The Ghost in the Box – Chapter 4

4

Successful Biofeedback Training

Elements of the mastery model have been used from the beginning of biofeedback applications, and it has evolved into a powerful multicomponent approach to psychophysiological self regulation.

 

When does biofeedback training succeed? The answer depends on how biofeedback training and the goals of biofeedback training are conceptualized.

The goal of official doctrine research is to determine the specific effect of the independent variable: the feedback stimulus, reinforcer, contingency, or information, sometimes called “biofeedback.” This goal has resulted in numerous unsuccessful biofeedback studies. Researchers who accurately conceptualize biofeedback as a training process have the goal of voluntary control of a psychophysiological process for symptom reduction. The independent variable is self regulation. These researchers understand the essential aspects of biofeedback training, (1) the biofeedback instrument is no more and no less than a mirror-like a mirror, it feeds back information, but has no inherent power to create change in the user; (2) to maximize results, biofeedback training, like any type of complex skill training, involves clear goals, rewards for approximating the goals, enough time and practice for achieving mastery, proper mstructions, a variety of systematic training techniques and feedback of information; (3) the person using the feedback must be conscious, must have cognitive understanding of the process and goals, must have positive expectations and positive

Shellenberger and Green 58

interaction with the trainer, and must be motivated to learn. Studies based on these ingredients are often successful.

In this chapter, the first task is to examine research studies in which subjects have demonstrated self regulation skills and symptom reduction. The second task is to describe a mastery model of biofeedback training as exemplified in these studies, and in clinical biofeedback practice.

 Essential Hypertension and Biofeedback Training

(Table 2)

At a time when researchers were abandoning biofeedback for treatment of essential hypertension because their results were statistically, but not clinically significant, Patel (1973 and 1975) achieved statistically and clinically significant results in her work with hypertensive patients.

Schwartz and Shapiro (1973), Surwit and Shapiro (1976), Miller (1975), Elder and Eustis (1975), Fey and Lindholm (1975), and Lutz and Holmes (1981), were trying to isolate a specific effect of blood pressure feedback. Consequently, their methodologies eliminated the essential ingredients for successful biofeedback training. In contrast, Patel’s methodology included the essential ingredients for learning successful self regulation and control of essential hypertension, namely, deep levels of general relaxation, home practice, clear instructions and coaching. These are basic elements of a mastery model. Furthermore, Patel used a powerful research design:

An interesting feature of this study was that 4 months after the completion of a treatment, the subjects in the control condition were given a similar treatment and also showed significant decreases in blood pressure of 28 mm. mercury systolic and 16 mm. mercury diastolic. This use of half cross-over design, in which the untreated controls are now treated and show a response similar to the treated subjects, is a very powerful demonstration of effects because it answers the

Ghost in the Box 59

possibility that the treatment effect was specific to the experimental group even with random assignment of subjects. The replication of effects on the controls rules out this possibility. Follow-up data on these control subjects at 4 months and 7 months showed a maintenance of the gains obtained during treatment (Blanchard, 1979, p.38).

The work by Patel and her colleagues is summarized in Table 2 with that of other successful studies on essential hypertension.

Table 2

Successful Clinical Biofeedback Training for
Essential Hypertension

Study Treatment Training Result Symptom Result
Patel, 1973           Single group outcome N = 20 B: 3 (30 mm.) Low arousal training with GSR, autogenic & meditation (36, 30 mm. sessions) breathing & relaxing phrases Avg. decrease in BP: Syst. 25mm Diast.: l4mm 12 out of 20 reduced medications; 12 mo follow-up: Syst. l5 mm decrease Diast. l3mm decrease
Patel, 1975        Resting control N = 20; exp group N = 20 B: 3 session T: same as 1973 study C: 30 mm. Avg. decrease in BP: Syst. 2Omm Diast. l4mm C resting Group: Syst. 1mm, Diast. 2mm 12 out of 20 reduced meds.
Patel & North, 1975, E=17, C=17, controlled outcome with crossover. B:3 sessions T:same      (12 Sessions) Avg. decrease in BP: Syst: E=26mm; C=9mm; C after treatment: 28mm     Diast: E=15mm; C=4mm; C after treatment: l6mm

Shellenberger and Green 60

Table 2 continued

Study Treatment Training Result Symptom Result
Patel, Marmot, & Terry, 1981         C =99, E =99 T: deep breathing, deep muscle relaxation, meditation, GSR feedback, stress management group, training, (8, 60 min. sessions). C: no-treatment control with health education materials 8 month follow-up showed experimental group significantly lower than control 1l/8.8mm Hg lower than control group.
Moeller & Love, 1974 Single group outcome, N=6 B: 2 sessions T: forehead EMG & autogenic-17 sessions Avg. decrease in  BP: Syst. l8mm Diast: l2mm same as training effect
Love, Montgomery, & Moeller, 1974 Control group E=26, C=10 B: 1 session           T: 16-32 sessions, forehead EMG & autogenic training Avg. decrease in BP Syst: l5mm Diast: 13mm No change in control group same as training; 8 months follow up resulted in an additional decrease of 4mm dias. & 6.5mm syst.
Sedlacek, Cohen, 1979 C=10, Benson Relaxation 10, Biofeedback= 10 B: 2 yrs.                T: 8 sessions of cassette tapes using breathing, relaxation, visual imagery, etc. Thermal & EMG feedback for 12 more sessions training to criteria 90°F & 3 µV (p-p) on forehead, home practice training F=reduced from 144/95 to 130/83 (.0001) Relaxation group reduced diastolic (.05) but no change in   systolic. 4 month follow-up: T=maintained decrease, 7 reduced medications by 50% or more. Relaxation= 1 reduced meds. C=no change.

