Reduce stress, anxiety and negative thoughts with posture, breathing and reframing

This post has been adapted from Peper, E., Harvey, R., & Hamiel, D.  (2019). Transforming thoughts with postural awareness to increase therapeutic and teaching efficacy.  NeuroRegulation, 6(3), 153-169.  doi:10.15540/nr.6.3.1533-1 

When locked into a position, options appear less available. By unlocking our body, we allow our brain to unlock and become open to new options.

Changing positions may dissolve the rigidity associated with a fixed position. When we step away from the conflict, take a walk, look up at the treetops, roof lines and clouds, or do something different, we loosen up and new ideas may occur. We may then be able see the conflict from a different point of view that allows resolution.

When stressed, anxious or depressed, it is challenging to change. The negative feelings, thoughts and worries continue to undermine the practice of reframing the experience more positively. Our recent study found that a simple technique, that integrates posture with breathing and reframing, rapidly reduces anxiety, stress, and negative self-talk (Peper, Harvey, Hamiel, 2019). 

Thoughts and emotions affect posture and posture affects thoughts and emotions. When stressed or worried (e.g., school performance, job security, family conflict, undefined symptoms, or financial insecurity), our bodies respond to the negative thoughts and emotions by slightly collapsing and shifting into a protective position. When we collapse/slouch, we are much more at risk to:

When we are upright and look up, we are more likely to:

Experience how posture affects memory and the feelings (adapted from Alan Alda, 2018)

Stand up and do the following:

  1. Think of a memory/event when you felt defeated, hurt or powerless and put your body in the posture that you associate with this feeling. Make it as real as possible . Stay with the feeling and associated body posture for 30 seconds. Let go of the memory  and posture. Observe what you experienced.
  2. Think of a memory/event when you felt empowered, positive and happy put your body in the posture that you associate with those feelings. Make it as real as possible. Stay with the feeling and associated body posture for 30 seconds. Let go of the memory and posture. Observe what you experienced.
  3. Adapt the defeated posture and now recall the positive empowering memory while staying in the defeated posture. Observe what you experience.
  4. Adapt the empowering posture and now recall the defeated hopeless memory while staying in the empowered posture. Observe what you experience.

Almost all people report that when they adapt the body posture congruent with the emotion that it was much easier to access the memory and feel the emotion. On the other hand when they adapt the body posture that was the opposite to the emotions, then it was almost impossible to experience the emotions. For many people, when they adapted the empowering posture, they could not access the defeated hopeless memory. If they did access that memory, they were more likely be an observer and not be involved or emotionally captured by the negative memory.

Comparison of Posture with breathing and reframing to Reframing 

The study investigated whether  changing internal dialogue (reframing)  or combining posture change and breathing with changing internal dialogue would reduce stress and negative self-talk more effectively.

The participants were 145 college students (90 women and 55 men) average age 25.0 who participated as part of a curricular practice in four different classes.

After the students completed an anonymous informational questionnaire (history of depression, anxiety, blanking out on exams, worrying, slouching), the classes were divided into two groups. They were then asked to do the following:

  • Think of a stressful conflict or problem and make it as real as possible for one minute. Then let go of the stressful memory and  do one of the two following practices.
    • Practice A: Reframe the experience positively for 20 seconds.
    • Practice B: Sit upright, look up, take a breath and reframe the experience positively for 20 seconds.
  • After doing practice A or practice B,  rate the extent to which your negative thoughts and anxiety/tension were reduced, from 0 (not at all) to 10 (totally).
  • Now repeat this exercise except switch and do the other practice.  (Namely, if you did A now you do B; if you did B now you do A).

RESULTS

Overwhelmingly students reported that sitting erect, breathing and reframing positively was much more effective than only reframing as shown in Figure 1 and 2.figure 1Figure 1. Percentage of students rating posture, breath and reframing practice (PBRP) as more effective than reframing practice (RP) in reducing negative thoughts, anxiety and stress.slides Figure 2. Self-rating of reduction of negative thoughts and anxiety/tension

Stop reading. Do the practice yourself. It is only through experience that you know whether posture with breathing and reframing is a more beneficial than simply reframing the language.

Implications for education, counseling, psychotherapy. 

Our findings have implications for education, counseling and psychotherapy because students and clients usually sit in a slouched position in classrooms and therapeutic settings. By shifting the body position to an erect upright position, taking a breath and then reframing, people are much more successful in reducing their negative thoughts and anxiety/stress. They report feeling much more optimistic and better able to cope with felt stress as shown by representative comments in table 1.

Reframing Posture, breath and reframing
After changing my internal language, I still strongly felt the same thoughts. I instantly felt better about my situation after adjusting my posture.
I felt a slight boost in positivity and optimism. The negative feelings (anxiety) from the negative thoughts also diminished slightly. The effects were much stronger and it was not isolated mentally. I felt more relief in my body as well.
Even after changing my language, I still felt more anxious. Before changing my posture and breathing, I felt tense and worried. After I felt more relaxed.
I began to lift my mood up; however, it didn’t really improve my mood.  I still felt a bit bad afterwards and the thoughts still stayed. I began to look from the floor and up towards the board. I felt more open, understanding and loving. I did not allow myself to get let down.
During the practice, it helped calm me down a bit, but it wasn’t enough to make me feel satisfied or content, it felt temporary. My body felt relaxed overall, which then made me feel a lot better about the situation.
Difficult time changing language. My posture and breathing helped, making it easier to change my language.
I felt anger and stayed in my position. My body stayed tensed and I kept thinking about the situation. I felt anger but once I sat up straight and thought about breathing, my body felt relaxed.
Felt like a tug of war with my thoughts. I was able to think more positively but it took a lot more brain power to do so. Relaxed, extended spine, clarity, blank state of mind.

Table 1. Some representative comments of practicing reframing or posture, breath and reframing.

The results of our study in the classroom setting are not surprising.  Many us know to take three breaths before answering questions, pause and reflect before responding, take time to cool down before replying in anger, or wait till the next day before you hit return on your impulsive email response.

