1. BSC Short Course 11 Identifying the Therapeutically Meaningful Signal: Sharpening Your Bio and Neurofeedback Skills.. In One Hour! Bob Grove, PhD

2. Some ideas for beginners. So what do you look for?

3. We all begin somewhere…

4. Hand warming?

5. Follow the Data..

6. Who am I talking to? Somatic BFB? EEG HEG BFB? Both? Relatively new to BFB/NFB? ETC…

7. My agenda is flexible.. The emphasis is on techniques. My techniques are not the only ones. You are encouraged to interrupt at any time… So.. Here we go!

8. 1840s –Professional Hypnosis 1950s- Professional Biofeedback What is the difference between hypnosis and biofeedback? HINT: One uses words. What do they share in common?

9. CONFUSION! The public is not well-informed. Many are called; few are chosen. Our job is to break down that confusion.

10. At least 3 Traditions... Feel-Good Tradition in BFB: Goal is to relax, to desensitize, etc. –Or ‘calm and focussed’ in ADHD, etc. Psychotherapy Tradition in BFB: –BFB for Stress Reactivity, Mental Rehearsal –Monitoring crossovers for neurotherapy. Flexibility Tradition in BFB: –From Physiology & Neuroplasticity –The signal can wax and wane and be good. What about conditioning theory?

11. Still confused? Read a book. The Clinical Handbook of Biofeedback: A Step-by-Step Guide for Training and Practice with Mindfulness By: Inna Z. KhazanInna Z. Khazan Price from:$59.95? See Stens Provider: E Books Suggests ways of introducing Biofeedback, including Mindfulness. Research-based protocols.

12. Mindfulness compliments / competes with Biofeedback? Mindfulness is a special form of old-school awareness training. Mindfulness adds a non-judgmental attitude and self-compassion to awareness training. You acquire a type of continuous awareness of things around you at the moment [external] AND your many reactions to past, present and future events [internal]. double visionYou acquire a kind of ‘double vision’, or double concentration, a kind of continuous trance-like ability [looking inward and outward]. Mindfulness requires motivation, focused awareness, and a different attitude. More in a minute…

13. Evangelical or ecumenical BFB? Everybody has their own best protocol. –What if you have trouble? Often Clients report that BFB did not work. New members confide they are discouraged. – Let’s see if we can correct this.

14. What is the Best Single Indicator? Productive sleep – most important. [Comments?]

15. Remember you Role: BFB requires a coach.. You and your assistant.. + A Threshold Coach

16. Can You Coach? Motivate by Hx of Success – –Use Research Data to market a technique. Assess current state – –Snapshot of Stress-Recovery –Snapshot of Movement-Recovery –Snapshot of Attention-Fatigue Encourage examination of thoughts, motions, etc. –Monitor SC –Explore Stress-Reactivity with client

17. How many types of BFB are there? –Somatic BFB – SC, Temp, EMG –True movement-based Myofeedback –HRV Feedback –Neurotherapy –ILF –Traditional Neurofeedback –Loretta-base Neurofeedback –Etc. Is there common ground?

18. Possible Common Ground: All kinds of biofeedback help calm the brain. Somatic BFB changes brain function. Hypnosis changes blood flow. The Default Mode Network can be activated by any technique that turns off self-talk: Self-Regulation, BFB, Relax, Drugs, etc.

19. Details on the DMN. “In neuroscience, the default mode network(DMN) is a network of brain regions that are active when the individual is not focused on the outside world and the brain is at wakeful rest. [ The DMN oscillates ] at a rate lower than 0.1 Hz (one every ten seconds). [It’s more complicated] The DMN may correspond to task- independent introspection, or self-referential thought.”introspection Inference? –When activated regularly, brain and body have the opportunity to begin self-repair, a kind of self-healing. This is the core of most BFB training.

20. Default Mode Network involves many regions, ferquencies.

21. More on the DMN Self-identity network, a task-negative net. Mind can wander, etc. without a specific goal. Involves Cingulate, Frontal &Limbic sites. [It is not the only network:] [Tibitan Meditators surpress DMN – become egoless?]

