PROFESSIONAL ISSUES. Positive Aspects of Side Effects: Part I, an Overview. Sebastian Seb Striefel, PhD. Definitions. Introduction

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1 Biofeedback Volume 35, Issue 3, pp PROFESSIONAL ISSUES Association for Applied Psychophysiology & Biofeedback Positive Aspects of Side Effects: Part I, an Overview Sebastian Seb Striefel, PhD Department of Psychology, Utah State University, Logan, UT Keywords: side effects, symptoms, individualized treatment, comorbidities Not all aspects of the side effects that occur during the treatment of stress are negative. In fact, many of the socalled side effects, including abreactions, physiological and psychological discharges, and other cognitive distortions, that occur during treatment are common, and one can argue that they are often an integral part of successful treatment. Side effects occur at different frequencies depending on factors such as the treatment approach used (e.g., autogenic training, biofeedback, or neurofeedback) and client history and symptoms. Side effects and symptoms can be detected via observation, client report, checklists, and physiological measurements. Some side effects can be avoided by using a different treatment approach; for example, clients undergoing autogenic training are likely to experience very different side effects than those who are undergoing progressive relaxation training. It can be argued that side effects occur in 100% of patients if treatment is successful; thus, practitioners should be prepared and competent so that they can anticipate, identify, and appropriately deal with side effects when they occur. Individualized approaches are necessary for dealing with side effects in an ethical and beneficial manner. Introduction This is Part I of two articles that provide information about some aspects of treatment side effects, especially those that are positive. Part I provides definitions for important terms such as symptoms, iatrogenic side effects, and terminology used by others to refer to the same phenomena. It also provides some information on the role of side effects in autogenic training, biofeedback, neurofeedback, and some other psychophysiological treatment approaches; the terminology used to label them; and some ways of minimizing or preventing negative impacts on clients. The second article (Part II) will discuss why side effects develop, where they come from, and their role in successful treatment (Striefel, in press). Stress in daily life, individual coping skills, and categories of symptoms, cautions, and contraindications will also be discussed, along with factors to consider in dealing with individual client symptoms. Questions to ask, issues of competence and referral, and other potential solutions will also be covered. Definitions Practitioners who use general biofeedback, neurofeedback, relaxation training, cognitive behavioral therapy, other applied psychophysiological treatment approaches, and/or various forms of psychotherapy have all observed patients who appear to become anxious or depressed, go into crying jags, and/or exhibit tics, fatigue, irritation, anger, or other thoughts, emotions, physiological changes, and behaviors that are distressing for the patient. When clients experience such sensations, thoughts, or behaviors before treatment, they are used to help make a clinical diagnosis and are called symptoms. One dictionary definition of the word symptom is subjective evidence of disease or physical disturbance or something than indicates the presence of bodily disorder (Mish et al., 1993, p. 1195). One might add that a symptom could be anything that is indicative of a psychological disorder. When such sensations, thoughts, and behaviors occur during the treatment process, they are often called side effects, abreactions, autogenic discharges, contraindications to treatment, or iatrogenic effects. The word iatrogenic is defined by Merriam-Webster s dictionary as induced inadvertently by a physician, or surgeon, or by medical treatment or diagnostic procedures (Mish et al., 1993, p. 573). For purposes of this article, I will use the definition of iatrogenic to mean side effects induced by the treatment process. In fact, many of the psychological and physiological sensations, thoughts, and behaviors exhibited or experienced by clients before and during treatment are often identical. As such, it can be confusing. I will try to restrict the use of the word symptom to what a client experienced before treatment and/or is experiencing outside of treatment sessions when treatment begins; thus, symptoms are the complaints that resulted in the patient s entering treatment. In turn, I will restrict the term side effects to indicate what a client experiences during assessment, diagnosis, and/or treatment. Part of the confusion is that when treatment is initiated, a client may, during and between treatment sessions, start to experience a variety of thoughts, behaviors, physiological sensations, and/or emotions, some of which were previously experienced and some of which are new. 75

