The Highway Patrol periodically places a radar speed display on
residential roads. The device shows motorists how closely their speed
matches the posted 20-mph limit. This speed display illustrates the
concept of biofeedback: the display of information about biological
activity (speed) back to an individual (a motorist) to improve
performance. Defined broadly, the biological activity we feed back can
be about muscle action potentials, the position of a limb, or driving
Your conceptual model of biofeedback affects the way you think about
biofeedback and how you define your patient's role in training. Before
you proceed, write down a paragraph that describes how you explain
biofeedback to your patients.
At the start of this module, we will review perceptual learning,
classical and operant conditioning, and relational learning. We will
examine five models that have shaped conventional beliefs about
biofeedback. Next, we will study two models that emphasize skill
development. Finally, we will discuss how to optimize the training
Students completing this module will be able to describe and explain
1. definitions of biofeedback
2. concepts of control in biological systems
3. overview of principles of human learning as they apply to
biofeedback: (a) learning theory (e.g., classical and operant
conditioning, discrimination, generalization, and habituation)
4. cybernetic, operant conditioning, drug, placebo, and relaxation
models of biofeedback
5. Blanchard and Epstein's (1978) self-regulation model and
Shellenberger and Green's (1986) mastery model
6. critical training factors including sources of biofeedback
information, the social relationship between therapist and
patient (including the person effect), modeling, coaching skills,
patient motivation, continuous assessment, the patient's role in treatment,
practice, and bidirectional training
7. voluntary control through active and passive volition
8. incorporating current studies in treatment design
9. personalizing treatment
10. patient selection of effective self-regulation strategies
11. popular biofeedback metaphors
We learn most psychophysiological responses through the
unconscious processes of perceptual learning, and classical and
operant conditioning, and the conscious process of relational
© 2000 John Balven
allows us to categorize stimuli and recognize that we've encountered
them before. This learning process enables a patient to recognize that
her headache is a migraine as opposed to a tension headache.
prepares us to respond rapidly to future situations. Classical
conditioning underlies the placebo response, which can be
conceptualized as a learned healing response.
An unconditioned stimulus
(conflict) elicits an unconditioned
response (blood pressure increase) without learning.
Classical conditioning associates a neutral
stimulus (meeting with boss) with an unconditioned
stimulus (conflict). Through repeated pairing, the neutral
stimulus becomes a conditioned
stimulus that elicits a conditioned response (blood
pressure increase). Failure of an unconditioned stimulus to follow the
neutral stimulus extinguishes
(weakens) a conditioned response.
© 2000 John Balven
adjusts behavior (operant) in response to its consequences.
A person's actions in a situation result in consequences that may
increase or decrease the likelihood of this behavior in similar
situations. The identifying characteristics of a situation are called
its discriminative stimuli
and include how the situation looks, sounds, and feels. Discriminative
stimuli tell us which consequences are operating.
In positive reinforcement,
behavior (diaphragmatic breathing) is followed by a positive
consequence (calm) that increases its future likelihood in situations
with similar discriminative stimuli (therapist's office).
In negative reinforcement,
behavior (diaphragmatic breathing) allows the person to escape or
avoid an aversive state (anxiety), thereby increasing its future
likelihood in situations with similar discriminative stimuli
the frequency of behavior (diaphragmatic breathing) declines in a
situation (workplace) when it is not reinforced (patient is unable to
© 2000 John Balven
Both classical conditioning and operant
conditioning involve generalization, discrimination, and
a person learns to respond (blood pressure increase) to stimuli that
resemble the conditioned stimulus (argument with spouse) or to perform
an operant behavior (diaphragmatic breathing) in situations that have
different discriminative stimuli (driving during rush hour).
