Hamiel and Rolnick prepublication to Schwartz and Anrdasik : Biofeedback fourth edition

1. Biofeedback and Cognitive Behavioral Interventions:
Reciprocal Contributions
Daniel Hamiel and Arnon Rolnick
This chapter discusses the integration of two major interventions; cognitive behavioral therapy
(CBT) and biofeedback. Integrating these two intervention approaches allows each to be utilized to their
utmost potential, and ultimately increases their individual viability.
The concept of a common law marriage can be used figuratively to describe the relationship
between biofeedback and CBT. A common law marriage is an informal or de facto relationship that is
legally recognized as a marriage even though no legally recognized marriage ceremony has been
performed. Similarly, CBT and biofeedback, “live together" de facto: both are short-term goal-directed
interventions that aim to maintain and reinforce their evidence-based status. Early in their relationship,
both approaches were related to learning theory and were heavily based on relaxation techniques and
desensitization. CBT handbooks today do not include chapters about biofeedback (cf. Dobson, 2001;
Bond & Dryden, 2005). The biofeedback literature, on the other hand, continues to recognize the role of
cognitive factors in biofeedback interventions. Nevertheless, to the best of our knowledge there is no
clear therapeutic protocol that suggests how to integrate the two methods.
The first part of this chapter discusses how biofeedback practitioners can be assisted by cognitive
behavioral concepts and techniques, while the second part demonstrates how cognitive behavioral
psychotherapists can use biofeedback techniques. The chapter concludes by considering which patients
should be directed to which intervention based upon their general attitude and presenting problem.
Biofeedback intervention was originally based on a learning theory model; however it soon
became clear that thoughts, emotions and interpersonal processes can affect the success of biofeedback
intervention. Several authors contend that from a theoretical point of view the efficacy of biofeedback is
at least partially due to cognitive factors (Wickramasekera, 2002; Meichenbaum, 1976; Holroyd et al.,
1984; and Penzien & Holroyd, 2008 for a newer perspective).
One of the reasons for integrating CBT principles into biofeedback is to help biofeedback
practitioners use this form of intervention to treat psychological disorders, and particularly anxiety. Whilst
there is no comprehensive model to guide biofeedback practitioners in dealing with anxiety disorders,
biofeedback has been found to reduce both state and trait anxiety (Hurley & Meminger, 1992; Wenck,

2. Leu & D'Amato, 1996). In addition, there is a growing body of research that suggests the combination of
biofeedback with particular elements of CBT is significantly effective (eg. Reiner, 2008).
PART 1: HOW BIOFEEDBACK PRACTITIONERS CAN INTEGRATE COGNITIVE BEHAVIORAL
ELEMENTS INTO THEIR PRACTICE
The suggested model should take into account the client‟s thoughts during the session and the basic
assumptions (sometimes hidden) that impact the client‟s views about himself and his ability to self-
regulate.
In a typical biofeedback session, the client‟s physiological responses are monitored on a single
screen. The proposed model considers the existence of two screens in each session – an actual screen
showing the client‟s objective physiological responses and a metaphoric screen, showing the client‟s
subjective experience as it is shared with the therapist.
While working with the physiological screen usually involves practice, working with the subjective
experience requires a significant amount of discussion. Deciding when and how to focus on the training
elements and when to focus on the verbal therapeutic discussion presents a special challenge.
One additional element of the integrated model is the therapeutic relationship and how it
influences the client‟s ability to self-regulate. According to Taub (1978), "perhaps the most powerful factor
influencing whether or not thermal biofeedback learning will occur is the quality of the interaction between
the experimenter/ therapist and the subject/patient, that is, the „person factor.‟” The new directions in
CBT, for example Schema Focused Therapy (Young, 2003), also emphasize the importance of the
therapeutic relationship. Hence, the proposed model maintains that the client-practitioner interaction is a
factor that warrants repeated consideration.
The proposed model introduces new elements to classic biofeedback training on two levels:
[1] Macro level: How to use CBT elements in the various stages of training.
[2] Micro level: How to use CBT elements within each session.
The Macro Level
Acquaintance and Educational Stage
The acquaintance and educational stage is usually considered the "psychophysiological profiling" stage,
in which the biofeedback practitioner measures a client‟s physiological responses to a variety of stimuli
(see Chapter 7). The model described below incorporates a cognitive conceptualization. The term
“acquaintance” is suggested for this stage of the model, because the practitioner becomes acquainted
with the client‟s psychological and physiological responses and the client is introduced to the
psychophysiological view of their disorder for the first time.
The client becomes familiar with the “dialogue” between themselves, the practitioner, and their
physiology, and can then learn how to associate physiological, cognitive, and emotional responses. The
rationale for this stage derives from the fundamental assumptions of the cognitive approach, which deal
with the formation and symptomatology of the problem. Many of those who seek treatment adhere to the
medico-biological model for “sickness”. According to this model, disease is managed as a result of the
physician‟s active role on the one hand, and the patient‟s passive cooperation on the other. The cognitive

