Did you ever have a mood ring? This type of ring features a clear plastic or glass “stone” with liquid inside that changes color as it changes temperature. Mood rings were generally sold along with a chart purporting to tell you what mood you were in, based on the color of the stone at any given moment. If you had a mood ring, did you ever intentionally try to get it to change color? If so, you’ve done biofeedback.
Biofeedback involves connecting a device’s sensor to your body to measure brain waves, heart rate variability, breathing depth, muscle tension, body temperature, or some other physiological indicator (Yucha & Montgomery, 2008). The gathered information is conveyed through a feedback machine that provides visuals or sounds that tangibly depict your physiological state. For example, a dot on the screen will buzz and move as you become emotionally or physiologically activated, and will become increasingly still as you relax. By being able to view a graphic real-time portrayal of mind/body activation, individuals can learn and practice various strategies for bringing their mind and body into an optimal state (Yucha & Montgomery).
That optimal state is the point of biofeedback. Biofeedback-assisted development of self-regulation skills and practices have contributed to symptom reductions in many types of mental health disorders (Schoenberg & David, 2014). Even children can do this; video game style biofeedback technologies, designed to engage children, have been successful in reducing anxiety and depression (Knox et al, 2011). A number of studies have found that biofeedback led to symptom reduction – but not cure* – among individuals with PTSD (Gapen et al, 2016; Tan, Wang, & Ginsberg, 2013).
To treat psychological trauma and associated symptoms, it is best to rely on efficient, well-tolerated research-supported treatments such as EMDR and PC, that have reliably been found to cure or substantially mitigate post-traumatic stress. Even so, there can be important roles for biofeedback. During treatment, biofeedback can be used adjunctively to promote the therapy client’s stability between sessions, as well as their ability to tolerate the trauma work during the therapy session. Furthermore, even after successful trauma healing, some people find that their hyper-arousal symptoms persist, and then biofeedback can be used to retrain the brain to a better habit of self-regulation.
You can pick up a mood ring for just a few dollars, but the higher quality biofeedback technologies cost somewhat more. Even so, biofeedback no longer requires an investment of tens of thousands of dollars for equipment that would only be owned by specialists. The technology is much more accessible now, and many devices are sufficiently small and inexpensive to be suitable for home use.
Biofeedback as a stand-alone is not going to cure PTSD. But for therapy clients – and former therapy clients – who are looking for ways to improve self-regulation, biofeedback has a lot to offer. We’ve come a long way from mood rings!
*A single study by Peniston & Kulkosky (1991) did find that biofeedback cured PTSD. However, that study had methodological issues, and the finding has not been replicated.
Gapen, M., van der Kolk, B. A., Hamlin, E., Hirshberg, L., Suvak, M., & Spinazzola, J. (2016). A pilot study of neurofeedback for chronic PTSD. Applied Psychophysiology And Biofeedback, 41, 251-61.
Knox, M., Lentini, J., Cummings, T. S., McGrady, A., Whearty, K., & Sancrant, L. (2011). Game-based biofeedback for paediatric anxiety and depression. Mental Health In Family Medicine, 8, 195.
Peniston, E.G. & Kulkosky, P.J. (1991). Alpha-theta brainwave neurofeedback therapy for Vietnam veterans with combat-related posttraumatic stress disorder. Medical Psychotherapy: An International Journal, 4, 47-60.
Schoenberg, P. L., & David, A. S (2014). Biofeedback for psychiatric disorders: A systematic review. Applied Psychophysiology and Biofeedback, 39, 109-135.
Tan, G., Wang, P., & Ginsberg, J. (2013). Heart rate variability and posttraumatic stress disorder. Biofeedback, 41, 131-135.
Yucha, C., & Montgomery, D. (2008). Evidence-based Practice in Biofeedback and Neurofeedback. Wheat Ridge, CO: AAPB.
Note: This post was authored by Ricky Greenwald, PsyD and Margot Reilly, LCSW.
It is not be entirely inaccurate to refer to biofeedback in the context of working with trauma. However, neurofeedback would probably be a more appropriate and helpful term to use in this context because practitioners use neurofeedback instruments to helps regulate overstressed or underactive brains. Neurofeedback has been shown through empirical research (Bessel, Joseph van der Kolk, Spinazolla, Ed Hamlin, et. al. 2016) to help calm the ‘fear driven brain (see: Sebern Fisher’s book). In my own personal experience, it is effective in helping to calm down the nervous system. However, when you calm down the nervous system, that’s when trauma memories will often emerge. The same thing can happen with yoga or somatic experiencing or meditation. Healing from PTSD is not just about ‘doing’ or engaging in a treatment modality. I think that keeping treatment objectives in mind is key. For example, where is this person in their healing journey? What does this particular client most need in terms of professional support and intervention? As Marylene Cloitre has demonstrated through her research, no ‘one size fits all’ treatment can effectively heal trauma. This has been Bessel’s argument for years. I like the idea of creating interventions that combine various modalities such as neurofeedback (to calm down the nervous system/help with emotional regulation) and then using EMDR to process and intergrate trauma. I just returned from the trauma conference in Boston where I heard Sebern Fisher speak informally about neurofeedback during a session with Bessel, Paul Frewen and Ruth Lanius. These trauma ‘experts’ are quite invested in their focus in neurofeedback as they see it as the new froniter. It is quite exciting, as neuroscience research advances, that we’re now able to develop a greater understanding of how develomental trauma effects the brain. Martin Teicher’s work is significant as well insofar as he has essentially, in my opinion, successfully deconstructed the DSM. His lab is showing how the development of most every psychopathology is rooted in childhood trauma. They can see this by measuring the size of the hippocampus and different brain structures for example, the differences between boys and girls. It becomes quite apparent that there’s something more going on than just genetics when we talk about chronic depression. The potential applications for neurofeedback and the implications of neuroscientific research that underlies it is quite huge. I believe that is why this is Dr. Bessel van der Kolk’s primary areas of interest now. My own take on these developments is slightly different, however. One of the limitations of neurofeedback is that is does not constitute ‘relational repair’. I do not see anything particularly ‘relational’ about sticking probes on a brain or sitting across from a computer screen. So for the purposes of working with complex trauma, I think neurofeedback definitely has its limitations.
