Biofeedback Volume 43, Issue 3, pp DOI: /

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1 Biofeedback Volume 43, Issue 3, pp DOI: / SPECIAL ISSUE ÓAssociation for Applied Psychophysiology & Biofeedback Pilot Study of a University Counseling Center Management Program Employing Mindfulness and Compassion-Based Relaxation Training with Biofeedback Dana R. Wyner, PhD Counseling and Psychological Services (CAPS), Emory University, Atlanta, GA Keywords: mindfulness, compassion, biofeedback, stress, university A pilot study was conducted with clients at a university student counseling center stress management and biofeedback clinic to determine whether mindfulness and compassion-based instruction in relaxation strategies, along with peripheral biofeedback, would reduce perceived stress, enhance perceived coping, and lead to improvement in symptoms of anxiety, depression, and academic distress. Results support that the inclusion of mindfulness and compassion-based biofeedback may enhance treatment efficacy for stress and its associated problems above and beyond that of mindfulness and compassion-based relaxation skills training provided in the absence of biofeedback. In a culture where working around the clock is worn as a badge of honor, where a news headline can read, Vacation- Phobic Americans Donate a Million Years of Work Annually (Steverman, 2014), and where the highest of intellectual standards is termed critical thinking, it is no wonder that fears of inadequacy and judgment fuel the fierce work ethics of many Americans. Learning that the body s stress response can be deliberately self-regulated appears to be empowering. Yet effortful attempts to create a relaxation response paradoxically produce the exact opposite of the desired effect (Wegner, Broome, & Blumberg, 1997). To bring about the calming experience associated with relaxed alertness, clients must learn to focus on the process and not on the desired outcome. This can be a difficult concept to embrace for individuals who seek therapeutic assistance because they are losing their battles against controlling stress and are still insisting that if they only could try harder their concerns would be alleviated. How can clinicians assist such clients in learning to find tranquility in a sea of stressors when the answer is antithetical to increased effort or self-scrutiny? Centuriesold traditions in mindfulness and compassion-oriented philosophies may hold the keys (Khazan, 2013; Klich, 2014). Mindfulness is conceptualized in a variety of ways. Baer, Smith, and Allen (2004) outlined four commonly occuring elements within the most widely used psychological conceptualizations of mindfulness: observing, describing, acting with awareness, and accepting (or allowing) without judgment. In other words, mindfulness practices involve (a) adopting a moment-to-moment presence (b) with a stance of curiosity (c) while noticing external and/or internal stimuli, (d) applying neutral labels for those observed phenonomena then finally (e) recentering the focus of attention to the task at hand. Another way to phrase accepting (or allowing) without judgment is with the term compassion. Compassion, as a vehicle for healing, may be self- (e.g., Neff, 2011) or otherdirected (e.g., Negi, 2005). It is so often viewed as an essential component of mindfulness that many do not consider the constructs to be conceptually distinct. However, not all researchers incorporate compassion in their operationalizations of mindfulness (Gu, Strauss, Bond, & Cavanagh, 2015). Nomenclature is emphasized in this report only to provide clarity. Mindfulness and compassion, as ways of being in the world, may be taught through a variety of exercises and meditations. A central premise to the current study is that biofeedback may be a tool for enhancing awareness that can bring about greater mindfulness. And, mindfulness, with its emphasis on compassion, can allow one to engage in the process-oriented focus necessary for succeeding in using biofeedback to learn emotion-regulation skills. Biofeedback Fall