3. approach, in contrast, is based upon the bio-psycho-social model, which emphasizes the crucial role
played by the client‟s thinking and active involvement in treatment (REF).
The acquaintance stage also involves education and instruction. The practitioner invests a great
deal of effort in explaining the problem and the intervention methods. Much of the explanation is through
psychophysiological demonstrations. The practitioner shows the client how specific external stimuli
influence physiological responses, demonstrating how behavior, thoughts, and imagination are a powerful
component in effecting physiological changes. These psychophysiological demonstrations are crucial in
establishing the client‟s motivation and trust in the process that is about to be embarked on.
Client motivation is also reinforced during the psychophysiological intake interview, when the
practitioner gathers information pertaining to the client‟s reactiveness and recovery rate. The trainer
shares this information with the client. Physiological measurements are taken and correlated with the
processes the client has gone through, thus establishing a therapeutic triangle of client, practitioner, and
device.
Each component in the triangle “assesses” the client‟s condition. The device reports objective
readings and changes, the client reports on subjective experience, and the practitioner helps integrate
between the two. This triangle enables clients to understand themselves better and to identify avenues for
improving both their physical and emotional condition.
Behavioral Techniques Stage: Acquiring Self-Regulation
Biofeedback is aimed at helping the client self-regulate and balance their physiology. Trial and error, of
course, is a basic principle of learning theories, and biological signal feedback is clearly a major tool in
trial and error. Nevertheless, it is postulated that the client should be offered assistance via the teaching
of relaxation techniques. First, muscle relaxation and breathing techniques should be taught,
representing the B in CBT, namely behavioral techniques. Though practice is the key for success in this
stage, a cognitively oriented practitioner will always listen to the client‟s cognitions during the training
process. What is the client‟s internal dialogue with his body? Does the client believe in their ability to train
their physiology? Does the client feel betrayed by their body? Failures in the self-regulation process
should be used as an opportunity to learn about possible cognitions that should be observed, discussed,
and modified.
Cognitive Techniques Stage: Acquiring Self-Regulation
Most of the biofeedback literature focuses on teaching behavioral means to achieve relaxation. Yet
cognitive techniques can be very useful as well. Autogenic therapy – the repetition of sentences about the
body's relaxed state – has a long history of assisting with self-regulation. Meichenbaum's (2007) Stress
Inoculation Technique (SIT) is a natural addition to autogenic therapy. In SIT, subjects are taught to
substitute negative self-statements about their ability to relax with positive expectations by repeating
positive self-statements.
Sometimes the practitioner might find that the client is having difficulties reducing physiological
arousal. This is the time to help the client understand the automatic thoughts blocking acquisition of
relaxation techniques. According to the ABC model, the source of an individual‟s emotional, physiological
or behavioral Consequences is not the Actual events but rather the individual‟s thoughts and Belief
system. Using the ABC model, we can help the client identify automatic thoughts and beliefs that should
be addressed in order to achieve self-regulation.
A "third generation" of cognitive interventions has emerged in recent years. While mindfulness-
based stress reduction was clearly the frontrunner in biofeedback practice for more than 20 years,
Acceptance and Commitment Therapy (ACT;Hayes, 2006) interventions unmistakably add an additional

4. level to the self-regulation process. One of the main premises of ACT is the understanding that trying too
hard is unproductive. Biofeedback practitioners can use this principle to help the client learn to “let go”
and “not try too hard.”
Generalization Stage
After a client has learned self-regulation techniques under optimal conditions, they must learn to
implement them outside the clinic. The challenge is to relax under less comfortable conditions. Altering
the conditions is carried out gradually. At first, the client practices while reclining in a comfortable chair,
followed by sitting up normally in an office chair, and finally standing up. The client's mental state should
also be more similar to normal conditions. The client is trained to remain alert and still stay relaxed, to be
involved with the environment without being overwhelmed by its demands. Using the cognitive
perspective, we ask the client what external and internal conditions help or thwart self-regulation. The
practitioner then introduces these elements to aide generalization.
Exposure and Desensitization Stage
CBT practice for anxiety disorders usually involves two classical interventions: desensitization and
exposure. While biofeedback procedures do not necessarily include such interventions, the proposed
model suggests integrating such procedures into biofeedback practice.
The cardinal principle to remember during this stage is to achieve a state of relaxation while
simultaneously recreating a real or imaginary stressful scenario. For example, a client who is afraid of
speaking in front of an audience will be asked to prepare and deliver a speech while continuing to
regulate their physiology. An instruction to maintain physiological readings at a low level or to lower them
as soon as they begin to rise, will be provided. A client who is anxious about taking tests provides another
example. The practitioner can create test scenarios during the therapy session and train the client to
reduce stress during a test. At times it may be necessary to recreate an actual test scenario, but usually
in vitro re-creation is sufficient.
Thus we can train clients to implement and practice relaxation techniques during difficult
situations, whether in vivo or in vitro. Clients can advance to the final stage only after they acquire and
learn to implement control abilities in stressful situations as well.
Weaning and Termination Stage
All forms of treatment are geared towards enabling clients to separate from and leave the supportive
environment. Clients who sought out biofeedback because they were not able to regulate their tensions
acquire the ability to do so without the intervention. It is also assumed that some of the client‟s
psychological problems will emerge during the transitional or separation phases. Therefore, working
through this stage while the client is still in treatment provides the opportunity to recreate difficulties
pertaining to this process. In biofeedback therapy, termination involves “weaning” the client off the device
as well, thus enabling the client to gain control over his psychophysiological responses without direct
feedback. During this stage one of the client‟s task is to link internal physiological clues with
psychophysiological readings and then to construct a replacement in the form of a habitual internal
feedback. Hence, this stage deals with the ability to generate the relaxation response even without the aid
of the device. To achieve this goal, the practitioner measures the physiological variable without displaying
the feedback. The client is asked to “guess” his physiological status as well as to try to estimate whether
the line of the graph is sloping upward or downward (discrimination training; Andrasik & Blanchard, 1983;
Gainer, 1978). This stage is marked by the client‟s deliberations over whether the time has come to

