Pilot Study of a University Counseling Center Stress Management Program Employing Mindfulness and Compassion-Based Relaxation Training with Biofeedback
A pilot study was conducted with clients at a university student counseling center stress management and biofeedback clinic to determine whether mindfulness and compassion-based instruction in relaxation strategies, along with peripheral biofeedback, would reduce perceived stress, enhance perceived coping, and lead to improvement in symptoms of anxiety, depression, and academic distress. Results support that the inclusion of mindfulness and compassion-based biofeedback may enhance treatment efficacy for stress and its associated problems above and beyond that of mindfulness and compassion-based relaxation skills training provided in the absence of biofeedback.
In a culture where working around the clock is worn as a badge of honor, where a news headline can read, “Vacation-Phobic Americans Donate a Million Years of Work Annually” (Steverman, 2014), and where the highest of intellectual standards is termed “critical” thinking, it is no wonder that fears of inadequacy and judgment fuel the fierce work ethics of many Americans. Learning that the body's stress response can be deliberately self-regulated appears to be empowering. Yet effortful attempts to create a relaxation response paradoxically produce the exact opposite of the desired effect (Wegner, Broome, & Blumberg, 1997). To bring about the calming experience associated with relaxed alertness, clients must learn to focus on the process and not on the desired outcome. This can be a difficult concept to embrace for individuals who seek therapeutic assistance because they are losing their battles against controlling stress and are still insisting that if they “only could try harder” their concerns would be alleviated. How can clinicians assist such clients in learning to find tranquility in a sea of stressors when the answer is antithetical to increased effort or self-scrutiny? Centuries-old traditions in mindfulness and compassion-oriented philosophies may hold the keys (Khazan, 2013; Klich, 2014).
Mindfulness is conceptualized in a variety of ways. Baer, Smith, and Allen (2004) outlined four commonly occuring elements within the most widely used psychological conceptualizations of mindfulness: observing, describing, acting with awareness, and accepting (or allowing) without judgment. In other words, mindfulness practices involve (a) adopting a moment-to-moment presence (b) with a stance of curiosity (c) while noticing external and/or internal stimuli, (d) applying neutral labels for those observed phenonomena then finally (e) recentering the focus of attention to the task at hand.
Another way to phrase “accepting (or allowing) without judgment” is with the term compassion. Compassion, as a vehicle for healing, may be self- (e.g., Neff, 2011) or other-directed (e.g., Negi, 2005). It is so often viewed as an essential component of mindfulness that many do not consider the constructs to be conceptually distinct. However, not all researchers incorporate compassion in their operationalizations of mindfulness (Gu, Strauss, Bond, & Cavanagh, 2015). Nomenclature is emphasized in this report only to provide clarity.
Mindfulness and compassion, as ways of being in the world, may be taught through a variety of exercises and meditations. A central premise to the current study is that biofeedback may be a tool for enhancing awareness that can bring about greater mindfulness. And, mindfulness, with its emphasis on compassion, can allow one to engage in the process-oriented focus necessary for succeeding in using biofeedback to learn emotion-regulation skills.
Present Study
Surrounded by technologies that reinforce immediate gratification and an outcome-focused orientation, university students, like many in present day America, often struggle to be mindful. Biofeedback is unique as a training tool because it appeals to an interest in the ongoing assessment of progress. Simultaneously, biofeedback also reinforces a process-focused orientation that may promote resiliency in the face of difficulties. The present study, with its emphasis on the application of mindfulness and compassion-based biofeedback for stress reduction, was conducted to assess the effectiveness of an intervention for the most frequently occuring concerns in college and university student populations, namely, those of anxiety, depression, and academic distress.
Method
Study Setting and Intervention Format
The study was conducted in a university counseling center's stress management and biofeedback clinic (The Stress Clinic) over the course of two consecutive academic years (2009–2010 and 2010–2011). The Stress Clinic offers a structured group therapy program in which clients learn strategies to reduce the physical and mental aspects of anxiety while enhancing coping skills. Biofeedback is a tool that augments the Clinic's education of clients about the central role that the mind-body connection plays in ones' abilities to self-regulate emotions.
