Erik Peper, PhD, BCB, Jillian Cosby, and Monica Almendras
In at the beginning of 2021, I broke my L3 vertebra during a motor cycle accident and underwent two surgeries in which surgeons replaced my shattered L3 with a metal “cage” (looks like a spring) and fused this cage to the L4 and L2 vertebrae with bars. I also broke both sides of my jaw and fractured my left shoulder. I felt so overwhelmed and totally discouraged by the ongoing pain. A year later, after doing the self-healing project as part of the university class assignment, I feel so much better all the time, stopped taking all prescription pain medications and eliminated the sharp pains in my back. This project has taught me that I have the skill set needed to be whole and healthy. –J.C., 28-year-old college student
Chronic pain is defined as a pain that persist or recurs for more than 3 months (Treede et al., 2019). It is exhausting and often associated with reduced quality of life and increased medical costs (Yong, Mullins, & Bhattacharyya, 2022). Pain and depression co-exacerbate physical and psychological symptoms and can lead to hopelessness (IsHak, 2018; Von Korff & Simon, 1996). To go to bed with pain and anticipate that pain is waiting for you as you wake up is often debilitating. One in five American adults experience chronic pain most frequently in back, hip, knee or foot (Yong, Mullins, & Bhattacharyya, 2022). Patients are often prescribed analgesic medications (“pain killers”) to reduce pain. Although, the analgesic medications can be effective in the short term to reduce pain, the efficacy is marginal for relieving chronic pain (Eriksen et al., 2006; Tan, & Jensen, 2007). Recent research by Parisien and colleagues (2022) reported that anti-inflammatory drugs were associated with increased risk of persistent pain. This suggest that anti-inflammatory treatments might have negative effects on pain duration. In addition, the long-term medication use is a major contributor to opioid epidemic and increased pain sensitivity (NIH– NIDA, 2022; Higgins, Smith, & Matthews, 2019; Koop, 2020). Pain can often be successfully treated with a multidisciplinary approach that incorporates non-pharmacologic approaches. These include exercise, acceptance and commitment therapy, as well as hypnosis (Warraich, 2022). This paper reports how self-healing strategies as taught as part of an undergraduate university class can be an effective approach to reduce the experience of chronic pain and improve health.
Each semester, about 100 to 150 junior and senior college students at San Francisco State University enroll in a holistic health class that focused on ‘whole-person’ Holistic Health curriculum. The class includes an assessment of complementary medicine and holistic health. It is based upon the premise that mind/emotions affect body and body affect mind/emotions that Green, Green & Walters (1970) called the psychophysiological principle.
“Every change in the physiological state is accompanied by an appropriate change in the mental emotional state, conscious or unconscious, and conversely, every change in the mental emotional state, conscious or unconscious, is accompanied by an appropriate change in the physiological state.”
The didactic components of the class includes the psychobiology of stress, the role of posture, psychophysiology of respiration, lifestyle and other health factors, reframing internal language, guided and self-healing imagery. Students in the class are assigned self-healing projects using techniques that focus on awareness of stress, dynamic regeneration, stress reduction imagery for healing, and other behavioral change techniques adapted from the book, Make Health Happen (Peper, Gibney, & Holt, 2002).
The self-practices during the last six weeks of the class focus on identifying, developing and implementing a self-healing project to optimize their personal health. The self-healing project can range from simple life style changes to reducing chronic pain. Each student identifies their project such as increasing physical activity, eating a healthy diet and reducing sugar and junk food, stopping vaping/smoking, reducing anxiety or depression, stopping hair pulling, reducing headaches, decreasing ezema, or back pain, etc. At the end of the semester, 80% or more of the students report significant reduction in symptoms (Peper, Sato-Perry, & Gibney, 2003; Peper, Lin, Harvey, Gilbert, Gubbala, Ratkovich, & Fletcher, 2014; Peper, Miceli, & Harvey, 2016; Peper, Harvey, Cuellar, & Membrila, 2022). During the last five semesters, 13 percent of the students focused reducing pain (e.g., migraines, neck and shoulder pain, upper or lower back pain, knee pain, wrist pain, and abdominal pain). The students successfully improved their symptoms an average of 8.8 on a scale from 0 (No benefit) to 10 (total benefit/improvement). The success for improving their symptoms correlates 0.63 with their commitment and persistence to the project (Peper, Amendras, Heinz, & Harvey, in prep).
The purposes of this paper is to describe a case example how a student with severe back pain reduced her symptoms and eliminated medication by implementing an integrated self-healing process as part of a class assignment and offer recommendations how this could be useful for others.
Participant: A 28-year-old female student (J.C.) who on January 28, 2021 broke her L3 vertebra in a motor cycle accident. She underwent two surgeries in which surgeons replaced her shattered L3 with a metal “cage” (which she describes as looking like a spring) and fused this cage to the L2 and L4 vertebrae with bars. She also broke both sides of her jaw and fractured her left shoulder. More than a year later, at the beginning of the self-healing project, she continue to take 5-10 mgs of Baclofen and 300 mgs of Gabapentin three times a day to reduce pain.
Goal of the self-healing project: To decrease the sharp pain/discomfort in her lower back that resulted from the motor cycle accident and, although not explicitly listed, to decrease the pain medications.
During the last six weeks of the 2022 Spring semester, the student implemented her self-healing practices for her personal project which consisted of the following steps.
1. Create a self-healing plan that included exploring the advantage and disadvantage of her illness.
2. Develop a step-by-step plan with specific goals to relief her tension and pain in her lower back. This practice allowed her to quantify her problem and the solutions. Like so many people with chronic pain, she focused on the problem and feelings (physical and emotional) associated with the pain. As a result, she often feel hopeless and worried that it would not change.
3. Observe and evaluate when pain sensations changed. She recognized that she automatically anticipated and focused on the pain and anxiety whenever she needed to bend down into a squat. She realized that she had been anticipating pain even before she began to squat. This showed that she needed to focus on healing the movement of this area of her body.
Through her detailed observations, she realized that her previous general rating of back pain could be separated into muscle tightness/stiffness and pain. With this realization, she changed the way she was recording her pain level. She changed it from “pain level” into into two categories: tightness and sharp pains.
4. Ask questions of her unconscious through a guided practice of accessing an inner guide through imagery (For detailed instructions, see Peper, Gibney, & Holt, 2002, pages 197-206). In this self-guided imagery the person relaxes and imagines being in a special healing place where you felt calm, safe and secure. Then as you relaxed, you become aware of another being (wise one or guide) approaching you (the being can be a person, animal, light, spirit, etc.). The being is wise and knows you well. In your mind, you ask this being or guide questions such as, “What do I need to do to assist in my own healing?” Then you wait and listen for an answer. The answer may take many forms such as in words, a pictures, a sense of knowing, or it may come later in dreams or in other forms. When students are assigned this practice for a week, almost all report experiencing some form of guide and many find the answers meaningful for their self-healing project.
Through this imagery of the inner guide script, she connected with her higher self and the wise one told her to “Wait.” This connecting with the wise one was key in accepting that the project was not as daunting as she initially thought. She realized that pain was not going to be forever in her future. She also interpreted that as reminder to have patience with herself. Change takes practice, time and practice such as she previously experienced while correcting her posture to manage her emotions and edit her negative thoughts into positive ones (Peper, Harvey, Cuellar, & Membrila, 2022). Whenever she would have pain or feel discouraged because of external circumstances, she would remind herself of three things:
A. I need to have patience with myself.
B. I have all the healing tools inside me and I am learning to use them.
C. If I do not make time for my wellness, I’ll be forced to make time for my illness.
5. Practice self-healing imagery as described by Peper, Gibney, & Holt (2002) and adapted from the work by Dr. Martin Rossman (Rossman, 2000). Imagery can be the communication channel between the conscious/voluntary and the unconscious/autonomic/involuntary nervous system (Bressler, 2005; Hadjibalassi et al, 2018; Rossman, 2019). It appears to act as the template and post-hypnotic suggestion to implement behavior change and may offer insight and ways to mobilize the self-healing potential (Battino, 2020). Imagery is dynamic and changeable.
