Biofeedback and Psychotherapy M E L V Y N
R. W E R B A C H ,
M . D . * j Los Angeles,
Calif.
Biofeedback, a procedure in which patients observe and interact with personal physio¬ logic events, may serve as an experiential adjunct to the psychotherapeutic process, perhaps by assisting them to develop their abilities to recognize and affect the internal events under scrutiny. T h e i m p o r t a n t r o l e o f f e e d b a c k i n p s y c h o t h e r a p y is w e l l r e c o g n i z e d by m o s t t h e o r e t i c i a n s , r e g a r d l e s s o f t h e i r o r i e n t a t i o n . T h e therapist observes his p a t i e n t a n d f e e d s b a c k to h i m i n f o r m a t i o n c o n c e r n i n g aspects o f his d y n a m i c s a n d b e h a v i o r o f w h i c h he is u n a w a r e . B i o f e e d ¬ back, the p r o v i s i o n o f p e r s o n a l p h y s i o l o g i c f e e d b a c k , m a y be v i e w e d as simply an extension o f the psychotherapist's role i n p r o v i d i n g feedback to his p a t i e n t . A n e l e c t r o n i c i n s t r u m e n t m o n i t o r s c h a n g e s i n t h e activity o f the physiologic measures u n d e r scrutiny a n d converts that informa¬ t i o n i n t o a f o r m o f d a t a w h i c h c a n be c o n t i n u o u s l y o b s e r v e d by t h e t h e r a p i s t a n d , i f d e s i r e d , b y t h e p a t i e n t . T h u s , i n c o n t r a s t to t r a d i t i o n a l p s y c h o t h e r a p y , t h e i n f o r m a t i o n f e d b a c k is d e r i v e d f r o m t h e m o n i t o r i n g o f p h y s i o l o g i c events a n d p r o v i d e s a n objective " w i n d o w " i n t o the un¬ conscious. 1
PROCEDURE O n e o r m o r e b i o f e e d b a c k i n s t r u m e n t s a r e a t t a c h e d to t h e p a t i e n t , u s u a l l y at t h e start o f t h e h o u r , a n d r e m a i n i n p l a c e as t h e session proceeds. A u d i t o r y and/or visual displays provide feedback for whatever physiologic variables are m o n i t o r e d . W h i l e feedback displays b a s e d e i t h e r o n the e l e c t r i c a l activity o f t h e s k i n ( G S R ) o r o n t h e e l e c t r i c a l activity o f s t r i a t e d m u s c l e s ( E M G ) a r e c o m m o n l y u s e d , d i s p l a y s o f o t h e r p h y s i o l o g i c v a r i a b l e s m a y also be o f v a l u e . T h e s e v a r i a b l e s i n e l u d e h e a r t r a t e , r e s p i r a t i o n r a t e , b l o o d flow (as m e a s u r e d by t h e p h o t o P l e t h y s m o g r a p h ) , s k i n s u r f a c e t e m p e r a t u r e , a n d t h e e l e c t r i c a l activity o f the c e r e b r a l c o r t e x ( E E G ) . T h e i n t e g r a t e d e l e c t r o n i c signals d e r i v e d f r o m t h e p a t i e n t ' s moni¬ t o r e d p h y s i o l o g i c activities c a n be d i s p l a y e d to b o t h p a t i e n t a n d t h e r a p i s t s i m u l t a n e o u s l y . A l t e r n a t i v e l y , t h e t h e r a p i s t , by t h e use o f e a r p h o n e s o r a v i s u a l d i s p l a y w h i c h is t u r n e d a w a y f r o m t h e p a t i e n t , c a n a r r a n g e to r e s t r i c t t h e r e c e p t i o n o f t h e i n t e g r a t e d e l e c t r o n i c signals to h i m s e l f so as *Director, Biofeedback Medical Clinic, 18370 Burbank., T a r z a n a , Calif. 91356.
