Psychophysiological Therapy from a Distance: The Art of Sharing
This article evaluates the effects of the transition to online work for professionals who are engaged in psychophysiological therapy.
The art of sharing will be in the focus of this paper. We believe that sharing is central to all types of therapy, and a fortiori for biofeedback. We posit that the transition to distant biofeedback necessitates mastering the art of sharing. We suggest that in biofeedback training, two types of sharing take place: Sharing of the objective physiological data and sharing of the subjective process of the training.
One may assume that the main challenges in remote biofeedback are how to collect the data and how to share it. While referring to these issues, we argue that sharing of the subjective elements in biofeedback training is even more challenging.
The first part of this article reviews the effects of COVID-19 on our profession. After examining the dimensions in which therapy takes place, the second part emphasizes that the clinician no longer solely has the role of handling the physiological information. We review solutions in which the patient is the owner and supplier of the objective data and highlight some of the implications. This part has a technological orientation as we deal with the question of how to share the physiological data. The third part emphasizes the importance of the verbal sharing of the subjective elements accompanying the monitoring of physiology. The focus is primarily on the psychological facets and sharing is described as an art of creating intimacy.
Distance Therapy: The Dimensions of the Therapeutic Setting
The advantages of remote biofeedback have been known for many years. Two decades ago Folen, James, Earles, and Andrasik (2001) described how biofeedback via telehealth can provide accessibility to patients in rural and remote areas. Indeed, NASA has been experimenting with remote telemetry since the 1970s (DeJesus et al., 2017; Randle, 1970). It took the COVID-19 pandemic to require working remotely, and thus many of us found ourselves required to transfer the treatment methods we are familiar with from face-to-face sessions to remote working through screens. As remote work is becoming routine, it is time to pay close attention to remote-work building blocks. This will allow us to examine certain concepts that are central in our work, such as sharing, joint attention, and mutual experience.
At first, online therapists considered the logistics of the setting and the legal aspects of the therapeutic relationship for therapy carried over the internet. They attended to issues of discretion and privacy, proper internet connection, payments, etc. Lockdown and social distancing restrictions have forced us to move forward and reconsider our views and attitude toward online treatment and how it is carried out. Furthermore, the increased and intensified practicing of online therapy has demanded considering other fundamental aspects of treatment. The elementary settings of therapy—space and time—have changed.
Space
Online therapy enables both parties—therapist and client—to manipulate their visibility. By adjusting the camera's angle, each one can decide which part of his body the other one will see. Communication apps allow users to change the background of their images, allowing them to pretend they are somewhere else—in a real or imagined place. Altogether, these features promote the freedom of each part of the therapeutic act—therapist and client—to customize his presence in the therapy “room.”
Time
When examining the therapeutic setting in the time dimension, we can relate the parameter of synchronicity. Synchronicity can be described at the one extreme as synchronous—a constant real-time flow of information usually during a limited time frame (e.g., a session)—and at the other, asynchronous—fragmented, intermittent ongoing communication. This parameter is reflected in communication mode and content. Meeting applications are synchronous by nature – while at distance bringing therapist and client closer in time. The importance and impact of synchronicity is accentuated when a poor internet connection disrupts therapy flow. It hinders our ability to be tuned to client mood changes.
Asynchronous communication using various applications can strengthen the therapeutic bond. We make ourselves available for clients by letting them make contact at will. Furthermore, we have the opportunity to plan and fine-tune our response, not bound to a time restriction.
When it comes to communication content, different types of information collected about the client are considered part of the treatment. A client who practices relaxation techniques aided by a home unit or a wearable device may share data collected in training with his therapist. It corresponds with familiar types of information commonly gathered in cognitive-behavioral therapy—journals tracking mood, stress, and thoughts.
However, data collected through journals differs from psychophysiological data accumulated by a wearable device, both quantitatively and qualitatively. Vast amounts of psychophysiological information accumulate in a wearable device compared to thoughts or moods recorded by hand. While personal data describing mental activity is considered subjective information, psychophysiological data is deemed to be objective. In other words, the wearable devices grant the therapist exposure to personal and intimate information about internal occurrences in the client's life.
Wearables and Domestic Biofeedback Devices
The Association of Applied Psychophysiology and Biofeedback in general and biofeedback equipment companies in particular have always led the search for devices that measure psychophysiological data. However, they are now not alone. Consumer tracking devices are now available and can continuously measure physiological activity. This is part of the trend of personal informatics systems that help people collect personally relevant information for the purpose of self-reflection and gaining self-knowledge.
