Return
to Menu Page Return
to Menu PageIn a normal session, electrodes are attached to the area being monitored (the involved muscles for muscle therapy, the head for brain wave activity); these electrodes feed the information to a small monitoring box that registers the results by a sound tone that varies in pitch or on a visual meter that varies in brightness as the function being monitored decreases or increases. A biofeedback therapist leads the patient in mental exercises to help the patient reach the desired result (e.g., muscle relaxation or contraction, or more alpha and theta brain waves). Through trial and error, patients gradually train themselves to control the inner mechanism involved. Training for some disorders requires 8 to 10 sessions. Patients with long-term or severe disorders may require longer therapy. Obviously, the aim of the treatment is to teach patients to regulate their own inner mental and bodily processes without help from the machine. In its simplest form, biofeedback therapy always involves a therapist, a patient, and a monitoring device capable of providing accurate physiological information.
A major reason why many patients like biofeedback training is that, like behavioral ~approaches in general, it puts them in charge, giving them a sense of mastery and self-reliance over their illnesses and health. Such an attitude may play a crucial role in the lower health care costs seen in patients after learning biofeedback skills.
Background. In 1961, experimental psychologist Neal Miller proposed that the autonomic, or visceral, nervous system was entirely trainable. Miller's suggestion ran contrary to prevailing orthodoxy, which held that all autonomic responses--heart rate, blood pressure, regional blood flow, gastrointestinal activity, and so on--were beyond voluntary control. In a remarkable series of experiments he showed that instrumental learning and control of such processes were indeed possible. One result of his work was the creation of biofeedback therapy.
In the succeeding three decades, Miller's work has been expanded by scores of researchers. Approximately 3,000 articles and 100 books have been published to date describing biofeedback and its applications. There are currently about 10,000 practitioners in the United States. Two organizations certify biofeedback professionals and paraprofessionals, ~and more than 2,000 individuals have received national certification.
Biofeedback does not belong to any particular field of health care but is used in many disciplines, including internal medicine, dentistry, physical therapy and rehabilitation, psychology and psychiatry, pain management, and more.
The most common forms of biofeedback involve the measurement of muscle tension (electromyographic, or EMG, feedback), skin temperature (thermal feedback), electrical conductance or resistance of the skin (electrodermal feedback), brain waves (electroencephalographic, or EEG, feedback), and respiration. More recently, increasingly sophisticated measurement devices have expanded biofeedback possibilities. Sensors can now measure and feed back the activity of the internal and external rectal sphincters (for the treatment of fecal incontinence), the activity of the detrusor muscle of the urinary bladder (for the treatment of urinary incontinence), esophageal motility, and stomach acidity (pH). Currently there are approximately 150 applications for biofeedback. Medical awareness of biofeedback is increasing, and referrals to biofeedback clinics continue to climb. Some ~treatments are already widely accepted. The American Medical Association, for example, has endorsed EMG biofeedback training for treating muscle contraction headaches.
Research accomplishments and clinical applications. Substantial research exists demonstrating the effectiveness of biofeedback in a number of conditions, including bronchial asthma, drug and alcohol abuse, anxiety, tension and migraine headaches, cardiac arrhythmias, essential hypertension, Raynaud's disease/syndrome, fecal and urinary incontinence, irritable bowel (spastic colon) syndrome, muscle reeducation (strengthening weak muscles, relaxing overactive ones), hyperactivity and attention deficit disorder, epilepsy, menopausal hot flashes, chronic pain syndromes, and anticipatory nausea and vomiting associated with chemotherapy (Basmajian, 1989).
Like all other forms of therapy, biofeedback is more useful for some clinical problems than for others. For example, biofeedback is the preferred treatment in Raynaud's disease/syndrome (a painful and potentially dangerous spasm of the small arteries) and certain types of fecal and urinary incontinence. However, it is one of several preferred ~treatments for muscle contraction (tension) headaches, migraine headaches, irritable bowel (spastic colon) syndrome, hypertension, asthma, and a variety of neuromuscular disorders, especially during rehabilitation. EEG biofeedback therapy is one of several preferred treatments for certain patients with epilepsy or attention deficit disorder.
