Biofeedback And Counseling For Stress And Anxiety Among .
Biofeedback and Counseling for Stress and Anxiety Among CollegeStudentsPaul RatanasiripongKevin SverdukJudy PrinceDiane HayashinoJournal of College Student Development, Volume 53, Number 5, September/October2012, pp. 742-749 (Article)Published by The Johns Hopkins University PressDOI: 10.1353/csd.2012.0070For additional information about this 53/53.5.ratanasiripong.htmlAccess Provided by Cal State Univ @ Long Beach at 10/04/12 6:24PM GMT
Research in BriefKitzrow, M. A. (2003). The mental health needs of today’scollege students. NASPA Journal, 41, 167‑181.Orbe, M. P. (2004). Negotiating multiple identities withinmultiple frames: An analysis of first-generation collegestudents. Communication Education, 53, 131‑149.Pascarella, E. T., Pierson, C. T., Wolniak, G. C., & Terenzini,P. T. (2004). First generation college students: Additionalevidence on college experiences and outcomes. Journal ofHigher Education, 75, 249‑284.Pascarella, E. T., & Terenzini, P. T. (2005). How college affectsstudents: A third decade of research. San Francisco, CA: Jossey-Bass.Perna, W., & Titus, M. A. (2005). The relationship betweenparental involvement as social capital and college enrollment:An examination of racial/ethnic group differences. Journal ofHigher Education, 76, 485‑518.Pieterse, A. L., & Carter, R. T. (2007). An examination ofthe relationship between general life stress, racism-relatedstress, and psychological health among black men. Journalof Counseling Psychology, 54, 101‑109.Smith, B. (2007). Accessing social capital through the academicmentoring process. Equity and Excellence in Education, 40,36‑46.Walton, G. M., & Cohen, G. L. (2007). A question ofbelonging: Race, social fit, and achievement. Journal of Socialand Personality Psychology, 92, 82‑96.Biofeedback and Counseling for Stress andAnxiety Among College StudentsPaul Ratanasiripong Kevin Sverduk Judy Prince Diane HayashinoWith the rise in stress and anxiety among collegestudents, there is a need for more comprehensiveand effective counseling options for counselors incollege counseling centers. This study investigatedthe impact of using biofeedback and briefcounseling in treating stress and anxiety in anethnically diverse college student population.Results indicated that participants who receivedbiofeedback training and counseling hadgreater reduction in anxiety symptoms thandid participants who received counseling alone.Implications for augmenting biofeedback trainingto traditional college counseling model arediscussed.Over the past decade an increase in thefrequency and severity of psychologicalsymptoms among college students has beendocumented (Benton, Robertson, Tseng,Newton, & Benson, 2003; Bishop, Bauer,& Becker, 1998; Hyun, Quinn, Madon, &Lustig, 2006; Kitzrow, 2003). In addition,tragic events, such as the 2007 shootings onthe campus of Virginia Tech, seem to havegenerated a new dialogue as to the importanceof adequate mental health education andservices being available to college students.Although violent and other antisocial behaviorsshould not be regarded as typical for thosesuffering from mental health disorders, thenew attention to mental health issues ontoday’s college campuses is greatly needed.Young adults in college today clearly facenumerous pressures, and when students’resources to cope are taxed beyond their limits,the consequences can include stress, anxiety,depression, sleep disturbance, eating disorders,impulsive behaviors, and suicide (Kadison& DiGeronimo, 2004; Lee, Olson, Locke,Michelson, & Odes, 2009).Of particular interest to the currentstudy is the high level of stress and anxietyPaul Ratanasiripong is Professor of Counseling, Department of Advanced Studies in Education and Counseling;Kevin Sverduk is lecturer in the Department of Kinesiology; and Judy Prince and Diane Hayashino are psychologistsat Counseling and Psychological Services; each at California State University, Long Beach.742Journal of College Student Development
