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Stairway to Togetherness: Taking Mindfulness and Biofeedback into the Intersubjective Realm
Nimrod Tom Oren, MA,1,2 Dror Gronich, BSc, MBA,2 and Arnon Rolnick, PhD2
1Tel Aviv University, Tel Aviv, Israel; 2Rolnick’s Clinic, Ramat Gan, Israel
Keywords: mindfulness, biofeedback, couples therapy, intersubjective space, space of acceptance
This paper proposes an integration of three therapeutic languages—biofeedback, mindfulness, and multiple-person oriented therapy (family, couple, etc.)—using a novel narrative we call the ‘‘Stairway to Togetherness.’’ Relying on recent theoretical and empirical developments, we present a model that combines these three languages into a single coherent therapeutic approach. This approach points to a new direction for multiperson therapy, emphasizing mindfulness interventions, conflict de-escala-tion, and psychophysiological mutual-regulation patterns, as opposed to content-based and behavioral interventions that have so far been the norm. We suggest that mindfulness and biofeedback practices and insights can find a proper place in the context of multiperson therapy, by making the intersubjective space between individuals the object of mindful attention. We show how mindfulness principles apply to this relational space, and how biofeedback can support this endeavor. A metaphor of a four-story home is provided to help couples navigate their relationship as they attempt to reach a place of felt togetherness—a therapeutic goal that goes beyond problem solving or communication training. Although this paper focuses on couples therapy, it can easily encompass other forms of multi-person therapy.
Integrating Three Languages
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In the last 10 years our group has been concerned with developing a more complete and robust integration among various therapeutic frameworks and theoretical viewpoints. We feel that underlying the great plethora of methodologies is a limited set of common factors, which can give rise to simpler and more applicable therapeutic interventions (see Barlow et al., 2017, for a similar approach).
One of our main focal points has been working on extending mindfulness and biofeedback beyond their traditional paradigms. Rolnick and Rickles (2010) suggested applying biofeedback in the interpersonal space of psychodynamic psychotherapy. In Levit Binnun, Golland, Davi-
dovitch, and Rolnick (2010), we took the regulatory capacity of interpersonal interactions as the cornerstone for a new model of biofeedback, called dyadic biofeedback, which allows for real-time training of interpersonal interactions. Following Khazan’s (2013) integration of biofeedback with mindfulness, Rolnick, Oren, and Bassett (2016) developed the concept of sensor-enhanced therapy, proposing that biofeedback could be highly beneficial in learning mindfulness skills such as nonjudgment and acceptance, and in facilitating the use of mindfulness in therapy in general.
In this paper we continue this line of research by presenting a unique mixture of three languages—the languages of biofeedback, mindfulness, and couples therapy. For the sake of brevity and simplicity, we’ve chosen to focus on couples therapy, but our proposal can be easily applied to any other dyadic or interpersonal therapy, such as parent–child consultations, family therapy, conflict resolution, or any other group dynamic setting. This unique combination of languages and methods provides a ‘‘stairway’’ to the art of being together—the togetherness of a couple, a family, and a group.
We should note that the interventions we propose in this paper have not been tested in a full experimental setting. They are, however, based on work we’ve been doing in the clinic using mindfulness, biofeedback, or traditional family/ couples therapy for many years. We propose this model as both a way to understand what we mean by a fuller and more coherent integration of therapeutic methods, and as an intervention that practitioners can utilize in their everyday practice.
Literature Review: Other Integration Attempts and the Narrative of Intersubjective Space
A careful reading of couples therapy literature reveals two emerging patterns. The first is that an increasing number of authors are proposing mindfulness-based interventions as a
primary treatment tool. For example, Sprenkle, Davis, and Lebow (2013) suggest training couples to ‘‘slow down,’’ ‘‘stand meta to oneself,’’ ‘‘make space,’’ etc. Gottman (1999) suggested that the most destructive and biggest predictors of divorce and separation are criticism, defensiveness, contempt, and stonewalling; unsurprisingly, the inverse of these are basic mindfulness skills such as nonjudgment, patience, flexible interpretation, and openness. This shift from communication skills such as reflecting (e.g., imago), emphasizing emotiveness and empathy training, to nonreactive mindful attention seems to have arisen with the rise of mindfulness interventions throughout the therapeutic literature.