2 Positive Aspects of Side Effects: Part I Fall 2007 Ô Biofeedback Practitioners commonly encounter patients who report experiencing such side effects either during the treatment session or between treatment sessions. Sometimes the cognitive, behavioral, physiological, and/or psychological side effects are so severe that patients want to drop out of treatment, actually drop out, or exhibit what are called regressive and/or dissociative behaviors (i.e., behaviors common at an earlier developmental period in life, e.g., talking and behaving like a 2-year-old when they are in their 40s). In addition, they may become so dysfunctional that they become dangerous to themselves or others (e.g., suicidal or violent) and need to be hospitalized either voluntarily or involuntarily, or they exhibit behaviors that are frightening or otherwise disconcerting and stressful for the practitioner. Practitioners have an ethical obligation to provide clients with the information they need to make informed choices, to minimize risk and harm to patients, to be competent to deal with any such side effects that arise during treatment or to refer the client elsewhere for treatment, and not to abandon a client in severe need during the referral process (Striefel, 2004). There is no way for a practitioner to be completely certain about who will exhibit side effects, severe or otherwise, or when this will occur, other than that they will occur, sooner or later, if one works in a clinical setting with patients for any length of time. Both the symptoms and side effects experienced by patients could be placed on a continuum that goes from very mild and almost undetectable, to clearly present and uncomfortable, to very severe, and to so severe as to incapacitate the patient. Autogenic Training Schultz and Luthe (1969) discussed such client experiences, their frequency of occurrence, their severity, and methods for dealing with them. It should be noted that they considered such experiences, which they labeled autogenic discharges, to be an integral part of the treatment process and an indicator that treatment was having the effect of moving the person toward a state of homeostasis. This is quite different from considering such discharges to be a negative side effect of treatment. In fact, in autogenic training, the standard exercises were often prolonged specifically to give the brain a better opportunity to produce autogenic discharges of various types, including those that are severe and uncomfortable for the patient (Schultz & Luthe, 1969). Schultz and Luthe believed that these discharges (a) were controlled by unknown brain mechanisms, (b) consisted of a selective release of neuronal impulses from various areas of the brain, (c) occurred at a physiological and psychological level within the tolerance level of the patient, (d) were usually of a relatively short duration and were always selfterminating, and (e) had a tendency for periodic and serial repetition. The number of repetitions varied from patient to patient based on various individualized variables such as severity of problem, duration, and adaptive skills of the individual. Of course, the severe, more durable discharges were often associated with serious psychological and medical disorders. The autogenic discharges could be sensory, motor, visual, and/or psychological. The discharges tended to decrease in both severity and duration as treatment progressed, until they completely disappeared. To help patients control the severity and/or duration of discharges, practitioners would make various adjustments in the way the standard exercises were practiced. A practitioner might shorten the duration of an exercise from 1 minute to 30 seconds or even to 15 seconds. He or she might change the wording used in conjunction with a specific exercise; for example, rather than repeating, My right arm is warm, the wording might be changed to, My right arm is slightly warm. The practitioner might also skip or change the sequence of exposure to specific standard exercises; for example, if a patient was having extreme cardiovascular discharges during the heaviness and warmth exercises (Standard Exercises 1 and 2), the third exercise having to do with the heart might be skipped, and the patient might go on to the fourth exercise, which has to do with respiration. In autogenic training, there were various other adjustments that could be made, depending on what the practitioner observed during training sessions and what the patient reported experiencing during practice. Autogenic training also includes more advanced processes for producing physiological and psychological readjustments in the brain-directed self-normalizing functions. These include, but are not limited to, organ-specific formulae (e.g., My neck and shoulders are heavy, to reduce tension in these areas of the body), intentional formulae (e.g., Names are interesting might be used if a patient has difficulty remembering names), and autogenic neutralization (complex and advanced methods for encouraging the normalization of brain functions, i.e., homeostasis). Schultz and Luthe (1969) reported that autogenic discharges of one type or another occurred in up to 69% of patients during Standard Exercise 1 (e.g., 40% of patients reported experiencing anxiety). The highest percentage of patients reporting any specific autogenic discharges during Standard Exercise 2 was 52%; in Exercise 3, 40%; in Exercise 4, 37.8%; in Exercise 5, 41.2%; and in Exercise 6, 33.3%. Anxiety was reported by some patients during each of the standard exercises, ranging from a high of 40% during Standard Exercise 1 to a low of 26.2% during Standard 76

