Attachment-Informed Biofeedback—The Next Generation of Biofeedback Therapy
Traditional biofeedback generally focuses on individual therapy that serves one of two purposes: (a) treating a functional health disorder that stems from an organic source or a mental disorder caused by high levels of stress or (b) improving performance. The author describes a therapy model that was developed based on biofeedback to treat interpersonal challenges such as parent–child relationships and spousal relationships. The author begins by describing the principles of the interpersonal biofeedback model and continues with practical examples.
Biofeedback and Psychotherapy
A person's emotions and thoughts are always borne in existential isolation. The only available tools for sharing emotions and thoughts with others are words and actions. For example, when a young boy first begins to discover his body, he may say to his father, “Look, my heart is beating,” and place his father's hand over his tiny heart to share the experience. He lacks the words to express the wonder of the discovery that his heartbeat can be shared with his father. This experience will intensify as he grows older and realizes that others have no access to his physical experiences, his emotions, and his self-concept. The boundary created by the skin on his body grows thicker and taller over time. A smile, a caress, a slap, or tears expose how he feels about others or express a need for others to acknowledge his emotions.
Graphic representation of physical sensations overcomes some of this isolation. Emotions are displayed without words or actions, without smiles or tears. They receive an external reflection, outside of the person's body. When the sensor is placed on a person's body, there is a sense of the metaphorical skin becoming just a little thinner. The person becomes more exposed and less alone. It is almost like a father placing his hand over his son's heart, so that the child's heart can once again share its story with another.
Literature on therapy contains references to psychophysiological assessments of patient pairs (Gottman & Levenson, 2002) and of therapist–patient pairs (Marci & Riess, 2009). Yet literature focuses only on one-time measurements as opposed to ongoing assessments that include providing the patient with feedback on the results of the psychophysiological indices that were measured. However, the exceptional influence of the imaging feature of biofeedback when it is given a therapeutic interpretation was reflected by a test case described by Marci and Riess (2009). They describe a relatively long therapy process in which a turning point was the therapist's referral to the patient's psychophysiological indices. In 2005, Don Moss presented a summary of the different ramifications of incorporating biofeedback into psychotherapy as well.
Biofeedback can also be used to improve physical performance. Treatment of this kind is based on the assumption that performance is optimal when the level of stress in the body is ideal. A model was developed to determine the optimal stress level for different indices for that individual, based on the performance that the individual is interested in improving. This enables the user to learn how to reach the desired level of stress by training with biofeedback equipment. Performance improvement is extremely popular among athletes in many national teams. Members of elite units and managers train themselves to make quick decisions while maximizing their attentive focus. However, the ability to improve performance is not limited to physical and professional functions. The sections below will describe two other areas in which biofeedback technology can improve performance and reduce stress—parenting and spousal relationships.
Biofeedback in the Interpersonal Context—What Happens When the Therapist is Connected As Well?
Binnun, Golland, Davidovich, and Rolnick (2010) proposed a model called dyadic biofeedback. According to this model, presenting the physiology of the patient and the therapist, or of the patient and a significant other, can enhance the patient's understanding of the components that regulate interpersonal interactions. Both the therapist and the patient are connected to the biofeedback equipment. Biofeedback is an imaging method that enhances the experience and understanding of interpersonal interaction as having regulation potential. This model facilitates consideration of the interpersonal context as one that regulates behavior through biofeedback therapy. The biofeedback equipment is a tool used to measure that interpersonal domain.
The model presented by Binnun et al. (2010) did not fully utilize the features of the biofeedback device or of biofeedback as a therapeutic tool. Although it expands the therapeutic setting, unique features of biofeedback as a therapeutic tool are absent. When using biofeedback, patients learn to pay attention to the physiological changes that occur under changing circumstances on the one hand, while on the other hand they learn how to influence their own physiology in order to change how circumstances affect them. The Binnun et al. (2010) model assumes a unidirectional impact, from the interpersonal domain/relationship to a person's physiology. In other words, the model utilizes only one dimension of biofeedback therapy. As explained, biofeedback therapy considers the patient's physiology to be a means toward reaching a solution, because the impact can work in the opposite direction as well, meaning that physiology influences function.
