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How Biofeedback Complements CBT (Cognitive Behavioural Therapy)

If you're a professional coach or therapist you'll be aware of Cognitive Behavioural Therapy (CBT) as one of the most if not the most widely-used psychological therapy for anxiety and depression, and one of the best supported in terms of research evidence.

CBT's tools and methods are undoubtedly useful, but like any model, CBT neglects or under-emphasises certain truths. In this article I explain what I think these missing factors are, and how biofeedback can complement CBT to plug the gaps.

Thoughts Condition Feelings

Aaron Beck's basic insight was that negative emotions such as anxiety and despair arise in dependence on aberrant or unhelpful thinking patterns. An example: you're feeling anxious about giving a presentation to the bosses at work. You believe the bosses will think you're not up to the job, so you feel anxious (i.e. the anxiety is caused by your belief).

So to gain relief from anxiety or depression etc. you should target the relevant thoughts and beliefs: if you can see that the bosses don't really think you're stupid the anxiety will start to evaporate.

Behaviour Patterns Also Condition Feelings

Cognitive Behavioural Therapy adds behaviour patterns to the picture. Behaviour patterns are also conditioning factors for difficult emotions, and likewise are targets for change. For example if you tend to decline every opportunity to give presentations, then that will maintain your belief that you're really bad at them and thus the anxiety. What you need to do is stop avoiding and start giving presentations so that you can find out you're actually ok.

Feelings Also Condition Thoughts & Beliefs

It's hard to deny the logic of the above examples, but I don't think it's the whole story.

What I think is missing (or not sufficiently emphasised) is that what you believe is conditioned by how you feel, or putting it more concretely, by the state of your physiology.

If you believe everyone thinks you're stupid, just as you stand up to speak, then yes of course you're going to be anxious. But it's quite likely you only believe it in the heat of the moment, because you're already anxious. Three hours later when you've calmed down again, do you still believe everyone thinks you're stupid? Probably not. The belief is conditioned in part by the feeling, or the over-aroused ("fight-or-flight") physiology. Change the physiology and you change the belief.

So it seems that thoughts and feelings condition each other (here I'm defining feelings as the perception of body states).

thoughts feelings connection

What comes first? What starts off the chain reaction? To an extent it's a matter of chicken-and-egg. But for a fuller understanding we can bring in the concept of pattern matching (as the Human Givens model does). What happens is that the mind can recognise or classify any given situation as just another example of such-and-such, and this unthinking, automatic recognition kicks off a patterned or conditioned response such as getting anxious (just like Pavlov's dogs salivated when they heard their dinner bell).

Here's this fuller picture in diagramatic form.

thoughts feelings connection

Implications for Therapy

CBT doesn't work for all stress, anxiety and depression clients. These clients often have the impression that CBT is telling them their thoughts aren't true and they should just stop believing them. But that's actually very hard to do. Sometimes you just can't help believing in what you've always thought.

But with the more complete picture, we have two possible points of attack, or opportunities to change the response:

  • change the thoughts (the CBT way)
  • change the physiology that is the basis of anxiety, depression, etc. (Physiology is perceived as feeling and sensation.)

A simple example of the second way: suppose when you're anxious, your muscles tighten up (e.g. shoulders, brow). Maybe this tightness is part of what conditions your negative beliefs and thoughts. Learning to release tension effectively can help you let go of the negative thought.

Here's another way to think about the process. CBT targets the "hot" thoughts - the specific thoughts that immediately trigger strong feelings. These thoughts are "hot" to the extent that physiological changes follow. But if you're able to reign in these physiological changes (by being skilled in relaxation) then these same thoughts don't hurt any more - they're just thoughts. Even if you still believe them.

Third Wave of CBT

New forms of psychotherapy see themselves as the third wave of CBT – building on but going beyond CBT. Examples are ACT or Acceptance and Commitment Therapy, and Mindfulness-Based Cognitive Therapy (MBCT).

They hold that it's not necessary to actually change problematic beliefs such as that you're stupid, but merely to "hang loose" to them, stop taking them so seriously, not getting so caught up in them, and to start relating to thoughts in a different way, e.g. as like a radio playing in the background of your mind, that you just don't have to pay attention to. In other words, you only need to open up some space between you and your belief, or not identify with beliefs to the same extent. (This is called cognitive defusion in ACT).

How Biofeedback Can Help

What actually happens when you step apart from your own thinking process like this? I think a really key aspect of the process is that your physiology changes. When you "let go" of a negative thought, you literally let go - your muscles loosen.

Using biofeedback, clients can develop their skill in letting go of muscle tension. And that can make it much easier to step apart from negative thoughts.

Of course muscle tension is not the only factor in the physiology of anxiety, and it's not the only useful biofeedback parameter, but you get the idea.

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