Paula S. Cochran (2005)
described the use of biofeedback in speech-language pathology: "Biofeedback does not require a computer. Examples of low-tech biofeedback often provided by clinicians to help their clients monitor airflow include straws, nasal mirrors, and pinwheels. Low-tech biofeedback for voicing and loudness include voice-activated toys and lights. The key characteristic here is that while clients are speaking, they experience consequences that help them modify their speech. Whether the feedback is visual, auditory, or tactile, if it happens during the speech act and changes as a result of the speech act, it can be considered biofeedback" (pp. 200-201).

As speech biofeedback illustrates, biofeedback is not confined to popular modalities like EEG, heart rate variability (HRV), SEMG, and temperature. Practitioners can provide biofeedback training for any activity that can be monitored.

deCharms and colleagues (2005) expanded the boundaries of biofeedback when they provided real-time functional MRI (fMRI) biofeedback for rostral anterior cingulate activity (represented as a virtual flame that brightened and dimmed) to control experimental pain induced by pulses of heat applied to the leg.

Scott Adams (2006), the author of the Dilbert comic strip, struggled with spasmodic dysphonia, in which he could not speak in person using a normal voice. This disorder involves abnormal laryngeal muscle contraction, its cause is unknown, and spontaneous remission is rare. Conventional treatment, which includes Botox injections, speech therapy, and surgery attempts to reduce symptom severity, but not cure, this disorder (Bliznikas & Baredes, 2005).

Adams used multiple strategies to regain social speech, including visualization, affirmation, hypnosis, speech therapy exercises, changing pitch, singing words, and speaking in foreign accents (self-regulation). He adjusted his strategy based on its results (feedback) and actively searched for patterns (self-monitoring) to explain why some strategies were more helpful than others. He achieved a breakthrough when he discovered that he could speak in rhyme and repeatedly practiced this strategy for several days until he largely regained normal speech.

Scott Adams's self-treatment for spasmodic dysphonia contains elements of biofeedback like self-regulation exercises, feedback or knowledge of results, self-monitoring, and practice, and illustrates Shellenberger and Green's (1986) mastery model. His success story illustrates the impressive potential of biofeedback to retrain the neuromuscular system.

Biofeedback can be low-tech, high-tech, or no-tech, as in the case of Scott Adams. Biofeedback is defined by the training process, not by the hardware used. Your conceptual model of biofeedback affects the way you think about biofeedback and how you define your client's role in training.

This unit covers Definitions of biofeedback (I-A), Concepts of feedback and control in biological systems (I-C), and Overview of principles of human learning as they apply to biofeedback (I-D).

Students completing this unit will be able to discuss:

  1. Definitions of biofeedback
  2. Concepts of feedback and control in biological systems
  3. Overview of principles of human learning as they apply to biofeedback
    A. Learning theory
    B. Application of learning principles to biofeedback training

Birk (1973)
“Biofeedback can be defined as the use of monitoring instruments (usually electrical) to detect and amplify internal physiologic processes within the body, in order to make this ordinarily unavailable internal information available to the individual and literally feed it back to him in some form.”

Hassett (1978)
Biofeedback is a process that "involves making one aware of very subtle changes in physiological states in the hope of bringing those processes under conscious control.”

Basmajian (1979)
“Biofeedback may be defined as the technique of using equipment (usually electronic) to reveal to human beings some of their internal physiological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating and displaying signals.”

Olton and Noonberg (1980)
“Biofeedback may be defined as any technique which increases the ability of a person to control voluntarily physiological activities by providing information about those activities…feedback is information and biofeedback is information about the state of biological processes.”

Schwartz and Fehmi (1982)
“Biofeedback involves the use of sensitive (e.g., electronic or electromechanical devices) to measure, process, and indicate (i.e., feedback) the ongoing activity of various body processes or conditions of which the person is usually unaware so that the client, client, or student may have the opportunity to change and to develop beneficial control over these body processes.”

Shellenberger and Green (1986)
“Biofeedback training is the process of mastering psychophysiological self-regulation skills, with the aid of information from a biofeedback instrument, and is similar to skills learning in any activity such as sports, music, or education. The essential ingredients of biofeedback training are those of training in any complex skill: clear goals, rewards for approximating goals, enough time and practice for learning, proper instructions, a variety of training techniques, and feedback of information. The essential ‘ingredients’ of the user of the information from the biofeedback machine are those of any learning of a complex skill: consciousness, cognitive understanding, language, positive expectations, motivation, and positive interaction with the coach, teacher, or therapist.”

Schwartz and Schwartz (1995)
“As a process, applied biofeedback is: a group of therapeutic procedures that uses electronic or electromechanical instruments to accurately measure, process, and feed back, to persons and their therapists information with educational and reinforcing properties, about their neuromuscular and autonomic activity, both normal and abnormal, in the form of analogue or binary, auditory and/or visual feedback signals. Best achieved with a competent biofeedback professional, the objective are to help persons develop greater awareness of, confidence in, and an increases in voluntary control over their physiological processes that are otherwise outside awareness and/or under less voluntary control, by first controlling the external signal, and then with internal psychophysiological cognitions, and/or by engaging in and applying behaviors to prevent symptom onset, stop it, or reduce it soon after onset.”