Cost-effectiveness. Biofeedback-assisted relaxation training has been shown to be associated with decrease in medical care costs to patients, decrease in number of claims and costs to insurers in claims payments, reduction of medication and physician usage, reduction in hospital stays and rehospitalization, reduction of mortality and morbidity, and enhanced quality of life (Schneider, 1987).
Efforts are being made to further increase the cost-effectiveness of biofeedback therapy through the use of group and classroom instruction, reduced therapist contact, and home-based training. No studies have yet been made that discuss cost-benefit issues for the nonrelaxation-based biofeedback therapies, such as neuromuscular education and seizure reduction training.~Research needs and opportunities. The following are some of the research questions about biofeedback that need answering:
• What is actually learned during biofeedback? An awareness of some internal response or an awareness of associations between stimuli and responses?
• What variables influence learning in the biofeedback setting? How do they exert their effects? For example, what are the effects of the quality and quantity of reinforcements used to promote learning?
• What is the full range of bodily responses that can be modified by instrumental training procedures? Are the influences of biofeedback large enough to make a clinical difference? Or, are they laboratory curiosities?
• Which physiological responses are best to modify with respect to a specific disorder? For example, is lowering of blood pressure best achieved by feedback of blood pressure, or ~is feedback of muscle tension or skin temperature more effective?
• To what extent does transfer of training take place from the laboratory to real life? Can an individual self-regulate a physiological response at home as well as in a clinic? How long does the learning last?
• How do motivation and expectancy relate to the successful learning of biofeedback skills? What criteria predict who will be a successful biofeedback subject?
• How does biofeedback compare with other approaches (e.g. meditation, relaxation, suggestion, hypnosis) in altering physiological processes?
• How can biofeedback's effects be separated from other treatment variables such as the therapist's attention, verbal exchanges, suggestion, patient expectation, the clinical atmosphere, or participation in a self-help program?
~ • In which situations can biofeedback-assisted learning be used in lieu of pharmacological or surgical therapies, and in which situations as an adjunct to these approaches?
• For what conditions might group instruction in biofeedback skills be as effective as individual teaching? How can subjects be identified as more suitable for group teaching or individual instruction?
• How can biofeedback teaching procedures be more widely applied to the medical problems of children? Might the widespread teaching of biofeedback skills to children emphasizing self-care and self-responsibility at a young age counteract the widespread dependence and reliance on the medical system demonstrated by adults?
• What innovations in chip and microprocessor technology are needed to open up new areas of experimental and clinical research in biofeedback? How might miniaturization provide opportunities for patients to wear portable devices in real-life situations, thus expanding biofeedback learning?~Progress in this field, as in many other alternative and orthodox therapies, will entail three general steps or phases:
1. Pilot studies to determine whether there are any promising effects worthy of investigation and to detect any negative side effects or practical difficulties. These may be anecdotal case reports, systematic case studies, or uncontrolled single-group studies.
2. Controlled comparisons with the best available other techniques or with placebo treatments, using larger groups of patients, double-blind procedures, and adequate followup.
3. Broad clinical trials on large patient populations under ordinary conditions, to determine the effectiveness of the treatment in conditions other than unusually favorable ones with especially talented therapists.
Most clinical research in biofeedback has been done in Phase I, although some studies have appeared in Phase II. Phase III studies are needed and can be expected if funding becomes available.
Because dance is a direct expression of the mind and body, it is an intimate and powerful medium for therapy. Throughout the world, people have always danced to celebrate major events, to bond communities, to share sentiments, and to heal the sick and the alienated.
