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Biofeedback ÓAssociation for Applied Psychophysiology & Biofeedback
Volume 44, Issue 3, pp. 111–120 www.aapb.org
DOI: 10.5298/1081-5937-44.3.10
SPECIAL ISSUESPECIAL ISSUE
Taking Human Performance to the Next Level
(with FLARE)
Inna Khazan, PhD, BCB
1,2
1
Harvard Medical School, Boston, MA;
2
Boston Center for Health Psychology and Biofeedback, Boston, MA
Keywords: biofeedback, mindfulness, optimal performance, reappraisal, FLARE
This paper introduces a comprehensive methodology for
achieving optimal human performance in a variety of
professional settings, including highly challenging ones.
This methodology harnesses the power of empirically
validated biofeedback and mindfulness techniques. As part
of this methodology, I present a step-by-step approach to
training, including an easy-to-use technique called FLARE.
Introduction
Imagine yourself . . . Sitting in the front row of a large
conference room, waiting for the current speaker to finish,
before it’s your turn—your turn to come up on to the stage
and present. You have your materials prepared. You
rehearsed. You memorized. Yet, as you are sitting in that
chair, you do not feel in control of yourself. You are not at
ease. You are in a panic! You can’t focus on what the
current speaker is saying or on anything else. Your mind is
foggy. You keep repeating in your head the opening
sentences of your presentation, praying that you don’t
screw up the words. Your heart is beating fast. Your
breathing is shallow. Your palms are clammy . . . Maybe
instead of a large conference room, it’s a boardroom. Or it’s
a small meeting with an important prospective client or an
investor. Or it’s a negotiation with another company. You
get the point. You have been there. The stakes are high,
your mind is foggy, your heart is racing, and it is
SHOWTIME! . . . If only you could relax, right?
As human beings, we are constantly striving to do
better. As students, we strive to improve our grades and test
scores. As athletes, we strive to increase the number of
wins. As musicians, we strive to express the meaning of the
music we play. As professionals, we strive to be engaging
and interesting in public speaking, efficient and productive
in our work, and effective and respected in our leadership.
Most of us have beliefs and ideas about the best ways to
improve our performance that we spend a significant
amount of time implementing. Think about how you might
be responding to the scenario described above—what might
you be saying to yourself as you prepare for speaking? You
may be surprised to hear that, as shown by recent research,
most of our ideas about what to do to optimize our
performance are wrong. We spend a lot of time and put
much emphasis on efforts that are not only not helpful to
our performance, but are, in fact, detrimental to it. A 2014
study by Alison Wood Brooks showed that over 90% of
participants hold the belief that the key to optimizing
performance is to relax and/or calm down. It seems pretty
natural to say ‘‘just relax’’ prior to an important academic,
professional, or athletic performance. And yet, that is the
opposite of what we need.
Prior to a performance situation of any kind, our bodies
prepare for that situation with increased physiological
activity—heart beating faster, breathing becoming faster,
and increased sweating. This is natural, normal, and
helpful. Imagine what would happen if you were actually
relaxed when going in for a job interview or sitting for an
exam. Imagine what would happen if the goalie in a
championship soccer game was relaxing in the goal.
You may be familiar with the Yerkes-Dodson (1908)
curve illustrating the relationship between physiological
activation and performance. This curve (see Figure 1) shows
that we need a moderate amount of physiological activation
in order to perform at our best. When activation is low (i.e.,
feeling relaxed), so is our level of performance. When
activation is overly high, performance level suffers as well.
In other words, we need to find an optimal level of
activation that will help produce an optimal level of
performance.
The Yerkes-Dodson curve begs the question: How to do
that? How do we find that sweet spot of activation? As
Brooks (2014) confirms, RELAXATION IS NOT THE
ANSWER.
In her studies, participants who attempted to get into a
relaxed state prior to a performance were both unsuccessful
in that goal (their heart rate did not decrease) and did not
actually perform at their best, both in their own estimation
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Biofeedback |Fall 2016
and according to the evaluation of objective judges. These
findings are consistent with earlier findings by Wegner,
Broome, and Blumberg (1997) who demonstrated that
participants instructed to relax while solving a challenging
mental task exhibited physiological activation (measured by
skin conductance) significantly higher than participants
solving the same task without the instruction to relax.
