Category: Balance

Peer support act is dead (for now) in California Assembly

AB 1116, which would have created privilege (legal confidentiality) for CISM and peer support, is dead for this session of the California legislature. However, it is expected to come back in the 2018 session.

Although the bill passed the Assembly and several Senate committees, no agreement had been reached on how to define the training standards required for CISM or peer support team members to be protected. The current version specifies that the state Office of Emergency Services (OES) would create a new class – and nobody in state emergency services (apparently including OES) thought that was a good idea. But there was not enough time in this legislative session to work out the definition, so the bill went to the inactive file.

Hopefully the relevant state agencies (corrections, CHP, CAL FIRE, OES) will work out a training requirements strategy before the bill comes around again, so that it can pass next year.

From Quora: Is there a way to make yourself immune to PTSD?

I wrote the following in response to a question on Quora.

Although all of the reasons PTSD develops are not understood, the first thing to keep in mind is that it is a spectrum. For many people it is usually mild and manageable, although it can become quite uncomfortable (or just tiresome) when it is triggered. Realize that hundreds of thousands of public safety workers, who don’t fit any of your categories, live and work with PTSD. Many go though most of their days without giving it a thought.

One of the strong correlations to PTSD risk is how much REM sleep you get. A person who isn’t getting good REM sleep, due to sleep apnea, alcohol or drug use, or anything else that prevents them from dropping into that deeper sleep, is at higher risk. The theory is that our brains consolidate memories during REM sleep, so that we we essentially forget the emotions along with the event. (PTSD is sort of like “remembering” – or re-living – the emotions separately from the event.) There is a good argument that energy drinks and other substances that improve memory also can increase your risk, simply because they improve your memories of the bad event.

It is a mistake to decide if you “should” have a post-traumatic stress injury, based on what happened. “Should” is a word to get rid of in this context. What matters is how you reacted. I meet with people who witnessed or experienced terrible things, but they don’t have a strong reaction – they didn’t feel particularly helpless or out of control. They may not need any intervention at all, even though the incident would have been traumatic for many other people. But the converse is true – a person can experience extreme feelings of helplessness and out-of-control from a seemingly “minor” event and have a significant post-traumatic stress injury. Although those events usually involve loss of life or the threat of it, serious injury, etc. , the common factor is the reaction, not what happened.

There is absolutely nothing in the news article that would indicate whether or not someone involved might be at risk for PTSD. Again, the facts of what happened are not very important; your perception of what happened, along with physiological factors and what else you may have experienced previously (prior trauma can set you up for a more serious injury) all contribute.

I often invite people in your position to say this to themselves: “My stress is the worst stress because it is MY stress.” Comparing yourself to others – especially based only on the facts – is always a mistake (“No comparison stress shopping.”)

Be gentle with yourself. Be as gentle with yourself as you would be with a friend who had the same reactions.

I doubt there is any guaranteed way to become immune to PTSD, but if you aren’t getting good REM sleep and can make changes to do so, that almost certainly will help. Social support has also been shown to correlate to reducing the impact of traumatic events. Connecting with your body and nature – things like meditation, yoga, hiking – also help to activate the part of your nervous system that tells your “fight or flight” response that it is safe to de-activate. Spirituality, in the sense of having bigger-than-self values, also seems to help.

Stress doesn’t have to be toxic. Kelly McGonigal (“The Upside of Stress”) gives a good summary of this in her TED Talk. Watch to the very end, where she gives a great bit of advice: “Chasing meaning is better for your health than trying to avoid discomfort.”

CISM Protection Bill Introduced in California

California may join Michigan and other states that have made CISM activities “privileged” communications, meaning they could not be subpoenaed or otherwise demanded by a court. Michigan’s legislature unanimously passed the “First Responder Privileged Communications Act” a year ago.Subpoena protection for California CISM

California will consider AB 1116, the Critical Incident Stress Management Services Act.

Here is the key provision.