Research in Briefamong college students (Abouserie, 1994;Dixon & Robinson Kurpius, 2008; Lucas &Berkel, 2005) and, specifically, the need formore comprehensive and effective treatmentoptions for students with anxiety. Accordingto the Anxiety Disorders Association ofAmerica (2012), anxiety disorders are themost commonly diagnosed of mental healthconditions with more than 40 million Ameri cans affected annually. College students are noexception to these trends. In a recent studyconducted by the American College HealthAssociation (2009), stress ranked as thenumber one health issue that impedes students’academic performance. In addition, the latestannual survey of college counseling centerdirectors across the country indicated anxietyand depression as the top two presentingconcerns for their student clients (Associationfor University and College Counseling CenterDirectors [AUCCCD], 2011).Although traditional counselingapproaches are often effective in helpingcollege students when used alone, researchhas shown that counseling may be even moreeffective when combined with alternativeforms of treatment such as biofeedback(Goodwin & Montgomery, 2006; Minkin,Prout, & Masterpasqua, 2009; Moss &Lehrer, 1998; Reiner, 2008). According tothe Biofeedback Certification InternationalAlliance (2012) biofeedback enables the userto alter physiological activity for the purposeof improving health and performance. Usingspecialized equipment, biofeedback methodsmeasure and utilize various signals from thebody including brain activity, blood pressure,muscle tension, heart rate, skin temperature,and sweat gland activity (Mayo Clinic, 2009).Further, biofeedback may be thought of as athree-step process, including (a) becomingaware of a physiological response, (d) learningto control the response, and (c) transferringcontrol of the response to everyday lifeSeptember/October 2012 vol 53 no 5(Calderon & Thompson, 2004).Of particular relevance to the currentstudy is research that combined biofeed backwith other interventions such as counsel ing. Goodwin and Montgomery (2006)demonstrated the effectiveness of biofeed back as an adjunct to cognitive–behavioraltechniques in the treatment of panic disorderwith agoraphobia, comorbid with depression.Turner (1991) studied the effectivenessof combining biofeedback with didacticinstruction for students enrolled in a universitystress management course; results showedsignificant decreases in anxiety.Present StudyThe present study focused on exploringwhether an alternative treatment modelfor treating stress and anxiety would yielda better outcome than the traditional briefcounseling for college students at universitycounseling centers. The outcomes, specificallythe reduction in anxiety symptoms, werecompared between clients receiving bothbiofeedback training and brief counselingand those receiving only brief counseling. Wehypothesized that clients who received bothbiofeedback training and counseling wouldhave better outcomes than would clients whoreceived only counseling.The present study utilized both computerbased and portable biofeedback devices. Easeof use is an important factor to be consideredin an effective treatment approach amongcollege students. A relatively new method ofbiofeedback based on heart rate variability(HRV) has emerged in recent years andmay in fact serve to make biofeedback moreaccessible and user-friendly. HRV can bedefined as the beat-by-beat variations inone’s heart rate (Schwerdtfeger & FriedrichMai, 2009). Although other methods ofbiofeedback training work by controlling thelevel of various physiological functions (i.e.,743
Research in Briefblood pressure, finger temperature), HRVbiofeedback training helps participants learnto control the variability in heart rate; becauseHRV biofeedback more directly targets thebody’s physiological control mechanisms, it iseasier to learn than methods that approach thetarget physiological mechanism in a less directmanner (Lehrer, 2007). Siepmann, Aykac,Unterdorfer, Petrowski, and Mueck-Weymann(2008) utilized a form of HRV biofeedbackand reported a decrease in depressive symptomsin patients with moderate to severe levels ofdepression as well as additional benefits ofreduced anxiety levels.Also relevant to the ease of use of biofeed back equipment is the portability of the devicesbeing utilized in the treatment approach.Reiner (2008) examined the effectivenessof a portable biofeedback device combinedwith traditional counseling for addressinganxiety disorders in an outpatient population.Participants were assessed over a 3-week periodwith significant reduction in levels of anxietyfound. Participants reported that they foundthe biofeedback device to be more helpful thanother methods such as yoga, meditation, andbreathing techniques.MethodParticipantsThe current study was conducted at a largepublic university in the western United Statesthat is a Hispanic-Serving Institution (HSI).The study’s participants were 30 counselingclients from one university counseling center.Their age range was between 18 and 42 years(M 24.43, SD 5.78). The 20 womenand 10 men in the study self-identified toone of four ethnic groups: African American(3%), Asian American (13%), Latino (47%),and White (37%). There were 5 freshmen,1 sophomore, 7 juniors, 10 seniors, and 7graduate