Currently, counseling, psychotherapy, psychiatry and education tend not to incorporate body posture as a potential therapeutic or educational intervention for teaching participants to control their mood or reduce feelings of powerlessness.  Instead, clients and students often sit slightly collapsed in a chair during therapy  or in class.  On the other hand, if individuals  were encouraged to adopt an upright posture especially in the face of stressful circumstances it would help them maintain their self-esteem, reduce negative mood, and use fewer sadness words as compared to the individual in a slumped and seated posture (Nair, Sagar, Sollers, Consedine, & Broadbent, 2015).

THE VALUE OF SELF-EXPERIENCE

What makes this study valuable is that participants compare for themselves the effects of the two different interventions techniques to reduce anxiety, stress and negative thoughts. Thus, the participants have an opportunity to discover which strategy is more effective instead of being told what to do.  The demonstration is even more impressive when  done in groups because nearly all participants will report that changing posture with breathing and reframing is more beneficial.

This simple and quick technique can be integrated in counseling and psychotherapy by teaching clients this behavioral technique to  reduce stress. In Cognitive Behavioral Therapy (CBT), sitting upright can help the individual replace a thought with a more reasonable one. In third wave CBT, it can help bypass the negative content of the original language and create a metacognitive change, such as, “I will not let this thought control me.”   

It can also help in Acceptance and Commitment Therapy (ACT) since changing one’s body posture may facilitate the process of “acceptance” (Hayes, Pistorello, & Levin, 2012). Adopting an upright sitting position and taking a breath is like saying “I am here, I am present, I am not escaping or avoiding.” This change in body position represents movement from inside to outside, movement from accepting the unpleasant emotion related to the negative thoughts toward a “commitment” to moving ahead, contrary to the automatic tendency to follow the negative thought. The positive reframing during body position or posture change is not an attempt to color reality in pretty colors, but rather a change of awareness, perspective, and focus that helps the individual identify and see some new options for moving ahead toward commitment according to one’s values. This intentional change in direction is central in ACT and also in positive psychology (Stichter, 2018).

CONCLUSION AND RECOMMENDATIONS

We suggest that therapists, educators, clients and students get up out of their chairs and incorporate body movements when they feels overwhelmed and stuck. Finally,  this study points out that mind and body are affected by each other. It provides another example of the psychophysiological principle enunciated by Elmer Green (1999, p 368):

“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 findings of this study echo the ancient spiritual wisdom that is is central to the teaching of  the Zen Master, Thich Nhat Hanh.  He recommends that his students recite the following at any time:

Breathing in I calm my body,
Breathing out I smile,
Dwelling in the present moment,
I know it is a wonderful moment.

References

Alda, A. (2018). If I Understood You, Would I have This Look on My Face?: My Adventures in the Art and Science of Relating and Communicating. New York: Random House Trade Paperbacks.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are

Green, E. (1999). Beyond psychophysics, Subtle Energies & Energy Medicine, 10(4), page 368.

Hayes, S. C., Pistorello, J., & Levin, M.E. (2012). Acceptance and Commitment Therapy as a unified model of behavior change. The Counseling Psychologist 40(7), 976-1002.

Michalak, J., Mischnat, J., & Teismann, T. (2014). Sitting posture makes a difference-embodiment effects on depressive memory bias. Clinical Psychology and Psychotherapy, 21(6),

Nair, S., Sagar, M., Sollers, J. 3rd, Consedine, N., & Broadbent, E. (2015). Do slumped and upright postures affect stress responses? A randomized trial. Health Psychology, 34(6), 632-641. 

Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.

Peper, E., Harvey, R., & Hamiel, D. (2019) Transforming thoughts with postural awareness to increase therapeutic and teaching efficacy.  NeuroRegulation, 6(3), 153-169.

Peper, E., Harvey, R., Mason, L., & Lin, I-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67-74.

Peper, E. & Lin, I-M. (2012). Increase or decrease depression: How body postures influence your energy level. Biofeedback, 40(3), 126–130.

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback, 45(2), 36-41.

Risking, J.H. & Gotay, C.C. (1982). Physical posture: Could it have regulatory or feedback effects on motivation and emotion? Motivation and Emotion, 6(3), 273-298.

Stichter, M. P. (2019). Positive psychology and virtue: Values in action. The Journal of Positive Psychology, 14(1).

Tsai, H. Y., Peper, E., & Lin, I. M. (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23–27.

Westfeld, G.E. & Beresford, J.J. (1982). Erectness of posture as an indicator of dominance or success in humans. Motivation and Emotion, 6(2), 113-131.

 

 


Toning quiets the mind and increases HRV more quickly than mindfulness practice

Adapted from: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133. 

Disruptive thoughts, ruminations and worrying are common experiences especially when stressed. Numerous clinical strategies such as cognitive behavioral therapy attempt to teach clients to reduce negative ruminations (Kopelman-Rubin, Omer, & Dar, 2017). Over the last ten years, many people and therapists practice meditative techniques to let go and not be captured by negative ruminations, thoughts, and emotions.  However, many people continue to struggle with distracting and wandering thoughts.

Just think back when you’re upset, hurt, angry or frustrated. Attempting just to observe without judgment can be very, very challenging as the mind keeps rehearsing and focusing on what happened. Telling yourself to stop being upset often doesn’t work because your mind is focused on how upset you are. If you can focus on something else or perform physical activity, the thoughts and feelings often subside.

Over the last fifteen years, mindfulness meditation has been integrated and adapted for use in behavioral medicine and psychology (Peper, Harvey, & Lin, 2019). It has also been implemented during bio- and neurofeedback training (Khazan, 2013; Khazan, 2019).  Part of the mindfulness instruction is to recognize the thoughts without judging or becoming experientially “fused” with them. A process referred to as “meta-awareness” (Dahl, Lutz, & Davidson, 2015). Mindfulness training combined with bio- and neurofeedback training can improve a wide range of psychological and physical health conditions associated with symptoms of stress, such as anxiety, depression, chronic pain, and addiction (Creswell, 2015, Khazan, 2019).

