Psychophysiological Psychotherapy,

The use of Biofeedback, biological monitoring, and stress management principles in Psychotherapy.

Donald Moss, Ph.D., Saybrook Graduate School , San Francisco , CA USA - Correspondence should be addressed to: dmoss@saybrook.edu

Sigmund Freud described the interpretation of dreams as the "royal road to the unconscious" for psychotherapy (1900). Today psychophysiology can provide that royal road for psychotherapists. This program introduces fifteen principles guiding the use of psychophysiology in psychotherapy, including specific techniques and case examples, showing the use of biofeedback instrumentation to augment the work of psychotherapy. The author also cites the work of pioneers such as Sandor Ferenczi, Wilhelm Reich, Marjorie and Hershel Toomim, and Ian Wickramasekera, who contributed to understanding the potential role of the body in psychotherapy.

Principle 1.

Cultivating physiological relaxed states facilitates psychotherapy. Freud began his psychoanalytic practice initially with hypnosis, and after he abandoned hypnosis continued to invite the patient to recline on a couch. The early psychoanalyst Sandor Ferenczi advised the use of relaxation exercises to overcome inhibitions to free association (1925). Commencing a psychotherapy session with a brief relaxation exercise increases the patient's awareness and expression of emotion, and eases those inhibitions which impede therapeutic awareness (Moss & Lehrer, 1998). When patients either block or struggle with emotional pain, a return to relaxation reduces the intensity of distress and enables acceptance.

Principle 2.

Observing changes in the body leads to detection of defensive and inhibitory operations. Therapist observations of movement, posture, and changes in non-verbal expression provide keys to current emotional and cognitive processes in the patient. Sudden changes in the body often reveal current moves to block emerging thoughts, feelings and impulses. Patterns of bracing and tension in the musculature support the defensive operations of the mind. The repetitive and chronic suppression of emotions and impulses creates an "armoring" in the musculature (Wilhelm Reich, 1927, 1933). Anna Freud (1936) commented that the "defenses meet our eyes in a state of petrifaction when we analyze the permanent 'armor plating of character'."

Principle 3 .

Electronic monitoring of physiology enhances this recognition of mind-body linkages. Biofeedback instrumentation detects subtle physiological changes and processes not evident to the observer, providing a signal to therapist and patient alike of emotionally significant internal responses. The display of the biological signal reduces therapeutic tensions around "resistance." The patient perceives the biological signal as "objective" and accepts its image more readily than therapist-initiated interpretations.

Principle 4.

Biofeedback instrumentation identifies maladaptive physiological responding: Maladaptive responses are disproportionate to the triggering situation, either exaggerated or minimized.

In addition, the individual may fail to recover in a timely manner when the triggering stimulus passes.Once maladaptive physiological response patterns are recognized, the biofeedback instrumentation enables a retraining and modification of the maladaptive elements. Toomim and Toomim (1975) introduced a framework utilizing electrodermal biofeedback to identify patterns of over-reactors and under-reactors, and showed how biofeedback training could facilitate a more optimal pattern of responding for each group.

Principle 5.

Recognizing the mind-body linkage facilitates psychotherapeutic progress. The psychophysiological principle is that: "Every change in the physiological state is accompanied by an appropriate change in the mental emotional state, conscious or unconscious, and conversely, every change in the mental emotional state, conscious or unconscious, is accompanied by an appropriate change in the physiological state" (Green, Green, and Walters, 1970, p. 3). When the patient directly experiences this reciprocal integrity of body and mind, it facilitates an awareness and ownership of many previously unrecognized emotional and motivational elements in everyday living.

Principle 6.

When the patient is verbally stuck, turning to physiological pathways moves psychotherapy forward. Exploration of body posture and tensions often serves to move therapy forward, when verbal processing is at an impasse. Direct physical interventions, such as breath training, postural re-alignment, and therapeutic massage, also can facilitate renewed movement toward awareness and health. In general, "body-work" enables expanded subjective awareness.

Principle 7.