The process of self-healing imagery consists of three parts.
- Inspection the problem and drawing a graphic illustration of the problem as it is experienced at that moment of time.
- Drawing of how that area/problem would look when being completely well/whole or disappeared.
- Creation of a self-healing process by which the problem would become transformed into health (Peper, Gibney & Holt, 2002, pp. 217-236). The process focused on what the person could do for themselves; namely, each time they became aware of, anticipated, or felt the problem, they would focus on the self-healing process. It provideshope; since, the person now focuses on the healing of the problem and becoming well.
The drawings of inspection of the pain and problem she experienced at that moment of time are shown in Figure 1.
Figure 1. Illustration of the problem of the pain. Thorns dug deep, muscles tight, and frozen vertebrates grinding.
The resolution of the problem and being well/whole are illustrated in Figure 2.
Figure 2. Resolution of the problem in which her muscles are warm, full of blood, free of thorns, relaxed and flexible and being whole happy and healthy in which her spine is warm, her muscles are warm, her back is flexible and full of movement.
Although she utilized the first image of the muscles warm, full of blood, free of thorns and the muscles relaxed and flexible, her second image of her fully being healed was inspired through a religious statue of Yemaya that she had in her room (Yemaya is a major water spirit from the Yoruba religion Santeria and Orisha of the seas and protector of women). Each time she saw the statue, she thought of the image of herself fully healed and embodying the spirit Orisha. Therefore, this image remained important to her all the time.
Her healing imagery process by which she transforms the image of inspecting of the problem to being totally well are illustrated in Figure 3.
Figure 3. The healing process: The sun’s warm fingers thaw my muscles, lubricate my vertebra, thorns fall out, and blood returns.
For five weeks as she implemented her self-healing project by creating a self-healing plan, asking questions of her unconscious, drawing her self-healing imagery. She also incorporated previously learned skills from the first part of the semester such diaphragmatic breathing, hand warming, shifting slouching to upright posture, and changing language. Initially she paired hand warming with the self-healing imagery and she could feel an increase in body warmth each time she practiced the imagery. She practiced the self-healing imagery as an in-depth daily practice and throughout the day when she became aware of her back as described in one of her log entries.
I repeated the same steps as the day prior today. I did my practice in the early morning but focused on the details of the slowed down movements of the sun’s hands. I saw them as they stretched out to my back, passed through my skin, wrapped around my muscles, and began to warm them. I focused on this image and tried to see, in realistic detail, my muscles with a little ice still on them, feeling hard through and through, the sun’s glowing yellow-orange fingers wrapped around my muscles. I imaged the thorns still in my muscles, though far fewer than when I started, and then I imaged the yellow-orange glow start to seep out from the sun’s palms and fingers and spread over my muscles. I imaged the tendons developing as the muscle tissue thawed and relaxed, the red of the muscle brightened, the ice on and within my muscles started to melt, and the condensation formed as it ran down into collected droplets at the bottom of my muscles. I imaged the thorns lose their grip and fall out, one at a time, in tandem with the droplets falling. I continued this process and imaged my muscles expanding with warmth and relaxation as they stayed engulfed in the warmth of the sun.
At the end of my practice, I did a small stretch session. I felt extremely refreshed and ready for yet another extremely busy day between internship, graduation, and school. I would say I felt warm and relaxed all the way into the afternoon, about 6 hours after my practice. This was by far the most detailed and impactful imagery practice I have had.
The self-healing imagery practice provided me with the ability to conceptualize more than my problem as it showed me the tools to (and the importance of) conceptualizing my solution, both the tool and end result.
Pain and tightness decreased and she stopped her medication by the third week as shown in Figure 4.
Figure 4. Self-rating of sharp pains and tightness during the self-healing project.
At the 14-week follow-up, she has continued to improve, experiences minimal discomfort, and no longer takes medication. As she stated, I was so incredibly shocked how early on [in the project] I was able to stop taking pain medications that I had already taken every day for over a year.
This individual case example provides hope that health can be improved when shifting the focus from pain and discomfort to focusing on actively participating in the self-healing process. As she wrote, The lesson was self- empowerment in regard to my health. I brought comfort to my back. There is metal in my back for the rest of my life and this is something I have accepted. I used to look at that as a horrible thing to have to handle forever. I now look at it as a beautiful contraption that has allowed me to walk across a graduation stage despite having literally shattered a vertebra. I am reintegrating these traumatized parts of my body back into a whole health state of mind and body. Doctors did not do this, surgeries did not, PT didn’t and neither did pain medications. MY body and MY mind did it. I did this.
Besides the self-healing imagery and acting upon the information she received from the asking questions from the unconscious there were many other factors contributed to her healing. These included the semester long self-practices and mastery of different stress management techniques, learning how stress impacts health and what can the person can do to self-regulate, as well as being introduced to the many case examples and research studies that suggested healing could be possible even in cases where it seemed impossible.
The other foundational components that was part of the class teachings included attending the weekly classes session and completing the assign homework practices. These covered discussion about placebo/nocebo, possibilities and examples of self-healing with visualization, the role of nutrition, psychophysiology of stress and factors are associated with healthy aging across cultures. The asynchronous assignments investigated factors that promoted or inhibited health and the role of hope. The discussions pointed out that not everyone may return to health; however, they can always be whole. For example, if a person loses a limb, the limb will not regrow. The healing process includes acceptance and creating new goals to achieve and live a meaningful life.
The possibility that students could benefit by implementing the different skills and concepts taught in the class were illustrated by sharing previous students’ successes in reversing disorders such as hair pulling, anxiety, psoriasis, and pain. In addition, students were assigned to watch and comment on videos of people who had overcome serious illness. These included Janine Shepherd’s 2012 TED talk, A broken body isn’t a broken person, and Dr. Terry Wahl’s 2011 TEDxIowaCity talk, Minding your mitochondria. Janine Shepard shared how she recovered from a very serious accident in which she became paralyzed to becoming an aecrobatic pilot instructor while Dr. Terry Wahl shares how she he used diet to cure her MS and get out of her wheelchair (Shepherd, 2012; Wahl, 2011). Other assignments included watching Madhu Anziani’s presentation, Healing from paralysis-Music (toning) to activate health, in which he discussed his recovery from being a quadriplegic to becoming an inspirational musician (Anziani, & Peper, 2021). The students as read and commented on student case examples of reversing acid reflux, irritable bowel and chronic headaches (Peper, Mason, & Huey, 2017a; Peper, Mason, & Huey, 2017b; Peper, 2018; Peper et al., 2020; Peper, Covell, & Matzembacker, 2021; Peper, 2022).
Although self-healing imagery appears to be the major component that facilitated the healing, it cannot be separated from the many other concepts and practices that may have contributed. For example, the previous practices of learning slow diaphragmatic breathing and hand warming may have allowed the imagery to become a real kinesthetic experience. In addition, by seeing how other students overcame chronic disorders, the class provided a framework to mobilize one’s health.
Lessons extracted from this case example that others may be able use to mobilize health.
- Take action to shifts from being hopeless and powerless to becoming empowered and active agent in the healing process.
- Change personal beliefs through experiential practices and storytelling that provides a framework that healing and improvement are possible.
- Teach the person self-regulation skills such as slower breathing, muscle relaxation, cognitive internal language changes, hand warming by which the person experiences changes.
- Provide believable role models who shared their struggle in overcoming traumatic injury, watch inspirational talks, and share previous clients or students’ self-reports who had previously improved.
- Transform the problem from global description into behavioral specific parts. For example, being depressed is a global statement and too big to work on. Breaking the global concept into specific behaviors such as, my energy is too low to do exercise or I have negative thoughts, would provide specific interventions to work on such as, increasing exercise or changing thoughts. In JC’s case, she changed the general rating of pain into ratings of muscle tightness and sharp pains. This provided the bases for strategies to relax and warm her muscles.
- Focus on what you can do at that moment versus focusing on the past, what happened, who caused it, or blaming yourself and others. Explore and ask what you now can do now to support your healing process and reframe the problem as a new opportunity for growth and development.
