enhancing personal wellness in counselor trainees using biofeedback: an exploratory study

P1: GDX/GCZ/GCX P2: GDB/GCR

Applied Psychophysiology and Biofeedback [apb] PP068-296054 February 7, 2001 8:11 Style file version Nov. 19th, 1999

Applied Psychophysiology and Biofeedback, Vol. 26, No. 1, 2001

Enhancing Personal Wellness in Counselor TraineesUsing Biofeedback: An Exploratory Study

Cynthia Chandler,1,2 Eugenia Bodenhamer-Davis,1 Janice Miner Holden,1

Thomas Evenson,1 and Sue Bratton1

The purpose of this study was to explore whether biofeedback-assisted relaxation trainingcould reduce stress-related symptoms and enhance personal well-being in a group of coun-selor trainees enrolled in a basic counseling skills course. Treatment participants receivedten sessions of weekly biofeedback-assisted relaxation training, whereas the control par-ticipants received no intervention. The treatment group showed, significant improvementsin several symptom areas measured by the Symptom Checklist 90-Revised: physical com-plaints (Somatization), personal inadequacy (Interpersonal Sensitivity), confused thinkingor alienation or both (Psychoticism), and the overall number and severity of symptoms(Global Severity Index and Positive Symptom Total). The control participants showed nosignificant improvements in any symptom areas. Biofeedback-assisted relaxation was shownto be an effective stress-reducing intervention for counselor trainees, which resulted in agreater sense of personal well-being.

KEY WORDS: wellness; counselor trainees; biofeedback; Symptom Checklist 90-Revised.

Counseling can be a stressful activity for the professional, especially during the coun-selor’s early training period. Although a certain amount of stress is helpful to promoteproductive activity, many studies have documented reports of high stress levels often lead-ing to burnout among professional counselors and others in helping professions (Bruning& Frew, 1987; Flett, Biggs, & Alpass, 1995; Folkman, Lazarus, Dunkel-Schetter, Delongis,& Gruen, 1986). Numerous studies have documented the stress experienced by gradu-ate students in professional training programs during their first attempts to apply tech-niques they have learned in the classroom (Bradley, 1989; Cole, Kolko, & Craddick, 1981;Kampfe & Mitchell, 1990; Kaslow & Rice, 1985; Whitman, Spendlove, & Clark, 1986).Dubin (1991) pointed out that many therapists, especially those who are inexperienced, feelsuch a sense of urgency to do something to help their clients that they are prevented fromquieting their own inner chatter enough to be receptive and open to what clients arecommunicating.

1Counselor Education Program, University of North Texas, P.O. Box 311337, Denton, Texas 76203-1337.2Address all correspondence to Cynthia Chandler, Counselor Education Program, University of North Texas,P.O. Box 311337, Denton, Texas 76203-1337; e-mail: [email protected].

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1090-0586/01/0300-0001$19.50/0C© 2001 Plenum Publishing Corporation



2 Chandler, Bodenhamer-Davis, Holden, Evenson, and Bratton

The body’s response to events that are perceived to be stressful will not differ muchfrom a response to events having an actual threat of personal or physical harm (Lazarus& Folkman, 1984). Perceived stress in social situations, such as in difficult interpersonalencounters or when one is being judged or evaluated, can produce physiological changesvery similar to those resulting, for example, when one narrowly avoids an automobileaccident (Frankenhaeuser, 1981; Lazarus & Folkman, 1984).

Stress produces changes within the autonomic nervous system, which include increasedheart rate, blood pressure, respiration, muscle tension, sweat gland activity, and the pe-ripheral vasoconstriction associated with cold hands and feet. These autonomic responsescan produce significant cognitive interference, anxiety, panic, headaches, irritable bowel, orother symptoms (Basmajian, 1989; den Boer, 1997; Ellison, 1996; Sarason, 1980; Schwartz,1995).

The human psychophysiological response to perceived stress has been well-documented. Arena, Goldberg, Saul, and Hobbs (1989) determined stability in responsesover time to perceived stress as measured by increased muscle tension in the forehead, coolerhands due to vasoconstriction of the peripheral blood vessels, and increased pulse rate. Thestressor was the simple arithmetic task of counting backwards by 7 s from a large randomthree-digit number (serial-7 stressor) for 4 min. Researchers have obtained elevations inboth forehead muscle tension and heart rate when presenting a serial-7 stressor, and similarelevations when having the participant imagine a stressful life event, such as a divorce ormeeting deadlines (Rosenthal et al., 1989). Thus, the body’s response to a perceived stressis similar regardless of whether it is a stressful life event or a mental stressor, and this stressresponse seems to be stable across time.