Ghost in the Box 61

Table 2 continued

Study Treatment Training Result Symptom Result
Green, Green & Norris, 1980     Single group out come, 9 hypertensives, 6 on medications T: autogenic feedback training on hands & feet, cognitive training, home practice with temperature machines. B=1 session at intake. Train to criterion 95°F. + on hands, 90°F. + on feet 6 of 6 at end of training were  medication free; other 3 results: 1 subject 139/86 and ended at 118/83; 1 subject 143/94 and ended 145/90 (least amount of training); 1 subject 142/82, ended at 114/179.
Blanchard et al. 1984 Control group outcome to reduce medications         E=20, C=20 B: 4 wks home pressures assessment. T: 16 Thermal (20 min.), and autogenic training. C: 8 progressive. Home training for both. E=13 off 1drug;  C=9 off 1 drug 3 weeks follow-up maintained low pressure even after reduction in medication. Thermal relaxation group showed greater reduction in home blood pressures (.007) than progressive group.
Fahrion, Norris, Green & Green, 1986 Group outcome; 42 patients on medications. B: 1 week             T: Train to criterion of 93°F on foot, 95.5°F on hands, 3 µV (forehead peak-peak) or below. Sustain criterion levels for 10 min. Treatment included cognitive explanation, breathing exercises, relaxation techniques, home practice with small thermometers & home BP monitoring. End of treatment results: 30 of 42 medicated patients eliminated medications and maintained a reduction of 15/ l0mm Hg.   9 of the 42 patients cut medications by 1/2 and maintained a reduction of 18/l0mm Hg. Only 3 of the medicated patients showed no improvement. In addition, reduction in BP achieved significance at .0001. 33 month follow-up: All patients maintained improvement.

Abbreviations: B = Baseline; E = Experimental Group; C = Control Group; T = Treatment

Shellenberger and Green 62

In examining the work of Patel and her associates (Patel, 1973; Patel, 1975; Patel & North, 1975; Patel & Carruthers, 1977; and Patel, Marmot, & Terry, 1981) the essential ingredients for successful treatment of essential hypertension clearly emerge. These are:

(1) Goal: to achieve mastery of generalized and deep relaxation at the clinic and at home;

(2) Method: systematic feedback relaxation training i.e. autogenic training, meditation, diaphragmatic breathing, meditation (body scan) with feedback from GSR and EMG:

(3) Extended training and transfer of training: homework training, stress management training, and short relaxation exercises (deep breathing used with phrases such as “relax”):

(4) Coaching: clear instructions and encouragement based on a “teacher-student” model of learning;

(5) Mastery: demonstration of learning in response to stressor challenges i.e. cold pressor and exercise tests.

In addition to significant decreases in blood pressure, Patel’s patients showed significant decreases in medications, serum cholesterol, triglycerides, and fatty acids (Patel & Caruthers, 1977, Patel et al., 1981).

Elements of Patel’s model have been successfully replicated by other researchers. Moeller and Love (1974), and Love, Montgomery, and Moeller (1974) included four of the essential ingredients in their study: (1) the goal of generalized deep relaxation, (2) the method of systematic feedback training: autogenic training assisted with EMG feedback, (3) extended training and transfer of training: homework training, and (4) coaching: clear instructions and encouragement. An eight month follow up showed that subjects who continued to regularly practice home training further decreased pressures.

Sedlacek, Cohen, and Boxhill (1979) in a successful study included four of the five essential ingredients: (1) the goal of generalized deep relaxation, (2) the method of systematic feedback training: diaphragmatic breathing, imagery, and autogenic training assisted with EMG and thermal feedback, (3) extended training and transfer of training: home practice, and (4) coaching: clear instructions and encouragement.

Significant additions to the treatment model for essential

Ghost in the Box 63

hypertension originated with the Menninger Foundation group (Green, Green, & Norris, 1980 and Fahrion, Norris, Green, & Green, 1986). They include four of the essential ingredients of successful training but refined and systematized the procedures, and added training to criterion on hand temperature (95+°F), EMG forehead (3  µV p-p), and most importantly, foot temperature to 92+°F. An essential element of their program is extensive feedback training at home and the completion of home training records. Subjects train on hands and feet daily and monitor blood pressure before and after each home training session. Ingredient four, coaching, includes a detailed rationale that explains how perceptions alter physiology and how feedback assisted training works. In addition they encourage patients to take responsibility for improving lifestyle. Fahrion and colleagues are currently conducting a large controlled group study of this training model, funded by the National Heart, Lung, and Blood Institute.

Blanchard and Andrasik (Blanchard et al., 1984) at the Center for Stress and Anxiety Disorders have also developed a training procedure based on the Fahrion and Green model. While Blanchard originally used direct feedback of blood pressure (Blanchard et al., 1977), his work has evolved with developments in the field. Blanchard and his associates are now applying a systematic autogenic temperature feedback training approach to the treatment of essential hypertension with successful results. An addition to the treatment model of this group is the use of simple mastery tasks:

(1) asking the patient to warm hands on command with no feedback; (2) demonstrating self regulation skills in response to stressors such as a cold pressor, mental arithmetic, and stressful imagery. The results of this thermal feedback training study demonstrate a clinically and statistically significant effect for the treatment of essential hypertension (Blanchard et al., 1984).

These studies indicate that a model of systematic biofeedback training and stress management for essential hypertension is successful. Direct blood pressure feedback studies have failed with the exception of Krisst and Engel (1975). Krisst and Engel’s study, however, included self control and self management training. Patel’s work with a team at the National Heart, Lung, and Blood Institute (Frankel et al., 1978) included direct blood pressure feedback but removed many of the essential ingredients. The study

Shellenberger and Green 64

was unsuccessful. The report states: “. . . For these patients the frustration experienced in unsuccessfully coping with the demands of the blood pressure and EMG feedback procedures may have contributed to a pressor effect . . ,” (Frankel, Patel, Horwitz, Friedewald, & Gaarder, 1978, p.287). When Patel returned to the original model that included GSR feedback, breathing exercises and stress management training, her work was again successful (Patel, et al., 1981).