376
B I O F E E D B A C K
(
՝*
•
AND
377
P S Y C H O T H E R A P Y
to m i n i m i z e a n y i n t e r r u p t i o n t h a t t h e signals m a y cause to t h e flow o f the patient's associations. H e c a n t h e n m a k e his p a t i e n t a w a r e o f physio¬ l o g i c shifts b y v e r b a l m e a n s at a p p r o p r i a t e t i m e s . T h e l a t t e r m e t h o d is s i m i l a r to m a k i n g t h e p a t i e n t a w a r e o f his n o n v e r b a l c o m m u n i c a t i o n s , e x c e p t t h a t t h e m o n i t o r e d signals m a y n e v e r h a v e b e e n m e a n t as com¬ munications. "Biofeedback-assisted relaxation response training" differs further f r o m traditional psychotherapeutic p r o c e d u r e s i n that the establishment o f the " r e l a x a t i o n r e s p o n s e " o r " t r o p h o t r o p h i c r e s p o n s e " is a s p e c i f i c goal t o w a r d w h i c h the patient trains. T h e r a p i s t a n d p a t i e n t see a n d h e a r t h e e l e c t r o n i c signals s i m u l t a n e o u s l y . A s t h e f e e d b a c k d i s p l a y s indi¬ cate n o t o n l y t h e l e v e l o f a c t i v a t i o n b u t also w h e t h e r t h e p a t i e n t is p r o c e e d i n g at t h a t m o m e n t t o w a r d t h e t r a i n i n g g o a l , m u c h o f the learn¬ i n g p r o c e s s c a n be by " t r i a l a n d e r r o r . " T h e t h e r a p i s t g u i d e s his p a t i e n t t o w a r d the d e s i r e d r e s p o n s e p a t t e r n a n d m a y i n t r o d u c e a d d i t i o n a l r e l a x a t i o n - o r i e n t e d p r o c e d u r e s to a i d t h e p a t i e n t i n f o c u s i n g his m e n t a l processes. These include meditative mantras, hypnosis, g u i d e d imagery, b r e a t h i n g techniques, autogenic t r a i n i n g , a n d progressive retaxation. W i t h i n t h e c o n t e x t o f p s y c h o t h e r a p y , t h e t r a i n i n g g o a l is less im¬ p o r t a n t t h a n t h e i n t r a p s y c h i c c h a n g e s w h i c h m a y be n o t e d as r e l a x a t i o n t r a i n i n g p r o c e e d s . T h e p a t i e n t is i n s t r u c t e d to n o t e w h a t e v e r t h o u g h t s a n d f e e l i n g s r e a c h his a w a r e n e s s as h e r e l a x e s o r as h e finds h i m s e l f r e s i s t i n g r e l a x a t i o n . C a t h a r s i s is e n c o u r a g e d a n d d i s c u s s e d w h e n it oc¬ c u r s . T h e t h e r a p i s t c o m m e n t s o n the p h y s i o l o g i c r e a d i n g s a n d assists his p a t i e n t i n r e l a t i n g those r e a d i n g s to t h o u g h t s a n d f e e l i n g s i n the " h e r e a n d n o w . " T r a i n i n g m a y b e i n t e r r u p t e d w h e n t h e p a t i e n t wishes to v e r b a l i z e , a n d e n t i r e sessions m a y o c c a s i o n a l l y be s p e n t t a l k i n g i f im¬ p o r t a n t t h e r a p e u t i c issues a r e e m e r g i n g . 2
3
4
Ւ
B e t w e e n t r a i n i n g sessions, t h e p a t i e n t is i n s t r u c t e d to p r a c t i c e t h e re¬ l a x a t i o n - o r i e n t e d p r o c e d u r e s h e has b e e n t a u g h t a n d to u t i l i z e t h e m i n e m o t i o n a l l y s t r e s s f u l s i t u a t i o n s . I f h e has a b i o f e e d b a c k i n s t r u m e n t at h o m e , h e m a y be a s k e d to k e e p r e c o r d s o f t h e r e a d i n g s d u r i n g his p r a c t i c e sessions. As in more traditional forms of psychodynamic psychotherapy, issues c o n c e r n i n g t r a n s f e r e n c e a n d resistance are a n a l y z e d as t h e y e m e r g e . A f r e q u e n t f o c u s is o n the patient's resistance to r e l a x a t i o n a n d its p s y c h o d y n a m i c i m p l i c a t i o n s . T h e e a r l i e r c l i n i c a l r e s e a r c h i n b i o f e e d b a c k was g e n e r a l l y l i m i t e d to the a p p l i c a t i o n o f a s i n g l e m o d a l i t y o f f e e d b a c k to t h e t r e a t m e n t o f a specific s y m p t o m . W h a t m o r e , f o r e x a m p l e , o n e o f t h e e a r l i e s t w o r k e r s i n t h e field, has u t i l i z e d E M G f e e d b a c k e x c l u s i v e l y . M a n y clinicians 5