Except as otherwise provided in this section, a communication made by an emergency service provider to a CISM team member while the emergency service provider receives CISM services is confidential and shall not be disclosed in a civil, criminal, or administrative proceeding. A record kept by a CISM team member relating to the provision of CISM services to an emergency service provider by the CISM team or a CISM team member is confidential and is not subject to subpoena, discovery, or introduction into evidence in a civil, criminal, or administrative proceeding.

The exceptions are not problematic – they cover referrals, events where most of us are already mandated reporters, imminent threats and waivers.

The bill was introduced last month by Assemblyman Tim Grayson, former mayor of Concord, California, who is also a Concord Police Department “Critical Response Chaplain.” He undoubtedly knows a thing or two about this issue.

In my dozen years in CISM I’ve dealt with this through our team’s policy of never keeping written records and my own lousy memory for what other people say during interventions.

New! Pocket Guide to Stress Management and Crisis Intervention

Until now, nobody has offered a pocket guide covering all of the protocols and methods that we use in stress management and crisis intervention.

Good news! Now there is one.

I have written and published a 60-page pocket guide (spiral-bound with durable, Stress Management and Crisis Responsewaterproof covers), including essential references for self-care, peer support, psychological first aid, critical incident stress management (CISM), suicide, death and trauma notification and more. I’ve included sections on helping children and grieving people, and what to keep in mind when dealing with various faiths and cultures – the essentials to review and remember.

In the back of the book, I’ve included a guide on when and how to make referrals, with contact information for national crisis lines and online resources, plus plenty of space for you to write in your own contact and referral information.

For more information, including the Table of Contents, see the Pocket Guides page, where you’ll also find testimonials from the expert reviewers who helped me ensure that this is  a high-quality reference guide.

You can order the guide on Amazon, where you will also find a Kindle version.

Registration opening for “The New Science of Stress”

If you are in or near Santa Clara, California, registration opens tomorrow for The New Science of Stressoffered by Santa Clara Adult Education.

Class meets for ten Thursday evenings, 7:30-9:00, starting February 16th. Here’s the description.

Stress management is more than just learning to relax. This class will show how insights from cognitive neuroscience and medical research are revealing how to thrive and perform under pressure. Classes will cover how and why stress — at home or at work — doesn’t have to be toxic to your health. Relaxation methods will be described and practiced, along with coping techniques that use beliefs and social habits to balance your mind, nerves and hormones for greater health and performance. Instructor is experienced in public safety and high-tech business, with more than 10 years in crisis intervention and stress management.

Some of the feedback about a recent class I taught (Psychological and Spiritual Care):

  • Very informative, great Powerpoint, examples and videos.
  • Everything was awesome!
  • Professionalism. Good information/topics.
  • Easily understood and could apply to helping out a friend as well as somebody in a natural disaster.
  • Perfectly balanced with visual aids, group participation and anecdotes. Truly an expert in how to effectively teach on this subject.

Article: You Can Improve Your Default Response to Stress

The Harvard Business Review has published an article by Michelle Gielan (a positive psychology researcher married to Shawn Achor, author of The Happiness Advantage), describing how our response to stress matters more than what happened to cause it.

Our perception of an event – what psychologists call appraisal – makes a big difference in our emotional and physical reactions. If we see a threat, our stress response will be negative. If we see a challenge instead, stress is an ally helping us rise to the occasion. Gielan reports on the results of a study by Plasticity Labs that shows how we can change our response. There are three keys, she says.

  • Cool under pressure.
  • Open communications.
  • Active problem-solving.

People with poor stress management fall into two categories, Gielan suggests, which she calls “Venters” and “Five Alarmers.”  Venters are the people who are quite open about their stress, but they are not cool under pressure and not good problem-solvers. Five Alarmers also share their stress, but they are better able to take action. However, they make no distinction between small and large stresses. They are headed toward burnout, exhaustion and guilt.

Gielan calls people with a healthy, adaptive response to stress “Calm Responders” – they express their stress, but aren’t overwhelmed by it.