We shall briefly review available categories of devices that allow patients to collect physiological data about themselves, including devices that may be categorized as personal informatics systems. The devices are grouped according to the physiological parameters measured (modality). We included devices that are either (a) wearable, such as smart wristwatches, or (b) designed for use by nonprofessionals and relatively affordable. For this purpose, we set an arbitrary maximum recommended retail price of US $400. The review here is not intended to provide an exhaustive market review, merely to demonstrate the market maturity of usable devices.
Usage
Although presently most of the wearable/domestic devices and the supporting applications focus on relaxation training, the field is by no means limited to this.
Modalities less commonly used in clinical biofeedback relate to daily behavioral patterns and measures such as activity levels and sleeping patterns. As wearables continually gather data regarding the wearer, we can track and measure long-term patterns, as opposed to the brief glimpse that measurement in the clinic offers. The data can include extremely sensitive information such as nocturnal activity, therefore increasing the potential levels of intimacy required during sharing.
From the above, we can see that the synchronicity is also related to other parameters in the time dimension, duration and frequency. Devices that are suited for more prolonged and more frequent use (wearables) are more asynchronous by nature.
Software
Complementary to the hardware devices, the software also needs to be taken into consideration. We can examine whether the software is proprietary or open (i.e., if the software supports a single hardware device manufacturer or if the software is open to various devices from different manufacturers). We should also take into consideration whether the software is geared toward patients or professionals. A third category is the platform; because smartphones have become ubiquitous, they are highly suited for use with wearables. Apps for smartphones also tend to be considerably cheaper. Computer-based products are predominately geared toward home and professional dedicated biofeedback devices.
Challenges
An obstacle for widespread adoption of home-based biofeedback in clinical contexts is the patient's ability to share data with the clinician. There are a few software products that are open to several devices; however, these are mostly compatible with professional biofeedback hardware. The lack of standardization of biofeedback data formats may be the main hindrance to home-based clinical biofeedback development.
Heart Rate Variability and Pulse Rate
Hunkin, King, and Zajac (2019) suggested that heart rate variability (HRV) has the highest supported benefit among existing wearables. Their paper includes a summary of wearable devices with potential benefits for anxiety symptoms.
Technologies commonly used for wearable/domestic biofeedback are photoplethysmograph (PPG) and electrocardiography (ECG). PPG is presently particularly fascinating as it is increasingly accurate and available in many sports wristwatches. ECG is still regarded as more accurate; however, most nonprofessional devices tend to rely on chest straps that are less well suited for daily use.
Another exciting direction is the use of PPG utilizing smartphone cameras. This technology is yet to reach the required level of accuracy (Tyapochkin et al., 2019); however, the algorithmic improvements will allow the use of smartphone cameras for reliable biofeedback in the very near future.
Electroencephalography
Electroencephalography (EEG) can provide a plenitude of relevant information allowing therapeutic various modalities working with disorders such as anxiety (Tolin et al., 2020), ADHD (Melo et al., 2019), epilepsy, schizophrenia (Markiewcz, 2017), sleep disorders—although benefits are indecisive (Bolea, 2010)—and many others.
Traditionally, nonprofessional EEG devices use headbands, which are not well suited for wearing for long periods. Future directions for nonprofessional use include glasses and in-ear sensors.
Galvanic Skin Response
One of the first technological biofeedback measurements—galvanic skin response—is still the most common. Many affordable, accurate devices are available, most using finger or ear sensors (or both). The ease of use and affordability make it easy for patients to purchase and use these devices. The key disadvantage is that the sensors require the patient to be relatively stationary, and they are less well suited for continual daily monitoring.
Respiratory Rate
A wide variety of different sensing systems are used to measure respiratory rate (RR), including PPG, accelerometers, ECG, smartphone microphones—and recent research has examined the possibility of remotely measuring RR using PPG from video imagery.
Two novel solutions we identified are: the simple approach using the built-in accelerometer of smartphones—merely placing the smartphone on the person's abdomen and using widely available apps to measure RR. This method is clearly suited for short-duration use. The second solution is the futuristic approach of (wearable) smart garments such as Hexoskin, in which various sensors are integrated into the garment. Smart garments are at the other end of the synchronicity scale, potentially gathering data 24/7.
Skin Temperature
Although skin temperature (ST) is a well-established modality, few domestic devices are offered. The key benefit of ST home devices we identified is the relatively low price. Similar to GSR units, ST is not suited to continual daily monitoring.
A review of Google Scholar search results (for skin temperature + biofeedback) showed that 58% of the mentions include the term “pain” and 50% “children,” suggesting that this modality is used mainly in the domains of pain management and pediatric psychotherapy or psychiatry.
