Why Should You Take a Basic Biofeedback Course and When do You Need an Advanced one?

1. Why Should You Take a Basic Biofeedback Course and When do You Need an Advanced one? Audiovisual set-up slide: If you are hearing my voice now,know how to advance slides, and how to end the slide show, you can skip this slide. To hear my voice and to see the slides best, you need to view the slides using Power Point’s “view slide show” setting. When in Power Point, go to “view” on the top bar of the power point display. Select “slide show” so the slide occupies your entire screen. To advance slides, double click the down arrow key on your key board (not the arrow on the “2” key). You can see and hear the preceding slide by pressing the up arrow key. The slides are NOT set to advance automatically so you can spend as long on each as you wish. To leave the slide show, move your cursor around slowly near the lower left edge of the screen until a small, translucent box appears on the slide. Click it for options including “end show”. If you are in the full screen “view slide show” and your computer’s sound is on, you should be hearing my voice right now. If you can’t hear me, something is wrong with your sound system.

2. Why Should You Take a Basic Biofeedback Course and When Do You Need an Advanced one? I’m Rich Sherman. I have been president of AAPB and have been involved in biofeedback for over 30 years so am familiar with many of the problems which happen when people try to perform biofeedback without an adequate background. I’m going to give you an idea of why you need a basic course in the first place and then when you should consider taking an advanced biofeedback course. Richard A. Sherman, Ph.D. Dean, College of Psychophysiology, University of Natural Medicine. rsherman@nwinet.com

3. (This slide appears in all 4 basic skills talks so skip it if you already read it.) • You are attending one of four brief talks in the series on • “what you need to know to perform biofeedback effectively”. • The series contains talks on why: • You need to know how biofeedback devices actually record physiology and how to set the devices to produce useful recordings (Biofeedback Instrumentation). • 2. You need to know how the body works in order to use biofeedback effectively to change physical and mental functioning. Otherwise, you may try to do training which can’t work well or can’t be done at all (A&P / Human Biology). • 3. You need to be able to tell if there is enough solid evidence supporting the use of a technique for you to even try it, let alone charge for it, and to tell whether the results you see or hear about are due to placebo or treatment effects (Basics of clinical research). • 4. Everybody needs a basic biofeedback course before doing biofeedback. You need to know when an introductory level general biofeedback or neurofeedback course doesn’t provide the depth you need to effectively incorporate biofeedback into interventions for the kinds of disorders you treat (e.g. chronic pain, incontinence, muscle rehabilitation, etc.).

4. (This slide appears in all 4 basic skills talks so skip it if you already read it.) Before we get started, let’s be sure you and I have the same general concept of what biofeedback is. Biofeedback includes (a) performing accurate psychophysiological recordings using standard techniques to evaluate known problems with levels and patterns of function of one or more known physiological systems and then (b) immediately showing these levels and patterns to a client as they are recorded so he or she can learn to recognize and control them. Numerous placebo controlled studies with long term follow-ups have proven that biofeedback is effective for many disorders. The crucial points here are (1) that biofeedback includes actual learning by the client and (2) that widely recognized problems in function are corrected. Biofeedback devices are NOT magic machines recording unverified physical problems using methods not explainable through normal scientific means. They do not magically cause the body to change its functioning through unproven methods to fix problems which can not be demonstrated through standard tests. No scientifically acceptable studies have shown devices making such claims to be effective. If you are not familiar with psychophysiological recording and biofeedback, please see the introductory lecture in the “Want to know what biofeedback and psychophysiology are?” section on this site.

5. You absolutely must have at least a basic course in biofeedback / neurofeedback to competently perform psychophysiological recordings and provide useable feedback signals. People who don’t take a basic biofeedback course think they don’t need to either because (1) they think the machines are so sophisticated the devices can work themselves (an incredibly common belief) or (2) because their licensing board includes biofeedback as a technique they can use and don’t realize that the tiny exposure to biofeedback they received in school or from a manufacturer doesn’t cover many crucial concepts. A great many aspects of (a) setting biofeedback devices so they actually record what you need them to and provide a useable display people can learn from and (b) incorporating biofeedback into treatments are not obvious and can’t be learned in a few hours. The next three slides include just a few of the critical points you are not likely to learn on your own or from a few hours of training.