3 Striefel Exercise 6 (Schultz & Luthe, 1969, p. 21). In my experience, different treatment approaches have different frequencies, types, and probabilities of patients experiencing autogenic discharges or side effects. For example, my work with people undergoing progressive relaxation training and those undergoing autogenic training, those undergoing progressive relaxation training consistently reported experiencing less side effects, and I observed far fewer crying jags, motor tics, and so forth. In summary, what are considered to be symptoms of some sort, abreactions, or side effects during training are a common occurrence that can be anticipated during autogenic training, and the level of such discharges varies with the kind of patients being treated. Practitioners might find it useful to read or reread some of the Schultz and Luthe (1969) guidelines for dealing with abreactions and autogenic discharges because what clients report during autogenic training is the same, or very similar, to what some clients undergoing biofeedback training report. Other Approaches Such discharges or side effects also occur when biofeedback and other applied psychophysiological relaxation treatment approaches are used. Schwartz, Schwartz, and Monastra (2003) called them negative reactions. The negative reactions they reported included musculoskeletal activity such as tics, cramps, and spasm; disturbing sensory experiences such as sensations of heaviness, floating, and feelings of depersonalization; sympathetic activity such as increased heart rate; cognitive and emotional activity such as feelings of anger, sadness, depression, fear, and anxiety; and other negative side effects such as headaches, sexual arousal, and psychotic symptoms. They go on to discuss the research findings of various authors on the frequency of such side effects that ranged from 0.4% for psychotic symptoms to 15% for fear of losing control and even higher percentages for other negative reactions. Schwartz et al. (2003) also discussed the causes as being due to various fears, shifts in breathing, parasympathetic shifts, and so on. They considered relaxation-induced anxiety to be an indicator that the patient is one who is in most need of psychophysiological self-regulation; that is, it is not an indicator to avoid using relaxation training or biofeedbackassisted relaxation training but rather an indicator that the patient needs such an intervention. They discussed the need for patients to understand that such sensations and thoughts might well occur during training. Although Schwartz et al. did not specifically mention the informed consent process, one might assume that giving patients such an explanation is part of the informed consent process. Clearly, patients should be informed that such unpleasant sensations and thoughts are possible so that the patient can chose whether to proceed with the proposed treatment. It can be useful to patients to be informed about the pros and cons of several treatment approaches for the same problem; for example, if relaxation is a treatment target, the client might be informed about biofeedback, progressive relaxation, autogenic training, and/or other approaches, along with the advantages and disadvantages of each, so that he or she can make a truly informed choice. Schwartz et al. (2003) also presented some very good information on how to deal with problems that occur during treatment. The range of options is far too large to discuss in this article, so readers are referred to the Schwartz et al. book chapter. Suffice it to say that in addition to a good informed consent process, biofeedback practitioners should frequently ask themselves whether biofeedback is the treatment of choice for this particular patient at this point in time and whether a client s needs might better be met if he or she received a different treatment before or simultaneously with biofeedback. For example, Michael Thompson (personal communication, March 30, 2007) reported that if clients have family/emotional difficulties then they should address these problems before considering NFB [neurofeedback]. Hammond (2001) also reported the occurrence of adverse reactions and iatrogenic effects during neurofeedback training. Some of the effects he reports are due to diagnostic issues; for example, the patient comes to treatment for a problem such as attention-deficit hyperactivity disorder (ADHD) or alcoholism but in fact has other problems as well, so that a dual diagnosis is appropriate (e.g., the person diagnosed with ADHD also has obsessive-compulsive disorder problems). Othmer, Othmer, and Kaiser (1999) reported that comorbidities are very common; for example, more than 50% of individuals with ADHD have comorbidities. If a canned treatment protocol (treatment not individualized based on an individual s electroencephalogram [EEG] pattern in multiple sites) is used for such a patient, he or she might well experience treatment-induced adverse reactions that might well not be experienced if a very careful, thorough, and accurate assessment is made to ensure that all comorbidities are diagnosed and treatment decisions made based on all of the patient s presenting problems. Misdiagnosis, failure to consider that a patient may have comorbidities, and using canned protocols rather then obtaining a quantitative EEG and brain map before deciding what treatment to offer could result in a patient experiencing unnecessary adverse reactions during treatment. Practitioners have an ethical, and often legal, obligation to minimize the likelihood of such unnecessary adverse reactions whenever possible. 77

4 Positive Aspects of Side Effects: Part I Fall 2007 Ô Biofeedback Peniston and Kulkosky (1989) reported that their patients experienced anxiety, spontaneous imagery, and recollections of traumatic events while undergoing alpha-theta training. Some of their patients required treatment with other behavioral techniques such as flooding, in addition to EEG biofeedback. Monastra, Monastra, and George (2002) reported that about 20% of their patients receiving both EEG biofeedback and stimulant medication for ADHD became irritable, and the irritability was reduced or eliminated if the stimulant medication was reduced. Unless one is a physician or otherwise licensed with prescription authority, a practitioner must work closely with the client s physician to deal with medication reduction possibilities. One should not practice medicine without having the appropriate license. Clearly, patients experience various thoughts, sensations, and other side effects during EEG biofeedback, but none reported here were severe enough to warrant not offering the patient the option of EEG biofeedback. Several authors have pointed out the importance of a practitioner s having the right type of training, experience, and even academic degrees as a part of demonstrating competence to deal with various client disorders and abreactions (e.g., Demos, 2005; Byers, 1995; Laibow, 1999; Striefel, 2006). Competence is important in preventing harm to clients, to the reputation of the practitioner, and to the reputation of biofeedback and neurofeedback. Not all practitioners are competent to treat all disorders, and some are by law prevented from treating some conditions. Frequency of Occurrence and Related Issues So how often do such side effects occur? I believe that they occur in 100% of patients, but for some, they are so minor that the patient does not report them, if he or she is even aware of them. Nor are they always severe enough or obvious enough for the practitioner to detect them without some sort of physiological markers as measured by the biofeedback equipment or through the use of good observation skills, checklists, and client report. For example, Tom Allen (personal communication, September, 1999) has used electrodermal data with some patients to determine when to give the patient a break and avoid having the patient experience too many side effects too quickly. Brownback and Mason (1999) reported using a cognitive-behavioral checklist for weekly assessment of healthy functioning of patients with dissociative identity disorder. Of course, patients often report feelings of irritation, fatigue, anxiety, and so forth, and practitioners often observe behaviors that are indicative of discomfort and concern in patients. Clients might often cope better if they were prepared in advance for these likely occurrences during the informed consent process. My rational for believing that side effects occur 100% of the time is as follows. Any proposed treatment implies the need for the patient to produce changes in behavior, cognitive beliefs, physiology, and/or psychological states. Change produces unknowns in the form of disruptions in the way the patient thinks about and responds to his or her internal and external environment. In fact, the major goal of treatment is to produce various changes. Treatment cannot be successful if changes do not occur. Many disruptions experienced by the patient may well be manifest in the form of side effects and can provide useful information that the practitioner and patient can use in making decisions that will guide treatment and, thus, the outcomes produced. Remember the old adage, Things may get worse before they get better. For example, in behavioral treatments when reinforcement contingencies are eliminated for a behavior so that extinction occurs, there is often an increase in the frequency of the problem behavior before the behavior decreases or disappears. It should not be surprising that there is some