The good news is that we really can change how we respond.

We should stop teaching “eustress and distress”

Stress management often teaches that there are two kinds of stress – distress, which is what we usually think of as stress, and “eustress” – stress that is good for you. The idea of eustress – the word itself – came from Hans Selye, a pioneer in understanding how our bodies respond to challenges. Selye was an endocrinologist, focusing on hormones and the systems that regulate them.

One of Selye’s great insights is that when we experience a change or other challenge, we will have a physical stress reaction, whether we see it as positive or negative. For example, graduation from high school or college – an event the graduate certainly considers positive – is stressful. And of course it is – a fresh graduate faces uncertainty about what will happen next. Their social support network, a key source of resiliency,  is disrupted as they lose touch with classmates.

Selye’s fundamental insight, that both positive and negative events are stressful, has been demonstrated to be true in many, many research projects. Cognitive neuroscience is unveiling more of the mechanisms and complexities of our physical and emotional responses to stress.

Talking about “distress” and “eustress” is confusing. Psychologists use them because in casual talk, ee use the word “stress” to refer to both the cause and our reaction. “Graduation is stressful” and “I’m stressed about graduation” are both reasonable sentences, but they are saying two different things. The first is about what happened, the second is the graduate’s reaction to it.

Let’s swap in the other words. “Graduation is distressing me” sounds reasonable, but means the same thing as “Graduation is stressing me.” Let’s try the other one. “Graduation is eustressing me” not only sounds awkward, it doesn’t make any sense, since “eustress” is about the graduate’s reaction.  The accurate way to use the word would be “I am having a eustressful reaction to graduation” – a sentence that could only be pleasing to a psychologist.

Using these words was been based on the belief that the difference between eustress and distress is the intensity of our reaction.  We taught people that too much stress is bad for their health, so we should reduce and avoid stress in order to avoid crossing the line from eustress into distress. Now we know that there is no such line.

In recent years, convincing evidence shows that our perception makes a big difference in how our body reacts to stress. If we see a threat, our bodies react in ways that probably will cause illness in the long run. If we see a challenge, stress becomes our friend, we perform better and don’t undergo the physical reactions that cause health problems.

Our perceptions of whether we are facing a threat or a challenge are influenced by how much social support we have. When we are alone, almost anything will look like a threat. Isolation is toxic to our health. Values and spiritual beliefs also make a difference in whether we perceive stressful occasions as threats or challenges.

Instead of talking about distress and eustress, we should be teaching people that they can handle enormous amounts of stress and thrive, then give them tools – attitudes and actions – that transform how they think and react to life’s challenges.

 

You cannot starve the evil wolf

Have you heard the Native American legend of the two wolves?

An old Cherokee is teaching his grandson about life. “A fight is going on inside me,” he said to the boy.

“It is a terrible fight and it is between two wolves. One is evil – he is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.” He continued, “The other is good – he is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion, and faith. The same fight is going on inside you – and inside every other person, too.”

The grandson thought about it for a minute and then asked his grandfather, “Which wolf will win?”

The old Cherokee simply replied, “The one you feed.”

As the legend says, you need to feed the good wolf. But just as important, it is impossible to starve the evil wolf. That’s why simplistic “stress reduction” usually fails. If you don’t also feed the good wolf, escaping and avoiding stress backfires and you actually end up feeding the evil wolf.

Plopping in front of the TV, mindlessly surfing the Internet, shopping for stuff you don’t need, avoiding decisions (“What do you want for dinner?” “Whatever.”) and other ways of emotionally checking out or withdrawing do not deactivate your fight-or-flight instinct. Fight-or-flight is the protective response from your nervous system and hormones, which can become stuck “on” when you have chronic or acute stress. When your fight-or-flight system stays activated through psychological flight, you may not even notice it any more, but your health is still at risk.