When the patient is physiologically stuck, turning to psychological exploration moves the process forward. Body-work such as breath training or biofeedback can also get stuck, and when this happens, discussing the emotional accompaniments of the physical impasse often clears the way for renewed bodily learning. Wilhelm Reich introduced these classical strategies of mind-body therapies, expressed in principles 6 and 7, in the following comment: "When a characteristic inhibition would fail to respond to psychic influencing, I would work at the corresponding somatic attitude. Conversely, when a disturbing muscular attitude proved difficult of access, I would work on its characterological expression and thus loosen it up" (Reich W., 1927/1942, p. 241).

Principle 8.

The human being can push negative emotion out of the mind, but not out of the body (Wickramasekera I., 1988, 1998). Individuals can deny many emotions and desires to themselves cognitively, yet the body will disclose undeniable physical reactions when the subject is discussed. Increases in skin conductance, changes in rate and manner of breathing, and increases in muscle tension may all be a warning of such unrecognized emotional distress or conflict.

Case Example: Larry illustrates this principle that negative emotion can be pushed out of mind, but not out of body. Larry presented himself adamantly as happy and content with his marriage and family. He appeared to be an angry, resentful man, but resisted any discussion contrary to his rigid self-perception. His psychotherapist monitored electrodermal and heart-rate variability biofeedback to monitor Larry's physiology during therapy sessions. His electrodermal response elevated noticeably, and his Very Low Frequency range in his heart rate variability spiked in activity each time the topic of his marriage and wife was mentioned. The physiology was more convincing for him than the therapist's perceptions. He became receptive to this "objective" witness to his unrecognized feelings. The physiological display opened a psychotherapeutic window over time in his therapy

Principle 9.

Observing the physiological display can convince the patient of the reality and significance of subjective cognitive and emotional changes. The patient often is surprised by simple recognitions: "You mean that just because I am upset about my spouse, my breathing becomes erratic, my heart rhythms change, and my brain wave patterns are different?" The physiological display can also show patients the power of relaxation skills or a hypnotic induction to bring about dramatic physical changes, and convince the patient to continue to cooperate with such therapies.

Case Example: Nora provides an illustration of how the display of physiological data can enhance the patient's confidence in the therapy process. Nora, a 43-year-old EMT and fire fighter, was presented with repeated trauma in the line of duty, and classic symptoms of PTSD. Her symptoms included nightmares, daytime flashbacks, baseline vigilance and a heightened startle response. She also showed a loss of emotional spontaneity and social withdrawal which contributed to the breakdown of her marriage. Nora was repeatedly referred by her employer for psychological services. Each time she initially made some progress, but continued to experience intermittent flashbacks. She became discouraged by setbacks and quit psychotherapy several times. Monitored with EEG during a therapy session, Nora showed a dramatic spike of cortical activity at 28 Hz. This EEG feature was interpreted to her as a ruminative reliving of a trauma scene. During a hypnotic induction, the spectral display flattened across entire spectrum, completely erasing the 28 Hz spike. Nora was shocked: "I knew I felt better but I didn't think it really made any difference." Seeing the change in her brain convinced her that the therapy might have lasting impact.

Principle 10.

A variety of biofeedback modalities can usefully disclose information relevant for psychotherapy. Some patients are muscular responders, others are cardiovascular responders, others gastrointestinal responders, and others cognitive responders. Access to a wide range of physiological instrumentation allows the therapist to choose specific modalities for monitoring during psychotherapy.

Widely used biofeedback instruments for monitoring during psychotherapy include:

Alternatively, a therapist may use a multi-line graph, monitoring several modalities at once, to detect the patient's personal stress response, physiological activation and recovery patterns.

Principle 11.

