BIOFEEDBACK AND MINDFULNESS IN EVERYDAY LIFE

Practical Solutions for Improving Your Health and Performance

INNA KHAZAN, PH.D.

W. W. NORTON & COMPANY Independent Publishers Since 1923 A Norton Professional Book

Acknowledgments

The book you hold in your hands would not have been possible without the many wonderful
and supportive people in my life whose contributions have been invaluable and to whom I am
forever grateful. First, I'd like to thank the amazing team of editors at W. W. Norton. To
Deborah Malmud, Vice President and Editorial Director at Norton Professional Books, thank
you for encouraging me to undertake this project and your wise and thoughtful guidance in
making it come to fruition. Thank you to Mariah Eppes and Sara McBride for your keen
attention in making sure all the details of the book were well taken care of. To Trish Watson,
thank you for your masterful editing of the book. Thank you to everyone else at Norton
working behind the scenes. I owe an immense debt of gratitude to Christopher Germer who
has been my mentor and friend for many years. Chris, thank you for introducing me to
mindfulness and self-compassion and guiding me in practice, for patiently helping me work
through the nuances of how mindfulness and biofeedback fit together, for providing
inspiration, and most of all, for your unwavering support and belief in my ideas. I am grateful
to my biofeedback mentors and colleagues who have shared their knowledge, expertise, and
friendship with me over the years. To Fredric Shaffer, thank you for everything you have
taught me, for giving me opportunities to grow and contribute to the field, and for your trust
and friendship—they mean more to me than words can express. To Donald Moss, thank you
for sharing your passion for writing, for encouraging me to write more on the subject of
biofeedback and mindfulness, and for your ever-present support. Christopher Gilbert, thank
you for our deep enlightening conversations, your willingness to review and improve chapters
of this book, and tireless encouragement. Richard Gevirtz, Paul Lehrer, and Erik Peper—so
much of what I know about biofeedback I've learned from you. Thank you for your generosity
in sharing your expertise, materials, and passion for the science and practice of biofeedback. I
am grateful to my friends and colleagues at Biofeedback Certification International Alliance:
Randy Lyle, Leslie Sherlin, Dave Hagedorn, Don Moss, Fred Shaffer, Denise Graf, and especially
Judy Crawford. Judy, thank you for your wisdom and friendship over the years.

I am honored to work with incredibly talented scientists and clinicians at the Association for
Applied Psychophysiology and Biofeedback, many of whom I call my friends. A special thank
you to Michelle Cunningham, Ethan Benore, Katie Fleischman, Tracy Heller, Heather King,
Urszula Klich, Leah Lagos, Brad Lichtenstein, Diana Martinez, Ainat Rogel, Christine Sanchez,
and Patrick Steffen. I am grateful to my colleagues at the Institute for Meditation and
Psychotherapy, and especially to Susan Pollak, who was also one of my first meditation
teachers. Susan, I have learned so much from your kind and compassionate presence. Thank
you for helping me deepen my practice and for your support and encouragement throughout
this process. To my colleagues at the Biofeedback Federation of Europe and Thought
Technology LTD—thank you for your support of my work and for the many years of fruitful
collaboration, and especially to Carol Meyers, Hal Myers, and Jon Bale. A special thank you to
Lawrence Klein for his unending enthusiasm in advocating for mindfulness-based biofeedback
and my work in particular. I am grateful to my early biofeedback mentors Saul Rosenthal, Satya
Bellerose, Leslie Borne, and Amaro Laria, as well as local Mends and colleagues Elizabeth
Gagnon, Vikki Brown, and Rebekah Montgomery for supporting and fostering this work. I am
grateful to Judy Krulewitz for her wisdom and guidance over many years. My international
colleagues and Mends—David Arroyo and Claudia Coronel-Arroyo, Hiroko Demichelis, Yuval
Oded, Federico Pedrabissi, Arnon Rolnick, and Jan Vagedes—thank you for your friendship,
collaboration, and enthusiasm for bringing biofeedback and mindfulness together. To my
colleagues at Meru Health—Kristian Ranta, Albert Nazander, Outi Hilgert, and Disha Roy—
thank you for your wisdom and ingenuity in bringing mindfulness and biofeedback together. I
am grateful to my students who have helped me refine ideas presented in this book and to my
clients who have sought me out and allowed me to learn from them on their journey to
improving their health and performance. I owe a profound debt of gratitude to my family and
friends, who have supported me throughout this project in every possible way. To my husband
Roger—this book would not have happened without you. Thank you for being a sounding
board, a tireless editor, and a steadfast supporter. Thank you for the sacrifices you've made in
order to give me time to write. Thank you for always being there. To my children Robert,
Aaron, and Eliana—thank you for your laughter, smiles, and a limitless supply of hugs. Thank
you for your patience and understanding when I had to work late to meet a deadline. To my
father, Simon Zaslaysky, who passed away 5 years ago—even though you are no longer here, I
am forever grateful for the lessons you've taught me and for the encouragement to follow my
passion. To my mother, Sima Zaslaysky, thank you for being just a phone call away, your
unconditional support, and always being willing to help with the kids to allow me to write. I am

fortunate to have an amazing extended family who have always believed in me and supported
me. I am grateful to Leonard Khazan and Lana Brodsky, Irina, Alex, and Dana Dubovis, Izolda
Lishansky and Jacob Fink, Marina and Mark Lishansky. And finally, I couldn't have done this
without the support of my friends: Lucy and Igor Lubashev, Buket and Dan Grau, Anya and
Eugene Dashevsky, Anna and Mark Gurevich, Gami and Seth Maislin, Eddie and Debra
Bruckner, Marina Shtern and Grant Heard, Dan and Marianna Utin, Katya and Leonid Taycher,
and Maria and Leo Mirkis. Thank you all! I could not have done this without you.
Introduction

