Essentials of Complementary and Alternative Medicine (June 1999)

A
LTERING
 T
REATMENT
Treatment is altered according to the needs of the patient. It is common to begin therapy for the presenting symptom and discover an important secondary symptom or 
psychosocial issue that must be addressed. When the biofeedback therapist has a repertoire of skills, changing therapeutic strategies is possible. In some cases, the 
therapist refers the patient to another specialist and/or recommends other treatment.
Treatment is also altered when a component appears to be ineffective despite the patient's attempted use; in this case, other strategies are introduced. Treatment is 
altered, or may be terminated, when the patient fails to comply with home-training instructions. Failure to comply is addressed frankly, and the patient and therapist 
decide on a strategy to improve compliance. Therapists may introduce simpler techniques, create short-term goals, or reexplain the rationale and expected changes. 
We emphasize that self-regulation is similar to taking a medication—if not used, it will not work. Biofeedback therapists continually explore ways to improve therapy.
USE OF THE SYSTEM FOR TREATMENT
Biofeedback therapy has matured in the past two decades and is currently a primary or complementary treatment for many disorders. Once efficacy has been 
established, the approach (whether it is primary or complementary) depends on patient desires, effectiveness of conventional therapy, likelihood of success, and other 
factors. For example, biofeedback therapy may be selected as the primary therapy by patients seeking a nonpharmacologic approach to their condition.
Major Indications
P
RIMARY
 A
PPROACH
In l989, a select committee of biofeedback clinicians and researchers from several institutions accepted the task of assessing the clinical efficacy of biofeedback 
therapy for a variety of disorders. This group concluded that biofeedback therapy is primarily indicated for the following disorders in adults and children: Raynaud's 
disease/syndrome; certain types of fecal incontinence; urinary incontinence; muscle contraction headache; migraine headache; irritable bowel or spastic colon 
syndrome; essential hypertension; asthma; several neuromuscular disorders; epilepsy in certain patients; and attention deficit disorder (
2
).
The committee found that biofeedback therapy is also effective for anxiety disorders, disorders of intestine motility, enuresis, insomnia, motion sickness, myofascial 
pain, temporomandibular joint pain and mandibular dysfunction, some types of chronic pain, such as rheumatoid arthritic pain, and stroke rehabilitation.
C
OMPLEMENTARY
 A
PPROACH
Biofeedback therapy may be considered complementary when the patient is being treated by a primary health care professional, particularly when the illness 
necessitates traditional medical intervention, as in epilepsy, asthma, and diabetes. The synergistic interaction of two or more therapies can be highly efficacious and 
enables the patient to receive specialized yet complementary treatment. When biofeedback therapy benefits the patient but is not a specific treatment of the patient's 
disorder, it may be considered complementary. For example, cancer patients may benefit greatly by the relaxation and stress management components of 
biofeedback therapy. These skills improve quality of life and enhance the patient's sense of control; when used with desensitization training, these skills may help the 
patient overcome the side effects of chemotherapy, such as conditioned vomiting (
35
). Relaxation skills are also combined with visualization. Visualization may effect 
immune system functioning (
36
, 
37
) and relaxation may promote healing through homeostatic mechanisms. Anyone coping with a life-threatening illness or stressful 
life circumstance could benefit from biofeedback therapy.
Least Useful Indications
Relaxation and stress management skills, coupled with increased sense of self-responsibility and self-control, are useful and may bring relief to many patients. 
However, biofeedback therapy is least useful for treating chronic conditions in which structural damage has occurred. As a behavioral medicine, biofeedback therapy 
is also least useful for treating infectious disease, although evidence suggests that relaxation and stress reduction enhance the immune system (
37
, 
38
); therefore, 
biofeedback therapy may, under some circumstances, help patients with an impaired immune system. Biofeedback therapy is also less useful for patients who cannot 
or will not invest the necessary time and effort in training; it may be of limited use for patients who have difficulty developing internal awareness.
Contraindications
There are no recognized contraindications for biofeedback therapy because the therapy is nonpharmacological, noninvasive, and promotes homeostasis. An 
incompetent therapist or faulty instrumentation may hinder successful outcome, but the components of biofeedback therapy are not contraindicated or dangerous for 
any condition. However, because relaxation can induce homeostatic change, patients who use medications to maintain homeostatic balance (e.g., insulin for diabetes, 
antihypertensives) must be treated with caution. In this case, the patient must conscientiously monitor his or her condition and adjust medications accordingly. 
Schwartz (
1
) lists several psychiatric disorders that are assumed to be contraindicated for biofeedback therapy, but no data are available.
Occasionally, a patient experiences emotional or physical discomfort (e.g., dizziness, floating sensations, body disorientation, anxiety) when attempting to relax. We 
have worked with seven patients who became anxious in the first relaxation exercise. Six patients reported a traumatic experience while undergoing ether anesthesia 
in childhood, and one patient had encephalitis as a child and recalled the panic of losing consciousness. With coaching, these patients were able to disassociate 
relaxation and panic and continued therapy. These reactions are rare and do not constitute a contraindication, yet therapists should be cautious and immediately 
interrupt a relaxation procedure when necessary. By monitoring finger temperature during initial training, the therapist can detect autonomic arousal even when the 
patient appears to be relaxed.
Prevention
Preventing both the onset of illness and symptom recurrence is facilitated through psychophysiological self-regulation. Biofeedback procedures and self-regulation 
skills for prevention can be taught in many settings—hospitals, outpatient clinics, schools, and corporations. Soaring health costs necessitate these types of 
preventive measures. Biofeedback procedures may also be useful in preventing symptoms secondary to a known disease. For example, patients diagnosed with 
diabetes mellitus type I could learn to increase blood flow in hands and feet and use the skill regularly. This training might prevent or retard the development of 
vascular pathology in the extremities. As a treatment, biofeedback therapy is uniquely preventive in two aspects: patients learn how to prevent symptoms (e.g., 
preventing a migraine headache during the aura) and biofeedback therapy facilitates healthy homeostasis and thus reduces the likelihood of symptom onset and 
recurrence.
Scope of Therapy
Throughout this chapter, the broad scope of biofeedback therapy and the mechanisms for this have been discussed: the mind-body interaction and neuronal 