Alongside this growing emphasis on mindful communication, many authors are beginning to question the efficacy of well-known content-based interventions for interpersonal therapy, such as attempting to establish reciprocity in marriage (Gottman, 1999), attempting to change negative views of one’s partner (Ferguson, 2010), or discussing difficult marital issues (Atkinson, 2005; Doherty, 2002; Gottman, 1999). It seems that couples experience any attempt to force such discussions as insensitive and stressful, resulting in psychophysical overstimulation (van der Kolk, 1994). This reaction suggests that psychophysiological regulation skills need to be taught in order to mitigate these experiences. The emerging conclusion is that until a psychophysiologically relaxed, open, mindful attitude is established, it is very difficult to help couples resolve their difficulties.
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The next logical step, then, would be to use existing tools to train couples in psychophysiological regulation and mindful attention skills. It seems that only recently have serious attempts been made to introduce mindfulness and biofeedback into therapy involving more than one person. Kassel and LeMay (2015) proposed a framework for couple and family therapy of interpersonal biofeedback, which they defined as ‘‘the process by which patients learn to manage their physiology, such as heart rate, hands temperature, muscle tension. . . in a relational context.’’ They suggested augmenting well-known interpersonal interventions with biofeedback regulatory practices. According to the authors, the underlying mechanism of unresolved interpersonal struggle is that such conflicts evoke the fight-or-flight response, thus thwarting the work of higher cognitive functions, which are necessary for calm and creative conflict resolution. The authors suggested that using biofeedback to moderate extreme psychophysiological reactions and prevent escalation allows other established interpersonal interventions to do their work.
Brody, Scherer, Turner, Annett, and Dalen (2017), working with similar ideas but focusing exclusively on familial conflicts, proposed ‘‘teaching mindfulness in a family context’’ (p. 3). They too emphasized the role of physiological regulation in maintaining interpersonal conflict patterns, citing studies showing that family members adversely co-regulate emotions and stress/intimacy reactions. Often, troubled family members increase anxiety in each other by their stress-prone psychophysiology and their maladaptive responses, creating a closed-feedback loop of response escalation. The authors proposed that teaching mindfulness skills may help prevent such escalations.
We wholeheartedly agree with the viewpoints expressed in these studies; they are aligned with our own results concerning the relationship between unresolved interpersonal conflict and the lack of beneficial psychophysiological regulation and co-regulation. Our model builds upon these viewpoints as well as other works, but differs in three significant ways: First, we have combined both mindfulness and biofeedback into our framework, rather than using one or the other. Second, we wish to go beyond better communication and de-escalation, to promote a felt experience of togetherness. Third, whereas these two steps employ elements of biofeedback, mindfulness, and interpersonal therapy, arranging them side by side, our project aims to form a main gestalt to this integration, as we will discuss later in this paper.
Taking direction from personal mindfulness practice, we see that it always begins with cultivating nonreactivity. This is an internal setting, which we may call a nonreactive space, or a space of acceptance, which suspends the meditator’s habitual evaluations of and responses to anything that appears in his mind. This, in time, allows the meditator to choose better, more adaptive responses arising out of patience, trust, openness, nonjudgment, etc. In the intersubjective realm, this space of nonreactivity, this ability to pause, is precisely what is lacking in so many troubled relationships. Reactivity—the urgent need to react as quickly as possible—is the hallmark of immediate physical or emotional threat. As we know, this way of being is accompanied by an autonomic psychophysiological fight-flight-freeze response, which impedes higher, slower cognitive functions such as reflection, empathic listening, and the ability to reevaluate one’s own judgments— precisely those abilities that partners need in order to resolve even the most basic marital disagreements. Trapped in a cycle of threat and blame, both partners become increasingly entrenched in their quick-fire reactivity, negative judgments, and maladaptive responses, all the
while perpetuating their perception of threat, as they gradually lose any hope for improvement.