Imagine you are learning to fly an airplane and someone covers up the instrument panel—you
are learning to fly with only what you see outside the window for feedback; you don't know
what's going on inside the plane. Then, the instrument panel is opened, and you can suddenly
see all the instruments. You no longer have to guess what the plane's altitude is by looking out
the window; you know exactly how high you are flying. You no longer have to guess the plane's
direction, or fuel level, or air pressure. How different would your experience be flying with full
information about the external and the internal environment of the plane? Having full
information from the instruments, you can now adjust your altitude and direction to get
exactly to where you need to go, rather than guess and hope you get close enough without
crashing in the process. Has there been a time in your life when you've attempted to make
changes to the way you feel or do things and felt like you were flying blind, not knowing which
changes to make and how to make them, or whether they would even help? Perhaps you've
fried to control your anxiety, stop feeling depressed, fix your pain, or reduce stress? Perhaps
you've wanted to do better at your job, in a sport, or in artistic performance? Or maybe you've
wanted to do better in your personal life, be a better partner, parent, or friend? Did you ever
feel like you had a general idea of what you needed to do to make changes but had a hard
time doing it or getting the results you wanted? Often, in our attempts to fix ourselves—get rid
of anxiety, sadness, or pain or fix whatever gets in the way of performing at our best—we end
up making those things worse and then "beat up" on ourselves for being unable to achieve our
desired goals. For example, in our professional lives, we as human beings often bring a great
depth of skill and knowledge to our work. We excel in many areas of expertise and lead
successful lives and careers. And yet, we are not always able to bring our knowledge and skills
to bear in high-stress situations, leaving us dissatisfied with our performance. Similar situations
happen in our personal lives too. We might know how we want to act but are unable to act in
accordance with this knowledge because automatic reactions from our minds and bodies
override our intentions. These challenges are not related to a lack of any professional or
academic skill or experience and require a set of skills not typically taught anywhere. Our
mind's and body's abilities to regulate our physiological and emotional activation are at the
core of how we handle stressful situations. Ideally, we want our brains and our bodies to work
in ways that foster a resilient response to stress, and we want them to recover quickly once
the stressful event is over. For most of us, the only way to get there is to specifically train our
brains and bodies to self-regulate at all times, and especially when the stakes are high. This is
what this book is about. This book is intended to help you find simple, practical solutions for
improving the way you respond to life challenges and increasing your resilience and emotional
flexibility. Simply put, this book is about helping you do what you do, but better. Many books
have been written about ways to fix what's wrong with people. This book is not about fixing
yourself—it is not helpful to see yourself as broken. Rather, this book is about using the
powers of your mind and body to their fullest potential. The purpose of this book is to guide
you in training your body and your brain to perform at their best to meet whatever challenges
come your way. It addresses three components of training—physiological, emotional, and
interpretive. The physiological component is the ability of your body to self-regulate, or adjust
your physiological activity to be most helpful at each moment throughout your day, whether
facing a challenge, recovering from a challenge, or engaging in everyday life. In this book I
discuss physiological concepts vital to your ability to self-regulate and ways to use this
knowledge in everyday life. I introduce the technology of biofeedback and suggest practical
skills using this powerful tool to train self-regulation. With biofeedback, you learn to activate
or power up your body to just the right level for the task or challenge you face and then, once
that challenge is over, to recover quickly and fully. The emotional component is the ability of
your mind to respond in the most helpful way to emotions that arise moment to moment,
without getting stuck in difficult emotions, while cultivating compassion and fostering
resilience. Mindfulness and compassion training are central to our ability to regulation
emotion. I discuss these concepts in detail and provide you with practical skills aimed at
cultivating mindfulness and compassion in training emotional regulation. The interpretive
component is the ability to integrate the physiological and emotional training you have done.
With physiological and biofeedback-based training, you train your body to find the sweet spot
of activation needed to meet the challenge and to recover fully. With mindfulness training you
train your brain to activate in just the right way to allow dear thinking, decision making, and
emotion regulation. Nov your brain and your body are able to do what they do best to support
you during a challenge. Sounds great, right? Except that's not enough. What you also need is
the ability to recognize the signs of physiological and emotional activation as being helpful and
adaptive and not fight against them with attempts to calm down. This book will help you to tell
the difference between helpful and unhelpful activation, both physiological and emotional, to
provide you with skills to allow helpful activation to stay and to respond to the unhelpful
activation. In other words, this book will allow you to take the cover off the instrument panel
and stop flying blind. You will benefit from reading this book and incorporating the skills
discussed here if you would like to achieve any of the following goals: Improve our professional
performance Improve your athletic performance Improve your academic performance Better
regulate your emotional reactions Improve your ability to make quick decisions Improve
flexibility in responding to difficult situations Improve ability to cope with stress, anxiety,
sadness and depression, pain, shame and anger Improve your sleep Improve communication
with important people in your life Find ways to better take care of yourself This book contains
three parts. The first part is dedicated to psychophysiological biofeedback-based skills. You will
learn about the concept of biofeedback and five modalities of physiology that you may be able
to improve by using the skills described in each chapter, as well as ways in which these skills
may be helpful to you in your everyday life. You will learn ways in which you may be able to
train your physiology using biofeedback devices, as well as things you can do by using
psychophysiological knowledge without the use of devices. All skills are described in a clear,
step-by-step manner, enabling you to begin practicing right away. The second part addresses
mindfulness and compassion. You will learn ways to introduce meditation into your life or
deepen your existing meditation practice. You will also learn mindfulness and compassion-