Applications. The use of dance as a medical therapy in the United States began in 1942 through the pioneering efforts of Marian Chace. Psychiatrists in Washington, DC, found that their patients were deriving therapeutic benefits from attending Chace's dance classes. As a result, Chace was asked to work on the back wards of St. Elizabeth's Hospital with patients who had been considered too disturbed to participate in group activities. At about the same time, Trudi Schoop, a dancer and mime, volunteered to work with patients at Camarillo State Hospital in California. A group approach for nonverbal and noncommunicative patients was needed, and dance/movement therapy (DMT) met that need.~In 1956, dance therapists from across the country founded the American Dance Therapy Association, which has now grown to more than 1,100 members.12 It publishes a journal, the American Journal of Dance Therapy; fosters research; monitors standards for professional practice; and develops guidelines for graduate education. It also maintains a registry for therapists: the certification registered dance therapist (D.T.R.) is granted to individuals with a master's degree and 700 hours of supervised clinical internship; the certification "Academy of Dance Therapists Registered" (A.D.T.R.) is awarded after therapists have completed 3,640 hours of supervised clinical work, which qualifies an individual to teach, supervise, and engage in private practice.
Dance/movement therapists are employed in a wide range of facilities, work with diverse populations, and address the needs of a broad spectrum of specific disorders and disabilities. Typically, dance/movement therapists work with individuals who have social, emotional, cognitive, or physical problems. Evolving specializations include using DMT as a disease prevention and health promotion service with healthy people and as a method of reducing the stress of caregivers and of patients with cancer, AIDS, and Alzheimer's ~disease.
Therapy goals vary according to the population served: for the emotionally disturbed, goals are to express feelings, gain insight, and develop attachments; for the physically disabled, to increase movement and self-esteem, have fun, and heighten creativity; for the elderly, to maintain a healthy body, enhance vitality, develop relationships, and express fear and grief; and for the mentally retarded, to motivate learning, increase body awareness, and develop social skills.
The underlying assumption in DMT is that visible movement behavior is analogous to personality. Thus, the process of changing how one moves (e.g., from fragmented to integrated or graceful) can effect total functioning. Specific aspects in DMT--such as music, rhythm, and synchronous movement--promote the healing processes by altering mood states, reawakening stored memories and feelings, organizing thoughts and actions, reducing isolation, and establishing rapport. Dancing in a group creates the emotional intensity necessary for behavioral change, and physical activity increases the endorphin level, inducing ~a state of well-being. Total body movement stimulates functioning of body systems (circulatory, respiratory, skeletal, and neuromuscular). Activating muscles and joints reduces body tension and body armoring. Unspeakable events, expressed in dance, can then be verbalized.
DMT has been demonstrated to be clinically effective in developing body image, improving self-concept, increasing self-esteem, facilitating attention, ameliorating depression, decreasing fears and anxieties, expressing anger, decreas-ing isolation, increasing communication skills, fostering solidarity, decreasing bodily tension, reducing chronic pain, enhancing circulatory and respiratory functions, reducing suicidal ideas, increasing feelings of well-being, promoting healing, and increasing verbalization (Fisher and Stark, 1992).
Research needs and opportunities. Although the efficacy of DMT has been demonstrated since the 1940s through extensive clinical practice, the following kinds of research should be done:
~ • Experimental studies to establish cause-effect relationships between specific approaches and patient outcomes. For example, what is the effect of daily DMT on depressed teenagers and drug abusers? What are the effects of psychotropic drugs on the ability of patients to respond to DMT? What are the effects of DMT on the ability of autistic children to communicate (Holtz, 1990)?
• Regression studies to isolate the independent and interactive effect of DMT. In many settings DMT is but one of several treatment modalities. Studies addressing the question of how much of the variation in patient change is accounted for by DMT alone and by DMT in combination with other therapies would yield useful information (Holtz, 1990).
• Studies about how specific elements of dance--such as exuberance, vitality, social contact, and bonding--promote healing, longevity, and health-enhancement. Can the effects of these different components be dissected and quantified?
