Adapted from: Peper, E., Wilson, V., Martin, M., Rosegard, E., & Harvey, R. (2021). Avoid Zoom fatigue, be present and learn. NeuroRegulation, 8(1), 47–56. https://doi.org/10.15540/nr.8.1.47
After a while, it all seems the same. Sitting and looking at the screen while working, taking classes, entertaining, streaming videos and socializing. The longer I sit and watch screens, the more I tend to feel drained and passive, and the more challenging it is to be present, productive and pay attention.
Overnight, the pandemic transformed college teaching from in-person to online education. Zoom became the preferred academic teaching and learning platform for synchronous education. Students and faculty now sat and looked at the screen for hours. While looking at the screen, the viewers were often distracted by events in their environment, notifications from smartphones, social media and email, which promoted multitasking (Solis, 2019). The digital distractions causing people to respond to twice as many devices with half of our attention—a process labeled ‘semi-tasking’- meaning getting twice as much done half as well.
For many students synchronous online learning was more challenging, especially after teaching was shifted to a Zoom environment without adapting the course materials to optimize online learning. During polling of 325 undergraduate university students at a metropolitan university who were all taking synchronous online Zoom classes, the vast majority reported that learning was somewhat to extremely difficult, with only the minority of students (approximately 6%) preferring online learning as shown in Figure 1.
Figure 1. Survey of 325 Undergraduates comparing Zoom online learning compared to the previous in person classes. Approximately 94% had moderate to considerable difficulty with on line learning.
The increased self-report on difficulty experienced in synchronous Zoom online learning may also affect academic achievement. At the same time, many people have reported an increase in physical, behavioral and psycho-emotional problems (e.g. backache, headache, stomachache, eye-strain, sore neck and shoulder pain, over or under eating, over or under sleeping, over or under exercising, ruminative thoughts related to categories of anxiety/fear, boredom/numbness, depression/sadness, anger/hostility, etc) (Fosslien & Duffy, 2020; Lee, 2020; Intolo, 2019; Leeb et al, 2020; McGinty et al, 2020; Peper & Harvey, 2018; Peper, Harvey and Faas, 2020).
This post explores factors that contribute to zoom fatigue and offers practical suggestions to optimize learning during synchronous Zoom online education. The concepts are derived from our teaching athletes to sustain peak mental and physical performance, with the implication that the same concepts can help students towards sustaining on-topic attention during online learning (Wilson & Peper, 2011). In sports, the coach can help guide the athlete; however, the athlete needs to be present and motivated. Faculty have a responsibility to support, encourage, and engage students while students have the responsibility to configure themselves into an optimum learning state.
Part 1: Factors that contribute to Zoom fatigue
Differences in communication between live and computer communication
Until the 20th century, almost all communication included non-verbal expressions. The speaker used verbal and nonverbal expressions while the respondent would immediately show a reaction to the speaker. There was a continuous dynamic verbal and nonverbal exchange. The listener would respond to the speaker. If they agreed they nodded their head. If they disagreed or were intimidated they would provide alternative body movements (e.g., shake their head) or facial expressions (look away or frown). During normal conversations, both the speaker’s facial expression and body language are noticed and responded to, which are in turn, can be used as feedback by the other person. In large group sessions with many participants, the visual feedback is reduced and facial responses are difficult to distinguish especially the gallery view.
In a Zoom environment, both the sender and receiver are watching the computer screen without awareness that nonverbal cues are essential for the purpose of understanding not only what is being said but also for the implied meaning and its importance. These non-verbal cues are usually processed without awareness in live person-to-person exchange. While sending and receiving are usually simultaneous, there can exist a disconnect between the attached meanings of the encoded information and that of the decoded information due to the inconsistent existence of important nonverbal components. In a Zoom environment, the end-result could mean multiple images of receivers providing the sender with little or no non-verbal cues with which to interpret the meaning they have attached to your message. The person may appear to look at you; however, you do not know whether they are attending to you, have a neurological disorder and cannot respond, are reading their emails, watching YouTube videos, or texting on their phone. Additionally, the nonverbal cues they are sending may not be related to your message but to their reaction to other media, people or distractions not seen by the presenter.
