The purpose of this study was to conduct a process evaluation of the use of a training protocol integrating biofeedback and neurofeedback applications to alleviate symptomology of mental health conditions. Both objective and subjective data were gathered. This chapter begins with a description of the sample demographics followed by the descriptive statistics for the objective and subjective data. Relationships between these variables were explored. This chapter concludes with a summary of the results. Results of this study will be used to define a prospective model to identify how the implementation of a training protocol integrating biofeedback and neurofeedback impacts the counseling relationship as defined by process variables including the working alliance and treatment satisfaction.
Sample Demographics
This section reports a description of the sample using participant demographic information. The sample consisted of 10 adults, age 32 to 81 years, who reported to experience symptoms of anxiety and engaged in the integrated training protocol. Out of the 10 participants, 2 were male and 8 were female. The distribution of ethnicity was 1 African-American, 1 Belizean-Creole, and 8 Caucasian. Table 2 shows a summary of these demographics.
81 Table 2
Participant Demographic Information
Client Id Age Gender Ethnicity
1 34 Male Belizean-Creole
2 48 Female Caucasian
3 64 Female Caucasian
4 61 Female Caucasian
5 45 Female African American
6 81 Female Caucasian
7 68 Female Caucasian
8 66 Female Caucasian
9 32 Female Caucasian
10 60 Male Caucasian
Note. The mean age of participants is 56 years with a standard deviation of 15.70. 80% of the participants were female and 20% were male. 80% of the participants were
Caucasian, 10% were African American, and 10% were Belizean-Creole.
The following section presents the descriptive statistics of the objective and subjective data collected during this study.
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This section consists of the descriptive statistics for the objective data and subjective data. The objective data, which was gathered before and after engaging in the integrated training protocol, consists of the following physiological measurements: 1) HRV, 2) skin temperature, 3) skin conductance, and 4) theta/SMR ratios. The subjective data, gathered from clients after they had completed the integrated training protocol, consists of the WAI and the TxSI. Participants also ranked the following biofeedback training measurements from most to least helpful: 1) HRV, 2) skin temperature, 3) skin conductance, 4) neurofeedback, and 5) combination of HRV training and neurofeedback. Both objective and subjective data are included in Appendix E.
Data Analysis Results
This section includes the results of the analyses for each research question. This information is followed by a summary of the research question and testing results. Research Question 1 Data Analyses
Research Question 1: Is there a difference between clients’ baseline physiological scores and their post-training physiological scores? Specifically, the following
physiological scores taken before and after engaging in the integrated training protocol were compared: 1) regulatory power of HRV, 2) skin temperature, 3) skin conductance, and 4) theta/SMR ratios. A one-way repeated measures MANOVA was conducted to determine changes in physiology measured before and after engaging in the integrated training protocol in regards to each physiological measurement. Data were gathered at the pre-training and at the post-training. The mean differences and the percent of change of these physiological scores are reported. Significant changes are evaluated through the F and p – values as shown in Table 3.
83 Table 3
Results of MANOVA for Objective Data Pre-train Mean Pre-train SD Post-train Mean Post-train SD Mean Diff % Diff F Sig HRV 96.80 162.17 752.00 911.22 902.03 38.09 5.28 .047* ST 87.44 8.10 90.94 5.19 6.58 0.09 2.82 .127 SC 2.63 2.09 1.50 1.01 1.39 0.47 6.55 .031* T/S 0.46 0.07 0.64 0.27 0.27 0.62 4.13 .073
Note. Biofeedback measurements have been abbreviated as follows: ST = skin temperature, SC = skin conductance, T/S = theta/SMR ratio. p<.05*
The first within subject variable was the regulatory power captured by HRV. A one-way repeated measures MANOVA revealed a significant change in the
within-subjects HRV scores [F (1, 9) = 5.78, p = .047, partial 2 = .37]. The mean for the pre-training was 96.80 Hz and the mean for the post-training was 752.00 Hz. These findings suggest that HRV scores improved (increased) as shown in the Figure 1. Figure 1
Figure 1. Changes in Heart Rate Variability gathered before training (pre) and after training (post). 96.80 752.00 0 500 1000 Pre Post
Heart Rate Variability
measured in Hertz
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The second within-subject variable was skin temperature. A one-way repeated measures MANOVA revealed the difference between pre and post scores in skin temperature was not significant [F (1, 9) = 2.82, p = ns, partial 2 = .32]. The mean for the pre-training was 87.44 degrees Fahrenheit and the mean for the post-training was 90.94 degrees Fahrenheit. Skin temperature scores improved (increased) as shown in the Figure 2, however, the change was not significant.
Figure 2
Figure 2. Changes in skin temperature gathered before training (pre) and after training (post).
The next within subject variable was skin conductance. A one-way repeated measures MANOVA revealed a significant change in the within-subjects skin conductance scores [F (1, 9) = 6.55, p = .037, partial 2 = .63]. The mean for the pre-training was 2.63 mhos and the mean for the post-training was 1.50 mhos. The unit for electric conductance is the siemens. One siemens is equal to 1,000,000 micromho. The term ‘mho’ is short for ‘micromho’. These findings suggest that skin conductance scores improved (decreased) as shown in the Figure 3.
