A New View of Temperature
Len Ochs, Ph.D.
Copyright 1991 Len Ochs
Previously published in the Fall, 1991 issue of California Biofeedback
I began using imagery combined with skin temperature feedback when I first attempted to change my skin temperature, sixteen years ago. When I imagined myself sitting in a rocking chair in front of a warm, sunny window, my temperature immediately began to drop, much to my surprise. Even though it was not the reaction I wanted, it was at least a reaction which I supposed fit my oppositional nature. With continued practice my reaction straightened out all by itself, allowing me to warm when I visualized warming scenes.
Later I began my study of autogenic phrases, and found their use a singularly unproductive way to modify my skin temperatureuntil I listened, actually while doing something else, to a cassette recording of Elmer Green as he led an audience through an autogenic exercise. What began as a tingle in my feet turned to warmth as he began saying "My feet are heavy and warm." I also began to notice my hands and feet warming while going through the autogenic phrases with others, although I still couldn't make them work for me directly. I even began to flood with warmth when a patient would refer to his or her own warming. These experiences taught me something about the difference between active striving and letting something happen. They helped me convey important information to patients in order to help them learn. I learned how to deal with complex and perverse reactions of patients by developing complex and strategic teaching methods.
From a great deal of reading and talking with other professionals I "knew" that skin temperature increases meant:
1. The parasympathetic section of my autonomic nervous system was affecting my peripheral circulation,
2. I had to use some mediating cognitive activity, such as imagery or covert verbalization, to evoke the warmth in my hands and feet. That is, I couldn't simply do something directly in order to warm, such as moving my finger (that is, without any imagery) in order to warm my finger.
This "knowledge" satisfied me until I worked with a flautist to help her relax her throat while she played in a symphony. She rapidly learned to not only bring warmth to her hands, feet, and neck, but to move a small spot of warmth wherever she wanted across the surface of her body. I had several reactions. I envied her ability to do this, since I couldn't do it myself. I was puzzled about how the parasympathetic system could be involved in such a complex voluntary process. Third, she was moving warmth to areas other than what I considered peripheral, to chest, throat, shoulder, belly, etc. Next, while she couldn't say what she was doing, she claimed to have no imagery or covert verbalizations in her head at the time. She further claimed that she could play much better and ceased treatment leaving me wondering how she did what she had done.
This brings us to 1985, when one summer morning I awoke realizing my chest was enjoyably warm. I couldn't pick out anything that I was imaging or thinking about; I just felt the warmth. As I continued to enjoy the warmth it seemed to spread on its own accord into my arms and feet, accompanied by tingling and pulsating sensations. Something had shifted for me, and I began to be able to evoke the warmth by simply attending to the movement of my chest as I breathed. I was further able to move warmth anywhere I wanted by spanning my attention between a place that was already warm, to a place that was not yet warm (bridging warmth). It became possible to adjust the degree of warmth by varying the length of time I let my attention linger over an area already warm.
In my clinical work I began to ask patients to let their attention linger over the movement of their chests and see if their chests became warm. Many could evoke warming easily. Some, who could not, found that they could find warm hands, feet, faces, and soon, and could move the warmth deliberately and selectively by shifting their attention from one area to another. This became a way to teach warming that generally succeeded within fifteen minutes.
It became clear to me that the chest movement was only useful in that it attracted the patient's attention to his or her skin. Asking for attention to movement was a great deal more palatable than asking them to pay attention either to their breath. (This wasn't California, and they would ask, "And just how do I do that?"), or to their skin ("Where is it?). Any other strategy that permitted them to sense the presence of their skin was also useful. Some examples are: paying attention to the feeling of the presence of pints (shoulders, elbows, wrists), where movement of skin seems to allow people to be more sensitive; paying attention to the hairline at the back of the neck, where movement of hair and differences in air temperature and direction are more easily noticed (for cervical pain reduction), and the very subtle movement of the lower back against a chair back (for lower back pain), all provide stimuli for focusing attention to skin where vasodilation can take place and be more easily noticed.