This mode of communication is different from communication patterns that evolved through natural selection and allowed the human species to thrive and survive. For the first time in human history we learn, teach, work, socialize, and entertain in front of the same screen. In many cases, communication in the era of smartphones has been reduced to texting, writing digital responses or reacting to media content on any screen. Over the past few decades, it is possible for people to communicate through more disembodied, off-topic and external modes of interaction. So many types of learning activities vie for our attention and can occur without leaving our chairs, thus, it may be difficult to stay on-topic online Zoom classes (Keller, Davidesco, & Tanner, 2020).
Normal communication typically involves whole body movements (face, head, arms and hands) which tends to energize or sometimes distract the speaker or listener (Kendon, 2004). When communicating with friends-we often move our bodies dynamically and responsively during the discussion. With synchronous large online lectures, students tend to be passive and just sit and watch. This state of sitting and just watching the screen is similar to watching video entertainment where we sit for a long time and are covertly conditioned not to act.
Unknowingly, we have trained ourselves not to initiate action since the screen does not provide feedback to our responses- a process so different from talking and responding spontaneously in groups of participants.
When communication is safe, people interact, respond and chime in. In large groups, just like large lectures, Zoom tends to inhibit this process because it delays social feedback since most people mute their microphone to avoid extraneous noise. This is usually the rule for large groups although for small groups, people often unmute themselves. The physical act of unmuting is an additional barrier to spontaneous verbal responses. This shift of attention induces a delay before responding. From a communication perspective, a delay before responding reduces the spontaneity and is may be interpreted more negatively by the listener (Roberts, Margutti, & Takano, 2011).
Facial Expressions and Auditory Processing
Facial expressions are a critical part of non- verbal feedback and signals to the other person that they are being listened to and provide cues that the interaction is safe. We unknowingly react to facial expressions–processed unconsciously through neuroception (Porges, 2017)–to indicate whether the person is signaling safety or danger. Usually when the person is facially responsive and shows expression, it signals safety and allows communication and intimacy to be developed. If the person shows no facial expressions (a still/flat face), we unconsciously interpret this as a signal of danger (Porges, 2017). The importance of responsive feedback is illustrated in the study by Tronick et al (1975) where mothers were instructed not to respond with facial and body cues to their infant. The babies rapidly became highly disturbed when the mother stayed nonresponsive as dramatically illustrated in the YouTube video, Still Face Experiment: Dr. Edward Tronick (Tronick, 2007). In adults lack of verbal and nonverbal feedback during social evaluations is extremely stressful (Gruenewald, Kemeny, Aziz, & Fahey, 2004; Birkett, 2011).
The absence of social facial and body feedback often makes teaching and learning more challenging. Namely, are the receivers–the invisible, (only their picture or name is shown), partially visible (facial features are indistinct due to backlighting) or ghosting (those whose picture and name are shown but are physically absent from the session)–understanding the information the way the sender intended?
Unlike traditional classroom settings where one has the benefit of seeing/sensing nonverbal cues, the Zoom gallery view often, the speaker may not know what how the audience is responding and this contributes to Zoom fatigue. In addition, the communication bond is often reduced when the speaker does not look at audience and the listener does not respond to the speaker with facial expressions. Zoom fatigue can also be reduced when online teaching tools are used appropriately by involving active feedback responses through polls, chat, etc. as well as asking specific participants to speak and give feedback.
What is unique to the synchronous online environment is that the speakers and participants view themselves. This is the first time in human history that people are seeing themselves while speaking. For some people, seeing themselves may increase anxiety and negative self-judgement- a process that is even more prevalent in teens. Some are self-conscious and some have social anxiety and do not want their face to be shown (Degges-White, 2020). In the past, most of us had no idea how we looked when others or ourselves are communicating—it is totally novel experience to see yourself while talking and communicating.
Reduced physical activity and increased near vision stress.