Mindfulness is an effective technique; however, it may not be more effective than other self-regulations strategies (Peper et al, 2019). Letting go of worrying thoughts and rumination is even more challenging when one is upset, angry, or captured by stressful life circumstances. Is it possible that other strategies beside mindfulness may more rapidly reduce wandering and intrusive thoughts?  In 2015, researchers van der Zwan, de Vente, Huiznik, Bogels, & de Bruin found that physical activity, mindfulness meditation and heart rate variability biofeedback were equally effective in reducing stress and its related symptoms when practiced for five weeks.

Our research explored whether other techniques from the ancient wisdom traditions could provide participants tools to reduce rumination and worry. We investigated the physiological effects and subject experiences of mindfulness and toning.  Toning is vocalizing long and sustained sounds as a form of mediation. (Watch the video  the toning demonstration by sound healer and musician, Madhu Anziani  at the end of the blog.)

COMPARING TONING AND MINDFULNESS

The participants were 91 undergraduate college students (35 males, 51 females and 5 unspecified; average age, 22.4 years, (SD = 3.5 years).

After sitting comfortably in class, each student practiced either mindfulness or toning for three minutes each. After each practice, the students rated the extent of mind wandering, occurrence of intrusive thoughts and sensations of vibration on a scale from 0 (not all) to 10 (all the time).  They also rated pre and post changes in peacefulness, relaxation, stress, warmth, anxiety and depression. After completing the assessment, they practice the other practice and after three minutes repeated the assessment.

The physiological changes that may occur during mindfulness practice and toning practice was recorded in a separate study with 11 undergraduate students (4 males, 7 females; average age 21.4 years. Heart rate and respiration were monitored with ProComp Infiniti™ system (Thought Technology, Ltd., Montreal, Canada).  Respiration was monitored from the abdomen and upper thorax with strain gauges and heartrate was monitored with a blood volume pulse sensor placed on the thumb.

After the sensors were attached, the participants faced away from the screen so they did not receive feedback.  They then followed the same procedure as described earlier, with three minutes of mindfulness, or toning practice, counterbalanced.  After each condition, they completed a subjective assessment form rating experiences as described above.

RESULTS:  SUBJECTIVE FINDINGS

Toning was much more successful in reducing mind wandering and intrusive thoughts than mindfulness. Toning also significantly increased awareness of body vibration as compared to mindfulness as shown in Figure 1.0 Intrusive wandering thoughts comparison

Figure 1. Differences between mindfulness and toning practice.

There was no significant difference between toning and mindfulness in the increased self-report of peacefulness, warmth, relaxation, and decreased self-report of anxiety and depression as shown in Figure 2.

Figure 2. No significant difference between toning and mindfulness practice in relaxation or stress reports.0 relax comparison

RESULTS: PHYSIOLOGICAL FINDINGS

Respiration rate was significantly lower during toning (4.6 br/min) as compared to mindfulness practice (11.6 br/min); heart rate standard deviation (SDNN) was much higher during toning condition (11.6) (SDNN 103.7 ms) than mindfulness (6.4) (SDNN 61.9 ms). Two representative physiological recording are shown in Figure 3.

0 physiological comparison black white a

Figure 3. Representative recordings of breathing and heart rate during mindfulness and toning practice. During toning the respiration rate (chest and abdomen) was much slower than during mindfulness and baseline conditions.  Also, during toning heart rate variability was much larger than during mindfulness or baseline conditions.

DISCUSSION

Toning practice is a useful strategy to reduce mind wandering as well as inhibit intrusive thoughts and increase heart rate variability (HRV). Most likely toning uses the same neurological pathways as self-talk and thus inhibits the negative and hopeless thoughts. Toning is a useful meditation alternative because it instructs people to make a sound that vibrates in their body and thus they attend to the sound and not to their thoughts.

Physiologically, toning immediately changed the respiration rate to less than 6 breaths per minute and increases heart rate variability. This increase in heart rate variability occurs without awareness or striving. We recommend that toning is integrated as a strategy to complement bio-neurofeedback protocols. It may be a useful approach to enhance biofeedback-assisted HRV training since toning increases HRV without trying and it may be used as an alternative to mindfulness, or used in tandem for maximum effectiveness.

TAKE HOME MESSAGE

1) When people report feeling worried and anxious and have difficulty interrupting ruminations that they first practice toning before beginning mindfulness meditation or bio-neurofeedback training.

2) When training participants to increase heart rate variability, toning could be a powerful technique to increase HRV without striving

TONING DEMONSTRATION AND INSTRUCTION BY SOUND HEALER MADHU ANZIANI

For the published article see: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133.

REFERENCES

Creswell, J. D. (2015). Mindfulness Interventions. Annual Review of Psychology, 68, 491-516.

Dahl, C. Lutz, A., & Davidson, R. J. (2015). Reconstructing and deconstructing the self: Cognitive mechanisms in meditation practice. Trends in Cognitive Science, 19(9), 515-523.

Khazan, I. Z. (2013). The Clinical Handbook of Biofeedback: A Step-by-Step Guide for Training and Practice with Mindfulness. John Wiley & Sons.

Khazan, I. Z. (2019). Biofeedback and Mindfulness in Everyday Life.  New York: W. W. Norton & Company.

Kopelman-Rubin, D., Omer, H., & Dar, R. (2017). Brief therapy for excessive worry: Treatment model, feasibility, and acceptability of a new treatment. Journal of Psychotherapy Integration, 29(3), 291-306. 

Peper, E., Harvey, R., & Lin, I-M. (2019).  Mindfulness training has themes common to other technique. Biofeedback. 47(3),

van der Zwan, J. E., de Vente, W., Huizink, A. C., Bogels, S. M., & de Bruin, E. I.  (2015). Physical activity, mindfulness meditation, or heart rate variability biofeedback for stress reduction: A randomized controlled trial. Applied Psychophysiology and Biofeedback, 40(4), 257-268. https://doi.org/10.1007/s10484-015-9293-x

 


Hope for teens with pain

Erik Peper, PhD and Rachel Zoffness, PhD*

 KM was 14 years old when he came to my (Zoffness) office for treatment. He’d been diagnosed with migraine and cyclical vomiting syndrome and had been in bed for about 3 years. He had long, unwashed hair; was a sickly, pasty white; and rocked himself back and forth from the pain. He’d seen 15 doctors and had been prescribed 30 medications, including occipital nerve injections and Thorazine. Nothing had worked. Like most teens with chronic pain, KM was depressed, stressed, and terrified he’d never get his life back.