Other phenomena became apparent. Patients automatically began to breathe diaphramaticly, in a way they could feel the involvement of their trunks from their anal to their shoulder regions in breathing operationswith no instruction in proper breathing.
They began to report becoming deeply comfortablenot just relaxed. The word "comfort" seemed to involve qualities of emotional safety and satisfaction, in addition to the simple softness and looseness of relaxation.
However easily patients recognized warmth using the above cues, bridging the warmth from one location to another added a noticeable increase in their ability to direct warmth in a desired direction. The most dramatic example of bridging occurs when someone complains of throbbing head pain, and is able to attend not only to the accompanying facial warmth, but to bridge the warmth to the hands and feet. Since the head pain is impossible to ignore, it is much easier to pay attention to the accompanying facial heat and to the outer extremities, than to try to ignore that facial heat and try to concentrate instead on the hands and feet.
Patients reported being surprised at the speed and simplicity of their achievement of control, calling the process "weird," and strange because the process was so simple, uncomplicated, rapid, and foreign to their understanding. One patient would wonder whether mere distraction made her pain go away, that she would try to make the movements that would ordinarily bring her pain back without success, and went away shaking her head as she tried to cope with the disappearance of her pain. Another started to say "Hey, I bet I can do this at ho...," not finishing the sentence, but appearing to feel that he could "rip off" the technique to use it secretively at home.
The patients' ability to reliably and differentially treat pain increased as they understood how different kinds of pain need to be treated differently. Patients not infrequently have both throbbing and steadily aching pain at the same site, are bothered more by the throbbing pain, but are usually asked about the ache, or soreness. The patient, in fact, may complain only about the soreness, only to go home to find that compliance at bringing warmth to the soreness triggers the throbbing pain. The patient returns to the next session to complain, and is often fascinated by learning to send warmth away from the site of the throbbing to reduce it for a few weeks, and then to bring warmth back to the soreness to reduce it. The patients' ability to turn the throbbing pain on and off by bringing warmth to and sending it away, respectively, from throbbing pain emphatically validates the approach for many patients.
Comments from patients shed further light on this sensory process. One woman used to warm herself, attending to the movement of her chest while sleeping in a tent in the army while stationed in West Germany. She instantly recognized what I was teaching her as something she already had learned by herself. Another example is that of an accountant, a war hero, who suffered intense throbbing pain in all his limbs from war wounds. He was referred for throbbing neck pain from an auto accident. I could not find a pain-free arm or leg to which he could bridge warmth, because of his prior injuries. After two weeks of discussion of the principles he told me not to worry. "I can't send the warmth to my arms or legs," he said, "because they hurt too much. But now I understand what I've already been doing, since the war ended, to control the pain I have. I reduce my limb pain by warming my chest." He then extended his focus to his neck pain as well, from then on.
Vasodilation does not make pain go away forever; it just lowers it effectively and reliably when used skillfully.
The degree of directional control attained by using sensory awareness has been so high that if a body area was too tense to warm, patients could bridge over that area to warm other areas on the same side, or on the other. Finally, 88 % of those able to achieve warming (of nearly 800 patients who showed this ability) reported reductions not only in the expected throbbing pain of migraine, but unexpected reduction of muscle contraction pain, paresthesias, and "arthritic" pain as well.
Remember that these accomplishments all started by noticing the movement of the chest and looking for, i. e., w-a-i-t-i-n-g, for sensations of warmth, or tingling, or pulsations to occur in the center part of the chest at the sternum area. And while the demonstration of the ability to do this was exquisitely simple, I don't consider the system well learned until patients have shown they can evoke warmth, deepen it, direct it in a way appropriate to the problem at hand, evoke it and maintain it while performing non-stressful tasks, maintain it during stressful tasks, begin to establish a self-perpetuating system of cues so that it operates in a recursive, automatic fashion, find it an exercise of strength to hold their attention to themselves physically, and can link the feelings of warmth to feelings of appreciation, love, and gratitude. So while the first demonstration occurs easily, the rest of the process of deepening integration of these skills is vastly more complex.