Generalization allows us to transfer performance of self-control
skills to situations outside a therapist's office like home and the
a person learns to ignore stimuli that differ from the conditioned
stimulus (not react to an argument with spouse) or to withhold an
operant behavior (diaphragmatic breathing) when the situation is
inappropriate (sprinting). Discrimination insures that our behavior is
appropriate to a specific situation.
the brain ignores a constant stimulus because it provides no new
information. Office workers learn to ignore the sound of an elevator
so that it no longer produces a conditioned response. The color
of a relaxation reminder (a plastic dot) may have to be regularly
changed so a patient will not ignore it.
is conscious and allows us to associate stimuli that occur at the same
time. This learning process provides us with autobiographical
knowledge (information about our experiences). In a clinical
context, it provides conscious memories a patient can retrieve and use
to guide behavior (how he warmed his hands during an autogenic
exercise in his therapist's office last week).
A relational memory of handwarming is illustrated below. The
patient experienced all these elements at the same time and linked
Five models have greatly influenced therapist and
researcher conceptions of biofeedback. These include the cybernetic,
operant conditioning, drug, placebo, and relaxation models.
The cybernetic model
proposes that "biofeedback is like a thermostat." The term,
biofeedback, originated in cybernetic theory. The components of a
thermostat system include a set
point or goal (75
degrees), system variable or what is controlled (room
temperature), negative feedback or corrective instructions
(commands to change furnace output), and positive feedback
or commands to continue action (commands to continue furnace output).
From the perspective of the cybernetic model, biofeedback training
supplements a patient's proprioception to bring a malfunctioning
biological system variable (blood pressure) under better control.
Operant conditioning model
conditioning model proposes that "biofeedback is the
operant conditioning of physiological processes." From this
perspective, voluntary changes (reduced muscle bracing) are
strengthened by reinforcing consequences (feedback display). This
model implies that awareness of which change is being reinforced is
unnecessary and disregards the instructional elements that are
critical to training success.
The operant model has several problems. First, operant conditioning is
only one of several learning processes involved in self-regulation
training. Classical conditioning, cognitive learning, motor learning,
and social learning may also be involved.
Second, reinforcement without systematic instruction is an inefficient
way to teach a skill. This would be like a track coach who announced a
sprinter's time, but never demonstrated technique or corrected her
The drug model
asserts that "biofeedback treatment corrects symptoms like a
drug." This model is implied when a patient receives only three
sessions of temperature biofeedback regardless of whether she can warm
her hands to 95 degrees F on command.
The drug model is counterproductive because it places the patient in a
passive role (analogous to taking aspirin) and emphasizes dosage (the
number of sessions) over skill mastery. If you believe that skill
mastery affects treatment outcome, then patients should be trained to
criterion and not be limited to an arbitrary number of sessions.
Therapists using the placebo
model believe that "biofeedback produces nonspecific
effects, like a drug, due to patient beliefs."
While the "laying on of electrodes" undoubtedly
produces symptom improvement, this model discounts the contribution of
skill learning. Second, the changes produced through biofeedback, like
increased end-tidal CO2, can be very specific and are due to modified
breathing mechanics instead of patient beliefs.
The relaxation model
views biofeedback as inherently relaxing. Based on this model,
therapists may administer biofeedback without relaxation instructions
and researchers may compare biofeedback to relaxation procedures like
This approach suffers from serious misconceptions about biofeedback.
First, feedback about your physiology is not always relaxing. For
example, a patient told that her blood pressure is elevated will not
be calmed by this news.
Second, whether biofeedback training produces cultivated
low arousal depends
on relaxation instruction and the patient's approach to learning. For
example, an extreme Type A patient learning to lower EMG levels could
exacerbate stress symptoms by competing against the electromyograph.
Finally, even traditional relaxation procedures like Autogenic
exercises can produce distress. Relaxation-induced
anxiety has been reported for up to 40% of patients
receiving relaxation training.
MODELS THAT EMPHASIZE SKILL DEVELOPMENT
Blanchard and Epstein (1978) and Shellenberger and Green (1986)
developed models of self-regulation that emphasize the mastery of
self-regulation skills. These approaches are consistent with the view
is information. From this perspective, a therapist coaches the patient
to use information about her physiological performance to achieve
voluntary control to reduce symptoms and promote optimal functioning.