2 Mindfulness and Compassion-Based Biofeedback Fall 2015 Biofeedback 122 Present Study Surrounded by technologies that reinforce immediate gratification and an outcome-focused orientation, university students, like many in present day America, often struggle to be mindful. Biofeedback is unique as a training tool because it appeals to an interest in the ongoing assessment of progress. Simultaneously, biofeedback also reinforces a process-focused orientation that may promote resiliency in the face of difficulties. The present study, with its emphasis on the application of mindfulness and compassion-based biofeedback for stress reduction, was conducted to assess the effectiveness of an intervention for the most frequently occuring concerns in college and university student populations, namely, those of anxiety, depression, and academic distress. Method Study Setting and Intervention Format The study was conducted in a university counseling center s stress management and biofeedback clinic (The Clinic) over the course of two consecutive academic years ( and ). The Clinic offers a structured group therapy program in which clients learn strategies to reduce the physical and mental aspects of anxiety while enhancing coping skills. Biofeedback is a tool that augments the Clinic s education of clients about the central role that the mind-body connection plays in ones abilities to self-regulate emotions. Summary of services (initial study). The Clinic services in the year were offered in a twophase group format. The first phase provided opportunity for clients to participate in four Relaxation Training Skills modules, which were attended once per week for 50 minutes. Each week, the focus shifted to a new topic related to stress management taught from mindfulness and compassion-based perspectives (e.g., life balance, communication, handling stress in the moment). All modules also incorporated the practice of a relaxation skill conceptually linked to the topic being covered (e.g., diaphragmatic breathing, loving kindness meditation). Clients were encouraged to practice skills at home using recordings, practice logs, and fingertip thermometers for biofeedback. Participation in a minimum of four relaxation training skills classes was a prerequisite to the second phase of treatment, which included five weekly 50-minute biofeedback training classes. The biofeedback training classes could accommodate two clients at a time, allowing them to hone relaxation skills using several modalities (i.e., heart rate variability, skin conductance, and fingertip temperature). The biofeedback equipment used during classes included Thought Technology s Procomp Infiniti 5-Channel System and HeartMath s emwave PC. This split-phase format was done out of necessity because of scarcity of equipment. However, it was a fortunate consequence for the research that relaxation skills training was conducted prior to and separately from biofeedback. Barring some carryover effects from phase I into phase II, the specific contributions of each treatment component could be identified as a result of the design. Summary of services (follow-up restudy). With the acquisition of two more biofeedback stations in , a follow-up restudy assessment was conducted to determine how a shorter treatment program would fare in comparison with the Clinic s initial performance. In the year, an integrated treatment plan was offered in which both the psychoeducational and biofeedback components for mindfulness and compassion-based relaxation skills training were incorporated into 90-minute modules. There were up to four participants per session, and 6 weeks defined a full course of treatment. Participants Treatment adherence and attrition rates. Thirty-four clients were included in the sample of Clinic participants. In , 48 students were served, representing a 30% increase over the previous year. Whereas only 7 of the 34 clients (38%) in had complete data on levels of stress-related symptomatology (i.e., prerelaxation, prebiofeedback, and posttreatment data), 34 of the 48 clients (56%) in completed both pre- and posttreatment assessments (see the Figure for clarification regarding timing of assessments for both years). Measures Brief questionnaires were administered immediately before and after each session to assess changes in levels of stress and in perceptions of coping skills. For this measure, clients were asked to indicate on a 10-point Likert-type scale their overall level of stress in the moment and how equipped they felt to cope with life stressors in that moment. Scores of 1 represented minimum levels of perceived stress and perceived competency to cope with stressors, respectively, whereas scores of 10 represented maximum levels. A third question added to the postsession questionnaire asked, During the next 4 weeks, on average, how often can you see yourself using the skills or material you covered