 

Biofeedback Training for Treatment of Headache

The original impetus for treatment of headache with biofeedback training developed from the models and work of Budzynski and Stoyva (Budzynski et al., 1973, and Stoyva & Budzynski, 1974) and Green, Green, and Walters (1970). The original study by Budzynski et al., (1973) triggered a flurry of research on the use of EMG biofeedback training for the treatment of tension headache. Budzynski’s research and other successful studies are summarized in Table 3.

Table 3

Successful Clinical Biofeedback Training for Migraine, Tension, & Mixed Headache

Study Treatment Training Results Symptom Result
Budzynski et al 1973, control group outcome E=6, Cl=6: False feedback, C2=6: Waiting list control T: EMG (forehead) 16 sessions-home practice (same as in lab) (goal was explained as deep relaxation) B: 2 sessions E=10 µV to 3  µV (p-p), C1= 10 ~V to 6 ~V (p-p) +.90 correlation between training & treatment effect. Cross-over design training for Cl & C2 if desired. (8 chose to be trained, 6 achieved a significant training & treatment effect.) E=.001 decline in tension headaches at 30 mo. follow-up; significant decrease in meds. 18 mo. follow-up (4 located-3 maintained decrease while 1 had moderate reduction (same individual with minimum training effect.)

Ghost in the Box 65

Table 3 continued

Study Treatment Training Results Symptom Result
Hutchings & Reinking, 1976 control group outcome: El =6, E2=6, E3=6 B: 28 days for Symptom, B: 3 sessions, T1: Relaxation tapes (15 min. (Progressive, Autogenics, Passive Volition), T2: Relaxation tapes + EMG (forehead) (30 min.), T3: EMG (forehead) (15 min.)-“keep signal as low as possible” (home practice twice a day based on what learned in laboratory) E=20 µV to 7.5 µV(p-p) to 9 µV (follow-up),  E2=16 to 5.5 µV(p-p) to 5 (follow-up), E3 = 19 to 6 µV(p-p) to 5+ (follow-up) El =20% reduction in headache  (15 to 11), E2=66% (14 to 3) E3=66% (10 to 3); (headache scores computed by multiplying # of headache hours  times average intensity for the day)
Raskin, Johnson, & Rondestvedt (1973), group outcome, 4 muscle tension headache patients. B: 8 weeks Train to criterion, 2.5 µV p-p (forehead) Home practice twice a day. Relaxation exercises. All four achieved criterion averaged over 25 minute period. All four achieved significant symptom reduction for frequency, intensity, and duration of headache using Budzynski’s quantification scale.
Blanchard et al.,  1982, group outcome study, 33 tension headache, 30 migraine, 28 mixed. All were given 10 sessions of relaxation training. Those who had not achieved 60% symptom reduction were given biofeedback training. 14 migraines, thermal biofeed back, 15 tension headaches EMG biofeedback, 14 mixed headache thermal biofeedback, all had 12 sessions of home practice and cue-controlled exercises not reported 6 migraine; 7 tension; & 9 mixed; achieved significant (statistical & clinical) reduction in frequency and duration of headaches.

She1lenberger and Green 66

Table 3 continued

Study Treatment Training Results Symptom Result
Jurish, et al., 1983; group outcome study. 40 migraineurs or combined migraine & tension Tc: 20 clinic based (11.39 hrs. of therapist time), Th: 20 home based (2.59 hrs. of therapist time), Tc received 12 sessions of relaxation; Tc received 10 thermal biofeedback sessions in clinic; Th group received three clinical sessions (1) relaxation (60 min.), (2) temperature (60 min.) and (3) final visit (30 min.). Th group received 7 manuals & five audio-tapes. Both groups did home practice in warming hands with the use of small thermometers. Clinic based group achieved 93°F in self-control task & 94°F in training 78% of home based group achieved 50% or greater decrease in headache index. 52.4% of clinic based group achieved 50% or greater decrease in headache index. Both groups complied equally with home training requirements. 61.5% success rate for mixed headache, 45.3% success rate for migraineurs
Libo & Arnold, 1983b. 7 migraine, 5 tension headache, 13 mixed headache Trained to criterion on EMG forehead (1 RMS microvolt) and 95°F. on hands with temperature feedback, 5 to 7 relaxation techniques were taught for home practice e.g. autogenics, progressive, meditation, guided imagery. etc. All subjects reached criterion. Follow-up between 1-5 years, 25 of 27 retained complete symptom relief, 1 tension headache person relapsed, and 1 mixed headache found a new medication.

Abbreviations: B=Baseline; E=Experimental Group; C =Control Group; T=Treatment; Tc=Treatment group at Clinic; Th=Treatment group at home.

Ghost in the Box 67

Tension Headache

The early study of Budzynski et al., (1973) was a good beginning model for biofeedback training research: (1) adequate baselines (two 30 minute no feedback sessions and two weeks of symptom charting); (2) subjects trained to deep levels of relaxation (3 microvolts peak-peak, forehead); (3) correlating the training effect with the treatment effect (+ .90); (4) lengthy follow-up (one year); (5) using a crossover design in which the control subjects receive biofeedback training. Budzynski referred to this model as a “bare-bones” procedure (1973) and in training the cross-over control subjects added relaxation cassette tapes and a portable EMG unit for home use.

Several early studies replicated Budzynski’s model by training subjects to levels of deep relaxation (Raskin, 1973; Hutchings & Reinking, 1976) and achieved successful clinical results for tension headache. Unfortunately, many studies on biofeedback training for treatment of headache either did not report training data (Chesney & Shelton, 1976; Haynes et al.,l975; Fried et al., 1977; McKenzie et al., 1974), did minimal training of 1 to 3 sessions (See Table 1 in Error 1), or failed to include many of the other essential ingredients that are necessary for successful biofeedback training, as discussed in the methodological errors and in this chapter.

Recent studies have successfully replicated the model of Budzynski, Stoyva, and Peffer (1977). In a long term follow up study, Libo and Arnold (1983b) demonstrated that patients who achieved training criteria of 95°F on hands and 1 microvolt (RMS) on forehead successfully alleviated tension headaches.