ř
378
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h a v e b e c o m e c o n v i n c e d , h o w e v e r , that, d e s p i t e t h e l a c k o f r e s e a r c h studies investigating t h e advantages o f a m u l t i m o d a l i t y a p p r o a c h , t h e p r o v i s i o n o f a d d i t i o n a l f e e d b a c k c h a n n e l s i m p r o v e s t h e efficacy o f t h e technique. I n multimodality biofeedback, the clinician monitors the instrument r e a d i n g s f r o m s e v e r a l p h y s i o l o g i c v a r i a b l e s a n d selects o n e o r m o r e mo¬ dalities f o r f e e d b a c k . T h e v a r i a b l e m o s t closely r e l a t e d t o t h e present¬ i n g s y m p t o m o r t h e v a r i a b l e w h i c h a p p e a r s t o b e best c o r r e l a t e d t o t h e patient's d e g r e e o f " a c t i v a t i o n " is u s u a l l y s e l e c t e d . I f the patient e x p e r i e n c e s d i f f i c u l t y i n m o d i f y i n g this v a r i a b l e , a n o t h e r m a y t h e n b e selected f o r f e e d b a c k o r a d d i t i o n a l f e e d b a c k c h a n n e l s m a y b e i n ־ troduced. RESULTS AND DISCUSSION T h e c o n t r i b u t i o n o f b i o f e e d b a c k t e c h n i q u e s to p s y c h o t h e r a p y r e m a i n s t o b e e s t a b l i s h e d . T h e l i t e r a t u r e is c u r r e n t l y l i m i t e d t o a f e w case r e p o r t s , w i t h c o n t r o l l e d s t u d i e s totally l a c k i n g . W h i l e t h e r e is a larger research literature o n general clinical applications o f biofeedback, it also s u f f e r s f r o m a l a c k o f a d e q u a t e c o n t r o l s . A similar comment c o u l d b e m a d e a b o u t s t u d i e s i n v e s t i g a t i n g t h e effects o f t h e e l i c i t a t i o n o f the relaxation response. Clinicians should therefore be advised o f the experimental nature o f the procedure. 6 к ?
8
2
O n t h e basis o f a n e c d o t a l i n f o r m a t i o n , p h y s i o l o g i c f e e d b a c k a p p e a r s to serve as a n e x p e r i e n t i a l a d j u n c t t o t h e p s y c h o t h e r a p e u t i c p r o c e s s . • T h e equipment provides a continuous stream o f relevant physiologic d a t a , access t o w h i c h m a y p e r m i t t h e p a t i e n t t o r e c o g n i z e t h e i n t e r n a l cues that r e l a t e t o c h a n g e s i n t h e d a t a . W h e n repressed thoughts o r f e e l i n g s , w h e t h e r h i s t o r i c o r t r a n s f e r e n t i a l , h a v e c o v e r t l y a l t e r e d physio¬ l o g i c activities, r e c o g n i t i o n o f these c u e s t h r o u g h b i o f e e d b a c k m a y pro¬ mote awareness o f the repressed m a t e r i a l . T h e therapist, by monitor¬ i n g t h e p h y s i o l o g i c d a t a , m a y also i n c r e a s e h i s a w a r e n e s s o f h i s p a t i e n t ' s responses to b o t h i n t e r p e r s o n a l a n d intrapsychic stimuli. Murphy has r e v i e w e d t h e e x p e r i m e n t a l l i t e r a t u r e i n v e s t i g a t i n g t h e perceptual distortions o f m e m o r y a n d thought w h i c h occur to avoid awareness o f stressful i n f o r m a t i o n . H e notes, f o r e x a m p l e , h o w a person m a y limit perceptual i n p u t by a v o i d i n g scanning o f stressful images o r by creating "noise" t h r o u g h a n increase i n muscle tension, a n d suggests t h a t b i o f e e d b a c k , b y o p e n i n g c h a n n e l s o f i n f o r m a t i o n , m a y a i d in overcoming self-deception. 6
7
9
1 0
1 1
CASE
REPORTS
Case 1.