The first step toward resolution of this state of affairs would be to help couples practice nonreactivity, make flexible judgments, nurture confidence in one’s own self-regulatory ability, and develop adaptive responses. This can be taught to both partners separately or together. What we are suggesting, however, goes a step further; it is to take the technique itself, as well as the mindful state, and place it between individuals, rather than as something each person does individually or jointly in the presence of others. Mindfulness, in this view, is a characteristic of the
interpersonal space. Just as the inner space can be relaxed
or chaotic, constrained or open, so can the intersubjective space. Partners affect this space just as much as it is affected by them. If a calm, reflective, nonreactive space is attained and felt, we can call this a mindful space or a space of acceptance.
This shift in focus reflects recent findings that speak loudly to the reality of an intersubjective link, or intersubjective space, that is formed between people living in long-standing relationships (Timmons, Margolin, & Saxbe, 2015).This space exists, at least inasmuch as it is affects participants in an experiential and measurable way. We have found that relating to this in-between space evokes a fruitful mindset in researchers, therapists, and our clients. It encourages an alert attitude towards actions performed and witnessed in the intersubjectively shared space, moment by moment. Thinking of this space as a sort of common commodity or shared endeavor, similar to a playground, an apartment or even a child, increases clients’ awareness of mutual affectedness, and engenders a sense of mutual responsibility towards the creation of a space beneficial to all parties. This sort of attitude is surprisingly natural to assimilate once it is presented, and it can quickly promote a lived experience of camaraderie and interdependence, which is so important for the success of any interpersonal treatment.
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Taking this shift toward an intersubjective point of view a step further, we believe that if certain properties of the interpersonal space are maintained, then other characteristics of a healthy and intimate relationship will naturally flourish. Employing individual mindfulness practice as an analogy once more, a novice meditator will always begin practice with an emphasis on nonreactivity—and indeed this has to be maintained throughout one’s lifetime— however, in time this simple practice leads to deep experiences of self-love, emotional awareness, compassion, and intimacy with one’s being, a felt togetherness of one with oneself.
In the same vein, a couple who succeeds in nurturing and maintaining a shared space of nonreactivity will, in time, experience a sense of intimacy and togetherness, arising from knowing that whatever conflict arises, it can be mindfully discussed. The relationship is perceived as a sturdy container that is able to contain conflict without breaking. Disagreements and negative emotions are no longer perceived as dangerous. The space of acceptance becomes a place where feelings, thoughts, and sensations can be expressed, observed, and examined without having catastrophic consequences.
Later we will describe how we propose to translate mindful interventions into the intersubjective realm, a transition that we have found is surprisingly simple. But what of the role of biofeedback in such a model? As we have stated a number of times, adverse psychophysiological co-regulation plays a key role in maintaining the viciousness of marital and familial conflict. Biofeedback plays several complementary roles in this context: First, psychophysiological sensors present the reality of adverse co-regulation and mutual affectedness in an accessible way; biofeedback training serves to exemplify, narrate, and finally mitigate these states of mutual escalation and overstimulation. Biofeedback assists the couple to co-regulate in an adaptive way, soothing their physiology and creating a shared sense of psychophysiological peace. One could even say that biofeedback shows what togetherness is like, in a very tangible way. Second, we suggest that biofeedback and mindfulness therapies mutually reinforce one another, making both mindfulness and biofeedback training more coherent and approachable. We have written extensively about this elsewhere (N. T. Oren, Bassett, & Rolnick, 2017; N. T. Oren & Rolnick 2016; T. M. Oren & Rolnick, 2015), so we will not repeat this here. Lastly, biofeedback equipment can become a useful distraction from sensitive therapeutic content, bringing focus into a more fundamental, simpler, aspect of couplehood—feeling good together, being relaxed, and attentive, and helping each other maintain these beneficial states.
Stairways to Togetherness: The Four-Story Home
In order to integrate the three languages of mindfulness, biofeedback, and couples therapy using the notion of an intersubjective space, we propose a narrative of a four-story home, which serves as a metaphor for the state of the relationship-space as it is experienced by the couple. Each floor corresponds with a quality of shared attention, which may be assessed moment by moment, or as a more general quality of the couples’ shared space. This schema provides
partners with a map by which they can recognize their state at any given moment. The stairway, which is a combination of biofeedback, mindfulness, and couples therapy techniques, serves as a sort of compass, a means by which they can navigate upward through the various floors. The map tells you where you are; the compass shows where to go.