• If dance is engaged in for a specific purpose, is its therapeutic effect diminished? That ~is, to what extent does the effect of dance depend on spontaneity?
• Studies indicate that DMT is an aid to recovery after illness. However, few studies exist on the use of dance therapy for prevention of illness. Studies could be done to evaluate the adjunctive use of dance in blood pressure control or in reduction of blood lipids.
Throughout history, music has been used to facilitate healing. Aristotle believed the flute in particular was powerful. Pythagoras taught his students to change emotions of worry, fear, sorrow, and anger through the daily practice of singing and playing a musical instrument. The first accounts of the influence of music on breathing, blood pressure, digestion, and muscular activity were documented during the Renaissance (Munro and Mount, 1978).
Music, more than the spoken word, "lends itself as a therapy because it meets with little or no intellectual resistance, and does not need to appeal to logic to initiate its action . . . [and] ~is more subtle and primitive, and therefore its appeal is wider and greater" (Altshuler, 1948). This wide appeal, as well as the considerable research base, suggests music may be used more and more both by itself and in conjunction with other treatments to ameliorate certain illnesses.
Music therapy began as a profession in the 1940s, when the Veterans Administration Hospital incorporated music into rehabilitation programs for disabled soldiers returning from World War II. The National Association for Music Therapy, Inc. (NAMT), was established in the United States in 1950. At the same time, degree programs were developing to educate and train professional music therapists. Since then, the organization has established curricular programs in music therapy, which include both clinical practice and internships at sites in a wide variety of medical and community settings; organized an impressive scientific database for the profession; developed standards of practice and a code of ethics; and fostered the development of a theoretical rationale for music's beneficial effect on the mind and body.
~There are more than 5,000 registered music therapists (R.M.T.s) in the United States, and more than 80 undergraduate and graduate degree programs. In addition, there are 165 clinical internship training sites. A baccalaureate degree in music therapy requires course work in music therapy; psychology; music; biological, social, and behavioral sciences; disabling conditions; and general studies. It includes field work in community facilities or on-campus clinics serving individuals with special needs. After graduation, a student must serve a 6-month internship in an approved facility to be eligible to take the exams to become a board-certified therapist.
Two refereed journals are sponsored by NAMT: the Journal of Music Therapy and Music Therapy Perspectives. Three published indexes in music therapy exist with more than 6,000 citations of periodical articles published between 1960 and 1980 (Eagle, 1976, 1978; Eagle and Minter, 1984). An electronic database of medical music therapy (Computer-Assisted Information Retrieval Service System, CAIRSS) has been established with citations from more than 1,000 journals including empirical studies, case reports, and program reviews.
~Music therapy is used in psychiatric hospitals, rehabilitation facilities, general hospitals, outpatient clinics, day care treatment centers, residences for people with developmental disabilities, community mental health centers, drug and alcohol programs, senior centers, nursing homes, hospice programs, correctional facilities, halfway houses, schools, and private practice.
Music therapy is used to address physical, psychological, cognitive, and social needs of individuals with disabilities and illnesses. After assessing the strengths and needs of each client, a qualified music therapist provides the appropriate treatment, which can include creating music, singing, moving to music, or just listening to it.
Music therapy can be used to meet medical goals in many areas, including the following:
• Physical and emotional stimulation for those with chronic pain or impaired movement. Music evokes a wide range of emotional responses. It can be a sedative to promote relaxation, or it can be a stimulant to promote movement to other physical activity (Coyle, ~1987; Kerkvliet, 1990; Zimmerman et al., 1989).
• Communication for those with autism or communication disorders. Music is a unique form of communication. Using music with people who are nonverbal or who have difficulty communicating facilitates their social interaction and may increase their functioning (Grimm and Pefley, 1990; Street and Cappella, 1989).