Of course not everyone can find warmth initially. Success at finding warmth can range between fifteen seconds and six months, depending on the sub-population from which the patient is drawn. Age, social class, occupation (including that of therapist), or education offer no inherent advantage.
Two major factors hinder finding warmth. First, if a patient is phobic about his or her sensations ("The only reason to pay attention to myself is that there's something wrong.") desensitization must be done first. Second, if a patient believes that the most important thing in life is to get things done, and conversely, that attention to one's sensations offers no advantage, then the therapist will have to deal with the devaluation of sensation. The award for the lowest percentage of rapid learners of warming through sensory attention goes to a group of hard-core county office workers who attended a stop-smoking group. Twenty-five percent of these were able to warm initially, rising to fifty percent at the end of eight weeks. Eighty percent of a group of over three hundred blue collar workers being treated for soft-tissue injuries paid through automobile insurance received the high score for those using this approach.
They were able to warm in the first session in an average of 40 minutes. I have found biofeedback helpful twenty percent of the time for those lacking the sensitivity to notice very small temperature changes. Imagery can help some times, but it will hinder progress many other times.
I believe that a homeostatic reflex is the mechanism that allows warming triggered by sensory attention. That is, with the two major exceptions noted above, attention to the skin will automatically evoke warmth of the patient if encouraged to let attention linger over an area for as long as forty-five seconds or a minute. An example of this sensory principle gone awry is the increased blushing we have all seen when a blusher's attention is called to his or her cheeks. Cognitive mediation is unnecessary much of the time.
In a sense, then, I no longer believe that the parasympathetic system is the exclusive mediator of skin temperature. The degree of control that is possible seems to defy such a restriction (unless the functional capability of this system has been grossly underestimated), and points to the possibility of auxiliary central voluntary control that is as precise as that seen in the skeletal muscle system. In fact with adequate training vasodilation now seems possible much of the time just by doing it, with as much specificity and rapidity as is involved in moving a finger. That there is great applicability of peripheral vasodilation to skeletal muscle and arthritic pain, as well as to temporary reductions in paresthesias in the presence of protruding or herniated disks is remarkable when patients are well-equipped to follow through and learn the intricacies of this process. I am continually surprised by people's ability to learn to apply sensory attention to the task of warming, and to achieve results that please and surprise them as well.
Note that passive attention is still an important part of this process. It is a tribute to the intelligence of the body outside of the cranium that it can make use of sensory attention and produce localized, directable vasodilation in a way far more efficacious than cognitive activity, and regulate steadily aching and much throbbing pain far more rapidly than orally administered medication. None of this should be taken to demean the importance of cognitive activity. It is important, however, to have a range of tools from which one can select the most cost effective. Sensory tools seems to have been either overlooked or avoided because of the vagueness with which they were talked about.
These principles and observations will be extended in the next paper on a sensory approach to emotional self regulation.
(Dr. Ochs has been asked to make available, in single quantity, a 165 page patient instruction manual for the cost of printing, binding, and postage ($15.00). This manual includes detailed training materials for both temperature and emotional self regulation.)
Len Ochs, Ph.D. has applied the principles of simplicity, directness, and obviousness to such diverse endeavors as the design and development of the Orion biofeedback system and its Apple II-based predecessor, psychiatric aftercare facility merger, psychotherapy issues and techniques, and behavioral medicine. He has worked extensively with the physically injured, teaching them to rapidly and purposefully direct their blood flow for pain control, and with the chemically dependent to alter their brain rhythms to relieve addiction. He is a past president of the Biofeedback Society of New York, and was recognized by the AAPB for his pioneering contributions to biofeedback instrumentation .