Before sheltering in place, I would walk from my house to the BART station, take the train to Daly City station and then walk to the university. At the university, I would climb stairs to go to my office, meet with other faculty and walk to the classroom. At the end of the day, I would walk back to the Bart station and eventually walk home. Without any thinking or trying to do any exercise, I usually would do 12,000 steps and about 25 stairs. Now, I am lucky if I do 3000 unless will myself to do more exercise. –Erik Peper
The move to a Zoom environment and sheltering in place meant that we sit more and more which tends to increase mortality, decrease subjective energy and contributes to an attitude of passive engagement, more as an observer than as a participant (Stamtakis et al, 2019; Patel et al, 2018; Oswald et. al., 2020; Yalçin, Özkurt, Özmaden & Yagmur, 2020). While sitting, we also tend to slouch as we look at the screen that may be a covert factor in the increasing rates of depression and anxiety.
This slouching position tends to decrease access to positive memories and allow easier access to negative memories (Peper et al, 2017) as well as interfere with academic performance. Peper et al (2018) found that students have more difficulty performing mental math in the slouched as compared to upright sitting position. To reduce the impact of sitting, Peper & Lin (2012) found that when student perform some physical activities (e.g., skipping in place) for just a minute they report a significantly increase subjective energy and attention levels.
When looking at the screen our eyes only focus on the screen, which is different from in-person communication where you look at the person and then look at behind or to the side of the person. Only looking at the screen means that to focus on the screen the muscles of the eyes tighten so that the eyes can converge and the ciliary muscles around the lens contract so that the lens curvature is increased which results in near visual stress. This continuous looking at a near object is different from normal eye function in which we alternately focus on nearby objects and then look far away which allows the muscles of the eyes to relax.
Numerous students reported that it was much easier to be distracted and multitask, check Instagram, facebook, TikTok, or respond to emails and texts than during face-to-face classroom sessions as illustrated by two students’ comments.
“Now that we are forced to stay at home, it’s hard to find time by myself, for myself, time to study, and or time to get away. It’s easy to get distracted and go a bit stir-crazy.”
“I find that online learning is more difficult for me because it’s harder for me to stay concentrated all day just looking at the screen.”
Students often reported that they had more difficulty remembering the materials presented during synchronous presentations. Most likely, the passivity while watching Zoom presentation affected the encoding and consolidation of new material into retrievable long term memory. The presented material was rapidly forgotten when the next screen image or advertisement appeared and competed with the course instructor for the student’s attention. We hypothesize that the many hours of watching TV and streaming videos have conditioned people to sit and take in information passively, while discouraging them to respond or initiate action (Mander, 1978; Mărchidan, 2019). Learning requires engagement, which means a shifting from passively watching and listening to being an active, participant shareholder in synchronous online classes. However, in most cases, students have not received information/education or training on HOW TO be a more active/engaged participant in a synchronous Zoom class.
Instructors also have many of the same issues when presenting classes online. They engage in multiple simultaneous roles: presenter, director, and producer. While teaching, they need to engage students, monitor the chat for feedback and look at the screen for facial responses. At the same time, they may face similar technical issues as those experienced by students such as internet connectivity, limited bandwidth, and mastering the technical features of synchronous online learning technology. At times, instructors feel that students expect each presentation to be as captivating as a TED talk. Thus, teaching has shifted from education to edutainment.
Part 2: Practical suggestions to optimize learning
To optimize learning in the synchronous online environment, teachers have the responsibility to reconfigure their teaching so that it incorporates active student involvement and students have the responsibility to be present and engaged. The following practices may facilitate learning:
Be present to learn
Mastering media presence is becoming even more important for everyone. The skill implemented in attending an online learning class will also be useful for professional development. Although the pandemic shifted personal interviews to online interviews, most likely, synchronous and asynchronous video interviews are part of the first automatic screening level to assess candidates for a job (Rubinstein, 2020).
Be visible for the other person looking at you to create a positive impression
Adjust your camera and lights so that your face is visible and you are looking at the person to whom you are talking. Your screen presence is representing you. Does the camera show you engaged or distracted lying on bed? Be aware that you and your background together create an impression. The concept that looking directly at the audience– looking directly at the camera–is not new. Everyone working in media (newscasters, politicians, actors) have been trained to make their faces visible and expressive. This means arranging your webcam at eye level right in front of you and speaking to the camera as if it is the person. Avoid looking down at the person on the screen since the viewer would see you looking look down and away. Be sure your face is illuminated and there are no bright light sources behind you (Purdy, 2020). We recommend that in small group, participants unmute their microphones so that people can respond spontaneously to each other unless there is excessive background noise.
