Abstract and Figures

With the rise in stress and anxiety among college students, there is a need for more comprehensive and effective counseling options for counselors in college counseling centers. This study investigated the impact of using biofeedback and brief counseling in treating stress and anxiety in an ethnically diverse college student population. Results indicated that participants who received biofeedback training and counseling had greater reduction in anxiety symptoms than did participants who received counseling alone. Implications for augmenting biofeedback training to traditional college counseling model are discussed.
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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
Access Provided by Cal State Univ @ Long Beach at 10/04/12 6:24PM GMT
http://muse.jhu.edu/journals/csd/summary/v053/53.5.ratanasiripong.html
742 Journal of College Student Development
Research in Brief
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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
students, there is a need for more comprehensive
and eective counseling options for counselors in
college counseling centers. is study investigated
the impact of using biofeedback and brief
counseling in treating stress and anxiety in an
ethnically diverse college student population.
Results indicated that participants who received
biofeedback training and counseling had
greater reduction in anxiety symptoms than
did participants who received counseling alone.
Implications for augmenting biofeedback training
to traditional college counseling model are
discussed.
Over the past decade an increase in the
frequency and severity of psychological
symptoms among college students has been
documented (Benton, Robertson, Tseng,
Newton, & Benson, 2003; Bishop, Bauer,
& Becker, 1998; Hyun, Quinn, Madon, &
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.
Lustig, 2006; Kitzrow, 2003). In addition,
tragic events, such as the 2007 shootings on
the campus of Virginia Tech, seem to have
generated a new dialogue as to the importance
of adequate mental health education and
services being available to college students.
Although violent and other antisocial behaviors
should not be regarded as typical for those
suering from mental health disorders, the
new attention to mental health issues on
today’s college campuses is greatly needed.
Young adults in college today clearly face
numerous pressures, and when students’
resources to cope are taxed beyond their limits,
the consequences can include stress, anxiety,
depression, sleep disturbance, eating disorders,
impulsive behaviors, and suicide (Kadison
& DiGeronimo, 2004; Lee, Olson, Locke,
Michelson, & Odes, 2009).
Of particular interest to the current
study is the high level of stress and anxiety
S/O      743
Research in Brief
among college students (Abouserie, 1994;
Dixon & Robinson Kurpius, 2008; Lucas &
Berkel, 2005) and, specically, the need for
more comprehensive and eective treatment
options for students with anxiety. According
to the Anxiety Disorders Association of
America (2012), anxiety disorders are the
most commonly diagnosed of mental health
conditions with more than 40 million Ameri-
cans aected annually. College students are no
exception to these trends. In a recent study
conducted by the American College Health
Association (2009), stress ranked as the
number one health issue that impedes students’
academic performance. In addition, the latest
annual survey of college counseling center
directors across the country indicated anxiety
and depression as the top two presenting
concerns for their student clients (Association
for University and College Counseling Center
Directors [AUCCCD], 2011).
Although traditional counseling
approaches are often effective in helping
college students when used alone, research
has shown that counseling may be even more
effective when combined with alternative
forms of treatment such as biofeedback
(Goodwin & Montgomery, 2006; Minkin,
Prout, & Masterpasqua, 2009; Moss &
Lehrer, 1998; Reiner, 2008). According to
the Biofeedback Certication International
Alliance (2012) biofeedback enables the user
to alter physiological activity for the purpose
of improving health and performance. Using
specialized equipment, biofeedback methods
measure and utilize various signals from the
body including brain activity, blood pressure,
muscle tension, heart rate, skin temperature,
and sweat gland activity (Mayo Clinic, 2009).
Further, biofeedback may be thought of as a
three-step process, including (a) becoming
aware of a physiological response, (d) learning
to control the response, and (c) transferring
control of the response to everyday life
(Calderon & ompson, 2004).
Of particular relevance to the current
study is research that combined biofeed back
with other interventions such as counsel-
ing. Goodwin and Montgomery (2006)
demonstrated the eectiveness of biofeed-
back as an adjunct to cognitive–behavioral
techniques in the treatment of panic disorder
with agoraphobia, comorbid with depression.