Blanchard and Epstein's self-regulation model
Blanchard and Epstein
that self-regulation consists of five components. Self-monitoring
is scanning yourself in a situation (checking your breathing
during a job interview). Discrimination means identifying when
selfregulation skills should be used based on situational (stressful
confrontation) and internal (rapid heart rate) cues.
Self-control is the use of a skill to achieve a desired state
(practicing effortless breathing to lower arousal). Self-reinforcement
is use of internal (self-praise) or external rewards (clothing) for
use of a skill. Finally, self-maintenance is long-term
skill practice which is aided by regular review.
In the context of this self-regulation
model, a successful hypertension patient:
understands hypertension and the strategy for control
modifies risk factors (reduced saturated fat and salt
monitors symptoms (scans body several times a day for
posture and breathing pattern, and charts blood
practices self-control (relaxes posture, breathes
effortlessly, and performs both abbreviated and deep
rewards her self (praises her self for practice and
results, and draws a connection between practice and
lower medication dosage and pressure)
maintains progress (reviews progress, modifies
practice based on experience, and schedules booster
sessions with a therapist as needed).
After six months practice, cues like red traffic lights and cold hands
automatically trigger self-regulation responses. They become
attractors. Now, a healthy lifestyle becomes rewarding and cheating
Shellenberger and Green's mastery model
Shellenberger and Green
(1986) advanced a mastery model that compares biofeedback
training to coaching an athletic skill. This training process is social,
since you are working with another person or group, and biobehavioral,
since this instruction uses behavioral principles to control
The biofeedback training process contains these components:
relationship with therapist
2. competent therapist who has
developed and models
3. clear training goals
4. rewards for
5. sufficient time and
practice for mastery
6. effective instructions
as part of systematic training
7. feedback of information
to the patient
THE TRAINING PROCESS
Mere exposure to information about our physiological
performance produces no dependable effects. For example, viewing a
stopwatch does not reliably improve a runner's form.
The effect of information depends on how it is used. When biofeedback
is combined with physical therapy, it becomes biofeedback-assisted
rehabilitation. When combined with relaxation training, it
becomes biofeedback-assisted relaxation. Without rehabilitation
or relaxation coaching, the information is neither rehabilitating or
Sources of performance information
Don't assume that biofeedback requires hardware. Information about
your personal biological activity can be detected with or without
hardware. Natural proprioception
(bodily sensory feedback) will be your patient's main source of
information when she has learned to scan her body. Examples:
touch your finger to your wrist to detect pulse rate or touch your
cheek to detect hand temperature.
During training, you can supplement proprioception with high
technology or low technology instruments that monitor performance.
Don't confine your concept of biofeedback to the traditional
modalities like EEG, EMG, skin conductance, and temperature. While
invaluable in many clinical applications, your patient may not require
suggested that ordinary devices can provide valuable performance
feedback. For example, facial expression during public speaking
can be modified using a mirror. Balance can be improved
using a pair of bathroom scales and hand tremor by a graduated
set of bells. Finally, a tennis serve can be refined using a camcorder
for video feedback.
Training is social
The training process is social
whether a patient works alone with a therapist or within a group. A
patient's relationship with the therapist may be the most critical
aspect of training. In the context of complexity theory, models can be
Taub reported a person
effect when teaching handwarming. A warm, confident trainer
successfully taught 20 of 21 subjects to raise their finger
temperature. In contrast, an impersonal trainer only succeeded with 2
of 22 subjects. The interpersonal dynamics that make psychotherapy
successful are equally important in biofeedback training.
Therapists should be credible models
Unlike stereotypical "out-of-shape" coaches with "beer
guts," biofeedback therapists have to develop and practice the
skills they are teaching. Peper (1994) strongly argued that therapists
must be "selfexperienced." Would you be confident with
a therapist who looked "stressed out" and extended an
Therapists learn to self-regulate so they can model self-regulatory
behaviors (like low arousal), personally know that training works, and
understand their patients' learning experiences. Since modeling
a therapist who sits tensely or breathes rapidly may inadvertently
teach these behaviors to a patient.
