Biofeedback and Counseling for Stress and Anxiety Among College

Students
Paul Ratanasiripong
Kevin Sverduk
Judy Prince
Diane Hayashino

Journal of College Student Development, Volume 53, Number 5, September/October

2012, pp. 742-749 (Article)

Published by The Johns Hopkins University Press

DOI: 10.1353/csd.2012.0070

For additional information about this article

http://muse.jhu.edu/journals/csd/summary/v053/53.5.ratanasiripong.html

Access Provided by Cal State Univ @ Long Beach at 10/04/12 6:24PM GMT
 Research in Brief

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multiple frames: An analysis of first-generation college the relationship between general life stress, racism-related
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Pascarella, E. T., Pierson, C. T., Wolniak, G. C., & Terenzini, of Counseling Psychology, 54, 101‑109.
P. T. (2004). First generation college students: Additional Smith, B. (2007). Accessing social capital through the academic
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Pascarella, E. T., & Terenzini, P. T. (2005). How college affects Walton, G. M., & Cohen, G. L. (2007). A question of
students: A third decade of research. San Francisco, CA: Jossey-Bass. belonging: Race, social fit, and achievement. Journal of Social
Perna, W., & Titus, M. A. (2005). The relationship between and Personality Psychology, 92, 82‑96.
parental involvement as social capital and college enrollment:

Biofeedback and Counseling for Stress and

Anxiety Among College Students
Paul Ratanasiripong   Kevin Sverduk   Judy Prince  Diane Hayashino

With the rise in stress and anxiety among college Lustig, 2006; Kitzrow, 2003). In addition,
students, there is a need for more comprehensive tragic events, such as the 2007 shootings on
and effective counseling options for counselors in the campus of Virginia Tech, seem to have
college counseling centers. This study investigated generated a new dialogue as to the importance
the impact of using biofeedback and brief of adequate mental health education and
counseling in treating stress and anxiety in an services being available to college students.
ethnically diverse college student population. Although violent and other antisocial behaviors
Results indicated that participants who received should not be regarded as typical for those
biofeedback training and counseling had suffering from mental health disorders, the
greater reduction in anxiety symptoms than new attention to mental health issues on
did participants who received counseling alone. today’s college campuses is greatly needed.
Implications for augmenting biofeedback training Young adults in college today clearly face
to traditional college counseling model are numerous pressures, and when students’
discussed. resources to cope are taxed beyond their limits,
the consequences can include stress, anxiety,
Over the past decade an increase in the depression, sleep disturbance, eating disorders,
frequency and severity of psychological impulsive behaviors, and suicide (Kadison
symptoms among college students has been & DiGeronimo, 2004; Lee, Olson, Locke,
documented (Benton, Robertson, Tseng, Michelson, & Odes, 2009).
Newton, & Benson, 2003; Bishop, Bauer, Of particular interest to the current
& Becker, 1998; Hyun, Quinn, Madon, & study is the high level of stress and anxiety

Paul 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 psychologists
at Counseling and Psychological Services; each at California State University, Long Beach.

742 Journal of College Student Development

Research in Brief

among college students (Abouserie, 1994; (Calderon & Thompson, 2004).

