By Mark S. Schwartz, Ph.D.

    The purpose of this booklet is to provide you with guidelines when seeking biofeedback and related professional services which usually is in your home community. My goal for writing this is to help readers, often patients, locate professionals who provide biofeedback and consider guidelines when seeking such providers.

Sometimes the professional making the referral knows the provider of biofeedback. Sometimes, the only information available is from a website, primarily the Biofeedback Certification Institute of America (BCIA), clearly the major and oldest national credentialing organization in the biofeedback field.

Another major sources of information about providers is the Association for Applied Psychophysiology and Biofeedback (AAPB), the oldest and major membership organization in this field. Membership does not provide information about the member’s competence but often provides useful information about educational degrees and experience.

Certification by the BCIA means that the person has fulfilled a variety of competency related criteria including passing a written test and having been supervised by a properly credentialed professional. Passing the test means that the certified person has at least the fundamental knowledge and skills for using biofeedback.

However, none of the above information is sufficient to tell us specifically what they know and how they use biofeedback. Only very rarely has the professional making the referral ever been in the office of the provider to whom you are referred. Therefore, the professional making the referral cannot or at least should not overly strongly endorse the professional to whom you are referred.

These guidelines are my opinion. I base them on over 3 decades in this field, as author and editor of a textbook in this field for which the 4th edition is being prepared, many years of administrative roles in BCIA and AAPB, and my years on the staffs of the Mayo Clinic.

  1. Consider your impressions when you enter and wait in the offices of the health care professional. How are you greeted? Are you physically comfortable? Is the office neat and clean? These factors often reflect on the professionals.

2. Consider your comfort with the health care professional treating you with relaxation therapies, biofeedback, and related therapies. Their personality, their interest in you, their appearance, their personal warmth and friendliness, their understanding of you, their sense of humor, and how they talk with you all will influence your comfort and confidence. Do they provide sufficient time with you? Do they encourage and reassure you?

If you are uncomfortable with the professional(s) then consider discussing your concerns with them before starting therapy or very soon after starting. If you feel unable to discuss your concerns directly and remain uncomfortable then it may be wise to consider seeking help elsewhere if that is practical.

3. Do you trust him/her? Trust is developed in many ways. For example, ask yourself whether your health care professionals present a consistent approach, discuss ahead of time anticipated and possible changes in therapy, realistically discuss therapy goals and expectations, are usually on time, and, of course, maintain confidentiality. Obviously, trusting the professionals working with you is very important.

  4. Do your health care professionals appear relaxed?  Do they use relaxation for themselves. In other words, are they good models of what they recommend to you? If not, that is not sufficient reason to be discouraged or change therapists. However, it is another piece of information with which to make such a judgment. If you do not have a good algernative and/oryou like most other other aspects of the professional, then consider staying and learn to accept the statement, “He or she knows what to do and what is best for me although they have not mastered some of it. I can still learn from him/her.” On the other hand, unless there are strong additional reasons for remaining, a health care professional who is a poor model might not be worth your investment.

5. The professional’s qualifications and experience are obviously very important. Your confidence in them and your comfort will be affected by what you know about their qualifications and experience. Professionals in many different health care fields provide biofeedback. There are many fine and well qualified professionals in this field but some providers have less than desirable educations, training, experience, and/or credentials in the biofeedback field. Furthermore, some professionals are well qualified in another field and dabble with biofeedback, meaning that they use it periodically or as a small part of their practice. I recommend that you ask about their qualifications and experience.

The professional who spends very little time in this field may not be sufficiently prepared to provide ideal therapies for you. You may also wish to ask about their experience with your particular symptoms and disorder. Limited specific experience does not necessarily mean a lack of competence to be helpful to you. It means only limited experience and a need to be open with you about such time. Even those professionals highly experienced and competent in many areas might not have much experience in other areas.

  Ask about their experience with biofeedback therapies and with your particular problems. If other reasons for remaining with that professional are solid, then remain. However,  if other factors are not strong then consider alternatives.

  Some useful information may also be obtained by reading the certificates in their office. The only credible national credential in the field of biofeedback is that of the BCIA. In fairness, the absence of that certificate does not necessarily mean that the professional is not otherwise qualified but its presence should be considered a useful piece of information.

   6. A related item is whether the therapist is licensed to provide services without supervision? If not licensed, then what type and how much supervision are they receiving? There are many fine professional therapists who work with the supervision by other professionals who ideally have more experience and credentials. It is acceptable for your therapy to be provided by professionals supervised by others but those providing your therapy should be willing to discuss who is providing the supervision, how often, and for what aspects of your therapy. If your therapist is supervised, then the qualifications and experience of both the therapist and the supervising professional should be discussed with you, especially if you have any questions or concerns.

7. Another consideration is whether the therapist is with you during at least most of the therapy sessions.  Biofeedback therapists are usually present with their patients/clients during most or all therapy sessions. Their presence is to provide important observations and help when needed, to operate and adjust the instruments, and to record information from the instruments.  