pathways underlying this interaction, the universality of stress and its impact on the body, homeostasis and the power of relaxation, the value of information feedback, 
and people's ability to gain a degree of psychophysiological self-regulation through training and practice. The broad application of biofeedback therapy for 
stress-related disorders and for disorders exacerbated by stress is explained by the fact that physiological processes that respond to stress also respond to stress 
reduction, returning the body to healthy homeostasis. Furthermore, the principles of psychophysiological self-regulation underlie the unusual cases of recovery from 
organic disease. Finally, the usefulness of feedback in enhancing inner awareness and proprioception underlies the applications of biofeedback therapy for 
neuromuscular disorders.
ORGANIZATION
Training
P
REREQUISITES AND
 R
EQUIREMENTS
Biofeedback therapists should be licensed in their profession and/or certified in clinical biofeedback by an accrediting agency. In the United States, the Biofeedback 
Certification Institute of America (BCIA) is the only certification agency, established in l981. For certification, BCIA requires 200 hours of formal training from an 
approved institution in the following areas: didactic education in biofeedback, personal experience with biofeedback, and supervised clinical biofeedback experience 
(
39
).
Clinicians applying for certification must have at least a bachelor's degree in an approved health care field, and applicants must complete 30 clinical hours supervised 
by a certified therapist.
C
URRICULUM
The BCIA requires the following for biofeedback therapists: introduction to biofeedback; preparing for clinical intervention; neuromuscular intervention (general); 
neuromuscular intervention (specific); central nervous system interventions (general); autonomic nervous system interventions (general); autonomic nervous system 
interventions (specific); biofeedback and distress; instrumentation; adjunctive techniques and cognitive interventions; and professional conduct. There are several 
avenues for training in these areas, ranging from academic classes to training given by private corporations to seminars given by the Association of Applied 
Psychophysiology and Biofeedback (AAPB) and other organizations. Training programs are assessed and approved by the BCIA.
Quality Assurance and Certification
The current credential for biofeedback clinicians is certification. To be certified, the applicant must meet educational and training requirements and must pass a 
written and a practical (instrumentation) exam, all of which are established and administered by the BCIA. Certification is granted for 4 years. Recertification is based 
on continuing education credits and/or retaking the written examination when sufficient credits have not been earned or when certification has expired. The primary 
objective of the BCIA is to provide a standard in biofeedback that can be accepted as reliable and valid evidence that the individual provider has attained minimum 
specific professional competency. A Register of certified individuals is published annually. Certification as a specialist in EEG feedback and in nontherapeutic stress 
management education are also provided by the BCIA.
Legal Status and Regulation
Legal recognition of biofeedback therapy as a treatment entity varies by state. Generally, it is considered under mental health provisions, and biofeedback therapists 
follow the guidelines and procedures established in their state for health professionals. Biofeedback therapists who are licensed in another specialty follow the 
guidelines and procedures established for their specialty and for biofeedback therapy.
Professional Societies and Continuing Education
The AAPB is an international society that serves its members and the public through publications, oversight committees, working committees for the advancement and 
acceptance of the field, annual meetings, seminars and workshops, and peer review. Thirty-seven state societies and six international chapters serve some of these 
functions and hold regional meetings that provide continuing education credit. AAPB comprises six interest sections: EEG, surface EMG, instrumentation, allied 
professionals, pediatric biofeedback, and education.
Reimbursement Status
Biofeedback therapy is covered by many third-party payers and by worker's compensation in several states. The range of coverage varies with the provider and policy 
and may exclude certain disorders. With the advent of managed care, restrictions on fees, number of sessions, and the provider have increased. Like other 
therapeutic modalities, biofeedback therapy is scrutinized by third-party payers and intermediary organizations with an aim at reducing short-term costs. It is our 
experience, however, that some insurance companies are willing to evaluate coverage on a case-by-case basis and often preauthorize treatment. We anticipate 
increased coverage as long-term cost-effectiveness studies are completed, and as the value of covering preventive medicine is recognized.
Current CPT treatment codes for biofeedback applications are as follows:
90901—Biofeedback training by any modality
90911—Biofeedback training, anorectal, including EMG and/or manometry
90875—Individual psychophysiological therapy incorporating biofeedback training by any modality (face to face with the patient)
ICD classification for biofeedback—other individual psychotherapy (biofeedback)
Relations with Conventional Medicine
Most practitioners of conventional medicine understand the effects of stress and psychological factors on physical health. It is estimated that 70 to 80% of physician 
visits are for stress-related disorders. Physicians and other practitioners who inform themselves of the applications and principles of biofeedback therapy readily 
appreciate the potential of the therapy. Patients who request biofeedback therapy are usually encouraged by their physician to pursue treatment, and some 
physicians routinely refer patients to biofeedback therapy.
The introduction of behavioral medicine into medical school curricula is increasing and has been well received by medical students and interns (
40
). This sets the 
foundation for the incorporation of biofeedback therapy into mainstream medicine.
PROSPECTS FOR THE FUTURE
In l976, pioneers in the field predicted that in the twenty-first century it will be taken for granted by every school child that mind and body interact (
17
). The implication 
is that both lay persons and health care professionals will understand and use mind-body interaction for health. This is becoming true, and biofeedback therapy is 
becoming an integral part of mainstream medicine. In addition, the use of psychophysiological self-regulation procedures for prevention is becoming more common.
Currently, there are powerful social, economic, and political forces working against health and self-responsibility, including a “quick-fix” mentality that permeates the 
culture, industries that promote “worseness” habits (e.g., smoking, alcohol), a medical model that focuses on biological rather than psychosocial causes of illness and 
treatments, and increasing violence and stress. Today, the soaring cost of conventional medicine affects complementary treatments as third-party payers employ 
cost-containment and managed-care procedures. Nonetheless, the prospects for biofeedback therapy are good. The potential of this therapy for cost-containment and 

