A methodology for psychophysiological therapy

This is a summary of few years of consulting a British company in the field of psychcophysiological therapy

Biofeedback therapist have been assisted, in treating patients, by computers for many years.  The computer served as a processor that received the psychophysiological data, displays it on the monitor, and stored it on the hard disk.  This function, considering the functions a computer can provide, is relatively limited.

Extensive portions of the treatment can be provided automatically by the computer.  The therapist can utilize the computer as a trainer, or to provide a tool for the completion of components of the treatment without his presence.  Partial structuring of the therapeutic process and conceptualization in a lucid model, is required in order to plan utilizing the computer in such a fashion.

A few basic principles that underlie the model :

1. Every therapeutic process comprises of two elements : awareness and change. Many therapist regard biofeedback as a technique by which one can obtain self control over the autonomic system.  This understanding, that was derived from the preliminary experiments in the filed that dealt with biological feedback as a technique of conditioning, does not take into account the function of cognitive and emotional processes involved in the method.  In this context, the EDA device suites the task exceptionally well due to it’s extended sensitivity to cognitive and emotional issues as well as to states of muscular tension or a variety of breathing processes.  The device can greatly assist in identifying and discovering the internal processes that bring about increase in tension.
2. Biofeedback therapy is first and far most practice, practice, and practice. When we come to plan a structure of a treatment we must bear in mind that it would have to include “lesson layout” elements.  Investing in the study of  theoretical background  should precede gradual, practice commencing without a device and later on accompanied by the feedback received from the device.
3. The patient being treated by biofeedback must also serve as “assistant to therapist”. It is imperative that he understands the therapeutic rationale and should always hold a position of curious and inquisitive interest in the process itself.  In contrast to other therapeutic methods used in the physiological field and at times in the mental field, biofeedback therapy achieves it’s best results when the patient “takes control” of the therapy.

The work presented below analyzes the various stages of treatment at two levels :

1. Macro level : the analysis of the session process beyond time.
2. Micro level : the analysis of the session structure.

Macro level : the analysis of the session process beyond time.

The structure of treatment includes the following stages:

1. Acquaintance stage
2. Acquisition of relaxation techniques stage
3. Implementation and generalization stage
4. Separation and termination stage

Acquaintance and instructing Stage

During this stage the therapist becomes acquainted with the patient’s psychological and physiological responses.  Via the psychophysiological intake two aspects are evaluated:

1. The patient’s rate of reactiveness : the rate of physiological change in response to a specific stimulus.
2. The patient’s rate of recovery: the path by which the psychophysiological reading regains balance proceeding arousal caused by a stimulus.

The patient is introduced, for the first time, to the technique of “dialogue” between the therapist, patient, and computer.  He learns how to correlate between physical responses and emotional responses  that  accompany him throughout the treatment.  The rationale for this stage is derived from the fundamental assumptions of the cognitive approach that deal with the formation and symptomotology of the problem.  Many of the patients that come for treatment have in mind the medico-biological model for “sickness”.  According to the medical model the disease is cured as a result of the physician’s active role on the one hand, and the passive cooperation of the patient on the other. the cognitive approach, to the contrary,  emphasizes the crucial part the patient’s thinking and his active involvement in the treatment, play in the process of cure.

The acquaintance stage is characterized, also, by an “educational-instructional” portion. The therapist will invest a lot of effort in explaining the problem and the means of treating it. The explanations are carried out verbally, by various illustrative accessories (diagrams, animation, video movies and such).  A significant part of the explanation is carried out by psychophysiological demonstrations.  The therapist will show the patient how specific external stimuli  effect his physiological responses.  How deviations in modes of behavior create different physiological responses, and how one’s thoughts and imagination are a powerful component in creating physiological changes.  These psychophysiological demonstrations have a crucial function in establishing the patient’s motivation and trust in the process he is about to embark on.

This motivation is strengthened as a result of the psychophysiological intake in which information pertaining to the rate of reactiveness and recovery rate of the patient is gather.  As mentioned, following the therapist obtaining the information regarding these questions, he shares that information with the patient.  He indicates computer readings and correlates them with the processes that the patient went through.  In this manner, the therapeutic triangle of patient, therapist, and computer, that accompanies the patient through the various stages of the treatment, is established.

The patient is introduced, for the first time, to the technique of “dialogue” between the therapist, patient, and computer.  And how each of these components presents it’s opinion about the patient’s condition:  the computer displays the readings and the changes on the objective plane, the patient reports his subjective experience, and the therapist helps to perform the integration between the two, to enable the patient to achieve better understanding of himself and the avenues by which he can improve his physical and emotional condition.