The interpersonal therapy model that first proposed using biofeedback for couples in therapy was introduced by Steve Kassel (Kassel & LeMay, 2015). Kassel's model expands the perspective presented by Gottman and Levenson (2002) about couples to create a therapeutic model that combines couples' psychophysiological assessment and couples therapy that incorporates biofeedback. The model presented here is based on earlier ones and proposes a structured, four-step therapeutic approach that incorporates biofeedback in all stages of therapy.
Attachment-Informed Biofeedback—Therapy Model
In the attachment-informed therapy model, biofeedback plays several roles in therapy situations that involve two participants or more. Biofeedback is used to mirror the body and to expand the interpersonal domain to offer a window into the physical dimension as well, which will moderate adaptation and regulation processes and enable merger and distinctiveness. The model includes several stages (see Table):
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“Hello, this is your body talking” – Understanding the window into the body
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“Hi! I'm here too. There's more than one body here” – Attending to the physiology of the partner/spouse/dyad
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Meeting of body images – Inviting dyadic acknowledgment through merging and distinctiveness exercises
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Changing the encounter – Generalizing skills to accommodate routine dyadic/spousal situations
Hello, This is Your Body Talking
Attachment-Informed Biofeedback generally begins in the same way as individual biofeedback therapy. Patients encounter themselves through the biofeedback device and learn how their bodies respond to different anxiety-provoking situations, while addressing the problem that was presented. Special attention is given to the fact that the therapist views the patient's physical response to the problem that was presented. For many patients, this encounter with their bodies is a new experience. At this stage, patients begin to acquire an initial technique for self-regulation through biofeedback.
Issues related to relationships and parenting often cause significant stress. As demonstrated before, this stress is often unconscious. For example, parents who believe that they respond calmly to their child's misbehavior may be surprised to discover that this is not the case.
One couple who sought parental education to cope with their son's behavioral problems at school reported that the school does not place boundaries. They said that they manage better at home because there are rules. The therapist asked the parents to picture an incident in which their son disobeyed them at home. Both parents were connected to the skin conductance level (SCL) indicator, which is sensitive to interoceptive stimulations (mental/imagined occurrences). At this stage, they were asked to describe the situation aloud. They were unable to see the screen while imagining or while describing the situation. The mother was surprised to discover that her SCL score showed that when she was instructed to think about the incident, her body entered a high state of arousal. On the other hand, no irregular arousal was shown for the father. But when the mother began to describe the incident aloud, the father's SCL index showed a very high state of arousal despite his expressionless face. He later said that this was the first time in his life that he noticed he was not as calm as he thought he was. We later discovered that he was emotionally detached while thinking about the incident, which is why his body showed no activity. The last part of the session involved an open and honest discussion that enabled the parents to discuss their struggles to set boundaries at home as well.
In this example, the first stage involved developing a working agreement with the therapist regarding the problem and the technique to be used to treat it. Patients learn about the opportunities that this technique offers in order to become more familiar with themselves and with their bodies in the context of the problem presented. Even at this early stage, like the Binnun et al. (2010) dyadic model, expansion and enrichment of the interpersonal domain using biofeedback are enabled. The parents' responses toward their son and their representation on the SCL screen allowed them to more fully experience themselves with regard to their son's behavior.
Hi! I'm Here Too. There's More Than One Body Here
At the second stage, the patient begins to notice that he or she is not alone. Another person is connected to the computer and that person's physiology is present as well. Now, not only is the patient transparent to the therapist, but the therapist or the patient's spouse or children are transparent as well. The patient sees them on the same screen and can observe their heart rate or skin conductance. This is a moment of discovery. Although most of the indices of those present in the room appear on the same screen and patients know that the others are connected, they tend not to attribute any significance to this fact. At the initial stage, patients are usually so preoccupied by their own graph that they are not available to notice what the other graphs are showing. Sometimes the graphs intersect, and it is at that moment that the other person's graph moves up from the background to center stage and suddenly has presence. This discovery is illustrated with the following examples.
A couple who came in for parenting education agreed to try a stress-reduction technique as a basis for developing relaxed and conscious communication with their young daughter, who suffered from night terrors and separation anxiety. The goal was to help the parents acquire the ability to contain their daughter's anxiety by enhancing their ability to cope with their own stress when she becomes distressed. Both parents were connected to the biofeedback device via sensors that measure skin conductance. Each of the parents was instructed to pay attention to the unique animation that appeared on each of their graphs, which indicated the varying levels of stress in their bodies. The graphs themselves appeared at the bottom of the screen, on the same axes. Once the parents acquired the technique, they practiced using it at the same time. During the second exercise, they began to look only at the graphs instead of watching the animation. There was a relaxed atmosphere in the room, and the father suddenly said, “Look, I passed you,” when his graph dropped at a faster pace and crossed his wife's graph. The attention that was drawn to the intersecting graphs triggered competitive tension—who would be better at relaxation?