3 Wyner Figure. Timeline of administration of measures. today? Choices included never, once a week, 2 to4 days out of the week, 5 to 6 days out of the week, and every day. The Counseling Center Assessment of Psychological Symptoms (CCAPS; Center for Collegiate Mental Health, 2010), a 62-item measure of symptom severity, was also administered. The sample completed it at three time points (i.e., prerelaxation, prebiofeedback, and posttreatment), and the sample completed it at two time points (pre- and posttreatment; the Figure). The subscales used in this study included Depression, General Anxiety, Social Role Anxiety, and Academic Issues. At treatment termination, clients were asked to provide evaluations. On a scale from 1 to 5 (1 ¼ completely disagree; 3 ¼ neutral; and, 5 ¼ strongly agree), they rated items such as, The stress clinic classes were helpful to me in dealing with my concerns, and The stress clinic has helped me to improve my academic performance and/or focus. Results Pre- and Postsession Perceptions of and Coping Skills Within-session changes in perceived stress and perceived coping. Data were analyzed according to session number in order to eliminate the possibility that clients would contribute multiple data points to the same data set. For the cohort, there were significant reductions in stress from pre- to postsession in 78% of sessions and improvements in perceived coping abilities in only 33% of sessions (see Tables 1 and 2). In contrast, the clients showed significant decreases in their levels of stress and significant increases in perceived coping abilities from pre- to postsession in 100% of sessions (see Table 3). Relevance and utility of skills taught. The relevance and utility of skills taught were assessed by client ratings of the frequency with which they planned to use those strategies. At each session, a majority indicated they would use the skills on at least 2 to 4 days out of the week. Furthermore, there were demonstrated improvements in perceptions of relevance and utility in compared with in (see Table 4). That is, in , it was not until the second phase of treatment (i.e., during which biofeedback was employed) that clients reported higher levels of intent to practice. However, it was earlier in treatment during that clients reported greater intentions to use the skills outside of sessions. CCAPS Data Depression. In , there were no significant differences between prerelaxation skills and prebiofeedback training or between prebiofeedback training and posttreatment. However, there was a significant linear trend marking a decrease in depressive symptoms over the full Biofeedback Fall

4 Mindfulness and Compassion-Based Biofeedback Table 1. Pre- and postsession ratings for relaxation skills classes in Pretest Level of Posttest Level of Pretest Equipped Posttest Equipped Session 1 n M (SD) 6.88 (1.71) 3.75 (1.61) 5.13 (1.78) 6.31 (1.89) Paired t test t(15) ¼ 6.37* t(15) ¼ 1.96 Session 2 n M (SD) 6.78 (1.79) 4.56 (1.67) 4.78 (1.99) 6.67 (1.80) Paired t test t(8) ¼ 3.59* t(8) ¼ 3.90* Session 3 n M (SD) 6.73 (1.49) 4.45 (1.21) 5.82 (1.78) 7.00 (1.67) Paired t test t(10) ¼ 3.86* t(10) ¼ 2.95* Session 4 n M (SD) 5.18 (1.47) 3.64 (1.69) 6.18 (1.83) 6.91 (1.51) Paired t test t(10) ¼ 3.02* t(10) ¼ 2.19 Note. Items were scored a 10-point Likert-type scale, with higher scores reflective of greater levels of stress and greater perceptions of ability to cope in that moment. *p,.05. Fall 2015 Biofeedback week course of treatment, F Linear (1, 7) ¼ 6.11, p,.05. This was consistent with findings in (n ¼ 34), with CCAPS-Depression T-scores showing a statistically significant decrease from pre- (M ¼ 46.26, SD ¼ 7.95) to posttreatment (M ¼ 42.76, SD ¼ 6.82), t(33) ¼ 2.80, p,.05. Thus, depressive symptoms were significantly reduced in the 6-week treatment, whereas improvements in the cohort were identified only after the full 9-week protocol, which was inclusive of biofeedback. General anxiety. In , there was a significant reduction in general anxiety between prerelaxation skills (M ¼ 53.76, SD ¼ 7.31) training and prebiofeedback training (M ¼ 49.38, SD ¼ 8.61), t(20) ¼ 2.67, p,.05. There was also a significant linear trend marking a decrease in symptoms over the 9-week course of treatment, F Linear (1, 7) ¼ 10.08, p,.05. That is, although there were significant reductions in general anxiety before biofeedback was instituted in the 9-week protocol, even greater gains were achieved after participants experienced the biofeedback component. Participants in the integrated protocol also exhibited significant reductions in general anxiety from pre- (M ¼ 51.26, SD ¼ 9.34) to posttreatment (M ¼ 46.32, SD ¼ 8.31), t(33) ¼ 3.55, p,.05. Taken together, results for and suggest that biofeedback is an important component of treatment for general anxiety. Social role anxiety. Social role anxiety scores were expected to decrease over the course of treatment. In , participants actually displayed a slight but nonsignificant increase in social anxiety symptoms from pretreatment to prebiofeedback followed by a significant decrease from prebiofeedback training (M ¼ 48.25, SD ¼ 4.65) to posttreatment (M ¼ 42.50, SD ¼ 5.83), t(7) ¼ 5.58, p,.05. There was also a significant difference between prerelaxation training (M ¼ 47.38, SD ¼ 4.60) and the posttreatment assessment, (M ¼ 42.50, SD ¼ 5.83), t(7) ¼ 5.57, p,.05. For clients in , there were also significant reductions in social role anxiety from pre- (M ¼ 50.35, SD ¼ 10.46) to posttreatment (M ¼ 46.24, SD ¼ 8.69), t(33) ¼