resistance to experiencing new thoughts, feelings, physiological sensations, or emotions during treatment. Leaving one s comfort zone can be stressful, and most often is. Some of the potential disruptions experienced by patients are or will be of little or no concern to either the patient or the practitioner, but discussing them in advance (i.e., having the practitioner predict their possible occurrence) or discussing them when they do actually occur can be most useful in establishing trust, credibility, and a good working relationship with the client. Other side effects/disruptions should be discussed in some detail during the informed consent process so that a client can decide whether he or she wants to risk experiencing or reexperiencing them as part of the treatment process (Ochs, 2006). It may well be that some previously experienced cognitive, behavioral, physiological, and/or psychological symptoms produce more pain and disruption in the patient s daily life than do the symptoms of the presenting problem(s). In addition, it is also possible, but maybe less likely, that during treatment, the patient will experience negative side effects that he or she has never previously experienced, unless they are truly treatmentinduced negative side effects. The implications of these two different classes of side effects (i.e., those previously experienced versus side effects not previously experienced) will be discussed in Part II (Striefel, in press). So what is a practitioner to do? Clearly, practitioners should expect to encounter side effects and should be competent to deal with them in an appropriate manner that meets or exceeds the expected standard of care (Striefel, 2004). 78

5 Striefel Summary Side effects, positive and negative, are an integral part of the treatment process. Information about them can be used by the competent practitioner to guide and individualize the treatment process for each client. Nonindividualized treatment approaches can create unnecessary risks for both the client and practitioner. Due care must be taken to ensure that practitioners are aware of the side effects that are common for different treatment approaches and those associated with different diagnostic labels. A careful diagnosis of all comorbidities and inclusion of that information throughout the treatment process is also important. The practitioner should be competent in dealing with all potential side effects that might arise during the treatment process and should know when to seek consultation or supervision and when a referral to another practitioner is needed to best meet the client s needs. Part II will expand this discussion and will provide some specific recommendations for practitioners to consider (Striefel, in press). References Brownback, T., & Mason, L. (1999). Neurotherapy in the treatment of dissociation. In J. R. Evans & A. Abarbanel (Eds.), Introduction to quantitative EEG and neurofeedback (pp ). San Diego, CA: Academic Press. Byers, A. P. (1995). The Byer s neurotherapy reference library. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback. Demos, J. N. (2005). Getting started with neurofeedback. New York: W. W. Norton and Company. Hammond, D. C. (2001). Adverse reactions and potential iatrogenic effects in neurofeedback training. Journal of Neurotherapy, 4(4), Laibow, R. (1999). Medical application of neurobiofeedback. In J. R. Evans & A. Abarbanel (Eds.), Introduction to quantitative EEG and neurofeedback (pp ). San Diego, CA: Academic Press. Mish, F. C., et al. (Eds.). (1993). Merriam-Webster s collegiate dictionary (10th ed.). Springfield, MA: Merriam-Webster. Monastra, V. J., Monastra, D. M., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback, 27, Ochs, L. (2006). The low energy neurofeedback system (LENS): Theory, background and introduction. Journal of Neurotherapy, 10(2/3), Othmer, S., Othmer, S. F., & Kaiser, D. A. (1999). EEG biofeedback: An emerging model for its global efficacy. In J. R. Evans & A. Abarbanel (Eds.), Introduction to quantitative EEG and neurofeedback (pp ). San Diego, CA: Academic Press. Peniston, E. G., & Kulkosky, P. J. (1989). Alpha-theta brainwave training and beta endorphin levels in alcoholics. Alcoholism: Clinical and Experimental Research, 13, Schultz, J. H., & Luthe, W. (1969). Autogenic therapy: Volume I, Autogenic methods. New York: Grune & Stratton. Schwartz, M. S., Schwartz, N. M., & Monastra, V. J. (2003). Problems with relaxation and biofeedback-assisted relaxation, and guidelines for management. In M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A practitioner s guide (3rd ed., pp ). New York: Guilford Press. Striefel, S. (2004). Practice guidelines and standards for providers of biofeedback and applied psychophysiological services. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback. Striefel, S. (2006). Are QEEGs necessary? Biofeedback, 34, Striefel, S. (in press). Positive aspects of side effects: Part II. Treating stress. Biofeedback, 35. Sebastian Seb Striefel Correspondence: Sebastian Striefel, PhD, 1564 E 1260 N, Logan, UT , Sebst@msn.com. 79