Activity Level
As smartphones are frequently in close proximity to us (usually in hand, pocket, or personal bag), they can constantly gather data regarding our physical movement. Most smartphones today are equipped with GPS, gyroscopes, and accelerometers. The integration of the data from these sensors allows the accurate estimation of various parameters such as activity level, time awake, and energy expenditure (Badawi & El Saddik, 2013; Bolea, 2010). As smartphones have almost become an extension of ourselves, with us throughout the day and using various sensors, the data gathered offers a unique ability to measure behavior patterns.
The ubiquity of smartphones, along with the processing power and variety of built-in sensors, leads us to believe that smartphones will become central in the domestic/wearable biofeedback offerings. As most phones are already well equipped, the emphasis will shift to the ability to share and process the data suitably—i.e., software products.
In addition to using smartphones for activity level monitoring, an abundance of wearable activity trackers provide accurate activity measures. The quantity of potential data that can be gathered strengthens the argument for standardization of data standards.
The table presents the prevalence of domestic biofeedback products in a search of Google Scholar. Wearable devices can clearly enhance our field and can be used for remote biofeedback. Yet there is one major difference between personal informatics and psychophysiological therapy: While the purpose of the two fields is to gain self-knowledge, we believe that it should be done with the help of a professional.
Li, Dey, and Forlizzi stated that “[t]here are two core aspects to every personal informatics system: collection and reflection” (2010, p. 558). The reader might note what is missing in this approach—the sharing element—the understanding that sharing the data and the reflection with the therapist is an important part in the achievement of well-being.
Sharing the Subjective Experience in Psychophysiological Therapy
The New Roles in Psychophysiological Data
The following conceptualization can help in formulating the new roles of the therapist and the patient in online therapy: It is the patient who brings the data and shares it with the therapist. It is the therapist who facilitates a fruitful discussion about the patient's internal events.
During a synchronous session, the physiological data can be presented in real-time using home-based biofeedback devices, as described. These graphs or animations can be shared using the screenshare function of many of the video conference programs (Zoom, Skype, Google Meet, etc.) However, this new era allows us to go a step further: We might be interested in data that has been constantly gathered between sessions. We might want the patient to share his physiological data collected during his working hours, family time, at night, and even during his sleep.
Our job becomes helping the client share with us the subjective correlate of the objective data.
Sharing and Intimacy—The Building Block of Therapy
The biofeedback literature for many years has emphasized the physiological and some technical aspects of the therapy. We usually describe what type of sensors were used, which relaxation techniques were employed, and how they were measured. In this section, we shift our focus to sharing the subjective experience with the therapist.
Cordova and Scott (2001) defined intimacy as a sequence of events in which another person's response reinforces behavior vulnerable to interpersonal punishment—suggesting intimacy as a function of sharing. Determining the degree of exposure is bound to the extent of possible vulnerability by information shared. Kanter, Kuczysnki, Manbeck, Corey, and Wallace (2020) further expanded this definition to a complete model of intimate relations. Their model, which relates to both verbal and nonverbal aspects, describes three distinct relations within an intimate relationship: nonverbal emotional expression and safety, verbal self-disclosure and validation, and asking and giving. In a nutshell, the model describes a cascade of interpersonal exchanges, both verbal and nonverbal. These are reciprocal exchanges, where one part self-discloses and receives a safety-providing and validating response. Upon getting the response, he is further encouraged to ask what he needs and receives (once again) an “empathically accurate and tailored response” (Kanter et al., 2020, p. 83).
Kanter's model describes the circumstances within which therapy occurs. The therapist is committing to provide safety and validation and meet the client's emotional needs. At the same time, the client is sharing his personal needs.
Implementing Kanter's model to online therapy stresses the unique features of distant treatment. The client's ability to manipulate the amount of information flow through the camera diminishes the probability of receiving punishment for nonverbal self-disclosure. At the same time, it reduces the likelihood of validation and, therefore, safety—this kind of exchange compromises the opportunity for an intimate relationship. Behaviorally speaking, online biofeedback therapy potentially hinders building a strong therapeutic bond, which is essential for therapy success.
Biofeedback therapy involves sharing, and we suggest adding a third type of self-disclosure (besides verbal and nonverbal emotional expression) to Kanter's model—psychophysiological data, which we shall elaborate on next.
Sharing from a Psychoanalytical and Developmental Perspective
As mentioned earlier, the screensharing option of the various video conferencing programs is very useful in remote therapy. This type of sharing emphasizes the “therapeutic triangle” in each biofeedback session (patient, therapist, and physiological data presentation). The therapeutic triangle is highly emphasized when the biofeedback is done from a distance. The therapeutic triangle's impact can be understood using the “join attention” concepts that emerged in the developmental psychology literature.