Turner (1991) studied the effectiveness
of combining biofeedback with didactic
instruction for students enrolled in a university
stress management course; results showed
signicant decreases in anxiety.
Present Study
The present study focused on exploring
whether an alternative treatment model
for treating stress and anxiety would yield
a better outcome than the traditional brief
counseling for college students at university
counseling centers. e outcomes, specically
the reduction in anxiety symptoms, were
compared between clients receiving both
biofeedback training and brief counseling
and those receiving only brief counseling. We
hypothesized that clients who received both
biofeedback training and counseling would
have better outcomes than would clients who
received only counseling.
e present study utilized both computer-
based and portable biofeedback devices. Ease
of use is an important factor to be considered
in an effective treatment approach among
college students. A relatively new method of
biofeedback based on heart rate variability
(HRV) has emerged in recent years and
may in fact serve to make biofeedback more
accessible and user-friendly. HRV can be
defined as the beat-by-beat variations in
one’s heart rate (Schwerdtfeger & Friedrich-
Mai, 2009). Although other methods of
biofeedback training work by controlling the
level of various physiological functions (i.e.,
744 Journal of College Student Development
Research in Brief
blood pressure, finger temperature), HRV
biofeedback training helps participants learn
to control the variability in heart rate; because
HRV biofeedback more directly targets the
body’s physiological control mechanisms, it is
easier to learn than methods that approach the
target physiological mechanism in a less direct
manner (Lehrer, 2007). Siepmann, Aykac,
Unterdorfer, Petrowski, and Mueck-Weymann
(2008) utilized a form of HRV biofeedback
and reported a decrease in depressive symptoms
in patients with moderate to severe levels of
depression as well as additional benets of
reduced anxiety levels.
Also relevant to the ease of use of biofeed-
back equipment is the portability of the devices
being utilized in the treatment approach.
Reiner (2008) examined the effectiveness
of a portable biofeedback device combined
with traditional counseling for addressing
anxiety disorders in an outpatient population.
Participants were assessed over a 3-week period
with signicant reduction in levels of anxiety
found. Participants reported that they found
the biofeedback device to be more helpful than
other methods such as yoga, meditation, and
breathing techniques.
METHOD
Participants
e current study was conducted at a large
public university in the western United States
that is a Hispanic-Serving Institution (HSI).
e study’s participants were 30 counseling
clients from one university counseling center.
eir age range was between 18 and 42 years
(M = 24.43, SD = 5.78). The 20 women
and 10 men in the study self-identied to
one of four ethnic groups: African American
(3%), Asian American (13%), Latino (47%),
and White (37%). ere were 5 freshmen,
1 sophomore, 7 juniors, 10 seniors, and 7
graduate students.
Procedure and Measure
Participants were recruited from the university
counseling center client. ey were referred
to the study based on presentation of
stress and anxiety symptoms at the time
of intake evaluation by staff psychologists
and predoctoral interns at the counseling
center. Each prospective participant met
with one of the researchers for a research
preview appointment which consisted of
(a)a brief screening to ensure that all criteria
for inclusion in the study had been met and
(b)completion of the informed consent form,
the demographic form, and the pretreatment
Beck Anxiety Inventory (BAI).
The BAI (Beck, Epstein, Brown, &
Steer, 1988) was used as a measurement of
self-reported anxiety. The BAI was chosen
because of its validity and wide usage with
the counseling client population as well as the
diverse college student population (Contreras,
Fernandez, Malcarne, Ingram, & Vaccarino,
2004; Levy Berg, Sandell, & Sandahl, 2009;
Pillay, Edwards, Sargent, & Dhlomo, 2001).
e BAI is a 21-item scale developed with an
adult clinical population to measure the severity
of anxiety in adult and adolescents. Each answer
is scored on a scale of 0 (not at all ), 1 (mildly),
2 (moderately), or 3 (severely). Participants are
instructed to rate each item according to how
they have felt in the past week. A higher score
on the BAI indicates higher level of anxiety.