In another example, a mother and her 10-year-old daughter sought therapy for the child's inability to control her anger. They agreed to use a joint relaxation technique that each of them had learned separately (the mother learned the technique during parenting education classes, and the daughter learned it during her therapy sessions). They both used the relaxation technique while focusing on their animation for several minutes. When the exercise was over, we looked at their graphs (Figure 1), which were displayed over the entire screen and described the course of the exercise. The moment that the graphs appeared on the screen, the daughter said to her mother, “Look, we did the same things.” She was referring to the fact that their slopes were very similar and progressed at a consistent pace. The child's discovery of her mother via the graph on the computer screen was enhanced even further when the mother smiled and said, “That's right, we are very much alike.” This reinforced the child's sense of compatibility. Toward the end of the session, the child asked if her mother could join her in other therapy sessions, which resulted in continued dyadic therapy.
Citation: Biofeedback 46, 3; 10.5298/1081-5937-46.3.03
In both of these examples, the ability to see what the other was experiencing was a therapeutic turning point. This turning point has several characteristics that are related to the presence of the other, including performing the exercise in another person's presence and the depth of exposure. Both of these characteristics form the beginning of a shared experience.
Performing an exercise in the presence of the other
The presence of another person can be ignored when the patient focuses on his or her own body and the occurrences on the screen. Focusing while performing relaxation techniques requires physical attentiveness and concentration, as well as disengagement from the interpersonal domain. Attention is drawn inward and reduced to the minimal degree necessary to receive feedback from the computer screen. Once the ability to relax has been acquired, the patient must extend this ability in order to apply it outside of the clinic as well. This is a genuine challenge for most patients. The world outside of the clinic does not offer ideal conditions for relaxation. When a person realizes that he or she is not alone, the ability to perform relaxation techniques diminishes. Working in pairs after each person acquires the skill separately, as in the mother–daughter example described here, increases the ability of both the mother and the daughter to practice the technique under conditions that more closely resemble their natural environments. This capability is crucial for enabling them to achieve mutual regulation during therapy. The attention of both mother and daughter was drawn to their compatibilities. Even when the graphs do not reflect compatibility and each person progresses at a different pace, as in the first example, drawing the participants' attention to these differences can lay the groundwork for discussions on the ability to achieve mutuality and on the importance of variance.
Depth of exposure
Biofeedback enables the other to expose himself or herself to us, so that we can understand what the person is going through. When a girl discovers that her mother's experiences are similar to her own, she is directly exposed to her mother's physical sensations. This direct exposure is buffered by the computer screen. The graphic medium draws people closer to one another, while also maintaining a distance. It echoes the incident without being the incident itself. This makes it easier to process the discovery. Regardless of whether or not the participants' physical responses are compatible, the depth of exposure is mutual and identical. However, it is not complete. At this point, the parallel experiences must be shared verbally to expand the shared domain even further. The empathy that develops between the two participants begins with similar physical sensations. In situations in which each part of the dyad sets off the other (e.g., arguing parents and children, couples in conflict), the physical familiarity that is mediated by the computer screen enables empathetic familiarity in the presence of the other. At the very least, it can ease the conditioning that controls us in the presence of a person we generally experience as a threat.
According to the model presented here, the two people who perform the exercise together will attend one or two additional joint sessions in the same format. The session will start with a parallel experience (performing the exercise on the same screen) and will have a shared ending (joint observation of the parallel experience). The difference between this model and the dyadic model described by Binnun et al. (2010) is evident even at this stage, as the physiology of the two halves of the pair influences their performance. In other words, the ability to attend to the body and relax in a shared domain affects the relationship between the couple or between the parent and the child. Repeating the exercise once or twice reinforces the bidirectional movement between the interpersonal domain or function and the physiology, and facilitates mutual influences. The domain influences the physiology, and the physiology influences the domain. Once this stage has been established, it is time to progress to the next stage, in which the graphic images of each of the participants are expanded.