6. Biofeedback Topics Frequently not Understood by people who haven’t had a good biofeedback course • Failure to understand the relationship between biofeedback and the actual physiology of the disorder being treated. Practitioners’ lack of understanding of these relationships results in more treatment failures of efficacious biofeedback based interventions than any other cause. • Failure to be able to explain the relationship between the feedback display, the underlying physiology being recorded, and the disorder being treated is a common reason efficacious biofeedback based interventions fail. • How to properly attach the sensors for each physiological parameter you record so you actually record the signal rather than noise and minimize movement artifacts. This includes how and when to use reference sensors – not to mention where to put them. • How to use the (a) offset, (b) averaging / integration, (c) gain / amplification, and (d) sweep speed (time it takes the signal to cross the screen) to produce an optimal feedback signal patients can actually learn from. Are you aware that having your device set these automatically may make learning difficult or impossible? • continued

7. Crucial information not known – continued 2 of 3 • 5. The overwhelming effect of bandwidth / filters on whether you actually record the signal you are trying to record relative to its power spectrum. For example, using a narrow bandwidth of 100 – 200 Hz means you can not tell how tense most muscles are at most levels of contraction and may think a muscle is relaxed when it is tense. • 6. How to easily test each signal before you begin a session to insure that it is recording properly (garbage in = garbage out) and that changes in the signal accurately reflect changes in the subject’s physiology. • 7. How to recognize noise and interference from other signals during a recording (more garbage in – garbage out). Did you know that typical EEG signals can look just like recordings from Jell-O and some types of EMG? • 8. How to use shaping techniques to teach patients physiological control by properly setting the feedback display. • 9. How to protect your patient from electrical shock when using typical biofeedback devices. Not to mention how to avoid transmitting disease by knowing how to properly clean and use sensors. • continued

8. Crucial information not known – continued 3 of 3 10. Do you actually understand what you are looking at on the display when you record: a. Muscle Tension b. Heart Rate / heart rate variability c. Sweating in response to stress / GSR / SCL d. Respiration e. Temperature (for blood flow) f. Electroencephalogram (EEG)? 11. Do you know how these signals are actually generated so you avoid the very common sensor placement mistakes which result in recording garbage (e.g. recording across rather than along a muscle)? 12. Do you understand the relationships between changes in sweating and changes in GSR signals or the relationships between conductance and resistance? 13. Do you know how Ohm’s law (the relationship between resistance to the flow of current, amount of current, and voltage / signal magnitude) effects SEMG, EEG, and especially, SCL / GSR signals. 14. Do you know the effects of foods and medicines on (a) the disorders your are treating, (b) the physiology you are recording, and (c) the signals you are showing?

9. I’m willing to bet that lots of the people viewing this presentation skimmed over the list I just gave, don’t see the point to most of it, and think they can pick it up on their own by finding some reading on it in a device manual. Do you know that many people doing biofeedback who have never had an adequate basic course in biofeedback largely waste their and their clients’ time? Studies by my group and (unfortunately) insurance companies show that many clinicians (regardless of their clinical degree) who are undereducated in biofeedback get results no better than the placebo effect but think they are doing a great job! Please see the talk on “why you need to know research and placebo effects” for more on this. Many people doing biofeedback who have never had a basic biofeedback course are unaware of the strengths and weaknesses of biofeedback applications for specific disorders. They apply the wrong type of biofeedback, use it incorrectly, and frequently use and charge for treatments which have not been shown to work for the disorder they are treating. This information can only come from a course or a review of the literature by an expert. It isn’t found in web chat groups who have vociferous members claiming that their type of biofeedback works for everything.