Fleeing, like fighting, backfires because it feeds the evil wolf. You won’t truly relax unless you feed the good wolf. In biological terms, if all you do is escape and withdraw, your sympathetic nervous system will remain aroused. That’s what leads to sleep problems, belly fat, heart disease, Type 2 diabetes, stroke and other health issues. When stress becomes a problem, you cannot directly turn down your sympathetic nervous system; you need to adopt attitudes and activities that turn up its counterpart, the parasympathetic nervous system –  nurturing the good wolf.

You feed the good wolf through attitudes and activities that grow connections with people, creation (including yourself) and your values. Social connections are a powerful way to feed your good wolf. A hike in nature or doing yoga feed him. Spiritual practices like meditation, worship and compassion also feed the good wolf. You don’t need to wait for somebody else’s help – the most powerful ways to feed the good wolf are through your own acts of generosity, kindness and trust. What you give away matters far more than what you receive. But don’t make the mistake of just getting away from the things that stress you. You cannot starve the evil wolf.

Stress advice (mostly bad) from business websites

I’m  developing workshops and seminars for public safety and business, related to my upcoming book. I’ve been struck by similarities in the stressors experienced by Silicon Valley entrepreneurs and public safety. The primary risk in any high-pressure career is that you lose your identity in your work, which can leave you disconnected from essential sources of resilience – your social support network (outward disconnection), yourself and creation (inward disconnection) and your values, ethics and spirituality (upward disconnection). The big difference is that in business the stress tends to be chronic, while public safety workers regularly face life-and-death acute stresses. In Silicon Valley business, people sometimes (often, in some companies) act as if their work is life-and-death!

I thought I’d take a look at what kind of advice businesses are getting about stress. I know there’s a lot of bad information out there.

First, let me tell you my point of view. “Stress reduction” is largely a myth – most of us have little power to remove the sources of stress in our lives (families and jobs are big stressors – get rid of them???). Advice about “fighting stress” or “combating stress” is even worse, since it treats stress as an enemy that must be defeated, activating the very neurophysiological systems that stress balancing will help calm down. The good news is that methods of balancing stressors, unlike trying to reduce or eradicate them, actually work, allowing us to take on enormous challenges without doing damage to our health.

Let’s see what the business publications have to say.

5 Tips for Coping With Stress at Work Starting First Thing in the Morning(Entrepreneur, 12/8/2014)

This article is in trouble and I haven’t even read past the headline. Although there are ways to balance work-related stress while you are at work, if your job is truly challenging, you don’t want to lower your performance by turning off the positive aspects of your stress response. They help you rise to the challenge. However, when you are done with the day’s duties, your body’s ability to leave them behind, to turn down the stress response, is critical. When that system stays “on duty,” health problems inevitably follow.

The Yahoo article suggest a “morning mantra” and “enter smiling,” which encourage positive thinking. Research does show that optimists cope with stress better… but studies also indicate that your optimism is largely a matter of genetics. It’s not clear that you can force yourself to become an optimist.

The article has a warning against coffee. It’s true that caffeine, like any other stimulant, will increase anxiety. But it is okay in moderation – a cup in the morning and another one when the afternoon sleepies hit won’t hurt. There’s also a recommendation here to have a “caffeine-free warm beverage that counteracts stress.” I’m not aware of any evidence to support this idea.

Finally, Yahoo says “Allow honesty.” Here, they’re onto something, suggesting that if you find yourself in a toxic situation, “extend compassion or remove yourself.” Self-compassion is the antidote to the perfectionism that pervades entrepreneurs and public safety workers – they are a lot alike in imposing unreasonable performance on themselves.

How Successful People Handle Stress (Forbes, 12/9/2014)

Travis Bradberry writes that “90% percent of top performers are skilled at managing their emotions in times of stress in order to remain calm and in control.”

Huh? Suppressing your emotions will not balance your stress one bit. In fact, holding onto unexpressed emotions is a stressor.

Moderate stress can be good for you, this article says, citing research at U.C. Berkeley. It’s only a problem when it is chronic and sustained. So we’re back to stress reduction. A list of techniques follows.