A 20-year-old college student sadly noted how acquaintances saw
her as cool and aloof while she considered herself a "feeling person." The
B I O F E E D B A C K
AND
P S Y C H O T H E R A P Y
therapist attached a G S R feedback resistance)
to h e r a n d c o n t i n u e d
379
device (which indicates changes i n skin the session.
f r e q u e n t r e s p o n s e s as s h e s p o k e o f h e r f e e l i n g s .
T h e instrument
indicated
M u c h to h e r delight, she n o t e d
that she n o w k n e w that h e r feelings w e r e " r e a l " a n d thus felt m o r e secure i n sharing t h e m with others. Case
2.
A 28-year-old m a r r i e d secretary sought psychotherapy
t h e start o f a n a f f a i r b e c a u s e " I d o n ' t k n o w w h o I a m . " lous a n d was u n a w a r e o f the cause o f h e r r e a c t i o n .
following
O n e d a y she was tremu¬
T h e therapist attached the
G S R to h e r a n d f o c u s e d t h e session o n h e r r e l a t i o n s h i p s w i t h h e r significant others.
N o shifts o n the i n s t r u m e n t w e r e n o t e d u n t i l she s p o k e o f h e r conversa¬
tion with h e r m o t h e r the night before c o n c e r n i n g h e r affair.
She queried
w h e t h e r she m i g h t be f e e l i n g guilty since h e r m o t h e r was s t r o n g l y o p p o s e d to the affair, b u t the m a c h i n e s h o w e d n o response.
W h e n , however, she spoke o f
h e r c o n c e r n that h e r actions c o u l d aggravate h e r mother's heart c o n d i t i o n , the m a c h i n e indicated a s u d d e n decrease i n skin resistance. ι
T h e r e m a i n d e r o f the
session f o c u s e d o n h e r fear that asserting h e r s e l f to h e r m o t h e r m i g h t l e a d to h e r mother's death. Case
3.
A
severely
withdrawn,
psychotherapy because o f depression.
obsessional
male,
age
27,
entered
A t t a c h e d o n e session to b i o f e e d b a c k
i n s t r u m e n t s , t h e i n s t r u m e n t s i n d i c a t e d l o w levels o f a c t i v i t y i n e a c h p h y s i o l o g i c m e a s u r e as h e s p o k e o f h i s o b s e s s i v e f e a r s a n d h i s e x t r e m e i s o l a t i o n .
W h e n he
spoke o f his m o t h e r , however, a s u d d e n decrease i n his skin resistance indicated ז
h e i g h t e n e d nervous system activation.
T h e t h e r a p i s t c o m m e n t e d o n h i s reac¬
tion a n d asked h i m what he h a d just experienced.
H e b e g a n to c r y a n d s p o k e o f
his fear that s o m e d a y his m o t h e r w o u l d d i e a n d leave h i m a l o n e i n t h e w o r l d . T h e r e m a i n d e r o f the session f o c u s e d o n that c r u c i a l r e l a t i o n s h i p .
Biofeedback-assisted r e l a x a t i o n r e s p o n s e t r a i n i n g , i n a d d i t i o n to the k
e f f e c t s o f p h y s i o l o g i c f e e d b a c k , h a s e f f e c t s r e l a t e d to t h e t r a i n i n g o f re¬ laxation.