students.744Procedure and MeasureParticipants were recruited from the universitycounseling center client. They were referredto the study based on presentation ofstress and anxiety symptoms at the timeof intake evaluation by staff psychologistsand predoctoral interns at the counselingcenter. Each prospective participant metwith one of the researchers for a researchpreview appointment which consisted of(a) a brief screening to ensure that all criteriafor inclusion in the study had been met and(b) completion of the informed consent form,the demographic form, and the pretreatmentBeck Anxiety Inventory (BAI).The BAI (Beck, Epstein, Brown, &Steer, 1988) was used as a measurement ofself-reported anxiety. The BAI was chosenbecause of its validity and wide usage withthe counseling client population as well as thediverse college student population (Contreras,Fernandez, Malcarne, Ingram, & Vaccarino,2004; Levy Berg, Sandell, & Sandahl, 2009;Pillay, Edwards, Sargent, & Dhlomo, 2001).The BAI is a 21-item scale developed with anadult clinical population to measure the severityof anxiety in adult and adolescents. Each answeris scored on a scale of 0 (not at all ), 1 (mildly),2 (moderately), or 3 (severely). Participants areinstructed to rate each item according to howthey have felt in the past week. A higher scoreon the BAI indicates higher level of anxiety.Beck et al. (1988) reported the Cronbach’salpha for the BAI to be .92 in their study withoutpatient counseling clients. For the presentstudy, the internal reliability (Cronbach’s alpha)was .92 for the pretreatment BAI and .93 forthe posttreatment BAI.Upon enrolling in the study, participantswere randomly assigned to either the treatmentgroup or the placebo control group. Thosein the placebo control group received foursessions of individual counseling in 4 weeks.Journal of College Student Development
Research in BriefParticipants in the treatment group receivedfour sessions of individual counseling plusfour sessions of biofeedback training in 4weeks. The timeframe of four sessions waschosen based on both this counseling center’saverage number of sessions seen by clients peracademic year as well as the national mediannumber of sessions seen for 4-year publicuniversities (AUCCCD, 2009). Counselingsessions were conducted by the universitycounseling center staff consisting of licensedpsychologists and predoctoral interns; thetreating therapists were not informed whetherthe participants were in the treatment or theplacebo control group. Biofeedback sessionswere conducted by the researchers.During the weekly 30-minute biofeedbacktraining session, participants were providedwith a visual display of their heart ratevariability and instructed to increase thecoherence of their heart rate pattern (reduceHRV) through breathing and visualization;lower HRV is associated with reduced anxietyrelated psychological symptoms. After eachbiofeedback session, participants in thetreatment group also received a portablebiofeedback device for use at home betweenthe biofeedback sessions. They were instructedto use the portable biofeedback device a fewminutes per day and to maintain a daily logof these practice sessions.Upon completion of the study, all partici pants met with one of the researchers for apoststudy debriefing session and completedthe posttreatment BAI within 1 week after thefourth counseling session.ResultsThere were no significant differences in the age,gender, and ethnicity between the treatmentTable 1.Demographics for the Treatment Group and Control GroupTreatment Group (n 15)VariableAgeMSD23.274.25nControl Group (n tynsAfrican American10Asian American13Latino77White65Class te student43Note. ns not significant.September/October 2012 vol 53 no 5745
Research in BriefFIGURE 1. Mean Pretreatment and Posttreatment Beck Anxiety Inventory Scoresgroup and control group (see Table 1). Therewere also no significant differences in the BAIscores for the different treating therapists,including licensed psychologists and interns.Both the treatment group and the placebocontrol group participants showed signifi cant reduction in anxiety symptoms (seeFigure 1). For the treatment group, themean posttreatment BAI score (M 10.53,SD 8.08) was significantly reduced fromthe mean pretreatment BAI score (M 24.13,SD 10.71). A paired-samples t test showedsignificance beyond the .05 level, t(14) 5.28,p .001. Cohen’s d was 1.43, which isa large effect. For the control group, themean posttreatment BAI score (M 13.13,SD 11.38) was significantly reduced fromthe mean pretreatment BAI score (M 19.80,SD 11.70). A paired-samples t test showedsignificance beyond the .05 level, t(14) 3.31,p .01. Cohen’s