In a successful study on tension headache, Blanchard et al. (1982) used systematic feedback training (EMG feedback with systematic relaxation exercises); they also included home training and clear instructions. A contribution to this training model is a demonstration of muscular relaxation in the absence of feedback (Blanchard et al., 1982).

Shellenberger and Green 68

Migraine Headache

The discovery that biofeedback training could be effective for the treatment of migraine headache led to numerous studies that used a variety of training techniques in isolation or combined: autogenic training, progressive relaxation, EMG training, temperature biofeedback training, autogenic feedback training. Double-blind studies (Kewman & Roberts, 1980) and minimal training studies (Price & Tursky, 1976) resulted in no learning and no symptom reduction.

In a meta-analysis of relaxation techniques for treatment of migraine Blanchard (1982) reported: (1) Thermal feedback relaxation with autogenic training achieved a 65.1 % success rate with 146 patients; (2) Thermal feedback relaxation achieved a 51.8% success rate with 41 patients; (3) Relaxation training (progressive relaxation or the relaxation response) achieved a 52.7 % success rate with 159 patients. In contrast medication placebos achieved a 16.5% success rate with 234 patients. There was no statistically significant difference between the three relaxation groups although the autogenic feedback training group showed a slight “arithmetic advantage.”

A major difficulty in a meta-analysis is the absence of training data. Fahrion (1977) showed a 71% success rate at a six month follow-up after training 21 migraineurs to 95°F on hands using autogenic feedback techniques. The long term follow-up study by Libo and Arnold (1983), however, showed a 100% success rate with migraineurs who achieved training criteria of 95°F on hands and 1 microvolt (RMS) on forehead.

Two recent studies on migraine headache and mixed headache (Blanchard et al., 1982, and Jurish et al., 1983) demonstrated significant clinical results using autogenic feedback training with home practice, clear instructions, clear rationale and demonstration of learning tasks such as increasing hand temperature on command without feedback.

Jurish et al. (1983) compared a home based training group and a clinic based training group. Both groups were given several types of relaxation procedures and thermal feedback. It is interesting that symptom reduction in the home based group exceeded that of the clinic based training groups, 78.9% to 52.4% in spite of

Ghost in the Box 69

the fact that both groups did equal amounts of training. There is no ghost in the clinic either.

Raynaud’s Disease and Biofeedback Training

Double-blind and “bare-bones” studies for treatment of Raynaud’s disease have been ineffective. Biofeedback training studies that are successful in the treatment of Raynaud’s disease, train patients to deep levels of relaxation and hand warming, and, to mastery during cold stressors. Freedman, Ianni, and Wenig (1983) conducted the most successful study for the treatment of Raynaud’s disease. They compared four groups: (1) finger temperature feedback, (2) finger temperature feedback under cold stress, (3) autogenic training, and (4) forehead EMG. Each patient did home training and received cognitive stress management 10 minutes before and after each clinic training session. Frequency of symptom was reduced by 92.5% for the temperature biofeedback under cold stress group, 66.8% for the temperature biofeedback group, 32.6% for the autogenic training group, and 17.0% for the EMG training group. Teaching patients to master self regulation with biofeedback training in the face of cold stress was clearly the most effective. The model used by Freedman et al., is similar to the other models for the treatment of essential hyperten sion, migraine headache, mixed headache, and tension headache. The model includes: (1) goal: deep relaxation and blood flow control, (2) method: systematic feedback training i.e. autogenics, thermal feedback etc., (3) extensive training and transfer of training: home training, (4) coaching: clear instructions, cognitive training, and (4) mastery: training subjects to master cold stressors.

Biofeedback Training for other Disorders

Other areas of successful biofeedback treatment in which extensive training is done and clear instructions are provided include the following:

(1) Insomnia: Hauri, (1981); Hauri, Percy, Hellekson, Hatmann, & Russ (1982);

(2) Neuromuscular disorders: Brudny, Korein, Grynbaum,

Shellenberger and Green 70

Belandres, and Gianutsos, (1979); Finley, Niman, Standley, and Ender (1976); Hurd, Pegram, and Nepomuceno (1980); Krebs (1981); Middaugh (1978); Wolf (1980);

(3) Chronic Pain: Nouwen and Solinger (1979); Wolf et al. (1982);

(4) Attention Deficit Disorders: Carter and Russell (1983); Denkowski, Denkowski, and Omizo, (1983); Lubar and Lubar (1984);

(5) Motion Sickness: Cowings and Toscano (1982); Toscano and Cowings (1982);

(6) Epilepsy: Lubar and Bahier (1976); Sterman (1973); Sterman and MacDonald (1978); Sterman, MacDonald, and Stone (1974);

(7) Irritable Bowel Syndrome: Giles (1981); Neff and Blanchard, (1985);

(8) Subvocalization: Aarons (1971); Hardyck, Petrinovich, Ellsworth, (1967); Hardyck, and Petrinovich, (1969);

(9) Fecal incontinence: Cerulli, Nikoomanesh, and Schuster (1979); Latimer, Campbell, and Kasperski, (1984); Wald (1981);

(10) Urinary incontinence: Burgio, Robinson, and Engel, (1985); Burgio, Whitehead, and Engel, (1983); Middaugh, Whitehead, Burgio, and Engel, (1985).

(11) Generalized anxiety and panic disorders: Cohen, Barlow, Blanchard, Di Nardo, O’Brien, and Klosko (1984).

 

 

Applied Clinical Biofeedback Studies and the Mastery Model

 

The power and depth of biofeedback training are most clearly seen in single case clinical reports and long term follow up studies of patients treated in biofeedback clinics (see Tables 4 and 5 at end of chapter). It is in clinical practice that the mastery model is most fully developed.

The Mastery Model

Elements of the mastery model for clinical practice were first systematically described by Stoyva and Budzynski (Budzynski,

Ghost in the Box 71

1973; Budzynski & Stoyva, 1972; Stoyva & Budzynski, 1974; Budzynski, Stoyva, & Peffer, 1977). Their criteria for successful clinical training is mastery in three domains, physiological, cognitive, and behavioral.