Summary of 2009–2010 services (initial study)
The Stress Clinic services in the 2009–2010 year were offered in a two-phase group format. The first phase provided opportunity for clients to participate in four Relaxation Training Skills modules, which were attended once per week for 50 minutes. Each week, the focus shifted to a new topic related to stress management taught from mindfulness and compassion-based perspectives (e.g., life balance, communication, handling stress in the moment). All modules also incorporated the practice of a relaxation skill conceptually linked to the topic being covered (e.g., diaphragmatic breathing, loving kindness meditation). Clients were encouraged to practice skills at home using recordings, practice logs, and fingertip thermometers for biofeedback.
Participation in a minimum of four relaxation training skills classes was a prerequisite to the second phase of treatment, which included five weekly 50-minute biofeedback training classes. The biofeedback training classes could accommodate two clients at a time, allowing them to hone relaxation skills using several modalities (i.e., heart rate variability, skin conductance, and fingertip temperature). The biofeedback equipment used during classes included Thought Technology's Procomp Infiniti 5-Channel System and HeartMath's emWave PC.
This split-phase format was done out of necessity because of scarcity of equipment. However, it was a fortunate consequence for the research that relaxation skills training was conducted prior to and separately from biofeedback. Barring some carryover effects from phase I into phase II, the specific contributions of each treatment component could be identified as a result of the design.
Summary of 2010–2011 services (follow-up restudy)
With the acquisition of two more biofeedback stations in 2010–2011, a follow-up restudy assessment was conducted to determine how a shorter treatment program would fare in comparison with the Clinic's initial performance. In the 2010–2011 year, an integrated treatment plan was offered in which both the psychoeducational and biofeedback components for mindfulness and compassion-based relaxation skills training were incorporated into 90-minute modules. There were up to four participants per session, and 6 weeks defined a full course of treatment.
Participants
Treatment adherence and attrition rates
Thirty-four clients were included in the 2009–2010 sample of Stress Clinic participants. In 2010–2011, 48 students were served, representing a 30% increase over the previous year. Whereas only 7 of the 34 clients (38%) in 2009–2010 had complete data on levels of stress-related symptomatology (i.e., prerelaxation, prebiofeedback, and posttreatment data), 34 of the 48 clients (56%) in 2010–2011 completed both pre- and posttreatment assessments (see the Figure for clarification regarding timing of assessments for both years).
Citation: Biofeedback 43, 3; 10.5298/1081-5937-43.3.01
Measures
Brief questionnaires were administered immediately before and after each session to assess changes in levels of stress and in perceptions of coping skills. For this measure, clients were asked to indicate on a 10-point Likert-type scale their overall level of stress in the moment and how equipped they felt to cope with life stressors in that moment. Scores of 1 represented minimum levels of perceived stress and perceived competency to cope with stressors, respectively, whereas scores of 10 represented maximum levels. A third question added to the postsession questionnaire asked, “During the next 4 weeks, on average, how often can you see yourself using the skills or material you covered today?” Choices included “never,” “once a week,” “2 to 4 days out of the week,” “5 to 6 days out of the week,” and “every day.”
The Counseling Center Assessment of Psychological Symptoms (CCAPS; Center for Collegiate Mental Health, 2010), a 62-item measure of symptom severity, was also administered. The 2009–2010 sample completed it at three time points (i.e., prerelaxation, prebiofeedback, and posttreatment), and the 2010–2011 sample completed it at two time points (pre- and posttreatment; the Figure). The subscales used in this study included Depression, General Anxiety, Social Role Anxiety, and Academic Issues. At treatment termination, clients were asked to provide evaluations. On a scale from 1 to 5 (1 = completely disagree; 3 = neutral; and, 5 = strongly agree), they rated items such as, “The stress clinic classes were helpful to me in dealing with my concerns,” and “The stress clinic has helped me to improve my academic performance and/or focus.”