5. terminate treatment and whether the treatment has achieved its goals. Questions are raised pertaining to
dependence and independence. Moreover, the client must cope with the loss of fantasies that “all my
problems will be solved” or “I will not get tense anymore.” Indeed, the client must relinquish some of his
basic assumptions regarding constantly being in control and feeling good. We expect that during this
stage of treatment, the emphasis will be on the verbal component of the psychotherapeutic dialogue.
(See Lynn & Freedman, 1979, for a discussion of other ways to facilitate generalization and transfer of
training.)
The Micro Phases: Session Structure
As cognitive and emotional factors are introduced into biofeedback training, the structure of the sessions
must be transformed from trial and error technical training to a more sophisticated process in which the
client‟s cognitions are identified and discussed. Hence, each session is divided into different phases, with
each phase using the biofeedback equipment differently. The idea is to use the sensors to take
measurements several times during a session. Each biofeedback event is then accompanied by a period
dedicated to verbal discussion about the subjective and objective results of the psychophysiological
exercise. Hence, the verbal dialogue is used to enhance the physiological changes and vice versa.
Beck (1995) suggests that CBT sessions should be divided into a number of phases: brief update
and mood check, transition from previous session, setting agenda, homework review, discussion of
agenda issues, homework assignment, summary, and feedback. The biofeedback literature is less
consistent regarding this issue. Some writers describe the various sensors used to take measurements,
the feedback screen, and other equipment in great detail, however the session format is often left
unmentioned. This may explain why so many laymen believe that each biofeedback session consists of a
full hour with the client sitting in front of the screen trying to control some line graphs. In contrast,
Andrasik and Schwartz (see chapter 6) describe a possible format for headache sessions: adaptation,
baseline, self regulation, stimulation, biofeedback, reassessment of self-regulation (see Andrasik &
Blanchard, 1983, as well). We propose the following stages for a biofeedback session enhanced by CBT
principles:
Welcome, homework discussion, and agenda setting
Self-regulation ability evaluation
Sharing phase I
Learning to practice
Sharing phase II
Relaxation, reframing and creation of alternatives (RRCA)
Homework assignment and session termination

6. Table: Format of integrated Biofeedback training assisted by CBT elements
Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Phase 7
Evaluating
Biofeedback Learning &
Self - RRCA
exercise part practicing
Regulation
Ability
Verbal/ Welcome,
Homework &
Cognitive homework, Sharing I Sharing II
termination
part agenda
Duration
3-5 4-7 8-15 11-14 4-7 6-8 3-5
(mins.)
Welcome, homework discussion and agenda setting
Each session should begin with some type of welcome from the practitioner. Typically, the client begins
by describing his or her feelings and symptoms. In the proposed approach, it is suggested that the
practitioner postpone this evaluation phase for a few minutes. Instead, the practitioner should describe
the session agenda and ask the client about the homework assignment. Beginning the session with the
agenda conveys a clear message that the program is well structured and has a target to be achieved.
Evaluation Phase
First the client completes a five minute biofeedback exercise aimed at evaluating the balance between
"calming forces" and "disturbing forces." This evaluation is, in fact, a brief ritual during which the subject
tries to relax while simultaneously focusing on issues that are bothersome. The EDA sensor is most
suitable for this exercise because it is very sensitive to slight emotional changes.
The client is given the following statement: “Your aim during this phase is twofold: to try to
influence your physiological reading towards greater self-regulation and at the same time to pay attention
to inner processes that might keep you from relaxing.” The advantage of this wording is that it enables the
client to avoid experiencing stress in the case that they do not succeed. The client is able to comprehend
that they are undergoing a process of observation and not simply a process aimed at “straightening the
lines.” In a way, this is a process of acceptance, which is a main component of CBT and increases the
potential to make a change.
During measurements, a client may sometimes feel that they must provide explanations for what
is happening to them and why they are unsuccessful. The biofeedback practitioner should encourage
them to follow through with the practice and not feel the need to explain performance. The following
recommended phrasing has been found effective: “While practicing you may learn some important things
about yourself, and possibly you will want to articulate them. It is better that you place these thoughts into
a „basket‟ or on a „clipboard‟ in your mind so we can discuss them immediately after the practice.”