based skills that you may be able to use in moments of increased challenge or distress. The
third part of the book is dedicated to applying biofeedback and mindfulness-based skills to
specific challenges you may encounter: sleep difficulty, stress, anxiety, sadness and depression,
pain, anger, and communication with important people in your life. As you move through each
chapter and section of the book, you will be able to formulate your own training plan. You will
decide whether your plan will include biofeedback and, if so, which modalities. You will decide
whether to include a biofeedback device or follow the guidelines without one, or whether to
enlist the help of a biofeedback therapist, as well as how to choose one. You will decide how to
practice mindfulness: Will you meditate? If so, which meditation will you start with? Will you
use mindfulness-based skills, and if so, which ones seem the most helpful to you? Will you
practice compassion, gratitude, and appreciation, and how might they fit into your life? You
will decide how to apply these skills to any of the issues described in part 3—stress, anxiety,
anger, sadness, depression, pain, shame, sleep difficulty, and communication challenges. At
the end of the book the appendices provide a collection of meditation scripts that you will find
useful in your practice. I have made recordings of these meditations available on my website at
wvvvv.innakhazan.com/meditation_recordings.html. And throughout the book I've placed
notes to additional scientific sources, if you would like to dig deeper into the evidence for the
concepts and techniques I describe. Finally, I would like to offer a few tips that may make it
easier for you to make good use of this book: I suggest many different exercises and practices
to guide your training. I encourage you to do the practices—don't skip over them. You will
benefit a lot more from doing the practice than from just reading about the concepts. Many of
the concepts introduced in one chapter are intertwined with concepts in other chapters. Refer
back and forth between chapters as you need to. Skills I discuss in the context of one
application are not exclusive to that application; they can be applied to other situations as
well. For example, anxiety skills can be applied to sadness/depression, shame, or pain. I
encourage you to keep a notebook to write down thoughts that occur to you as you read, to
do some of the exercises in the book, and to keep track of what's important. Writing things
downs as you go will help you process them and remember them much better than if you just
read them. I hope you enjoy the book and find the practical skills useful in improving your
health and performance. If you have questions or comments, you can reach me through my
website at www.innakhazan.com.

BIOFEEDBACK AND MINDFULNESS IN EVERYDAY LIFE

PART I

Physiological Principles

CHAPTER 1

Biofeedback

As David sat on the train on the way to work, he silently ran through the mental checklist of
everything he had to do that day. He had a very important meeting with his boss as soon as he
got to work, followed by a team brainstorming meeting for a new project he was heading, and
then a lunch date with Kate, whom he recently met online, and he really wanted to make a
good impression. The rest of the afternoon he would spend making phone calls and answering
e-mails, and maybe getting some of his own work done as well. The train suddenly came to a
stop. Startled, David looked around. They were in a tunnel. The train engineer's voice came on
the intercom announcing that there is a medical emergency at the stop ahead and they would
be standing by for a while. David's stomach tied itself in knots—this could not have happened
on a worse day! Now hell be late for the meeting with his boss, and since there was no cell
reception in the tunnel, he didn't even have a way to let him know. By the time the train
started moving, David was fidgeting in his seat, feeling sweaty and anxious. He checked the
heart rate monitor he wore on his wrist—his heart rate was in the nineties! Once he was off
the train, David ran all the way to work, bursting into his boss's office, panting. The meeting
was short, and David could barely remember what happened. He could not focus during the
brainstorming session with his team. All he could do was think about whether this meeting
with his boss was going to affect his promotion and feel his heart pounding in his chest. His
wrist monitor confirmed that his heart was beating too fast. He met Kate for lunch, but his
stomach was tense and he was feeling nauseous. It was hard to keep a smile on his face and
have a conversation. David spent the rest of the afternoon beating up on himself for what
must have been a terrible impression he made on Kate. She'll never want to talk to him again.
He checked his heart rate monitor again—still nineties, but he didn't know what to do about or
how to bring it down.

Like David, you've probably heard the advice, Listen to your body. You often hear it when you
exercise, play sports, perform, make lifestyle changes, or fry to find ways to improve your
health. Your body is constantly sending you signals—through your heart rate, your breath,
your muscles, your skin, and so forth. Unfortunately, many of those signals are subtle, and
either you are not aware of them, don't recognize their importance, or don't know what to do
with them. At some point, your body will turn up the volume of its messages to get your
attention. Pain, high blood pressure, headaches, stomach aches—all those are your body's way
of turning up the volume to get your attention. You definitely hear those, but do you know
how to respond to them? Biofeedback gives you the clearest and most effective way to
understand the messages your body is sending you, learn to recognize them before the signals
intensify, and know what kinds of changes you need to make and how to make them. This
chapter discusses what biofeedback is, scientific evidence for its effectiveness, how you may
be able to use it in your own life, and the process of biofeedback training.

