Biofeedback and Self-Regulation,

VoL 21, No, 2, 1996

B o o k Review

Biofeedback: A Practitioner's Guide, second edition. Mark S. Schwartz and Associates. New York: G u i l f o r d P u b l i c a t i o n s , 1995, ISBN 0-89862-806-7; 908 pages + xx. Price: $60

It is a rare privilege to have the opportunity to review a book of this stature. Schwartz has outdone his previous edition of this book, both in size and comprehensiveness, reflecting the growth of knowledge and professional expertise in the biofeedback field as a whole. This is unquestionably the definitive book on biofeedback today, written by one of the country's leading biofeedback clinicians, primarily for use by other clinicians. For anyone entering the biofeedback field, seeking a comprehensive reference or update on the field, or studying'for BCIA certification, this text should be consulted first. More than any other single source, it defines the field of biofeedback as it currently is practiced. Indeed, the writer of this review is cognizant of the fact that, in reviewing it, he is reviewing the whole field of biofeedback as it is understood and practiced today. It has therefore been written with some trepidation. Although most of the book was written by Schwartz himself, selected chapters were authored or coauthored by other leading experts in the field. It contains detailed descriptions of clinical procedures, presents the variety of options available for presenting feedback and recording data using various biofeedback modalities for various problems, and provides reasoned cautions about possible adverse effects and how to avoid them. It has a good chapter on biofeedback instrumentation by Charles Peek. It includes chapters on taking baseline recordings (should they be taken? under what conditions? for how long?), and treatment compliance, and it details and explains technical aspects of biofeedback instrumentation. It has an excellent chapter on ethics by Sebastian Striefel, which is worthwhile reading for all biofeedback practitioners, no matter how experienced, and even has chapters on such "nuts and bolts" practice issues as how to write professional reports, and job descriptions for professional practice of biofeedback. It also provides examples of record forms that 199 0363-3586/96/0600-0199509.50/09 1996 Plenum Publishing Corporation

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can be useful to assess problems and record success, and myriad "good sense" recommendations for working with patients. A glossary follows most chapters, along with an up-to-date (if not exhaustive) list of references. The biofeedback practitioner who consults this book may feel as if a wise and experienced biofeedback clinician were sitting in the room as a coach, guiding his/her practice. Similarly, the book's careful treatment of research findings makes it definitive and worthwhile reading even for the most advanced biofeedback practitioner and researcher. Its personalized writing style makes it accessible to all. Coverage of clinical applications is encyclopedic. Chapters include biofeedback applications for headache, temporomandibular disorders, Raynaud's disease, essential hypertension, diabetes, attention deficit disorder, musculoskeletal rehabilitation, and elimination disorders. Areas of application that are new and more experimental also are presented, including fibromyalgia, and idiopathic scoliosis. Any faults that can be found in the book reflect shortcomings in the field. Its generally positive outlook may paint a slightly overoptimistic picture; there is little in it to discourage the potential biofeedback practitioner from embarking headlong on a clinical career. I would be a bit more cautious. If biofeedback interventions were scrutinized by the FDA nearly as closely as new drugs, few biofeedback procedures would be allowable in standard medical practice. Credibility of the field, and, ultimately, availability of third-party reimbursement depend on the willingness and ability of the biofeedback community to conduct large-scale placebo-controlled trials with adequate follow-up. Compared with pharmacotherapy, biofeedback is at a distinct disadvantage in this regard. Federal support for research is dwindling, and biofeedback instrumentation c o m p a n i e s are " m o m and p o p " shops, c o m p a r e d with the international conglomerates that dominate the pharmaceutical industry and finance drug research. Schwartz softpedals this issue by focusing on ways that academic biofeedback researchers and biofeedback clinicians can better understand each other, and work toward common goals. Although important in AAPB politics, this issue is a side show in the current health care revolution, and, in the interests of survival, must be treated as such by the biofeedback community. It is therefore notable that some of the methods described in this volume have received almost no empirical evaluation, other than that provided by their inventors (e.g., the method of using apex temperature to measure cerebral blood flow, or using finger pulse volume rather than the R-spike of the EKG wave to measure respiratory sinus arrhythmia). Similarly there is little discussion of problems involved in the ubiquitous use of biofeedback instruments to assess and modify E M G amplitudes

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and finger temperature. EMG amplitude has been proven to be an unreliable index of skeletal muscle tension, which is much better assessed by analyzing EMG frequencies. Peripheral vasodilation and finger warming are not necessarily consistent with stress-reduction. Increased beta sympathetic arousal, after all, can produce warmer hands, and the reverse (even including Raynaud's syndrome) is sometimes produced by medications that block the beta-sympathetic system. Such discrePancies combine with lack of sufficient objective evaluation research to make the field of applied psychophysiology rather vulnerable in the current health policy climate. Also, the biofeedback clinician should understand that the current NIH position on self-regulation methods for treating hypertension is that they are relatively ineffective. Whether or not one agrees with this position, it defines that standard of medical practice, and must be seriously addressed. Similarly, for treating asthma, biofeedback methods have not yet been proven to produce bronchodilation of clinically significant magnitude, although there is evidence that the methods may make a positive contribution as part of a comprehensive treatment program. This may occur more from reductions in panic/fear and better adherence to medical regimen than from direct self-regulation of pulmonary function. In addition, more thought and discussion is needed to define areas where biofeedback instrumentation is necessary to achieving self-regulation, or adds any measurable benefit over less technology-intensive methods such as hypnosis, psychotherapy, progressive relaxation, meditation, and autogenic training. The book does deal with the combined use of these various treatment modalities, but shies away from the more uncomfortable question of "Are the machines necessary at all?" in clinical practice, other than as methods for evaluation of results. Finally, in looking toward the future of the field, what about reassessing some of the more fundamental issues in the enterprise of self-regulation? For example, healthy functioning rarely involves unidirectional change and stability. Rather, psychophysiological function is designed to meet the constantly changing needs of external adaptation and internal homeostasis; but biofeedback methods as applied to stress-related disorders usually are confined to producing constant and low levels of physiological arousal. Oscillatory rhythms, such as respiratory sinus arrhythmia of the heart, are correlated with health in a variety of populations, and healthy functioning allows for little predictability from moment to moment. Adequate performance during active coping tasks (which can be measured in the laboratory by mental arithmetic or visual-motor tasks) may require the ability to produce increases in heart rate and ventilation. Inability to produce this response, or to recover from it afterward, may be a sign of

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dysfunction. Stability and viability of the organism depends on the existence and functioning of a host of regulatory mechanisms. The more of these mechanisms that operate, the healthier and more adaptive the organism, but the more variable and unpredictable the physiological and behavioral profile. At this stage of the field, it is important to consider potential chaos theory applications in applied psychophysiology, and to speculate on possible methods of training people for greater flexibility and variability in psychophysiological response. In summary, our field is a growing and evolving one. This, the definitive book on biofeedback practice, reflects both the accomplishments and the problems of biofeedback as a profession. It teaches the reader how to practice according to current knowledge and standards. It is comprehensive and scholarly. It is informative and though-provoking even for the most experienced biofeedback practitioner, yet it is accessible to the intelligent beginner. At the reasonable price of $60, it should be on the bookshelf of every biofeedback clinician, teacher, and researcher. Paul Lehrer Department of Psychiatry UMDNJ -- Robert Wood Johnson Medical School 671 Hoes Lane Piscataway, NJ 08824