And yet, becoming overly activated is also not helpful to
performance. When physiological activation is too high,
anxiety may feel overwhelming. We may have trouble
thinking straight and have trouble finding the skills we
know we have to perform the task at hand, and our
performance suffers.
A study by Indovina, Robbins, N ´u˜
nez-Elizalde, Dunn,
and Bishop (2011) demonstrated that people with high
trait anxiety (those who frequently get overly activated)
show higher activation of the amygdala (the fight or
flight center of the brain) and lower activation of the
ventral prefrontal cortex (vPFC; responsible for regula-
tion of emotional responses and decision making). It is
difficult, if not impossible, to perform at your best when
your actions are being guided by an automatic, often
irrational, reaction, and the part of the brain responsible
for problem solving and decision making is not
sufficiently active.
The task of achieving optimal performance is two-fold:
1. Activation: Optimize activation of the brain and the
autonomic nervous system during times of stress to
meet the challenge without becoming overly activated.
2. Recovery: Optimize ability of mind and body to recover
once the challenge is met.
How do we train our minds and bodies to optimize
activation and recovery?
In this paper, I propose that we have at our disposal two
powerful tools: mindfulness and biofeedback, that, when
combined into a comprehensive training approach, provide
an opportunity to take our professional performance to its
peak. This paper brings together a broad body of empirical
evidence supporting the effectiveness of biofeedback and
mindfulness in optimizing performance. The research on
reappraisal and proper interpretation of physiological
sensations is also related to optimal performance. I briefly
review this evidence in the next section.
In the third section, I describe a methodology for
combining biofeedback and mindfulness to enable optimal
physiological and emotional activation. As part of this
methodology, I introduce the FLARE technique that can be
used in the moment to bring up the skills learned during
training.
1
Conclusions and future directions are discussed in
the final section.
Performance-Focused Empirical Evidence for Biofeed-
back and Mindfulness Biofeedback
Biofeedback is a tool used to train self-regulation, the
ingredient necessary for optimizing activation. Multiple
modalities of biofeedback can be effectively used to optimize
performance. An excellent article by Larson, Wyckoff, and
Sherlin (2016), provides guidance for using neurofeedback
together with mindfulness for peak performance training
with athletes. In this section, I briefly address ways in
which heart rate variability (HRV) biofeedback may be used
to optimize performance.
Heart rate variability is an indicator of the autonomic
nervous system’s ability to regulate itself (Gevirtz, 2013).
More specifically, it is an indicator of the strength of the
vagal nerve and the ability of the parasympathetic nervous
system to put on the brakes to stress activation (Gevirtz,
2013). In other words, it is the balancing mechanism we
need to regulate the amount of physiological activation
necessary to function at our best during performance
related situations.
HRV biofeedback training increases the flexibility of the
autonomic nervous system and its ability to recover from
stress-related, fight or flight situations, and return to a state
of balance (Gevirtz, 2013). HRV biofeedback has been
shown to increase heart rate variability (Del Pozo, Gevirtz,
Scher, & Guarneri, 2004; Nolan, Kamath, Floras, &
Figure 1. Yerkes-Dodson curve (1908) demonstrating relationship between
activation and performance.
1
The FLARE technique presented here is an adaptation to optimal
performance of the FLARE technique first introduced by Khazan (2015)
as a skill used in mindfulness and acceptance based biofeedback in
clinical practice.
Human Performance and FLARE
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Fall 2016 |Biofeedback
Stanley, 2005; Prinsloo, Rauch, & Derman, 2014); reduce
symptoms of anxiety (Henriquez, Keffer, Abrahamson, &
Horst, 2011), depression (Karavidas et al., 2007; Siepmann,
Unterd¨
orfer, Petrowski, & Mueck-Weymann, 2008), and
chronic pain (Hallman, Olsson, von Scheele, Melin, &
Lyskov, 2011); increase endurance (Kiviniemi, Hautala,
Kinnunen, & Tulppo, 2007); and enhance performance in
music (Thurber, 2006; Wells, Outhred, Heathers, Quinta-
na, & Kemp, 2012), dance (Raymond et al., 2005), and
baseball (Strack & Gevirtz, 2011).