7. Sharing Phase I
The first sharing phase is designed to facilitate interaction between the client and the practitioner. Its
purpose is to gain some insight into the client‟s internal processes. The client is asked to tell the
biofeedback trainer whether they felt they were able to relax and what was going on in their mind during
the previous exercise.
On the superficial level, this is the client‟s way of telling the therapist what helped with the
regulation of their physiology and what hampered the process. On a more profound level, a highly
valuable therapeutic procedure commences during this stage. From birth, our processes of self-control
are constructed through the dialogue between the mother and her baby. The baby is overwhelmed by
physical and emotional discomfort and by the experience of incompetence. The mother “listens to her
baby‟s complaints” and the mother provides comfort by responding to the pain. The act of sharing
between client and practitioner resembles this very primary process between child and caregiver.
Research indicates that the interaction between client and practitioner can serve as a “curative factor.”
Taub (1978) posited that when a “warm” therapeutic dialogue exists between client and practitioner, the
client is better able to control physiological variables such as expansion or constriction of blood capillaries
(skin temperature measure).
The sharing phase emerges in a variety of ways during the stages of treatment. The biofeedback
serves as a trigger for discourse and sharing of thoughts between client and practitioner. The practitioner
should not show the client the results immediately after completing the practice so as to allow discussion
of the client‟s subjective experience to take place. The client is questioned regarding his feelings during
the session: Did they feel relaxed or tense, and at what stage? What was done to make the graph
descend? What caused the graph to ascend? Observations indicate that clients frequently do not
evaluate the results correctly. Often they perceive their performance as good when their actual relaxation
capacity is low. Alternatively the graph may depict a good rate of relaxation but the client‟s subjective
evaluation differs. This lack of agreement is significant from a diagnostic point of view and can serve as a
trigger for discourse. The table below describes the possible significance of four theoretical cases.
Table: Subjective and objective assessment (with EDA –arousal level)
.
Descending graph Ascending graph
Subjective Internal and external indicators are May be seen in cases where clients
experience in accord and in the desired are convinced they know how to
of relaxation direction. Practitioner tells client that achieve relaxation, or alternatively in
they have an inherent ability to cases where clients are unaware of
relax, and that aim of the treatment the extreme state of stress they are
is to learn to apply this ability under experiencing. It is very important to
conditions of stress. explain to such clients that this may be
a consequence of a lack of ability to
The client is also informed that their
be fully aware of their stress.
objective and subjective data are in
Therefore, one of the purposes of the
accord; hence feelings can be
treatment is to develop awareness of
trusted.
their state of stress.
Subjective Occurs often with clients who have a In this condition, the negative results
experience negative perception of their body concur. In such situations, relaxation
of stress control abilities. These people quite abilities and self-control need to be
often have mistaken assumptions improved.
and assessments of themselves. We The practitioner should further tell the

8. can make use of this gap to point out patient that now, perhaps for the first
their thought distortions and time, they are receiving objective
gradually teach them to trust their corroboration for their ongoing inner
abilities. experiences of stress. For the first
time they have a way to change and
evaluate their progress on a continual
basis.
As treatment progresses, clients learn to better link their inner experiences to the physiological
measurements. The practitioner should devote time to discuss with the client what helped as well as what
hampered their ability to achieve balance. In time, these discussions should lead the client to deal with
perceptions and thoughts that might interfere with their ability to achieve balance.
Working Phase – Learning and Training
In contrast to other psychotherapy approaches, CBT combines insight and work. This is what makes the
integration of biofeedback and CBT intervention so natural. The basic assumption is that in most cases,
clients‟ difficulties stem from conditioning or automatic linkage between certain stimuli and the stress
reaction. Our model suggests that the primary way to deal with these conditioned responses is to learn
relaxation and alternative thinking methods to produce a “counter response” to the stress and anxiety.
Learning and training are required to “break” conditioned habits and create new habits or alternative
means of response. This can be time-consuming and requires patience. The behavioral aspect of
biofeedback therapy is crucial during this phase. The practitioner must insist on pursuing the training and
not comply with the client‟s request to “talk about it.” We encourage feedback about the client‟s relaxation
technique – but in a way that does not hamper the training.
Sharing Phase II
After the intensive training, the client should share with the biofeedback practitioner what else went on in
his mind during practice. Several points may arise during this phase. The client may be too embarrassed
to relax in the presence of the practitioner (see chapter by Schwartz in this book ). He/she may also
speak of being frustrated about not being able to fulfill the assignment of relaxing. On the other hand, the
client may reveal, for the first time, how eager he was for a chance to “let go” and how much he missed
having a warm and tender significant other. All these possible issues can be discussed and elaborated in
sharing phase II
Relaxation, Reframing and Creation of Alternatives (RRCA)
In the RRCA phase, the biofeedback device can be used as a tool to facilitate attitude change or
reframing. The client‟s ability to alter their behavioral and thought patterns improves significantly when
they are no longer anxious and stressed. The consensus is that individuals are more flexible in their
thinking and ready for change when they are in relaxation mode. Wickramasekera (2002) argued that
biofeedback can alter people‟s hypnotic level - the level at which they can be affected by suggestions or

9. statements made by the therapist or by themselves. Costa and McCrae (1986) suggested that
biofeedback may increase a client's openness to alternative cognitive explanations and perception of
clinical symptoms. In this phase, therefore, the client uses the biofeedback device to train, but as a
routine prompt to achieve some degree of relaxation and openness of mind. The client is asked to close
their eyes and listen to the auditory feedback of the device or set of devices. This auditory feedback may
serve as a lullaby that helps deflect the client‟s focus from current anxieties.
In this phase, the material gathered at the beginning of the session is reframed. Reframing
involves presenting some alternative assumptions about oneself and the world, thus allowing for
alternative solutions. This reframing can occur with or without the practitioner‟s help. At first the client is
asked to enter into a relaxation mode without the practitioner‟s help by just letting go while listening to the
device feedback. Then he/she is advised to use one of the methods that increases HRV. Though the
client can choose respiration to increase his HRV, we suggest using the HRV sensor to cultivate positive
feelings. McCraty and Childre (2004) and Bhat and Bhat (??) have argued that optimal wellness and
success in HRV biofeedback require the conscious and systematic cultivation of positive emotions and
joyfulness. It is therefore advised that HRV feedback be used as the main tool in this RRCA phase.
Homework Assignment
Although homework itself is not conducted during the session, it is an integral part of the therapeutic
approach. The fundamental assumption of the technique is that changing how a person regulates himself
requires a great deal of training. Therefore it is of vital importance to practice outside the clinic and as
frequently as possible.
Through the homework assignments, the advantages of the integrated approach emerge in two ways.
First, instead of asking clients to write a list of symptoms at home, they are asked to listen to their
internal dialogue about their symptoms: What thoughts served as a trigger for the physiological change?
What thoughts were caused by the physiological change? Identifying both types of thoughts at home
enables the client to challenge them in later sessions and leads to improved self-regulation.
Second, the homework can help identify whether the client has given up on practicing and
sometimes on therapy altogether. From a CB perspective, when a client fails to do homework there is
usually a thought or dysfunctional assumption behind this. Identifying and challenging this assumption
may pave the way to successful intervention. Without this cognitive intervention, practitioners and clients
often give up on the intervention when the client fails to do their part.
Here is an example. A client who suffers from hypertension is not practicing breathing at home
even though sessions are regularly attended and biofeedback training is proceeding well. Without a
cognitive approach in mind, the practitioner might say, "It's up to you. If you do not practice, our
intervention will not be useful." Taking the cognitive approach, the practitioner will ask the client to monitor
thoughts at home, mainly those related to practice (as described above). This process may reveal that the
client has some perfectionist assumptions, such as "if I am not doing it exactly as I have been asked to
do, it‟s worthless." As the client skipped some of the training, the belief that there is no need to continue
arises. The practitioner should challenge this assumption and help the client continue practicing at home.
Termination stage >>