Relaxation
is
a
psychophysiologic
multaneous intrapsychic and physiologic shifts.
event 1 2
resulting
in
si¬
It a p p e a r s t o be a n in¬
tegrated h y p o t h a l a m i c response m a r k e d physiologically by g e n e r a l i z e d decreased sympathetic, a n d possibly increased parasympathetic, nervous sytem activity. ՛
2
I n a state o f d e e p r e l a x a t i o n , t h e p a t i e n t a p p e a r s less
p r o n e to utilize h a b i t u a l e g o defenses a n d thus m a y be m o r e receptive to therapeutic interventions.
R e p r e s s i o n d e c r e a s e s as r e l a x a t i o n d e e p e n s
so t h a t p r e v i o u s l y r e p r e s s e d m a t e r i a l m a y b e c o m e a v a i l a b l e .
1 1
1 3
R e l a x a t i o n is a f e a t u r e c o m m o n t o m a n y p s y c h o t h e r a p e u t i c niques.
t h e p a t i e n t to a s s u m e a s u p i n e p o s i t i o n ( w h i c h f a c i l i t a t e s K
changes
tech¬
I n F r e u d i a n psychoanalysis, f o r e x a m p l e , the analyst instructs in
the
direction
of relaxation)
and
physiologic
to f r e e - a s s o c i a t e
facilitates i n t r a p s y c h i c changes i n the d i r e c t i o n o f r e l a x a t i o n ) .
(which
It m a y b e
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t h a t m o r e systematic t r a i n i n g i n r e l a x a t i o n , s u c h as t h a t p r o v i d e d b y biofeedback training, w o u l d expedite the analytic w o r k .
1 4
T h e m a n n e r i n w h i c h the clinician provides physiologic feedback will influence the results o f the p r o c e d u r e .
A n aversive feedback signal, f o r
example, will interfere with relaxation.
Similarly, the i m p o r t a n c e o f the
relationship
between
the
clinician
and
his
patient
should
not
be
n e g l e c t e d , p a r t i c u l a r l y b e c a u s e t h e r e g r e s s i v e effects o f r e l a x a t i o n m a y intensify the d e v e l o p m e n t o f transference. T h e r e has b e e n n o s y s t e m a t i c i n v e s t i g a t i o n o f t h e p o s s i b l e a d v e r s e ef־ fects o f b i o f e e d b a c k r e l a x a t i o n t r a i n i n g .
C o m p a r e d to t h e s i d e effects
of medication and other intrusive methods of therapeutic intervention, t h e fact t h a t b i o f e e d b a c k is n o m o r e t h a n a d a t a d i s p l a y i f t h e p a t i e n t d o e s n o t actively u t i l i z e t h e i n f o r m a t i o n f e d b a c k to h i m b y t h e m a c h i n e w o u l d m a k e the p r o c e d u r e a p p e a r i n n o c u o u s .
A d v e r s e effects
are
p o s s i b l e , h o w e v e r , as t h e y a r e w i t h a n y o t h e r d e r e p r e s s i v e t e c h n i q u e , w h e n the process proceeds faster t h a n the patient's ability to tolerate the resultant a n x i e t y . depression.
1 5
S u c h effects w o u l d i n c l u d e p s y c h o t i c r e a c t i o n s
2
and
1 6
A t present, biofeedback relaxation t r a i n i n g appears indicated w h e n patients
present
with
tension,
anxiety
or
other
psychophysiologic
symptoms, particularly w h e n established methods o f treatment been
ineffective
or
had
to
be
abandoned
due
to a d v e r s e
have
effects.
G u i d e l i n e s h a v e yet to be e s t a b l i s h e d as t o w h i c h o f these p a t i e n t s w i l l b e m o s t r e s p o n s i v e to t h e p r o c e d u r e , a n d w h i c h s h o u l d be g i v e n t r a i n i n g o n l y i f it is c o n c u r r e n t w i t h p s y c h o t h e r a p y , a l t h o u g h t h e r e is s o m e evi¬ d e n c e that, as w i t h o t h e r p s y c h o t h e r a p e u t i c p r o c e d u r e s , e g o s t r e n g t h is positively
correlated with i m p r o v e m e n t .