Recent research also shows the role of HRV in
executive function of the brain, and therefore further
demonstrates its crucial importance in optimizing per-
formance. Studies have shown that higher HRV is
associated with better memory retrieval (Gillie, Vasey,
& Thayer, 2014), working memory, sustained attention,
situational awareness, and goal directed behavior (Han-
sen, Johnsen, & Thayer, 2003; Hansen, Johnsen, Sollers,
Stenvik, & Thayer, 2004; Thayer, Hansen, Saus-Rose, &
Johnsen, 2009), as well as emotion regulation (Kim et al.,
2013). Furthermore, a meta-analysis performed by
Thayer, Ahs, Fredrikson, Sollers, and Wagere (2012)
indicated that higher HRV is associated with better
ability to reappraise manifestations of stress in more
helpful ways. We will return to this point in the section
of this paper that specifically addresses the importance of
healthy appraisals of physiological and emotional man-
ifestations of stress and arousal. The same meta-analysis
also discusses the role of HRV in decreasing activation of
the amygdala and increasing activation of the ventrome-
dial prefrontal cortex, a balance vital to proper emotion
regulation and executive functioning under stress.
Take-away. Collectively, these findings demonstrate the
effectiveness of biofeedback as a tool for optimizing
performance, by improving both physiological functioning
of the body and executive function of the brain.
Mindfulness
Mindfulness is another powerful empirically validated tool
for improving performance. Brad Lichtenstein (2016)
provides an excellent overview of mindfulness and its
definitions in another paper in this issue. In this section, I
briefly address evidence for the effectiveness of mindfulness
in optimizing performance.
Mounting evidence demonstrates the functional and
structural changes that occur in the brain as a result of
mindfulness meditation practice. H ¨
olzel and colleagues
(2010, 2011) have conducted a series of studies examining
the effect of an 8-week mindfulness-based stress reduction
(MBSR) course on participants’ brains. In these studies,
participants with no meditation experience were assigned
either to the MBSR (experimental) group or a wait-listed
control group. All the participants’ brains were then
scanned using an fMRI machine. The experimental group
took part in the 8-week course, and the control group was
placed on the waiting list for the same course to be
completed after the study. All the participants’ brains were
scanned again after the course (or the equivalent waiting
period for the control group) was over. Results of these
studies demonstrated remarkable changes that took place in
the brains of the participants that practiced mindfulness
meditation for 8 weeks. I provide a summary of findings
most relevant to optimizing performance.
Hippocampus, the part of the brain responsible for
learning,memory,andemotion regulation, became
larger.
Lateral cerebellum and cerebellar vermis, responsible for
emotional and cognitive regulation; speed, capacity,
consistency, and appropriateness of cognitive and
emotional processes, became larger.
Anterior cingulate cortex (ACC), responsible for regula-
tion of attention and behavioral control, became more
active.
Right amygdala, responsible for fear and anxiety,
became smaller.
Right insula, responsible for interoceptive awareness,
empathy, and perspective taking, became larger and
more active.
Temporoparietal junction (TPJ), responsible for conscious
experience of the self, social cognition, and compassion,
became larger.
Posterior cingulate cortex (PCC), responsible for inte-
gration of self-referential stimuli, such as body position
and body ownership (Guterstam, Bjornsdotter, Gentile,
& Ehrsson, 2015), became larger.
These findings are directly relevant to optimizing
performance. Functions such as awareness, attention,
memory, and learning impact our ability to learn and
utilize new skills. Improved emotion regulation and a
reduction in the fear response improve our ability to focus
on the task at hand.
There is also ample evidence of the positive impact of
mindfulness training on performance. A randomized
controlled study by Mrazek, Franklin, Phillips, Baird, &
Schooler (2013) showed that a 2-week mindfulness training
resulted in improved reading comprehension GRE scores
and increased working memory capacity. The authors
Khazan
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Biofeedback |Fall 2016
pointed out that these improvements were mediated by a
reduction in mind wandering.