10. PART 2: HOW COGNITIVE BEHAVIORAL THERAPISTS CAN INTEGRATE BIOFEEDBACK INTO
THEIR PRACTICE
In the past, physiology was neglected in psychotherapy, and to a certain extent this remains true
today. This trend began when Freud abandoned his project aimed at combining neurology and psychiatry
(Gay, 1998) and continued when cognitive therapists ascribed an exclusive position in therapy to
thoughts (Beck, 1995). Yet more current works by Servan-Schreiber (2005) and Ledoux (1996)
emphasize the special characteristics of the emotional brain. This brain is responsible for emotions and
physiology, but often functions separately from the cortex and from cognitive influences. Hence, the
physiological component in therapy becomes very important.
Under the assumption that physiology plays a major role in mental health, this section focuses on
the role of biofeedback as therapeutic agent in a CBT setting. The role of biofeedback and physiology in
therapy has recently become more natural with the reinforcing influence of the third generation of CBT.
This new therapy trend introduced the role of mindfulness (Hayes, 2006) and controlling attention in
therapy (Wells, 2000). In this section we show how biofeedback is relevant to these developments,
theoretically and practically.
Rationale: Biofeedback as Training for Meta-Control
Individuals seek out therapy because they are unable to stop or control their suffering, whether physical
or mental. Naturally, they believe that regaining their control will put an end to their suffering. Rather than
directly trying to stop suffering and get the individual back in control, CBT challenges and changes the
concept of control. CBT proposes the notion that a person's problem is not with reality (i.e., not being able
to stop the suffering) but rather with the way he or she perceives this reality (the belief that the person
should stop the suffering to go on with life - ABC model, above). The goal of therapy is to persuade
patients to give up their dysfunctional basic assumption that life should go the way they want or expect it
to go. CBT seeks to provide a more sophisticated concept of control, that is, the freedom to relate to
one‟s situations rather than trying to control them completely (something that is not always possible).
Individuals should be liberated from the (western) addiction to achieving everything they want. According
to the CBT concept, control is the freedom to make a decision about whether to try to change actual
reality or whether to take on the more challenging task of accepting reality when necessary. This ability is
referred to as "meta-control."
Relaxation can serve as an important step toward achieving acceptance and "meta-control."
Therapists like to help their patients choose between holding on (remaining tense to make a change) and
letting go (relaxing and accepting). Yet this choice might be threatening for a patient. In contrast to
relaxation, hyper-vigilance and tension serve a patient‟s need to feel in control, which is very hard to
abandon. Biofeedback can provide an exciting solution to this obstacle. Relaxation using biofeedback
involves experiencing control (though it is actually an act of giving up), and is therefore much less
threatening. Indeed, biofeedback is unique in that the individual experiences a sense of control while
actually letting go. This is precisely the meaning of "meta-control," as mentioned above.
In CBT patients learn to give up their basic dysfunctional assumptions related to their need for
control. The therapist persuades the patient to distract themselves from things that used to make them
feel more responsible and more in control (being preoccupied with worries, for example). Feeling in
control based on continuous worrying is an illusion, but is still not an easy feeling to let go of. In therapy
patients are exposed to scenarios that create the most threatening state of mind for them - relinquishing
the wish for complete confidence. To do so, patients must abandon the bodily state of alertness that they
use to maintain the illusion of being in control. By going through such a process, the patient eventually
gives up the need for absolute control and the illusion of having it. In return the patient achieves the best

