In 2016, we have watches that count each step we take, phone applications that tally each calorie swallowed and burned, "smartshirts" that measure our heart rate and respiration. We are living in an era of personal data tracking — yet many experts say we're missing a huge opportunity to use our body's data to change our physiological activity for the better.
Biofeedback is hardly new; its therapeutic use dates back nearly 50 years. Yet the technique is easier than ever, says Paul Lehrer, PhD, a psychologist at Rutgers-Robert Wood Johnson Medical School.
"People used to think biofeedback was this esoteric procedure that required complicated equipment and a lot of money," he says. "Nowadays, I have a [biofeedback] device on my phone that cost me five bucks."
While that app isn't exactly the most high-tech version of the tool, Lehrer says that psychologists can be certified in biofeedback and acquire the necessary equipment without a major financial investment. And biofeedback is as effective as it is accessible, he adds. "It's a very powerful technique."
Meanwhile, researchers are beginning to develop new forms of neurofeedback, which could help people learn to alter patterns of brain activity associated with any number of maladaptive cognitions and behaviors. Early studies indicate that feedback with real-time functional magnetic resonance imaging (fMRI) could help in treating clinical disorders including depression, schizophrenia, addiction and chronic pain.
"A lot of the pharmacological interventions we have [for these disorders] were shots in the dark," says Kymberly Young, PhD, a neuropsychologist who studies fMRI neurofeedback at the Laureate Institute for Brain Research in Tulsa, Oklahoma. With neurofeedback, "we can use what we've learned from neuroscience studies to target specific regions of the brain. It's a huge step forward for treatment."
Biofeedback basics
The goal of biofeedback is to teach people to take control of physiological functions such as heart rate, respiratory rate and muscle tension. In a typical training session, a person is hooked up to electrical sensors that provide information about those functions. Over time, the person can learn to pace breathing or relax muscles to produce a desired change in physiology. After mastering the technique, says Lehrer, most people are able to replicate the benefits in their everyday lives, without help from sensors.
Lehrer focuses on heart rate variability feedback. He finds it especially useful for managing anxiety and panic disorders, which are typically marked by hyperventilation and a racing heart, he explains. But he and other proponents emphasize that almost anyone can benefit from the technique.
As a clinical psychologist, Lehrer spends most of the time in his sessions with clients using standard techniques of cognitive and behavior therapy. Biofeedback might only account for a fraction of the time spent in a typical session, he says — "but for some patients, it's the most important thing I do."
Biofeedback got its start in psychology. In the 1960s, psychologists developed the technique to demonstrate that the autonomic nervous system was subject to operant conditioning (the principle that behavior is controlled by positive and negative consequences). Unfortunately, Lehrer and others say, the field has since moved away from "applied psychophysiology," and too few psychology training programs teach biofeedback today.
"Biofeedback is not common, and that's a shame," agrees Carol Austad, PhD, a psychologist at Central Connecticut State University.
She frequently teaches biofeedback to the college students she counsels to help them manage stress by regulating their respiration and heart rate variability. Her clients have also found it helpful in managing depression, anxiety and chronic pain, she says.
"As an adjunctive aid to psychotherapy, it's fantastic," she adds. "The patient feels as though they have control over their own bodily functions. When they have that feeling of mastery, you can accomplish more in psychotherapy."
Electroencephalography neurofeedback
Other clinicians have found similar benefits with biofeedback that provides information about the brain. Electroencephalography (EEG) neurofeedback measures the brain's electrical activity through sensors placed on the scalp, allowing people to learn to regulate their brain function.
EEG neurofeedback may help with a variety of brain-based disorders, including anxiety, mood disorders and sleep disorders. To date, though, most of the clinical evidence for the technique involves the treatment of ADHD, says Lynda Thompson, PhD, who directs the ADD Centre and Biofeedback Institute of Toronto.
In a meta-analysis of randomized controlled trials, Jean-Arthur Micoulaud-Franchi, MD, PhD, and colleagues found that EEG neurofeedback improves symptoms of inattention for children with ADHD (Frontiers of Human Neuroscienceopens in new window, 2014). And in a study two years ago, Naomi Steiner, MD, and colleagues found that EEG neurofeedback was more effective than cognitive behavioral therapy for reducing ADHD symptoms (Pediatricsopens in new window, 2014).
The typical training looks a lot like a video game, Thompson says. Children receiving the training play a computerized game that proceeds only when they are calm and focused. If the EEG detects patterns of brain waves associated with distraction, the game stops. "The method rewards the healthier brainwave patterns," she says.
Neurofeedback doesn't just teach good habits, Thompson says. Over time, regular neurofeedback practice can change the brain. Jimmy Ghaziri and colleagues at the University of Montreal have found that neurofeedback training aimed at improving attention resulted in structural changes involving both white and gray matter (Clinical EEG and Neuroscienceopens in new window, 2013).
Still, the scientific evidence base for EEG neurofeedback isn't yet as solid as many clinicians would like. Early trials frequently failed to include adequate "sham" neurofeedback for control groups, so it was often clear to participants and researchers who had received the real therapy, says Luke Stoeckel, PhD, director of the Cognitive and Clinical Neuroscience of Obesity and Diabetes program at the National Institutes of Health.
