Jeffrey J. Magnavita, PhD, ABPP
Optimizing Treatment with Easy to Use Technologies: Updating Your Clinical Toolbox
Author Footnote: The author has no financial interest in any of the companies mentioned in this article. He incorporates some of the devices mentioned in this article in his practice.
Technology is beginning to provide tools to assist and support psychological intervention, particularly in cases involving anxiety and depression. Heart Rate Variability Biofeedback (HRV), Cranial Electrotherapy Stimulation (CES), and Neurofeedback (NFB) are relatively easy to incorporate into clinical practice. This article describes their use in clinical practice.
Imagine that the following case has been referred to you for re-assessment and recommendations for further treatment: Rachel, a physical therapist with 10 years of experience, is referred for assessment because of a DUI incident on a week night while driving a vehicle owned by the comprehensive outpatient facility at which she works. Reviewing her life history, several traumatizing events during her teenage years are revealed and chronic anxiety during her college years reported. After college she sought out a psychiatrist for medicine for her anxiety, and was diagnosed with an anxiety disorder and PTSD. She has been on anxiolytics for 8 years and supportive psychotherapy. She reports some symptom improvement but questions are raised about long-term maintenance on anxiolytic medication, which can cause dependence and require increasing dosages to manage anxiety. She has never received a course of evidence-based trauma treatment.
What are your clinical options for recommending future treatment? A different medication or no medication at all? Cognitive Behavior Therapy (CBT), Emotion-Focused Psychotherapy (EFT), or Short-Term Dynamic Psychotherapy (STDP)? Something more specialized for trauma? Eye Movement Desensitization and Reprocessing (EMDR), Prolonged Exposure Therapy (PE), or a Unifying Approach (Magnavita & Anchin, 2014). How would the new American Psychological Association clinical practice guidelines for the treatment of PTSD (see https://www.apa.org/about/offices/directorates/guidelines/ptsh.pdf) apply? Are there additional evidence-based approaches that might augment or enhance treatment, such as exercise, diet, yoga, meditation or relaxation training? And, finally, are there technology-based devices that can be used as primary or supplemental treatment?
The last question may well be the most puzzling of the clinical options for most practitioners. But many clinical devices have been developed to be compatible with smartphone platforms, making them accessible to most patients. Technology is rapidly changing the way health care can be and is being delivered (Canton, 2015). Increasingly we are seeing the development of more sophisticated devices and applications that can aid in the improvement and enhancement of mental and behavioral health (Magnavita, in press). For those who grew up with technology (e.g., “digital natives”), these devices are intuitive. Those of us who are digital “immigrants” may not be so likely to adopt these technological aids in treatment. Hopefully this article will serve to increase the curiosity and interest of those unfamiliar with technology assisted psychotherapy.
There are hosts of emerging technologies that can substantially add to our clinical toolbox. Some technologies have been available for decades, and many have been made easier to use (and, with decreasing costs, available for patients to use outside the office to augment treatment). By 2020, it is predicted that health care will be digital and data driven, being feed by biometric devices such as our smartphone and digital sensors (Deloitte, 2014). Smartphone applications (apps) that can track mood, anxiety, and sleep are rapidly developing and widely available (Simmons, Garcia, Howell, & Leong, 2016). Many of these have the capability of not only providing information to patients, but to relay clinical data directly to clinicians as well. Heart Rate Variability Biofeedback (HRV), Cranial Electrotherapy Stimulation (CES), and Neurofeedback (NFB) can be incorporated into one’s practice at a reasonable cost (both in financial terms and training time to mastery), and they are much less costly and time consuming compared to Transcranial Magnetic Stimulation (TMS) or Virtual Reality Therapy (VR). Also, patients can use many of these devices between sessions to maximize treatment effect.
Most experienced clinicians know that no single approach works with every patient. Part of optimizing treatment is to select approaches that suit a particular patient, have evidence supporting use with a particular condition or diagnosis, and are consistent with patient values. Although there is a growing body of empirical evidence about psychotherapy effectiveness, much of what we do is based on clinical expertise, and relies on incremental trial and error. We try something and see if it works, and then try something else until the benefit is seen. The same is true in most of physical medicine. Clinical decision-making requires us to be cognizant of our biases, especially when selecting from treatment modalities that do not have a robust evidentiary base. While we rely on the best evidence and carefully considered clinical decision-making, each intervention must be measured against its efficacy with the patient in question (Magnavita, 2016b). The more evidence-based treatment options we have at our disposal, the broader the range of our psychotherapeutic options.