10. What should you look for in a Basic biofeedback course? • BCIA (Biofeedback Certification Institute of America) approval of the course. BCIA sets criteria for the contents of each basic and technique specialty course (but not advanced courses) based on what panels of experts feel people doing a particular type of biofeedback need to know. They evaluate each course to insure it provides the minimum material required in a useable format. • Without BCIA approval, you have no idea whether the course covers crucial material you need to know. • 2. Sufficient time and depth must be allotted to cover the material. You can’t cover basic general biofeedback in much less than 40 hours. No course much shorter than that can cover the required material in sufficient depth. • 3. The course should not be based mainly on teaching participants how to use the hardware and software for one particular device. This eats up too much time and doesn’t permit comparisons between devices. • 4. Regardless of whether the course is given in a classroom or by distance education, it should include extensive personal interaction with an instructor who is actually an expert in the field. Look for peer reviewed publications by the instructor in the area the course is given in. • continued

11. What should you look for in a biofeedback course – continued 2 of 2 • 5. If you are considering a distance education course, find out: • a. Is there an actual instructor with appropriate credentials? • b. Does the course have audiovisual lectures or is it just a series of readings? • c. Is extensive interaction with the instructor an integral part of the course? • d. Can you easily contact the instructor with questions? • e. Is the instructor prepared to provide extra material to meet your • particular interests and needs? • Look at the organization providing the course. Find out: • a. Is the organization established and in good standing with the professional • community? Most good CE groups will have program approval by state and national boards while colleges should have regional accreditation. • b. Does the organization appear to be biased toward one viewpoint or • product? • c. Can you get CE credit for the course toward license renewal, etc.? • d. Are there student, hardship, and / or developing nation scholarships? • e. Can you take parts of the organization’s courses if that is all you need?

12. Biofeedback courses are given both in-person and by distance education. How do you decide which is best for you? Consider how you learn best: If you aren’t self-directed enough to make the time to sit down and do a distance course on your own, don’t take a distance course. If you need others around you to bounce ideas off of and like to have the instructor right there in front of you, then an in-person course is best for you. If you are sufficiently self-directed to do the course on your own and like to be able to initially learn and then review the lectures and materials at your convenience, a distance education course should work for you. Lots of people never get around to completing distance education courses which they do at their own paces. Consider your economic circumstances: In-person courses can be a week long. Unless one happens to be given in your town, they require you to travel, then pay for the travel, meals, hotel, etc. If you are in private practice, you also give up your income for the week. If you are from a place very distant from the course and have an exchange rate problem, language barriers, etc. then a distance course may be best for you. Many distance education courses can be divided into segments so you may only need to purchase and take the parts you need.

13. Basic vs. “basic subspecialty” vs. advanced courses Most biofeedback courses are set at one of three levels: (a) general / basic, (b) basic with technique based subspecialty emphasis, and (c) disorder based specialized / advanced. For most people, the way to begin learning about biofeedback is with a general biofeedback course so you can get an overview of what the field is all about. This is where you learn how biofeedback is incorporated into treatments. However, if you have watched an introductory slide show such as the one on this site and have sufficient knowledge of biofeedback to know that you are only likely to do a specialized type of biofeedback using one main technique such as EEG or pelvic floor muscle tension, then you can begin with a basic course concentrating on these techniques as long as it includes a good overview of biofeedback so you know where it fits in. Examples include pelvic floor muscle dysfunction (behavioral interventions for pelvic floor disorders) and EEG biofeedback / neurofeedback. If you work primarily with one particular class of disorders (such as ADHD or chronic pain) or want to use biofeedback for that one class, then you probably need an advanced course AFTER you learn the basics in one of the basic courses. Advanced courses cover many biofeedback techniques as applied to one class of disorders. This is where you learn the detailed physiology of the disorders and many behavioral approaches to them in relation to other techniques.

14. Well, I certainly hope I’ve provided some convincing support for the idea that people need a basic or technique oriented course in biofeedback before getting started and then an advanced course when getting ready to use biofeedback for specific classes of disorders. If you have questions about where to find great basic and advanced biofeedback courses, please feel free to contact me. Some are listed on AAPB’s and BCIA’s web sites. Thanks for listening and, especially, for keeping an open mind! Rich Sherman rsherman@nwinet.com