"There are reasons to believe that some of these technical brain-based therapies are highly susceptible to placebo effects," Stoeckel says.
More robust studies are now underway to establish the benefit of EEG neurofeedback for ADHD and other disorders.
Cautious optimism
Meanwhile, in the last few years, researchers including Stoeckel have begun pushing neurofeedback further, using newer brain imaging technologies, such as real-time fMRI. Stoeckel and his colleagues are cautiously optimistic as they explore neurofeedback's next frontier. "We really want to lead with the evidence," he says.
Real-time fMRI offers one big advantage over EEG, Stoeckel says. While EEG is mostly limited to detecting activity on the brain's surface, fMRI can provide detailed information about what's going on deep within the brain. But there's a catch. While EEG signals can be detected milliseconds after a neuron fires, it can take as many as five seconds to translate a signal from fMRI. Furthermore, fMRI is significantly more expensive.
In theory, however, the two techniques could be combined to maximize the benefits, Stoeckel says. If researchers can reliably identify the patterns of neural activity associated with neuropsychiatric disorders using fMRI, they might be able to find correlates of that activity that could be detected using the less expensive, more accessible EEG.
Such an approach would have wide clinical applications, Stoeckel predicts. In a typical session of cognitive behavioral therapy, for instance, he might help a patient develop a behavioral strategy, then send him or her home to test that strategy in the real world. At the next session, they'd talk about how well it was working. One day, neurofeedback might squeeze that process into a single hour.
"With real-time neurofeedback, you could actually have a person test behavioral strategies [while in the scanner], look at their brain and determine whether one strategy produces more adaptive brain changes than another," he says. But so far, he says, that type of neurofeedback is still an "if" rather than a "when."
"It's a very new field," agrees Young, who is exploring fMRI feedback for treating depression. "We're still working out which brain regions we should be targeting for different diseases, and how to turn that into treatments."
But she's making headway. She's focusing on the amygdala and its role in responding to rewarding stimuli. Unlike healthy people, those with depression don't experience an increase in amygdala activity when they recall positive personal memories, as she and colleagues described in a recent paper (American Journal of Psychiatryopens in new window, 2016). But neurofeedback could change that.
In a pilot study, she and her colleagues encouraged depressed volunteers to recall positive memories inside an fMRI scanner. Meanwhile, they watched a thermometer image on a screen in front of them. When the amygdala was active, the thermometer bar moved up. With practice, the volunteers learned to make the red bar rise by thinking of their happy memories. Learning to self-regulate their amygdala activity in this way resulted in an improved mood (PLOS Oneopens in new window, 2014).
There's more to the treatment than just remembering happier times, Young says. Simply asking people with depression to recall positive memories can make mood worse. The key, she says, is to recall those memories while bringing the amygdala online. The amygdala interacts with a network of brain regions involved in maintaining the prominence of emotional stimuli, she explains. "We're making these positive memories salient to depressed individuals."
Mind-body medicine
Before fMRI neurofeedback can be broadly useful, scientists have a lot to learn about what psychological disorders look like in the brain. Recording activity in individual brain regions is an obvious place to start, but it's only a first step, says Nicholas Turk-Browne, PhD, a psychologist specializing in cognitive neuroscience at Princeton University.
While the field of cognitive neuroscience has made a lot of progress, it is just now graduating from studying individual regions to exploring brain networks involved in a given cognitive process. And instead of only measuring how active a region is, scientists are beginning to uncover the actual content — the so-called "neural representations" — stored in the brain.
Recently, Turk-Browne and colleagues demonstrated how such neural representations could be harnessed to train attention. Participants viewed images of both scenes and faces, and were instructed to focus on one category and ignore the other. Unlike EEG, which generally only shows that a person is paying attention to something, fMRI allowed the researchers to identify which of the two categories each participant was tuning into.
When participants clued into the correct stimuli, they were rewarded with an easier task. When the brain scans showed their minds wandering from the task at hand, it automatically became more difficult. Participants learned to focus their attention over sustained periods, performing better on a follow-up test after one neurofeedback session (Nature Neuroscienceopens in new window, 2015).
One day, this type of attention training could help treat a number of problems, Turk-Browne says. People with depression often ruminate on the negative, for instance. People with social anxiety are hyper-aware of potential threats in the environment. "Sustained attention deficits are a problem in many mental health disorders," he says.
Designing fMRI neurofeedback training tools based on specific brain states is a compelling idea. But it's also a technically challenging one. "To figure out what a person is attending to or remembering, and to do these analyses in real time, is computationally demanding," Turk-Browne says. His lab and others at Princeton have partnered with Intel in hopes of developing computer systems and software that can handle that load.
While real-time fMRI isn't yet ready for prime time, proponents of biofeedback say the time is ripe for adding those techniques to standard psychological practice. "It is becoming mainstream to measure our physiology," says Thompson. Biofeedback is a logical next step.
For psychologists interested in adding the methods to their practice, Lehrer suggests contacting the Association for Applied Psychophysiology and Biofeedback and the Biofeedback Certification International Alliance to learn about training and certification in both biofeedback and neurofeedback techniques.
"Mind-body medicine is so prominent right now, and this is a way to help people learn mindfulness more quickly," Austad says. "This is a tool that should be in most psychologists' toolboxes."