Learn to say no. I hear this advice quite a bit in the context of stress management. It raises the question of where the wisdom and strength to say “no” come from. We say “yes” too much because we want to be liked, or are stuck in perfectionism or ambition. Where’s the instruction manual for how to turn those personality traits down? Not here.

Avoid asking “what if?” Like the previous advice, this is missing the how-to information. The goal is wonderful – we absolutely need to stay present and grounded to be able to let go of the “what ifs.”

Disconnect. Take regular time off the grid. This is another item I see frequently. Turn off your cell phone and all the other electronics and take a break. However, disconnecting is emptiness unless you also choose what you will connect with instead – friends, yourself, causes bigger than yourself.

Sleep. Yes, yes, yes. Sleep and stress are deeply related. Disrupted sleep adds increases the hormone levels that you want to turn down when you don’t need their energy-giving effects. It aggravates post-traumatic stress But again where are the instructions? “You should sleep more” is impractical advice for the person who is so keyed up that they don’t want to or can’t get to sleep, or they keep waking up early. Luckily, the next bit of advice, Exercise, is one of the activities that can help with sleep. But there is much, much more.

Don’t Hold Grudges. “Learning to let go of a grudge will not only make you feel better now but it can improve your health.” Unfortunately, that sentence is the last one in this section. It needs to be the starting point for advice on how to let go of grudges and resentments. The best work I’ve ever seen on this subject is Frederic Luskin’s Forgive for Good. People who are holding onto grudges are doing so because they don’t know how to let go – telling them “Let go” is not a solution.

Don’t Die in the Fight. This has something to do with “unchecked emotions,” but how it relates to stress is a mystery.

Mindfulness. Yes, indeed, mindfulness is the latest name for practices that help us remain present and grounded. However, it is not, as this article claims, “an effective way to gain control of unruly thoughts and behaviors.” It is about accepting things we cannot control, not controlling them!

Squash Negative Self-Talk. Similar to the positive thinking above, this bit of counsel suggests that you just stop ruminating on negative things. Just stop it. The author suggests writing down the negative thoughts and examine them for truth, which seems to be a sort of self-guided cognitive behavior therapy. Okay, but the fact is, our brains sometimes ruminate for a good reason – trying to learn from experience. My preference is to remember that it is earning its paycheck, which helps me to accept and view rumination positively – and that helps me let go of it. The danger in labeling any stress reaction as “bad” is that it blocks us from having compassion for ourselves, which as I mentioned previously, is the antidote to poisonous perfectionism.

Those articles are typical, so here are a few other tidbits of terrible and so-so advice from the business press.

Mentally strong people are aware of their stressors, and “they’re aware of the warning signs that they’re becoming stressed out.” Because of their self-awareness, they are able to “adjust their activities and their lifestyle accordingly so they can combat stress effectively.”

“Combat stress effectively.” Shall we fight stress? Wrestle with it? Do battle? No!!!

Stress is not an enemy that threatens your health and well-being. This reminds me of President Merkin Muffley’s wonderfully ironic line in Stanley Kubrick’s film Dr. Strangelove, “Gentlemen, you can’t fight in here! This is the War Room!”

“One of the best ways to combat stress is to engage in leisure activities.” It can be anything — hanging with family, engaging in a hobby, watching TV. As long as it relaxes you and improves your mental state, it will be beneficial.

Not necessarily. Kevin Gilmartin, author of Emotional Survival for Law Enforcement, like other psychologists, recommends hobbies and engagement with family and friends – the kinds of activities that can become lost when the job takes over. But there is a huge difference between truly connecting with family and hobbies, versus “hanging out” or mindlessly watching TV. Gilmartin calls this using “The Magic Chair.” To someone watching, the person in the Magic Chair seems relaxed, but inside they are still vigilant for the dangers the workday held. Don’t confuse “checking out” (disengagement, withdrawal) with relaxation.

Balancing stress is not about physical relaxation, it is about maintaining caring and compassionate connections with yourself, others, nature and values. If you are disconnected from these, you will never really relax – that’s the way we are wired. If you do maintain these kinds of relationships, you won’t need any other advice about how to manage stress.