Figure 3 87.44 90.94 83 86 89 92 95 Pre Post
Skin Temperature
measured in degrees
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Figure 3. Changes in skin conductance gathered before training (pre) and after training (post).
The last within subject variable was theta/SMR ratios. A one-way repeated measures MANOVA revealed there was not a significant change in the difference between pre and post theta/SMR scores [F (1, 9) = 4.13, p = .073, partial 2 = .44]. The mean for the pre-training was 0.46 ohms and the mean for the posttest was 0.64 ohms. These findings suggest that while theta/SMR ratio scores improved (increased) as shown in the Figure 4, the change was not statistically significant.
Figure 4
Figure 4. Changes in theta/SMR ratios gathered before training (pre) and after training (post). 2.63 1.50 0 1 2 3 Pre Post
Skin Conductance
measured in mho's
0.46 0.64 0 0.2 0.4 0.6 0.8 Pre PostTheta/SMR Ratios
measured in ohms
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The output from one-way repeated measures MANOVA provides results of the changes in physiological scores taken before and after engaging in the integrated training protocol. Results indicate there was significant improvement in skin conductance (p = 0.031) and HRV (p = 0.047). While skin temperature scores improved (increased), changes made were not significant (p = 0.127). There were also changes in theta/SMR ratios when measured before and after engaging in the integrated training protocol, however, these changes were not significant (p =0.073).
Research Question 2 Data Analysis.
Research question 2: How do clients rate the working alliance after completing the integrated training protocol? There are three subscales of the WAI-SR which coincide with the three main components of the working alliance: 1) bonding, 2) goals, and 3) tasks. Scores for each subscale range from 4.00 (minimum) to 28.00 (maximum). The means, standard deviations, and ranges in the results from this study are provided for each subscale and reported in Table 4. Participants in this study rated the subscale, bonding, with a mean score of 7.00. Therefore, no variability occurred within this score resulting in no range between the scores as shown as ‘Not Applicable’ in Table 4. Table 4
Descriptive Statistics for the Working Alliance Inventory – Short Revised
Mean SD Range
Bonding 7.00 0.00 NA
Goals 6.83 0.38 6.00-7.00
Tasks 6.68 0.76 5.75-7.00
87 Research Question 3 Data Analysis.
Research question 3: How do clients rate their treatment satisfaction after completing the integrated training protocol? Scores for the TxSI can range from 16 (minimum) to 80 (maximum) points. The mean score, standard deviation, and range of scores for the TxSI for participants in this study is shown in Table 5.
Table 5
Descriptive Statistics for the Treatment Satisfaction Index Mean SD Range of Study Results
TxSI 78.90 1.73 75.00 – 80.00
Research Question 4 Data Analysis.
Research question 4: How do clients rank their preferences of biofeedback measurements after completing the integrated training protocol? Participants ranked the following biofeedback training measurements from 5 (most) to 1 (least): HRV, Skin Temperature, Skin Conductance, Neurofeedback, and Combination of HRV and
Neurofeedback. The researcher computed mean score for each measurement to determine how each measurement was ranked as shown in Figure 5.
88 Figure 5
Note. Biofeedback measurements have been abbreviated as follows: skin temp = skin temperature, skin cond = skin conductance, neuro = neurofeedback, HRV + neuro = combination of HRV training and neurofeedback.
Research Question 5 Analysis.
Research question 5: After completing the integrated training protocol, is there a relationship between clients’ perception of the working alliance and changes in
physiological scores taken pre and post training? A Pearson’s correlation was conducted and results indicated no significant relationships existed between difference or percent of changes in physiological scores and the WAI-SR as shown in Table 6. The WAI-SR correlated with the change in HRV was not significant (r = -0.36, p = 0.31). The WAI-SR correlated with the percent of change in HRV was not significant (r = 0.14, p = 0.70). The WAI-SR correlated with the change in skin temperature was not significant (r = -0.07, p = 0.84). The WAI-SR correlated with the percent of change in skin temperature was not significant (r = -0.03, p = 0.94). The WAI-SR correlated with the change in skin
conductance was not significant (r = -0.22, p = 0.55). The WAI-SR correlated with the percent of change in skin conductance was not significant (r = -0.45, p = 0.20). The WAI-SR correlated with the change in theta/SMR ratios was not significant (r = 0.35, p =
3.10 1.90 1.90 4.30 3.80 0 1 2 3 4 5
HRV Skin Temp Skin Cond Neuro HRV + Neuro
Ranking Biofeedback
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0.32). The WAI-SR correlated with the percent of change in theta/SMR ratios was not significant (r = 0.36, p = 0.31).
Table 6
Pearson’s Correlation: Relations Between the WAI-SR and Changes & Percent of Change in Physiological Scores
Physiological Measurement in Pre-training – Post-training Scores % in Pre-training – Post-training Scores HRV -0.36 0.14 ST -0.07 -0.03 SC -0.22 -0.45 T/S 0.36 0.36
Note. Biofeedback measurements have been abbreviated as follows: ST = skin temperature, SC = skin conductance, T/S = theta/SMR ratio. *p < .05.