Beck et al. (1988) reported the Cronbach’s
alpha for the BAI to be .92 in their study with
outpatient counseling clients. For the present
study, the internal reliability (Cronbachs alpha)
was .92 for the pretreatment BAI and .93 for
the posttreatment BAI.
Upon enrolling in the study, participants
were randomly assigned to either the treatment
group or the placebo control group. ose
in the placebo control group received four
sessions of individual counseling in 4 weeks.
S/O      745
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Participants in the treatment group received
four sessions of individual counseling plus
four sessions of biofeedback training in 4
weeks. e timeframe of four sessions was
chosen based on both this counseling center’s
average number of sessions seen by clients per
academic year as well as the national median
number of sessions seen for 4-year public
universities (AUCCCD, 2009). Counseling
sessions were conducted by the university
counseling center sta consisting of licensed
psychologists and predoctoral interns; the
treating therapists were not informed whether
the participants were in the treatment or the
placebo control group. Biofeedback sessions
were conducted by the researchers.
During the weekly 30-minute biofeedback
training session, participants were provided
with a visual display of their heart rate
variability and instructed to increase the
coherence of their heart rate pattern (reduce
HRV) through breathing and visualization;
lower HRV is associated with reduced anxiety-
related psychological symptoms. After each
biofeedback session, participants in the
treatment group also received a portable
biofeedback device for use at home between
the biofeedback sessions. ey were instructed
to use the portable biofeedback device a few
minutes per day and to maintain a daily log
of these practice sessions.
Upon completion of the study, all partici-
pants met with one of the researchers for a
poststudy debrieng session and completed
the posttreatment BAI within 1 week after the
fourth counseling session.
RESULTS
ere were no signicant dierences in the age,
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 MSD 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signicant.
746 Journal of College Student Development
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group and control group (see Table 1). ere
were also no signicant dierences in the BAI
scores for the dierent treating therapists,
including licensed psychologists and interns.
Both the treatment group and the placebo
control group participants showed signifi-
cant reduction in anxiety symptoms (see
Figure 1). For the treatment group, the
mean posttreatment BAI score (M = 10.53,
SD = 8.08) was signicantly reduced from
the mean pretreatment BAI score (M = 24.13,
SD = 10.71). A paired-samples t test showed
signicance beyond the .05 level, t(14) = 5.28,
p < .001. Cohens d was 1.43, which is
a large effect. For the control group, the
mean posttreatment BAI score (M = 13.13,
SD = 11.38) was signicantly reduced from
the mean pretreatment BAI score (M = 19.80,
SD = 11.70). A paired-samples t test showed
signicance beyond the .05 level, t(14) = 3.31,
p < .01. Cohen’s d was 0.58, which is a medium
eect. Even though the mean pretreatment
BAI score for the treatment group is higher
than the control group, the dierence was not
statistically signicant.
In comparing the outcome between the
treatment and control group conditions,
the mean improvement score for the
treatment group (M = 13.60, SD = 9.98)
was signicantly higher than the mean for
the control group (M = 6.67, SD = 7.81),
t(28) = 2.12, p < .05. Cohens d was 0.77, a
medium eect size. e results conrmed the
hypothesis that participants who received both
weekly counseling and weekly biofeedback
sessions showed signicantly greater reduction
in anxiety symptoms than did participants who
received weekly counseling alone.
DISCUSSION
e results of this study found that the group of
participants who received biofeedback training
in conjunction with counseling reported
significantly greater reduction in anxiety
symptoms than did the group of participants
FIGURE 1. Mean Pretreatment and Posttreatment Beck Anxiety Inventory Scores
S/O      747
Research in Brief
who received counseling alone. Although both
groups dropped from a moderate to mild
anxiety level based on the BAI interpretation
guideline (Beck & Steer, 1990), the treatment
group had a significantly greater decrease
in anxiety symptoms, both statistically
and clinically. The findings suggest that
biofeedback training enhances the eectiveness
of counseling for the treatment of stress and
anxiety among college students.