How Well Connected are Your Brain and Body?

Adapted from my upcoming book, Stress, Science, Spirit: Connecting Out, Up and In to Thrive Under Pressure.

Ever heard of Heart Rate Variability (HRV)? It measures how well synchronized your breathing and heart rate are – but it is also increasingly recognized as an index for how well you are handling physical and emotional stress.

Every time you exhale, your heart slows down a bit. That’s why breathing techniques for relaxation always instruct you to exhale slowly. The more it slows down, the higher your HRV is likely to be and the better you are coping with stress, numerous studies have found. High HRV is good, in other words.

HRV gives a snapshot into the activation level of your vagus nerve, which is the communications superhighway between your brain and your body.

Research shows that people with high HRV – their hearts speed up and slow down more, synchronized to their breathing – are more resilient, physically and emotionally. Since the vagus nerve influences many of our body’s automatic systems, low HRV is associated with a wide variety of issues – emotional struggles, antisocial behavior, inflammatory and cardiovascular diseases, poor fitness and others. People with low HRV are much more likely to die after a heart attack (Robert E. Kleiger, J.Philip Miller, Thomas Bigger Jr., & Arthur J. Moss, 1987; Thayer, Yamamoto, & Brosschot, 2018).

Although our HRV is determined by genetics and your life experiences, you can change it. Early studies of HRV biofeedback has shown promise for helping to heal a variety of illnesses and injuries:

  • Major depression (Karavidas, et al., 2007),
  • Brain injuries (Lagos, Thompson, & Vaschillo, 2013),
  • Cardiac rehabilitation (Climov, et al., 2014),
  • Addictions – including food (Eddie, C. Kim, Deneke, & Bates, 2014; Meule, Freund, Skirde, Vögele, & Kübler, 2012; Penzlin, et al., 2015),
  • PTSD (Reyes, 2014),
  • High blood pressure (Guiping Lin, 2012),
  • Hostility (Lin, et al., 2015),
  • Chronic pain (Melanie E. Berry, et al., 2014).

HRV biofeedback is also showing promise in life-enhancing uses, including:

  • Improving sports performance by reducing anxiety (Paul & Garg, 2016),
  • Preparing military for combat deployment (Lewis, et al., 2015),
  • Grandmothers raising grandchildren (Zauszniewski, Au, & Musil, 2013),
  • Accelerated learning (Harmelink, 2016).

What do all of these have in common? They are interconnected via your “rest and digest” system (the parasympathetic nervous system). Central to it, the vagus (“wandering”) nerve connects the brain, gut (intestines, stomach), heart, liver, pancreas, gallbladder, kidney, ureter, spleen, lungs, fertility organs (in women), voice, ears and tongue.

High HRV indicates that your brain has greater control over the fight-or-flight system, so you are better able – consciously and unconsciously – to turn it down when danger passes.

Imagine that your body is a fire engine speeding down the road “Code 3” – siren screaming and lights flashing. The fire is out and the emergency is over, but you’re not the driver – you are in a back seat repeating to the driver over the intercom, “Slow down, slow down.” The driver will only ease off the gas and hit the brakes when she can hear your instructions.

“You” are your brain, the driver is your flight-or-flight system, the intercom is your vagus nerve and the speed at which your “slow down” messages are actually reaching the driver is your HRV.

If you are saying “slow down” 20 times a minute, but the driver only hears it five times, that’s low HRV. Your brain isn’t well connected to your body. As a result, neither your conscious mind nor your automatic nervous systems have much control, so the fire truck continues to barrel down the road as if there is still a crisis. In contrast, if most of your messages get through, the driver eases off the gas and the wear and tear on your body is reduced.

The usual goal of “stress management” would be to reduce the stressors, which would be like parking the fire engine – stop responding. Avoid “fires.” But how do you do that if it’s your job?