Dixon & Robinson Kurpius, 2008; Lucas & Of particular relevance to the current
Berkel, 2005) and, specifically, the need for study is research that combined biofeed­back
more comprehensive and effective treatment with other interventions such as counsel­
options for students with anxiety. According ing. Goodwin and Montgomery (2006)
to the Anxiety Disorders Association of demonstrated the effectiveness of biofeed­
America (2012), anxiety disorders are the back as an adjunct to cognitive–behavioral
most commonly diagnosed of mental health techniques in the treatment of panic disorder
conditions with more than 40 million Ameri­ with agoraphobia, comorbid with depression.
cans affected annually. College students are no Turner (1991) studied the effectiveness
exception to these trends. In a recent study of combining biofeedback with didactic
conducted by the American College Health instruction for students enrolled in a university
Association (2009), stress ranked as the stress management course; results showed
number one health issue that impedes students’ significant decreases in anxiety.
academic performance. In addition, the latest
annual survey of college counseling center Present Study
directors across the country indicated anxiety The present study focused on exploring
and depression as the top two presenting whether an alternative treatment model
concerns for their student clients (Association for treating stress and anxiety would yield
for University and College Counseling Center a better outcome than the traditional brief
Directors [AUCCCD], 2011). counseling for college students at university
Although traditional counseling counseling centers. The outcomes, specifically
approaches are often effective in helping the reduction in anxiety symptoms, were
college students when used alone, research compared between clients receiving both
has shown that counseling may be even more biofeedback training and brief counseling
effective when combined with alternative and those receiving only brief counseling. We
forms of treatment such as biofeedback hypothesized that clients who received both
(Goodwin & Montgomery, 2006; Minkin, biofeedback training and counseling would
Prout, & Masterpasqua, 2009; Moss & have better outcomes than would clients who
Lehrer, 1998; Reiner, 2008). According to received only counseling.
the Biofeedback Certification International The present study utilized both computer-
Alliance (2012) biofeedback enables the user based and portable biofeedback devices. Ease
to alter physiological activity for the purpose of use is an important factor to be considered
of improving health and performance. Using in an effective treatment approach among
specialized equipment, biofeedback methods college students. A relatively new method of
measure and utilize various signals from the biofeedback based on heart rate variability
body including brain activity, blood pressure, (HRV) has emerged in recent years and
muscle tension, heart rate, skin temperature, may in fact serve to make biofeedback more
and sweat gland activity (Mayo Clinic, 2009). accessible and user-friendly. HRV can be
Further, biofeedback may be thought of as a defined as the beat-by-beat variations in
three-step process, including (a) becoming one’s heart rate (Schwerdtfeger & Friedrich-
aware of a physiological response, (d) learning Mai, 2009). Although other methods of
to control the response, and (c) transferring biofeedback training work by controlling the
control of the response to everyday life level of various physiological functions (i.e.,

September/October 2012 ◆ vol 53 no 5 743

 Research in Brief

blood pressure, finger temperature), HRV Procedure and Measure

biofeedback training helps participants learn
to control the variability in heart rate; because Participants were recruited from the university
HRV biofeedback more directly targets the counseling center client. They were referred
body’s physiological control mechanisms, it is to the study based on presentation of
easier to learn than methods that approach the stress and anxiety symptoms at the time
target physiological mechanism in a less direct of intake evaluation by staff psychologists
manner (Lehrer, 2007). Siepmann, Aykac, and predoctoral interns at the counseling
Unterdorfer, Petrowski, and Mueck-Weymann center. Each prospective participant met
(2008) utilized a form of HRV biofeedback with one of the researchers for a research
and reported a decrease in depressive symptoms preview appointment which consisted of
in patients with moderate to severe levels of (a) a brief screening to ensure that all criteria
depression as well as additional benefits of for inclusion in the study had been met and
reduced anxiety levels. (b) completion of the informed consent form,
Also relevant to the ease of use of biofeed­ the demographic form, and the pretreatment
back equipment is the portability of the devices Beck Anxiety Inventory (BAI).
being utilized in the treatment approach. The BAI (Beck, Epstein, Brown, &
Reiner (2008) examined the effectiveness Steer, 1988) was used as a measurement of
of a portable biofeedback device combined self-reported anxiety. The BAI was chosen
with traditional counseling for addressing because of its validity and wide usage with
anxiety disorders in an outpatient population. the counseling client population as well as the
Participants were assessed over a 3-week period diverse college student population (Contreras,
with significant reduction in levels of anxiety Fernandez, Malcarne, Ingram, & Vaccarino,
found. Participants reported that they found 2004; Levy Berg, Sandell, & Sandahl, 2009;
the biofeedback device to be more helpful than Pillay, Edwards, Sargent, & Dhlomo, 2001).
other methods such as yoga, meditation, and The BAI is a 21-item scale developed with an
breathing techniques. adult clinical population to measure the severity
of anxiety in adult and adolescents. Each answer
Method is scored on a scale of 0 (not at all ), 1 (mildly),
2 (moderately), or 3 (severely). Participants are
Participants
instructed to rate each item according to how
The current study was conducted at a large they have felt in the past week. A higher score
public university in the western United States on the BAI indicates higher level of anxiety.
that is a Hispanic-Serving Institution (HSI). Beck et al. (1988) reported the Cronbach’s
The study’s participants were 30 counseling alpha for the BAI to be .92 in their study with
clients from one university counseling center. outpatient counseling clients. For the present
Their age range was between 18 and 42 years study, the internal reliability (Cronbach’s alpha)
(M = 24.43, SD = 5.78). The 20 women was .92 for the pretreatment BAI and .93 for
and 10 men in the study self-identified to the posttreatment BAI.
one of four ethnic groups: African American Upon enrolling in the study, participants
(3%), Asian American (13%), Latino (47%), were randomly assigned to either the treatment
and White (37%). There were 5 freshmen, group or the placebo control group. Those
1 sophomore, 7 juniors, 10 seniors, and 7 in the placebo control group received four
graduate students. sessions of individual counseling in 4 weeks.