Similarly, studies have demonstrated the effects of
mindfulness training on several aspects of executive
function. A study by Jha, Stanley, Kiyonaga, Wong, &
Gelfand (2010) showed that mindfulness training mitigates
the impact of high stress situations on working memory
capacity, preventing its deterioration during highly stress-
ful times. Mindfulness training has also been shown to
improve attention (e.g., Brefcyznski-Lewis, Lutz, Schaefer,
Levinson, & Davidson, 2007; Jha et al., 2015), alleviate
physiological response to high stress (e.g., Meland et al.,
2015), enhance episodic memory (e.g., Brown, Goodman,
Ryan, & Analayo, 2016), improve learning effectiveness
(e.g., Ching, Koo, Tsai, & Chen, 2015), and improve high
stakes academic performance (e.g., Bellinger, DeCaro, &
Ralston, 2015).
These findings are consistent with the conclusion drawn
by Gallant (2016) in a meta-analysis of the effects of
mindfulness-based training on executive functioning.
Gallant demonstrated that mindfulness training most
consistently affects the inhibitory aspects of executive
functioning, namely the ability to ignore irrelevant stimuli
(e.g., mind wandering, intrusive thoughts, stimuli not
relevant to the task at hand). In the performance arena, this
benefit shows up in situations such as the ability to direct
your attention to the speech you are giving, disregarding
the movement and irrelevant conversation of people in the
audience, the ability to refocus on the athletic performance
following a mistake, and the ability to keep calm in the
middle of an intense negotiation with an aggressive
opponent.
Bellinger et al. (2015), who conducted a meta-analysis of
complementary therapies in the workplace, concluded that
mindfulness interventions are helpful in improving em-
ployee health and performance, but cautioned that long-
term effects need continued examination. Studies included
in this meta-analysis focused on employee health and
performance in varied settings, from health care (e.g.,
Cohen-Katz et al., 2005; Shapiro, Astin, Bishop, &
Cordova, 2005) to corporate (e.g, Aikens et al., 2014;
Bazarko, Cate, Azocar, & Kreitzer, 2013).
Take-away. Collectively, these findings demonstrate that
mindfulness-based training optimizes brain activation,
enhances performance-related skills, and leads to superior
performance. While the results are similar to those
achieved with biofeedback, the mechanisms of action are
different.
Reappraising Physiological Sensations
In addition to biofeedback and mindfulness applications to
performance training, another crucial ingredient in opti-
mizing performance is reappraisal and proper interpretation
of physiological sensations of activation.
Biofeedback gives us a way to regulate our physiological
activation to achieve the optimal level needed for the
situation. Biofeedback also trains awareness of our physi-
ological sensations. Mindfulness gives us a way to observe
our experience without getting caught up in it, allowing us
to choose a response best suited for the situation at hand. In
order to choose the best response in a challenging
performance situation, we also need to know how to
interpret the physiological sensations we are experiencing.
With biofeedback and mindfulness training, our bodies may
be better able to produce optimal activation, and our minds
may be better able to give us the space to choose the most
helpful response. However, if we continue choosing a
response inconsistent with optimal performance, we will
not achieve our goal.
Remember the study by Brooks (2014), which showed
that most of us believe that relaxation is necessary for
optimizing performance? That study also showed that
attempts at relaxation or calming down are, in fact,
detrimental to performance. Brooks also demonstrated that
interpreting physiological sensations that naturally come
along with preparing to perform (singing karaoke in front
of strangers, giving a speech, and solving challenging math
tasks) as excitement instead of anxiety or relaxation
produces both best performance and best internal percep-
tion of one’s performance.
These findings are consistent with several other studies.