- Practice, practice, and practice with a childlike exploratory attitude. Focus on the small positive benefits that occur as a result of the practices. It is not mindless practice; it is practice while being present and being gentle with yourself. Do not discard very small changes. The benefits accrue as you practice more and more, just many people have experienced when learning to play a musical instrument or mastering a sport. Even though many participants think that practicing 15 minutes a day is enough, it usually takes much more time. Reflect on how a baby learns to walk or climb. The toddler practices day-long and takes naps to regenerate and grow. When the toddler is not yet successful in walking or climbing, it does not give up or interpret it as failure or blaming himself that he cannot do it, it just means more practice.
- Have external reminders to evoke the self-healing practices. In JC’s case, the small statue of Yemaya in her room was the reminder. It reminded her to thinks of the image of herself fully healed each time she saw it.
- Guide yourself through the wise one imagery, ask yourself a question and listen and act on the intuitional answers.
- Develop a self-healing imagery process that transforms the dysfunction to health or wholeness. Often the person only perceives the limitations and focusses on describing the problem. Instead, acknowledge, accept what was and is, and focus on developing a process to promote healing. What many people do not realize that if they think/imagine how their injury/illness was caused, it may reactivate and recreate the initial trauma. This can be illustrated through imagery. When we think or imagine something, it changes our physiology. For example, when one imagines eating a lemon, many people will salivate. The image affects physiology. Thus, focus on processes that support healing.
- While practicing the imagery, experience it as if it is real and feel it happening inside yourself. Many people initially find this challenging as they see it outside themselves. One way to increase the “felt sense” is to incorporate more body involvement such as acting out the imagery with hand and body movements.
- When having a relapse, remind yourself to keep going. Every morning is the beginning of a new day, do each practices anew. In addition, reflect of something that was challenging in the past but that you successfully overcame. Focus on that success. As JC wrote, I was also successful in that I gave myself slack and reminded myself that relapses will happen and what matters more is the steps I take to move forward.
- Make your healing a priority that means doing it often during the day. Allow the self-healing imagery and process to run in the back of the head all the time just as a worry can be present in the background. So often people practice for a few minutes (which is great and better than not practicing at all); however, at other times during the day they are captured by their worry, negative thoughts or focus on the limitations of the disorder. When a person focuses on the limitations, it may interrupt the self-healing process. The analogy we often use is that the healing process is similar to healing from a small cut in the skin. Initially a scab forms and eventually the scab falls off and the skin is healed. On the other hand, if you keep moving the skin or pick on the scab, healing is much slower. By focusing on the limitations and past visualization of the injury, self-healing is reduced. This is similar to removing the scab before the skin has healed. As JC stated, “If you don’t make time for your wellness, you’ll be forced to make time for your illness” was 100% a motivating factor in my success.
- Explore resources for providers and people living with pain. See Dr. Rachel Zoffness website which provides a trove of high quality articles, books, videos, apps, and podcasts. https://www.zoffness.com/resources
In summary, we do not know the limits of self-healing; however, this case example illustrates that by implementing self-healing strategies health and recovery occurred. As JC wrote:
To have broken a vertebra in my back and experience all the injuries that came with the accident when I already did not have the strongest mind-body connection was incredibly intense and really heartbreaking and discouraging in my life. And, that made things difficult because I was not able to 100% focus on my healing because I felt so overwhelmed by the feeling of discouragement that I felt. Experiencing this self-healing project, seeing the imagery that helped me not just feel so much better all the time but be able to stop taking all prescription pain medications and eliminate the sharp pains in my back has taught me that I have the skill set needed to be whole and healthy.
Watch the interview will Jillian Cosby inwhich she describes her self-healing process.
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Warraich, H. (2022). Medicine has failed chronic pain patients. Here’s what they need. Pscyhe, Aeon, https://psyche.co/ideas/medicine-has-failed-chronic-pain-patients-heres-what-they-need
Yong, R. J., Mullins, P. M., & Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States. Pain, 163(2), e328-e332. https://doi.org/10.1097/j.pain.0000000000002291
Adapted from: Peper, E. & Harvey, R. (2022). Nausea and GI discomfort: A biofeedback assessment model to create a rational for training. Biofeedback, 50(1), 24–32. https://doi.org/10.5298/1081-5937-50.1.05
Abdominal discomfort and pain such as functional abdominal pain, acid reflux or irritable bowel affects many people. Teaching slower biofeedback-assisted HRV breathing with biofeedback is a useful strategy by which the person may be able to reduce symptoms. This essay provides detailed instruction for a first session assessment for clients who have abdominal discomfort (functional abdominal pain). Descriptions include how the physiological recording can be used to understand a possible etiology of the illness, to create a biological/evolutionary based explanation that is readily understood by the client, and finally to offer self-regulation suggestions to improve health.
Background of abdominal discomfort (irritable bowel syndrome, acid reflux, functional abdominal pain, recurrent abdominal pain)
Irritable bowel syndrome (IBS) affects 7% to 21% of the general population in Western cultures with a global prevalence estimated at around 11% (Fairbrass, Costantino, Gracie, & Ford, 2020). The chronic symptoms (i.e., lasting more than 30 days) usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, which can significantly reduce the quality of life (Chey et al., 2015). A precursor of IBS in children is called recurrent abdominal pain (RAP), which affects 0.3% to 19% of school children (Chitkara et al., 2005). Both IBS and RAP appear to be functional illnesses, as no organic causes have been identified to explain the symptoms. IBS and RAP are contrasted to various types of diseases such as Crohn’s disease, inflammatory bowel disease or ulcerative colitis.
Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, infections, psychological status and stress. More recently, dietary factors contributing to changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth have been suggested as another risk factor (Dupont, 2014). Generally, standard medical treatments (reassurance, dietary manipulation and of pharmacological therapy) are often ineffective in reducing IBS symptoms (Chey et al., 2015). On the other hand, complementary and alternative approaches such as biofeedback-assisted relaxation techniques (Davidoff & Whitehead, 1996; Goldenberg et al., 2019; Stern et al. 2014), autogenic training (Luthe & Schultz, 1969) and cognitive therapy are more effective than traditional medical treatment (Vlieger et al., 2008).
Biofeedback-assisted relaxation training typically moderates IBS or RAP symptoms by restoring balance in the nervous system (sympathetic/parasympathetic autonomic balance), such as through heart rate variability (HRV) breathing training. For example, Sowder et al. (2010) as well as Sun et al. (2016) demonstrated that functional abdominal pain can be reduced with HRV feedback training. In most cases, increased vagal tone was achieved by breathing at about six breaths per minute. While Taneja et al. (2004) reported that yogic breathing decreased diarrhea-predominant irritable bowel syndrome symptoms significantly more than conventional treatment in a randomized control study.Sympathetic/parasympathetic balance can be enhanced by increasing HRV, which occurs when a person breathes at their resonant frequency, which is usually 5–7 breaths per minute. For most people, the HRV training means breathing at much slower rate. A benefit of slow abdominal breathing appears to be a self-control strategy that can reduce symptoms of IBS, RAP and similar functional abdominal pain symptoms.
Mastery of effortless diaphragmatic breathing can be affected by injury, surgery or similar insults to the abdominal area (Peper et al., 2015). In addition, dysregulation of diaphragm, which is enervated by the phrenic nerve and the vagus nerve, along with dysregulation of other abdominal muscles appears to be associated with irritable bowel syndrome (Bordoni & Morabito, 2018). It is likely that slower biofeedback-assisted HRV breathing training restores abdominal muscles and diaphragmatic movement, theoretically by tonic and phasic regulation of the phrenic and vagal nerve activity (cf. Marchenko et al., 2015; Streeter et al., 2012). The theory, simply stated, is that HRV breathing training at an individual’s resonant frequency produces increases in regulatory neurotransmitters, particularly gamma amino butyric acid (GABA). Many of our students who complain of abdominal discomfort report reductions of symptoms following HRV breathing training.