Our choices of the words story and home rather than
floor and house is not accidental. We wish to convey to couples that they are, or are trying to become, a home for each other; they are both living in the intersubjective realm, as well as co-creating it. Moreover, each of these floors, as will be seen in a moment, is a story in itself, a deep experience that every couple has lived through at some stage. Therapy has always been about telling one’s story, and we believe that hearing these stories will help couples feel that they are accepted and understood, by the therapist and perhaps by each other, despite all their troubles and flaws.
The Four Floors—The Map
The basement. The basement is the conflict floor, the least mindful floor. This is an arena where partners are driven primarily by their fears and by their inner, catastrophic, and often exaggerated interpretations, thus perceiving the other as a threat, possibly even as an enemy. The basement is dark and overrun by shadows, judgments, and automatic negative thoughts (ANTs), and the intersubjective space is experienced as reactive, critical, and oppressive. Here the mind is inclined to fight-or-flight-or-freeze (FFF) reactions rather than observational insights. It is a ‘‘do or die’’ existential state. This may involve overt conflict or a very strained daily atmosphere. When a person is in the FFF mode, increased blood flow is directed to the more primal brain areas (cerebellum and brainstem), a center for unconscious, automatic behavior. Emotions of victimhood, fear, loneliness, and helplessness are dominant and behavior is defensive and aggressive; this is expressed by disharmonious heart rate variability, low hand temperature, and high electrodermal response levels.
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The ground floor. The ground floor is the de-escalation and practice floor. Here subjects have a cognitive understanding of what’s needed to create a more functional and loving partnership, but they are not always able to follow through with it, nor do they feel any differently about each other. They are learning and practicing mindfulness skills, and are willing to sometimes suspend their automatic reactions and interpretations in the hope that some lasting change will appear. They practice acceptance, but they don’t really feel it yet. From a behavioral point of view, they agree to refrain
from aggression towards the other and ‘‘count to 10’’ when escalation starts. They learn to feel how the spectrums of calmness/stress and distraction/mindful attention are experienced in the intersubjective space.
Emotions shown in this level still include anger, victimhood, and fear, but at the same time there is a transition towards nonreaction as an intermediate tool. Physiological patterns are likely to still involve high levels of sympathetic nervous system hyperactivity with its concomitant physiological personal psychosomatic symptoms.
The acceptance floor. When on this floor, partners are able to sustain self-regulation and mutual regulation for certain periods of time and even during crises. They accept that practicing mindfulness will help them and they have been able to apply their mindful attitude not only to their own minds but also to the intersubjective space that exists between them. As they are reasonably adept at standing ‘‘meta’’ to themselves and each other, they are now aware of certain associations of bodily responses with emotions and perceive these as controllable and manageable. Expe-rientially understanding that they affect each other deeply, they have mutually agreed cues for stopping aggression and escalations, turning to introspection and inspection of the intersubjective space instead. Emotionally we expect this floor to be very dynamic in demonstrating visible transitions from negative energy-consuming to positive energy-strengthening emotions. We expect to see some signs of feelings of hope and expressions of love.
The togetherness floor. This is the North Star, the floor of high hopes. People who reach this floor treat their relationship as a developing infant. Although it requires constant attention, it is a source of energy for them in many essential ways. They are the significant caretaker of their own relationship, and each has his/her own unique contributions and responsibilities to fulfill in order to make it flourish. The space that they create between them often feels warm, accepting, and nurturing. They feel seen and appreciated. Ideally, this is a state where conflicts are just another way to cultivate the development of each of the subjects as well as the relationship. As such, the couple does not attempt to avoid conflict, as it is unavoidable, natural, and probably necessary. This is a triadic organism consisting of each subject separately as well as the relationship itself.
The Stairway—The Compass
In order to navigate these floors, we offer the following ‘‘staircase,’’ each level guiding the couple in how to move upward from one story to the next (see Table 1).