11. type of control possible in the actual situation. Biofeedback plays an important role in achieving this "best
possible control" experience, that is, "meta control."
Conditioned Emotional Triggers: What CBT Cannot Resolve
Dysfunctional basic assumptions can usually be addressed by CBT. However, direct and
increased sensitivity to external triggers related to the emotional brain (above) often cannot be influenced
by the cortex and therefore should be treated by a system other than the cognitive one. This sensitivity is
conditioned and very much connected to physiology.
The integrated CBT and biofeedback (physiological) intervention relates to each individual as a
whole, including both cognitive and emotional-physiological dimensions. This proposed intervention
attempts to respond to the challenge posed by direct, non-cognitive, emotional, and physiological
sensitivity by adding a physiological dimension to therapy. As in the first part of this chapter, two different
views of the intervention are presented. First the general role of biofeedback in the different stages of
CBT is discussed, and then its practical application in the sessions themselves is considered. Each
subsequent CBT stage is needed if the previous one proved insufficient to solve the patient's problem
reasonably.
Stages in Biofeedback-Assisted CBT Intervention
Stage 1 - Attempting to stop the suffering: At this stage of therapy, the patient has already identified
the catastrophic thoughts that accompany suffering but they are not yet being effectively challenged. The
therapist assumes at this stage that the patient does not really believe in the catastrophic thoughts, which
serve other purposes, and therefore has no need to challenge them. The patient is aware of the poisoning
effect of these thoughts and has learned not to cooperate with them. Biofeedback at this stage helps
deflect the patient‟s focus from the thoughts and relieves suffering by reducing the bodily stress that
accompanies these thoughts. This step reflects the normal role of biofeedback as a tool for improved
control over the body. By reducing bodily stress, the patient can shift their focus from the "thinking about"
mode to a more positive and active coping mode. This is sometimes sufficient to stop the suffering.
Stage 2 - Attempting to reduce suffering by changing a patient’s way of thinking in order to
change the resultant destructive behavior. Changing the patient‟s thinking is the hard core of most CB
interventions. At this stage, the therapist tries to challenge the patient‟s dysfunctional basic assumptions
which are the source of suffering, and to shift the focus of attention from fixed suffering to functionality.
The patient learns to accept that direct efforts to stop the suffering are insufficient. Biofeedback helps
patients learn and use the concept of "meta-control" to achieve this goal.
The therapist helps the patient understand the reasons they are stuck by negative and
catastrophic thoughts. Together they try to discover the hidden reasons ("meta-cognitions" according to
Wells (2000)) that make the patient focus on the negative thoughts. One major hidden reason is the
concomitant experience (or rather, illusion) of taking control over one‟s situation by constant thinking or
worrying. The therapist and the patient attempt to discover dysfunctional basic assumptions that make the
patient believe in the catastrophic thoughts. For example, if a patient believes that to feel safe they need
a strong supportive figure, when alone they might be afraid of “falling apart.”
The patient may try to avoid being alone, and this effort may be expressed physiologically. CBT
that works on cognition alone will not be sufficient because of the strong negative conditioning usually
involved in such a case. Here, the role of biofeedback is to release the physical tension preventing the
patient from thinking realistically. Bodily alertness and hyper-vigilance are related to narrowed attention
and a polar way of thinking, which may be effective in emergencies but not under normal circumstances.

12. Biofeedback and physiological techniques in general help patients expand their attention and
open them up to more flexible ways of thinking and behaving. They serve to release bodily tension from
emergency mode.
Stage 3 – Directly Experiencing Emotions and Sensations: When an individual cannot control their
behavior due to the intensity of the negative emotions, a third stage is needed. Changing cognitive
assumptions, releasing physical tension, and defocusing are not sufficient. Some forms of suffering are
resistant to disappearing.
At this stage, the patient is taught to overcome judgmental thinking that feeds negative
uncontrolled emotions and is related to the past. The patient is directed to remain focused on the difficult
emotions and sensations of bodily stress. The patient learns how to enhance skills to remain in the
present (mindfulness) with the suffering (the emotions and sensations) and to deflect the focus away from
negative judgmental thoughts (the past) and anticipatory anxiety (the future). Bodily sensations reflect the
most pure experience of the present. Hence biofeedback, which helps connect the patient to their body,
plays an important role in developing this "present-orientation skill."
By teaching the patient to recognize bodily changes, partly control them, and accept the fact that
control is only partial, biofeedback helps the patient to keep from returning to a focus on the negative
thoughts (usually judgmental self-evaluation). Consequently it helps minimize the emotional and
physiological impact on suffering and behavior. The amount of suffering that remains probably is
necessary to illuminate some problematic issues the patient still needs to address.
Integrated biofeedback-assisted CBT interventions are recommended primarily for treating people
with anxiety disorders that are marked by elements of hyper-arousal and “fear of loss of control” or states
of uncertainty. These characteristics are associated with many other psychiatric disorders, such as eating,
mood, sleep, and impulse-control disorders. The following is a clinical demonstration of the potential
advantage of using biofeedback techniques in CBT. First, the use of biofeedback in the psycho-
educational part of the therapy session is described, followed by a demonstration of the core of therapy.
The Use of Biofeedback Techniques in CBT
Experiential Psycho-education
The psycho-educational part of CBT can be very influential, and, for some patients, this accounts for most
of the change effected by the therapy. In simple CBT, the therapist uses the cognition itself to
demonstrate some cognitive distortions and relevant information. However, this remains on the verbal
level, which in turn is affected by the patient‟s cognitive distortions and subjective perceptions. On the
other hand, integrated therapy can help the patient directly experience various effects of their thoughts
and expectations. Here are some examples:
Demonstration of “fight or flight response”- Eliciting any surprise response from patients enables
them to experience the normality of such a response, which they otherwise would have perceived as
some form of personal weakness. In such a response, the EDR line graph ascends rapidly and then
slowly descends. One of the major problems in dealing with anxiety is the patient‟s response to their
symptoms. The patient becomes anxious and sometimes depressed because of this anxiety.
Normalizing this anxiety by demonstrating the "fight or flight response" and other mind-body
connections can alleviate some of the patient‟s worries about their own responses and symptoms.

