on the verbal level, which in turn is affected by the patient’s cognitive distortions and somewhat detached from his subjective perceptions. On the other hand, integrated (BF +CBT) therapy can help the patient directly experience various effects of his thought and expectations.

Biofeedback Enhances Cognitive Elements of Therapy All patients arrive with a set of beliefs and ideas regarding their anxiety, for example whether anxiety is learned or innate, whether anxiety can be managed, eliminated, or lead to loss of control. The role of psycho-education when combined with biofeedback is to address and alter beliefs that prevent the adoption of a more realistic and functional perspective.

Integrating Biofeedback with Desensitization and Exposure The therapist is guided to provide better instructions during the desensitization process as the feedback allows for a parallel to be created in reaction to patient’s responses. The arrangement of stimuli in a hierarchy is the second component of systematic desensitization. Biofeedback assists with the creation of the hierarchy by providing an objective measure of response to imagined stimuli (Wood, Murphy, Center, Russ, McLay, & Reeves, 2008). That is, biofeedback reveals, to therapist and patient, the point at which a particular trigger activates the anxiety response

Fostering Awareness and Acceptance (I) A primary obstacle for anxious patients when attempting to relax is the very high level of arousal with which they arrive, and their use of extreme effort to reduce this arousal. Therapists who use biofeedback can show patients that this goal may be achieved without exertion and in fact will only be completely achieved once the effort to control is released, i.e., once a patient "let's go.

Fostering Awareness and Acceptance (II) The principle of effortless work and "letting go" is a primary principle in Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). ACT is only one example of a therapeutic approach that teaches patients to observe reality without judgment or criticism, and to cease efforts that are made in the struggle against anxiety. Biofeedback can certainly assist with this aspect of change

Examples Panic and Social Phobia

Our suggested method – (Barlow +Psychophysiology)

The unique “exposure” that exists in Biofeedback therapy Or The Role of the Other who see/know that the subject is anxious

אלמנט הבושה מהאחר בהפרעות חרדה רוב הפרעות החרדה מערבות את אלמנט הבושה. הבושה קשורה בכך שאנשים אחרים רואים את התרגשותי/חרדתי הדבר בולט מאוד בחרדה חברתית אבל גם בהפרעת פאניקה

Blushing and social phobia the case of blushing suggests that biofeedback can enhance the therapy of anxiety disorders in general, and social anxiety in particular, by being a unique tool for simulating blushing or simulating a situation where the patient feel shame for the fact that other people can see their stress. There is a strong parallel between blushing, which usually occurs only when the subject is in a social or interpersonal situation and the triadic situation where the patient is aware that the therapist sees their internal reaction, and this is a unique type of exposure that other CBT methods can not create as easily, or at all..

Biofeedback and Psychodynamic therapy Physiological screen Thought screen How the therapist existence affect the self regulation ability

The Role of the other in Anxiety Disorders Originally based on work by Winicott (1971), and later Bollas (1987), anxiety disorders are perceived as a function of poor ability to self regulate, a capacity that typically develops throughout infancy via interaction with parental figures.

children typically react with fear in new situations resulting in fear-based dependency on caregivers (Milrod, Busch, Cooper, & Shapiro, 1997). A parallel may be drawn within biofeedback assisted psychotherapy. The fearful, anxious, patient is exposed as helpless and dependent before the therapist, which may incite feelings of shame, impotency and hopelessness.

Linehan’s Model Linehan (1993) who asserts that individuals with emotional disorders are biologically vulnerable to experiencing emotions more intensely than the average person, and also have more difficulty modulating their intensity. In psychophysiological terms they are high reactors with a very limited ability to calm down. The second element in Linehan's theory states that emotional disorders develop during childhood wherein an invalidating environment contributes to emotion dysregulation.

More specifically the issues are that parents fail to teach the child how to label and regulate arousal, how to tolerate emotional distress, and when to trust their own emotional responses as reflections of valid interpretations of events. Therapy conducted with biofeedback calls for validation, empathy and the acquisition of self regulation ability.

In contrast to the patient’s developmental experience, the biofeedback therapist reacts calmly. Observing with the patient their physiological make up, an opportunity is provided for the therapist to validate this experience, label it and explain emotional arousal. The therapist also offers the patient an explanation of the process that produces their arousal. Then the therapist teaches self regulation, fulfilling a role that was absent in the original parenting unit.

Biofeedback and psychotherapy BF integrates withCBT BF integrates with interpersonal psychotherapies Physiological screen Thought screen

התשובה אם כן לשאלה מה היחס בין ביופידבק לטיפול Biofeedback and CBT ה CBT "לא נותנת לו" Biofeedback and interpersonal Psychotherapy הביופידבק מפלרטט עם טיפול דינמי!