Biofeedback is a learning process that helps you develop greater awareness and ability to
influence your physiological, emotional, and cognitive activity by using signals from you own
body to improve your health and performance. Sensors are placed on the surface of your skin
to read the signals your body is sending—your breathing, heart rate, muscle tension, finger
temperature, and skin conductance. I say more about these modalities shortly. Biofeedback
software picks up these signals and displays them for you on a computer screen in a clear,
easy-to-understand way. You can see what happens to your heart rate when you make
changes to your breathing. You can see what happens to your muscle tension when you
change positions or release your muscles. You can see what happens to your breathing and
heart rate when you meditate. You can see what happens to your finger temperature when
you imagine yourself sitting on a beautiful, warm beach. You get the point—you can observe
subtle changes in your body's functioning in response to your thoughts, feelings, and actions.
This feedback allows you to "hear" the signals from your body in a different way and learn how
to interpret them and how to respond to them. In other words, biofeedback allows you to truly
listen to your body.

BIOFEEDBACK IS NOT A RELAXATION TOOL

Many people believe that biofeedback is a way to learn to relax. While it is true that you can
learn to relax using biofeedback, relaxation is not the main goal. The main goal is self-
regulation, which means being able to activate your nervous system most optimally for action
and being able to relax and recover after the action is complete.

The goal of biofeedback is to increase your body's ability to regulate itself. Self-regulation is
the ability of your nervous system to respond adaptively to changes in your environment, both
internal and external. Much of the regulation in your body happens automatically, without
conscious awareness on your part. For example, your brain monitors and adjusts your body
temperature and pH levels to keep them stable. Your brain also monitors your heart rate,
breathing, and blood pressure and adjusts them based on the needs of your body at that
moment. This kind of self-regulation is necessary for your mind and body to switch gears
smoothly while going from one state to another. For example, self-regulation is necessary to
transition from an intense argument with a spouse to being able to sleep. It is necessary to
transition from running late to a meeting to being able to lead it. It is necessary to quickly
access your physiological and emotional resources to attend to an unexpected crisis. Your
ability to self-regulate in these complex ways can get disrupted and lead to difficulty in
adjusting to changes in your environment and meeting daily life challenges, as well as
undermine your resilience. In the example above, David had trouble with self-regulation as he
waited on the train, transitioned from a difficult meeting with his boss to brainstorming with
his team, and attempted to be present during his lunch with Kate. Your body's ability to self-
regulate can get disrupted by circumstances such as trauma, chronic stress, physical, or mental
illness. It can also get disrupted when you have a hard time understanding the signals your
body is sending you.

WHAT IF YOU DON'T HAVE A BIOFEEDBACK DEVICE?

You may use the principles of psychophysiology underlying biofeedback to strengthen your
self-regulation and improve your health and performance without the use of biofeedback. I
encourage you to use the most easily accessible devices (such as a heart rate variability app on
your phone, or a thermometer or even a piece of chocolate) if at all possible. The feedback
these simple devices provide will give you benefit above and beyond training without it.
However, if using biofeedback is simply not possible, or if your device measures some but not
all modalities you'd like to train, you may use psychophysiological principles outlined in each
chapter without measurement and still derive benefit.

Biofeedback provides you with the information you need to train and strengthen your ability
to self-regulate. Biofeedback works by measuring parameters of your body's physiological
functioning and displaying that information back to you for use in making appropriate
adjustments. Biofeedback training is learning how to make adjustments to your physiological
functioning based on the feedback you receive. Biofeedback and biofeedback training can be
done using various devices, from very simple to very sophisticated: Biofeedback can be done
without technology, such as by using a mirror to observe your breathing patterns and make
adjustments to it, or by using a piece of chocolate to give you information about finger
temperature (see Chapter 5 for more on this). You can use simple technology, such as a
thermometer to measure finger temperature. You can use sophisticated but simple-to-use
self-training devices, such as heart rate or heart rate variability (HRV) measurements using
your smartphone's camera or small devices that connect to your mobile device and measure
skin conductance or HRV. You can use sophisticated, multimodality devices using advanced
graphics and software. These devices are typically used by biofeedback therapists.

Biofeedback Modalities

Biofeedback devices can measure several parameters of your body's physiological functioning
—these are called biofeedback modalities. Each one gives you important and unique
information about the way your body functions. Each modality can help you listen to different
signals your body is sending and help you train your ability to self-regulate in different ways. I
review various biofeedback modalities in this section and then discuss scientific evidence for
how each modality is best used. Biofeedback modalities include the following:

Breathing. Some biofeedback devices measure rate and pattern of your breath using a belt
that goes around your waist. Other devices measure concentration of oxygen and/or carbon
dioxide in your blood using a finger oximeter to measure oxygen or a nasal cannula of an
instrument called the capnometer to measure levels of carbon dioxide. Heart rate. These
biofeedback devices measure heart rate using a finger photoplethysmograph, a device that
sends a red light through your finger and determines your heart rate based on how much red
light is absorbed, or an electrocardiogram sensor that detects electrical signals from your
heart. Heart rate variability (HRV). This measurement is done with software from your heart
rate signal. HRV is the difference in time that passes from heartbeat to heartbeat and is
determined through statistical calculations using the heart rate measurements. Muscle
tension. These biofeedback devices measure electrical activity of the muscles using surface
electromyography (sEMG), which detects electrical impulses sent out by the muscles as they
activate. Temperature. These biofeedback devices measure finger and sometimes toe
temperature using a thermistor, which transforms warming of the sensor into electrical
information that is displayed on the screen as your temperature. Skin conductance. These
biofeedback devices measure activity of sweat glands on your fingers or the palm of your
hand. As your sympathetic nervous system (the one responsible for the stress response) is
activated, sweat glands become more active and produce more sweat. The sensor sends a very
small electrical current through your finger to determine how conductive your skin is—the
more moisture there is, the more conductive your skin is. Higher skin conductance indicates
increased stress activation. (You don't need to worry about being electrocuted by the electrical
current—it is a very small current that you don't even feel.) Brain waves. This type of
biofeedback, called neurofeedback or EEG (electroencephalogram) biofeedback, measures
electrical activity of the brain. Because this book is dedicated to body biofeedback, I do not
discuss neurofeedback.

Research Evidence for Biofeedback Success Biofeedback has been scientifically shown to be an
effective tool for improving many areas of your health and performance. Keep in mind that it
is not a panacea, not a fix for everything. Think about what kind of changes you'd like to make,
and then decide whether the research evidence supports the use of biofeedback for these
areas. To help you decide, I include a list of conditions for which biofeedback has been
scientifically shown to be helpful.' This list does not include conditions best treated with
neurofeedback. Please keep in mind that self-training in biofeedback is not intended to be a
substitute for treatment with a biofeedback therapist. If any of these conditions listed present
a significant problem in your life, consider seeking out a biofeedback therapist to help you with
training. Asthma Anxiety Chronic back pain Depression Diabetes (for glucose control)
Fibromyalgia High blood pressure Insomnia Irritable bowel syndrome (135) Migraine
headaches Noncardiac chest pain Posttraumatic stress disorder (PTSD) Preeclampsia Repetitive
strain injury Raynaud's disease, a condition in which fingers and; or toes, and sometimes nose
and ears, temporarily lose circulation (because of blood vessel constriction), tarn colors (white,
blue, and red), and feel very painful Temporomandibular joint (TMJ) disorders Tension
headaches Tinnitus Traumatic brain injury Biofeedback has also been shown to be an effective
tool in enhancing performance in professional fields, music, and athletics. Specifically,
biofeedback is helpful in enhancing the following qualities: Overall self-regulation ability
Athletic performance, endurance, and reaction time Performance in dance and music Ability to
interpret manifestations of stress in helpful ways _Ability to sustain attention Decision making
Emotion regulation Goal-directed behavior Memory capacity and retrieval Situational
awareness All of these qualities establish an important foundation for optimal performance in
multiple professional and athletic arenas.

Self-Training Versus Working With a Biofeedback Therapist

Given the availability and improving quality of low-cost biofeedback devices, you have a lot of
excellent options for self-training. Appendix B gives examples of self-training devices you can
use for each biofeedback modality. Following the guidelines provided in Chapters 2-6,
dedicated to each of the biofeedback modalities, will equip you with the ability to train
yourself. You may consider working with a biofeedback therapist if you have complex medical
or psychological needs or if self-training is not producing the benefits you are hoping for.

How to Find a Biofeedback Therapist

As with any medical or mental health professional, it is important to ensure that the
biofeedback therapist you choose is properly credentialed and trained. There is no license to
practice biofeedback, but there is biofeedback board certification for those who are licensed in
a related field and are trained to practice biofeedback. Biofeedback therapists are typically
licensed in medical or mental health fields, such as psychology, medicine, social work,
occupational or physical therapy, dentistry, nursing, or counseling. Biofeedback therapists not
licensed in a medical field, who provide only optimal performance training without treating
any medical or mental health conditions, may also be board certified in biofeedback.

Biofeedback practitioners may hold one or more of four certifications: biofeedback (BCB),
neurofeedback (BCN), heart rate variability biofeedback (BCB-HRV), and pelvic floor
biofeedback (BCB- PMD). Biofeedback-certified therapists (BCB) are trained in all the
biofeedback modalities described in this book. Those certified in HRV biofeedback are trained
in heart rate and respiratory biofeedback only. Neurofeedback-certified therapists are trained
in neurofeedback, a modality I do not cover in this book. Pelvic floor biofeedback therapists
are typically occupational or physical therapists who work with pelvic floor pain and
incontinence. The Biofeedback Certification International Alliance (BCL1) can help you find a
board-certified biofeedback therapist. BCL1 is the certification body for biofeedback
practitioners in the United States and around the world. Visit the BCI4 website at BCIA..org and
click on Find a Practitioner. If you would like to find a therapist who can help advance your
biofeedback training using the guidelines in this book, look for BC& or BCB-HRV-certified
practitioners.

What Biofeedback Is and Is Not

As you decide how to use biofeedback training in your own life, it is important to recognize
what biofeedback can and cannot do, and also important to recognize what biofeedback can
and cannot do, and also what it is and what it is not.