Birbaumer and Flor (1999)
"Applied Psychophysiology is a scientific discipline that uses noninvasive psychophysiological measurements for clinical and other applied purposes. As the applied section of psychophysiology it shares with its mother discipline the scope of understanding and modification of the relationship between behavior and physiological functions by using noninvasive physiological recordings. Noninvasive physiological recordings encompass all the classical psychophysiological variables such as EEG, MEG (magnetoencephalography), EMG, skin conductance, skin temperature, blood pressure, heart rate, gastro-intestinal motility, blood flow and vasomotor variables, endocrinological and biochemical measures in blood, urine, feces and saliva but also modern imaging techniques such as optical recording and functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS). Psychophysiology and applied psychophysiology never use these methods in isolation but always simultaneously with psychological/behavioral measurement techniques.”

"Applied psychophysiology reflects an evolving scientific discipline and specialty involving understanding and modifying the relationship between behavior and physiological functions by a variety of methods including noninvasive physiological measures. The term applied psychophysiology is a rubric encompassing evaluation, diagnosis, education, treatment, and performance enhancement."

Schwartz (1999)
“Applied psychophysiology includes a group of interventions and evaluation methods with the exclusive or primary intentions of understanding and effecting changes that help humans move toward and maintain healthier psychophysiological functioning. AP involves helping people change physiological functioning and psychological function (measured, theoretical, and potential) and/or to achieve sensorimotor integration and motor learning within physical rehabilitation. The group of interventions use all forms of biofeedback, relaxation methods, breathing methods, cognitive behavioral therapies, client education, behavioral changes, hypnosis, meditative techniques, and imagery techniques. In some situations, dietary and other biochemical (nonmedication) changes and some truth detection research and applications may be considered under the rubric of applied psychophysiology. Evaluation methods use all forms of physiological measurements. The physiological functioning includes but is not limited to accurately measured changes in skeletal muscles, all autonomic physiology, breathing measures, biochemistry, electroencephalographic activity, both normal and abnormal and imaging techniques. Autonomic measures include electrodermal, skin temperature, blood pressure, heart rate, gastrointestinal motility, and vasomotor. The interventions need to be part of or have implications for applications to humans. These could, but do not need to, involve therapy procedures and/or symptoms of medical and psychophysiological disorders.”

Common elements of these definitions are that (1) biofeedback is information about personal, couple, or group psychophysiological performance, (2) this information is obtained by noninvasive monitoring, (3) this information is used to help individuals achieve self-regulation (voluntary self-control), and (4) the learning process resembles motor skill learning.

We can learn psychophysiological responses through the unconscious processes of perceptual learning, and classical and operant conditioning, and the conscious process of relational learning.

Perceptual learning allows us to categorize stimuli and recognize that we've encountered them before. This unconscious learning process enables a client to recognize that her headache is a migraine as opposed to a tension-type headache.

Classical conditioning is an unconscious associative learning process that modifies reflexive (elicited) behavior and prepares us to rapidly respond to future situations. Classical conditioning underlies conditioned emotional responses, like anxiety when you see a Highway Patrol vehicle, and the placebo response, where client expectancies promote healing.

An unconditioned stimulus (physical pain) elicits an unconditioned response (blood pressure increase) without conscious learning.

Classical conditioning associates a neutral stimulus (dental visit) with an unconditioned stimulus (physical pain). Through repeated pairing, the neutral stimulus becomes a conditioned stimulus that elicits a conditioned response (blood pressure increase).

Extinction occurs when failure of an unconditioned stimulus (physical pain) to follow the conditioned stimulus (dental visit) weakens or completely eliminates a conditioned response (blood pressure increase). Spontaneous recovery occurs when the conditioned response (blood pressure increase) reappears after a period of time without exposure to the conditioned stimulus (dental visit). Stimulus generalization occurs when the conditioned response is elicited by stimuli (blood draw) that resemble the conditioned stimulus (dental visit). Stimulus discrimination occurs when the conditioned response (blood pressure increase) is elicited by one stimulus (dental visit), but not another (blood draw).

Operant conditioning is an unconscious associative learning process that modifies the form and occurrence of an operant behavior (emitted behavior) by manipulating its consequences.

Operant conditioning occurs with a situational context. The identifying characteristics of a situation are called its discriminative stimuli and can include the physical environment and physical, cognitive, and emotional cues. Discriminative stimuli teach us when to perform operant behaviors.

The Quieting Response is a six-second relaxation exercise developed by Stroebel that consists of four stages:

  1. Focus on a stress cue (anxiety, change in breathing, frustration, or tension)
  2. Smile inwardly, including the eyes and mouth. Suggest to yourself: "Alert amused mind, calm body"
  3. Take an easy deep breath
  4. Let your jaw, tongue, and shoulders go limp as you exhale, and feel the flow of warmth down your body to your toe

In positive reinforcement, behavior (Quieting Response practice) is followed by a positive consequence (feeling good) that increases the likelihood that your client will use the behavior in situations with similar discriminative stimuli (distress cues).