• Emotional expression for those with mental health problems. Music can be used to express a wide variety of emotions, ranging from anger and frustration to affection and tenderness. These feelings often take the form of vocalizations that may or may not employ words (Jochims, 1990; Schmettermayer, 1983).
• Associations with music for those with Alzheimer's disease and other dementias. Selecting music from an individual's past may evoke memories of times, places, and persons. These memories can contribute additional information to the treatment of the individual (Clair and Bernstein, 1990; Gibbons, 1988; Hanser, 1990).~Research accomplishments. Thousands of specific research studies have been undertaken in the clinical uses of music in medical and dental treatment, and many others are currently in process. Among those clinical uses are the following:
• As an analgesic. As early as 1914, Kane investigated using a phonograph in the operating room for calming patients prior to anesthesia. Music as an analgesic for dental procedures was one of the earliest and most thoroughly investigated areas. It also has been used successfully during childbirth and with obstetric patients. A 1985 study using music as an anxiolytic showed suppressed stress hormone levels in orthopedic, gynecologic, and urologic surgery patients (Bonny and McCarron, 1984; Frandsen, 1989).
• As a relaxant and anxiety reducer for infants and children. Many studies have dealt with music's effect on hospitalized infants and pediatric patients. Lullabies in the neonatal nursery increased the weight gain and movements of newborns; music activities reduced fear, distress, and anxiety in hospitalized infants, toddlers, and their families and promoted "wellness" attributes in very ill children (Aldridge, 1993; Armatas, 1964; Atterbury, 1974; ~Chetta, 1981; Crago, 1980; Daub and Kirschner-Hermanns, 1988; Fagen, 1982; Kamin et al., 1982; Locsin, 1981; MacClelland, 1979; Mullooly et al., 1988; Oyama et al., 1983; Sanderson, 1986; Tanioka et al., 1985).
• With burn patients. Burn patients experienced alleviation of aesthetic sterility and distraction from constant pain.
• With terminally ill individuals. Cancer patients, using music therapy, increased their ability to discuss their feelings and talk about the trauma of the disease (Fagen, 1982; Frampton, 1986; Gilbert, 1977; Walter, 1983).
• With persons with cerebral palsy. As early as 1950, music therapy together with physical therapy was shown to reduce the neurological problems of children with cerebral palsy.
• With individuals who have had strokes or have Parkinson's disease. Federal funding ~from the Administration on Aging is currently being used for research into the effects of music therapy and physical therapy on people with strokes or Parkinson's disease.
• With persons who have sensory impairments or AIDS. Many studies have explored the applications of music therapy to individuals who have sensory impairments (visual and hearing), mental retardation, or AIDS.
• With elderly persons. In 1991 the U.S. Senate Special Committee on Aging convened a hearing on the therapeutic benefits of music for elderly persons, which included neurologist Dr. Oliver Sacks, singer Theodore Bikel, rock musician Mickey Hart, music therapists, and clients. The hearing record documents in detail the benefits of music therapy to the elderly (Special Committee on Aging, 1991). After the hearing, Senator Harry Reid (D-NV) introduced the Music Therapy for Older Americans Act, which was later folded into the Older Americans Act Amendments of 1992. This act lists music therapy as both a supportive and a preventive health service. The new Title IV initiative creates research and demonstration projects and education and training initiatives, for which Congress ~appropriated nearly $1 million. In 1993, six nationwide music therapy projects were funded (Renner, 1986).
• With persons with brain injuries. In 1993, the Office of Alternative Medicine awarded one of its first 30 grants "to investigate any beneficial effects of a specific music therapy intervention on empirical measures of self-perception, empathy, social perception, depression, and emotional expression in persons with brain injuries." This research is now under way (Lehmann and Kirchner, 1986; Lucia, 1987).
Research needs and opportunities. In areas where it has not been done, systematic review and meta-analysis should be performed to assess the quality and outcomes of the research. In addition, further research is needed in the following areas:
• Neurological functioning, communication skills, and physical rehabilitation.