The details of this mastery model and its refinements as applied to psychophysiological disorders are as follows:

(1) Goals with clear criteria:

(a) Physiological mastery. This includes: (1) Cultivated, generalized low arousal-defined by Budzynski et al. (1977) as low arousal on three parameters, EMG, hand warming and EDR. These researchers defined low arousal as 2.5 microvolts peak-to-peak on forehead and forearm, 90°F hand temperature, and 2 micromhos (EDR). Since then research by Libo et al., (1983), Fahrion (1978), Green, et al, (1980), and our own work (Shellenberger et al., 1983, Shellenberger, et al., 1986) indicate that criterion should be as high as 95°F on hands and 92°F on feet; (2) and learned control of specific physiological processes such as finger tip blood flow in migraine and Raynaud’s patients, blood pressure in hypertension, and EMG in tension headache.

(b) Cognitive mastery. The ability to: (1) rapidly change perceptions, (2) permanently change maladaptive perceptions, (3) identify irrational thinking, (4) dispute irrational thinking, (5) maintain cognitive flexibility, and (6) maintain cognitions of personal power and personal responsibility for health.

(c) Behavioral mastery. The ability to transfer both physiological and cognitive skills to any situation, to achieve healthy psychophysiological homeostasis and maintain homeostasis when encountering stressors, or to recover from stress rapidly.

(2) Method: systematic feedback training techniques such as breathing exercises, body scan, autogenic training, quieting response, and progressive relaxation assisted by EMG, thermal, EDR, and EEG feedback.

(3) Extended training and transfer of training: homework training and practice records, desensitization, flooding, stress management practice, and short relaxation exercises.

(4) Coaching: clear instructions and rationale, encouraging successful behaviors, positive interaction with the patient, and positive expectancies. Coaching focuses on the unique strengths and limitations of the trainee; a program is created for the individual.

Shellenberger and Green 72

(5) Mastery Tasks: demonstration of self-control without feedback in relaxed settings (i.e. increase temperature on feet to 92°F or more in 5 minutes), demonstration of self-control without feedback in stressful situations, i.e. cold room, cold pressor test, stress profile, performance tasks, and interpersonal confrontations.

A major emphasis in this model is the use of desensitization and stress management procedures for training to high levels of mastery. The early articles by Budzynski and Stoyva focus on the importance of biofeedback instrumentation for desensitization procedures and the importance of desensitization procedures for mastering the use of low arousal skills during life stressors (Budzynski & Stoyva, 1972 and Budzynski, 1973). This element of training has not been included in research studies.

The effectiveness of the mastery model is seen in the many successful eases reported by clinicians (Table 4). The case study of three stutterers reported by Craigh and Cleary (1983) is exemplary. The patients were first trained to EMG criterion of 4 microvolts (peak-peak) or less on forehead. Second, subjects were given three challenging situations: (1) read and converse fluently in the clinic in the presence of strangers, while lowering EMG feedback; (2) read and converse fluently in the clinic in the presence of strangers without feedback; (3) converse fluently in a cafeteria, without EMG feedback. Finally, maintenance techniques were taught: self reinforcement, self monitoring, and self practice.

A mastery model provides clear procedures for maximum performance training. By establishing high goals, the trainee is encouraged to achieve maximum success in psychophysiological self regulation and symptom reduction, and training will necessarily be thorough. The success of the model depends upon skilled clinicians who are good coaches and teachers, who can establish realistic goals appropriate to the individual, and can develop ingenious stressors for demonstrating mastery.

The mastery model provides guidelines for research and clinical practice that will eliminate the hit-and-miss approach of many research studies. And finally, the mastery model allows the experimenter or clinician to know with certainty that the trainee has learned, overcoming the problems of adaptation and variability. The exact parameters of the mastery tasks and criteria for psychophysiological mastery are unique to the trainee, and must

Ghost in the Box 73

be developed in relation to symptoms and life stressors.

Perhaps if prizes were given for a Biofeedback Olympics, this model for biofeedback training and the mastery of somatic and autonomic self regulation would hastily be accepted by all.

 

Clinical Biofeedback Practice

Biofeedback training is, above all, a clinical tool. This is because psychophysiological feedback for psychophysiological self regulation is, theoretically and practically, in the domain of health. When biofeedback training is used in clinical settings, in which it is properly understood, the maximum potential of the tool, and the maximum potential of the trainee, are demonstrated. For this reason, we include below the salient elements of clinical practice. The elements of clinical practice are in strong contrast to traditional research.

Unlike “official doctrine” research training, applied clinical biofeedback training includes:

(1) A clinician trained in individual assessment.

(2) A clinician trained to effectively interact with patients. Research studies use technicians, graduate students, or research psychologists with minimal interpersonal skills. In addition, research designs often eliminate interaction between trainer and trainee and create impersonal environments.

(3) A certified or licensed clinician. Clinicians are required to demonstrate therapeutic and biofeedback training skills. Researchers are not certified, nor do they need to demonstrate knowledge of biofeedback training and therapy.

(4) A clinician who can creatively design unique training programs for each patient. Research studies have continually failed to design unique training programs for individuals. A standard training protocol is used with all subjects.

(5) A multicomponent procedure that maximizes treatment for each individual. Official doctrine research dilutes treatment effectiveness by using simplistic training procedures and a single biofeedback component.

(6) A flexible protocol. Clinicians are able to adapt training pro-

Shellenberger and Green 74

cedures to life changes of their patients. Research studies follow a set training procedure throughout the study.

(7) Goals of stress management and enhancing the quality of life. Clinicians focus on symptom reduction, prevention, stress management and enhanced quality of life. Researchers do not focus on broad effects such as “enhanced quality of life” and are not necessarily “invested” in symptom reduction, if it is not a specific effect of the independent variable. The use of double-blind design is an example.