744 Journal of College Student Development

Research in Brief

Participants in the treatment group received coherence of their heart rate pattern (reduce
four sessions of individual counseling plus HRV) through breathing and visualization;
four sessions of biofeedback training in 4 lower HRV is associated with reduced anxiety-
weeks. The timeframe of four sessions was related psychological symptoms. After each
chosen based on both this counseling center’s biofeedback session, participants in the
average number of sessions seen by clients per treatment group also received a portable
academic year as well as the national median biofeedback device for use at home between
number of sessions seen for 4-year public the biofeedback sessions. They were instructed
universities (AUCCCD, 2009). Counseling to use the portable biofeedback device a few
sessions were conducted by the university minutes per day and to maintain a daily log
counseling center staff consisting of licensed of these practice sessions.
psychologists and predoctoral interns; the Upon completion of the study, all partici­
treating therapists were not informed whether pants met with one of the researchers for a
the participants were in the treatment or the poststudy debriefing session and completed
placebo control group. Biofeedback sessions the posttreatment BAI within 1 week after the
were conducted by the researchers. fourth counseling session.
During the weekly 30-minute biofeedback
training session, participants were provided Results
with a visual display of their heart rate There were no significant differences in the age,
variability and instructed to increase the gender, and ethnicity between the treatment

Table 1.
Demographics for the Treatment Group and Control Group
Treatment Group (n = 15) Control Group (n = 15)
Variable M SD n M SD n p

Age 23.27 4.25 25.60 6.95 ns

Gender ns
Female 10 10
Male 5 5
Ethnicity ns
African American 1 0
Asian American 1 3
Latino 7 7
White 6 5
Class Level ns
Freshman 3 2
Sophomore 0 1
Junior 3 4
Senior 5 5
Graduate student 4 3

Note. ns = not significant.

September/October 2012 ◆ vol 53 no 5 745

 Research in Brief

FIGURE 1. Mean Pretreatment and Posttreatment Beck Anxiety Inventory Scores

group and control group (see Table 1). There than the control group, the difference was not
were also no significant differences in the BAI statistically significant.
scores for the different treating therapists, In comparing the outcome between the
including licensed psychologists and interns. treatment and control group conditions,
Both the treatment group and the placebo the mean improvement score for the
control group participants showed signifi­ treatment group (M = 13.60, SD = 9.98)
cant reduction in anxiety symptoms (see was significantly higher than the mean for
Figure 1). For the treatment group, the the control group (M = 6.67, SD = 7.81),
mean posttreatment BAI score (M = 10.53, t(28) = 2.12, p < .05. Cohen’s d was 0.77, a
SD = 8.08) was significantly reduced from medium effect size. The results confirmed the
the mean pretreatment BAI score (M = 24.13, hypothesis that participants who received both
SD = 10.71). A paired-samples t test showed weekly counseling and weekly biofeedback
significance beyond the .05 level, t(14) = 5.28, sessions showed significantly greater reduction
p < .001. Cohen’s d was 1.43, which is in anxiety symptoms than did participants who
a large effect. For the control group, the received weekly counseling alone.
mean posttreatment BAI score (M = 13.13,
SD = 11.38) was significantly reduced from Discussion
the mean pretreatment BAI score (M = 19.80,
SD = 11.70). A paired-samples t test showed The results of this study found that the group of
significance beyond the .05 level, t(14) = 3.31, participants who received biofeedback training
p < .01. Cohen’s d was 0.58, which is a medium in conjunction with counseling reported
effect. Even though the mean pretreatment significantly greater reduction in anxiety
BAI score for the treatment group is higher symptoms than did the group of participants