Research Question 6 Data Analysis.
Research question 6: After completing the integrated training protocol, is there a relationship between clients’ treatment satisfaction and changes in physiological scores taken pre and post training? A Pearson’s correlation was conducted and revealed one of the eight possible relationships was significant as shown in Table 7. The TxSI negatively correlated with the percent of change in skin conductance was significant (r = -0.80, p =0.006). These results indicate a negative relationship exists between improvement
(decrease) in skin conductance and high (increase) treatment satisfaction with alpha at .01. None of the other relationships were significant at alpha 0.05 level. Correlations ranged from (r = -0.51to 0.34, p = 0.14 to 0.88) as shown in Table 5.
90 Table 7
Pearson’s Correlation: Relationships between TxSI and Changes & Percent of Changes in Physiological Scores Physiological Measurement in Pre-training – Post-training Scores % in Pre-training – Post-training Scores HRV -0.30 0.34 ST 0.06 0.10 SC -0.51 -0.80** T/S 0.23 0.24
Note. Biofeedback measurements have been abbreviated as follows: ST = skin temperature, SC = skin conductance, T/S = theta/SMR ratio. *p < 0.05. **p < 0.01 Research Question 7 Data Analysis.
Research question 7: After completing the integrated training protocol, is there a relationship between the clients’ ranking of biofeedback measurements and changes in physiological scores taken pre and post training? A Spearman’s correlation was
conducted between differences and percent of changes in physiological scores and how participants ranked the biofeedback measurements as shown in Table 8. Two of these relationships were significant. A negative significant relationship (r = -0.65, p = 0.04) existed between an improvement (decrease) in skin conductance as measured by the percent of change between pre and post training, and how clients ranked skin temperature measurement at the alpha = .05 level. A significant positive relationship (r = .67, p = 0.03) existed between the percent of change in HRV scores as measured before and after
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engaging in the integrated training protocol and how clients ranked training combining HRV and neurofeedback.
Table 8
Spearman’s Correlation: Physiological Scores and Ranking of Biofeedback Measurements
Physiological Measure
Rank HRV Rank ST Rank SC Rank Neuro Rank Combo
HRV -0.10 0.01 0.30 -0.57 0.40 HRV % -0.23 0.55 -0.05 -0.57 .67* ST -0.18 0.31 0.17 -0.48 0.42 ST % -0.18 0.31 0.17 -0.48 0.42 SC 0.35 -0.55 0.29 -0.15 -0.18 SC % 0.47 -.65* 0.36 -0.13 -0.30 T/S 0.01 -0.13 0.08 0.34 -0.28 T/S % 0.04 -0.18 0.13 0.25 -0.23
Note. Biofeedback measurements have been abbreviated as follows: ST = skin
temperature, SC = skin conductance, neuro = neurofeedback, combo = combination of HRV training and neurofeedback, T/S = theta/SMR ratio. *p < 0.005.
Chapter Summary
This study explored both objective and subjective data to evaluate the participants’ experience of engaging in an integrated training protocol. To examine research question 1, a one-way repeated measures MANOVA was conducted. While changes occurred in all
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four physiological scores (HRV, skin temperature, skin conductance, and theta/SMR ratios) after engaging in the integrated training protocol, only those made within HRV and skin conductance were significant. To examine research question 2 and 3, the researcher computed the mean scores and standard deviations of the subjective
measurements. Results revealed participants experienced a strong working alliance and a high level of satisfaction with the services provided, measured after engaging in the integrated training protocol. To examine research question 4, the researcher computed the mean scores for how participants ranked their preferences of the biofeedback
measurements from most to least helpful. Results revealed participants found
neurofeedback to be most helpful, followed by the combination of training HRV and neurofeedback simultaneously, followed by HRV, and then skin temperature and skin conductance.
Pearson’s correlations were conducted to examine research questions 5 and 6. For research question 5, results revealed no significant relationship existed between the differences in or percentage of change of physiological scores measured pre and post training and the working alliance. For research question 6, results revealed a negative relationship existed between improvement (decrease) in skin conductivity and high (increase) treatment satisfaction. A Spearman’s correlation was conducted to examine research question 7. Results revealed a negative significant relationship existed between an improvement (decrease) in skin conductance as measured by the percent of change between pre and post training, and how clients ranked skin temperature measurement at the alpha = .05 level. In addition, this correlation also revealed a significant positive relationship existed between the percent of change in HRV scores as measured before
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and after engaging in the integrated training protocol and how clients ranked training combining HRV and neurofeedback.
Results of these analyses revealed physiological changes occurred after engaging in the integrated training protocol as measured by the objective data, and participants experienced a strong working alliance with the counselor and were satisfied with the services they received as measured by the subjective data. The correlations which were conducted revealed few significant relationships existed between the subjective and objective data. Results from these analyses may be used to develop a prospective model to identify how the implementation of a training protocol integrating biofeedback and neurofeedback impacts the counseling relationship as defined by process variables
including the working alliance and treatment satisfaction. Findings from the results of the statistical analyses computed with the data from this study are discussed in the following chapter.
CHAPTER 5: DISCUSSION