In negative reinforcement, behavior (Quieting Response practice) allows your client to escape or avoid an aversive state (distress), thereby increasing the likelihood that your client will use the behavior in situations with similar discriminative stimuli (distress cues).

In operant generalization, your client performs an operant behavior (Quieting Response) with a new discriminative stimulus (anger instead of anxiety). In operant discrimination, your client performs an operant behavior (Quieting Response) when one discriminative stimulus (anxiety) is present, but not during another (calm).

In aversive punishment (positive punishment), an operant behavior (Quieting Response) is weakened when followed by an aversive stimulus (frustration). In response cost (negative punishment), an operant behavior (Quieting Response) is weakened when followed by the removal of a rewarding stimulus (client loses attention for symptoms). In operant extinction, the frequency of behavior (Quieting Response) declines when it is not reinforced (client is unable to achieve calm). 

Shaping is an operant procedure where a clinician rewards (provides praise and auditory and visual feedback) successive approximations of a final behavior (low  surface EMG levels in the upper trapezius muscles when performing the Quieting Response).                        

Therapists can teach clients to discriminate their psychophysiological state (hand temperature) by asking them to estimate its value and then by confirming or correcting their estimate.

Peper has recommended this strategy to teach clients to estimate their inhalation volumes (the amount of air they can inhale using an incentive inspirometer). Clients inhale a volume of air, estimate the volume, and then look at the actual measurement. This increases client awareness of the depth of their inhalation.

Relational learning is conscious, allows us to associate stimuli that occur at the same time, and underlies both working memory (blackboard memory) and long-term declarative memory (memory of facts and experiences). In a clinical context, it provides conscious memories a client can retrieve and use to guide behavior (how she calmed herself during meditation). A declarative memory of meditation might simultaneously associate a person's breathing pattern, repeated phrase, and somatosensory feedback (like reduced muscle tone and the slowing of the heart).


Five models have greatly influenced therapist and researcher conceptions of biofeedback. These include the cybernetic, operant conditioning, drug, placebo, and relaxation models.

The cybernetic model proposes that "biofeedback is like a thermostat." The term, biofeedback, originated in cybernetic theory. The components of a thermostat system include a setpoint or goal (75 degrees), system variable or what is controlled (room temperature), negative feedback or corrective instructions (commands to change furnace output), and positive feedback or commands to continue action (commands to continue furnace output).

The internal environment fluctuates around a setpoint and is never stationary. This allows rapid adaptation to changing activity levels and environmental conditions. Homeostasis is a state of dynamic constancy achieved by stabilizing conditions above and below a setpoint, which may change over time. From the perspective of the cybernetic model, biofeedback training supplements a client's proprioception to bring a malfunctioning biological system variable (blood pressure) under better control (Fox, 2006).

Homeostasis depends on sensory systems (networks that monitor system variables) to detect actual or anticipated change in physiological processes (temperature), an integrating center, which receives input from many sensors, and multiple effector systems (control systems) to adjust physiological processes.

The body maintains dynamic constancy through continuous negative feedback loops amplified by positive feedback and antagonistic effectors.

Negative feedback loops produce corrective changes when a physiological variable is outside an acceptable range. For example, we initiate clotting to stop blood loss from a wound.

Positive feedback amplifies the changes produced by negative feedback. For example, activation of one clotting factor activates others to create a blood clot.

Push-pull control by effectors that produce antagonistic effects achieves more precise control than turning a single effector on or off. For example, a sympathetic nerve accelerates the heart while the parasympathetic vagus nerve slows the heart.

The operant conditioning model proposes that "biofeedback is the operant conditioning of physiological processes." From this perspective, voluntary changes (reduced muscle bracing) are strengthened by reinforcing consequences (feedback display). This model implies that awareness of which change is being reinforced is unnecessary and disregards the instructional elements that are critical to training success.

The operant model has several problems. First, operant conditioning is only one of several learning processes involved in self-regulation training. Classical conditioning, cognitive learning, motor learning, and social learning may also be involved.

Second, reinforcement without systematic instruction is an inefficient way to teach a skill. This would be like a track coach who announced a sprinter's time, but never demonstrated technique or corrected her form.

The drug model asserts that "biofeedback treatment corrects symptoms like a drug." This model is implied when a client receives only three sessions of temperature biofeedback regardless of whether she can warm her hands to 95 degrees F on command.

The drug model is counterproductive because it places the client in a passive role (analogous to taking aspirin) and emphasizes dosage (the number of sessions) over skill mastery. If you believe that skill mastery affects treatment outcome, then clients should be trained to criterion and not be limited to an arbitrary number of sessions.

Therapists using the placebo model believe that "biofeedback produces nonspecific effects, like a drug, due to client beliefs."

While the "laying on of electrodes" undoubtedly produces symptom improvement, this model discounts the contribution of skill learning. Second, the changes produced through biofeedback, like increased end-tidal CO2, can be very specific and are due to modified breathing mechanics instead of client beliefs.