(8) A mastery model of biofeedback training.

There are so many major differences between experimental biofeedback training studies and clinical practice that the external validity of biofeedback research conducted in laboratories is questionable.

In conclusion, we have a clear model for successful biofeedback training. Evidence for this comes from: (1) control group studies (Tables 2, & 3) and the studies cited in “Biofeedback Training for Other Disorders;” (2) long term follow-up studies (Table 5); and (3) systematic case reports (Table 4). In examining the models for successful treatment described in these studies, we find that the protocol is essentially the same for a variety of disorders and therefore has been tested repeatedly over the years. These studies use a training protocol that, when followed, leads to clinically significant results. These results are not idiosyncratic to a few patients and clinics, but are “universal.” The protocol, including systematic feedback training, results in significant and lasting treatment effects, in some cases with patients who have had symptoms for many years and have undergone a variety of other treatments as exemplified by the many studies listed in Table 4.

The most valuable information for clinicians comes from the single case reports and follow-up studies of clinicians who have creatively treated a variety of difficult patients. These reports are of equal value to researchers who are interested in determining the elements of successful training.

Elements of the mastery model have been used from the beginning of biofeedback applications, and it has evolved into a powerful multi-component approach to psychophysiological self regulation. If essential elements are removed, training is less effective; as

Ghost in the Box 75

elements are included in the treatment protocol, learning and symptom reduction are facilitated.

Many researchers and clinicians have reported successful results, and yet, the status of biofeedback training is still questioned.

In the next chapter we examine the conditions that lead to the rejection of successful biofeedback studies by researchers of the official doctrine.

Shellenberger and Green 76

Table 4

Systematic Case Studies

Subjects Treatment Results
Campbell & Latimer,1980. 22 yr. old female with urinary retention. Feedback of intravesical pressure with a urinary catheter (7 sessions). Behavior analysis and therapy were used. After 6 months of treatment, she was symptom free. No relapse during a 9 month follow-up.
Carisson & Gale, 1976, 59 yr. old female with TMJ for over five years. EMG assisted relaxation training of masseter muscles. Symptom free at 1 year follow-up.
Craigh & Cleary, 1982, 3 male stutterers, ages 10, 13 & 14. Phase I: 3 EMG sessions 60 minutes each for relaxation mastery tasks; Phase II: EMG feedback while speaking; train to criterion of 4  µV (p-p); Phase III: transfer of training EMG feedback while speaking in front of strangers, and speaking in front of strangers in public setting. Reduction of stuttering and stabilization of speaking by all 3 patients.
Dietvorst & Eulberg, 1986, Treatment of a cold limb in a post-polio patient. Patient was unable to tolerate cold weather or excessive air conditioning. Systemic biofeedback training for foot warming. Autogenics, progressive, diaphragmatic breathing, and home training with portable temperature unit. Goal was training to mastery-demonstration of foot warming. (12 sessions). Results in training showed: Consistent increases of 5.72°F. to achieve 89°F. on foot. Demonstrated this ability 7 times.  Demonstrated in last sessions the ability to  increase temperature from 78.8°F. to 92.3°F. Outdoor temperature was 0°F., indoor temperature was 68°F. At 12 month follow-up patient was able to warm affected limb & shovel snow for two hours.

Ghost in the Box 77

Table 4 continued

Subjects Treatment Results
Duckro, Pollard, Bray, & Scheiter, 1984, middle aged man with complex tinnitus, before biofeedback treatment he had received 6 months of psychotherapy. Introduced to progressive relaxation then to EMG (frontal) feedback. Muscle tension was easily reduced and then had 16 temperature feedback sessions on hands. Tinnitus was reduced from severe to mild. Severe depression was eliminated. Severe anxiety was reduced to mild. He learned to increase temp from 83°F. to 95°F.
Fritz, 1985, cluster headache patients, two chronic & four episodic. All six had a history of at least six years of cluster headache. EEG & Open Focus training Two yr. follow-up for 4 patients and 1 yr. follow-up for 2 patients-5 reported complete remission and 1 reported significant decreases in frequency.
Hand, Burns, & Ireland, 1979, 56 yr. old Parkinsonian female with lip hypertonicity EMG feedback training with speech therapy (6 sessions). At end of treatment patient achieved voluntary control of both isometric & anisometric states of contraction and relaxed muscular levels in postural states.
Hoelscher & Lichstein, 1983,   Chronic Cluster Headache for over 20 years, 1-5 attacks a day, 61 yr. old male. Blood volume pulse feedback (14 sessions), home practice each day. Baseline: 18 days. 70% reduction in frequency and 45% decrease in severity- large decreases in medications (100% decrease in narcotics, 70% decrease in antimetics, 75% decrease in migraine abortives, 2 yr. follow-up showed decreases were maintained.)
Inz & Wineburg, 1985, sympathectomized Raynaud’s disease patient, female, age 45. Raynaud’s for 9 yrs. and in danger of losing first digit of right hand. 6 temp & autogenic sessions with probe on first digit of right hand with no improvement. 7th session with probe on second digit of right hand, 8th & 9th sessions probe on first digit of right hand. 7th session increased temp 13.3°F. in second digit, and 8 and 9 sessions increased first digit to 85°F. or more. Patient consistently demonstrated baseline temp of 85°F. on 8th & 9th sessions.