We started Cognitive Behavioral Therapy (CBT), beginning with pain neuroscience education. This involved teaching KM and his family how pain works in the brain, and how thoughts, emotions, physical sensations and behaviors work together to trigger and maintain flares. He then learned a variety of cognitive, behavioral and mind-body techniques to help manage and change pain. His parents received parent-training to support him behind the scenes. After a few weeks of treatment, KM was able to get out of bed and walk to the corner mailbox. After a few more weeks, he was able to walk his dog to the dog park and get a haircut. Within a few months he was jogging around the block, then running. As his functioning increased, his brain desensitized and his body strengthened, his pain started to recede. Gradually he returned to school and social relationships, eventually rejoining his soccer team. I attended his high school graduation a year ago. He got onstage and told the audience that, if you’d told him 4 years ago that he’d graduate high school, he’d never have believed you. He is currently in college, successfully managing his pain, living his important life.

Chronic pain (CP) in teens can be devastating. Teens are already tasked with managing the turbulence of hormone changes, social stress, academic stress, social media, family dynamics, and developing autonomy and independence. CP impacts not only the teen, but also the entire family. Because CP is framed as a biomedical problem, it is frequently treated with opioids and other minimally-helpful (and sometimes harmful) medications. Opioids are ineffective for long-term treatment of chronic pain, and are only useful in acute crises or to control pain at the end of life (Dowell, 2016; King et al, 2011).

Although we typically think of chronic pain as an issue primarily affecting adults coping with issues such as post-surgical pain and arthritis, CP affects up to 1 in 3 youth in the USA – more than 10 million children and teens (Friedrichsdorf,  2016; ).  Pain impacts self-esteem, hope, and functioning, relegating teens to their beds and denying them normal educations and healthy social interactions.  Like adults, teens often feel powerless and blamed.  In a superb workbook, The Chronic Pain & Illness Workbook for Teens, psychologist Rachel Zoffness describes what pain is; how pain is constructed by the brain; how mind, body and emotions interact to affect pain; and offers a sequence of assessments and practices to reduce pain and improve health in language children and teens can easily understand.  The approach combines cognitive behavioral therapy (CBT) with imagery, mindfulness, breathing, handwarming with biofeedback, and somatic practices (Turk & Gatchel, 2018; Peper, Gibney, & Holt, 2002).

This simple graphic of the pain cycle is helpful to clients (see Fig. 1).

pain cycle

 Fig 1. CBT Pain Cycle

The pragmatic practices in this book offer tools and guided instructions that any child or teen can use for themselves, with parents, or with health providers.  Therapists can use and adapt these activities with their clients of all ages. Although these scientifically-supported pain management techniques are written for teens, they can equally be used with adults. Below are two of many different practices described in the book that are useful for chronic pain.

Practice 1: Assessment: What sets off your pain?

The first step is to help youth identify factors that “trigger” – or set off – their pain. It’s helpful to define a trigger as a difficult emotion, situation, or event that causes pain to increase. Difficult situations and events of all kinds – biological, social, etc (situational triggers) can trigger difficult thoughts and emotions (cognitive and emotional triggers), and vice versa. For example, Adam was recovering from back surgery (situational trigger), got into a big fight with his sister about the car (situational trigger), and became angry and frustrated (emotional trigger). He felt the anger in his body, his muscles got hot and tight, and his back started spasming. Gina is an example of the reverse. She believed that nothing could cure her fibromyalgia (cognitive trigger), which made her feel depressed and hopeless (emotional trigger). She stayed home for weeks on end without school, friends, or distractions (situational trigger), and started feeling worse.

We can help youth with pain by asking:

  • What emotions trigger your pain?
    • Frustration
    • Anger
    • Stress
    • Anxiety
    • Loneliness
    • Sadness
  • What situations trigger your pain?
    • Not getting enough sleep
    • Arguing with family members
    • Inflammation after physical therapy
    • Missing fun events because you’re sick
    • Thinking about upcoming exams
    • Doctor’s appointments and hospital visits

Sometimes, the teen needs to keep a log for a week to identify the situations or triggers related to the pain.  Once these have been identified then the teen can explore strategies to reduce the negative reactivity triggered by the emotions or situations.

Practice 2: Changing the voice of pain (Note: this is a summary of a longer activity)

One technique we use in CBT for chronic pain is identifying and tracking cognitive distortions, also known as “thinking traps.” I (Zoffness) call these traps “Pain Voice.” This is the catastrophic, pessimistic, critical, and negative voice that tells us awful, worrisome things, particularly about our pain or health.

For example:

Pain Voice pretends she can predict the future, and says it’s going to be terrible. She says: “You’ll never get better. Nothing will ever help you.” But since she can’t predict the future (who can?), Pain Voice is a liar! Pain Voice is also very bossy about what you can and can’t do: “You can’t see your friends this week,” or “You can’t go for a bike ride, and you definitely can’t have any fun.” Science teaches us that negative thoughts increase pain by turning up the brain’s “pain dial,” so we must make sure not to listen to or believe them. To stop Pain Voice, we first catch negative thoughts.

As soon as you learn how to recognize Pain Voice, you gain the power to change negative thoughts into more helpful “Wise Voice” thoughts. One way to bust Pain Voice is to start tracking your negative thoughts. First, list these critical, self-defeating, catastrophic Pain Voice thoughts. Notice if they’re helpful or harmful. Then check and question them, thoughtfully determining whether they’re the truth or a trap. Next, gather evidence as to why Pain Voice might be wrong by asking yourself, is this thought a fact? What evidence do I have that this thought might not be true? What else might happen other than what I’m predicting? Write out your Wise Voice responses, and use them to fight back every time you hear Pain Voice!