• Perception of pain, need for medication, and length of hospital stay.~ • Cognitive, emotional, and social functioning in those with cognitive impairments.
• Emotional and social well-being of caregivers and families of those with disabilities.
• Clinical depression and other mental disorders.
• Disease prevention and health promotion of persons with disabilities.
Art therapy is a means for patients to reconcile emotional conflicts, foster self-awareness, and express unspoken and frequently unconscious concerns about their disease. In addition to its use in treatment, it can be used to assess individuals, couples, families, and groups. It is particularly valuable with children, who often cannot talk about their most pressing and painful concerns.
~The connection between art and mental health began to be recognized with the advent of mental institutions in the late 1800s and the early 1900s. Prinzhorn's book Artistry of the Mentally Ill, published in 1922, with stunning art made by institutionalized adults, helped ignite inquiries into the spontaneous graphic outpouring of disturbed patients. In addition to the interest in the artistic or diagnostic value of the patients' productions, there was the realization that the production of art was valuable in rehabilitating a patient's mental health.
In the 1940s, Margaret Naumberg blended ideas about psychoanalytic interpretive techniques and art to develop art as a tool to help release "the unconscious by means of spontaneous art expression . . . and on the encouragement of free association. . . . The images produced . . . constitute symbolic speech" (Naumberg, 1958). A decade later, Edith Kramer began her own exploration into the use of art. She focused her approach on the artmaking process itself. In her brand of therapy, a therapist is able to bring "unconscious material closer to the surface by providing an area of symbolic experience wherein changes may be tried out, gains deepened and cemented. The art therapist must be at once artist, therapist, and teacher . . ." (Kramer, 1958). Then, in 1958, Hana Kwiatkowska translated ~what she knew as an artist into the field of family work and introduced specific evaluation and treatment techniques at the National Institute of Mental Health.
Art therapy was formalized in the founding of the American Art Therapy Association in 1969.13 Along with the Art Therapy Credentials Board, the 4,000-member organization sets standards for the profession, strives to educate the public about the field, has a code of ethics and a system of approving educational programs and registering art therapists, and will soon certify art therapists. Registered art therapists (A.T.R.s) must have graduate degree training and a strong foundation in the studio arts as well as in therapy techniques and must complete a supervised internship with work experience. Currently, 2,250 art therapists are registered by the association. They practice in psychiatric centers, drug and alcohol rehabilitation programs, prisons, day care treatment programs, schools for the mentally retarded, residences for the developmentally delayed, geriatric centers, and hospices. Two journals are available: Journal of Art Therapy and Art Therapy Journal.
Art therapy differs from regular art classes such as painting, sculpture, and drawing, in that ~the therapist is trained both in diagnosis and in helping patients with specific health problems. In their art, for instance, patients may focus on parts of their bodies that unconsciously concern them but which they have never mentioned to their physicians or nurses. Such revelation can lead to further investigation and additional diagnosis. In helping patients express their feelings about a disease--such as cancer, for instance--therapists may lead them to draw images of themselves with cancer. These images may reveal a great deal about their feelings about their cancer, its severity, and its effect on their health and well-being.
Research accomplishments. Research on art therapy has been conducted in clinical, educational, physiological, forensic, and sociological arenas. Studies on art therapy have been conducted in many areas.
• Burn recovery in adolescent and young patients (Appleton, 1990).
• Eating disorders.
~ • Emotional impairment in young children (Bowker, 1990).
• Reading performance (Catchings, 1981).
• Chemical addiction (Chickerneo, 1993).
• As a prognostic aid in childhood cancer.
• As an aid in assessing ego development and psychological defensiveness in young children (Kaplan, 1986; Levick, 1983).
• Childhood bereavement (Zambelli et al., 1989).
• As a modifier of locus of control in behavior-disordered students.
• Sexual abuse in adolescents.