WEARABLE DEVICES

The popularity of wearable devices has been remarkable. Lots of people are walking around
with various devices that measure steps, sleep, movement, and heart rate, and some that also
measure blood pressure, temperature, calories, muscle tension, and heart rate variability.
Much of the information these devices give us would be considered biofeedback, because they
measure physiological parameters and give us feedback about it. However, not all of the
information these devices give you can be easily used for biofeedback training.

Several components are necessary to call something biofeedback and for that biofeedback to
help you with self-regulation training. First, biofeedback provides information about
physiological functioning of your body, such as breathing or heart rate. This component of
biofeedback is called psychophysiological monitoring. It is necessary, but not sufficient, for the
process of biofeedback. The second component is the feedback about your physiological
functioning. An example of physiological monitoring is the nurse at your doctor's office
measuring your blood pressure and heart rate during your physical exam. When she tells you
what your heart rate and blood pressure are, giving you feedback, the information becomes
biofeedback. The feedback is necessary for you to be able to make helpful changes to your
physiological functioning. Making these changes based on the feedback you receive is
biofeedback training. For example, as you change your breathing rate and pattern, you observe
the changes in your breathing and heart rate displayed on the screen, giving you the ability to
refine the change to what you need ii to be. Many apps are available on mobile devices that
deal with some aspects of physiology. Some apps measure your heart rate, which is a form of
biofeedback. David's heart monitor is that kind of biofeedback device. Some apps measure
your HRV, mostly with the use of an externs device that measures your heart rate and HRV and
sends information to your phone. There are also a few apps that measure HRV using the phone
camera. These apps are inexpensive and easily accessible forms of biofeedback. Keep in mind
that not all biofeedback devices allow you to train the physiological parameter they measure.
For example, some HR` apps measure and give you feedback about your HRV but do not offer
training using feedback. Just knowing what your HRV is over some period of time is not enough
to know how to make changes. Choose an app or device that gives you live, real-time feedback
about the moment-to-moment changes in your HRV. See Appendix B for examples of Choose
Your Modalities

Make a Plan for Practicing Biofeedback

Biofeedback devices that measure your HRV and allow you to train it, as well as examples of
devices for other biofeedback modalities. There are also numerous apps that guide and pace
your breathing in some way. These breathing pacing apps are not biofeedback because they do
not measure anything about your physiology and do not provide feedback. Some of these
apps, however, are quite useful in facilitating your biofeedback training and can be used to
guide your self-practice if you have chosen not to use a biofeedback device. Examples of these
apps are also listed in Appendix B. I've seen cases where, under the guise of biofeedback,
people were offered a recording with a relaxation exercise or a meditation. That is not
biofeedback, although recordings are often used as part of biofeedback training. Breathing
training without some sort of physiological measurement and feedback is also not
biofeedback. People sometimes see biofeedback as something that is done to them as a way of
curing whatever ails them. It is important to remember that biofeedback is not something that
is done to you. Biofeedback is a tool that helps you take an active part in your own training to
improve your health and well-being. Your willingness to be an active participant is crucial. The
next section outlines steps you can take to maximize the effectiveness of your biofeedback
practice.

Biofeedback Training Plan

1.-Decide which modalities of biofeedback are most likely to be useful to you. Choose
modalities based on the goals you'd like to achieve. The following is a concise list of modalities
and areas for which each modality may be helpful. Please refer to chapters devoted to each
modality for more details.

Breathing (Chapter 2)—breathing dysregulation, especially overbreathing; also asthma,

anxiety, chronic pain, headaches, anger, IBS, Rayisaud's disease, stress, and performance
improvement Heart rate variability .

(Chapter 3)—asthma, anxiety, anger, depression, headaches, high blood pressure, IBS, chronic
pain, preeclampsia, posttraumatic stress disorder, stress, and performance improvement.

Muscle tension (Chapter 4 —muscle-related pain, chronic back pain, anxiety, tension
headache, T u disorders, repetitive strain injury-, and muscle-related areas of performance,
such as learning to use correct muscles to perform certain movements.

Temperature (Chapter 5)—Rapsaud's disease, high blood pressure, migraine headaches,

stress, and performance improvement.

Skin conductance (Chapter 6)—anxiety, stress, motion sickness, and performance

improvement. If you choose to work with a biofeedback therapist, he or she will be able to
conduct stress and relaxation assessments, which will further guide your choice of training
modalities. These assessments will pinpoint which areas of your physiology need to be trained
and how.
Monitor Your Progress