Be a responsive and interactive listener to configure your brain to be engaged
Shift from being a passive absorber to an active participant even if your camera is off or the speaker cannot see you. Imagine being physically with the speaker and activate yourself by increasing your face and body animation as you are attending a synchronous online class. Thus, when you watch a presentation, act as if you are in a personal conversation with the presenter or the material. This means that if you agree, nod your head; if you disagree, shake your head (do this naturally without making it a work task). Do this for the whole session. Our research has shown that when college students purposely implement animated facial and body responses during Zoom classes, they report a significant increase in energy level, attention and involvement as compared to just attending normally in class (Peper & Yang, in press). See Figure 2.
Figure 2. Change in subjective energy, attention and involvement when the students significantly increase their facial and body animation by 123 % as compared to their normal non-expressive class behavior (Peper & Yang, 2021).
“I never realized how my expressions affected my attention. Class was much more fun”
-22 year old woman student.
“I can see how paying attention and participation play a large role in learning material. After trying to give positive facial and body feedback I felt more focused and I was taking better notes and felt I was understanding the material a bit better.”-28 year old medical student
Configure your body to attend and perform
Sit upright and adapt a position of empowerment. When we sit upright and expanded it is easier to have positive thoughts and detach from negative hopeless thoughts (Peper, Lin, Harvey, & Perez, 2017; Peper, Harvey, Mason, & Lin, 2018). Students also performed better in mental math when they sat upright as compared to collapsed. When students are provided ongoing feedback when they begin to slouch by an app that uses the computer camera to monitor slouching, they reported a significant decrease in neck and back symptoms (Chetwynd et al, 2020). As one of many students reported:
“Before when I didn’t use the app, I had a lots of shoulder and neck pain. Now when I use it, the pain went way down as I kept changing posture to the feedback signal. I had more energy and I was more alert. I did notice that when I would get the alert to sit up straight.”
Optimize concentration and learning
In the online environment, the structure more likely depends upon the person unlike the externally created structure of going to work or to class. Thus, purposely creating a time structure and scheduled time-periods to perform different tasks as time management skills are associated with improved school and work performance (Macan et al., 1990). Create an environment to promote concentration and reduce distractions.
- Stay on task and reduce interruption and practice refocusing on task. On the average we now check our phones 96 times a day—that is once every 10 minutes and an increase of 20% as compared to two years ago (Asurion Research, 2019). Those who do media multitasking such as texting while doing a task perform significantly worse on memory tasks than those who are not multitasking (Madore et al., 2020). Multitasking is negatively correlated with school performance (Giunchiglia et al, 2018). When working or attending a class or meeting, turn off all notifications (e.g., email, texts and social media). Then block out specific times when you work on Zoom and when you respond to email, phone or social media (Newport, 2016). Let people know that you will look at the notifications and respond in a predetermined time so that you will not be interrupted while working or studying. If you work where there are other people, arrange your workstation so that there are fewer distractions such as sitting with your back to other people. When students chose to implement a behavior change to monitor cellphone and media use and reduce the addictive behavior during a five-week self-healing project, many report a significant improvement of health and performance. One student observed that when she reduced her cellphone use her stress level equally decreased as shown in Fig 3.
Figure 3. Example of a student changing cellphone use and corresponding decrease in subjective stress level.
During this class project, many students observed that the continuous responding to notifications and social media affect their health and productivity. As one student reported,
The discovery of the time I wasted giving into distractions was increasing my anxiety, increasing my depression and making me feel completely inadequate. In the five-week period, I cut my cell phone usage by over half, from 32.5 hours to exactly 15 hours and used some of the time to do an early morning run in the park. Rediscovering this time makes me feel like my possibilities are endless. I can go to work full time, take online night courses reaching towards my goal of a higher degree, plus complete all my homework, take care of the house and chores, cook all my meals, and add reading a book for fun! –22 year old College Student
- Approached learning with a question. When you begin to study the material or attend a class, ask yourself questions that you would like to be answered. If possible, put your questions to the instructor. When you have a purpose, it is easier to stay emotionally present and remember the material (Osman, & Hannafin, 1994).