Table 1. The Staircase—The Map
Togetherness (the top floor)
Maintenance conversation with biofeedback
Expressing gratitude, meta meditation
Talking about real needs and dilemmas
Exposure to the other
Listening skills, compassion, trust, patience
Feeling of togetherness, realizing interdependence and
Awareness of intersubjective space acceptance, nonjudgment
A felt space of acceptance
Escalation, conflict (the basement)
Individual practice, nonreaction, suspension
Staircase one: From the basement to the ground floor. Floor One is characterized by reactivity, stress, and escalation. Hence the main goal is to learn how to be able to pause, observe, and de-escalate.
This stage is meant primarily for tenants of the basement. Its purpose is to make both partners aware of their automatic escalation patterns, and help them practice nonreactivity. Both partners will discover, separately, the world of mindfulness meditation, sensors, and graphs (or any other feedback) for the first time. They will practice various relaxation and awareness techniques in the session and outside of it, with or without sensors. The therapist will begin to develop the language of an observing self and a responding self—representing what I see versus how I interpret and respond.
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Here the main desired skill is the ability to pause without reacting. This can be practiced by each partner taking a minute to pause several times a day, by keeping a journal on reactive moments, or by asking for permission for unilateral disengagement. In addition, relaxation practices would be beneficial. This, combined with conversation about the role of stress and reactivity in the relationship, can be seen as a meaningful exposure, which will raise issues of trust and vulnerability. For both therapist and the partners, it is an important opportunity for identifying the initial psychophysiological fingerprint of each partner, alone and in the presence of the other, so that the partners can understand the triggers of both their own and their partner’s stress/relaxation autonomic nervous system responses. This information will be useful later on.
Staircase two: From the ground floor to a space of acceptance. On Floor Two the goal is to develop awareness of how the quality of the intersubjective space affects the couple, and to practice a space of acceptance.
Now that the couple is able to successfully create moments of respite at crucial times, they can begin to practice nonjudgment and acceptance toward themselves and toward each other. Here formal meditation practice can be introduced, separately or together, and the couple can be encouraged to share their observations and results with each other. The therapist presents the notions of intersubjective space and felt acceptance, encouraging a discussion on how this can be practiced and experienced. The therapist also discusses how judgment and nonjudgment affect body sensations and physiology, and how this affects the experience of the shared space. As home practice, the couple then begins to observe and monitor the state of their intersubjective space during the week and to practice maintaining the quality of acceptance within it.
Staircase three: From acceptance to togetherness. On Floor Three, a space of acceptance has already been established, hence the goal is to begin practicing listening skills, and to actively look for opportunities to help each other feel better. An interesting exercise at this stage may be to connect both partners to sensors at the same time, and have them watch each other’s readings. The partners become aware of what it feels like to watch and be watched, and are encouraged to ask, ‘‘How can I watch more compassion-ately?’’ By this, the couple will also be exposed to their psychological and physical interconnectedness in real time, thereby increasing empathy and becoming sensitive to how
their actions affect their partners. Later, these steps can be repeated while talking about sensitive relationship content, or issues that have arisen during therapy. The purpose can be to observe the influence of these sensitive topics while using the new language of acceptance, mutual regulation, and intersubjective awareness. At this stage, the point is not so much to resolve the issues as to be able to face them without becoming overly stimulated.
Another exercise will bring the idea of the intersubjective space to the foreground, by practicing a mutual biofeedback experience, connecting both partners to one set of electrodermal biofeedback sensors—one sensor of the bipolar circuit attached to one partner and the other sensor to the other. In this situation it is impossible to determine which of the two partners is influencing the graph at any given time—as is precisely the case in real-life situations. The graph is moving based on the response of both partners simultaneously. Using this setup, we can repeat the experiences of mutual excitation and soothing, presenting sensitive content or alternatively, regulating affects, and watch the impact on the graph displayed on the computer screen—as a mutual creation, a sort of joint painting. The partners learn that mutual regulation is an act of cooperation, of helping each other relax and get used to feelings of togetherness. For the couple this is an experience of being connected, quite literally.