22. DMN may be part of good Theta, too Bad theta is pretty constant, lower freq Good theta is a clinical neurofeedback term. –Usually self-talk is surpressed … Self-talk may be surpressed in several BFB procedures. –This means that one of the goals of all kinds of BFB is figuring out how to interrupt self-talk. So how to you do this?

23. One Way : Interrupt Stress Talk As a coach, teach clients how to short-circuit common stressful thoughts. –The goal is to short-circuit stress-filled talk. I use a so-called mindful technique called ‘Thought Interruption Training’ Developed before Mindfulness, about 1982..

24. Basics: GSR [SC] increases to a stressful thought Thought Interruption Training

25. It is a self-talk, pause, decide technique [ Gosh, that really pissed me off! ]

26. Mini-practicum What sensations are you aware of now? This is your baseline… “Stop [interrupt] a thought, “Look inside, “Listen. Make a choice.’

27. STOP, LOOK AND LISTEN:’ SLL “I just can’t stop thinking about it!” “I know it’s stupid, but I worry anyway.” “Every time I think of money, I get angry.” “I just can’t let go until the Doctor says it’s cleared up.” ___________________ The key is to rapidly break down big distressing thoughts into three steps: The three steps are remembered as “Stop,” “Look” and “Listen.” 1. STOP: Learning to “stop” a stressful thought within about 5 seconds. 2. LOOK: WHERE is the tension?. 3. LISTEN: Do I need this much tension NOW? MAKE A DECISION: Do I need to ACT on this thought NOW? That’s it. Just be sure to practice this all the time. For example – right now where do you sense unnecessary tension in your body? Did you anticipate it being difficult to remember Stop, Look and Listen? Practice it NOW and while combing your hair, driving, at lunch, on the phone, and in bed.

28. ‘Thought Interruption Training’ “Stop [interrupt] a thought, “Look inside, “Listen.Make a choice. Thought #1Thought #2Thought #3 Pleasant Thought SC Stop – Look – Listen – Decide [SLL]

29. Another Example

30. Thought Interrupt : Key Elements Don’t show SC yet. Keep it simple: A stressor, an irritant. –Repeat the same thought at least 3 times. –Ask if body feels the same amount of stress each time. Next do the same thing with pleasant thoughts. –Repeat the same thought at least 3 times. –Ask if body feels the same amount of stress each time.

31. Humm… So far, this is a lot like Desensitization Training. Repeat, repeat, repeat. It is … Speculation: –The reason it works is related to studies on Acquired Distinctiveness.

32. SC, Mindfulness & Acquired Distinctiveness : indicates better discrimination when you exaggerate/contrast the difference between adjacent, similar events. Repetition with short trials and breaks work best. Detailed understanding is not necessary. Repetition of the same stimuli are best.

33. What is different from Thought Stopping? From EMDR? Stopping within 5 sec is critical! Actually this is pausing a thought. And turning inward.. Maybe activating the DMN. [This is what makes it different].

34. Worry Takes 5 sec to Build. KEY: Thought takes 5 + Seconds to start –Perceived Threat

35. How does Biofeedback Training work? –Perceived Threat NEW POINT OF AWARENESS EMOTIONAL RESPONSE USUAL POINT OF AWARENESS

36. The therapeutic signal need not be the target signal TI sets up an expectation that something different is possible. –TI allows the client to focus on another BFB task, like EMG for pain, HRV for IBS or EEG for Attention.

37. Now, how does hand warming fit in here? ….

38. Temp Training Is it really easy?

39. First considerations When did you last eat? Are you hungry? Did you sleep well? Are you worried about something?

40. A Temp Training Procedure 1.Stand up. Clear hands. Clear minds. Arms at side. –Deeply inhale, raise shoulders a little. –Exhale and loosen arms and hands. 2.Now, raise one arm above head. Inhale as as before. Exhale & drop arm as you do so. Go for tingling.