The relaxation model views biofeedback as inherently relaxing. Based on this model, therapists may administer biofeedback without relaxation instructions and researchers may compare biofeedback to relaxation procedures like Progressive Relaxation.

This approach suffers from serious misconceptions about biofeedback. First, feedback about your physiology is not always relaxing. For example, a client told that her blood pressure is elevated will not be calmed by this news.

Second, whether biofeedback training produces cultivated low arousal depends on relaxation instructions and the client's approach to learning. For example, an extreme Type A client learning to lower SEMG levels could exacerbate stress symptoms by competing against the electromyograph.

Finally, even traditional relaxation procedures like Autogenic exercises can produce distress. Relaxation-induced anxiety has been reported for up to 40% of clients receiving relaxation training.

Blanchard and Epstein (1978) and Shellenberger and Green (1986) developed models of self-regulation that emphasize the mastery of self-regulation skills. These approaches are consistent with the view that biofeedback is information. From this perspective, a therapist coaches the client to use information about physiological performance to achieve voluntary control to reduce symptoms and promote optimal functioning.

Blanchard and Epstein (1978) proposed that self-regulation consists of five components. Self-monitoring is scanning yourself in a situation (checking your breathing during a job interview). Discrimination means identifying when self-regulation skills should be used based on situational (stressful confrontation) and internal (rapid heart rate) cues.

Self-control is the use of a skill to achieve a desired state (practicing effortless breathing to lower arousal). Self-reinforcement is use of internal (self-praise) or external rewards (clothing) for use of a skill. Finally, self-maintenance is long-term skill practice which is aided by regular review.

In the context of this self-regulation model, successful hypertension clients:

  1. understand hypertension and the strategy for control
  2. modify risk factors (reduce saturated fat and salt intake)
  3. monitor symptoms (scan the body several times a day for posture and breathing pattern, and chart
    blood pressure daily)
  4. practice self-control (relax posture, breathe effortlessly, and perform both abbreviated and deep
    relaxation exercises)
  5. reward themselves (praise themselves for practice and results, and draw a connection between practice and
    lower medication dosage and pressure)
  6. maintain progress (review progress, modify practice based on experience, and schedule booster
    sessions with a therapist as needed)

After six months practice, cues like red traffic lights and cold hands can automatically trigger self-regulation responses. They become habits or attractors. Now, a healthy lifestyle becomes rewarding and cheating becomes aversive.

Shellenberger and Green (1986) advanced a mastery model that compares biofeedback training to coaching an athletic skill. This training process is social, since you are working with another person or group, and biobehavioral, since this instruction uses behavioral principles to control biological processes.

The biofeedback training process contains these components:

  1. relationship with therapist
  2. competent therapist who has developed and models self-regulation skills
  3. clear training goals
  4. rewards for approximating goals
  5. sufficient time and practice for mastery
  6. effective instructions as part of systematic training
  7. feedback of information to the client
  8. practice


Mere exposure to information about our physiological performance produces no dependable effects. For example, viewing a stopwatch does not reliably improve a runner's form.

The effect of information depends on how it is used. When biofeedback is combined with physical therapy, it becomes biofeedback-assisted rehabilitation. When combined with relaxation training, it becomes biofeedback-assisted relaxation. Without rehabilitation or relaxation coaching, the information is neither rehabilitating or relaxing.

Don't assume that biofeedback requires hardware. Information about your personal biological activity can be detected with or without hardware. Natural proprioception (bodily sensory feedback) will be your client's main source of information after learning to scan the body. Examples: touch your finger to your wrist to detect pulse rate or touch your cheek to detect hand temperature.

During training, you can supplement proprioception with high technology or low technology instruments that monitor performance. Below is a BioGraph ® Infiniti heart rate variability (HRV) display.

Don't confine your concept of biofeedback to the traditional modalities like EEG, SEMG, skin conductance, and temperature. While invaluable in many clinical applications, your client may not require biomedical devices.

Peper and Shambaugh (1979) have suggested that ordinary devices can provide valuable performance feedback. For example, clients can correct their facial expression during public speaking by practicing with a mirror. They can improve their balance by training with a pair of bathroom scales. They can reduce hand tremor by using a graduated series of bells. Finally, athletes can refine their tennis serve using a camcorder for video feedback.


The training process is social whether a client works alone with a therapist or within a group. A client's relationship with the therapist may be the most critical aspect of training.

Taub and School (1978) reported a person effect when teaching hand-warming. An "informal and friendly" trainer successfully taught 19 of 21 subjects to raise their finger temperature. In contrast, a more formal and "impersonal" trainer only succeeded with 2 of 22 subjects (p. 617). The interpersonal dynamics that make psychotherapy successful are equally important in biofeedback training.

Unlike stereotypical "out-of-shape" coaches with "beer guts," biofeedback therapists have to develop and practice the skills they are teaching. Peper (1994) strongly argued that therapists must be "self­experienced." Would you be confident with a therapist who looked "stressed out" and extended an ice-cold handshake?