- Take written notes while attending a Zoom meeting or class. When participants take hand written notes versus on the computer they tend to integrate and remember the material much more than just watching passively (Mueller & Oppenheimer, 2014). Active note taking leads to focused attention and fewer distractions from social media content (Flanigan & Titsworth, 2020).
- Review materials. At the end of the class, meet with your fellow students on ZOOM or social media and review the class materials. As you discuss the materials, add comments to your notes and if possible, do a hierarchical outline to more easily remember the relationships among the ideas.
- Change your internal language. What we overtly or covertly say and believe is what we may become. When one says, “I am stupid”, “I can’t do math,” or “It is too difficult to learn,” one may become powerless which increases stress and inhibits cognitive function. Instead, change the internal language so that it implies that you can master the materials such as, “I need more time to study and to practice the material,” “Learning just takes time and at this moment it may take a bit longer than for someone else,” or “I need a better tutor.”
Create an environment to trigger the appropriate mental and emotional state for learning.
Learning and recall are state dependent. Without awareness, the learned content is covertly associated with environmental, emotional, social and kinesthetic cues. Thus, when you study in bed, the material is more easily accessed while lying down. When you study with music, the music becomes a retrieval cue. Without awareness, the materials are encoded with the cues of lying down or the music played in the background. When you take your exam in a different setting then you have studied, none of the covert cues are there, thus, it is more difficult to recall the material. Study and review the materials under similar conditions, as you will be tested.
To configure yourself to be ready to study, work, or socialize create different environments that are unique to each category of Zoom involvement (studying, working, socializing, entertaining). Pre COVID, we usually used different clothing for different events (work versus party) or different environments for different tasks (temple, churches, mosques, or synagogue for religious practice; bar or coffee shop to meet friends). Create a unique environment with each Zoom activity. The stimuli to be associated to the specific tasks can also include lighting, odors, sound or even drinks and food. These stimuli become the classically conditioned cues to evoke the appropriate response associated with the task just as Pavlov conditioned dogs to salivate by pairing a sound with the meat. Taking charge of the conditioning process may help many people to focus on their task as so many students use their bedroom, kitchen or living room for Zoom work which is not always conducive for learning or work.
- Wear task specific clothing just as you would have done going to work or school. When you plan to study, put on your study T-shirt. In time, the moment you put on the study T-shirt, you are cueing yourself to focus on studying. When finishing with studying, change your clothing.
- Arrange task specific backgrounds for each category of Zoom task. Place a different background such as a poster or wall hanging behind the computer screen-one for studying and another for entertainment. When finished with the specific Zoom event, take down the poster and change the background.
Optimize arousal and regenerate vision
- The longer we sit the more passive we tend to become. Teachers will benefit by interrupting the passive transfer of information by guiding students in fun short movements to increase arousal. If instructors fail to put in movement breaks, students sitting in front of screens can remind themselves to move. The challenge is that we are usually unaware of how much time has passed as we are captured by the screen. It is often helpful to use an app such as StretchBreak to remind yourself to get up and move.
- Get up and move every 30 minutes. After sitting for 30 minutes stretch, wiggle and move. Do the movements with vigor or even dance, look up and reach up. When you stand up and move your legs and feet, you tighten and relax your calf muscles that pump the venous blood and lymph fluids that have been pooling in your legs back to your heart. The calf muscle is often called the second heart because in facilitates venous blood return.
- Regenerate vision. Our eyes tend to get tired and world looks blurry. Interrupt the near vision stress by allowing the eyes to relax and regenerate.
- Palming. Bring your hands to your face and cup the hands so that there is no pressure on your eyeballs. Allow the base of the hands to touch the cheeks while the fingers are interlaced and resting your forehead. Then with your eyes closed imagine seeing black. Breathe slowly and diaphragmatically while feeling the warmth of the palm soothing the eyes. Feel your shoulders, head and eyes relaxing and do this for five minutes (Schneider, 2016; Peper, 2021).
- Look at the distance. Interrupt near visual stress (convergence of the eyes and tightening of the ciliary muscle around the lens allows us to focus on the screen) by looking away at the far distance. Every so look at the clouds, top of trees or rooftops outside the window to relax the eyes.
