Biofeedback is a recent addition to psychotherapy. The term feedback was derived from Norbert Weiner's concept of a method of controlling a system by reinstating into it the results of its past performance. These technics and the term biofeedback originated from laboratory research in which instrumentation was utilized to amplify a variety of physiological changes, such as blood pressure, muscle tension, skin temperature, and certain EEG patterns. The internal signal promptly initiates an external signal, such as a sound or light, that upon repetition enables the patient to identify the cues of his own internal state. Biofeedback theory and research assume that when the patient receives immediate information about his external changes, he might eventually control these processes without the continued utilization of instrumentation.
Kamiya noted that certain subjects could, on command, go into a kind of Zen meditation or hypnotic “trance” and alter physiological parameters.11 By means of biofeedback training (B.F.T.) employing electronic devices, it was seriously considered possible to implement control of inner thought processes. Kamiya's subjects recognized, with remarkable accuracy, whether or not they were emitting alpha waves at a given second. They were also trained to maintain or repress alpha waves by an audio feedback tone, achieving control over ephemeral and altered states of consciousness (A.S.C.). He explained that there are four primary brain-wave patterns—delta, theta, alpha, and beta rhythms—all of which are contained within a total energy spectrum of about 0 to 40 cycles per second (C.P.S.). The alpha rate moves at 8 to 12 C.P.S.; it is the most prominent brain wave activity, since it is readily recorded by EEG. It appears that everyone slips in and out of alpha from 5 to 30 times a minute without ever knowing it.
Good subjects contended that the alpha state was associated with feelings of detachment and yet was accompanied by alertness. These serene feeling states are also characteristic of autohypnotic states and A.S.C. Some subjects even referred to it as an “alpha high.” The latter state seemed to be accompanied by a lack of anxiety, suggesting that such beatific relaxation might be a useful substitute for tranquilizers, hypnotics, and soporific drugs. It was, however, doubted that the alpha state would ever be a substitute for relaxing drugs or meditation. Observations on Zen meditators and hypnotized persons indicate that alpha probably plays an important role, but is not the whole picture. Alpha training is probably nonspecific as far as neural processing is concerned. However, a broad neural system may be enhanced by its use.20 Nevertheless, it was theorized that if persons could be trained with B.F.T., they might learn control of desired inner states in a relatively short period of time and thus facilitate any type of psychotherapy.
Brown hypothesizes that alpha can act as a feedback control for regulating gastric acidity and body temperature.3 She believes that beta influences eye movements and that theta (4-7 C.P.S.) controls muscular activities, heart rate, and pulse pressure. She observed that when subjects learned to control their alpha, they became adept at controlling other bodily functions. The beta waves fall into a fastpaced 14 to 28 C.P.S. She also believes that theta, which is defined as that rhythmic EEG activity of from 4 to 7 C.P.S., may facilitate awareness, correlate with creative thinking and learning, and in general lead to an increased efficiency in mental functioning.
BIOFEEDBACK LEARNING PROCESSES
There seems to be no question that there is some validity to the biofeedback process per se. The instrumentation informs well-trained subjects of physiological changes occurring in the organism, who then temporarily can control those processes they have become aware of through feedback. However, it should be emphasized that a subject cannot be trained to produce alpha waves, but rather can be trained to produce the subjective state that is associated with alpha waves.20 Since EEG waves do not have any sensory representation that can be recognized as such, the trained subject can only recognize and learn to manipulate the feeling that accompanies any one of the various EEG patterns. In other words, no physiological processes can be sensed per se, yet all can come under volitional control by B.F.T.
There is, however, a welter of confusion and mutually contradictory theories regarding B.F.T. Not only is there the question of the reliability of the instrumentation, but over half of the brain rhythms are lost before they reach the surface, and between 30 and 60 per cent of those registered depend on the individual's consciousness and “state of mind,” as well as other factors. Deep brain activities simply cannot be assessed by surface potentials or EEG measurements. What the person is thinking, the amount of light involved, and whether eye closure is present or not can all affect EEG patterns. Relaxation is not needed to produce alpha, and some individuals do not even have alpha; the latter unfortunately have not been studied to see whether they too can learn to control their internal processes.