Jason’s example: Jason had terrible, daily back pain and hadn’t gone outside in 6 weeks. His friends texted, inviting him to watch a movie. Immediately he heard the thought, “I can’t go, I’m broken. If I leave my house my pain will spike and I won’t be able to function.” He recognized this as his Pain Voice and knew he had to fight back. He sat down with his worksheet and filled in the answers: yes, the thoughts were harmful, not helpful, and they were trying to trap him! He examined the evidence and wrote the Wise Voice thought, “This negative prediction is not a fact, it’s a trap. I’ve had back pain for 2 years, and sometimes going out and seeing friends actually reduces my pain.” Tuning into his Wise Voice gave him the strength to get the social support and distraction he needed to feel a little better! He went to his friend’s house, watched movies, ate popcorn, giggled, and had a great time. For the first time in 6 weeks, his pain went down. An example of his log is shown in table 1.

 Situation

Pain Voice

Helpful or Harmful?

Trap or

Truth

Wise Voice
Returning to school after missing 3 weeks If I go back to school, I’ll be so far behind that I won’t understand anything the teacher is talking about. Harmful Trap This negative prediction is not a fact. I’m smart and competent, I’ll probably understand some things. Last time I was behind, I made up the work and everything was fine.
 

 

Pain flare-up

 

 

 

I can’t handle this! Harmful Trap This negative prediction is not a fact. I’ve had 42 pain flare-ups this year, and I handled all of them. I’ve proven that I’m strong and resilient. There is a 0% chance I can’t handle this.

Table 1. Example from Jason’s log

Summary: There is hope for youth with chronic pain. Interventions like CBT, mindfulness, biofeedback and other mind-body approaches are scientifically-supported and have evidence of effectiveness. Adhering to the biopsychosocial model – targeting biological, psychological and social factors – is proven to be the most effective treatment for chronic pain across conditions and ages. For more information, see Rachel Zoffness’ book, The chronic pain & illness workbook for teens,  for pragmatic treatment practices and user-friendly pain education. 

book cover

References

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA315(15), 1624-1645.

Friedrichsdorf, S. J., Giordano, J., Desai Dakoji, K., Warmuth, A., Daughtry, C., & Schulz, C. A. (2016). Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. Children (Basel, Switzerland)3(4), 42. doi:10.3390/children3040042

King, S., Chambers, C., Huguet, A., MacNevin, R., McGrath, P., Parker, L., & MacDonald, A. (2011). The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain152(12), 2729-2738.

Peper, E. Gibney, K.H., & Holt, C.F. (2002). Make Health Happen-Training Yourself to Create Wellness. Kendall Hunt Publishing. ISBN-13: 978-0787293314

Turk, D. C., & Gatchel, R.J. (2018). Psychological approaches to pain management-A Practionere’s Handbook.  New York: The Guilford Press, ISBN-13: 978-1462528530

Zoffness, R. (2019). The Chronic Pain & Illness Workbook for Teens. Oakland, CA; New Harbinger Publications, ISBN: 978168403352

*Dr. Rachel Zoffness is a pain psychologist, consultant, writer and educator in Northern California’s East Bay specializing in chronic pain and illness.

 


Provide hope and purpose: Focus on the good for all!

Erik Peper and Derek DoylefigureSource: https://devinepartners.com/2015/12/03/positive-news-sheds-light-this-winter/

“Fear stops action; hope initiate action.”

-Tali Sharot, PhD., author of Influential mind

Observe how you feel after you read the following two news reports:

Report 1. The graduating class at Atlanta’s historically black Morehouse College got the surprise of a lifetime on Sunday when commencement speaker and billionaire Robert F. Smith announced that he wasn’t just there to give the nearly 400 graduating seniors a nice motivational speech — he was also going to pay off their student debt.

“On behalf of the eight generations of my family that have been in this country, we’re gonna put a little fuel in your bus,” Smith, the founder of the investment firm Vista Equity and the richest black person in the United States, told the newest graduates of the prestigious all-male college. “This is my class, 2019. And my family is making a grant to eliminate their student loans.” (Lockhart, 2019).

News report 2: Gerry Dean Zaragoza, 26, is accused of fatally shooting his father and brother at a San Fernando Valley apartment before killing his ex-girlfriend at a gas station in North Hollywood, Los Angeles authorities said. He then is thought to have killed someone on a bus as police were searching for him during the 12-hour manhunt, Los Angeles police said. (Andrew Blankstein and Doha Madani (2019).

Which story made you feel more fearful and defensive; which story made you feel more positive and likely to help others?

The effect of incessant news

With the headlines screaming about killing, the endless repeating and commenting on tweeting lies  that evoke hatred, the creation of concentration camps and separating children from their immigrant mothers, or Representatives and Senators  focusing on winning the next election instead of focusing on the common good, we become fearful, discouraged and hopeless about the future. Surrounded by negative news we become apathetic, freeze in place, and close down to protect against loss.

Having traveled in the last few years to Japan, India, the Netherlands, Spain, Poland, Italy, and Canada, we observed that the USA is becoming a failed state.  The failing infrastructure of bridges and roads, the student debt that locks students into years of servitude, and the millions of people bankrupted by medical bills are only a few of the symptoms of our failing state and lack of positive vision. The more we allow ourselves to be bombarded by negative visual and auditory messages, the more we feel hopeless and powerless. We do not want to react out of hatred and disgust.  We want to focus on possibilities and be motivated by positive role models that will encourage positive action. Where is the inspirational vision for the future and the “Restoration Story” of how to get there? (Monbiot, 2019). We need a common mission for all to contribute to in our own unique and special way.

The images, words and thoughts that we allow to enter our brain become the hypnotic template for tomorrow’s action.  There is a  difference in saying, “I do not want hatred, fear and degrading commentary” versus “I want to learn from the inspirational work, aspirations and visions of nation builders and participate in this process.”