Therapists learn to self-regulate so they can model self-regulatory behaviors (like low arousal), personally know that training works, and understand their clients' learning experiences. Since modeling involves implicit (unconscious) learning, a therapist who sits tensely or breathes rapidly may inadvertently teach these behaviors to a client.

An effective biofeedback therapist is a good coach. As in athletic coaching, successful biofeedback training requires clear goals, graduated rewards for success, sufficient time and practice for mastery, effective instructions delivered using systematic training techniques, useful feedback about performance, and practice of skills outside of the clinic.

Client motivation is often complex and may involve the same approach-avoidance and avoidance-avoidance conflicts seen in psychotherapy.

A client has an approach-avoidance conflict when aversive symptoms are also advantageous (gaining professional and family attention, control over relationships, and financial compensation). The rewards of symptomatic behavior are called secondary gains.

An avoidance-avoidance conflict exists when symptoms are unpleasant and biofeedback training is negatively perceived due to financial cost, time investment, or social stigma.

Finally, as in psychotherapy, significant others may sabotage training to maintain their existing relationship. This is particularly a problem in co-dependent relationships.

You can assess and modify motivation by focusing on the symptoms that concern your clients. R. Adam Crane asks his clients during assessment to select three symptoms they want to improve. The clients are then asked to chart these symptoms daily throughout the course of biofeedback training. His criteria for success are a 25% to 35% decrease in symptom frequency and severity.

This protocol increases client motivation three ways. First, involving clients in treatment decisions increases their commitment. Second, involving clients in treatment decisions and assigning responsibilities places them in an active role and increases perceived self-efficacy. Third, daily charting of symptoms should produce improvement on its own, independent of skill mastery.

Successful clients are active participants in this leaning process. A therapist has an opportunity to modify client expectations about their role in biofeedback training through educational literature, the assessment process, and initial training sessions.

Models that emphasize active skill learning, like Shellenberger and Green's mastery model, may produce better clinical outcomes than those that promote passivity.

Therapists routinely assign clients skill practice outside of their training sessions. These assignments often fall into five areas: lifestyle modification, biofeedback practice, abbreviated relaxation exercises, deep relaxation exercises, and self-monitoring.

Lifestyle modification involves changes in routine behavior to help achieve treatment goals. For example, a client treated for anxiety may reduce caffeine intake from 4 cups of caffeinated coffee to 1 cup of decaffeinated tea.

Biofeedback practice means continuing biofeedback training with portable monitors. This is designed to increase a client's proficiency in self-regulation and generalize it to settings outside of the clinic. For example, a migraine client may practice hand-warming at home using a portable feedback thermometer or disposable thermometer.

Abbreviated relaxation exercises like Stroebel's Quieting Response (QR) often require less than a minute and may be repeated many times a day to promote their acquisition and generalization. They are designed to replace symptoms like anxiety with more adaptive behaviors like cultivated low arousal or mindfulness. Unlike deep relaxation exercises, they can be easily performed when performing routine activities like commuting..

Deep relaxation exercises like Autogenic Training, meditation, and Progressive Relaxation require 15 minutes to several hours and involve a break from routine activity. For example, you could not safely meditate as you drove your car on an interstate highway. These exercises may profoundly reduce physiological arousal and reset physiological activity to healthier values. As a client can more readily experience lowered arousal, this may accelerate biofeedback training and increase the effectiveness of abbreviated relaxation exercises.

Self-monitoring means checking symptoms or performance outside of the clinic. Therapists often ask clients to chart this information to identify causal patterns, teach them when to use an abbreviated relaxation exercise to disrupt an escalating symptom, and measure change in performance.

Research indicates that clients succeed if they occasionally practice self-regulation skills. Why is practice crucial to client success? Practice helps a client acquire skills through more time on task. If a client trains 1 hour a week in the clinic, this leaves 167 hours available outside the clinic to refine skills learned during the training session.

Practice helps clients transfer self-regulation skills to environmental settings. Hand-warming in the clinic does not automatically generalize to driving in rush hour traffic. Unless clients practice these skills in the settings where they need them, they might only be symptom-free in the clinic.

Finally, practice makes self-regulation automatic. For example, when you learn to drive a manual transmission, you start out concentrating intensely on shifting, afraid that you will "strip the gears." After months of practice and several gear boxes, you shift without attention. Likewise, clients practicing Stroebel's Quieting Response perform this skill automatically after about 6 months.

Successful biofeedback training teaches voluntary control. Voluntary control is shown when a person can produce a requested physical change (warm your hand to 95 degrees F) on command without external feedback.

Voluntary control is achieved through passive and active volition. Passive volition means allowing your body to perform instead of trying to force it. Forcing defeats your purpose when urinating during intermission in a movie theater, having an erection, or performing Zen archery.

Active volition means forcing your body. This process is triggered by words like make or try. This is used in conjunction with passive volition in modern versions of Jacobson's Progressive Relaxation where clients are instructed to intentionally contract and relax muscle groups to detect and reduce residual muscle tension.

Despite identification of biofeedback training with passive volition, voluntary control actually involves flexibly shifting between these modes as required.