Skills Once you've chosen your modality or modalities to train, think about good practice
times. Having a regular time to practice will help you establish a routine, which is crucial for
developing new habits. Pick a time when you are able to practice most days of the week, when
you are less likely to be disturbed or be tired or hungry. Practicing at bedtime can often be a
good way to end the day and establish a consistent routine. However, if you fall asleep while
practicing your skills (which are often relaxing), consider picking a different time when you are
able to follow through with the practice and is predictable day to day. Helpful times may be
when you first wake up in the morning, right when you get to work or to school, before or
after lunch, before you leave work or school, or when you first get home. Regular practice is
crucial to biofeedback success. Practicing a skill once or twice or every once in a while is
unlikely to benefit you. Once your biofeedback practice is established, practicing your skills 7
days a week for 20 minutes a day is ideal. Set realistic goals for practice until it becomes a
habit. For example, you may start with 5 minutes 3 times a week and then increase to 5
minutes every day, then 10 minutes every day, then 15, and finally 20 minutes a day. It is often
difficult to figure out how to fit all the good things you can be doing for yourself into your day
—biofeedback, meditation, exercise, walking, massage, acupuncture, physical therapy,
meetings with a mental health therapist, and so on. Biofeedback and meditation can often be
combined into one practice time—you initially learn biofeedback and mindfulness skills
separately and then combine them. This makes it a little easier to make time for two important
components of health and well-being. Twenty minutes a day may be possible to find in
addition to everything else that is important for you to do. There will be days when something
else takes precedence—that's expected and understandable. Just make sure that if you have
decided to devote time to biofeedback (and mindfulness) practice, the practice happens as
regularly as possible. Don't over-practice. Limit each session of biofeedback practice to 20
minutes. Twenty-minute sessions are sufficient to make progress and will limit boredom and
frustration if things are not going as you'd like them to. If you'd like to practice more to reap
greater benefit, set aside two 20-minute time periods each day, one in the first and one in the
second part of the day.

3- Before starting your biofeedback skills training, choose areas of functioning where you
would like to see improvement. It could be your blood pressure readings, the way you perform
under pressure, your endurance in athletic training, your test-taking ability, your performance
in your professional arena, frequency, duration, and intensity of pain or headaches you
experience, or anything else you choose to track. Decide on your markers of progress, and rate
how well you are doing in that area before starting biofeedback training. Then check in with
yourself after 4-6 weeks of consistent training (consistency is key!). It will take a few weeks for
signs of progress to become apparent. Then continue checking in every 4-6 weeks to keep
track of continued progress. It is hard to keep track of so much information yourself. At the
end of this chapter I provide two worksheets you can use to keep track of your progress. The
first worksheet is designed to track continuous ratings of symptoms or performance goals,
which you can rate on a scale from o (low) to 10 (high). These ratings may be for symptoms of
anxiety, pain, gastrointestinal distress, mood, or level of stress or for performance and self-
regulation goals such as ability to shift from situation to situation, perceptions of your ability to
speak in public, or your rating of your sports or artistic performance. The second worksheet is
designed for specific physiological scores, such as your blood pressure readings or number of
headaches, or specific performance goals, such as the score on your tennis matches, the
number of goals you scored in soccer, and so forth. Each worksheet has a blank version for you
to copy and use and an example of one already filled out. It is not helpful to be constantly on
the lookout for ratings of how you feel or how you are doing, and it is often not realistic to
keep track of anything for very long, so I suggest rating your progress for one week at a time,
every few weeks (one week at baseline, one week at week 5 of training, one week at week Jo
of training, etc.)—this will give you sufficient data to track progress without overwhelming you.

4. Begin Training Follow protocols outlined in Chapters 2-6 depending on the specific modality
you've chosen to work with.

Biofeedback and Mindfulness

Biofeedback is often described as a way to control how you feel, emotionally and physically. As
I describe in detail in Chapter 9 on mindfulness-based skills, extensive research shows that
efforts to control your internal experience are unlikely to be helpful. In fact, these efforts are
much more likely to be counterproductive rather than helpful to your biofeedback training.
Instead of attempts to control what is out of your control (your feelings and emotions), I
suggest using a mindfulness-based approach to biofeedback. Chapter 7 provides background
information about mindfulness and Chapter 9 describes specific mindfulness-based skills that
you may use in life in general, as well as in your biofeedback practice to achieve the best
results from your practice. Please be sure to review chapters 7 and .g as you begin biofeedback
training. As you read more on mindfulness and mindfulness-based skills, compassion (chapter
n), as well as applications of biofeedback and mindfulness to specific conditions (chapters n-
11) such as anxiety and pain, you will learn more skills to integrate into your initial biofeedback
practice.

BIOFEEDBACK AND MINDFULNESS: STORY OF THE MIDDLE WAY

e synergy of biofeedback and mindfulness is reflected in the Parable of e Lute, a famous

Buddhist story describing the concept of the middle -ay. The parable tells the story of Sona,
the son of a rich businessman in cient India who became a monk. Sona meditated diligently all
day ong, attempting to experience nonattachment to worldly desires and the appiness that
comes with it. But despite his diligence and persistence, ona was frustrated by his lack of
progress toward happiness and the ersistent craving for worldly things. Sona went to the
Buddha and asked im why he was not successful in his practice. The Buddha replied with a
uestion: "Sona, are you not a skilled player of the lute?" "Yes," answered ona. The Buddha
then asked Sona: "When you played the lute, and its trings were too tight, was the lute tuneful
and easy to play?" "No,"

swered Sona. The Buddha went on: "And when the strings of the lute -ere too loose, was the
lute tuneful and easy to play?" "No, it was not," swered Sona once again. "But when the strings
of your lute were djusted just right, not too tight and not too loose, was your lute tuneful d
easy to play?" Wes." answered Sona. "So, Sona, just like the strings f the lute, if you strain too
hard or try to achieve your goal by force, you -ill fail, and if you don't try at all, you will fail, too.
Therefore, Sona, you hould find a balance between having a sense of purpose and moving
award it and exploring the moment the way it is." Biofeedback and mindfulness together
provide us with that middle -ay, finding the balance between goal-directed action and letting
go, like uning the strings of a lute—not too tight, not too loose.