The boundary blurs between psychophysiological training and psychotherapy. Ancient Chinese medicine tells us about the value of regulated breathing in mental calming: ". the tranquility of the mind regulates the breathing naturally and, in turn, regulated breathing brings on concentration of the mind naturally" ( Questions and Answers of Meisha , Yue Yanggui, Qing Dynasty, cited by Xiangcai, 2000, p. 7). Today, breath training is included as an adjunctive component within anxiety treatment. This simple skill often provides so much mastery over anxiety that patients proceed to use their new breath skills independently, recovering their self-confidence with little or no additional psychotherapy. Similarly, EEG biofeedback training to reduce a left/right frontal asymmetry in cortical activation often improves mood so rapidly, that patients proceed on their own to accomplish typical therapeutic goals, such as self-affirmation, assertion with peers, and cognitive reframing of problems.

Case Example: Susan provides an illustration of how physiological training sometimes cancels the need for psychotherapy. Susan was a 34-year-old high achiever, rapidly piercing the glass ceiling at a mid-sized corporation. She requested evaluation for a panic disorder with agoraphobia.
Her psychophysiological Stress Profile (PSP) showed a baseline of shallow, irregular rapid breathing (22-30 breaths/minute). A hyperventilation trial produced a full-fledged panic attack. In two sessions of respiration training, she showed excellent mastery of smooth, full diaphragmatic breathing. Susan returned the next session, and reported how she had used alternating hyperventilation and relaxed breathing trials to prepare herself to enter anxiogenic situations. For example, Susan sat in her car in a parking lot, first hyperventilated to the point of anxiety, then calmed herself with effortless full breathing, and then entered a supermarket without any incidence of anxiety. Her sense of mastery increased rapidly, she increased the range of situations she was able to master, and no "therapy" phase was needed.

Principle 12.

A stress management model and stress management skills facilitate symptom management in psychotherapy. The use of biofeedback instruments assists the therapist in teaching the patient a stress management paradigm. The patient can distinguish in a practical way between the provoking stressor and his/her own stress response to that stressor. Biofeedback training also models for the patient a modified and more adaptive response to that same stressor in the future.

Principle 13.

A variety of basic mind-body principles transfer readily to psychophysiological psychotherapy. For example, consider the principle of response mechanism stereotypy (Sternbach, 1966). When individuals encounter stress their physiological responding is often recurrent and unchanging over a variety of situations. This stereotypy decrees the types of stress-related medical symptoms an individual is likely to develop. The more consistent this stereotypic activation is, the greater is the likelihood of stress-related disease. Re-training a novel, non-stereotypic and more strategic response aids in restoring adaptive functioning.

Principle 14.

Psychophysiological monitoring supports a variety of behavior therapies and specialized interventions. Physiological indices can guide the course of behavior therapeutic interventions, such as systematic desensitization. Electrodermal feedback, peripheral temperature, respiration, or heart rate variability can each serve to indicate when the patient is calming his/her anxiety, and when the patient's anxiety is persisting or increasing. In addition, biofeedback assisted relaxation can facilitate recovery following each behavioral exposure trial.

Principle 15.

Psychophysiology provides a Trojan horse to open the individual's gates to psychotherapy (Wickramasekera I., 1988, 2003). This is especially true for somatizers, individuals who present physical complaints without any measurable pathophysiology. These patients represent 50 % or more of patient visits in primary care clinics; they often resent and resist referrals to mental health professionals. Biofeedback emphasizes physiological mechanisms, biomedical instrumentation and measurement of bodily processes, affirms the patient's somatic focus, and reduces the patient's defensive resistance against an inferred psychological understanding of their complaints. Once the patient has accepted biofeedback, relaxed defenses, and achieved physiological relaxation, emotional awareness and self-recognitions often unfold spontaneously.

Conclusion

In conclusion, biofeedback and biological monitoring are useful in creating readiness for selfexploration, reducing therapeutic resistance, and enabling the patient to recognize mind-body linkages.

Display of physiological signals enables therapist and patient alike to identify maladaptive and stereotypic responses to stress, and to retrain more flexible and adaptive responding. Biological monitoring during the course of psychotherapy can provide a "window into the soul" - alerting both patient and therapist to attune to specific topics and life situations which activate somatic threat and distress reactions.

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