5 Wyner Table 2. Pre- and postsession ratings for biofeedback training classes in Pretest Level of Posttest Level of Pretest Equipped Posttest Equipped Session 1 n M (SD) 5.29 (1.98) 3.29 (1.38) 6.57 (1.72) 6.57 (1.72) Paired t test t(6) ¼ 3.45* t(6) ¼ 0 Session 2 n M (SD) 4.86 (1.95) 3.71 (1.98) 6.57 (1.90) 7.29 (1.45) Paired t test t(6) ¼ 2.83* t(6) ¼ 1.70 Session 3 n M (SD) 4.86 (1.95) 4.00 (2.31) 6.86 (1.77) 7.86 (1.57) Paired t test t(6) ¼ 1.00 t(6) ¼ 3.24* Session 4 n M (SD) 2.67 (5.85) 3.00 (.89) 4.67 (6.83) 8.00 (1.11) Paired t test t(5) ¼ 0.14 t(5) ¼ 1.31 Session 5 n M (SD) 4.83 (2.23) 2.00 (1.55) 7.67 (1.97) 8.50 (1.23) Paired t test t(5) ¼ 3.78* t(5) ¼ 1.54 Note. Items were scored a 10-point Likert-type scale, with higher scores reflective of greater levels of stress and greater perceptions of ability to cope in that moment. *p, , p,.05. In other words, symptoms were significantly reduced in the 6-week integrated treatment, whereas improvements during were identified only after the full 9 weeks. This result, once again, supports the importance of including biofeedback. Academic issues. Academic issues scores were expected to decrease over the course of treatment. This was the case in , although differences did not appear until after biofeedback training had been completed, F Linear (1, 7) ¼ 30.42, p,.05. In other words, there was a significant difference between prebiofeedback training (M ¼ 46.75, SD ¼ 8.45) and posttreatment academic issues scores (M ¼ 40.00, SD ¼ 5.16), t(7) ¼ 2.47, p,.05. The difference between academic issues at the prerelaxation training assessment (M ¼ 49.25, SD ¼ 8.08) and at posttreatment (M ¼ 40.00, SD ¼ 5.16) was also significant, t(7) ¼ 2.47, p,.05. However, there was not a significant difference between prerelaxation training and prebiofeedback training. In , the decrease in academic issues scores was not statistically significant between pre- and posttreatment. Taken in isolation, these results suggest that the format appeared to outperform the 6-week protocol with regard to academic concerns, albeit only after biofeedback was implemented. However, as will be detailed in the next section, in , fewer participants were concerned about their academic performance than in Final stress clinic service evaluations. Final evaluations were obtained from 22 of the 44 participants in the sample and from 34 of 48 participants in the sample. A majority of clients rated the Clinic as Biofeedback Fall

6 Mindfulness and Compassion-Based Biofeedback Table 3. Pre- and postsession ratings of perceived stress and coping in Pretest Level of Posttest Level of Pretest Equipped Posttest Equipped Session 1 n M (SD) 6.28 (1.65) 4.19 (1.65) 4.89 (1.84) 6.45 (1.77) Paired t test t(46) ¼ 10.48* t(46) ¼ 7.24* Session 2 n M (SD) 6.09 (1.80) 4.19 (1.75) 5.47 (1.68) 6.74 (1.66) Paired t test t(42) ¼ 9.32* t(42) ¼ 6.66* Session 3 n M (SD) 5.94 (1.71) 4.49 (1.96) 5.83 (1.67) 6.91 (1.67) Paired t test t(34) ¼ 6.25* t(34) ¼ 6.02* Session 4 n M (SD) 6.03 (2.18) 4.07 (2.07) 5.62 (1.70) 6.79 (1.76) Paired t test t(28) ¼ 5.94* t(28) ¼ 3.27* Session 5 n M (SD) 5.74 (2.41) 4.06 (2.31) 6.61 (1.69) 7.58 (1.61) Paired t test t(30) ¼ 7.18* t(30) ¼ 5.91* Session 6 n M (SD) 5.64 (2.36) 3.84 (2.15) 7.00 (1.53) 7.80 (1.41) Paired t test t(24) ¼ 5.79* t(24) ¼ 5.24* Note. Items were scored a 10-point Likert-type scale, with higher scores reflective of greater levels of stress and greater perceptions of ability to cope in that moment. *p,.05. Fall 2015 Biofeedback 126 helpful across both cohorts; however, it appeared that there was greater satisfaction among the participants. Specifically, 100% of those who participated in the classes either strongly or somewhat agreed that the sessions were helpful. In , 91% of those who participated in relaxation skills classes and 72% of those who participated in biofeedback training classes either strongly or somewhat agreed that the sessions were helpful. In the cohort, 85% reported they strongly or somewhat agreed that they practiced relaxation skills outside of the sessions on a regular basis. This contrasts with results from , suggesting that only 68% strongly or somewhat agreed that they regularly practiced relaxation skills outside of sessions. With regard to improvement in academic performance/ focus, only 27% of the sample either strongly or somewhat agreed that the Clinic helped them to improve their academic performance/focus, whereas 50% indicated they were already doing well academically as assessed by a yes/no item on the final evaluation of services. In , 39% strongly or somewhat agreed that the Clinic was helpful despite the fact that