Consistently for more than 40 years, we have taught undergraduate students a semester-long integrated stress management program that includes modified progressive relaxation, slow diaphragmatic breathing and changing internal language as outlined in the book, Make Health Happen, by Peper, Gibney & Holt (2002). At the end of each semester, numerous students report that their anxiety, gastrointestinal distress and other symptoms related to self-described IBS or RAP have decreased or disappeared (Peper et al., 2014; Peper, Miceli, & Harvey, 2016; Peper, Mason, Huey, 2017; Peper et al., 2020). Abdominal discomfort is prevalent experience of distress by college students. In our recent survey of 99 undergraduate students, 41% self-reported abdominal discomfort (25% irritable bowel or acid reflux), 86% self-reported anxiety, 70% neck and shoulder tension and 48% headaches. After practicing slower breathing (i.e., typically directing them to breath abdominally at a rate of about six breaths a minute) and focus on slower exhalation and allowing the air to flow in without effort as the abdominal wall expands, as a homework assignment for a week, many reported that their symptoms significantly decreased (Peper, Harvey, Cuellar, & Membrila, in press).
Case example illustrating how to use the physiological recording to guide the client discussion and provide motivation
A 16-year-old high school junior suffered from abdomen discomfort for years. The symptoms mainly consisted of frequent constipation, and when it occurred, great discomfort from nausea. After having been diagnosed and undergoing all the necessary tests by the gastroenterologist, there was no identifiable cause of the chief complaints. Biofeedback was suggested as an alternative to medications for symptom reduction. During the biofeedback assessment and training session, the client discussed what she would like to learn from the session. It was challenging for her to respond to those questions. Not being able to report what the client would like from a training session is also a very common experience when working with students. A useful strategy is to describe experiences of other students that the clients could relate to, and imply that their abdominal discomfort is somewhat commonplace in other students.
Discussed during the session was the link between being very sensitive and reactive to other people’s feeling and being concerned about what others think of her. The client nodded her head in agreement. When describing herself, she discussed being very perfectionistic using a scale from being lackadaisical/undemanding to being perfectionistic (i.e., self-oriented perfectionism, self-worth contingencies, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, other-oriented perfectionism, hypercriticism; see Smith, Saklofske, Stoeber, & Sherry, 2016).
Furthermore, the client sat slouched in the chair. Possibly her slouched posture implied a state of powerlessness instead of empowerment, a state of being ready to react and protect (Carney, Cuddy, & Yap, 2010; Cuddy, 2012; Peper, Lin, & Harvey, 2017).
Working hypotheses. The client was very sensitive and continuously reacted to external and internal signals with sympathetic arousal, while masking her reactions. These ongoing flight/flight responses would decrease intestinal peristalsis and abdominal blood flow, which would result in nausea, constipation and abdominal distress. Namely, the body reacts to the stimuli as signals of danger and blood flow is shunted away from the abdomen into the large muscles to run and fight. To paraphrase Stanford University professor Robert Sapolsky (2004): Why should the body digest food and repair itself, if it is going to be the predator’s lunch? It is only when we are safe that we can digest and regenerate.
The session began by exploring how pressure on the abdomen could potentially affect experiences of nausea and abdominal distress. After explaining how the diaphragm descends and how abdominal content in the stomach can be displaced (spread out) during inhalation, we systematically changed her posture by placing and adjusting a small pillow behind her middle back so that she could sit tall. The tall posture resulted in an open feeling of empowerment not felt during slouching. She observed that breathing was slightly easier and felt there was more space in her abdomen. As she began to feel more comfortable during the training session, we discussed the impact of posture on the body. We also discussed the relationship between thoughts of perfectionism and abdominal discomfort. The discussion also included an exploration of why some people tend to curl-up and slouch in a protective posture (e.g., head down to protect the neck region and big bones of the arms and legs positioned to protect the core organs) when feeling self-consciousness or perfectionistic about body image.
Biofeedback monitoring for assessment
Psychophysiology was recorded with multichannel physiological system (Procomp Infinity System running Biograph Infinity software version 6.7.1, Thought Technology Ltd). Respiration was monitored with strain-gauge sensors placed around the abdomen and thoracic regions (for a discussion on sensor placement see Peper et al., 2016 and Chu et al., 2019). Blood volume pulse was recorded with the sensor placed on the left thumb. The thumb was used because the participant had small and cold fingers (for a discussion about blood volume pulse, see Peper et al, 2007 and Peper, Shafer, & Lin, 2010). Skin conductance was recorded with the sensor wrapped around the left index and middle fingers with the electrodes on the finger pads (for a discussion about skin conductance and normal values, see Khazan, 2019, and Shafer et al, 2016).
After sensors were attached and the signals explained, the client sat comfortably while looking at the screen. Unexpectedly the clinician clapped his hands and made a loud noise. The client reacted with a momentary startle and smile. The physiological response, showed an increase in skin conductance, decrease in pulse amplitude, decrease in abdominal diameter, and increase in heart rate, is shown in Figure 1.
Figure 1. Physiological response to a loud noise (clap) (1) increased skin conductance, (2) decrease in pulse amplitude, (3) decrease in decreased abdominal circumference, and (4) increased heart rate and decreased heart rate variability.
The client was aware that she reacted to the clap; however, she was totally unaware how much her body responded. The computer screen display of her physiological reaction made the invisible visible. It provided the opportunity to discuss how various body reactions related to heart rate, breathing, and skin conductance could contribute to experiences of abdominal discomfort.
She was unaware that skin conductance did not return to baseline levels for more than 20 minutes. An elevated skin conductance level may mean that the body’s reaction to the hand-clap noise triggered a defense reaction and maintained the increased sympathetic activity for more than 20 minutes. Having a sustained flight/fight reaction to external stimuli such as a hand-clap would most likely affect digestive and peristalsis processes, contributing to symptoms found in IBS and RAP. The observations made during biofeedback monitoring led to a discussion of how sympathetic activation affects the gastrointestinal track.
Blood volume pulse amplitude decreased, which indicated a decrease in blood flow through her hands, which would decrease hand temperature and again indicated a systemic sympathetic activation.
Abdominal circumference decreased, which indicated that she tightened her abdominal muscles as a protective response to the hand-clap. She was unaware of the abdominal muscles tightening; however, she stated that she was aware that her breathing had changed. The abdominal muscle, which pulled the abdomen in, took almost two minutes to relax. The sustained muscle constriction around the abdomen increased pressure around the core organs, which may contribute to ongoing abdominal discomfort. A fight-flight reaction includes body bracing (e.g. tightened muscles, head down to protect the neck, big bones of arms and legs curled to protect core organs), and she confirmed that she experienced neck and shoulder tensions.
The discussion of abdominal muscle tension led to another discussion of how holding your stomach in may relate to self-image. For example, tight clothing can contribute to constricted movement around the abdomen. Wearing corsets contributed to psychophysiological symptoms, mainly for women in the late 19th and early 20th centuries, during a time when women who wore very tight corsets were diagnosed with neurasthenia. Simply stated, neurasthenia was characterized as a condition of mental and/or physical fatigue with at least two of the following symptoms: dyspepsia, dizziness, muscular aches or pains, tension headaches, inability to relax, irritability and sleep disturbance.
“Dyspepsia” was the commonly reported symptom of neurasthenia, which included upset stomach, a gnawing or burning stomach pain, heartburn, bloating, and or burping, nausea, and vomiting. The constricted waist region that resulted from wearing a corset in the name of fashion compromises the functions of both digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing downward. Thus, the person is forced to breathe more shallowly by lifting their ribs; this increases neck and shoulder tension as well as the risk of anxiety, heart palpitation, and fatigue (Cohen & White, 1947; Courtney, 2009).