prevention are clear.
We anticipate a bright future in which patients and health care practitioners are partners, medical clinics house a variety of treatment facilities, clinicians work together 
as a treatment team, and biomedical engineers develop user-friendly instrumentation to feed back parameters that are not accessible today, such as blood sugar 
levels and white blood cell counts.
In the past two decades, the role of the mind in illness and health has been reinstated in both psychology and medicine. Currently, mind and body are seen as 
integrated systems. In parallel, medical treatments are becoming integrated, bringing together psychological and physiological forces for health. As the 
biopsychosocial approach to illness and wellness is adopted, a “whole person” and “whole society” approach to treatment and prevention will evolve, ultimately 
bringing together the most powerful ingredients of conventional and nontraditional treatments into a comprehensive and integrated prevention and treatment system.
C
HAPTER
 R
EFERENCES
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2.
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3.
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4.
Budzynski TH, Stoyva JM, Adler CS, Jullaney DJ. EMG biofeedback and tension headache: a controlled outcome study. Psychosom Med 1973;35:484–496.
5.
Brudny J, Grynbaum B, Korein J. Spasmodic torticollis: treatment by feedback display of the EMG. Arch Phys Med Rehabil 1974;55:49–53.
6.
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7.
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8.
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10.
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CHAPTER 25. H
YPNOTHERAPY
Essentials of Complementary and Alternative Medicine
CHAPTER 25. H
YPNOTHERAPY
Ian Wickramasekera
Background
 