d was 0.58, which is a mediumeffect. Even though the mean pretreatmentBAI score for the treatment group is higher746than the control group, the difference was notstatistically significant.In comparing the outcome between thetreatment and control group conditions,the mean improvement score for thetreatment group (M 13.60, SD 9.98)was significantly higher than the mean forthe control group (M 6.67, SD 7.81),t(28) 2.12, p .05. Cohen’s d was 0.77, amedium effect size. The results confirmed thehypothesis that participants who received bothweekly counseling and weekly biofeedbacksessions showed significantly greater reductionin anxiety symptoms than did participants whoreceived weekly counseling alone.DiscussionThe results of this study found that the group ofparticipants who received biofeedback trainingin conjunction with counseling reportedsignificantly greater reduction in anxietysymptoms than did the group of participantsJournal of College Student Development
Research in Briefwho received counseling alone. Although bothgroups dropped from a moderate to mildanxiety level based on the BAI interpretationguideline (Beck & Steer, 1990), the treatmentgroup had a significantly greater decreasein anxiety symptoms, both statisticallyand clinically. The findings suggest thatbiofeedback training enhances the effectivenessof counseling for the treatment of stress andanxiety among college students.One unique aspect of the study is that itwas conducted within a college counselingcenter and participants were recruited fromthe actual pool of students seeking counselingservices. Staff psychologists from the collegecounseling center were involved in counselingstudents in both the treatment and controlconditions of the study. It was an aim of thestudy not only to explore the effectivenessof biofeedback training as an adjunct to thetreatment of stress and anxiety for collegestudents but also to assess the practicalityof its use within a college counseling center.The biofeedback equipment was very easyto use for the researchers and, based onparticipants’ comments in the debriefingsessions, participants found the equipmentnoninvasive and easy to use as well.Another unique aspect of this study is thediversity of the sample; 63% of the participantswere students of color, including 47% whoidentified as Latinos. Given the increasinglydiverse college campus population, it isimportant that the services provided to studentsare culturally congruent to the students’ needs.Despite efforts to improve sensitivity todiversity issues on college campuses, recentstudies still found that students of color havenegative attitudes toward seeking counselingservices on college campuses (Kearney, Draper,& Baron, 2005; Spivey-Mooring, 2008).Given that the research on the efficacy ofbiofeedback with students of color is limited,the results of this study provide a promisingSeptember/October 2012 vol 53 no 5alternative to students of color who would nototherwise seek counseling services. Biofeedbackcan be seen as a nonthreatening and lessculturally stigmatizing adjunct or alternativeto traditional college counseling. Biofeedbacktraining does not require self-disclosure;participants are given instructions to practicebreathing and imagery while they watch acomputer screen. Psychosomatic symptomssuch as headaches or stomach distress tendto be more common among ethnic minoritypopulations, and thus, treatment that is moreholistically based may be more culturallycongruent. Additionally, it has been found thatAsian American and Latino college studentstend to report higher levels of distress at intakethan do White students (Kearney et al., 2005),and thus, biofeedback training may be a usefuladjunct to counseling in reducing symptoms.Implications and Future ResearchThere are several implications and researchrecommendations from the findings of thisstudy. The reality of many college counselingcenters is an inadequate number of psychologiststo meet the mental health needs of the studentpopulation. If biofeedback or other alternativeapproaches can enhance outcome and moreeffectively address the individual students’needs and strengths, then students can bebetter served by the college counseling center.With increasing demands for counselingservices on college campuses and limitedresources available, biofeedback training isan easy and cost-effective augmentation totraditional counseling approaches that collegecounseling centers could implement within avery short timeframe.Several studies have illustrated the negativeimpact of stress and anxiety on the adjustment,academic performance, and retention ofcollege students (Friedlander, Reid, Shupak,& Cribbie, 2007; Hyun et al., 2006; Kerr,Johnson, Gans, & Krumrine, 2004; Lee et al.,747