Acquisition of relaxation techniques stage

The stage in which the patient will learn the various techniques of relaxation, follows the acquaintance stage.  Even though the ultimate end result is that he find the best suited method for him to enter into relaxation, we believe that he should be offered assistance by teaching him a few prevalent techniques.  In the first phase we will teach him breathing control techniques, muscle relaxation and thought modification (cognitive technique). Every one of these techniques contains elements of guided imagery and autogenic therapies as well.

As was emphasized in the above mentioned fundamentals, any one of these techniques has to be learnt in a gradual fashion.  As a result, this stage is extends for a relatively long period and at times may be frustrating.  The therapist, during this stage, will be required to encourage the patient to continue practice – including home practice.

A methodological rule is formulated for the acquisition process of relaxation techniques, as well:

1. A rational theoretical explanation of the approach
2. A visual domestication of the technique in action is performed
3. The patient’s awareness as to how he was behaving prior to applying the technique, is refined
4. Practice with the aid of the therapist’s verbal instructions
5. Connecting to the device. This will be carried out, as much as possible, wvisual input but with audial input only and  verbal instructions
6. Practice with the aid of analogue visual feedback and verbal instructions
7. Performing relaxation techniques without verbal instructions at all.

Generalization and Implementation Stage

After the person has learnt how to perform the relaxation techniques under optimal conditions, it is necessary to implement these techniques outside the clinic. When the ambiance of the room is peaceful, the chair comfortable and the therapist at hand, it is easier to achieve relaxation and avoid excessive arousal.  The challenge is to perform relaxation under conditions in which a stress reaction develops such as, at work, during a flight, or prior to an examination.  Altering the conditions will be carried out gradually, for instance the preliminary practice of the technique will proceed without feedback (which is perceived as an evaluating measure) or only with tone feedback.  The feedback will gradually become more predominant.   The surroundings where the activity is carried out will under go change as well.  At first, the practice will be done sitting (in a comfortable chair) reclined backwards , to be followed by sitting in an normal, up right, posture in a office chair.   The cardinal principle being implemented during the Generalization stage is to combine a state of relaxation with recreating, whether in practice or imaginary, a stressful scenario.  For example,   a patient suffering from fear of speaking addressing an audience, will be asked to prepare a speech and deliver it while performing the relaxation.  The patient will be instructed to keep his physiological readings at a low level or decrease immediately when they rise.  Another example is of a patient that suffers from test anxiety.  The therapist will arrange to create test scenarios during treatment and in that way train the patient in the reduction of stress during a test.  At times it might be necessary to recreate an actual test scenario, but most often it is sufficient to recreate it in the imagination.  This therapeutic technique, is a psychological technique – systematic desensitization –based on the principle of bringing together relaxation with exposure to actual (in vivo) stress conditions, or imaginary (in vitro) ones.  The computer and the multimedia capabilities provide advanced utilization of this technique.  Exposure to simulated life like conditions can be created in ways that highly resemble virtual reality. A flight experience, the illusion of  fear of heights, or exposure to scenes following a car accident, can be recreated.

Research pertaining to post traumatic responses  have taught us that, at times, the best way to recreate the traumatic experience is  by utilizing the patients imagination.  It is also possible to call for the patient to recreate the trauma out- loud, and then use this recording during biological feedback practice.  In  such a manner we can provide implementing relaxation practicing capabilities when the difficult situation is experienced in actuality or in the imagination.   Advancing to the final stage is possible when control abilities have been attained in a stressful situations as well.

Separation and termination stage

Any psychotherapeutic treatment is geared towards the separation and termination abilities.   The guiding line is that the patient that did not succeed in regulating his life and his tensions, during the treatment acquired the capabilities and proficiencies that now enable him to make do without the treatment.   It is also assumed that some of the patient’s psychological problems exhibited themselves during transitional or terminal phases, and therefore, working through this stage while still in therapy  provides the opportunity to recreate difficulties pertaining to this process.  When undergoing biofeedback therapy, termination calls for “weaning” off the device as well – for the ability of the patient to gain control over his psychophysiological responses without direct feedback.  During this stage the patient’s task is to link internal physiological clues with the psychophysiological readings and by that to construct a replacement in the form of an habitual internal feedback.  It is this stage, therefore, that deals in the ability to carry out the relaxation response even without the aid of the device.  To achieve this goal the therapist will allow the measurement of the physiological variable without displaying the feedback.  The patient will be called upon to “guess” his physiological status as well as to try and estimate whether the line of the curve is on an upward or downward trend.  The patient’s deliberations if the time has come to terminate the treatment and whether it has achieved the goals, will characterize this stage.  Questions pertaining to dependency and independence as well as coping with the lose of fantasy “that all the problems would find a solution” or “I will not get excited anymore”.  We are to expect that during this stage of treatment most of the emphasis will be on the verbal component of the psychotherapeutic dialogue.