13. Demonstration of “anticipatory anxiety”- The goal of this intervention is to challenge the patient‟s
misconception that being ready in advance will help. The therapist asks the patient to get ready for
the same kind of "surprise" generated by the "fight or flight" response demonstration, but this time to
try to suppress the response in advance. The therapist counts from 10 to 0, and then presents the
previously used stimulus, while assessing arousal level throughout the entire process. The therapist
then shows the patient the high price of arousal that is paid for being prepared. This over-
preparedness is a very common component of many psychopathologies. Anxious patients are
constantly on the alert in order to be ready for possible future disasters. They are preoccupied with
thoughts related to the past and worries about future disasters. This intervention also demonstrates
very nicely the concept of "unnecessary suffering." Relinquishing this tendency toward being
prepared in advance will help the patient avoid accumulating unnecessary stress and worries.
Demonstration of “thought-physiology-emotion connection”- According to CBT, an event is not
the reason for the consequences, but is rather due to the person‟s thoughts or the belief system. The
following biofeedback demonstration can illustrate this unequivocally. The therapist says: "Try to
make the line graph descend, faster… faster… I am disappointed in you…" The therapist can also
“threaten” the patient with a difficult math test.
This simple exercise can also demonstrate the notion of "meta-control." Trying too hard will not help
the patient control their physiology. The physiological recordings cannot be controlled until the patient
gives up or relinquishes the desire to relax or achieve balance.
Understanding psychosomatic phenomena –This can be demonstrated by asking the patient
something that causes an internal conflict between the wish to please the therapist and the resistance
to the request. For example, the therapist might say, "May I ask you a personal question?" In a group,
the therapist might say the following to one of the participants: "Will you straighten up the room at the
end of the session?” The patient will probably say "yes," even though their body keeps saying "no,"
expressing all real feelings via physiological changes. by increased arousal level, increased muscle
tension, and lowered peripheral temperature. The therapist then explains that saying “no” too often
will bring about a continuous somatic response, or psychosomatic phenomenaSuch a demonstration,
in contrast to a purely theoretical explanation, has the potential to give the psychotherapy a real push

14. by offering a rationale for psychosomatic symptoms and the motivation to look for the mental source
of such symptoms.
Comparison between practicing biofeedback with eyes open and eyes closed – If a patient performs
better with their eyes open, this may signal an added need for control (very often the case with
children). Problems in controlling biofeedback measures with eyes open may indicate performance
anxiety and sometimes a coping model of avoidance. In such cases, the therapist should train the
patient in biofeedback therapy with eyes open while remaining aware of the patient‟s performance.
On the other hand, practicing biofeedback with eyes closed can provide exposure for a patient who
has difficulties performing under uncertainty. This kind of exposure can be a particularly important
experience for patients with anxiety disorders.
Demonstration of the power of acceptance and distraction – As described above, an important
element in CBT involves relinquishing the tendency to judge oneself through constant evaluations of
success. Using biofeedback to distract patients from this constant evaluation can help them accept
and evaluate results almost without self-judgment. During biofeedback practice, the patient is trained
to distract themselves from the direct goal of success. This usually improves performance. The
patient learns to give up on a coping model that focuses on results and learns to enjoy the process.
The patient is trained to be aware of their performance, to accept it even if they are not satisfied, and
to continue to do their best in a balanced and enjoyable way. The patient is taught the importance of
distraction from judgment and learns to focus on practical evaluation of performance, as well as to
decide what action to take. Both criticism and compliments of the patient‟s performance during
biofeedback will most probably harm performance. On the other hand, acceptance of what cannot
change for now (unavoidable suffering in the present) will maximize performance.
Understanding the activity of the autonomic nervous system (ANS) – The HRV as a measure of ANS
balance level is shown by the ratio between the activity of the sympathetic and the para-sympathetic
nervous systems. biofeedback software settings that provide direct feedback about the patient‟s
balance as reflected in the ratio of these two systemshelp patients learn that the goal is usually not
relaxation but achieving a balanced state. The understanding that relaxation is not the goal is
helpful to patients who fear losing control as balancing the ANS allows for control, sometimes without

15. the feature of relaxation . An increased belief in ability to control provides the patient with the
confidence they need to expose themselves to previously avoided "risky situations" .
Demonstrating the difference between a baseline state, which usually indicates low ANS balance,
and the results of short biofeedback intervention (biofeedback with slow breathing or guided imagery)
– Using this method, it is usually easy to generate a quick change. Low HRV usually co-occurs with a
coping model of alert hyper-vigilance or a simplified conception of control. "It would be awful for things
to happen against my will, so I have to remain alert." Simple physiological intervention such as slow
breathing with the help of biofeedback can be used to demonstrate how easy it is to relinquish this
attitude and increase HRV and balance level, at least for the present time.
The same can be demonstrated very nicely using EMG. Patients hooked up to EMG sensors on
their extensor or flexor muscles usually exhibit high EMG levels, sometimes even above 20mv. For
many patients, however, asking them to relax their muscles and sit comfortably is sufficient to monitor
a dramatic reduction in muscle tension (below 1mv)! So after a short intervention, excessively high
readings (usually a low balance of ANS at baseline) can turn into much more balanced ANS readings.
The simultaneous use of two sensors (modalities) can reveal some very interesting information about
an individual‟s coping model. Very often we find a contradiction between measurements in two
different modalities. For instance, during guided imagery, a child with encopresis describes an
"accident" while in class. As predicted, his peripheral temperature decreases, but his EDR also
decreases! When asked what he is doing in class during the "accident", the child answers, “I am
pretending I am not there!” The child is dissociating, or in CBT terms, using a coping model of
avoidance. In this case the child is not avoiding the situation itself but rather dealing with the situation.
Our conclusion is that as long as an individual‟s physiological modalities are not working in the
expected direction, he or she is still paying a physiological price for some unfinished psychological
issues or a non-adaptive coping model. Biofeedback can serve as a beacon lighting the way for
psychological intervention.
Core of therapy
In stage 1 of the therapy, the task is to of stop suffering. Here the role of the biofeedback in the core of
therapy is clear. The therapist trains the patient to better control physiological elements using different
biofeedback modalities. Specifically, the patient is taught to attempt to control symptoms directly, such as
headache and muscle tension, breathing problems due to stress, extreme sweating, cold hands, panic
attacks, and tremors.
In discussing the stages of CBT therapy above, the importance of controlling attention was
described. This skill is relevant in all stages of therapy. The easiest biofeedback modality to use for
enhancing this skill is the EDR. Using different kinds of meditation or mindfulness techniques, the
patient attempts to minimize distractions, reduce bodily responses to destructive ideas, and decrease