Schultz, who developed Autogenic Training, believed that imagery is the language the body best understands. He contended that an image serves as a blueprint for physiological change.

Research on successful self-regulators has shown that they use diverse strategies, including pictures, sounds, bodily sensations, feelings, and abstract concepts. You should encourage your clients to experiment with different strategies and then use the ones that work. This communicates respect for them as collaborators and increases their perceived self-efficacy, which is their perceived ability to achieve desired outcomes.

Both your conceptualization of a disorder and treatment design should be guided by the clinical literature. This can be frustrating for a clinician when research findings contradict conventional wisdom about a disorder. Evidence-Based Practice in Biofeedback and Neurofeedback, which is published by the Assocation for Applied Psychophysiology and Biofeedback, summarizes clinical efficacy studies for diverse biofeedback/neurofeedback applications and should often be consulted first when designing treatment plans.

The discredited sympathetic arousal model of Raynaud's disease provides an excellent example. The sympathetic arousal model asserts that stressors are powerful triggers for Raynaud's attacks and that interventions that lower sympathetic arousal will reduce symptom severity. Therapists who subscribe to this model usually provide biofeedback to lower sympathetic tone and teach stress management skills.

Research by Freedman and colleagues has challenged the sympathetic arousal model's assumptions. Raynaud's disease appears to be due to a "local fault" in peripheral blood vessels. Cold and cold-related stimuli are more likely to trigger hand-cooling than stressors. Temperature biofeedback does not prevent attacks by reducing sympathetic arousal. Finally, bidirectional temperature biofeedback with cold challenge produces greater symptom reduction than stress management techniques. In this strategy, clinicians teach clients to alternatively warm or cool their extremities within a cold room or while wearing a suit cooled by circulating cold water.

Failure to revise our models and treatment strategies may seriously reduce our clinical effectiveness.

Clients reporting a symptom, like hypertension, may have very different psychophysiological profiles. Treatment should be personalized to correct abnormalities: values that are too high, low, show excessive or insufficient variability, or recover too slowly.

Biofeedback training of astronauts and pilots to reduce motion sickness illustrates this approach. A therapist monitors an individual's autonomic responses during stress testing, in a Barany chair that tilts and rotates or in a centrifuge, and identifies the systems that respond abnormally. Biofeedback-assisted relaxation to correct abnormal responses can prevent or moderate motion sickness (Cowings et al., 1986; Cowings & Toscano, 1982).

Personalizing treatment also means training clients to mastery criteria. For example, you might provide temperature training until your client can achieve 95 degrees F without feedback. This is more flexible than limiting training to five sessions of temperature biofeedback whether the client has succeeded or not. Clients have different learning curves and learning styles.

The length and number of sessions should reflect research data concerning biofeedback training for a specific modality (temperature) and specific disorder (migraine). Realistically, treatment protocols will be affected by each client’s learning curve, availability, and ability to pay for training.

Bidirectional training teaches client to increase and decrease a physiological response. This strategy may be more effective than training in a single direction. This advantage may result from increased training time, higher proficiency standards, and learning to control more than one physiological mechanism.

Bidirectional training has been advocated in both temperature and EEG biofeedback. When teaching clients to hand-warm to prevent Raynaud's episodes, you might teach hand-warming and cooling in the same or successive sessions. In neurofeedback training to control pain by increasing theta activity, ON-OFF-ON protocols (theta increase-theta suppression-theta increase) may produce the best results.

Wherever feasible outside of neuromuscular rehabilitation, biofeedback training should be spaced instead of massed. In spaced practice, training sessions are scheduled over an extended period of time to produce greater skill acquisition and generalization. A 15-session training protocol might involve 2 weekly sessions for 5 weeks and then 1 session a week for the remaining 5 weeks.

In massed practice, training sessions are compressed into a shorter time period. A client might receive 5 sessions a week for 3 weeks. This training schedule might be necessary when a client is hospitalized (constraint-induced movement therapy for stroke) or treated as an out-client in another city.

Biofeedback therapists use multiple treatment strategies to aid generalization of self-regulation skills to life situations:

  1. teaching self-monitoring
  2. emphasizing “skills” instead of “pills,” thereby fostering self-efficacy)
  3. assigning daily self-regulation skill practice
  4. teaching clients how to modify their environments
  5. fading of feedback during training
  6. incorporating discrimination training
  7. training clients using realistic simulations (virtual reality) or real life settings
  8. encouraging clients to create and record their own training scripts

Olton and Noonberg (1980) advised that performance goals should be raised when a client succeeds more than 70% of the time and lowered when a client succeeds less than 30% of the time. Computer-based biofeedback systems incorporate algorithms like the 70-30 rule and automatically revise goals based on the client's performance during the previous 15- or 30-second trial.

This approach helps maintain client motivation and insure sufficient challenge. Training success can increase the client's perception of self-efficacy, which may positively affect a client's symptoms.

How do you explain biofeedback to your clients? Biofeedback metaphors help define your client's role in the training process. I recommend two metaphors that portray biofeedback as a process that teaches the client skills using information about personal performance.