It also can contribute to abdominal discomfort since the abdomen is being squeezed by the corset and forcing the abdominal organs upward. Even architects of the Victorian era recognized a need for a place to position a chair or chaise lounge, such as at the top of some stairs, because people wearing corsets could faint, pass out or otherwise experience breathlessness through the effort of climbing the stairs with restrictive clothing around their abdomen (Melissa, 2015). Many of these symptoms could be easily reduced by wearing looser clothing and learning slower diaphragmatic breathing. In modern times, a related phenomenon results when people wear items of clothing that are too tight around their waist or abdomen (e.g., tight jeans) in service to fashion trends often labeled as designer jean syndrome (MacHose & Peper, 1991; Stonehewer, 2009). Similarly, when people wear garments that are too tight around their chest or thoracic region (e.g., tight vests) in service to external protection (e.g., athletes, industrial workers, police or soldiers wearing heavy, restrictive gear), then restrictive ventilatory disorders can occur (Harty et al., 1999). Simply stated, when the muscles related to breathing are restricted from moving, respiration is affected.
The client’s heart rate increased and stayed high for more than 30 seconds. The first decrease in heart rate at about 20 seconds after the hand-clap was a long sigh of relief as breathing (i.e., oxygen/carbon dioxide exchange) started again. It took almost 90 seconds before breathing and heart rate returned to normal as reflected by measures of HRV. The computer screen showing increased heart rate was reviewed with the client to explain how her body reacted with a fight-flight response to the hand-clap, as well as how regulating breathing through biofeedback training could lower the heart rate and reduce the sympathetic activation and enhance the parasympathetic activation.
Body responds to cognitive stressful thoughts
After discussion about the psychophysiological response to the hand-clap (a physical external stressor) and how other external stressors (e.g., startling noise) or internal stressors (e.g., perfectionistic ruminations) could trigger a similar response of abdominal muscle tightening, the assessment was repeated by having her relax and then think about a mental stressor, as shown in Figure 2.
Figure 2. Physiological responses to thinking about a past stressor (1) increased skin conductance, (2) decreased pulse amplitude, (3) decreased abdominal circumference, and (4) increased heart rate and decreased HRV.
The physiological response pattern to thinking about a past stressor was similar to the bodily reaction to a loud noise. The skin conductance increased and blood volume pulse amplitude decreased immediately after hearing (e.g., anticipating) the task of evoking/thinking of a past stressor. Most likely, the initial response was triggered by performance anxiety, then 6 seconds later the heart rate increased and breathing changed as she began experiencing the somatic reaction evoked by the recall of a negative stressor. The recordings also showed that her pulse amplitude decreased. The decrease in pulse amplitude suggested that her hands would probably become colder, which was confirmed by her self-report that she often experienced cold hands and feet. She reported being aware of the feeling an emotional reaction, but mainly noticing the change of breathing in her chest, and she was unaware of the abdominal changes. The client was surprised by how her body reacted to emotional thoughts. The recording viewed on the computer screen demonstrated objectively that her thoughts (initial performance anxiety) had a physical effect on her body. Specifically, experiencing the emotions that were evoked by recalling the stressful memory had a direct effect on the body in the same way that a physical external threat leads to a fight-flight response.
Building a psychophysiological model
Using these recorded computer images reflecting physical reactions to the hand clap and emotional thoughts, the discussion focused on how abdominal discomfort could be the result of activating a normal biological survival response. Survival responses would occur hundreds of times throughout a day, especially when worrying. Each thought would evoke the response, and the awareness of body reaction would evoke another reaction. Similar to how awareness of blushing amplifies blushing.
The client shared that she was very sensitive and reactive especially when other people were upset. She reported feeling “cursed” by their sensitivity and reactivity. The linguistic metaphor that could be used to describe her reactions is “she could not stomach what was going on.”
The discussion about physiological reactions provided the client with a model how her disorder (IBS and RAP) could have developed and been maintained over the years. The model matched her subjective experience: when stressed, the discomfort often increased. The discussion shifted to reframing her internal labels. Instead of describing her sensitivity as a curse, the sensitivity was reframed and labeled a gift; namely, she could sense many people’s emotional reactions, to which they would react in a variety of ways. She just needed to learn how to manage this sensitivity. Once she learned to manage it, she would have many advantages in interpersonal relations at home and at work. She would be able to sense what other people are experiencing. By reframing her symptoms as a result of a survival physiological response pattern, it reduces self- blame and offers solutions about how to master and change reactions and thereby have more control in the world.
Training to demonstrate control is possible.
The discussion was followed by teaching her diaphragmatic breathing in sitting and lying down positions. As she had no history of abdominal injuries, similar to many of our students, she rapidly demonstrated slower diaphragmatic breathing as shown in Figures 3 and 4.
Figure 3. The client practiced a few slower diaphragmatic breaths in the sitting and reclining position, which increased heart rate variability, decreased skin conductance and increased blood volume pulse amplitude.
Figure 4. Practicing slower diaphragmatic breathing at about six breaths per minute in a reclining position increased HRV.
With tactile coaching, she demonstrated that she could breathe at about six breaths per minute with the heart rate increasing during inhalation and decreasing during exhalation. She reported feeling more relaxed and that the sensations of nausea had disappeared. Additionally, her hands felt warmer. This recording provided proof that there was hope and that she could do something about her body’s psychophysiological responses.
The discussion focused on how breathing affecting heart rate variability. Namely, if she allowed exhalation to occur without effort, her heart rate decreased (the vagal response of slowing the heart) and thereby increased the parasympathetic activation that would support digestion and gastrointestinal functioning. Often when people practice effortless diaphragmatic breathing, abdominal noises (borborygmus)– the gurgling, rumbling, or squeaking noise from the abdomen–occur and indicate that intestinal activity is being activated, and that food, liquids and digestive juice are moving through the intestines. It is usually a positive indicator that the person is relaxing and sympathetic activity has been reduced.
During the last part of session, we reviewed how posture affects physiology, emotions and cognitions, as well as how posture and breathing would be the first step in beginning to reduce symptoms and enhance health. To provide additional information using video and bibliotherapy/education, we suggested that she watches the embedded videos in the blogs listed at the end of the article.
Recommendations for future sessions and home practice
The recommended strategies for future sessions would focus on teaching the client to master slow diaphragmatic breathing and practicing that for 10–20 minutes per day. The teaching techniques would incorporate imagery to imagine air flowing down their arms and legs as she exhaled. . More importantly, the focus would shift to generalize the skill during the day; namely, whenever she would become aware of feeling stressed or observed herself holding her breath or breathing in her chest, she would use that as the cue to shift to slower abdominal breathing. Had the client continued training, future sessions would focus on mastering slower diaphragmatic breathing. The training would include relaxing the lower abdominal muscles during inhalation, increasing control of HRV, practicing imagining stress and use image to trigger slower breathing, and cognitive reframing practices to interrupt worrying and promote self-acceptance. The final goal is to generalize these skills into daily life as illustrated in the successful cases described in the following blogs
Blogs on posture:
Bordoni, B. & Morabito, B. (2018). Symptomatology correlations between the diaphragm and irritable bowel syndrome. Cureus, 10(7), e3036. https://doi.org/10.7759/cureus.3036
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 10, 1363-1368. https://dx.doi.org/10.1177/0956797610383437
Chitkara, D. K., Rawat, D. J., & Talley, N. J. (2005). The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. American journal of Gastroenterology, 100(8), 1868–1875. https://doi.org/10.1111/j.1572-0241.2005.41893.x
Chu, M., Nguyen, T., Pandey, V., Zhou, Y., Pham, H. N., Bar-Yoseph, R., Radom-Aizik, S., Jain, R., Cooper, D. M., & Khine, M. (2019). Respiration rate and volume measurements using wearable strain sensors. NPJ digital medicine, 2(1), 1–9. https://doi.org/10.1038/s41746-019-0083-3
Cohen, M. E. & White, P. D. (1947). Studies of breathing, pulmonary ventilation and subjective awareness of shortness of breath (dyspnea) in neurocirculatory asthenia, effort syndrome, anxiety neurosis. Journal of Clinical Investigation, 26(3), 520–529. https://doi.org/10.1172/JCI101836
Courtney, R. (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12, 78–85. https://doi.org/10.1016/j.ijosm.2009.04.002
Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are
Davidoff, A. L., & Whitehead, W. E. (1996). Biofeedback, relaxation training, and cognitive behavior modification: Treatments for functional GI disorders, In Olden, K, W. (ed). Handbook of Functional Gastrointestinal Disorders. CRC Press, 361–384.