Staircase four: Togetherness and beyond. On Floor Four, a feeling of togetherness permeates the interpersonal space. Now the couple may begin addressing deeper concerns and needs, as well as deepen their love and appreciation for each other.
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At this point the couple can begin practicing ‘‘meta’’ (loving kindness) meditation, as well as observing and expressing gratitude towards each other. They may begin, with or without the aid of the therapist, to put aside time to discuss core issues in their relationship, while maintaining the space of acceptance, and using all the tools they have learned thus far. At this level, we expect that sensor work will mainly be used for maintenance, or as an aid for very difficult talks. This is the stage in which other couple’s therapy interventions might be very useful. The partners are now psychophysiologically ready to accept suggestions and discuss difficult issues without feeling that they are in immediate danger. They begin to realize that any problem is a joint problem, and that it is up to both of them to maintain a steady intersubjective space of acceptance, which will allow them to face whatever issues may arise, now and
in the future.
We have presented a new model of interpersonal therapy, integrating three different languages—the languages of couples therapy, mindfulness, and biofeedback—an integration that we believe contributes to each of these fields. We may begin to wonder if perhaps these languages are not so different after all. Other authors have been working along similar lines. Our contribution to this ongoing integrative project is the focus on the intersubjective space, and on the creation of a narrative that we feel makes this integration more whole. This integration allows for treatment for couples, families, teams, and groups, using a new language that refers directly to interpersonal and intragroup processes—the language of mindful acceptance and psychophysiological experiencing in intersubjective space.
While the literature of family and couple therapists seems to accept the importance of de-escalation, mutual regulation, and arousal moderation, we feel that therapists have suffered from a lack of clear and effective tools for accomplishing these goals. We hope that the addition of tools and concepts from biofeedback and mindfulness will provide what was lacking.
An integration of three relatively independent languages does not come easily. To achieve this integration, we had to take each of these practices out of their traditional comfort zone and into new territory. Biofeedback, which originated in a behavioral context, is encouraged to embrace acceptance and nonjudgment as its primary regulatory driver. Mindfulness, which is today mostly practiced and employed intrasubjectively, is here woven into the fabric of intersubjective space. Couples therapy, we suggest, must de-emphasize listening and problem-solving as its first line of defense, especially in early stages of therapy, in order to focus on de-escalation, acceptance, and interventions that promote a feeling of togetherness. This attitude of accepting both what is within and without, is reminiscent of Carl Rogers’ definition of openness to
experience (Rogers, 1961), which, interestingly, he de-
scribed using not only experiential, but psychophysiological terms:
If a person could be fully open to his experience, every stimulus—whether originating within the organism or in the environment—would be freely relayed through the nervous system without being distorted by any defensive mechanism... The individual is becoming more able to listen to himself, to experience what is going on within himself. He is more open to his feelings of fear and discouragement and
pain. He is also more open to his feelings of courage, and tenderness, and awe. (Rogers, 1961, pp. 187–188)
Poster session presented at the ITACBT conference, Acre, Israel.
Oren, N. T., & Rolnick A. (2016, March). Sensor-enhanced
therapy (SET): Sensor-based mindfulness treatment. Poster
What Rogers was describing is, essentially, a state of
deep, mindful attention, in which psychophysiological experiences, pleasant and unpleasant, are naturally felt and regulated, without having to resort to various reactions and strategies in order to push away or retain them. We believe that this state occurs naturally in human beings who are at ease with each other, asserted in their togetherness, and that this is the foundation out of which deeper emotions, such as compassion, gratitude, and intimacy, arise. To regain this experience, both self-effort and good help are necessary for both partners. We hope that our proposition, combining in-session interventions with exercises that clients practice at home, provides a balanced therapeutic approach.
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Arnon Rolnick Nimrod Tom Oren Dror Gronich
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Correspondence: Arnon Rolnick, Rolnick’s Clinic, Ramat Gan, Israel, email: email@example.com; Nimrod Tom Oren, Tel-Aviv, Israel, email: firstname.lastname@example.org; Dror Gronich, Tel-Aviv, Israel, email: email@example.com.
enhanced therapy (SET), Sensor-based mindfulness treatment.