"Biofeedback is like coaching a runner using a stopwatch." This metaphor emphasizes the importance of coaching in improving client performance.

"Biofeedback is like teaching carpentry, not hammering." This metaphor communicates that the purpose of biofeedback training is to teach self-regulation instead of mastery of a particular technique.


70-30 rule: training thresholds should be adjusted when a client succeeds more than 70% of the time and lowered when a client succeeds less than 30% of the time.

abbreviated relaxation exercises: procedures like Stroebel's Quieting Response (QR) that produce weak-to-moderate subjective and physiological change, involve minimal sensory restriction, and are practiced for very brief periods of time, that are designed to replace symptoms like anxiety with more adaptive behaviors like cultivated low arousal or mindfulness.

active volition: a process where you direct yourself to perform an action like clenching a fist that is triggered by words like make or try.

approach-avoidance conflict: the client perceives her symptoms as both aversive (discomfort and disability) and advantageous (gaining professional and family attention, control over relationships, and financial compensation).

Autogenic Training: deep relaxation procedure developed by Schultz and Luthe that involves a sequence of three procedures: six standard exercises, autogenic modification, and autogenic meditation.

aversive punishment (positive punishment): the weakening of an operant behavior when it is followed by an an aversive stimulus (a client reduces relaxation practice when lack of progress frustrates her).

avoidance-avoidance conflict: the client perceives both her symptoms (low back pain) and training (SEMG biofeedback) as aversive.

bidirectional training: teaching a client to alternatively increase and decrease a physiological response (increase and decrease masseter SEMG).

bidirectional temperature biofeedback with cold challenge: biofeedback training to alternatively increase and decrease peripheral temperature in a cold room or while wearing a cold suit.

biofeedback: information about personal, couple, or group psychophysiological performance that is obtained by noninvasive monitoring and used to help individuals achieve self-regulation through a learning process that resembles motor skill learning.

classical conditioning: unconscious associative learning process that modifies reflexive behavior and prepares us to rapidly respond to future situations.

conditioned response (CR): in classical conditioning, a response (blood pressure rise) elicited by a conditioned stimulus (criticism).

conditioned stimulus (CS): in classical conditioning, a stimulus (dentist's office), that in association with an unconditioned stimulus (pain), elicits an unconditioned response (anxiety) like the original unconditioned response.

cultivated low arousal: reduced activation of the central nervous system (EEG) and peripheral nervous system (autonomic and somatic) observed during deep relaxation.

cybernetic model: explanation that biofeedback is like a thermostat system with a setpoint, system variable, and negative and positive feedback.

deep relaxation exercises: procedures like Autogenic Training, meditation, and Progressive Relaxation that may require 15 minutes to several hours, involve a break from routine activity, and profoundly reduce physiological arousal and reset physiological activity to healthier values.

discrimination: perception of psychophysiological performance, like the difference between 0.5 microvolt and 1 microvolt of SEMG activity in the masseter muscles, which is a crucial component of self-regulation.

discriminative stimuli: in operant conditioning, the identifying characteristics of a situation (the physical environment and physical, cognitive, and emotional cues) that teach us when to perform operant behaviors; for example, a traffic slowdown signals a client to practice effortless breathing.

drug model: explanation that biofeedback can be administered like a doses of a drug, which ignores the role of skill mastery and the need to train clients to criteria.

extinction (classical conditioning): the weakening and disappearance of a conditioned response (CR) when it is repeated presented without the unconditioned stimulus (UCS); for example, a client's blood pressure rise (CR) decreases and then disappears after several painless visits (UCS).

extinction (operant conditioning): the weakening and disappearance of an operant behavior when it is no longer reinforced; for example, a client reduces and then stops practicing the Quieting Response after she ceases to feel calm during this exercise.

homeostasis: state of dynamic constancy achieved by stabilizing conditions above and below a setpoint, which may change over time.

integrating center: in cybernetic theory, the site that receives sensory input; for example, the hypothalamus is the primary integrating center in the human body.

interoception: perception of the body's interior (pain and pressure).

lifestyle modification: changes in routine behavior like diet and exercise to help achieve treatment goals.

long-term declarative memory: system that creates conscious long-term memories about facts and our experiences (episodic memories).

massed practice: compression of training sessions into a brief period of time like 10 sessions in 2 weeks.

mastery model: Shellenberger and Green's (1986) explanation that compares biofeedback training to coaching an athletic skill.

multiple effector systems: in cybernetic theory, multiple control systems; for example, the hypothalamus regulates homeostasis through its control over the autonomic nervous system, immune system, and somatic nervous system.

negative feedback: corrective instructions when a physiological variable is outside an acceptable range (feedback tone).

negative reinforcement: in operant conditioning, the strengthening of an operant behavior (effortless breathing) when it is followed by the avoidance or removal of an aversive stimulus (pain).

neutral stimulus (NS): in classical conditioning, a stimulus (sight of a street light) that does not trigger a conditioned response (CR).