Results
Pre- and Postsession Perceptions of Stress and Coping Skills
Within-session changes in perceived stress and perceived coping
Data were analyzed according to session number in order to eliminate the possibility that clients would contribute multiple data points to the same data set. For the 2009–2010 cohort, there were significant reductions in stress from pre- to postsession in 78% of sessions and improvements in perceived coping abilities in only 33% of sessions (see Tables 1 and 2). In contrast, the 2010–2011 clients showed significant decreases in their levels of stress and significant increases in perceived coping abilities from pre- to postsession in 100% of sessions (see Table 3).
Relevance and utility of skills taught
The relevance and utility of skills taught were assessed by client ratings of the frequency with which they planned to use those strategies. At each session, a majority indicated they would use the skills on at least 2 to 4 days out of the week. Furthermore, there were demonstrated improvements in perceptions of relevance and utility in 2010–2011 compared with in 2009–2010 (see Table 4). That is, in 2009–2010, it was not until the second phase of treatment (i.e., during which biofeedback was employed) that clients reported higher levels of intent to practice. However, it was earlier in treatment during 2010–2011 that clients reported greater intentions to use the skills outside of sessions.
CCAPS Data
Depression
In 2009–2010, there were no significant differences between prerelaxation skills and prebiofeedback training or between prebiofeedback training and posttreatment. However, there was a significant linear trend marking a decrease in depressive symptoms over the full 9-week course of treatment, FLinear(1, 7) = 6.11, p < .05. This was consistent with findings in 2010–2011 (n = 34), with CCAPS-Depression T-scores showing a statistically significant decrease from pre- (M = 46.26, SD = 7.95) to posttreatment (M = 42.76, SD = 6.82), t(33) = 2.80, p < .05. Thus, depressive symptoms were significantly reduced in the 6-week 2010–2011 treatment, whereas improvements in the 2009–2010 cohort were identified only after the full 9-week protocol, which was inclusive of biofeedback.
General anxiety
In 2009–2010, there was a significant reduction in general anxiety between prerelaxation skills (M = 53.76, SD = 7.31) training and prebiofeedback training (M = 49.38, SD = 8.61), t(20) = 2.67, p < .05. There was also a significant linear trend marking a decrease in symptoms over the 9-week course of treatment, FLinear(1, 7) = 10.08, p < .05. That is, although there were significant reductions in general anxiety before biofeedback was instituted in the 9-week protocol, even greater gains were achieved after participants experienced the biofeedback component.
Participants in the 2010–2011 integrated protocol also exhibited significant reductions in general anxiety from pre- (M = 51.26, SD = 9.34) to posttreatment (M = 46.32, SD = 8.31), t(33) = 3.55, p < .05. Taken together, results for 2009–2010 and 2010–2011 suggest that biofeedback is an important component of treatment for general anxiety.
Social role anxiety
Social role anxiety scores were expected to decrease over the course of treatment. In 2009–2010, participants actually displayed a slight but nonsignificant increase in social anxiety symptoms from pretreatment to prebiofeedback followed by a significant decrease from prebiofeedback training (M = 48.25, SD = 4.65) to posttreatment (M = 42.50, SD = 5.83), t(7) = 5.58, p < .05. There was also a significant difference between prerelaxation training (M = 47.38, SD = 4.60) and the posttreatment assessment, (M = 42.50, SD = 5.83), t(7) = 5.57, p < .05.
For clients in 2010–2011, there were also significant reductions in social role anxiety from pre- (M = 50.35, SD = 10.46) to posttreatment (M = 46.24, SD = 8.69), t(33) = 3.54, p < .05. In other words, symptoms were significantly reduced in the 6-week integrated treatment, whereas improvements during 2009–2010 were identified only after the full 9 weeks. This result, once again, supports the importance of including biofeedback.
Academic issues
Academic issues scores were expected to decrease over the course of treatment. This was the case in 2009–2010, although differences did not appear until after biofeedback training had been completed, FLinear(1, 7) = 30.42, p < .05. In other words, there was a significant difference between prebiofeedback training (M = 46.75, SD = 8.45) and posttreatment academic issues scores (M = 40.00, SD = 5.16), t(7) = 2.47, p < .05. The difference between academic issues at the prerelaxation training assessment (M = 49.25, SD = 8.08) and at posttreatment (M = 40.00, SD = 5.16) was also significant, t(7) = 2.47, p < .05. However, there was not a significant difference between prerelaxation training and prebiofeedback training.