One question I sometimes get from my clients is whether mindfulness and biofeedback are
fundamentally incompatible because biofeedback is all about making changes, while
mindfulness is about letting things be. I see biofeedback and mindfulness to be extremely
compatible and complementary to each other. Biofeedback is indeed about making changes.
The best way to make changes is to do so mindfully, focusing on what is under your control
(actions), rather than unsuccessful attempts to change what is not under your control
(thoughts and feelings). Mindfulness allows you to tell the difference between what is and is
not under your control and to focus on mindfully changing what you can. Mindfulness, the way
it is used in the West for purposes of improving health and well-being, has a goal of making
helpful changes, mindful changes, through letting go of what is not under your control and
focusing on what is. Biofeedback enables you to make mindful changes by strengthening your
physiological ability to self-regulate in moments of challenge and providing you with helpful
ways to respond to what is not under your control. Fundamentally, goals of biofeedback and
mindfulness are the same. They achieve those goals by providing balance between goal-
directed action and letting go. Mindfulness enhances biofeedback in the following ways: Brings
biofeedback training to its full effectiveness Enables you to make mindful changes without
getting stuck in an unhelpful struggle with things that are not under your control Enhances
your awareness of and ability to attend to physiological and emotional experiences Improves
learning, planning and decision making Improves emotion regulation Allows you to work with
what gets in the way of biofeedback success: —Automatic reactions to thoughts, feelings, and
physiological sensations —Attempts to control or resist —Judgment

Biofeedback enhances mindfulness in the following ways: Increases ability to self-regulate and
reduces intensity of suffering without a struggle Makes it easier to accept experiences that
may otherwise be fundamentally unacceptable, for example, learning to regulate your
breathing physiology during a panic attack, making it easier to accept the presence of panic
and not struggle against it Increases body awareness Illustrates connection between
physiological and emotional states Decreases physiological arousal to facilitate quiet
awareness

Reduces physiological symptoms at times of distress to allow mindful awareness Provides real-
time feedback on the effects of meditation.

Biofeedback Safety and Contraindications Biofeedback is generally quite safe. A biofeedback

device itself is not doing anything to you; it is only recording signals from your body so that
you can use the feedback to make helpful changes. However, there are circumstances when
you need to be cautious in using biofeedback: Biofeedback is not a substitute for other medical
treatment in severe or life-threatening conditions, such as cancer or heart disease.
Biofeedback may be an excellent addition to traditional medical treatment. If you have severe
mental illness, such as schizophrenia or another psychotic disorder, be sure to consult with
your mental health provider before using biofeedback. If you use medications for conditions
that may be improved with biofeedback be sure to consult with your health care provider
about medication dosage. Your need for medication may decrease as your condition improves.
Conditions for which medication adjustments are most likely to be needed are high blood
pressure, diabetes, asthma, pain, and headaches. If you are taking thyroid replacement
medications or anticonvulsants, consult with your health care provider as well. It is possible
that some of the subjective experiences that occur during biofeedback training, such as
physiological sensations, images, thoughts, or feelings, may be unexpected or startling to you.
For example, you might feel lightheaded, experience faster heartbeat, feel sleepy, or be
reminded of unpleasant experiences from your past. These unwanted effects are almost
always temporary and virtually never dangerous. If such experiences are persistent, consult
with a biofeedback professional for the best way to manage them.

Chapters 2-6 review underlying psychophysiology for each biofeedback modality and offer
step-by-step guidelines for training: breathing, heart rate variability, muscle tension,
temperature, and skin conductance, to help you select your biofeedback modalities for
training. Parts II and III offer guidance in mindfulness (part II) and applications for common
challenges you may encounter (part III). Once you've selected the biofeedback modalities you
would like to train, and reviewed Chapters 7 and 9 on mindfulness and mindfulness-based
skills to help your biofeedback practice be most effective, start your practice. As you progress
further through the book, integrate the new skills you learn into your practice.

Outcomes Tracking Worksheet 1: Continuous Goals

This tracking worksheet is for outcomes that can be rated on the scale from o to 10. You can
track symptoms you'd like to reduce, performance goals, or your perception of your resilience
or ability to self-regulate.

Decide whether you are looking to lower your scores (symptoms) or raise your scores
(performance, self-regulation). Then rate your outcomes on the scale from o (lowest) to 10
(highest).

Examples of symptoms you can track with this worksheet: anxiety, pain, muscle tension, anger,
stress, mood Examples of performance goals you can track: athletic endurance, quality of
public speaking, communication skills, ability to focus on a task

You can also track resilience, overall self-regulation, emotion regulation, and adaptability to
change. Rate how you did on your measure at the end of each day for 1 week at a time—a
week before starting biofeedback and mindfulness training, to establish a baseline, and then at
weeks 5, 10, and 15 to track progress. Starting at week 5, you would also write down the
number of minutes of biofeedback and/or mindfulness practice you did that day. Table 1.1 is a
blank tracking worksheet for you to use, and Table 1.2 is an example of a worksheet already
filled out. You can download electronic copy of the worksheet at
www.innakhazan.com/resources.html.