Instead, you can restore balance through activities and attitudes that help make the “intercom” between your brain and body work better, which will show up as increased HRV. Good news: the vagus nerve is two-way communications, so if you improve your HRV, you will help the back-seat driver’s messages get through.

You can improve your HRV directly through biofeedback, breathing exercises and other relaxation techniques. Even more significantly, your HRV will also reflect the strength of your social support, which is crucial to resistance and resilience to stress. A host of other activities will activate your vagus nerve, which has cascading effects that tell the fire engine (the fight-or-flight instinct) to slow down. Researchers have observed that this happens with yoga, meditation, gratitude, prayer, generosity, trusting and trustworthiness, compassion (for yourself and others), hugging a friend and even having a good cry.  These are the “connecting out (to people), in (to yourself and creation, being grounded) and up (values, ethics, spirituality) that Stress, Spirit, Science will describe in stories and practical advice.

Bibliography

Berry, M., Chapple, I. T., Ginsberg, D., Gleichauf, J., & Nagpal, M. (2014). Non-pharmacological Intervention for Chronic Pain in Veterans: A Pilot Study of Heart Rate Variability Biofeedback. Global Advances in Health and Medicine, 3(2), 28–33. http://doi.org/10.7453/gahmj.2013.075

Climov, D., Lysy, C., Berteau, S., Dutrannois, J., Dereppe, H., Brohet, C., & Melin, J. (2014). Biofeedback on heart rate variability in cardiac rehabilitation: practical feasibility and psycho-physiological effects. Acta Cardiologica, 69(3), 299–307. http://europepmc.org/abstract/med/25029875

Eddie, D., Kim, C., Lehrer, P., Deneke, E., & Bates, M. E. (2014). A Pilot Study of Brief Heart Rate Variability Biofeedback to Reduce Craving in Young Adult Men Receiving Inpatient Treatment for Substance Use Disorders. Applied Psychophysiology and Biofeedback, 39(3–4), 181–192. http://doi.org/10.1007/s10484-014-9251-z

Harmelink, A. (2016). Pilot Study of the Effects of Heart Rate Variability Biofeedback on Perceived Stress, Perceived Coping Ability, and Resilience in Accelerated Baccalaureate Nursing Students. Theses and Dissertations. Retrieved from http://openprairie.sdstate.edu/etd/1015

Karavidas, M. K., Lehrer, P. M., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., … Hassett, A. (2007). Preliminary Results of an Open Label Study of Heart Rate Variability Biofeedback for the Treatment of Major Depression. Applied Psychophysiology and Biofeedback, 32(1), 19–30. http://doi.org/10.1007/s10484-006-9029-z

Lagos, L., Thompson, J., & Vaschillo, E. (2013). A Preliminary Study: Heart Rate Variability Biofeedback for Treatment of Postconcussion Syndrome. Biofeedback, 41(3), 136–143. http://doi.org/10.5298/1081-5937-41.3.02

Lewis, G. F., Hourani, L., Tueller, S., Kizakevich, P., Bryant, S., Weimer, B., & Strange, L. (2015). Relaxation training assisted by heart rate variability biofeedback: Implication for a military predeployment stress inoculation protocol. Psychophysiology, 52(9), 1167–1174. http://doi.org/10.1111/psyp.12455

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Lin, I.-M., Fan, S.-Y., Lu, H.-C., Lin, T.-H., Chu, C.-S., Kuo, H.-F., … Lu, Y.-H. (2015). Randomized controlled trial of heart rate variability biofeedback in cardiac autonomic and hostility among patients with coronary artery disease. Behaviour Research and Therapy, 70, 38–46. http://doi.org/10.1016/j.brat.2015.05.001

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Zauszniewski, J. A., Au, T.-Y., & Musil, C. M. (2013). Heart Rate Variability Biofeedback in Grandmothers Raising Grandchildren: Effects on Stress, Emotions, and Cognitions. Biofeedback, 41(3), 144–149. http://doi.org/10.5298/1081-5937-41.3.06