State Change Brain Retraining—Managing Anxiety and Creating Coherence
Neuroscientific findings are illuminating the underlying mechanisms and states that underlie most psychological disorders. Anxiety is one sign of a dysregulated system and is implicated in most forms of psychopathology. Learning how to modulate anxiety is a part of most psychotherapeutics. “There is growing interest in alternative approaches to the treatment of anxiety, though their effectiveness has not been evaluated in all cases. Mindfulness-based methods use relaxation, breathing exercises, meditation, yoga, and other techniques to focus on the present and reduce tension and worry” (LeDoux, 2015, p. 261).
“The brain, like all living systems, constantly seeks a stable state” (Doidge, 2015, p. 20). Technology offers additional options for many patients, retraining the brain to achieve coherence and thus reducing anxiety and depression associated with low coherence. According to McGrady (2007), these and other new ideas have the potential to change the brain “using neurophysiological pathways similar to those that react to stress” (p. 31). There are a variety of devices that can accelerate the course of treatment using state change technology, which can be easily incorporated in practice.
The brain, as an information-processing organ, transmits and receives information (Sigel, 2017). This flow of information affects the coherence and synchrony of our brain—and, if perturbed, our brain can become dysynchronous—characterized by anxiety and emotional dysregulation (Magnavita, 2016a). “State change” technologies, such as biofeedback, neurofeedback, and electro-cranial stimulation, can be used to achieve coherence by reinforcing positive states. Coherence is best described as the optimal balance between sympathetic and parasympathetic functions. Low coherence is present when the individual senses danger in the absence of physiological threat and an involuntary preparation for flight, fight, or (in cases where escape and fight are not options) freeze response is invoked. In many patients with a history of trauma there is evidence of an overactive limbic system response, which leaves the person in a state of high alert, vigilance, and exhaustion.
Stephen Porges (2011) developed polyvagal theory, which seeks to explain state changes and posits an evolutionarily derived neurophysiology based on the two branches of the vagus nerve: the dorsal vagal implicated in primal survival responses (i.e., the “freeze” response), and the ventral vagal, which drives flight and fight response. These are postulated to drive our elemental survival systems, and may also determine aspects of social engagement. According to Porges, social engagement systems are engaged when there is neuroception of safety and the two vagal systems are in a state of homeostasis.
Vagal tone has been shown to be an indicator of the state of coherence as measured by respiratory sinus arrhythmia (RSA), which is easily monitored by calculating the intervals between heartbeats. While it sounds counterintuitive, the greater variability in the time intervals between our heartbeats, the greater our level of coherence. HRV biofeedback trains the patient to increase their heart rate variability (HRV) employing methods of synchronized deep breathing, which retrains the vagal pathways. HRV biofeedback is just one of many technology-based approaches that are quite useful in providing relief for patients with a variety of stress and anxiety based clinical syndromes and mood disturbances (Lehrer, Woolfolk, & Sime, 2007). Some of these devices may augment extinction procedures essential in reducing the avoidant strategies that patients with anxiety disorders typically adopt as habit (LeDoux, 2015). Clinical reports, patient responses, and evidence from neuroscience suggest that these are beneficial in assisting those with low vagal system coherence to effect state change. Additional clinical research is needed to provide a stronger evidence-based claim for the effectiveness of such devices.
Incorporating HRV, CES and NFB Neurofeedback in Your Practice
Among the neurofeedback technologies currently available are HRV biofeedback, Cranial Electrotherapy Stimulation (CES), and Neurofeedback (NFB). While there are a variety of other potentially beneficial technology-based approaches, it is beyond the scope of this article to present a comprehensive review of these. These three technologies are relatively inexpensive and easy to add to your range of services offered.
Heart Rate Variability (HRV) biofeedback. HRV biofeedback has become a mainstay for many practitioners because of its versatility, ease of use, and ability to engage patients who enjoy technology. HRV uses very sophisticated but easy to learn devices that can be used by patients with very little guidance by the therapist. The Heartmath Company (https://www.heartmath.com/) offers useful HRV biofeedback devices that are relatively inexpensive. They offer a software program that is an excellent tool for in-office use that visually displays the patient’s state of coherence based on variability in their heart rate measured by intervals in heartbeats. The greater variability indicates a higher level of coherence. The patient is taught a form of resonant frequency breathing that maximizes HRV, and by way of the vagal nerve regulation creates emotional coherence, thought to be an optimal balance between sympathetic and parasympathetic systems. Of course with any treatment, the patient is given informed consent and then it is optimal to introduce the patient to the technology, which in this case requires him/her to view a monitor and calibrate their breathing to maximize HRV and thus increase coherence. The visual display is very well designed and shows coherence at three levels: low, moderate, and high, with each indicated by a color of red, blue, and green, respectively.