CLINICAL APPLICATIONS OF BIOFEEDBACK TRAINING
Serious-minded researchers believe that B.F.T. can, by diminishing secretions, cure ulcers. Other claims are for asthma and pulmonary insufficiency, pain of migraine, cardiac arrhythmias, Raynaud's disease, physical rehabilitation of stroke, cerebral palsy, and multiple sclerosis victims. Feedback of finger temperature has been employed as a visual signal. It has been demonstrated that B.F.T. can increase temperature over a 10°F. range, while simultaneously and effectively decreasing skin temperature of the forehead; the latter prevents development of migraine headaches by regulating the vascular supply to the brain and hand areas.10 Recently it has been observed that long-term retention was better for learning differential control of hand temperature when hypnosis was compared to a group receiving B.F.T.7 Others found that the degree of hypnotizability did not matter in reference to hand-warming.19
Muscle biofeedback has been utilized to reduce the incidence of anxiety-produced headaches.4 It has been observed that learning to control the difference in brain alpha wave activity between the two cerebral hemispheres has facilitated learning.18 B.F.T. is thought to be useful in essential hypertension,21 asthma, and other medical conditions. One investigator isolated a 12 to 14 C.P.S. high-voltage pattern which comes from the motor cortex.22 Cats could be conditioned to produce this rhythm, which was named the sensorimotor rhythm (SMR). Sterman found SMR training has qualitatively and quantitatively brought about significant reduction in anxiety and depression, and reduced the seizures in epilepsy.
In spite of all the voluminous publications, the data in the above areas are still ambiguous and the early enthusiasm accorded B.F.T., like any other new modality, is now being tempered with caution and assessed more realistically.
CURRENT STATUS OF BIOFEEDBACK TRAINING
It is agreed that B.F.T. is of little or no value for organic disorders. It is no mere coincidence that it works for the same psychosomatic disorders that are responsive to hypnosis and the behavior therapies. When thoughts are turned inward, the patient develops more responsibility for his own recovery, and through reduction of tension he develops a “do it yourself relaxation”—like self-hypnosis—to neutralize anxiety.
Melzack and Perry studied B.F.T. for pain relief in three groups receiving alpha B.F.T. and hypnotic training, hypnotic training alone, and alpha B.F.T. alone.13 Results indicated that the first group had less pain. Pain reduction was not due to alpha training per se, but it added something to the results either by distraction, reinforcing the idea that the pain would diminish, or by giving the sufferer the suggestion that he had the means to bring about anxiety reduction.
A more cautious attitude is now being taken. Miller, an ardent proponent of A.N.S. learning, states that B.F.T. “has not been rigorously proved by enough long term follow-up studies.”14 It has been referred to as “a furor therapeuticus.”20 Orne comments that it is interesting that B.F.T. researchers are now talking about the influence that suggestion, motivation, and emotions have on results.16 He notes, “This is another instance where a new technique is introduced and found to be wanting, so it is combined with older proven therapies but is presented as a new package.…” He added that alpha feedback “promises something for everybody, but it is a promissory note that is not likely to be delivered as written.”17 Brady warns that a placebo effect has not been ruled out.2
As B.F.T. researchers become interested in hypnosis, they will soon realize that demand characteristics, expectancies, and suggestions at various levels of awareness are the crucial variables chiefly responsible for the results of B.F.T. Thus we are dealing by and large with another suggestive approach. With further research, the combination of hypnosis and B.F.T. (hypnobiofeedback), together with behavioral technics, ultimately should prove to be a valuable therapeutic modality.
MEDITATION
The ancients employed magical rites and incantations to induce meditation by chanting, breathing exercises, and dancing. The Hebrews used fixation on the four letters of the tetragrammaton and developed other names for God.1 Methodical meditation, breathing exercises, and ecstasy states are similar to the practices of Yoga, Zen Buddhism, Hinduism, Shintoism, Sufism,8 and Christian meditation, including the repetitive prayers developed in the Byzantine Church15 and the praying of the Rosary.