A study by Beltzer, Nock, Peters, and Jamieson (2014)
examined the role of reappraisal of arousal in a socially
evaluative situation and examined the differences that
reappraisal makes for those meeting criteria for social
anxiety disorder and nonanxious controls. In this study,
socially anxious and nonanxious participants took part in a
stressful public speaking task. One group was instructed to
interpret their arousal as functional and adaptive, while the
second group was given no instruction. The results showed
that participants who reappraised their sensations of arousal
as adaptive and functional reported less difficult emotions
such as anxiety and shame, exhibited less avoidant
nonverbal behavior, and were rated by objective judges as
having performed better during the speech. Both anxious
and nonanxious participants benefited from reappraisals.
Just like in the study by Brooks (2014), the Beltzer et al.
(2014) study showed that the sympathetic nervous system
activation exhibited by the reappraisal group did not
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Fall 2016 |Biofeedback
decrease during performance. In fact, this study found that
sympathetic activation actually increased for the reappraisal
group compared to the controls. This means that interpret-
ing physiological sensations of stress as functional and
helpful does not bring relaxation, but rather helps us
achieve more optimal activation together with a more
helpful way of experiencing it.
Furthermore, research shows that interpreting phys-
iological and emotional sensations of activation as
functional and adaptive also leads to healthier underlying
physiological responses. Jamieson, Nock, and Mendes
(2012) examined cardiovascular and cognitive responses
of participants engaging in a stressful public speaking
event. One group received education on the adaptive
function of the stress response, the second group was
asked to ignore the stress, and the third group was not
given any instruction at all. The study findings showed
that those participants who interpreted their experience
of stress as functional and helpful exhibited the most
adaptive cardiovascular response to stress, namely
increased cardiac efficiency and lower vascular resistance,
compared to the other two groups. These participants
also reported having access to greater internal resources
and showed less attention to potential threats. Again, this
study showed that reappraising sensations of perfor-
mance-related activation does not dampen arousal, but it
does ‘‘reshape’’ the way we think about this arousal,
which, in turn, aids in performance.
Similar results were reported by Moore, Vine, Wilson,
and Freeman (2015), in a study where a group of
participants instructed to reappraise arousal as helpful in
performing a difficult motor skill in high pressure
conditions performed better and exhibited healthier
cardiovascular response compared to a control group.
Another study by Jamieson, Mendes, Blackstock, &
Schmader (2010) showed that reappraisal of arousal as
helpful to performance resulted in significant gains in
students’ performance on the math portion of the GRE in
the laboratory, as well as increases in actual math GRE
scores.
Despite common belief that stress-related arousal is
closely tied with negative emotional states, research
described in this section demonstrated that that is not
necessarily the case. As Beltzer et al. (2014) point out, an
increase in physiological arousal can lead to positive or
negative emotional states depending on the context of the
situation, the person’s knowledge and experience, and as we
know now, his or her choice of interpretation of
physiological sensations.
While physiological manifestations of arousal are not
under our conscious control, the way we interpret those
manifestations is. Choosing to interpret physiological
sensations of arousal as excitement (‘‘I am excited to
perform at the Symphony Hall’’ ) or adaptive functioning of
the body (‘‘My body is doing what it needs to do to prepare
me for this interview’’) allows us to stay focused on the task
at hand without engaging in a futile and detrimental fight
with our physiology. This approach allows us to benefit
from the mindfulness and biofeedback-based self-regulation
training, letting activation rest at the optimal level without
becoming overly activated through fighting with normal
and natural sensations of activation.
Take-away. Collectively, these findings indicate the need
for appraisal of physiological sensations of activation as
helpful and adaptive. This skill not only enhances
performance, but also produces a healthier physiological
response to stress.
Taking It to the Next Level: Combining
Mindfulness and Biofeedback
The following diagram (Figure 2) summarizes the conclu-
sions of the previous section.
Based on the above-cited research, it is reasonable to
predict that a combination of mindfulness and biofeedback
training, when catalyzed by proper appraisal, would
produce even stronger benefits.
To date, few published studies have examined the
effectiveness of using biofeedback and mindfulness in
combination. Several studies investigating the effect of
combining biofeedback and mindfulness are in progress at
this time. More research is needed to examine the effects of
combining the two interventions.
Figure 2. The contributions of biofeedback, mindfulness, and cognitive
reappraisal for optimal functioning.