41. Keep It Going.. Keep the tingling going. –If necessary, repeat arm drop. –Or, do an imaginary arm drop while sitting. –Keep it going…..

42. Keep It Going.. Keep It Positive, Short

44. Got it? Now exaggerate a worry as if it were happening now...

45. What happens to tingling?

46. [Sit down] The therapeutic signal need not be warmth.

47. More on Temp Waves Look again at the Temp graph [revert] Why the cycles? Finger Temp – in steady-state, waxes and wanes about once per minute.

48. Keep It Going..

49. What if Temp Training does’t work? [Audience – it’s your turn … ] But remember to keep the tingling going..

50. Start Breathing - This sets the condition to let go.. Start Temp Disclosure talk Don’t start with Temperature Feedback ….. Keep It Going..

51. Which Relaxation Technique is best?

52. Which Relaxation Training? Which is the best relaxation procedure? Why not do a Relaxation Profile? It only takes about 20 minutes and tells you a lot…

53. Relaxation profile for panic client. Breath Jacobson Relax Auto Imagery

54. Stress, Synchronies, Resonances, Oscillators, and Harmonics

55. Evolution of Stress Concepts Static Signal Approach: –EMG DOWN, SC DOWN, Finger Temp UP –SMR UP, Theta DOWN Dynamic Signal Approach: –BFB changed in the 1990s. –Capnometery showed static signals not that simple! –Researchers find Resonent Frequencies: In HRV –In Neurotherapy Othmier: Started with14 hz, x ½ =7 hz, x ½ = 3.5 hz, etc –Now Ulta-Low Frequencies, with variability. Ochs: Frequency-offsets as feedback. Found 5 hz triggers siezures. Goggles at 10 Hz triggered siezures.

56. Look for Synchronies & Harmonics Biological systems must protect the organism by conserving energy and communicating effectively. Organs can maximize energy by exercising systems together. Some systems take longer then others. They oscillate together So which is the fundamental frequency?

57. Synchronies & Harmonics

58. Exhale – EMG DOWN & SMR UP

59. Signal Synchrony EEG Synchronies –e.g. Coherence / Phase- RSA Cardio-Respiratory Synchrony Why is this important for finding the best signal? First, a little background..

60. Oscillator Theory in Physiology Central pattern generators (CPGs) are biological neural networks that produce rhythmic patterned outputs without sensory feedback.biological neural networks Alteration of the pattern is difficult because feedback received during only one phase may require changed movement in the other parts of the patterned cycle to preserve certain coordination relationships.

61. Oscillator Theories invade BFB Old idea: – Arousal as Sympathetic, as Stress. – Calm as Parasympathetic, as Relax. New Idea: –Flexibilty is best.. –Breathing Wave – relax and still breath? What not stop? –Bungee cord example.

62. Examples –Walking with a pebble in the right shoe alters the entire gait, even though the stimulus is only present while standing on the right foot. Even during the time when the left foot is down and the sensory feedback is inactive, action is taken to prolong the right leg swing and extend the time on the left foot, leading to limping.

63. 10/10/2015Gevirtz63 Breathing can disrupt HR in a similar manner…

64. Another Example

65. SIDEBAR:Respiration in Polygraph Why does the respiration system inflate here?

66. Panic DO: Why is Resid. Vol. High? Why elevated residual volume?

67. Role of Oscillations in HR In healthy individuals, a degree of interaction between activity of SNS and PSNS allows more effective responses to demands. This interaction produces variability in HR. Oscillations in HR interact with other systems (hormones, blood pressure, respiration, emotion, etc).

68. More on Oscillations Oscillations help bring the physiology back to equilibrium after stressors and contribute to stability of the system. Oscillations allow for a timed sequence of events to occur (e.g., firing of all sets of cells necessary to contract the ventricles) and for the repetition of those events.

69. More on Oscillations Oscillations help predict daily events, e.g., circadian changes in HRV. Pathology arises when these oscillations are disturbed, leading to a LOSS of variability and a decrease in ability to adapt.