ON-OFF-ON: training paradigm in which a client performs a target behavior (increases alpha amplitude), suppresses it (reduces alpha amplitude), and then produces it again (increases alpha amplitude),

operant behavior: behavior that operates on the environment and is under voluntary control (writing in a personal journal).

operant conditioning: unconscious associative learning process that modifies the form and occurrence of voluntary behavior by manipulating its consequences.

operant conditioning model: explanation that "biofeedback is the operant conditioning of physiological processes," which minimizes the importance of client awareness of physiological changes and instruction in training.

operant generalization: an operant behavior is performed when a new discriminative stimulus is present (client breathes effortlessly when both anxious or experiencing pain).

passive volition: a process where you invite yourself to perform an action like dropping your arm in your lap that is triggered by words like allow or permit .

perceptual learning: unconscious learning process that allows us to categorize stimuli and recognize that we've encountered them before.

person effect: Taub and School's (1978) observation that biofeedback training is a social situation and that a client's relationship with the therapist may be the most critical aspect of training.

placebo model: explanation that "biofeedback produces nonspecific effects, like a drug, due to client beliefs," which discounts the contribution of skill learning.

positive feedback (feedforward): in cybernetic theory, commands to continue action that amplifies the changes produced by negative feedback.

positive reinforcement: in operant conditioning, the strengthening of an operant behavior (aerobic exercise) when it is followed by a reward (praise).

Progressive Relaxation: Jacobson's deep relaxation procedure that originially trained patients to relax 2 or 3 muscle groups each session until 50 groups were trained during 50-60 sessions in the clinic and 1-2 daily one-hour practice sessions.

push-pull control: regulation by effectors that produce antagonistic effects and achieves more precise control than turning a single effector on or off; for example, parasympathetic and sympathetic motor neurons jointly adjust the heart rhythm.

Quieting Response (QR): Strobel's (1982) 6-second exercise which instructs a client to focus on a stress cue, smile inwardly, take an easy deep breath, and let the jaw, tongue, and shoulders go limp as she exhales.

relational learning: conscious learning process that associates stimuli that occur at the same time and underlies working memory and declarative memory (learning how to warm your hands using a biofeedback display)..

relaxation-induced anxiety: increased anxiety during relaxation training that may include increased perspiration, shivering, trembling, pounding heart, and rapid breathing

relaxation model: explanation that biofeedback is inherently relaxing, which could lead therapists to administer biofeedback without relaxation instructions.

response cost (negative punishment): the weakening of an operant behavior (pain complaints) when it is followed by the removal of a rewarding stimulus (narcotic medication).

secondary gains: the rewards of symptomatic behavior, like reduced housecleaning responsibilities following the display of pain behaviors.

self-control: using a skill to achieve a desired state (running on a treadmill to reduce weight).

self-efficacy: perceived ability to achieve desired outcomes (your belief that you can learn to lower your blood pressure).

self-monitoring: observing yourself in a situation (taking your pulse after a run).

self-maintenance: ensuring long-term skill practice (periodically reviewing your success with effortless breathing and fine-tuning this skill).

self-regulation: control of your behavior (voluntary hand-warming).

self-reinforcement: using internal or external rewards to increase performance of a behavior (praising yourself for using effortless breathing during an argument).

sensory systems: networks that detect actual or anticipated changes in system variables.

setpoint: goal like core body temperature of 98.6 degrees F.

social learning (observational learning): learning process in which observation of the consequences of a model's behavior can influence an individual's operant behavior (exposure to a therapist's slow breathing increases a client's practice of effortless breathing).

spaced practice: scheduling training sessions over an extended period of time like 15 sessions over 8 weeks.

spasmodic dysphonia: the inability to speak in person using a normal voice due to abnormal laryngeal muscle contraction.

spontaneous recovery: in classical conditioning, the reappearance of an extinguished conditioned response (CR) following a rest period; for example, your blood pressure increase returns after 6 months away from the dentist's office).

stimulus discrimination: in classical conditioning, when a conditioned response (CR) is elicited by one conditioned stimulus (CS), but not by another; for example, your blood pressure increases during a painful dental procedure, but not during an uncomfortable blood draw.

stimulus generalization: in classical conditioning, when stimuli that resemble a conditioned stimulus (CS) elicit a conditioned response (CR); for example, when your blood pressure increases during a painful dental procedures and an uncomfortable blood draw.

sympathetic arousal model of Raynaud’s: poorly-supported model that asserts that stressors are powerful triggers for Raynaud's attacks and that interventions that lower sympathetic arousal will reduce symptom severity.

system variable: in cybernetic theory, the variable that is controlled, like room temperature.

unconditioned response (UCR): an innate response that is elicited by an unconditioned stimulus (UCS) without prior learning (elevated blood pressure in response to physical pain).

unconditioned stimulus (UCS): a stimulus (physical pain) that elicits an innate response (increased blood pressure) without prior learning.

working memory: short-term conscious memory system that is called "blackboard memory."

Now that you have completed this module, write down your favorite biofeedback metaphor. Based on your own clinical experience, what would you add to the discussion of the training process?

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