If you say to yourself, “I do not want to eat a piece of pie,” then that thought  evokes the image of piece of pie, which you may reject by saying “No.” This means that you are rehearsing eating the sweets and thus strengthening the desire.  If on the other hand you say to yourself, ‘I choose to eat more fruits and vegetables,” you are strengthening that desire. The thoughts help you identify the presence of fruits and vegetables more easily. Just as when you plan a vacation to Hawaii. All of a sudden there seems to be adds about Hawaii everywhere.

What we remember the next day depends upon what we focused upon earlier.  What we focus our attention and emotions on before going to sleep is what is stored in permanent memory and more likely to be remembered and acted upon the next day. Be careful what to look at and watch before going to sleep. It also impacts our physical and mental health. Children whose parents were emotionally upset and continue to watch the collapse of the World Trade Center buildings many times during the 9/11 terrorist attack experienced more stress symptom (including difficulty concentrating, difficulty falling asleep, losing temper/irritability, and nightmares) and 47% were worried about their own safety or the safety of loved ones (Hooker and Friedman, 2005).

Ask yourself, what images, speech and thoughts  you allow to enter your brain? In most cases, the news focuses upon destructive acts that evoke fear and implicitly reduce actual action.  Similarly, we can watch violent and toxic program on different streaming media such as Netflix, YouTube or Amazon Prime. As a result, we see the world much more dangerous than it  is.  Thus, we hover over children because we now think that they would be abducted by strangers (Amber Alert).  This increases the  public’s moral panic yet it is not clear if there has been an actual  increase in stranger child abduction in the last fifty years (Zgoba, 2006).

People who watch the news before going to sleep perceive their neighborhood as significantly more dangerously as compared to those who do not watch the news.  Because they believe their neighborhood is more dangerous, they avoid going out and by not going out make the neighborhood less communal and friendly. The information supports our negativity bias which focuses our attention on things that are dangerous or threatening (Soroka & McAdams, 2015)..

We have a choice to focus on what we would like instead of allowing to be bombarded by negative toxic messages and images.  This does not mean we stick our heads in the sand and are unaware, it means that we choose carefully how to balance the messages we receive. Instead of watching and listening to repeated negative news, listen or read (to) the news once during the day and then fill the day with positive news that evokes hope, good deeds and better possibilities for our communities.

Consider an experiment for a day or so..

Try searching and discovering some good news to share with family and friends. Watch their reaction and then extend the experiment for a few days seeking and sharing positive news.

Watch and listen to positive media such as:

  • GoodNews Network: The website, with its archive of 21,000 positive news stories from around the globe, confirms what people already know—that good news itself is not in short supply; the broadcasting of it is. https://www.goodnewsnetwork.org
  • TED Ideas worth spreading. TED is a global community, welcoming people from every discipline and culture who seek a deeper understanding of the world. We believe passionately in the power of ideas to change attitudes, lives and, ultimately, the world. https://www.ted.com/#/

After a few days or a week, ask how do you feel?

  • Are you more optimistic?
  • Do you feel safer and more relaxed?
  • Is sleep more restorative?

If you are like many others, you would feel slightly more hopeful, optimistic and positive.

What we allow to enter our brain becomes the template for the choices we make.

References

Blankstein, A. & Madani, D. (2019). Gunman suspected killing least three people in California shooting spree. NBC News, July 26, 2019.

Hooker, K.E., & Friedman, H. (2005). Responding to the psychological needs of children after 9/11: A review of the literature.

Lockhart, P.R. (2019). The Morehouse debt cancellation and the growing black student debt crisis. VOX Media. May 20, 2019.

Monbiot, G. (2019). The new political story that could change everything. TEDSummit.

Sharot, T. (2019). The influential mind-What the brain reveals about our power to change others. New York: Henry Holt and Company

Soroka, S. & McAdams, S. (2015). News, politics, and negativity. Political Communication, 32(1), 1-22.

Zgoba, K.M. (2006). Spin doctors and moral crusaders: the moral panic behind child safety legislation. Criminal Justice Studies, 17(4), 385-404.


Do self-healing first

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“I am doing very well, and I am very healthy. The vulvodynia symptoms have never come back. Also,my stomach (gastrointestinal discomfort) has gotten much, much better. I don’t really have random pain anymore, now I just have to be watchful and careful of my diet and my exercise, which are all great things!”  —A five-year follow-up report from a 28-year-old woman who had previously suffered from severe vulvodynia (pelvic floor pain).

Numerous clients and students have reported that implementing self-healing strategies–common sense suggestions often known as “grandmother’s therapy”—significantly improves their health and find that their symptoms decreased or disappeared (Peper et al, 2014). These educational self-healing approaches are based upon a holistic perspective aimed to reduce physical, emotional and lifestyle patterns that interfere with healing and to increase those life patterns that support healing. This may mean learning diaphragmatic breathing, doing work that give you meaning and energy, alternating between excitation and regeneration, and living a life congruent with our evolutionary past.

If you experience discomfort/symptoms and worry about your health/well-being, do the following:

  • See your health professional for diagnosis and treatment suggestions.
    • Ask what are the benefits and risks of treatment.
    • Ask what would happen if you if you first implemented self-healing strategies before beginning the recommended and sometimes invasive treatment?
  • Investigate how you could be affecting your self-healing potential such as:
    • Lack of sleep
    • Too much sugar, processed foods, coffee, alcohol, etc.
    • Lack of exercise
    • Limited social support
    • Ongoing anger, resentment, frustration, and worry
    • Lack of hope and purpose
  • Implement self-healing strategies and lifestyle changes to support your healing response. In many cases, you may experience positive changes within three weeks. Obviously, if you feel worse, stop  and reassess. Keep a log and monitor what you do so that you can record changes.

This self-healing process has often been labeled or dismissed as the “placebo effect;” however, the placebo effect is the body’s natural self-healing response (Peper & Harvey, 2017).  It is impressive that many people report feeling better when they  take charge and become active participants in their own healing process. A process that empowers and supports hope and healing. When participants change their life patterns, they often feel better. Their health worries and concerns become reminders/cues to initiate positive action such as:

  • Practicing self-healing techniques throughout the day (e.g., diaphragmatic breathing, self-healing imagery, meditation, and relaxation)
  • Eating organic foods and eliminating processed foods
  • Incorporating daily exercise and movement activities
  • Accepting what is and resolving resentment, anger and fear
  • Taking time to regenerate
  • Resolving stress
  • Focusing on what you like to do
  • Be loving to yourself and others

For suggestions of what to do, explore some of the following blogs that describe self-healing practices that participants implemented to improve or eliminate their symptoms.