70. 10/10/2015Gevirtz70 Notice trend from three waves to a dominant.1 Hz Wave

71. Exercise Metaphor Do you need to practice every day?

72. Oscillations and Resonance Frequency Resonance frequency (RF) training is one of the primary mechanisms for increasing HRV. Resonance is the predisposition of certain systems to oscillate with greater amplitude at some frequencies of stimulation than others. Power reflects the amplitude of the signal relative to its frequency. It is actually measured as the square of amplitude divided by frequency.

73. Resonance Frequency While the exact RF of breathing is different for different people, Eugene Vaschillo, Paul Lehrer and their colleagues have determined that for most people the RF lies somewhere between 4.5 and 7 breaths per minute (bpm) Vaschillo et al., 1983, 2002 Lehrer et al., 2000.

74. Oscillations & multiple states

75. –In breathing, there is a sympathetic side and a parasympathetic side. “Some degree of modulation is required to allow one CPG [Central pattern generator] to assume multiple states in response to feedback.”modulation

76. Breath Wave Dynamics So where would you encourage relaxation?

77. Synchronies & Harmonics Exhale – EMG DOWN & SMR UP

78. The Logical Answer.. Humm, I’d choose the exhale side …. –But you can also encourage a full exhale by first encouraging a full inhale. –So what’s up?

79. Hering Breuer reflex Named for Josef Breuer and Ewald HeringJosef BreuerEwald Hering A reflex is triggered to prevent over-inflation of the lung. reflexlung –Pulmonary stretch receptorspresent in the smooth muscle of the airways respond to excessive stretching of the lung during large inspirations.Pulmonary stretch receptorsinspirations –Once activated, they send action potentials through the vagus nerve to the inspiratory area in the medulla and the pons.action potentialsvagus nervepons –In response, the inspiratory area is inhibited –This inhibits inspiration, allowing expiration to occur.

80. There is more.. Don’t exaggerate the depth of exhale either…

81. The Hering–Breuer deflation reflex Shortens exhalation when the lung is deflated. –It is initiated either by stimulation of stretch receptors or stimulation of proprioceptors activated by lung deflation. –Like the inflation reflex, impulses from these receptors travel afferently via the vagus. –Unlike the inflation reflex, the afferents terminate on inspiratory centers rather than the pontine apneustic center.

82. Don’t tell your client to make perfect waves! If you know more about HRV, you could talk about other influences… like …

83. Meyer Wave Mayer waves are cyclic changes or waves in arterial blood pressure.

84. Meyer Wave Mayer waves are cyclic changes or waves in arterial blood pressure. –The waves are seen both in the ECG and in continuous blood pressure curves. – Mayer waves have a frequency about 0.1 Hz (10-second waves). So what causes the oscillations?

85. These waves are regulated by pCO2 in the blood

86. CONSIDERATIONS: Three breaths, then breath normally! Look at the resp wave for hints of stress.. If you get stuck, try one max inhale. –This hyper-extend lungs & triggers HB Reflex – get a bigger letting go response. Consequences: For Jacobsonian Relax – Tense on inhale, relax on exhale. For ‘guarded’ breathing in pain patients -exaggerate breathing, etc

87. CAUTION I : Arrhythmias premature (extra) beats Supra-ventricular arrhythmias ventricular arrhythmias brady-arrhythmias “Most arrhythmias are harmless, but some can be serious or even life threatening. During an arrhythmia, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organ.” Prevalance Rate: approx 1 in 18 or 5.30% So what do you do? HINT: Engel, et all

88. CAUTION II: Parasympathic Rebound 3% of people will go into crisis: Lungs fill with fluids Can occur with any event that involves a rapid letting go: An abreaction, a confession, etc. SOLUTION: Keep their arousal from releasing to fast..

89. Dealing with Pain

90. Pain & Rebound Cautions Chronic Pain or GI patients – –hurts to breath. –PRP itself becomes frightening. Also for Cardiac Patients… –PRP itself becomes frightening. A danger for those doing biofeedback.