Khazan
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Biofeedback |Fall 2016
Guidelines for Combining Mindfulness
and Biofeedback
In this section, I provide suggestions for combining
biofeedback and mindfulness for optimizing performance.
First, I provide general guidelines important in combining
biofeedback and mindfulness in training. These guidelines
are based on those described in a paper by Khazan (2015),
here highlighting aspects particularly relevant to perfor-
mance. Following the general guidelines (see Figure 3), I
provide a step-by-step guide for training.
Using these general guidelines, the following specific
steps may be used in optimal performance training (see
Figure 4). These steps are not meant to be taken
sequentially, but rather intertwined together.
The FLARE technique described here (see Figure 5) is an
adaptation for optimal performance training of the original
technique that was introduced by Khazan (2015) for clinical
practice.
Feel. This is a sensory preverbal step, just awareness of
what you are experiencing.
Label. Giving your experience a short nonjudgmental
label, thereby reducing activation of the amygdala and
increasing the activation of the prefrontal cortex
responsible for executive function. This step gives us
the ability to disengage from intense emotion and follow
through with the rest of the steps.
Allow and appraise. Allow your thoughts, feelings and
physiological sensations to be there. Whether or not the
Figure 3. General guidelines for combining biofeedback and mindfulness.
Human Performance and FLARE
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Fall 2016 |Biofeedback
presence of this experience makes sense to you, it is there
for a reason. Thoughts, feelings, and physiological
sensations are not under your control, and therefore
allowing them is in your best interest. Appraising them
as functional and adaptive for the performance you are
about to undertake allows you to stop struggling with the
experience and direct your resources to the performance
itself.
Respond. Choose a response that is in your best interest
at the moment, one that serves the value of that moment.
Place the intention of this step on an action that is in
your control, such as engaging in resonance frequency
breathing in order to maximize your body’s self-
regulation skills.
Expand awareness. Once you’ve chosen your response,
take a moment to bring your attention to what is going
on and around you—the chair you are sitting in, the
floor under your feet, the people around you, the sky and
the trees outside the window—as well as internal
sensations, such as your heart beating and your body
breathing. This step allows you to see the difficult
experience as just a part of your experience rather than
all of your experience. This step is sometimes taken after
Figure 4. Steps for optimal performance training.
Figure 5. The FLARE technique.
Khazan
117
Biofeedback |Fall 2016
you’ve completed your chosen response, sometimes prior
to implementing the chosen response, and sometimes as
part of a longer response.
Example. Let’s use the example from the very beginning of
the paper to go through a FLARE exercise. You might take
a moment to reread the scenario.
F: Noticing the physical and emotional sensations.
L: This feeling is ‘‘overwhelmed.’’
A: It is ok to feel this way. It is ok to feel an intense
emotion prior to an important speech. I recognize the
physical sensations as my body preparing me to do my
best.
R: When I feel overwhelmed, the most helpful response
is to take some mindful resonance frequency breaths, and
allow my body to regulate itself, as it knows how to do so
well. When the time comes for me to go up on stage, I
will focus on my goal of delivering a clear message,
engaging with my audience, and doing the best that I can.
E: As I breathe, I notice the sensations of breathing. As I
expand awareness, I notice the chair I am sitting on, the
floor under my feet, the people in front on me, trees
swaying outside the window. I also notice my heart
beating, my belly coming up and down with each breath,
and my nose itching.
And now imagine going up on to the stage and
delivering a compelling and engaging speech, as the body
and mind find the optimal level of activation needed for the
performance.
Conclusion
This paper brought together performance-focused research
from three distinct areas of study (biofeedback, mindful-
ness, and reappraisal), and introduced a methodology for
harnessing the power of each in a comprehensive training
model. Several ongoing studies are currently evaluating the
efficacy of combining biofeedback and mindfulness in
different settings. This paper can be seen as a strong call
to the scientific community for empirical investigation of
the efficacy of the presented approach for optimizing
performance.
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Inna Khazan
Correspondence: Inna Khazan, PhD, 10 Post Office Square, 8th
Floor, Boston, MA 02109, email: inna.khazan@gmail.com.
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