Acid reflux (GERD) https://peperperspective.com/2018/10/04/breathing-reduces-acid-reflux-and-dysmenorrhea-discomfort/

Anxiety https://peperperspective.com/2019/03/24/anxiety-lightheadedness-palpitations-prodromal-migraine-symptoms-breathing-to-the-rescue/

Dyspareunia https://peperperspective.com/2017/03/19/enjoy-sex-breathe-away-the-pain/

Eczema https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Headache https://peperperspective.com/2016/11/18/education-versus-treatment-for-self-healing-eliminating-a-headaches1/

Epilepsy https://peperperspective.com/2013/03/10/epilepsy-new-old-treatment-without-drugs/

Irritability/hangry https://peperperspective.com/2017/10/06/are-you-out-of-control-and-reacting-in-anger-the-role-of-food-and-exercise/

Hot flashes and premenstrual symptoms https://peperperspective.com/2015/02/18/reduce-hot-flashes-and-premenstrual-symptoms-with-breathing/

Internet addiction https://peperperspective.com/2018/02/10/digital-addiction/

Irritable bowel syndrome (IBS) https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Math and test anxiety https://peperperspective.com/2018/07/03/do-better-in-math-dont-slouch-be-tall/

Neck stiffness https://peperperspective.com/2017/04/06/freeing-the-neck-and-shoulders/

Neck tension https://peperperspective.com/2019/05/21/relieve-and-prevent-neck-stiffness-and-pain/

Posture and mood https://peperperspective.com/2017/11/28/posture-and-mood-implications-and-applications-to-health-and-therapy/

Psoriasis https://peperperspective.com/2013/12/28/there-is-hope-interrupt-chained-behavior/

Smoking https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Surgery https://peperperspective.com/2018/03/18/surgery-hope-for-the-best-but-plan-for-the-worst/

Trichotillomania (hair pulling) https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Vulvodynia https://peperperspective.com/2015/09/25/resolving-pelvic-floor-pain-a-case-report/

References

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.

Peper, E. & Harvey, R. (2017). The fallacy of the placebo-controlled clinical trials: Are positive outcomes the result of “indirect” treatment effects? NeuroRegulation, 4(3–4), 102–113.

 


Biofeedback, breathing and health

In the video interview recorded at the 2018 Conference of the New Psychology Association, Jagiellonian University, Krakow, Poland,  Erik Peper, PdD, defines biofeedback and suggests three simple breathing and imagery approaches that we can all apply to reduce pain, resentment and improve well-being.


Breathing reduces acid reflux and dysmenorrhea discomfort

“Although difficult and going against my natural reaction to curl up in the response to my cramps, I stretched out on my back and breathed slowly so that my stomach got bigger with each inhalation.  My menstrual pain slowly decreased and disappeared.

“For as long as I remember, I had stomach problems and when I went to doctors, they said, I had acid reflux. I was prescribed medication and nothing worked. The problem of acid reflux got really bad when I went to college and often interfered with my social activities. After learning diaphragmatic breathing so that my stomach expanded instead of my chest, I am free of my symptoms and can even eat the foods that previously triggered the acid  reflux.”

In the late 19th earlier part of the 20th century many women were diagnosed with Neurasthenia.  The symptoms included fatigue, anxiety, headache, fainting, light headedness, heart palpitation, high blood pressure, neuralgia and depression. It was perceived as a weakness of the nerves. Even though the diagnosis is no longer used, similar symptoms still occur and are aggravated when the abdomen is constricted with a corset or by stylish clothing (see Fig 1).

Fig 1a

Figure 1. Wearing a corset squeezes the abdomen.

The constricted waist compromises the functions of digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing down. Thus, the person is forced to breathe more shallowly by lifting their ribs which increases neck and shoulder tension and the risk of anxiety, heart palpitation, and fatigue. It also can contribute to abdominal discomfort since abdomen is being squeezed by the corset and forcing the abdominal organs upward.  It was the reason why the room on top of stairs in the old Victorian houses was call the fainting room (Melissa, 2015).

During inhalation the diaphragm flattens and attempts to descend which increases the pressure of the abdominal content.  In some cases this causes the stomach content to be pushed upward into the esophagus which could result in heart burn and acid reflux.  To avoid this, health care providers often advice patients with acid reflux to sleep on a slanted bed with the head higher than their feet so that the stomach content flows downward. However, they may not teach the person to wear looser clothing that does not constrict the waist and prevent designer jean syndrome. If the clothing around the waist is loosened, then the abdomen may expand in all directions in response to the downward movement of the diaphragm during inhalation and not squeeze the stomach and thereby pushing its content upward into the esophagus.

Most people have experienced the benefits of loosening the waist when eating a large meal. The moment the stomach is given the room to spread out, you feel more comfortable.   If you experienced this, ask yourself, “Could there be a long term cost of keeping my waist constricted?”  A constricted waist may be as harmful to our health as having the emergency brake on while driving for a car.

We are usually unaware that shallow rapid breathing in our chest can contribute to symptoms such as anxiety, neck and shoulder tension, heart palpitations, headaches, abdominal discomfort such as heart burn, acid reflux, irritable bowel syndrome, dysmenorrhea and even reduced fertility (Peper,  Mason, & Huey, 2017; Domar, Seibel, & Benson, 1990).

Assess whether you are at risk for faulty breathing

Stand up and observe what happens when you take in a big breath and then exhale.  Did you feel taller when you inhaled and shorter/smaller when you exhaled?