Shellenberger and Green 78

Table 4 continued

Subjects Treatment Results
King & Arena, 1984, chronic cluster headache, 69 yr. old male with 37 yr. history of headaches once a day and head pain at night. 7, 30 minute temp sessions assisted by a variety of cognitive & relaxation strategies, home practice, self monitoring, and spouse contingency program. 15 mo. follow-up showed headaches reduced to 1 a week, pain was significantly reduced and medications reduced by 100%.
Latimer, 1981, diffuse esophageal spasm, 41 yr. old female with history of symptom now considering a long esophageal myotomy. Progressive relaxation, EMG (frontal) feedback, home practice, and feedback of esophageal motility & double swallowing technique. 6 mo. follow-up showed she could eat all foods & reduced spasm to 6 min. a week.
LeVine, 1983, 30 yr. old female, a functionally impaired professional violinist. Thermal feedback (6 sessions) with in vivo feedback exercises practiced at home. Four year follow-up still symptom free.
Levee, Cohen, & Rickles, 1976, Relief of tension in facial and throat muscles of a woodwind musician, alcoholic, 52 yr. old male. EMG (forehead) relaxation feedback and psychotherapy. End of treatment patient is symptom free with enriched family & work life.
Libo, Arnold, Woodside, Borden & Hardy, 1983, functional bladder-sphincter dyssynergia, 8 yr. old female. 14 (60 min.) sessions of EMG tense-relax training of perineal musculature, home practice of relaxation during voiding and Kegel exercises. Symptom free, maintained at 1 year follow-up.
Marrazlo, Hickling, & Sison, 1983, 15 yr. old girl with migraine & tension headaches since age 3. Medications were not helping and she was missing three days of school per week. Cognitive training, EMG and temp autogenic feedback, home training using imagery & autogenics. 18 mo. follow-up disclosed she was totally free of migraines & had only mild tension headaches occasionally.

Ghost in the Box 79

Table 4 continued

Subjects Treatment Results
Norton, 1976, 34 yr. old female, eye closure reactions, 13 yr. history of difficulty keeping eyes open. General relaxation training at home and in the clinic assisted with EMG forehead feedback, negative practice of exaggerating eye closures & tensing facial muscles. 6 month follow-up: normal eye closures; engagement in new social activities.
Olton & Noonberg, 1982, 21 yr. old female, migraine B: 74°F; B: 1 every  two weeks; T: 20 Thermal sessions. Home practice of Benson’s relaxation & stress management. 1 yr. follow-up only 2 headaches. Increase hand temp 5°F. in five  minutes. Base temp  now 90°F.
Olton & Noonberg, 1982, 52 yr. old female, migraine headaches, extensive medications B=84°F.; b=headaches (50 yrs.); T=18 autogenic feedback sessions home practice of muscle relaxation exercises. Eliminated medication.   –achieve 95°F. in 7 min. –decrease frequency by 73%
Peck, 1977,  Blepharospasm (spasmodic winking), 50 yr. old female. 17 EMG sessions, placements on left frontalis & lower orbicularis oculi muscles. Reduction from 1600 spasms per 20 min. to 15, massive contraction reduced to ordinary blink. 4 mo. follow-up retained improvement.
Reeves, 1976, 20 yr. old female, 5 yr. history of tension headache Phase 1: B: 9 µV  (RMS); Phase 2: 6 ses sions of cognitive training; Phase 3: 18 forehead EMG relaxation training. 66% decrease in headache activity maintained at 6 mo. follow-up.
Rosenbaum, 1983, insulin treated diabetes mellitus; 18 yr. male; 27 yr. female; 17 yr. female, 25 yr. female, 71 yr. male, 61 yr. female Budzynski’s System Aproach  (EDR, EMG, &  Temp to criterion),  psychotherapy as adjunctive treatment. 4 yr. follow-up shows significant improvement.

Shellenberger and Green 80

Table 4 continued

Subjects Treatment Results
Shulimson, Lawrence, & lacono, 1985, 3 males in their 50’s with diabetic ulcers. 22-27 temp sessions,  home practice with   tapes & liquid crystal  thermometer, probe in clinic placed on border of ulcer. 1st subject increased  temp consistently and had complete healing of ulcer; 2nd subject increased temp consistently and had almost total healing of the ulcer; 3rd subject did not consistently increase temp and had no healing.
Tansey, Bruner, 1983, 10 yr. old hyperactive boy with developmental reading disorder. 3 EMG (frontal) sessions  followed by 20   SMR sessions, relaxations  instructions and rewards of toy trucks. EMG: 60  µV (p-p) to 5  µV (p-p). Significant increases in SMR. 2 yr. follow-up: Significant improvement in reading, academic grades, ocular movement, etc.

Ghost in the Box 81

Table 5

Follow-up Studies

Subjects Treatment Results
Adler & Adler, 1983, Ten year follow-up of control group outcome. E=53 migraineurs (13  classical, 34 common, 5 mixed, 1 basilar artery). 19 year previous history of headache; C=15 subjects (3 classical 12 common). 16 year history of headache. T: Train to 950F. on  hands in relaxed &  stressed conditions using systematic relaxation methods, home practice, psychotherapy C: Train to 95°F. in relaxed conditions using systematic relaxation &  home practice. E=headache frequency per year decreased from 35 to 5.8; medications decreased significantly; 91 % continued to practice relaxation during stressful periods. Coping with anger was the most valuable skill learned in psychotherapy. C= headache frequency per year decreased from 35 to 23; medications did not decrease significantly; 45% continued to practice during stressful periods.
Adler & Adler, 1976, 58 patients with migraine, tension, mixed & cluster headaches, follow-up from 3½ yrs. to 5 EMG, Temperature and autogenic feedback sessions, adjunctive  psychotherapy. 42% had no headaches or very occasional ones, 44% reduced frequency by 75%
Ford, Strobel, Strong & Szarek, 1983, 340 patients with a variety disorders. Follow-up varied from 3 months to 2 years. Train to subjective  criteria of relaxation using EMG, temp,  quieting response training, home practice. Raynaud’s=18 of 23 improved, migraines =29 of 45 improved, irritable colon=7 of 13 improved, Raynaud’s disease with other symptoms=9 of 15 improved, tension headache=13 of 33 improved, hypertension = 5 of 15 improved, mixed headache=79 of 131improved, others=27 of 61 improved.