1 7
In
general,
biofeedback
t r a i n i n g d o e s n o t a p p e a r to be i n d i c a t e d w h e n , f o r a n y r e a s o n , t h e p a t i e n t is u n a b l e to a t t e n d to a n d u t i l i z e the d a t a f o r l e a r n i n g . CASE Case
REPORTS 4.
A
47-year-old business
executive
complaining
of
free-floating
a n x i e t y was r e f e r r e d f o r b i o f e e d b a c k t r a i n i n g t w o m o n t h s after s u s t a i n i n g a myocardial infarction.
D u r i n g the initial consultation he a p p e a r e d moderately
t e n s e a n d s p o k e o f c h r o n i c stresses p r e s e n t i n b o t h h i s f a m i l y a n d b u s i n e s s rela¬ tionships.
H e n o t e d t h a t h e h a d a l w a y s b e e n " a g g r e s s i v e , " restless, a n d e a s i l y
angered.
H e realized that c o n t i n u e d tension w o u l d decrease his life expectancy
b u t was u n a b l e t o l e a r n t o r e l a x . D u r i n g t h e f o l l o w i n g t w o m o n t h s , h e a t t e n d e d t e n sessions o f b i o f e e d b a c k relaxation training c o m b i n i n g surface-temperature, G S R , a n d striated-muscle feedback.
H e b e c a m e a w a r e t h a t h e h a d b e e n m a i n t a i n i n g e x c e s s m u s c l e ten¬
sion, p a r t i c u l a r l y i n his masseter a n d occipital muscles, a n d l e a r n e d to r e d u c e this tension considerably.
S e v e n p s y c h o t h e r a p y sessions w e r e s c h e d u l e d d u r i n g
B I O F E E D B A C K
AND
P S Y C H O T H E R A P Y
t h e s a m e t w o m o n t h s w h i c h f o c u s e d u p o n f a m i l y stresses.
381 I n t h e s e sessions h e
became increasingly aware o f h o w his r i g i d , j u d g m e n t a l attitudes f o r c e d others i n t o e q u a l l y u n c o m p r o m i s i n g p o s i t i o n s a n d b e g a n t o r e l a t e i n a less a u t h o r i t a t i v e and controlling manner. A t t h e c o n c l u s i o n o f t e n b i o f e e d b a c k sessions, h e s t a t e d t h a t h e n o w f e l t "dif¬ ferent inside."
W h a t h e h a d p r e v i o u s l y e x p e r i e n c e d as a n x i e t y h e n o w l a b e l e d
as i r r i t a t i o n a n d a s s o c i a t e d t h e f e e l i n g w i t h s p e c i f i c stresses.
H e felt generally
m u c h m o r e r e l a x e d a n d n o t e d that his relationships h a d greatly
improved.
C o m p a r i s o n o f h i s M M P I p r o f i l e s b e f o r e a n d a f t e r t r e a t m e n t c o n f i r m e d h i s im¬ ,
pression o f improvement. Case 5. cause o f a
A 2 4 - y e a r - o l d h o u s e w i f e was r e f e r r e d f o r b i o f e e d b a c k t r a i n i n g be¬ five-year
history o f muscle spasms in b o t h hips.
I n c o n s u l t a t i o n she
s t a t e d t h a t s h e was h a p p i l y m a r r i e d a n d u n d e r n o m a j o r c u r r e n t stresses o t h e r t h a n those caused by h e r physical disability.
A l t h o u g h she s h o w e d n o e v i d e n c e
o f psychotic i d e a t i o n , she r e p o r t e d that she h a d e x p e r i e n c e d a psychotic b r e a k s e v e n y e a r s a g o d u r i n g t h e first y e a r o f h e r m a r r i a g e w h e n h e r h u s b a n d was d r a f t e d to g o t o V i e t N a m . W i t h i n s e v e n sessions o f b i o f e e d b a c k r e l a x a t i o n t r a i n i n g , h e r h i p s p a s m s h a d ceased.