General Definitions and Descriptions
 
History and Development
 
Model: Mind-Body Interaction
 
Hypnosis and the High-Risk Model of Threat Perception
Principal Concepts
Provider-Patient Interactions
 
Hypnotizability
 
Tests of Hypnotizability
 
Therapy and Outcomes
 
Description of Treatments
 
Treatment Evaluation
Use of the System for Treatment
 
Major Indications
 
Contraindications
Organization
 
Training and Quality Assurance
 
Reimbursement Status
Prospects for the Future
Chapter References
BACKGROUND
General Definitions and Descriptions
Hypnosis is a form of cognitive information processing in which a suspension of peripheral awareness and critical analytic cognition can lead to apparently involuntary 
changes in perception, memory, mood, and physiology (
1
). One hundred years ago, hypnotherapy was an alternative form of therapy in which a patient was induced 
into a trancelike state, followed by suggestions for the relief of clinical symptoms. Today, hypnotherapy almost always involves adding hypnotic procedures to 
standard psychological, medical, or dental treatment. It is usually used by those who are already licensed by their state to diagnose and treat disorders within the 
scope of their medical, psychological, or dental license. This chapter focuses on the use of hypnosis with established forms of psychological therapy, such as 
psychodynamic psychotherapy or cognitive behavior therapy (CBT), to treat psychological, somatic, or organic symptoms. As our understanding of the 
neuroendocrine and immune links between mind and body grows (
2
), it appears that all diseases are psychophysiological in nature. Today, hypnotherapy is 
essentially a form of psychophysiological therapy (
1
, 
3
). There is growing empirical evidence that the addition of hypnosis to an established form of psychotherapy, 
such as CBT or behavior modification, may increase its long-term clinical efficacy even for some chronic intractable diseases like obesity (
4
, 
5
). For example, Kirsch 
(
6
) reported from a meta-analysis of eight studies (
Fig. 25.1
) that hypnosis can double the efficacy of CBT for obesity and that efficacy increases during long-term 
follow-up (two years). Earlier, a famous meta-analysis by Smith et al. (
7
) found that the addition of hypnosis to psychodynamic psychotherapy significantly increased 
its efficacy over all other types of nonhypnotic psychotherapies.
F
IGURE
 25.1. Weight loss as a function of assessment interval and inclusion of hypnosis in treatment. (Adapted with permission from Kirsch I, Montgomery G, 
Sapirstein G. Hypnosis as an adjunct to cognitive-behavioral psychotherapy: a meta-analysis. J Consult Clin Psychol 1995;63(2):214–220.)