Meeting of Body Images—A Refined Physical Encounter
Psychotherapy often uses the term meeting of minds to describe emotional encounters between two people, most commonly a therapist and a patient. This concept encompasses the prospect of the encounter yielding understandings and insights that will ultimately inspire change. The description above of the initial stage of dyadic biofeedback therapy showed that another encounter transpired as well. This is an encounter between two graphic images that represent the two parts of the dyad. Both are shown on a single screen, which enables both participants to observe both images together and at the same time. The graphic images add a physical but contactless dimension to the patients' interpersonal experience. Metaphorically, the points where the graphs intersect on the screen can be likened to very refined physical contact.
The encounter between body images that are physically present (as opposed to mental representations) is an important aspect of the new, shared interpersonal domain that is formed. At this stage, the therapeutic model of interpersonal biofeedback offers an opportunity to focus on two axes—merging and distinctiveness. The names of these axes hint at the well-known early childhood development process in which the baby initially considers himself or herself to be a part of the mother and later begins to develop a distinction between himself or herself and the mother. The model described here uses these concepts in order to distinguish between two types of exercises—joint exercises and distinctive ones. Although these conditions may be interpreted as reflecting two mental situations, this is not necessarily the only interpretation for this therapeutic model, and even those who do not accept interpretational therapy of this kind can still benefit from the interpersonal biofeedback model.
During merging exercises, the two participants (parent and child, couple, therapist and patient) must achieve a joint physiological change. The pair may be connected to a single sensor or to two separate ones, but in either case the screen will display a single graph that reflects their shared physiological state. When both participants are connected to a single SCL sensor, they must maintain continuous physical contact in order for the sensor to operate properly. This is a technical issue, but it has important therapeutic implications as well. In most cases, the pair holds hands with one hand while the other hand is connected to the sensor. Holding hands provides unconscious feedback about the stress that the other participant experiences, while having a mutual effect at the same time. This provides dual physiological feedback—the feedback from the graph on the computer screen that indicates the shared physiological state, and the direct feedback from the hand that is being held.
Let's return to the mother and daughter described above. They were both connected to the same sensor and were instructed to reach a state of relaxation. The results of this joint session were different from those of a similar exercise that they had done before. The mother and daughter were unable to achieve relaxation and the graph moved downward very slowly, although both participants were capable of rapid relaxation. The daughter felt that her mother's grip on her hand was not tight enough and declared suddenly, in a tone of voice that sounded desperate, “Mom, you're leaving me.” In response, the mother tightened her grip. Instead of this being reflected by a sharp upward incline, the graph rose only slightly, followed by a significant decline that indicated joint relaxation. The daughter clung to her mother after the graph dropped. During the conversation that followed, we realized that the daughter experienced her mother's relaxation as abandonment. Apparently, her relaxation response was slower and did not correlate with the mother's pace. Even though they remained connected, the daughter experienced the incompatibility between them as detachment.
This example is an excellent reflection of the importance of the dual feedback that is obtained from the merging exercise. The graphic feedback reflects the average stress level of the two participants; therefore discrepancies in progress rates between the two will be reflected in very slow changes on the graph. In this case, the feedback from the computer reflected the participants' lack of success in the merging task. However, the feedback received by holding hands explained their lack of success. The contribution of the dual feedback obtained from the merging exercise to the therapy process can be highly significant. Opening a window into the other's physiology offers an opportunity to discuss the daughter's need for her mother's presence in order to relax at her own pace.
As explained above, distinctiveness exercises differ from merging exercises in the guidelines and objectives. Distinctiveness exercises focus on the ability to maintain physiological distinctiveness of oneself in the presence of the other and to acknowledge the influence of another physiological presence on each member of the dyad (Figure 2). This is a complex task that can take a significant amount of time. By this point, the participants are aware of their mutual influence and must make room for a second physiological expression. For example, when two parents form the dyad, one may be instructed to relax while the other is agitated or upset.
Citation: Biofeedback 46, 3; 10.5298/1081-5937-46.3.03
The parents of the daughter with night terrors were attached to separate biofeedback sensors and instructed to function in conflicting ways. One was instructed to relax while the other was instructed to increase physical stress levels. The computer screen provided them with two forms of feedback. Each was aware of the other's physiological condition and their own physiological condition through the two graphs on the screen. Each time the gap between the stress levels of the two participants was elevated for approximately 30 seconds, they received one point. The score was displayed on the screen for them to see. This was, in fact, a joint task that required them to act differently from one another, in the other's presence.