By activating the evolutionary communication patterns that allowed us to survive and thrive and using known performance enhancement skills derived from peak performance training, we can enhance involvement and productivity. The instructor needs to stay current on methods that keep students attention. At the same time, students have a responsibility to configure themselves to optimize learning. We recommend practices 1) to be present and learn, 2) optimize concentration and learning, 3) create an environment to trigger the appropriate mental and emotional state for learning, and 4) optimize arousal and regenerate vision. By taking charge of your own teaching/learning process and configuring yourself to be present through active participation, learning is enhanced.
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 We thank Professor Jackson Wilson for his incisive comments.
 In this paper will use Zoom as the example for synchronous online teaching although the concepts may apply equally to other platforms such Microsoft Teams and Google Meet.
 Zoom and other synchronous online platforms provide tools to indicate that you would like to speak (e.g., electronic hand raising); however, it is an issue of how the class session is designed (e.g., do you use breakout rooms, are there structured requests for interaction).
 Zoom has a feature to hide yourself. Start or join a Zoom meeting. The meeting automatically begins in Speaker View and you can see your own video. Then, right-click your video to display the menu, then choose Hide Myself.
“I have had headaches for six years, at first occurring almost every day. When I got put on an antidepressant, they slowed to about 3 times a week (sometimes more) and continued this way until I learned relaxation techniques. I am 20 years old and now headache free. Everyone should have this educational opportunity to heal themselves.” -Melinda, a 20 year old student
Health and wellness is a basic right for all people. When students learn stress management skills which include awareness of stress, progressive muscle relaxation, Autogenic phrases, slower breathing, posture change, transforming internal language, self-healing imagery, the role of diet, exercise embedded within an evolutionary perspective as part of a college class their health often improves. When students systematically applied these self-awareness techniques to address a self-selected illness or health behavior (e.g., eczema, diet, exercise, insomnia, or migraine headaches), 80% reported significant improvement in their health during that semester (Peper et al., 2014b; Tseng, et al., 2016). The semester long program is based upon the practices described in the book, Make Health Happen, (Peper, Gibney, & Holt, 2002).
The benefits often last beyond the semester. Numerous students reported remarkable outcomes at follow-up many months after the class had ended because they had mastered the self-regulation skills and continued to implement these skills into their daily lives. The educational model utilized in holistic health courses is often different from the clinical/treatment model.
Educational approach: I am a student and I have an illness (most of me is healthy and only part of me is sick).
Clinical treatment approach: I am a patient and I am sick (all of me is sick)
Some of the concepts underlying the differences between the educational and the clinical approach are shown in Table 1.
|Educational approach||Clinic/treatment approach|
|Focuses on growth and learning||Focuses on remediation|
|Focuses on what is right||Focuses on what is wrong|
|Focuses on what people can do for themselves||Focuses on how the therapist can help patients|
|Assumes students as being competent||Implies patients are damaged and incompetent|
|Students defined as being competent to master the skills||Patients defined as requiring others to help them|
|Encourages active participation in the healing process||Assumes passive participation in the healing process|
|Students keep logs and write integrative and reflective papers, which encourage insight and awareness||Patients usually do not keep logs nor are asked to reflect at the end of treatment to see which factors contributed to success|
|Students meet in small groups, develop social support and perspective||Patients meet only with practitioners and stay isolated|
|Students experience an increased sense of mastery and empowerment||Patients experience no change or possibly a decrease in sense of mastery|
|Students develop skills and become equal or better than the instructor||Patients are healed, but therapist is always seen as more competent than patient|
|Students can become colleagues and friends with their teachers||Patients cannot become friends of the therapist and thus are always distanced|
Table 1. Comparison of an educational versus clinical/treatment approach
The educational approach focuses on mastering skills and empowerment. As part of the course work, students become more mindful of their health behavior patterns and gradually better able to transform their previously covert harm promoting patterns. This educational approach is illustrated in a case report which describes how a student reduced her chronic migraines.