However, some therapists leave you alone during parts of some sessions. This provides you with opportunities to “explore” the relaxation process with feedback from the instruments. Such procedures can be acceptable although I recommend that you should not be left alone during all or most sessions unless the therapist is observing you through a window and recording the physiological information from an adjacent room. Before starting therapy is it wise for you to ask whether the therapist will be observing and assisting you during the sessions.

8. Are you treated by one therapist or more than one?  Do you usually know in advance when a substitute therapist will be present? Are you much less comfortable with some than other therapists? Do you feel “shifted around”?

9.  There are many fine biofeedback instruments available to professionals. The therapist should both be and appear competent n using their instruments. You would be justified in being concerned if they did not appear able to smoothly and efficiently operate the instruments.  

     10. For many biofeedback applications the measuring and feedback from your muscle activity are appropriate. For example, if you are being evaluated and treated for muscle tension headaches, face or neck pain, then at least the initial recordings should be made from multiple areas of your head and neck instead of only from one location such as only your forehead.  Only if multiple areas have been recorded and evaluated under a few different conditions and found not to show excess tension would be appropriate to provide therapy sessions without such recordings and feedback.

   11.  Ask the biofeedback provider for justification for using biofeedback and related therapies, and/or investigate the applications before you schedule therapy sessions. There are many appropriate indications for using biofeedback therapies. There are many more of these with sufficient research support compared with many years ago. The AAPB publishes a document summarizing the efficacy ratings for most application. The text, Schwartz, M.S. & Andrasik, F. (2003). Biofeedback: A Practitioner’s Guide (3rd Edition). New York: Guilford Press is a good resource for deciding about applications. The 4th edition is in preparation and is expected to become available in 2011.  

Some providers of biofeedback justify the use of various types of biofeedback for applications that are more speculative and experimental. Be more cautious with these applications.  

12.  Biofeedback modalities include surface muscle tension (sEMG), hand or foot skin temperatures, hand perspiration (electrodermal) activity, breathing rate and location, heart rate, heart rate variability (HRV), and electroencephalography (EEG). These are all commonly used and all can be useful. Your biofeedback provider should adequately and clearly explain each modality to you so that you understand the rationale and procedures.  

13.  Recordings with and without biofeedback should usually be done with your eyes open and eyes closed in order to evaluate your self-regulation under both conditions. This provides opportunities for you to develop self-regulation under both conditions.  

14.  Recordings with and without biofeedback are often conducted while you are in different body positions such as reclining, sitting up, standing, and perhaps even during and after some daily types of activities that can be simulated in the therapist’s office. This is relevant for symptoms and conditions that occur in various body positions.  

   15. Self-report symptom diary or log is often important and very useful in assessing your progress. Many professionals ask their patients to maintain such records. Your therapist should review your symptom log and discuss it with you. If such a log is not requested if may be more difficult to assess your progress.

16. Is this therapy tailored for you? Tailoring therapy means that the therapy program takes into account your unique situation, symptoms, skills, and personality. Does the health professional adjust the therapy according to our individual needs/ Some professionals use “prefabricated” therapy programs. There is a set number or a minimum number of sessions. There is a set content to all or most of the sessions. There is a specific sequence of stages for everyone to progress through. There is a place for such “canned” programs but they are not ideal or appropriate for most people. If you have concerns then discuss your concerns with your health care professional.  

   17. For many persons the number of office sessions you need will vary for you to develop physiological self-regulation sufficient to enable you to greatly relieve or eliminate your symptoms.           Periodic reevaluation to determine whether additional biofeedback will be needed should be made after several sessions, sometimes 8 to 12 or sooner.  

For some applications of biofeedback, the number of sessions can be many more. Examples include physical rehabilitation and some applications for EEG biofeedback such as ADD.  

   Nevertheless, even with applications that require many sessions, there should be clear evidence of progress or other strong justification for more biofeedback sessions. Thus, additional sessions may be useful and needed but your therapist should discuss and justify to your satisfaction the reason for additional sessions. Office sessions which appear to repeat the same procedures without apparent progress should be questioned by you and the reason for them discussed with you to your satisfaction. Some repetition can be advised to help you consolidate your new skills. However, several sessions like this are usually unnecessary.  

There are other considerations which influence the total number of office sessions that might be needed. This includes the possible need for other therapies such as cognitive therapies, behavior modification, assertiveness, work stress management, child management, marital counseling, and/or time management. The possible need for such additional therapies should be clearly discussed with you by hour health care professional so that you have a good idea of what to expect and when.  

18.  The health care professional’s office should be professionally responsible and reasonable about fees and requirements. For example, if you call a health care professional’s office asking about biofeedback and you are told that the cost is several thousand dollars, that you have to pay an huge deposit of thousands of dollars, and you have to sign a contract for a set number of sessions such as 20 or more, then I believe you should consider going elsewhere. I believe it is unprofessional and highly inappropriate to make such demands.  

19. In conclusion, if you are pursuing biofeedback therapies, then I hope that you will consider the above guidelines in evaluating the services being proposed and planned for you. Information about the biofeedback and related applied psychophysiological therapies are available in books,  booklets, websites, and CDs.