In 2010–2011, the decrease in academic issues scores was not statistically significant between pre- and posttreatment. Taken in isolation, these results suggest that the 2009–2010 format appeared to outperform the 6-week protocol with regard to academic concerns, albeit only after biofeedback was implemented. However, as will be detailed in the next section, in 2010–2011, fewer participants were concerned about their academic performance than in 2009–2010.
Final stress clinic service evaluations
Final evaluations were obtained from 22 of the 44 participants in the 2009–2010 sample and from 34 of 48 participants in the 2010–2011 sample. A majority of clients rated the Stress Clinic as helpful across both cohorts; however, it appeared that there was greater satisfaction among the 2010–2011 participants.
Specifically, 100% of those who participated in the 2010–2011 classes either strongly or somewhat agreed that the sessions were helpful. In 2009–2010, 91% of those who participated in relaxation skills classes and 72% of those who participated in biofeedback training classes either strongly or somewhat agreed that the sessions were helpful.
In the 2010–2011 cohort, 85% reported they strongly or somewhat agreed that they practiced relaxation skills outside of the sessions on a regular basis. This contrasts with results from 2009–2010, suggesting that only 68% strongly or somewhat agreed that they regularly practiced relaxation skills outside of sessions.
With regard to improvement in academic performance/focus, only 27% of the 2009–2010 sample either strongly or somewhat agreed that the Stress Clinic helped them to improve their academic performance/focus, whereas 50% indicated they were already doing well academically as assessed by a “yes/no” item on the final evaluation of services. In 2010–2011, 39% strongly or somewhat agreed that the Stress Clinic was helpful despite the fact that 88.2% of the sample reported that they were “already performing well academically before entering the program.”
In both cohorts, an overwhelming majority indicated that they would recommend the Stress Clinic to a friend in need of similar help. More specifically, 96% of the 2009–2010 cohort and 94% of the 2010–2011 cohort endorsed that they strongly or somewhat agreed they would recommend services.
Discussion
Results suggest that the inclusion of mindfulness and compassion-based biofeedback may enhance treatment efficacy for stress and its associated problems above and beyond that of mindfulness and compassion-based relaxation skills training provided in the absence of biofeedback. This was reflected in the findings demonstrating that when biofeedback was integrated into a shortened 6-week protocol, there was increased treatment adherence. There was also a greater frequency of sessions in which, within the course of the session, perceived stress decreased and perceived coping abilities increased. In addition, it was found that the intent to use skills outside of sessions was greater when sessions included biofeedback training, perhaps because of the contributions of objective physiological data in augmenting perceptions of the skills' relevance and effectiveness. Moreover, symptoms of depression, social anxiety, and academic distress showed significant reductions only once biofeedback was incorporated into treatment. And, in the case in which academic concerns were not significantly reduced (2010–2011), the majority of clients indicated that they were already performing well academically prior to entering treatment. Finally, although the 2009–2010 cohort demonstrated significant reductions in general anxiety before biofeedback was instituted, even further gains were achieved after participants received the biofeedback component. This finding, combined with the fact that the 6-week format also was associated with significant reductions in general anxiety, could indicate that the immediate incorporation of biofeedback into treatment might contribute to greater efficiency in alleviating symptoms.
Despite these promising results, caution should be applied in taking the findings to offer more than preliminary evidence for the treatment-enhancing effects of mindfulness and compassion-based biofeedback to stress-related concerns. Limitations of the study include the absence of a control group, small sample sizes, and the lack of randomization to treatment conditions. In addition, there was no follow-up assessment to determine whether and for how long gains were maintained after treatment termination. Moreover, the replicability of results in a non–university student sample remains unknown. Future studies should address these issues as well as include physiological measures to determine how well clients actually learned to self-regulate their states of arousal. Still, results suggest that this area is ripe for further investigation.
Citation: Biofeedback 43, 3; 10.5298/1081-5937-43.3.01
Timeline of administration of measures.
Dana R. Wyner
Contributor Notes