Research in Brief2009). The results of this study demon stratedthat, within a 4-week timeframe, a combinationof weekly counseling and weekly biofeedbacksession could significantly reduce the symptomsof anxiety for students, which could help toimprove student success and retention.The benefit to the biofeedback programtested for this research is that the providerof biofeedback training does not need tobe a licensed therapist, therefore, freeing upthe time for licensed therapists to providethe needed counseling services while othertrained personnel (including student assistantsor peer counselors) provide the augmentedweekly biofeedback sessions. Although thereare twice as many contacts for students whoreceive biofeedback sessions, the biofeedbacksession is a different type of contact from thecounseling session and it is provided by a lesscostly provider. This situation is analogous toan English professor sending her student to thecampus writing tutor to help with the student’swriting skills. The campus writing tutor isa cost-effective alternative to the Englishprofessor meeting with all her individualstudents who needed help with writing skills.Furthermore, the HRV biofeedbackequipment used for the study is currently soldat the retail price of only 229 for the portablebiofeedback unit and 249 for the computerbased unit (compared with the traditionalbiofeedback equipment that generally costsbetween 1,500 and 6,000). Ratanasiripong,Sverduk, Hayashino, and Prince (2010)provided additional details on biofeedbackequipment comparison and program set up.College administrators could invest minimaladditional resources to the counseling centerbiofeedback program to help students reducetheir stress and anxiety symptoms at a fasterrate than traditional counseling alone.Future research may examine the effective ness of biofeedback and counseling for thetreatment of depression. More specific studiesmay wish to explore the influence of ethnicityand gender as they relate to acceptance ofand effectiveness of biofeedback training. Itwould also be beneficial to include measuresor qualitative data that assess possible changesin the management of symptoms with the useof biofeedback.A promising result of the study was theeffectiveness and acceptance of biofeedbacktraining as an adjunct to traditional counselingwithin a college counseling center. Given thenumber of students seeking mental healthservices for anxiety and stress-related issues,this study may provide a rationale for greaterimplementation and allocation of biofeedbacktraining services to be provided within collegecounseling centers. As clinical practitionersare becoming more open and knowledgeableabout mind–body health, studies such as thiscontribute to better preparation to meet theindividual needs of the students served.Correspondence concerning this article should beaddressed to Paul Ratanasiripong, Department ofAdvanced Studies in Education and Counseling,College of Education, California State University, LongBeach, 1250 Bellflower Blvd., Long Beach, CA erie, R. (1994). Sources and levels of stress in relationto locus of control and self esteem in university students.Educational Psychology, 14, 323‑330.American College Health Association. (2009). American CollegeHealth Association—National College Health AssessmentSpring 2008 reference group data report (abridged). Journalof American College Health, 57, 477‑488.748Anxiety Disorders Association of America. (2012). Facts andstatistics. Retrieved from atisticsAssociation for University and College Counseling CenterDirectors. (2009). The Association for University and CollegeCounseling Center Directors annual survey. Retrieved fromhttp://aucccd.org/img/pdfs/directors survey 2009 nm.pdfJournal of College Student Development
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With the rise in stress and anxiety among college students, there is a need for more comprehensive and effective counseling options for counselors in college counseling centers. This study investigated the impact of using biofeedback and brief counseling in treating stress and anxiety in an ethnic
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psychophysiologically based interventions (interpersonal biofeedback), into relational therapy contexts. It also illustrates the utility of this approach for both clients and clinicians. Background The correlation between health and relationships has been studied since the 1960s. Early studies focused on quality of life and relational satisfaction.
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