If the answer is YES, your breathing pattern may compromise your health.   Most likely when you inhaled you lifted your chest, slightly arched your back, tightened and raised your shoulders, and lifted your head up while slightly pulling the stomach in. When you exhaled, your body relaxed and collapsed downward and even the stomach may have relaxed and expanded. This is a dysfunctional breathing pattern and the opposite of a breathing pattern that supports health and regeneration as shown in figure 2.

Fig 2a

Figure 2.  Incorrect and correct breathing. Source unknown.

Observe babies, young children, dogs, and cats when they are peaceful.  The abdomen is what moves during breathing.   While breathing in, the abdomen expands in all 360 degrees directions and when breathing out, the abdomen constricts and comes in.   Similarly when dogs or cats are lying on their sides, their stomach goes up during inhalation and goes down during exhalation.

Many people tend to breathe shallowly in their chest and have forgotten—or cannot– allow their abdomen and lower ribs to widen during inhalation (Peper et al, 2016). These factors include:

  • Constriction by the modern corset called “Spanx” to slim the figure or by wearing tight fitting pants. In either case the abdominal content is pushed upward and interferes with normal healthy breathing.
  • Maintaining a slim figure by pulling the abdomen (I will look fat when my stomach expands; I will suck it in).
  • Avoiding post-surgical abdominal pain by inhibiting abdominal movement. Numerous patients have unknowingly learned to shallowly breathe in their chest to avoid pain at the site of the incision of the abdominal surgery such as for hernia repair or a cesarean operation. This dysfunctional breathing became the new normal unless they actively practice diaphragmatic breathing.
  • Slouching as we sit or watch digital screens or look down at our cell phone.

Observe how slouching affects the space in your abdomen.

When you shift from an upright erect position to a slouched or protective position the distance between your pubic bone and the bottom of the sternum (xiphoid process) is significantly reduced.

  • Tighten our abdomen to protect ourselves from pain and danger as shown in Figure 3.

Fig 3a

Figure 3. Erect versus collapsed posture. There is less space for the abdomen to expand in the protective collapsed position. Reproduced by permission from Clinical Somatics (http://www.clinicalsomatics.ie/).

Regardless why people breathe shallowly in their chest or avoid abdominal and lower rib movement during breathing, by re-establishing normal diaphragmatic breathing many symptoms may be reduced.  Numerous students have reported that when they shift to diaphragmatic breathing which means the abdomen and lower ribs expand during inhalation and come in during exhalation as shown in Figure 4, their symptoms such as acid reflux and menstrual cramp significantly decrease.

Fig 4a

Figure 4. Diaphragmatic breathing. Reproduced from:  www.devang.house/blogs/thejob/belly-breathing-follow-your-gut.

Reduce acid reflux

A 21-year old student, who has had acid reflux (GERD-gastroesophageal reflux diseases) since age 6, observed that she only breathed in her chest and that there were no abdominal movements.  When she learned and practiced slower diaphragmatic breathing which allowed her abdomen to expand naturally during inhalation and reduce in size during exhalation her symptoms decreased. The image she used was that her lungs were like a balloon located in her abdomen. To create space for the diaphragm going down, she bought larger size pants so that her abdominal could spread out instead of squeezing her stomach (see Figure 5).

squeezing the stomach

Figure 5. Hydraulic model who inhaling without the abdomen expanding increases pressure on the stomach and possibly cause stomach fluids to be pushed into the esophagus.

She practiced diaphragmatic breathing many times during the day. In addition, the moment she felt stressed and tightened her abdomen, she interrupted this tightening and re-established abdominal breathing.  Practicing this was very challenging since she had to accept that she would still be attractive even if her stomach expanded during inhalation. She reported that within two weeks her symptom disappeared and upon a year follow-up she has had no more symptoms For a detailed description how this successfully cured irritable bowel syndrome see: https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Take control of menstrual cramps

Numerous college students have reported that when they experience menstrual cramps, their natural impulse is to curl up in a protective cocoon. If instead they interrupted this natural protective pattern and lie relaxed on their back with their legs straight out and breathe diaphragmatically with their abdomen expanding and going upward during inhalation, they report a 50 percent decrease in discomfort (Gibney & Peper, 2003). For some the discomfort totally disappears when they place a warm pad on their lower abdomen and focused on breathing slowly about six breaths per minute so that the abdomen goes up when inhaling and goes down when exhaling. At the same time, they also imagine that the air would flow like a stream from their abdomen through their legs and out their feet while exhaling.  They observed that as long as they held their abdomen tight the discomfort including the congestive PMS symptoms remained.  Yet, the moment they practice abdominal breathing, the congestion and discomfort is decreased. Most likely the expanding and constricting of the abdomen during the diaphragmatic breathing acts as a pump in the abdomen to increase the lymph and venous blood return and improve circulation.

Conclusion

Breathing is the body-mind bridge and offers hope for numerous disorders. Slower diaphragmatic breathing with the corresponding abdomen movement at about six breaths per minute may reduce autonomic dysregulation. It has profound self-healing effects and may increase calmness and relaxation. At the same time, it may reduce heart palpitations, hypertension, asthma, anxiety, and many other symptoms.

References

DeVault, K.R. & Castell, D.O. (2005). Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The American Journal of Gastroenterology, 100, 190-200.

Domar, A.D., Seibel, M.M., & Benson, H. (1990). The Mind/Body Program for Infertility: a new behavioral treatment approach for women with infertility. Fertility and sterility, 53(2), 246-249.

Gibney, H.K. & Peper, E. (2003). Taking control: Strategies to reduce hot flashes and premenstrual mood swings. Biofeedback, 31(3), 20-24.

Johnson, L.F. & DeMeester, T.R. (1981).  Evaluation of elevation of the head of the bed, bethanechol, and antacid foam tablets on gastroesophageal reflux. Digestive Diseases Sciences, 26, 673-680. https://www.ncbi.nlm.nih.gov/pubmed/7261830

Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015.  Donloaded October 2, 1018. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/

Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49.

Peper, E., Mason, L., Huey, C. (2017).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4)

Stanciu, C. & Bennett, J.R.. (1977). Effects of posture on gastro-oesophageal refluxDigestion, 15, 104-109. https://www.karger.com/Article/Abstract/197991