If the patient responds positively and is interested, I recommend that they purchase a portable device. There are a number of companies that offer these devices. I usually have a few choices for them to try so each person’s preferences can be considered. Some chose to purchase the professional software package, which is easily downloaded on laptops and personal computers. There are also apps that can be downloaded on smartphones, some of which use the light sensor on the phone to measure heart rate variability. Other more accurate devices require the purchase of a sensor to plug into the smartphone. In my office, I have installed a large monitor that the patient and I can observe when they practice biofeedback. Sensors are placed on the finger or earlobe to monitor heart rate.
Cranial Electrotherapy Stimulation (CES). Another state change device, CES is an FDA approved treatment for anxiety, depression, and insomnia. The devices are user friendly, and the learning curve for clinicians is not steep. There are two companies that produce devices that can be purchased and used at home by patients. Training is offered free of charge and provides the necessary background to get up and running very quickly. The Alpha-Stim Company (http://www.alpha-stim.com/) offers two CES devices, which are very easy to use and many patients report immediate benefit after one treatment. One is solely for the treatment of anxiety, depression, and insomnia, and the other has an additional pain component. I have been using this device for about five years with good results and patient satisfaction. The Fisher Wallace Fisher Stimulator (https://www.fisherwallace.com/) is a similar device but uses sponge-like disks, which are moistened and put under a headband on each side of the patient’s head. These devices are more expensive (approximately $600 to $1,200 for the Alpha-Sim M) than HRV biofeedback devices and the new versions of NFB discussed next. But, when the costs of pharmaceutical agents are considered, these devices offer cost effective alternatives for state change training. Some third party insurers may reimburse for these devices.
Neurofeedback (NFB). NFB used to be a very complicated and costly treatment, which recently has become much more accessible for clinicians (Hamlin, in press). There appears to be a role for the use of inexpensive neurofeedback devices to augment state change work and enhance psychotherapeutic effect. Recently, many neurofeedback devices have become available. These tend to cost between $100 and $300, and are fairly easy to learn and incorporate in practice, as well as patient home use. Such devices include Neurosky, BrainLink, Muse, Versus, and iFocusBand (Hamlin, in press). Many of these devices are elegantly designed and connect with smartphones and computers. Software for different applications such as improving attention/concentration, reducing anxiety and so forth is rapidly developing.
Incorporating Technological Devices in the Treatment of Rachel
How can the treatment of Rachel be enhanced using some of these technological advances? Clearly from her case history she suffers from anxiety that is being treated primarily with anxiolytic agents. As noted earlier, use of such agents may result in physiological dependence, and medications cannot assist the patient in learning more adaptive psychological responses. The addition of technological devices into psychotherapy does not a take the place of the relational work that is the foundation of psychotherapy, but they may augment the potency of treatment. Rachel was introduced to a variety of technologies that were considered to be potentially useful to her, she then engaged in a process of experimenting with various devices and approaches. After trying HRV biofeedback and CES, Rachel decide to incorporate HRV biofeedback to use extra-therapeutically to build and sustain coherence. In session, she also benefited from the use of CES while doing extinction procedures, which allowed her to tolerate exposure therapy.
Benefits to Learning New Technology-Based Approaches
The use of technology is an accelerating trend that benefits both those seeking solutions to a broad range of psychological and emotional disorders. This provides psychologists with more tools that can be selectively used with each patient depending on his/her preferences and therapeutic goals. Innovative practitioners can offer new therapeutic modalities that can expand scope of practice.
Jeffrey J. Magnavita, PhD, ABPP, is a psychologist with offices in Glastonbury, CT and Orleans, MA. He is the past president of Division 29, the Society for the Advancement of Psychotherapy and previously served on APA's Clinical Practice Guidelines Advisory Steering Committee. He has been a member of the National Register for over three decades. He is the founder of Strategic Psychotherapeutics™, LLC a technology based behavioral and mental health company.
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