The stress response can create significant discomfort in the counselor trainee and mayimpair a counselor trainee’s clinical effectiveness with clients. Counselor trainees expe-rience high levels of stress and potential resulting discomfort in the counselor trainingenvironment, for example, performance anxiety and evaluation anxiety (Bradley, 1989). Tominimize the detrimental effects of self- or situation-induced stress on physical and psycho-logical functioning, it would appear highly desirable that counselors be able to recognizeand manage their own physiological stress reactions. The capability for psychophysiolog-ical self-regulation would provide counselors the ability to balance and quiet themselvesmentally and physically as a prerequisite to receptivity and rapport with their clients. CarlRogers addressed this issue and invited his trainees to follow his example of setting aside ashort period of time at the beginning of a counseling session for both counselor and clientto mentally and physically quiet themselves in preparation for their work together (Rogers,1985). Yet only recently has it been suggested that counselor education programs formallyaddress counselor stress and stress-coping methods as part of the counselor preparationcurriculum (Flett et al., 1995).

Control over the stress response, specifically, management of the autonomic nervoussystem, can be learned. Biofeedback-assisted relaxation therapy has been shown to bevery effective in reducing the stress response, reducing or alleviating unwanted stress-related symptoms, and producing a state of inner quiet, balance, and open mental focus(Basmajian, 1989; Fehmi, 1974; Schwartz, 1995). When one learns to self-regulate theautonomic response to stress, then one can expect less stress-induced physical discomfort.

Counselor education programs should consider the importance of teaching not onlycounseling theories and skills, but also techniques that enhance the personal wellness of



Biofeedback With Counselor Trainees 3

the counselor. The purpose of this study was to determine if biofeedback-assisted relax-ation training could reduce stress levels in a group of randomly selected counselor traineesenrolled in a basic counseling skills course.

METHOD

Participants

Participants were beginning-level counselor trainees enrolled in a required master’s-level basic counseling skills course in a counselor education program from a moderatelylarge metropolitan university in the south-central United States. The course involved theintroduction and practice of beginners’-level counselor techniques, such as nonverbal at-tending, minimal encouragement, reflection of content and feeling, summarization, andsession management.

The researchers approached the 33 students who comprised two sections of the basiccounseling skills course. Twenty-four students signed written informed consent forms toparticipate. The researchers then randomly assigned the participants, 12 to the treatmentgroup and 12 to the control group. All participants were requested not to engage in anyform of relaxation therapy other than that assigned as a part of the research. All participantsverbalized compliance with this request at the beginning and end of the study. Becauseof attrition, a total of 19 research participants completed the study, 8 participants in thetreatment group and 11 participants in the control group. Reasons given for attrition in thecontrol group were illness-related and in the treatment group were time-related demandsof the study. The ages of the participants ranged from 25 to 45 years. Six females and twomales comprised the treatment group; eight females and three males comprised the controlgroup. Eighteen participants were Caucasian, and one participant was Asian.

Stress Assessment

The Symptom Checklist-90-Revised (SCL-90-R) (Derogatis, 1983) was used as a self-report to determine the number of stress-related symptoms present for each participant. TheSCL-90-R provides scores on nine symptom categories as well as three global symptomscores. A description of symptom categories and global scores follows: Somatization (physi-cal complaints); Obsessive–Compulsive (impulsive and ruminating thoughts); InterpersonalSensitivity (personal inadequacy); Depression (withdrawal and sadness); Anxiety (nervous-ness); Hostility (anger and irritability); Phobic Anxiety (specific fear responses); ParanoidIdeation (suspiciousness); and Psychoticism (mild interpersonal alienation to psychosis).

The function of the three global SCL-90-R scores is to communicate the level ordepth of the individual’s overall state. The Global Severity Index (GSI) represents the bestsingle indicator of the individual’s overall state by including the number and intensity of allsymptoms endorsed. The Positive Symptom Total (PST) is simply a count of the numberof symptoms endorsed. The Positive Symptom Distress Index (PSDI) is a pure intensitymeasure of symptoms. A standard score (t score) of 63 or greater on the SCL-90-R on anytwo of the nine symptom categories or on the GSI global score is suggestive of a level ofsymptoms that could be clinically diagnosable.