Thank you for your comment. Some responses:
1. I used “biofeedback” because it’s a more general term, to include feedback based on body temperature, heart rate variability, etc. But this is not my area of expertise. Would the term “neurofeedback” cover those methods as well?
2. Another limitation of biofeedback is that it does not process the trauma memory. It can help people to manage and reduce their reactions to the trauma, but it does not heal the trauma via a memory reconsolidation process.
In response to #1, you are correct, Dr. Greenwald, body temperature and HRV are other measurements that are used, probably more commonly now due to a growing interest in polyvagal theory and the neurophysiological response as opposed to an emphasis on only the brain itself. Perhaps I mispoke because the field is expanding and evolving rapidly. I guess they call that biofeedback because you’re not placing probes directly on the brain when using those interventions.
This is how the connection is drawn on the new Boston Neurodynamics website: “HRV s one type of biofeedback, where the individual learns to alter his/her heart rate via breathing to improve self regulation and functioning. During the training, a sensor that detects the heart beat is placed on the ear or finger. The times between the heart beats are being calculated (coherence). When the coherence is high, the individual receive in real time a visual and audio reward.”
And, about HRV: “HRV stimulates the vagus nerve is connected to the brain stem and help the brain to switch from fight or flight mode to relax mode. The brain stem is connected to the limbic system, which helps the limbic system to calm.”
#2. I appreciate this comment. This is where I got stuck with my own trauma work. Neurofeedback helped calm down my nervous system but it didn’t consolidate the memories like EMDR. So, I do not honestly know if, perhaps, it has sonething to do with the client’s presentation. Some professionals draw a distinction between borderline personality disorder and others do not. I think it can get confusing because not everyone has conscious awareness of their traumas or has a willingness or ability to ‘go there.
Sebern Fisher’s work, for example, is really about ‘calming the fear driven brain’ and creating emotional regulation. That sounds a lot like DBT for BPD to me.
I think the following comments from Sebern Fisher gives one a sense of where she, as a neurofeedback practitioner and proponent, sees as the benefit of her work with clients: “I don’t think that Borderline personality disorder is a discreet disorder and I doubt highly that there is a genetic brain fault. I think of BPD as Complex Affect Regulation Disorder. The complexity comes from the fact that these are people whose early life experiences were terrible enough to leave them with developmental brain deficits -overstimulated fear circuitry in the limbic brain and sparse attachment experiences- that compromise prefrontal control of the sub cortical brain, just as this study suggests. This conspires to make it very difficult to shut down wild limbic firing leading to ambient and acute fear, rage and anger and shame ( self-hate) and all the cognitive and behavioral distortions that arise under these circumstances. They don’t just feel these things, which is bad enough. They are overcome by these emotions to such an extent that they become them. They are what they feel. They have no separate identity. If you look at the Lanius slide in my book (C.4) you will see another brain representation of this reality. She took fMRI scans of people with no history of developmental trauma and scans of those with serious early trauma and neglect. It will make you weep. There is robust blood flow in the self-system or the default mode network in those with no history. There is hardly any activation of this self network in those with severe developmental trauma.”
This has me wondering what Sebern Fisher means by ‘self networks’. Does this mean that in severely traumatized individuals there is no sense of self? Isn’t that the definition of BPD? No sense of self? Is this really the primary aims of ‘good’ neurofeedback or biofeedback is to create a sense of self? I imagine there might be more than one way to get there, but maybe neurofeedback or biofeedback is the most efficient means. Interestingly that is in direct contradiction with Frank Anderson’s belief that everyone has a SELF according to Internal Family Systems. It’s just a question of accessing it.
I am fascinated by the differences in various trauma treatment modalities and the process of trauma integration. I have personally found Internal Family Systems, Somatic Experiencing, Neurrofeedback, EMDR and now Flash EMDR all extremely helpful with my complex trauma – but each for different reasons. It’s still believe it’s the relational repair that is a key component regardless of what modality is chosen.
Thank you for responding to my original post. I also appreciate the ongoing dialogue and information you have posted about Flash EMDR. It has been validating as it has helped me make sense of my experience with this exciting new technique. 🙂