Joint attention or shared attention exist when two individuals look together at the same object (Corkum & Moore, 1995). This ability to attend to an aspect of one's environment is fundamental to developing relationships by sharing experience and knowledge. We place great importance on this sharing process of the subjective elements and the verbal interaction that should accompany biofeedback therapy. Following Rolnick and Rickles (2010), we will lean on some psychoanalytical and developmental concepts.
Biofeedback articles tended to focus on physiology and give little attention to states of mind and mental activity during biofeedback training. We assert that the psychoanalytic frame of reference can enhance biofeedback and biofeedback-assisted psychotherapy.
From an intersubjective point of view, we suggest that the therapist and patient interaction should be the center of attention. We suggest that within a biofeedback session, there occurs a replication of early interaction between a parental figure and a helpless child. The specific way the therapist (parental figure) interacts with patients regarding their efforts to self-regulate is crucial for psychophysiological psychotherapy's success. Biofeedback case studies tend to describe the advancement of the therapy between the sessions (i.e., what is being done on the first session in the second … and in the last). Somewhat less attention has been given to the description of the therapy within the session. Namely there is rarely a script of the specific step-by-step interaction between the therapist and the patient during a 1-hour session.
Rolnick (1999) and Hamiel and Rolnick (2017) suggested a model of integrating psychotherapy and biofeedback. In this model, there is a specific description of the way a meeting is conducted. They identified macro stages of treatment and divided each therapeutic session into alternating specific phases of practicing with the biofeedback equipment followed by phases of sharing.
The sharing phase is designed to facilitate interaction between the client and the practitioner. Its purpose is to gain some insight into the client's internal processes. The client is asked to tell the biofeedback trainer whether he felt he could relax and what was going on in his mind during the previous exercise.
At a superficial level, this is the client's way of telling the therapist what helped him regulate his physiology and what hampered the process. At a more profound level, a highly valuable therapeutic procedure commences during this stage. From birth, our processes of self-control are constructed through the dialogue between the mother and baby. The baby is overwhelmed by physical and emotional discomfort and by the experience of incompetence. The mother listens to her baby's complaints and comforts him by responding to his pain. The act of sharing between client and practitioner resembles this very primary process between child and caregiver.
To facilitate the sharing of the subjective process, after the period of training, the client should share with the biofeedback practitioner what else went on in his mind during practice and how he felt. Several points may arise during this phase. He may also speak of being frustrated about not being able to fulfill the assignment of relaxing. On the other hand, the client may reveal, for the first time, how eager he was for a chance to “let go” and how much he missed having a warm and tender significant other.
Sharing from an Experiential Perspective
Sharing builds intimacy. Intimacy facilitates sharing. Intimate interactions can be seen as the bridge between intimate experiences and intimate relationships (Prager, 1997). Interactions primarily consist of behaviors and experiences, which can be emotional, cognitive, social, and physical. The act of sharing in the context of biofeedback entails all the elements of a shared intimate experience. In order to achieve the level of sharing in which the patient is willing to volunteer information that can be potentially “punishable,” the therapist needs to gradually build a level of trust that will allow the open sharing.
We suggest that following the therapy stages as suggested by Hamiel and Rolnick (2017) becomes increasingly important as the ownership of the physiological data shifts from therapist to patient. In this light, we can see that biofeedback therapist's role will increasingly need to emphasize intimacy building.
Summary
It has been a year since the outbreak of the COVID-19 pandemic that has and is changing the world and the way we do therapy. While we hope that the vaccines being developed are going to change the picture, we have no doubt that this period during which we moved from face-to-face to remote therapy has permanently impacted the way we perform biofeedback and the way we conceptualize main elements in our work.
In this article we analyzed the main changes that characterize the remote therapy procedure: (a) The way we gather and share the physiological data, and (b) the way we share the subjective experience and the verbal interaction between the patient and the therapist. This analysis allowed us to emphasize a few elements in our biofeedback procedure that are somewhat neglected: the creation of a shared experience, and the creation of intimacy in psychophysiological therapy. We furthermore highlighted two interconnected topics that require further work: the partial convergence of biofeedback and personal informatics, and the need for standardization to facilitate the exchange and analysis of biofeedback and personal informatics data.
In a recent article, Ehrenreich and Rolnick (2019) suggested that we view biofeedback through the perspective of mentalization. They argued, “It makes it possible to see the unique contribution of the instrumentation to understanding internal processes as well as the importance of the presence of the therapist who sees these processes together with the patient” (p. 84). In this sense, the remote therapy paradigm and the sharing process further emphasize this unique combination of technical aspects and interpersonal processes.
Contributor Notes