The SCL-90-R instrument is used by clinical psychologists, psychiatrists, and counsel-ing professionals in mental health, medical, and educational settings as well as for researchpurposes. The SCL-90-R instrument is a well-researched instrument, with more than 940research studies demonstrating its reliability, validity, and utility (Derogatis, 1983, 1990;National Computer Systems, 2000).

Procedure

The treatment intervention consisted of ten weekly, 45-min individual sessions ofbiofeedback-assisted relaxation therapy provided by a master’s level counselor trained inbiofeedback techniques. During the first 10 min of the first session, the therapist explainedthe fight-or-flight response and the mind–body connection and demonstrated the biofeed-back equipment to the participant. During the first 10 min of all remaining sessions, theresearcher reviewed the participant’s homework assignments and made suggestions for en-hancing homework practice. Approximately 5 min of each session was used for sensorplacement and removal. One 5-min beginning measure was taken just prior to the readingof the relaxation script and one ending baseline was taken 5 min after the end of the readingof the script. During the baseline periods, each participant was asked to sit quietly and relaxwithout intervention by the therapist. A few minutes was taken at the completion of eachtraining session to review the session with the participant.

The counselor provided each treatment group participant with individual temperature-training biofeedback, using the J & JI-330 computerized clinical biofeedback system (J & JEnterprises & Garber, 1989). After seating the participant in the upright position of a reclinerchair, the counselor placed a thermistor on the surface of the distal pad of the little finger ofthe participant’s nondominant hand. The counselor then asked the participant to assume thereclined position and close his or her eyes. The counselor turned on the feedback tone andexplained that as the participant warmed the hands, a sign of increasing relaxation, the tonewould become lower pitched and slower in frequency; as the hands cooled, the tone wouldbecome higher pitched and faster in frequency. During each session the counselor helpedthe participant to relax by reading a 15-min relaxation script to the participant. The scriptwas based on an Autogenic Phrases technique (Green & Green, 1977), and included state-ments such as “My hands are heavy and warm.” The counselor monitored the participant’sfinger temperature throughout each session. Treatment participants completed all treatmentsessions at the counselor education program’s biofeedback clinic. In addition, the counselorprovided each treatment participant with an audiotape of the Autogenic Phrases script and asmall finger thermometer attached to cardboard for use in practicing relaxation and monitor-ing finger temperature at home. The counselor asked each treatment participant to practicefor 15 min at least once a day at home and to keep a daily log of the home practice sessions.Participants recorded on the homework logs the beginning and ending temperatures andany thoughts and feelings the participant had during the relaxation practice.

Cool fingers are typically indicative of a stress response due to peripheral blood flowconstriction. As one relaxes, the blood vessels dilate and allow the warm blood to flow to theperipheral areas of the body. All treatment participants had a beginning finger temperatureof 87◦F or lower. The goal of the biofeedback training was to assist each participant to reacha hand temperature of at least 94◦F and maintain this reading for at least a 5-min periodacross two consecutive in-clinic sessions. These warmer readings would reflect the ability of




the participant to achieve and maintain a state of deep relaxation and greater self-regulationof the autonomic nervous system (Danskin & Crow, 1981).

All participants completed the SCL-90-R at the beginning of the semester and again10 weeks later. During the interim, the treatment group received the biofeedback interven-tion, whereas the control group received no intervention.

RESULTS

Because of the exploratory nature of this study and the small sample sizes, data from theSCL-90-R were analyzed usingt tests that compared pre- and post-treatment scores for eachof the nine symptom categories and the three global scores. One-tailed tests of significancewere employed, because a priori predictions were made, but thep value needed for signifi-cance was reduced to .01 to compensate for the repeated use oft tests and to guard againstinflation of the experimentwise error rate. Analysis determined that the treatment group(N = 8) demonstrated statistically significant less symptomatology (p < .01) on three ofnine symptom categories (Somatization, Interpersonal Sensitivity, and Psychoticism) andon two of three global indices (Global Severity Index and Positive Symptom Total), whereasthe control group (N = 11) revealed no significant changes (see Table I). These results in-dicate that the treatment intervention of biofeedback-assisted relaxation therapy did resultin significantly greater reductions in negative symptomatology for counselor trainees.

Within the 10-week treatment period, all treatment participants achieved the train-ing goal. Participants who achieved the goal early continued until they completed 10 totalsessions. Four of the treatment subjects’ SCL-90-R pretest scores suggested clinically di-agnosable levels (t score>63 on GSI or on at least two symptom categories) and all four ofthese treatment subjects’ posttest scores had dropped below the diagnosable level. Four ofthe control subject’s SCL-90-R pretest scores suggested clinically diagnosable levels, and allfour of these control subject’s posttest scores had also dropped below the diagnosable level.