One unique aspect of the study is that it
was conducted within a college counseling
center and participants were recruited from
the actual pool of students seeking counseling
services. Sta psychologists from the college
counseling center were involved in counseling
students in both the treatment and control
conditions of the study. It was an aim of the
study not only to explore the eectiveness
of biofeedback training as an adjunct to the
treatment of stress and anxiety for college
students but also to assess the practicality
of its use within a college counseling center.
The biofeedback equipment was very easy
to use for the researchers and, based on
participants’ comments in the debriefing
sessions, participants found the equipment
noninvasive and easy to use as well.
Another unique aspect of this study is the
diversity of the sample; 63% of the participants
were students of color, including 47% who
identied as Latinos. Given the increasingly
diverse college campus population, it is
important that the services provided to students
are culturally congruent to the students’ needs.
Despite efforts to improve sensitivity to
diversity issues on college campuses, recent
studies still found that students of color have
negative attitudes toward seeking counseling
services on college campuses (Kearney, Draper,
& Baron, 2005; Spivey-Mooring, 2008).
Given that the research on the efficacy of
biofeedback with students of color is limited,
the results of this study provide a promising
alternative to students of color who would not
otherwise seek counseling services. Biofeedback
can be seen as a nonthreatening and less
culturally stigmatizing adjunct or alternative
to traditional college counseling. Biofeedback
training does not require self-disclosure;
participants are given instructions to practice
breathing and imagery while they watch a
computer screen. Psychosomatic symptoms
such as headaches or stomach distress tend
to be more common among ethnic minority
populations, and thus, treatment that is more
holistically based may be more culturally
congruent. Additionally, it has been found that
Asian American and Latino college students
tend to report higher levels of distress at intake
than do White students (Kearney et al., 2005),
and thus, biofeedback training may be a useful
adjunct to counseling in reducing symptoms.
Implications and Future Research
ere are several implications and research
recommendations from the ndings of this
study. e reality of many college counseling
centers is an inadequate number of psychologists
to meet the mental health needs of the student
population. If biofeedback or other alternative
approaches can enhance outcome and more
eectively address the individual students’
needs and strengths, then students can be
better served by the college counseling center.
With increasing demands for counseling
services on college campuses and limited
resources available, biofeedback training is
an easy and cost-eective augmentation to
traditional counseling approaches that college
counseling centers could implement within a
very short timeframe.
Several studies have illustrated the negative
impact of stress and anxiety on the adjustment,
academic performance, and retention of
college students (Friedlander, Reid, Shupak,
& Cribbie, 2007; Hyun et al., 2006; Kerr,
Johnson, Gans, & Krumrine, 2004; Lee et al.,
748 Journal of College Student Development
Research in Brief
2009). e results of this study demon strated
that, within a 4-week timeframe, a combination
of weekly counseling and weekly biofeedback
session could signicantly reduce the symptoms
of anxiety for students, which could help to
improve student success and retention.
e benet to the biofeedback program
tested for this research is that the provider
of biofeedback training does not need to
be a licensed therapist, therefore, freeing up
the time for licensed therapists to provide
the needed counseling services while other
trained personnel (including student assistants
or peer counselors) provide the augmented
weekly biofeedback sessions. Although there
are twice as many contacts for students who
receive biofeedback sessions, the biofeedback
session is a dierent type of contact from the
counseling session and it is provided by a less
costly provider. is situation is analogous to
an English professor sending her student to the
campus writing tutor to help with the student’s
writing skills. e campus writing tutor is
a cost-effective alternative to the English
professor meeting with all her individual
students who needed help with writing skills.
Furthermore, the HRV biofeedback
equipment used for the study is currently sold
at the retail price of only $229 for the portable
biofeedback unit and $249 for the computer-
based unit (compared with the traditional
biofeedback equipment that generally costs
between $1,500 and $6,000). Ratanasiripong,
Sverduk, Hayashino, and Prince (2010)
provided additional details on biofeedback
equipment comparison and program set up.
College administrators could invest minimal
additional resources to the counseling center
biofeedback program to help students reduce
their stress and anxiety symptoms at a faster
rate than traditional counseling alone.