Therapists should be good coaches
An effective biofeedback therapist is a good coach. As in athletic
coaching, successful biofeedback training requires clear goals,
graduated rewards for success, sufficient time and practice for
mastery, effective instructions delivered using systematic training
techniques, useful feedback about performance, and practice of skills
outside of the clinic.
Patient motivation is complex
Patient motivation is often complex and may involve the same approach-avoidance
and avoidance-avoidance conflicts seen in psychotherapy.
A patient has an approach-avoidance
conflict when aversive symptoms are also advantageous
(gaining professional and family attention, control over
relationships, and financial compensation). The rewards of symptomatic
behavior are called secondary
conflict exists when symptoms are unpleasant and
biofeedback training is negatively perceived due to financial cost,
time investment, or social stigma.
Finally, as in psychotherapy, significant others may sabotage training
to maintain their existing relationship. This is particularly a
problem in co-dependent relationships.
Assess and modify your patient's motivation
You can assess and modify motivation by focusing on the symptoms that
concern your patients. R.
Adam Crane asks his patients during assessment to select
three symptoms they want to improve. The patients are then asked to
chart these symptoms daily throughout the course of biofeedback
training. His criteria for success are a 25% to 35% decrease in
symptom frequency and severity.
This protocol increases patient motivation three ways. First,
involving patients in treatment decisions increases their commitment.
Second, involving patients in treatment decisions and assigning
responsibilities places them in an active role and increases perceived
self-efficacy. Third, daily charting of symptoms should produce
improvement on its own, independent of skill mastery.
Patients should be active participants
Successful patients are active participants in this leaning process. A
therapist has an opportunity to modify patient expectations about
their role in biofeedback training through educational literature, the
assessment process, and initial training sessions.
Models that emphasize active skill learning, like Shellenberger and
Green's mastery model, may produce better clinical outcomes than those
that promote passivity.
Practice determines patient
Research indicates that patients succeed if they only practice
self-regulation skills occasionally. Why is practice crucial to
patient success? Practice helps a patient acquire skills through
more time on task. If a patient trains 1 hour a week in the clinic,
this leaves 167 hours available outside the clinic to refine skills
learned during the training session.
Practice helps a patient transfer self-regulation skills to
environmental settings. Handwarming in the clinic does not
automatically generalize to driving in rush hour traffic. Unless a
patient practices these skills in the settings where she needs them,
she might only be symptom-free in the clinic.
Finally, practice makes self-regulation automatic. For example, when
you learn to drive a manual transmission, you start out concentrating
intensely on shifting, afraid that you will "strip the
gears." After months of practice and several gear boxes, you
shift without attention. Likewise, patients practicing
Response perform this skill automatically after about 6
Biofeedback training should teach voluntary control
Successful biofeedback training teaches voluntary
control is shown when a person can produce a requested
physical change (warm your hand to 95 degrees F) on command without
Voluntary control is achieved through passive and active volition. Passive
volition means allowing your body to perform instead of
trying to force it. Forcing defeats your purpose when trying to
urinate during intermission in a movie theater, having an erection, or
in Zen archery.
means forcing your body. This is used in conjunction with passive
volition in modern versions of Jacobson's Progressive Relaxation
where patients are instructed to intentionally contract and relax
muscle groups to detect and reduce residual muscle tension.
Despite identification of biofeedback training with passive volition,
voluntary control actually involves flexibly shifting between these
modes as required.
Patients should use the strategies that work for them
who developed Autogenic
Training, believed that imagery
is the language the body best understands. He contended that an image
serves as a blueprint for physiological change.
Research on successful self-regulators has shown that they use diverse
strategies, including pictures, sounds, bodily sensations, feelings,
and abstract concepts. You should encourage your
patients to experiment with different strategies and then use the ones
that work. This communicates respect for them as collaborators and
increases their perceived self-efficacy.