The Micro Phases : Describing the structure of the session

The therapeutic process is not only structured on the plane of change beyond the sessions (the macro stages) but in the definition of phases within the session.  The methodology that underlies this perception states that within each therapeutic session a number of phases that reflect a process of awareness and change occur.  The phases represent a combination of the structured approach that holds, that in therapy each patient undergoes similar stages, and the individualistic approach that calls for guiding the therapeutic intervention to fit the particulars of each patient’s problem.

The phases that are found in each therapeutic session are :

1. Evaluation and discovery phase
2. Sharing phase
3. Learning the practicing phase
4. Relaxation and correction phase
5. Homework phase

Evaluation and discovery phase

Each session begins with the evaluation of the patient’s status, and examining the factors that trouble and calm him.  Two type of software aids come to the assistance of the patient and therapist in performing this evaluation and identification: the tools are those of self report such as questionnaire or a VisuaScale that monitors the well being of the patient, and the curve software that depicts minute changes in the persons state and by that enables identification of issues and topics that trouble the patient.

Self report

The patient’s self evaluation of his condition is obtained by the reply to one question regarding his well being.  The need to constrict the evaluation of his condition  – creates for the person an inner weighting like mechanism of all the processes that affect him.  It is therefore advisable to check with him what are the reasons that prompted him to decide upon a certain marking.  Using a series of Socratic questions, such as what will enable you to signify a higher mark to your well being, or which mark will depict the success of the treatment.  Answers to these questions create a therapeutic dialogue in which the therapist begins to better understand the inner world of the patient : how he perceives his problems and what are his expectations from the treatment.  This therapeutic dialogue will be developed further during the Sharing phase.

During the first session additional evaluating tools, presented as a questionnaire, will come into use, however this is not characteristic of other sessions but are only specifically in use at beginning and the termination.   A description of possibilities of such tools available is given in the document that describes the Ultramind’s devices.

Evaluation via psychophysiological measure

After the patient has positioned himself using the computerized scale, a brief measurement (4 minutes) will be conducted of the psychophysiological responses of the patient and of his relaxation capabilities at this point and stage of time.

The statement given the patient is as follows :”Your aim during this stage is twofold: you are to try and influence the curve and the sound – biosound – to descend and at the same you are to pay attention to inner processes that enable the curve to ascebd or descend.  It is important, if you are not successful, to cause the curve to proceed in the direction you feel are in accordance with the conditions that bring it about (?)”

The advantage of this wording is in the fact that it enables the patient to avoid becoming stressed by the mere fact that the line is not descending – but to comprehend that what is taking place is a process of observation and not only a process aimed at “straightening the lines”

At times,  the patient finds it necessary to provide explanations as to what is happening to him and why he is unsuccessful, in the midst of the measurement.  This is a behavioral pattern which warrants attention, and to the extent that it is possible it is important to encourage the patient to follow through with the practice without speaking.  The following phrasing has been found effective and it is recommended for use: “While practicing you might learn some important things about yourself, and possibly you will want to articulate them.  It is better that in your minds eye you place the thoughts that come up into a “basket” or clipboard – so that we can discuss these topics immediately after the practice”.

It is most likely that some of the patients will bring up, at the beginning,  various technical aspects related to their sitting or body posture and only later will they be willing to deal with more profound questions such as the way in which they think and conduct their life.  It is recommended that a gradual exposure of the inner reasoning for stress will take place in the following manner: (1) exposure of technical reasons (2) exposure of reasons related to the way of breathing and body posture (4) exposure of reasons related to thoughts that came up during the trials in causing the curve to descend (5) reasons pertaining to their general stance to life.  It is most common that this order of exposure will present itself naturally throughout the treatment.

The Sharing Phase

The phase holds meanings on two levels :

On the superficial level this is the patient’s method to relate to the therapist what assisted him to achieve relaxation and what hampered the process.

On a more profound level during this stage a highly valuable therapeutic procedure commences.  The processes of self control are constructed, from birth, through the dialogue between the mother and her baby.  The baby is overwhelmed by the combined affect of physical discomfort and the experience of  incompetence,  the mother “listens to his complaints” and comforts him by responding to his pain.   This, therefore, is in a way feedback or a mirror that by accompanying the patient assist him (?).