Exercises of this kind have multiple purposes in parenting education. One purpose is to validate different but joint function, and to invigorate confidence when faced with challenging situations. It is legitimate for each parent to express different states. The second purpose uses role reversal throughout the exercise to learn to exit the previous state and transition from stress to relaxation or from relaxation to stress, while the other is unable to assist but remains present. The third purpose is to serve as a metaphor for ethical or moral disagreements between parents about appropriate responses to their children in different situations.
In the example discussed here, we explained to the parents that the exercise was designed to expand their range of responses to their daughter's distress. The child's emotional response was very stressful for the mother, while she viewed the father's ability to remain calmer as emotional detachment from the child. The exercise enabled the mother to sense her husband's relaxed presence despite her own distress. This experience was demonstrated, exercised, and processed using biofeedback exercises and conversations after the exercises. The couple later acquired the ability to transition from this state to relaxation exercises done with the father's support. This enabled the husband to exit his own space and approach his distressed wife, and she was able to experience her husband as a calming and supportive figure.
To continue the process of learning to support a person in distress, I introduced an exercise in which the parallel connection is used to transmit information to the calming individual about his or her own state and about the spouse's responses. In this example, the husband observed how placing a hand on his wife's shoulder had a calming effect on her and reduced her distress. He even learned how to identify his wife's physiological relaxation response without feedback from the computer screen by sensing how her shoulder gradually softened. On the wife's part, she allowed him to approach her despite her agitation.
Changing the Encounter
Exercises of this kind are a point of transition to the stage in which the encounter is changed. Mutual calming skills, relaxation in the presence of the other, maintaining distinctiveness, developing compatibility, and responding to the need for proximity and merging are all incorporated into the patients' daily lives. They are instructed to practice the exercises at home. The therapy sessions sometimes revolve around frustrations, but more often around successful experiences that are obtained by utilizing the different skills. At this stage, significant emphasis is placed on the ability to be attentive to the other's state without computer feedback, and on enhancing the ability to respond differently and to apply the most appropriate skills.
Summary
Biofeedback therapy was first introduced as a behavioral therapy technique designed to reduce stress. Later, this field was expanded to include areas in which optimal stress levels are required in order to improve performance. At this stage, therapy focused on the patients and their physical responses only. The attachment-informed biofeedback model is an expansion of the therapeutic capabilities that this technology offers. The technology exposes the physiological dimensions of interpersonal relationships. From this perspective, attachment-informed biofeedback also expands upon classic, dynamic, or cognitive-behavioral psychological therapy.
The interpersonal biofeedback model develops the presence of the body in psychological therapy in four stages. These stages are presented in a sequential order and follow a linear progression from expanding awareness to the interpersonal nature of therapy to the accommodated skilled encounter of the dyad pair. Yet skilled clinicians can relate to these stages as phases, adopting relevant exercises and guidelines. The model offers a physiological window that can expand the therapeutic encounter and the interpersonal domain. This domain now also includes the physiological dimension, which provides a glimpse into the patient's emotional world. What's more, this expansion facilitates more effective work with different types of dyads, including couples, parents, and parent–child pairs, in which each person discovers the partner in the dyad in a different light. Each dyad practices merging and distinctiveness exercises, while indirectly developing their mutual regulation ability.
It is clear how the physiological window enriches dyadic psychological therapy. Interpersonal biofeedback emphasizes the role of the patients' interpersonal relationship in different life situations. It can enhance couple and dyadic therapy and reinforce the therapeutic effect. This is a new stage in the development of biofeedback therapy, in which it moves from individual behavioral therapy to a new therapeutic domain.
Dyad parallel relaxation exercise match. Both parent and child performed the same way.
Three-phase exercise (boy represented by the darker line that begins and ends on top; mother is represented by the lighter line). In the first phase, both parts of the dyad are instructed to sit still. In the second phase, they are talking about a neutral subject. In the third phase, the mother opens with a controversial subject, not minding that her son is silently aggravated. Later, while noticing her son's internal reactions to her, she can develop empathy toward his stance.
Contributor Notes