Table I. Results oft Tests for Paired Samples of Pre and Post Scores on the SCL-90-R

Control Group (N = 11) Treatment Group (N = 8)

Pre Post Pre Post

Variable M SD M SD p valuea M SD M SD p valuea

Somatization 46 13 42 10 .22 58 8 45 10 .00Obsessive–Compulsive 51 10 48 10 .13 52 14 50 10 .32Interpersonal Sensitivity 53 9 48 8 .08 59 6 53 5 .01Depression 53 11 53 7 .48 58 8 52 8 .03Anxiety 49 11 45 12 .16 55 13 51 14 .24Hostility 47 13 46 10 .42 53 9 49 6 .04Phobic Anxiety 43 7 46 8 .21 41 5 40 0 .18Paranoid Ideation 49 12 46 11 .23 48 9 42 7 .02Psychoticism 50 11 47 8 .21 51 10 43 6 .01Global Severity 52 10 48 7 .12 58 8 50 9 .01

IndexPositive Symptom 52 8 49 7 .13 57 7 50 6 .01

TotalPositive Symptom 49 10 46 7 .10 54 8 49 14 .07

Distress Index

aOne-tailed significance.




DISCUSSION

Biofeedback-assisted relaxation therapy was effective in reducing negative symptomsin graduate students who were in training to become professional counselors. The greatestsymptom improvement occurred for Somatization (headaches, pain, physical discomfort,etc.). Somatization is directly related to symptoms mediated by the autonomic nervoussystem, the body system that participants learned to self-regulate through biofeedbacktraining. The area with the second greatest amount of improvement was Psychoticism,suggesting that counselor trainees felt less alienated and less withdrawn on a personallevel. The third greatest area of improvement was a reduction in Interpersonal Sensitivity,suggesting that the counselor trainees felt more adequate and confident.

The present investigators were surprised and interested to find that the treatment par-ticipants showed no significant reduction in Anxiety. These results suggest that counselortrainees who achieved a criterion of relaxation in biofeedback-assisted therapy still mayexperience some anxiety, but they are able to manage the anxiety with significantly lessdiscomfort and a greater sense of personal wellness. Also, the greatest variation in scores asreflected by the standard deviations was with Anxiety. Wide variations in perceived anxietycan be problematic for behavior change studies targeting anxiety. In addition, baseline meanscores for Anxiety were somewhat low, suggesting the probability of a floor effect.

Also noteworthy is the fact that only one of the 12 control group participants (8%)dropped out of the study, whereas four of the treatment group participants (33%) droppedout. This dropout rate among treatment group participants may reflect the extent to whichthey found the training to be an additional demand on their time and energy.

There are certain limitations of this study which need to be acknowledged. The com-parison of just a control group with a biofeedback treatment group presents limited findings.The addition of a comparison group, such as a social support group, might have lent ad-ditional quality to the study by comparing the efficacy of biofeedback with another typeof a potentially effective intervention for symptom-reduction. The differential dropout ratebetween the control group and the treatment group is also problematic. The ability or desireof the treatment group to complete the study could be impacted by a number of potentialconfounding variables such as motivation to comply, perceived self-efficacy, or the personalvalue placed on time demand versus the potential benefits of therapeutic intervention.

The small sample size of the study limits the generalizability of the results. Counselortraining courses are small by design, and thus it is difficult to achieve a large samplesize using this population. Also, given that many individual pretest scores were low, largeamounts of distress were not present for everyone. Thus the potential for change was lessfor some, suggesting a possible floor effect. The study should be replicated to lend greaterstability to the results.

To summarize, biofeedback-assisted relaxation therapy was shown to be a useful toolin enhancing both a physiological indication of relaxation (finger warming) and a self-reported sense of well-being (improved SCL 90-R scores) of counselor trainees. The skillslearned in biofeedback therapy may be utilized by the counselor trainee throughout his orher lifetime. These skills could allow the counselor to better manage the stress of life andof the job and perhaps enhance job satisfaction. A more long-term study examining thesepossibilities seems warranted. The results of this study suggest that biofeedback-assistedrelaxation therapy is a beneficial component of the counselor training process.




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enhancing personal wellness in counselor trainees using biofeedback: an exploratory study

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