746 Journal of College Student Development

Research in Brief

who received counseling alone. Although both alternative to students of color who would not
groups dropped from a moderate to mild otherwise seek counseling services. Biofeedback
anxiety level based on the BAI interpretation can be seen as a nonthreatening and less
guideline (Beck & Steer, 1990), the treatment culturally stigmatizing adjunct or alternative
group had a significantly greater decrease to traditional college counseling. Biofeedback
in anxiety symptoms, both statistically training does not require self-disclosure;
and clinically. The findings suggest that participants are given instructions to practice
biofeedback training enhances the effectiveness breathing and imagery while they watch a
of counseling for the treatment of stress and computer screen. Psychosomatic symptoms
anxiety among college students. such as headaches or stomach distress tend
One unique aspect of the study is that it to be more common among ethnic minority
was conducted within a college counseling populations, and thus, treatment that is more
center and participants were recruited from holistically based may be more culturally
the actual pool of students seeking counseling congruent. Additionally, it has been found that
services. Staff psychologists from the college Asian American and Latino college students
counseling center were involved in counseling tend to report higher levels of distress at intake
students in both the treatment and control than do White students (Kearney et al., 2005),
conditions of the study. It was an aim of the and thus, biofeedback training may be a useful
study not only to explore the effectiveness adjunct to counseling in reducing symptoms.
of biofeedback training as an adjunct to the
treatment of stress and anxiety for college Implications and Future Research
students but also to assess the practicality There are several implications and research
of its use within a college counseling center. recommendations from the findings of this
The biofeedback equipment was very easy study. The reality of many college counseling
to use for the researchers and, based on centers is an inadequate number of psychologists
participants’ comments in the debriefing to meet the mental health needs of the student
sessions, participants found the equipment population. If biofeedback or other alternative
noninvasive and easy to use as well. approaches can enhance outcome and more
Another unique aspect of this study is the effectively address the individual students’
diversity of the sample; 63% of the participants needs and strengths, then students can be
were students of color, including 47% who better served by the college counseling center.
identified as Latinos. Given the increasingly With increasing demands for counseling
diverse college campus population, it is services on college campuses and limited
important that the services provided to students resources available, biofeedback training is
are culturally congruent to the students’ needs. an easy and cost-effective augmentation to
Despite efforts to improve sensitivity to traditional counseling approaches that college
diversity issues on college campuses, recent counseling centers could implement within a
studies still found that students of color have very short timeframe.
negative attitudes toward seeking counseling Several studies have illustrated the negative
services on college campuses (Kearney, Draper, impact of stress and anxiety on the adjustment,
& Baron, 2005; Spivey-Mooring, 2008). academic performance, and retention of
Given that the research on the efficacy of college students (Friedlander, Reid, Shupak,
biofeedback with students of color is limited, & Cribbie, 2007; Hyun et al., 2006; Kerr,
the results of this study provide a promising Johnson, Gans, & Krumrine, 2004; Lee et al.,

September/October 2012 ◆ vol 53 no 5 747

 Research in Brief

2009). The results of this study demon­strated College administrators could invest minimal
that, within a 4-week timeframe, a combination additional resources to the counseling center
of weekly counseling and weekly biofeedback biofeedback program to help students reduce
session could significantly reduce the symptoms their stress and anxiety symptoms at a faster
of anxiety for students, which could help to rate than traditional counseling alone.
improve student success and retention. Future research may examine the effective­
The benefit to the biofeedback program ness of biofeedback and counseling for the
tested for this research is that the provider treatment of depression. More specific studies
of biofeedback training does not need to may wish to explore the influence of ethnicity
be a licensed therapist, therefore, freeing up and gender as they relate to acceptance of
the time for licensed therapists to provide and effectiveness of biofeedback training. It
the needed counseling services while other would also be beneficial to include measures
trained personnel (including student assistants or qualitative data that assess possible changes
or peer counselors) provide the augmented in the management of symptoms with the use
weekly biofeedback sessions. Although there of biofeedback.
are twice as many contacts for students who A promising result of the study was the
receive biofeedback sessions, the biofeedback effectiveness and acceptance of biofeedback
session is a different type of contact from the training as an adjunct to traditional counseling
counseling session and it is provided by a less within a college counseling center. Given the
costly provider. This situation is analogous to number of students seeking mental health
an English professor sending her student to the services for anxiety and stress-related issues,
campus writing tutor to help with the student’s this study may provide a rationale for greater
writing skills. The campus writing tutor is implementation and allocation of biofeedback
a cost-effective alternative to the English training services to be provided within college
professor meeting with all her individual counseling centers. As clinical practitioners
students who needed help with writing skills. are becoming more open and knowledgeable
Furthermore, the HRV biofeedback about mind–body health, studies such as this
equipment used for the study is currently sold contribute to better preparation to meet the
at the retail price of only $229 for the portable individual needs of the students served.
biofeedback unit and $249 for the computer-
based unit (compared with the traditional Correspondence concerning this article should be
biofeedback equipment that generally costs addressed to Paul Ratanasiripong, Department of
between $1,500 and $6,000). Ratanasiripong, Advanced Studies in Education and Counseling,
Sverduk, Hayashino, and Prince (2010) College of Education, California State University, Long
provided additional details on biofeedback Beach, 1250 Bellflower Blvd., Long Beach, CA 90840;
equipment comparison and program set up. Paul.Ratanasiripong@csulb.edu

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