Future research may examine the eective-
ness of biofeedback and counseling for the
treatment of depression. More specic studies
may wish to explore the inuence of ethnicity
and gender as they relate to acceptance of
and eectiveness of biofeedback training. It
would also be benecial to include measures
or qualitative data that assess possible changes
in the management of symptoms with the use
of biofeedback.
A promising result of the study was the
eectiveness and acceptance of biofeedback
training as an adjunct to traditional counseling
within a college counseling center. Given the
number of students seeking mental health
services for anxiety and stress-related issues,
this study may provide a rationale for greater
implementation and allocation of biofeedback
training services to be provided within college
counseling centers. As clinical practitioners
are becoming more open and knowledgeable
about mind–body health, studies such as this
contribute to better preparation to meet the
individual needs of the students served.
Correspondence concerning this article should be
addressed to Paul Ratanasiripong, Department of
Advanced Studies in Education and Counseling,
College of Education, California State University, Long
Beach, 1250 Bellower Blvd., Long Beach, CA 90840;
Paul.Ratanasiripong@csulb.edu
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... Also, this study showed that acceptance of biofeedback training as an adjunct to traditional counseling can increase the effect of counseling therapy in reducing stress and anxiety among college students. 52 Although conventional counseling approaches are often effective in assisting students when used alone, the investigation has shown that counseling may be even more effective when combined with alternative treatment methods such as biofeedback. 53 Therefore, along with counseling therapy, treatment methods such as biofeedback can be used to further reduce speech anxiety. ...
... Participating in behavioral basics courses to prepare people before the counseling process begins, 54 and the duration of the intervention (neither too long nor too short) can also increase the effects of counseling in reducing students' public-speaking anxiety. 52 ...
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One of the barriers to effective communication between speaker and listeners is public speaking anxiety (PSA). Over recent years, PSA has become common among students as the most widespread social anxiety (SA). Virtual reality (VR) and counseling therapy help reduce PSA. Therefore, the present study aimed to investigate the effect of VR therapy and counseling on students' PSA and SA. This quasi‐experimental study was conducted on 30 students at three levels of undergraduate, postgraduate, and PhD at Kerman University of Medical Sciences and Shiraz University of Medical Sciences (15 students in the intervention group and 15 in the control group). The intervention group observed four virtual classroom scenarios in a 30‐min session, and the control group attended a 90‐min group counseling session. Data were collected using by Personal Report of Public Speaking Anxiety, Liebowitz Social Anxiety Scale, and Igroup Presence Questionnaire. The data analysis was done using SPSS version 21. Descriptive analysis (frequency and percentage, mean, standard deviation, and quartiles) and analytical tests (paired t‐test and independent t‐test) were used to analyze the data. The results showed that VR and counseling did not affect SA scores and statistical differences before and after the intervention were not statistically significant. However, VR and counseling reduced PSA. The mean of IPQ/IGP (physical presence) was 63.73. The participants' SA means (93.76) were higher than the mean PSA (73.4). VR and counseling did not affect students' SA, but they reduced PSA. If the intervention duration in future studies are longer, the effect of VR and counseling on reducing SA is likely to become more apparent.
... Biofeedback could be useful for several mental health issues, such as stress, anxiety, hypertension, and depression [18]. Moreover, advances in technology have allowed biofeedback to become affordable, cost-effective, and easily used by practitioners as well as users [18]. ...
... Biofeedback could be useful for several mental health issues, such as stress, anxiety, hypertension, and depression [18]. Moreover, advances in technology have allowed biofeedback to become affordable, cost-effective, and easily used by practitioners as well as users [18]. The aim of this paper was to investigate the use of biofeedback in connected mental health solutions for anxiety disorders by conducting a systematic literature review. ...