Most of the research done on the effectiveness of psychotherapy, and a substantial portion of research dealing in biological feedback, indicates that the interaction between the patient and therapist serves as a “curing factor”.  Well known research, carried out by Prof. Edward Taub has shown that when a “hot” therapeutic dialogue exists between the patient and therapist, the patient is then able, significantly, to better control the physiological variable such as expansion or constriction of blood capillaries (skin temperature measure).

Like in all the other elements in this proposed methodology,  it is advised that the Sharing process should proceed gradually.  To start with it should focus on the superficial level and only later on the ability of the patient to share with the therapist the painful issues.  It is also important to remember that many patients that take up biological feedback therapy are in denial of the link between their emotional and physiological state, and this calls for a process that advances slowly and that will enable them the understanding that emotional processes may be a factor influencing their symptomotology.

The Sharing phase presents itself in a variety of ways during the different stages of the treatment.  The biological feedback serves as a trigger for discourse and sharing of thoughts between the patient and the therapist during the Acquaintance stage.  The patient is asked to try and cause the curve to descend, on his own.  It is advisable that the therapist not to agree that the patient view the results immediately after his completing the practice, to allow for discussion of the subjective experience of the patient to take place.  The patient is questioned regarding his feelings during the training, did he feel relaxed or tense and at what stage.  What had he done to effect the curve to descend, what cause the curve to ascend.  It is most frequently observed that patients do not  evaluate correctly the results.  It happens that they perceived their performance to be good while their relaxation capacity was low, or alternatively the curve depicts a good rate of relaxation but the subjective experience of the patient differs.  These situations of non accordance are significant from a diagnostic point of view as well as a trigger for discourse.

We can illustrate this situation with the 2 x 2 table below:

Quite often the result is not clear cut, we can view ascending as will descending movements of the curve.  It should be mentioned that the human body is a sophisticated apparatus that regulates itself and the mere existence of fluctuations is an important process in this regulatory function.  We will emphasize, to the patient, that the aim is not necessarily to cause the curve the descend but rather to balance it following a state of stress. Even though this table can be very useful in better understanding the patient and his therapeutic process, it should be stated that even though electrodermal activity is a highly regarded measure for the sympathetic system – it is, however influenced by a variety of other conditions.  Therefore the interpretation of the gap that occurs between the objective and subjective outcome most be taken with careful consideration.

Comparing the patient’s inner experience and the objective readings will take place more frequently during the initial sessions.  As the treatment advances, the patient will learn to better link his inner experience and the physiological measurements.  The therapist will devote time to discuss with thepatient the issues that assisted as well as those that hampered his ability to achieve relaxation.  These discussions will in time penetrate deeper dealing with more central issues of the patient’s life.  It will be possible to practice with the patient influencing the downward movement of the curve when it is elevated, and to teach him to generalize the link between his inner experience and the physiological parameters, with relation to a variety of issue he will bring up.  The Sharing phase during the Separation and Termination stage will be carried out as a discussion on questions of dependency and independence and their effect on the physiological parameters.

Working Phase – Learning and Training

The distinction of the biofeedback treatment is in the emphasis given to learning and training. Other therapeutic approaches place emphasis on insight as the cardinal instrument.  The psychoanalytic approach emphasizes the passage of repressed material from the unconscious to the conscious and the importance of understanding it’s signification. The cognitive approach will place emphasis on the understanding of thought disturbances and distorted assumptions held by the patient.  Biofeedback therapy combines insight and “work”.  The basic assumption is that a major portion of the patients difficulties stem from conditioning and automatic linkage that the major way to deal with them is to learn relaxation and alternative thinking that will enable a “counter response” to the stress and anxiety creating processes that the person has been conditioned to.  So that we can “break” conditional habits and create new conditional habits or alternative means of presence (?) , learning and training are required, a process that is time consuming and calls for patience.  The behavioral aspect of the biofeedback therapy is central during this phase.  It will not be enough that a person will succeed in sharing with the therapist his inclination to respond under stress, we will want to train him again and again so that he can control that stress.  This might call for the therapist’s insistence on training and not complying with the patient’s request  to “talk about it”.

The “work” phase will take different shapes in the various stages of the treatment.  During the Acquaintance stage the patient will be called upon to demonstrate relaxation techniques that he is familiar with aiming at influencing the curve downwards.  During the Training stage the therapist will systematically teach the patient the relaxation techniques and will ascertain that they are carried out properly.  The computer, with multimedia capabilities, provides the means to view demonstrations of the various relaxation techniques as video clips.  This significant assistance can be carried out with the presence of the therapist and therefore saves on his time.