91. HRV & Irritable Bowel Syndrome spastic colon, irritable colon, nervous colon

92. Breathing & IBS HRV is basic 6 bpm resp Can help with IBS. 3 cpm

93. HARMONICS: Rhythms overlap Cardio-Resp Rhythm – about 6 pm Gastro-Stomach – 1 CPM & 3 CPM Using BFB for EGG & HRV, once breath at 6 PM, the push stomach in, started GI contraction

94. EGG

95. DEPRESSION

96. Little-known BFB for depression? Alternatives to EEG BFB for Arousal? –Hypocapnic Depressive Syndrome Psychosomatic Medicine, 1990 –Encourage arousal breathing. –Results: About 80 % better in two weeks BDI

97. RI & Depression RI patients, Temp BFB & Depression. What happened?

98. EEG ECG again EMG

99. Breathing & SMR Exhale –prolong it just a bit –triggers SMR SMR

100. SMR, Theta & Resp EEG studies – from 30 years ago – Sterman Lubar –Inhale triggers-Beta & Good Theta –Exhale –SMR – called Mu Rhythm Theta –Good Theta is cyclic – consolidates memory – 5-7 hz –Bad Theta – Constant – 3-5 hz

101. EEG is rhytmic

102. Which is Therapeutic? Where to start? Look first at breathing signal. Attention – could train in about 20 minutes. Breath & EEG, then breath & keep EEG tone on while reading.

103. MUSCLES

104. Improving Muscle BFB Move a muscle to stress it. Look for: –Ascent Instabilities –Decent notch – Len Ochs – 1980s –….

105. Stress-Pain-Stress Cycle STRESS AND MUSCLE PAIN The Body's Reaction to Stress Defense Posture

106. Which organs express aggression? Jaw? Back? Forarms? Legs?

107. STRESS PROFILE EXAMPLE Headaches: Fontalis Muscle remains tense Task Times Recovery Time2 Frontalis Muscle Tension

108. Treat Dysponetic Muscles Relax tongue to relax head

109. STRAIN CAN INJURE

110. KEY TO MUSCLE INJURY: The Decent Notch The Hiccup Effect during Muscle Release KEY: A muscle is injured when it ‘hiccups.’

111. Decent Notch

112. Key Points –Trigger points are real. increase muscle activity and pain –Hyper-reactive sympathetic system Can’t relax heightens pain sensitivity –Increased sympathetic activity contributes to anxiety and depression –Look for the Descent Notch

113. SUMMARY

114. Lessions Learned Monitor everything. The meaningful signal may not be the feedback signal! Question what you think they need. Do a baseline, stress them, use social signals, see how they react and recover. REMEMBER: Hook up therapist – what % of time in synchrony? Just a few minutes.

116. Warm-Cold Estimates of Emotions

117. Topics NLP- synchrony – developed before neuroscience. EMDR – also developed without neuroscience. Psychoanalysis- what is flowing between analysist’s and patient's subconscious. The therapeutic encounter relies on true synchrony.

118. Color me mad! They were asked to mark in the bodily regions on the silhouettes where they felt a physical sensation response to each emotional image. What did the researchers find? The resulting body maps revealed that most people had similar physical sensations in response to eachemotional state.

120. TREAT WORRY WITH BIOFEEDBACK Use ‘SLL’ Protocol – Stop Look Listen [see appendix in handout]

121. STOP, LOOK AND LISTEN “I just can’t stop thinking about it!” “I know it’s stupid, but I worry anyway.” “Every time I think of money, I get angry.” “I just can’t let go until the Doctor says it’s cleared up.” ___________________ 1.STOP: “stop” a stressful thought within about 5 seconds. 2. LOOK: WHERE is the tension? 3. LISTEN: Do I need this much tension NOW? MAKE A DECISION: Do I need to ACT on this thought NOW?

122. Demo SLL

123. My Favorite – Thought Interruption SLL is “Stop, Look inside, and Listen” SL L Have them repeat same thought I still do not know the thought!