H o w e v e r , s h e n o w s t a t e d t h a t s h e w i s h e d to l e a v e h e r h u s b a n d to m o v e
to a h i d d e n r a n c h w i t h h e r n e i g h b o r w h o , s h e c l a i m e d , was c o l l e c t i n g g u n s a n d storing food in anticipation of a famine.
O n p s y c h i a t r i c e v a l u a t i o n , s h e was w e l l
o r i e n t e d b u t d i s p l a y e d i n a p p r o p r i a t e a f f e c t a n d a p p e a r e d to be p s y c h o t i c .
։
CONCLUSION F o r d a n d U r b a n , i n a c o m p a r a t i v e s t u d y o f t e n m a j o r systems o f p s y c h o t h e r a p y n o t e that these systems seek to m o d i f y " h a b i t s o f attend¬ i n g to events a n d habits o f t h i n k i n g a b o u t t h o s e e v e n t s . " B i o f e e d b a c k , w h i l e n o t a s y s t e m o f p s y c h o t h e r a p y , is a p r o c e d u r e w h i c h assists the p a t i e n t to d e v e l o p his ability to r e c o g n i z e , a f f e c t a n d , u l t i m a t e l y , to acc e p t r e s p o n s i b i l i t y f o r p e r s o n a l p h y s i o l o g i c events a n d t h u s s h o u l d be considered an adjunctive prcedure in psychotherapy. D e s p i t e its e v i d e n t p r o m i s e , the e x t e n t o f its c o n t r i b u t i o n i n f a c i l i t a t i n g t h e p s y c h o t h e r a p e u t i c p r o c e s s is still u n d e t e r m i n e d a n d awaits r e s e a r c h validation. 1 8
1
,
r
SUMMARY B i o f e e d b a c k , p e r h a p s b y assisting the p a t i e n t to d e v e l o p his a b i l i t y to r e c o g n i z e , t a k e r e s p o n s i b i l i t y f o r , a n d a f f e c t p e r s o n a l p h y s i o l o g i c events, m a y serve as a n e x p e r i e n t i a l a d j u n c t to the p s y c h o t h e r a p e u t i c p r o c e s s . T h e p a t i e n t a n d e v e n the t h e r a p i s t c a n be a t t a c h e d to b i o f e e d b a c k i n s t r u m e n t s d u r i n g t h e p s y c h o t h e r a p y session. T h e f e e d b a c k d a t a c a n t h e n be u t i l i z e d i m m e d i a t e l y to a f f e c t the d i r e c t i o n o f t h e session b y e x p a n d i n g m u t u a l awareness o f dynamically m e d i a t e d physiologic
382
A M E R I C A N
J O U R N A L
OF
P S Y C H O T H E R A P Y
events. A l t e r n a t i v e l y , t h e t h e r a p i s t c a n t r a i n h i s p a t i e n t t o l o w e r h i s l e v e l o f p h y s i o l o g i c a r o u s a l . I n this case, r e l a x a t i o n - o r i e n t e d t e c h n i q u e s a r e a p p l i e d w h i l e t h e i n s t r u m e n t a t i o n gives p o s i t i v e r e i n f o r c e m e n t f o r success. B y e n h a n c i n g r e l a x a t i o n , f r e e a s s o c i a t i o n a n d r e g r e s s i o n m a y be f a c i l i t a t e d a n d p s y c h o p h y s i o l o g i c s y m p t o m s r e l a t e d t o o v e r a r o u s a l may be r e d u c e d . As with any other procedure utilized i n psychotherapy, the ultimate value o f biofeedback depends u p o n the motivation a n d psychologic assets o f t h e p a t i e n t as w e l l as t h e skills o f t h e p s y c h o t h e r a p i s t . REFERENCES 1. S c h w a r t z , G . E .
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