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Background: Connected mental health, which refers to the use of technology for mental health care and technology-based therapeutic solutions, has become an established field of research. Biofeedback is one of the approaches used in connected mental health solutions, which is mainly based on the analysis of physiological indicators for the assessment and management of the psychological state. Biofeedback is recommended by many therapists and has been used for conditions including depression, insomnia, and anxiety. Anxiety is associated with several physiological symptoms, including muscle tension and breathing issues, which makes the inclusion of biofeedback useful for anxiety detection and management. Objective: The aim of this study was to identify interventions using biofeedback as a part of their process for anxiety management and investigate their perceived effectiveness. Methods: A systematic literature review of publications presenting empirically evaluated biofeedback-based interventions for anxiety was conducted. The systematic literature review was based on publications retrieved from IEEE Digital Library, PubMed, ScienceDirect, and Scopus. A preliminary selection of papers was identified, examined, and filtered to include only relevant publications. Studies in the final selection were classified and analyzed to extract the modalities of use of biofeedback in the identified interventions, the types of physiological data that were collected and analyzed and the sensors used to collect them. Processes and outcomes of the empirical evaluations were also extracted. Results: After final selection, 13 publications presenting different interventions were investigated. The interventions addressed either primarily anxiety disorders or anxiety associated with health issues such as migraine, Parkinson disease, and rheumatology. Solutions combined biofeedback with other techniques including virtual reality, music therapy, games, and relaxation practices and used different sensors including cardiovascular belts, wrist sensors, or stretch sensors to collect physiological data such as heart rate, respiration indicators, and movement information. The interventions targeted different cohorts including children, students, and patients. Overall, outcomes from the empirical evaluations yielded positive results and emphasized the effectiveness of connected mental health solutions using biofeedback for anxiety; however, certain unfavorable outcomes, such as interventions not having an effect on anxiety and patients’ preferring traditional therapy, were reported in studies addressing patients with specific physical health issues. Conclusions: The use of biofeedback in connected mental health interventions for the treatment and management of anxiety allows better screening and understanding of both psychological and physiological patient information, as well as of the association between the two. The inclusion of biofeedback could improve the outcome of interventions and boost their effectiveness; however, when used with patients suffering from certain physical health issues, suitability investigations are needed.
... Several studies have investigated the effects of biofeedback on the treatment of stress and anxiety. Results showed that participants who received biofeedback and counseling had more reductions in anxiety symptoms than those who only received counseling [16,17]. Another study on complementary alternative therapy resources suggests that yoga can be effective in helping with stress management [18]. ...
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College students encounter various types of stresses in school due to schoolwork, personal relationships, health issues, and future career concerns. Some students are susceptible to the strikes of failures and are inexperienced with or fearful of dealing with setbacks. When these negative emotions gradually accumulate without resolution, they can cause long-term negative effects on students’ physical and mental health. Some potential health problems include depression, anxiety, and disorders such as eating disorders. Universities commonly offer counseling services; however, the demand often exceeds the counseling capacities due to limited numbers of counsellors/psychologists. Thus, students may not receive immediate counseling or treatments. If students are not treated, some repercussions may lead to severe abnormal behavior and even suicide. In this study, combining immersive virtual reality (VR) technique with psychological knowledge base, we developed a VR empathy-centric counseling chatbot (VRECC) that can complementarily support troubled students when counsellors cannot provide immediate support. Through multi-turn (verbal or text) conversations with the chatbot, the system can demonstrate empathy and give therapist-like responses to the users. During the study, more than 120 students were required to complete a questionnaire and 34 subjects with an above-median stress level were randomly drawn for the VRECC experiment. We observed decreasing average stress level and psychological sensitivity scores among subjects after the experiment. Although the system did not yield improvement in life-impact scores (e.g., behavioral and physical impacts), the significant outcomes of lowering stress level and psychological sensitivity have given us a very positive outlook for continuing to integrate VR, AI sentimental natural language process, and counseling chatbot for advanced VRECC research in helping students improve their psychological well-being and life quality at schools.
... Such student's performance can be improved by enhancing their social connections and bringing in positive emotional states during their learning and training [78]. For this purpose, signals has been taken from skin to measure blood pressure, heart-rate, brain-activity and musclestension [79]. Similarly with heart-focus, heart-rate-coherency and emotional-self-regulation techniques are used to improve cognitive, learning and behaviours of students suffered from stress, anxiety and Attention-Deficit-Hyperactivity-Disorder (ADHD) [80][81][82]. ...
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