7 Wyner Table 4. Percentage of clients who indicated they would use skills at least 2 days per week Classes Relaxation Biofeedback n % n % n % Session Session Session Session Session Session % of the sample reported that they were already performing well academically before entering the program. In both cohorts, an overwhelming majority indicated that they would recommend the Clinic to a friend in need of similar help. More specifically, 96% of the cohort and 94% of the cohort endorsed that they strongly or somewhat agreed they would recommend services. Discussion Results suggest that the inclusion of mindfulness and compassion-based biofeedback may enhance treatment efficacy for stress and its associated problems above and beyond that of mindfulness and compassion-based relaxation skills training provided in the absence of biofeedback. This was reflected in the findings demonstrating that when biofeedback was integrated into a shortened 6-week protocol, there was increased treatment adherence. There was also a greater frequency of sessions in which, within the course of the session, perceived stress decreased and perceived coping abilities increased. In addition, it was found that the intent to use skills outside of sessions was greater when sessions included biofeedback training, perhaps because of the contributions of objective physiological data in augmenting perceptions of the skills relevance and effectiveness. Moreover, symptoms of depression, social anxiety, and academic distress showed significant reductions only once biofeedback was incorporated into treatment. And, in the case in which academic concerns were not significantly reduced ( ), the majority of clients indicated that they were already performing well academically prior to entering treatment. Finally, although the cohort demonstrated significant reductions in general anxiety before biofeedback was instituted, even further gains were achieved after participants received the biofeedback component. This finding, combined with the fact that the 6-week format also was associated with significant reductions in general anxiety, could indicate that the immediate incorporation of biofeedback into treatment might contribute to greater efficiency in alleviating symptoms. Despite these promising results, caution should be applied in taking the findings to offer more than preliminary evidence for the treatment-enhancing effects of mindfulness and compassion-based biofeedback to stressrelated concerns. Limitations of the study include the absence of a control group, small sample sizes, and the lack of randomization to treatment conditions. In addition, there was no follow-up assessment to determine whether and for how long gains were maintained after treatment termination. Moreover, the replicability of results in a non university student sample remains unknown. Future studies should address these issues as well as include physiological measures to determine how well clients actually learned to self-regulate their states of arousal. Still, results suggest that this area is ripe for further investigation. References Baer, R., Smith, G., & Allen, K. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11, Center for Collegiate Mental Health. (2010) Annual Report (Publication No. STA ). University Park, PA: Penn State University. Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psychology Review, 37, Khazan, I. (2013). The clinical handbook of biofeedback: A stepby-step guide for training and practice with mindfulness. Chichester, UK: John Wiley & Sons. Biofeedback Fall

8 Mindfulness and Compassion-Based Biofeedback Klich, U. (2014, June). The integration of compassion based theory with biofeedback treatment [Webinar]. In Association for Applied Physiology and Biofeedback Webinar series. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback. Retrieved September 2, 2015, from resourcenter.net/scripts/4disapi9.dll/4dcgi/events/494. html?action=conference_detail&confid_w=494& Neff, K. (2011). Self-compassion. New York: William Morrow. Negi, L. (2005). Cognitively-based compassion training as a research protocol. Retrieved September 24, 2015, from tibet.emory.edu/cognitively-based-compassion-training/ projects/index.html Steverman, B. (2014, June 30). Vacation-phobic Americans donate a million years of work annually. Bloomberg Business. Retrieved September 24, 2015, from com/news/articles/ /vacation-phobic-americansdonate-a-million-years-of-work-annually Wegner, D., Broome, A., & Blumberg, S. (1997). Ironic effects of trying to relax under stress. Behaviour Research and Therapy, 35, Dana R: Wyner Correspondence: Dana R. Wyner, PhD, Emory University CAPS, 1462 Clifton Road, Suite 235, Atlanta, GA 30322, dwyner@ emory.edu. Fall 2015 Biofeedback 128