16. arousal level. These parameters can easily be monitored with the EDR modality (and others as well),
hence making it possible to check the effectiveness of mindfulness and meditation techniques.
Paying attention to the body is an important element in mindfulness techniques. Eastern
philosophy and CBT share the notion that focusing on the present releases individuals from their fears
and worries. An individual cannot become anxious unless past negative memories and worries about the
future are combined. Focusing on experiencing the present can prevent this. Using biofeedback to
increase awareness of body sensations can support this process. Awareness of bodily sensations helps
distract the individual from thoughts that are not related to the present and therefore helps them
experience the present. This training is critical in the third stage of therapy described above.
Exposure is the main goal of each stage of CBT: being exposed to life's tasks and to challenges
the patient was trying to avoid. Biofeedback can support this process in several ways:
a. Demonstrating the exposure principle: The patient needs to learn that avoidance is not the
only way to reduce anxiety. Paradoxically, exposure does this much better, and the effect
remains for a longer time. The EDR and EMG line graphs descend (and the temperature rises)
with exposure (de-sensitization or even flooding type of exposure), demonstrating habituation,
while the patient keeps a focus on the source of their negative emotions. The therapist can use
sounds, pictures or movies, or can create a scene related to the patient's source of negative
emotions. This is appropriate for treating phobias, and can also work very well with exposure to
problematic thoughts, as in Obsessive Compulsive Disorder. For the patient, monitoring their
bodily sensations during exposure is like looking inside themselves. The screen presenting the
new balance in the patients‟ physiological responses convinces the patient that the anxiety has
been resolved even before it is noticed personally.
b. In-vivo exposure can often be implemented in the clinic (e.g., when treating fears related to
blood tests, injections, blood pressure measurement, or insects). The therapist prepares the
patients for an increase in stress and arousal level at the beginning of exposure, and later
habituation. Often, however, exposure occurs without any anxiety emerging. The patient
experiences the paradoxical effect of the exposure from the first moment. For example, asking
the patient to focus on negative thoughts leads to a decrease in arousal level and anxiety, while
asking them to avoid negative thoughts causes an increase in arousal level and anxiety. These
phenomena, best demonstrated by the biofeedback graph, demonstrate the importance of
exposure. Also demonstrated is the ineffectiveness of attempting to push thoughts out of one‟s
mind and the effectiveness of accepting thoughts.

17. c. In-vitro exposure – Guided imagery of the actual problematic scenario the patient is trying to
avoid is used in preparing for in vivo exposure. If the patient is hooked up to biofeedback sensors,
it is possible to identify the more problematic points during in-vitro exposure and better prepare
for in-vivo exposure. More importantly, implementing this imagined in-vitro exposure many times
makes the real exposure (in vivo) much easier.
These are all examples of how biofeedback can motivate, enhance, comment on and demonstrate a
variety of cognitive techniques at different stages of therapy.
CONCLUSION: BETWEEN THE TWO MODELS OR INTERVENTIONS
The first difference between these two models – CBT-assisted biofeedback and biofeedback-assisted
CBT - is in who implements the intervention. In the first model, this is a biofeedback practitioner, while in
the second it is a psychotherapist. Naturally, the client is the first to select between the two interventions
by deciding whether to pursue biofeedback intervention or psychotherapy. It is assumed that individuals
who select biofeedback will have some – though not all – of the following characteristics: pay more
attention to the body, more concrete, look for control, more scientifically orientated, less oriented to
talking about feelings, less able “to get into” thoughts and feelings, less aware of possible psychological
conflicts, and looking for a quick change (Wickramaskara, 2002). Those who prefer psychotherapy will
have more or less the opposite characteristics.
Still, if the decision is ours, whom should we refer to which type of intervention? The answer
depends first on the individual‟s characteristics, so it is important to explore the above characteristics in
every client. Second of course, the answer depends on the presenting problem. If extreme physiological
responding is involved, it makes sense to try to bring the patient some relief and use biofeedback.
However, this can still be achieved by a psychotherapist familiar with biofeedback (second model or
intervention).
Yet there is a clear difference between the two, and therefore there are clear criteria for when to
start or to switch to psychotherapy. When there is a major psychological problem (strong dysfunctional
basic assumptions), biofeedback intervention is not sufficient. If this is known in advance, through
experience with the patient or questionnaires, starting with the second intervention is advisable. If a major
psychological problem emerges during biofeedback intervention, it is prudent to move to psychotherapy
as well. Otherwise, the main criteria are personal characteristics as described above. Given that most
psychotherapists still refrain from the use of psychophysiological tools, we can imagine an opposite
scenario in the case of extreme physiological symptoms or unbalanced ANS that ordinary psychotherapy
cannot effectively address. In such cases it makes sense to refer the client to a biofeedback practitioner
for a parallel intervention.