It is obvious that the cadence and intonations of prayer in a relaxing environment, posture, eye fixation on an altar or religious symbol, and rhythmic chanting are hypnagogic. Finally, the self-contemplation and self-absorption characterizing prayer and meditation are practically identical with modern-day autohypnosis. Meditation as a potent modality for changing behavior has certainly withstood the test of time. A modern version is transcendental meditation (T.M.).24 Although the ritual for each differs, they are fundamentally the same and are based on similar principles of conditioning. A common EEG and neurophysiologic basis for mystical states of consciousness has been noted.9 That hypnosis and Eastern methodologies such as T.M. are now being increasingly accepted indicates they are here to stay and are modalities that American psychotherapy must eventually incorporate. Hypnosis, behavior therapy, and T.M. have recently been employed for reducing severe anxiety states.6
ALTERED STATES OF CONSCIOUSNESS
The behavioral technics of imagery conditioning during hypnosis have also stimulated renewed interest in attaining A.S.C. for modifying behavior. Through use of more precise technics, finer sensory discriminations will be made so that these states can facilitate therapy. At present there is a burgeoning interest in guided affective imagery, fantasy encounter, and the use of standardized images.12
The subjective experience of some practitioners of T.M., Zen, or Yoga resembles, in many respects, the heightened sensory awareness and uniqueness of perceptual and cognitive experiences of many LSD users. Patients undergoing hypnotic sensory-imagery conditioning report similar experiences. It has been noted that in states of meditation, habituation of the orienting reflex is delayed or abolished. This suggests that in some way the lack of habituation of the alpha blocking by sensory input is a correlate of heightened perceptual sensitivity. Clearly, the subjects, in unusual degrees of reduction in the level or variety of external sensory inputs to the brain, can induce “ecstasy” or an A.S.C. by appropriate training.
These altered states of consciousness also show a remarkable parallel to rapid-eye-movement (REM) sleep and dreaming. Both involve a state of cortical and visceral arousal associated with inhibition of skeletal muscle tone in trunk and limbs. A loss of distinctiveness in spatial orientations and vivid perceptual imagery with condensation of imagined persons and events are correlates of both dreams and the ecstasy state. The deepest, or plenary, hypnotic state achieved through sensory-imagery conditioning shows the same parallel.5 Skeletal muscle tone in trunk and limbs is inhibited. The time sense is distorted, expanded, or concentrated, and in some cases, abolished. Perceptual or sensory imagery is incredibly vivid. More study of the similarities between these altered states and hypnosis is needed, as is an examination of their relationship to anxiety reduction.
It is increasingly apparent that all altered states of consciousness have a common goal: the blocking out of the conscious mind to find the “No-Mind” of Zen, the “Immortal Self” of Yoga, the Fana el Fana(annihilation of the self) of Sufism. The early Judeo-Christian traditions taught that man must “empty” himself to hear God's voice, using fasting and meditation to attain that emptiness.
Ornstein believes that the objective study of A.S.C. may yield insights as to the capabilities for human self-regulation.18 The latter term is nothing more or less than self-hypnosis. A lack of sophistication in the West has led to much confusion and has impeded the scientific study of volitional control. The A.N.S. is not as autonomic as was formerly believed. By appropriate training it can be put under volitional control through autogenic or enteroceptive feedback. A well-trained Yogi, for example, does not need an external signal or device to control autonomic functions.
SUMMARY
Although B.F.T. establishes control over normally involuntary processes, its long-term effectiveness has yet to be demonstrated. There are important differences between B.F.T. and hypnosis. In B.F.T. the patient learns to be acutely aware of physiological changes. In hypnosis per se, the patient suppresses what is happening within. As Hilgard and Hilgard point out, the two approaches may be complementary. For the patient who can temporarily direct his attention away from bodily processes, hypnosis might be preferred. For those whose reality ties are too strong to do this, biofeedback might be preferable.10a
Practitioners of B.F.T. who are not familiar with modern and sophisticated technics of hypnosis, which do not require an induction technic, will naturally not believe they are using task-motivated instruction in a hypnotic manner. Likewise, those using various forms of meditation and A.S.C. are seldom aware that they are resorting to self-hypnosis.
A new interdisciplinary approach is emerging which combines the instrumentation of the West with the principles of behavioristic psychology and the practices of traditional Eastern philosophy. Whether these will provide a better understanding of human capabilities for self-regulation remains to be established. However, there is no doubt that increasing personal motivation in this modality will certainly help those with psychosomatic disorders—just like hypnosis.
REFERENCES
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