Case Example: Elimination of Chronic Migraines
Melinda, a 20-year-old female student, experienced four to five chronic migraines per week since age 14. A neurologist had prescribed several medications including Imitrex (used to treat migraines) and Topamax (used to prevent seizures as well as migraine headaches), although they were ineffective in treating her migraines. Nortriptyline (a tricyclic antidepressant) and Excedrin Migraine (which contains caffeine, aspirin, and acetaminophen) reduced the frequency of symptoms to three times per week.
She was enrolled in a university biofeedback class that focused on learning self-regulation and biofeedback skills. All these students were taught the fundamentals of biofeedback and practiced Autogenic Training (AT) every day during the semester (Luthe, 1979; Luthe & Schultz, 1969; Peper & Williams, 1980).
In the class, students practiced with surface electromyography (SEMG) feedback to identify the presence of shoulder muscle overexertion (dysponesis), as well as awareness of minimum muscle tension. Additional practices included hand warming, awareness of thoracic and diaphragmatic breathing, and other biofeedback or somatic awareness approaches. In parallel with awareness of physical sensations, students practiced behavioral awareness such as alternating between a slouching body posture (associated with feeling self-critical and powerless) and an upright body posture (associated with feeling powerful and in control). Psychological awareness was focused on transforming negative thoughts and self-judgments to positive empowering thoughts (Harvey and Peper, 2011; Peper et al., 2014a; Peper et al, 2015). Taken together, students systematically increased awareness of physical, behavioral, and psychological aspects of their reactions to stress.
The major determinant for success is to generalize training at school, home and at work. Each time Melinda felt her shoulders tightening, she learned to relax and release the tension in her shoulders, practiced Autogenic Training with the phrase “my neck and shoulders are heavy.” In addition, whenever she felt her body beginning to slouch or noticed a negative self-critical thought arising in her mind, she shifted her body to an upright empowered posture, and substituted positive thoughts to reduce her cortisol level and increase access to positive thoughts (Carney & Cuddy, 2010; Cuddy, 2012; Tsai, et al., 2016). Postural feedback was also informally given by Melinda’s instructor. Every time the instructor noticed her slouching in class or the hallway, he visually changed his own posture to remind her to be erect.
Melinda’s headaches reduced from between three and five per week before enrolling in the class to zero following the course, as shown in Figure 2. She has learned to shift her posture from slouching to upright and relaxed. In addition, she reported feeling empowered, mentally clear, and her acne cleared up. All medications were eliminated. At a two year follow-up, she reported that since she took the class, she had only few headaches which were triggered by excessive stress.
Figure 2. Frequency of migraine and the implementation of self-practices.
The major factors that contributed to success were:
- Becoming aware of muscle tension through the SEMG feedback. Melinda realized that she had tension when she thought she was relaxed.
- Keeping detailed logs and developing a third person perspective by analyzing her own data and writing a report. A process that encouraged acceptance of self, thereby becoming less judgmental.
- Acquiring a new belief that she could learn to overcome her headaches, facilitated by class lecture and verbal feedback from the instructor.
- Taking active control by becoming aware of the initial negative thoughts or sensations and interrupting the escalating chain of negative thoughts and sensations by shifting the attention to positive empowering thoughts and sensations–a process that integrated mindfulness, acceptance and action. Thus, transforming judgmental thoughts into accepting and positive thoughts.
- Becoming more aware throughout the day, at school and at home, of initial triggers related to body collapse and muscle tension, then changing her body posture and relaxing her shoulders. This awareness was initially developed because the instructor continuously gave feedback whenever she started to slouch in class or when he saw her slouching in the hallways.
- Practicing many, many times during the day. Namely, increasing her ongoing mindfulness of posture, neck, and shoulder tension, and of negative internal dialogue without judgment.
The benefits of this educational approach is captured by Melinda’s summary, “The combined Autogenic biofeedback awareness and skill with the changes in posture helped me remarkably. It improved my self-esteem, empowerment, reduced my stress, and even improved the quality of my skin. It proves the concept that health is a whole system between mind, body, and spirit. When I listen carefully and act on it, my overall well-being is exceptionally improved.”
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 Adapted from: 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://biofeedbackhealth.files.wordpress.com/2011/01/a-educational-model-for-self-healing-biofeedback.pdf