Treatment protocols should incorporate current clinical findings
Both your conceptualization of a disorder and treatment design should
be guided by the clinical literature. This can be frustrating for a
clinician when research findings contradict conventional wisdom about
a disorder. The discredited sympathetic
arousal model of Raynaud's disease provides an excellent
The sympathetic arousal model asserts that stressors are powerful
triggers for Raynaud's attacks and that interventions that lower
sympathetic arousal will reduce symptom severity. Therapists who
subscribe to this model usually provide biofeedback to lower
sympathetic tone and teach stress management skills.
by Freedman and colleagues
has challenged the sympathetic arousal model's assumptions. Raynaud's
disease appears to be due to a "local fault" in peripheral
blood vessels. Cold and cold-related stimuli are more likely to
trigger vasospastic attacks than stressors. Temperature biofeedback
does not produce prevent attacks by reducing sympathetic arousal.
Finally, bidirectional temperature biofeedback with cold challenge
produces greater symptom reduction than stress management techniques.
to revise our models and treatment strategies may seriously reduce our
Treatment protocols should be personalized
Patients reporting a symptom, like hypertension, may have very
different psychophysiological profiles. Treatment should be
personalized to correct abnormalities: values that
are too high, low, show excessive or insufficient variability, or
recover too slowly.
Biofeedback training of astronauts to reduce motion sickness during
space flights illustrates this approach. A therapist monitors an
astronaut's biological systems during stress testing in a centrifuge
and identifies the systems that respond abnormally. In an actual case,
the major abnormality was increased skin conductance.
The therapist then designs a personalized training program to
normalize the astronaut's simulator performance. Research shows that
correcting abnormalities in the simulator reduces the risk of motion
sickness in space.
Personalizing treatment also means training patients to mastery
criteria. For example, you might provide temperature training until
your patient can achieve 95 degrees F without feedback. This is more
flexible than limiting training to five sessions of temperature
biofeedback whether the patient has succeeded or not. Patients have
different learning curves and learning styles.
Bidirectional training may produce the best outcomes
is often more effective than training in a single direction. This
advantage may result from increased training time, higher proficiency
standards, and learning to control more than one physiological
Bidirectional training has been advocated in both temperature and EEG
biofeedback. When teaching patients to handwarm to prevent Raynaud's
episodes, you might teach handwarming and cooling in the same or
successive sessions. In neurofeedback training to control pain by
increasing theta activity, ON-OFF-ON
protocols (theta increase-theta suppression-theta increase)
may produce the best results.
Explaining biofeedback to your patients
How do you explain biofeedback to your patients? Biofeedback
metaphors help define your patient's role in the training process.
I recommend two metaphors that portray biofeedback as a process that
teaches the patient skills using information about personal
"Biofeedback is like coaching a runner using a stopwatch."
This metaphor emphasizes the importance of coaching in improving
patient performance. "Biofeedback is
like teaching carpentry, not hammering." This metaphor
communicates that the purpose of biofeedback training is to teach
self-regulation instead of the mastery of a particular technique.
cursor over your answer. The correct answer will "glow."
training is most like
volition is illustrated by
biofeedback training, we recommend
best way to describe the feedback a patient receives about her
biological performance is
concept of biofeedback comes from ______ theory.
Now that you have completed this module, write down your favorite
biofeedback metaphor. Based on your own clinical experience, what
would you add to the discussion of the training process?
Carlson, J. G., Seifert, A. R., & Birbaumer, N. (Eds.). (1994). Clinical
applied psychophysiology. New York: Plenum Press.
Schwartz, M. S. (Ed.). (1995). Biofeedback: A practitioner's guide.
New York: The Guildford Press.
Shellenberger, R., & Green, J. A. (1986). From the ghost in the
box to successful biofeedback training. Greeley: Health Psychology
Wickramasekera, I. A. (1988). Clinical behavioral medicine: Some
concepts and procedures. New York: Plenum Press.