Dupont, H. L. (2014). Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets. Alimentary Pharmacology & Therapeutics, 39(10), 1033–1042. https://doi.org/10.1111/apt.12728
Fairbrass, K. M., Costantino, S. J., Gracie, D. J., & Ford, A. C. (2020). Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 5(12), 1053–162. https://doi.org/10.1016/s2468-1253(20)30300-9
Goldenberg, J. Z., Brignall, M., Hamilton, M., Beardsley, J., Batson, R. D., Hawrelak, J., Lichtenstein, B., & Johnston, B. C. (2019). Biofeedback for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD012530.pub2
Harty, H. R., Corfield, D. R., Schwartzstein, R. M., & Adams, L. (1999). External thoracic restriction, respiratory sensation, and ventilation during exercise in men. Journal of Applied Physiology, 86(4), 1142–1150. https://doi.org/10.1152/jappl.1918.104.22.1682
Khazan, I. (2019). A guide to normal values for biofeedback. Biofeedback, 47(1), 2–5. https://doi.org/10.5298/1081-5937-47.1.03
Luthe, W. & Schultz, J. H. (1969). Autogenic Therapy Volume II: Medical Applications. Grune & Stratton.
MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation, 16(3), 261–265. https://doi.org/10.1007/BF01000020
Marchenko, V., Ghali, M. G., & Rogers, R. F. (2015). The role of spinal GABAergic circuits in the control of phrenic nerve motor output. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 308(11), R916–R926. https://doi.org/10.1152/ajpregu.00244.2014
Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015. Downloaded October 2, 2021. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/
Peper, E., Gibney, K. H., & Holt, C. F. (2002). Make Health Happen—Training Yourself to Create Wellness. Kendall/Hunt Publishing Company.
Peper, E., Gilbert, C. D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173–179. https://doi.org/10.5298/1081-5937-43.4.06
Peper, E., Groshans, G. H., Johnston, J., Harvey, R., & Shaffer, F. (2016). Calibrating respiratory strain gauges: What the numbers mean for monitoring respiration. Biofeedback, 44(2), 101–105. https://doi.org/10.5298/1081-5937-44.2.06
Peper, E., Harvey, R., Cuellar, Y., & Membrila, C.(in press). Reduce anxiety. NeuroRegulation.
Peper, E., Harvey, R., Lin, I. M., Tylova, H., & Moss, D. (2007). Is there more to blood volume pulse than heart rate variability, respiratory sinus arrhythmia, and cardiorespiratory synchrony? Biofeedback, 35(2), 54–61. https://www.researchgate.net/publication/259560204_Is_There_More_to_Blood_Volume_Pulse_Than_Heart_Rate_Variability_Respiratory_Sinus_Arrhythmia_and_Cardiorespiratory_Synchrony
Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback, 35(2), 42–48. https://doi.org/10.5298/1081-5937-45.2.03
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154–160. https://doi.org/10.5298/1081-5937-42.4.06
Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44–47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/
Peper, E., Mason, L., Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback, 45(4), 83–87. https://doi.org/10.5298/1081-5937-45.4.04
Peper, E., Miceli, B., & Harvey, R. (2016). Educational model for self-healing: Eliminating a chronic migraine with electromyography, autogenic training, posture, and mindfulness. Biofeedback, 44(3), 130–137. https://www.aapb.org/files/publications/biofeedback/2016/biof-44-03-130-137.pdf
Peper, E., Shaffer, F., & Lin, I. M. (2010). Garbage in; Garbage out—Identify blood volume pulse (BVP) artifacts before analyzing and interpreting BVP, blood volume pulse amplitude, and heart rate/respiratory sinus arrhythmia data. Biofeedback, 38(1), 19–23. https://doi.org/10.5298/1081-5937-38.1.19
Sapolsky, R. (2004). Why Zebras Don’t Get Ulcers. Owl Books ISBN: 978-0805073690
Shaffer, F., Combatalade, D., Peper, E., & Meehan, Z. M. (2016). A guide to cleaner electrodermal activity measurements. Biofeedback, 44( 2), 90–100. https://doi.org/10.5298/1081-5937-44.2.01
Smith, M. M., Saklofske, D. H., Stoeber, J., & Sherry, S. B. (2016). The big three perfectionism scale: A new measure of perfectionism. Journal of Psychoeducational Assessment, 34(7), 670–687. https://doi.org/10.1177/0734282916651539
Sowder, E., Gevirtz, R., Shapiro, W., & Ebert, C. (2010). Restoration of vagal tone: a possible mechanism for functional abdominal pain. Applied Psychophysiology and Biofeedback, 35(3), 199–206. https://doi.org/10.1007/s10484-010-9128-8
Stern, M. J., Guiles, R. A., & Gevirtz, R. (2014). HRV biofeedback for pediatric irritable bowel syndrome and functional abdominal pain: A clinical replication series. Applied Psychophysiology and Biofeedback, 39(3), 287–291. https://doi.org/10.1007/s10484-014-9261-x
Stonehewer, L. (2009). Dysfunctional breathing for women’s health physiotherapists. Journal of the Association of Chartered Physiotherapists in Women’s Health, 104, 38–40. https://pogp.csp.org.uk/system/files/stonehewer_hr.pdf
Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical hypotheses, 78(5), 571–579. https://doi.org/10.1016/j.mehy.2012.01.021
Sun, X., Shang, W., Wang, Z., Liu, X., Fang, X., & Ke, M. (2016). Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: An open-label, pilot, randomized trial. Diseases of the Esophagus, 29(7), 829–836. https://doi.org/10.1111/dote.12390
Taneja. I., Deepak, K.K., Poojary, G., Acharya, I.N., Pandey, R.M., & Sharma, M.P. (2004). Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback, 29(1), 19-33. https://doi.org/10.1023/b:apbi.0000017861.60439.95
Vlieger, A. M., Blink, M., Tromp, E., & Benninga, M. A. (2008). Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey. Pediatrics, 122(2), e446–e451. https://doi.org/10.1542/peds.2008-0266
Mindfulness-based strategies are drawn from ancient Buddhist practices and have found acceptance as one of the major behavioral medicine techniques of today (Hilton et al, 2016; Khazan, 2013). Throughout this blog the term mindfulness will refer broadly to a mental state of paying total attention to the present moment, with a non-judgmental awareness of inner and outer experiences (Baer, Smith, & Allen, 2004; Kabat-Zinn, 1994). This approach is the common core for many stress management approaches (Peper, Harvey, & Lin, 2019).
Transcendental meditation (TM), a form of concentrative meditation involving repetition of a sacred word or phrase known as a mantra, was a popular meditation technique introduced in the United States from India and participants reported improvement of mental and physical health (Wallace, 1970; Paul-Labrador et al, 2006; Rainforth et al, 2007; Hawkins, 2003). To make TM more acceptable for the western audience, Herbert Benson, MD, adapted and simplified the TM process and then labelled a core element, the ‘relaxation response’ (Benson, Beary, & Carol, 1974; Benson & Clipper, 1992). Instead of giving people a secret mantra and part of a spiritual tradition, he recommend using the word “one” as the mantra. Since that time numerous studies have demonstrated that when patients practice the relaxation response, many clinical symptoms were reduced.
In 1979, Jon Kabat-Zinn introduced a manual for a standardized Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center (Kabat-Zinn, 1994; Kabat-Zin, 2003). The eight-week program combined mindfulness as a form of insight meditation with mindful yogic movement exercises designed to focus awareness on body sensations, thoughts, feelings, and behaviors. Mindfulness based programs have become a predominant approach used in behavioral medicine.
Mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) combine mindfulness meditation training with cognitive therapy and is a useful approach to reduce a variety of mental and physical conditions such as stress, anxiety, depression, addiction, disordered eating, chronic pain, sleep disturbances, and high blood pressure (Andersen et al., 2013; Carlson, Speca, Patel, & Goodey, 2003; Fjorback, Arendt, Ørnbøl, Fink, & Walach, 2011; Greeson, & Eisenlohr-Moul, 2014; Hoffman et al., 2012; Marchand, 2012; Baer, 2015; Demarzo et al, 2015; Khoury et al, 2013; Khoury et al, 2015; Teasdale, Segal, & Williams, 1995; Kabat-Zinn, 1994; Kabat-Zin, 2003; Zimmermann, Burrell, , & Jordan, 2018). Although in most cases, MBSR is helpful, in some cases meditation can evoke negative physical and/or psychological outcomes and inhibit prosocial behavior (Kreplin et al, 2018; Lindahl et al, 2017). Based on this encouraging research, many people are learning to meditate on their own using meditation apps. However, there are many questions that can arise for people new to meditation – such as what is meditation, how do I do it, what are the challenges, and how is it helpful? Some people also develop misconceptions about what meditation is and can become discouraged.
Watch the outstanding presentation by Professor Jennifer Daubenmier presented for the Holistic Health Lecture Series, in which she discusses meditation myths and pragmatic tips for practice.
Andersen, S. R., Würtzen, H., Steding-Jessen, M., Christensen, J., Andersen, K. K., Flyger, H., … & Dalton, S. O. (2013). Effect of mindfulness-based stress reduction on sleep quality: Results of a randomized trial among Danish breast cancer patients. Acta Oncologica, 52(2), 336-344. https://doi.org/10.3109/0284186X.2012.745948
Baer, R., Smith, G., & Allen, K. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11, 191–206. https://doi.org/10.1177/1073191104268029
Benson, H., Beary, J. F., & Carol, M. P. (1974).The Relaxation Response. Psychiatry, 37(1), 37-46. https://www.tandfonline.com/loi/upsy20
Benson, H. & Clipper, M.Z. (1992). The Relaxation Response. Wings Books.
Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness‐based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65(4), 571-581. https://doi.org/10.1097/01.psy.0000074003.35911.41
Demarzo, M. M., Montero-Marin, J., Cuijpers, P., Zabaleta-del-Olmo, E., Mahtani, K. R., Vellinga, A., Vicens, C., López-del-Hoyo, Y., & García-Campayo, J. (2015). The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review. Annals of family medicine, 13(6), 573–582. https://doi.org/10.1370/afm.1863
Fjorback, L. O., Arendt, M., Ørnbøl, E., Fink, P., & Walach, H. (2011). Mindfulness‐Based Stress Reduction and Mindfulness‐Based Cognitive Therapy–A systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124(2), 102-119. https://doi.org/10.1111/j.1600-0447.2011.01704.x
Greeson, J., & Eisenlohr-Moul, T. (2014). Mindfulness-based stress reduction for chronic pain. In R. A. Baer (Ed.), Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications, 269-292. San Diego, CA: Academic Press. https://www.academia.edu/8092878/Mindfulness_Based_Stress_Reduction_for_Chronic_Pain
Hawkins, M. A. (2003). Effectiveness of the Transcendental Meditation program in criminal rehabilitation and substance abuse recovery, Journal of Offender Rehabilitation, 36(1-4), 47-65. https://doi.org/10.1300/J076v36n01_03
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., …Maglione, M. A. (2016). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51(2), 199-213. https://doi.org/10.1007/s12160-016-9844-2
Hoffman, C. J., Ersser, S. J., Hopkinson, J. B., Nicholls, P. G., Harrington, J. E., & Thomas, P. W. (2012). Effectiveness of mindfulness-based stress reduction in mood, breast-and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: A randomized, controlled trial. Journal of Clinical Oncology, 30(12), 1335-1342. https://doi.org/10.1200/JCO.2010.34.0331
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.
Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8, 73–107. https://www.proquest.com/openview/fef538e3ed2210c1201ef2a946faed43/1?pq-origsite=gscholar&cbl=29080
Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness. John Wiley & Sons.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M., Paquin, K., & Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33(6), 763-771. https://doi.org/10.1016/j.cpr.2013.05.005
Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). Mindfulness-based stress reduction for healthy individuals: A meta-analysis. Journal of Psychosomatic Research, 78(6), 519-528. https://doi.org/10.1016/j.jpsychores.2015.03.009
Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K, & Britton, W. B. (2017) The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoSONE, 12(5): e0176239. https://doi.org/10.1371/journal.pone.0176239
Marchand, W. R. (2012). Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress. Journal of Psychiatric Practice, 18(4), 233-252. https://doi.org/10.1097/01.pra.0000416014.53215.86
Paul-Labrador, M., Polk, D., Dwyer, J.H. et al. (2006). Effects of a randomized controlled trial of Transcendental Meditation on components of the metabolic syndrome in subjects with coronary heart disease. Archive of Internal Medicine, 166(11), 1218-1224. https://doi.org/10.1001/archinte.166.11.1218
Peper, E., Harvey, R., & Lin, I-M. (2019). Mindfulness training has themes common to other technique. Biofeedback. 47(3), 50-57. https://doi.org/10.5298/1081-5937-47.3.02
Rainforth, M.V., Schneider, R.H., Nidich, S.I., Gaylord-King, C., Salerno, J.W., & Anderson, J.W. (2007). Stress reduction programs in patients with elevated blood pressure: A systematic review and meta-analysis. Current Hypertension Reports, 9(6), 520–528. https://doi.org/10.1007/s11906-007-0094-3
Teasdale, J. D., Segal, Z., & Williams, J. M. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25–39. https://doi.org/10.1016/0005-7967(94)e0011-7
Wallace, K.W. (1970). Physiological Effects of Transcendental Meditation. Science, 167 (3926), 1751-1754. https://doi.org/10.1126/science.167.3926.1
Erik Peper and Elyse Shafarman
After taking Alexander Technique lessons I felt lighter and stood taller and I have learned how to direct myself differently. I am much more aware of my body, so that while I am working at the computer, I notice when I am slouching and contracting. Even better, I know what to do so that I have no pain at the end of the day. It’s as though I’ve learned to allow my body to move freely.
The Alexander Technique is one of the somatic techniques that optimize health and performance (Murphy, 1993). Many people report that after taking Alexander lessons, many organic and functional disorders disappear. Others report that their music or dance performances improve. The Alexander Technique has been shown to improve back pain, neck pain, knee pain walking gait, and balance (Alexander technique, 2022; Hamel, et al, 2016; MacPherson et al., 2015; Preece, et al., 2016). Benefits are not just physical. Studying the technique decreases performance anxiety in musicians and reduces depression associated with Parkinson’s disease (Klein, et al, 2014; Stallibrass et al., 2002).
The Alexander Technique was developed in the late 19th century by the Australian actor, Frederick Matthias Alexander (Alexander, 2001). It is an educational method that teaches students to align, relax and free themselves from limiting tension habits (Alexander, 2001; Alexander technique, 2022). F.M Alexander developed this technique to resolve his own problem of becoming hoarse and losing his voice when speaking on stage.
Initially he went to doctors for treatment but nothing worked except rest. After resting, his voice was great again; however, it quickly became hoarse when speaking. He recognized that it must be how he was using himself while speaking that caused the hoarseness. He understood that “use” was not just a physical pattern, but a mental and emotional way of being. “Use” included beliefs, expectations and feelings. After working on himself, he developed the educational process known as the Alexander Technique that helps people improve the way they move, breathe and react to the situations of life.
The benefits of this approach has been documented in a large randomized controlled trial of one-on-one Alexander Technique lessons which showed that it significantly reduced chronic low back pain and the benefits persisted a year after treatment (Little, et al, 2008). Back pain as well as shoulder and neck pain often is often related to stress and how we misuse ourselves. When experiencing discomfort, we quickly tend to blame our physical structure and assume that the back pain is due to identifiable structural pathology identified by X-ray or MRI assessments. However, similar structural pathologies are often present in people who do not experience pain and the MRI findings correlate poorly with the experience of discomfort (Deyo & Weinstein, 2001; Svanbergsson et al., 2017). More likely, the causes and solutions involve how we use ourselves (e.g., how we stand, move, or respond to stress). A functional approach may include teaching awareness of the triggers that precede neck and back tension, skills to prevent the tensing of those muscles not needed for task performance, resolving psychosocial stress and improving the ergonomic factors that contribute to working in a stressed position (Peper, Harvey & Faass, 2020). Conceptually, how we are use ourselves (thoughts, emotions, and body) affects and transforms our physical structure and then our physical structure constrains how we use ourselves.