Shellenberger and Green 82

Table 5 continued

Subjects Treatment Results
Libo & Arnold, 1983,  58 patients with follow up of more than 6 months after treatment. Train to criteria, 95°F. on hands, 1.1  µV (RMS) on forehead EMG, home practice, relaxation & stress management Significant improvement: migraine 100% improvement, tension =100% improvement, mixed headache = 87% improvement. chronic pain = 83% improvement, anxiety =100% improvement, hypertension =92% improvement.
Nakagawa-Kogan, Betrus, Beaton, Larson, Mitchell, & Wolf-Wilets, 1985, 360 patients completed training, and follow-up on 182 patients at 12 months. Comparison to a waiting list control group. Biofeedback and Stress Management-Pre and Post Stress Profiles to assess learning. End of treatment significance was obtained at .001 on tension headache, migraine headache, insomnia, hypertension, chronic muscle tension, and anxiety. Follow-up at 12 months: maintenance of symptom decrease at .001 confidence levels.  Measures on stress profile showed a continued decrease in muscle tension and increase in blood flow to the hands compared to no-treatment control.
Rosenbaum, Greco, Sternberg, & Singleton, 1981, 93 patients anxiety, headache, hypertension, Raynaud’s phenomenon, insomnia, bruxism, tinnitus, hyperhydrosis, asthma, dysmenorrhea, others. Budzynski systems model, systematic desensitization, progressive, autogenic, quieting response, home practice, stress management. 3-18 month follow-up: 32 very improved, 43 somewhat improved, 15 unchanged, 3 worse; 10 off med’s, 21 reduced med’s, 20 same med’s, 7 increased med’s.
Sedlacek, 1979,   20 Raynaud’s patients. EMG & Thermal feedback, autogenic and home practice, & imagery. 75% significant relief at 1 year follow-up.

Ghost in the Box 83

Table 5 continued

Subjects Treatment Results
Sellick & Fitzsimmons, 1983, 48 migraineurs Train to criterion (1.5 microvolts RMS on forehead), bi-directional temperature change, home practice, progressive & autogenics. 75% improvement for those who met criterion, 39.3% improvement for those who did not meet criterion at 48 week follow-up.
Shellenberger, et al., 1986, No treatment control (n=79); Treatment group (n=50), Two year follow-up on no treatment control group and treatment group. Biofeedback & Stress Management Classes, 16 EMG (forehead), 20 hand temperature, home practice, pre and post stress profiles at end of treatment. Post assessment showed significant change (.05) compared to the control group on EMG levels & State-Trait. Symptom severity decreased at .05 on migraine headache, heart palpitations, essential hypertension, smoking, worrying, insomnia, rage, tension headache, bruxism, ulcers, low back pain, hay fever, anxiety. Stress management group significantly lowered physician visits .01 in comparison to control group.
Solback & Sargent, 1977, and Sargent, Walters, & Green,  1973, 74 patients on 5 yr. follow-up. Autogenic & thermal feedback, home practice, imagery. 55 (74%) reduced headache symptom by 74%.
Wiedel, 1985, 28 post-traumatic stress syndrome with other symptoms such as insomnia, headache, hypertension, back pain. Train to criterion on temp, forehead EMG (2 microvolts or less p-p), coping skills training. 1 year follow-up: significant reduction in symptom severity (.01) and decrease in trait anxiety (.01) & state (.05)

Shellenberger and Green 84

Table 5 continued

Subjects Treatment Results
Yock, Schneider, Osterherg, & Stevenson, 1983, N=156 (105 responded to follow-up questionnaire), Treatment program for college students with a variety of disorders, migraine, tension, &  mixed headache, ulcers, irritable bowel, essential hypertension, anxiety. B: 50 minute stress profile. Treatment was EMG on forehead, temperature training on hands, relaxation techniques, home practice and stress management mean number of sessions =7. Six month follow-up: 77% had eliminated medications. 47% had significantly reduced or eliminated symptoms. 40% had moderately reduced their symptom(s). 10% reported slight improvement. 3% reported no improvement.-79% reported they were still practicing short relaxation skills.

[End of Chapter 4]

 

Attention: The Ghost in the Box is “Shareware”!
Please Register Your Copy Today

This internet publication of the historic monograph “From the Ghost in the Box to Successful Biofeedback Training” is itself an historic event — the first known publication of a masterpiece previously-published document as “shareware”.

For years computer software has been published under this “honor system”.  You can download a program for free, try it out, and see if you like it. And, if you continue to use the program, you are honor-bound to send the modest registration fee to the author.

If you download and read this Internet Edition of GHOST, either the whole book or any one or more of its chapters, and if you allow its message to influence your thinking about Biofeedback, you are asked to submit the modest sum of FIVE DOLLARS directly to the book’s authors, Bob and Judy.  That’s even a bargain, since the original 1986 publication, which is herewith reproduced in its entirety, cost $9.95!  Unfortunately, it has been out-of-print for several years, but would surely cost more if reprinted today.

License.  Payment of the $5.00 registration fee entitles the reader to print one (1) copy of the entire text, or any part of the entire text, for personal use.  Up to ten additional copies may be printed, provided that this notice is always included (once) and each recipient understands that the shareware fee applies to each and every printed copy of the book or any chapter of the book.   Reproduction beyond the scope of this license is a violation of US and International Copyright Laws.

To Register your copy of “Ghost”, print this page and send it with your check or US$ 5.00 cash to:

Bob Shellenberger & Judy Green
c/o Psychology Department
Aims Community College
PO Box 69
Greeley, CO 80632 USA

Dear Bob and Judy:

Thanks for making “The Ghost in the Box” available again. 

(Optional)
Name: _________________________________________

Address: _______________________________________

City/State: ______________________________________

Email Address: __________________________________

Remember, send only one registration per person, regardless of how many chapters you have.

A revised edition of Ghost is in the planning stages; if you do include your name and address, you will be notified if and when it becomes available.

A brief description of your professional involvement in biofeedback would be of great interest to the authors.

 

 

 

Comments, suggestions and criticism are most welcome.  Please feel free to make your suggestions or comments here.

Leave a Reply

Your email address will not be published. Required fields are marked *