During the Generalization stage the work will include the ability to implement the relaxation during imagined stress conditions.  During the Separation and Termination state the work will focus on the ability to perform relaxation without the aid of the device.  Weaning off the biofeedback device will be done gradually.

Correction and Relaxation Phase

The patients capabilities to alter his behavioral and thought patterns improve significantly when he is released from stress and anxiety.  There is a consensus that while in relaxation there is higher degree of thought flexibility and readiness for change.

Wickram (1977), a researcher in the fields of psychophysiology and hypnosis, has found that via biofeedback it is possible to alter the hypnotic level of  patients.  That is the level at which they are able to be effected by suggestion or statments that are spoken to them by the therapist or by themselves.   This stage is therefore the stage in which the emphasis is given to entering into relaxation with the aid and vocal accompaniment of the therapist.  The therapist will use suggestion to facilitate the entry into relaxation while he is monitoring the relaxation through biofeedback.

The correction phase is characterized by reframing of the material gathered at the beginning of the session.  Reframing is a technique by which the therapist redefines in a positive fashion negative issues, and by that allows for alternative solutions in places that are perceived as unsolvable.  At the end of the session the patient will be instructed to enter into relaxation.   The therapist will use reframing during the period the patient is performing relaxation.  For example a patient who is very troubled at work, that receives low grads in psychometric examinations.  It is possible to observe together with him the progress as a result of training and learning and to define some sort of improvement process which is not the end of the world.  The correction phase will present itself differently in the various stages of the treatment.  During the Acquaintance stage the therapist will check what is the ability of the patient to enter into relaxation and to what extent he is able to enter into relaxation in his presence. In learning relaxation techniques stage this phase will be characterized by accomplishing relaxation without an effort.   At this stage the therapist can introduce issues that hampered relaxation and try to work through them in an alternate manner while performing the relaxation.  In the Generalization stage the patient will be asked to remain relaxed even when he is in a stressful situation.  In the Separation stage the emphasis will be put on the patient’s ability to internalize the influence of the therapist when the actual process has been completed.

Fifth Phase : Homework

Even though this phase does not take place during the session it is an integral part of the therapeutic approach.  The fundamental assumption of the technique is that in order to achieve change in the way a person regulates himself there is need for much training.  Therefore it is of vital importance to practice outside the clinic and as frequently as possible.

The homework is challenging and it motivates the patient to bring about a significant change in his life.  The therapist will explain that one or two sessions a week are not sufficient to change life long habits.

The homework will vary throughout the various stages of the treatment.  During the Acquaintance Stage the patient will be asked to write down the issues that are troubling to him or as he experiences them at home or at work in real time.  This should not remain as a “symptom journal” but rather serve as a launcher for “problem hunting” a place that invites the patient to look at his problems as something external to him and “catch them” in order to bring them for joint observations in therapy.

During the stage of learning relaxation techniques, the patient will be asked to practice – at the least twice a day – the techniques he learnt.  It is important to request this of him only after he has performed the technique in a satisfactory way in the clinic.  At a later stage we can provide him with one type or another of Home Trainer.  This trainer can be a tool that will remind him of the technique through vocal instructions (cassette or computer voice file) or a visual video cassette or CD containing relaxation instructions.  In this cellular era we can envisage sending relaxation instruction to the patient’s voice mail so that he can practice the technique anywhere!

In the Generalization stage the patient will be requested to perform relaxation exercises near or during the stress or anxiety experience.

During this and the previous stages the patient can be furnished with a portable biological feedback device or a Home Trainer that will verify the adequate performance of the training.  The patient can send the results by e-mail and gain a some sort of progress follow up beyond the sessions.  Another technique that may be considered is live training through the internet, however this technique is very much time consuming for the therapist.  This also pertains to the homework given during the Termination stage and what follows.  At this point the treatment sessions will be more spread out. This spread wilrequire the patient to conduct intensively the work on his own .  To preserve the therapeutic relation even in the absence of physical contact, a few virtual session via internet can be scheduled, or alternatively, what conceptually is better fitted, the patient will be asked to send in a progress and status report every few days.

In spite of the importance the therapists finds in the homework, most often the practice carried out is partial or non existent.  The therapist will be wise to carefully listen to the reasons that barred home practice.  It is advisable to point out the moments of “giving up or despair” that arise as a result from the feeling that if its already been a day or two that I haven’t done anything, what is the sense to continue.  The therapeutic dialogue with respect to these processes of despair and giving up are just as important as the training itself.  The combination of a good therapeutic relationship, correct motivation of the patient, and technological ability to preserve contact in the absence of a meeting will enable the patient to “take himself under his control” and to start to change the way he manages his life.