Watch the video with Alexander Teacher, Elyse Shafarman, who describes the Alexander Technique and guides you through practices that you can use immediately to optimize your health while sitting and moving.
See also the following posts:
Alexander, F.M. (2001). The Use of the Self. London: Orion Publishing. https://www.amazon.com/Use-Self-F-M-Alexander/dp/0752843915
Alexander technique. (2022). National Health Service. Retrieved 19 April, 2022/. https://www.nhs.uk/conditions/alexander-technique/
Deyo, R.A. & Weinstein, J.N. (2001). Low back pain. N Engl J Med., 344(5),363-70. https://doi.org/10.1056/NEJM200102013440508
Hamel, K.A., Ross, C., Schultz, B., O’Neill, M., & Anderson, D.I. (2016). Older adult Alexander Technique practitioners walk differently than healthy age-matched controls. J Body Mov Ther. 20(4), 751-760. https://doi.org/10.1016/j.jbmt.2016.04.009
Klein, S. D., Bayard, C., & Wolf, U. (2014). The Alexander Technique and musicians: a systematic review of controlled trials. BMC complementary and alternative medicine, 14, 414. https://doi.org/10.1186/1472-6882-14-414
Little, P. Lewith, W G., Webley, F., Evans, M., …(2008). Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ, 337:a884. https://doi.org/10.1136/bmj.a884
MacPherson, H., Tilbrook, H., Richmond, S., Woodman, J., Ballard, K., Atkin, K., Bland, M., et al. (2015). Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial. Ann Intern Med, 163(9), 653-62. https://doi.org/10.7326/M15-0667
Preece, S.J., Jones, R.K., Brown, C.A. et al. (2016). Reductions in co-contraction following neuromuscular re-education in people with knee osteoarthritis. BMC Musculoskelet Disord 17, 372. https://doi.org/10.1186/s12891-016-1209-2
Stallibrass, C., Sissons, P., & Chalmers. C. (2002). Randomized controlled trial of the Alexander technique for idiopathic Parkinson’s disease. Clin Rehabil, 16(7), 695-708. https://doi.org/10.1191/0269215502cr544oa
Svanbergsson, G., Ingvarsson, T., & Arnardóttir RH. (2017). [MRI for diagnosis of low back pain: Usability, association with symptoms and influence on treatment]. Laeknabladid, 103(1):17-22. Icelandic. https://doi.org/10.17992/lbl.2017.01.116
Tuomilehto, J., Lindström, J., Eriksson, J.G., Valle, T.T., Hämäläinen, H., Ilanne-Parikka, P., Keinänen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N. Engl. J. Med., 344, 1343–1350. https://doi.org/10.1056/NEJM200105033441801
Uusitupa, Mm, Khan, T.A., Viguiliouk, E., Kahleova, H., Rivellese, A.A., Hermansen, K., Pfeiffer, A., Thanopoulou, A., Salas-Salvadó, J., Schwab, U., & Sievenpiper. J.L. (2019). Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients, 11(11)2611. https://doi.org/10.3390/nu11112611
Pain is so different for each person. It can range from mildly distracting to totally debilitating. It can be the result from a medical procedure (post- surgical pain), a traumatic injury, disease, trauma or unknown causes. It is challenging to know what to do to reduce suffering and improve health and functioning. Should I take narcotics, have surgery, see a pain psychologist, have acupuncture, receive physical therapy, use biofeedback, change my diet, or get a massage? Should I exercise or rest? Should I follow my doctor’s recommendations?
Before you do anything, first listen to this podcast by pain psychologist, Rachel Zoffness, PhD. In this podcast she will explain what pain is; how it works; and how thoughts, emotions, and sensations are always interconnected. You will also learn the fundamentals of treating chronic pain and helping patients living with it. As one of my close friends stated, “I only wished I could have listened to this before, it would have saved years of suffering.” The podcast is Ologies with Alie Ward and the episode is Dolorology. The link for the episode is:
Rachel Zoffness, PhD, a pain psychologist, Visiting Professor at Stanford, and Assistant Clinical Professor at the UCSF School of Medicine. She serves on the Board of Directors of the U.S. Association for the Study of Pain, and the Society of Pediatric Pain Medicine. She is the author of The Pain Management Workbook and The Chronic Pain and Illness Workbook for Teens. She is a 2021 Mayday Fellow and consults on the development of integrative pain programs around the world.
It is the time of year when we once again make New Year resolutions, “I plan to exercise every day,” “I will stop drinking,” “I will eat less processed foods and more fruits and vegetables.” We use our will power and positive thoughts to begin these new activities; however, our will power often fades out and we quickly fall of the wagon. The reason vary such as, I had planned to jog today; however it is raining, I was planning to eat more vegies; however, I had dinner with a friend and ate a juicy hamburger, I had planned to meditate; however, I needed to help my son. So many other things took priority and the motivation disappeared..
Yet it is possible to be successful with starting and then maintaining new health promoting habits. The key is to increase the friction for the behaviors that you want to reduce and decrease the friction for behaviors that you want to increase. Friction is the extra work you need to do in order to do the task. For example, to eat fewer cookies, increase the friction by not having them in the house (you now have to go to the store to buy them) or by placing them somewhere where it takes greater effort to get them such as the top shelf for which that you need a small ladder to reach them. The extra effort (increased friction) brings awareness to the automatic behavior. At that point, you can interrupt your unconscious eating pattern and choose to do something else. On the other hand, to increase eating fruits, decrease the friction by having the fruit right in front of you on the table so that you can take one without thinking.
The key is to interrupt the habit chain of behavior you want to reduce and automate the habit chains of behaviors you want to increase. The more you do a behavior and the more pleasurable it is, the more likely will the new behaviore become an automatic habit. To learn how to change friction and how to be successful in creating new habits, listen to Shankar Vedantam Hidden Brain’s Podcast, Creatures of Habit.
Madhu Anziani and Erik Peper
In April 2009, Madhu Anziani, just one month prior to graduation from San Francisco State University with a degree in Jazz/World music performance, fell two stories and broke C5 and C7 vertebras. He became a quadriplegic (tretraplegia) and could not breathe, talk, move his arms and legs and was incontinent. He also could not remember anything about the accident because of retrograde amnesia. Even though he was paralyzed and the medical staff suggested that he focussed on how to live well as a quadriplegic, he transcended his paralysis and the prognosis and is now a well-known vocal looping arts and ceremonial song leader/composer.
His recovery against all odds provides hope that growth and healing is possible when the mind and spirit focus on possibilities and not on limitations. Alongside physical thereapy he utilized energy healing and toning/sound vibrations to recover mobility. Toning, the vocalization of an elonggated monotonous vowel sound susteained for a number of minutes tends to vibrate specific areas in the body where the chakras are located (Crowe & Scovel, 1996; Goldman, 2017). Toning compared to mindfulness meditation reduces intrusive thoughts and mind wandering. It also increases body vibration sensations and heart rate variability much more than mindfulness practice (Peper et al, 2019). The body vibrations induced by toning and music could be one of the mechanisms by which recovery can occur at an accelerated rate as it allows the person’s passive awareness and sustained attention to feel the paralyzed body and yet be relaxed in the present without judgement.
Watch Madhu’s inspirational presentation as part of the Holistic Health Lecture Series by the Institute for Holistic Health Studies, San Francisco State University. In this presentation, he describes the process of recovery and guides the viewer through toning practices to evoke quieting of mind, bliss within the heart, and a healing state of being.
For an additional discussion and guided practice in toning, see the blog, Toning quiets the mind and increases HRV more quickly than mindfulness practice.
Madu Anziani is a sound healer who endured being a tetraplegic (paralysis affecting all four
limbs) and used sound and energy healing to recover mobility. He is a SFSU graduate and most
well-known as a vocal looping artist and ceremonial song leader/composer.