What is Biofeedback for Cardiovascular Health with Maggie Johnson, PhD

#087 [CEU Podcast]  There are currently unprecedented levels of stress in the United States. Stress directly impacts mental and physical health, including heart disease.

According to the American Heart Association, 50% of Americans are living with high blood pressure. With the combination of high levels of stress and high percentages of people living with high blood pressure. It is critical that we have tools to help people living with high blood pressure, heart disease, and other cardiovascular concerns manage stress and live a healthier life.

Today, I'm delighted to bring you a 60 minute continuing education episode on biofeedback therapy for cardiovascular health with Dr. Maggie Johnson

Dr. Johnson is a clinical psychologist at the Western North Carolina VA Health Care System where she provides behavioral health interventions to veterans coping with chronic health conditions, chronic pain, depression, PTSD and anxiety disorders. She specializes in Health Psychology and Complementary and Alternative Medicine. She is certified in HeartMath biofeedback and very passionate about mind body interventions.

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Transcript

Dr. Regina Koepp  
As we know, in the past few years with the COVID 19 pandemic, there have been unprecedented levels of stress in the United States. We also know that stress directly impacts mental and physical health, and one of those physical health concerns being heart disease. According to the American Heart Association, 50%, that's five zero 50% of Americans are living with high blood pressure. With the combination of high levels of stress and high percentages of people living with high blood pressure. It is critical that we have tools to help people living with high blood pressure, heart disease, and all sorts of cardiovascular health needs. So today, I'm delighted to bring you a 60 minute continuing education episode on biofeedback therapy for cardiovascular health with Dr. Maggie Johnson. Before I tell you about today's guest, Dr. Maggie Johnson, I want to just exercise a word of caution here. In this episode, Dr. Johnson walks us through an exercise it's kind of a mindfulness exercise. But I would encourage you to only participate in this exercise if you are in a place that is safe and secure, and where you're not operating a vehicle or heavy machinery or anything that could injure somebody if if you're not careful, including yourself. So just just use caution when engaging in the exercise. If you aren't able to do the exercise because you're driving or whatever else, come back to the episode and do it. It's a really wonderful experience. All right now, let me tell you about today's guest Dr. Maggie Johnson. Dr. Maggie Johnson is a clinical psychologist at the western North Carolina VA health care system, where she provides behavioral health interventions to veterans coping with chronic health conditions chronic pain, depression, PTSD and anxiety disorders. She specializes in health psychology and complementary and alternative medicine. Previously at the Atlanta VA Medical Center, she worked in the health psychology clinic and participated as a health coach in their home based cardiac rehabilitation program, where she assisted veterans in managing the risk factors for heart disease. She also helped them make lifestyle changes and manage their stress. She's presented at regional and national conferences on topics of health, psychology and biofeedback and is certified in Heart Math biofeedback and is very passionate about mind body interventions. I'm delighted for you to be joining us today Dr. Johnson and to share about biofeedback in cardiovascular health. So thank you so much for being

Dr. Maggie Johnson  
here. Yeah, absolutely. My pleasure.

Dr. Regina Koepp  
Can you kind of start us off by sharing about how chronic stress increases the risk of cardiovascular events? What's the relationship there?

Dr. Maggie Johnson  
Yeah, absolutely. So So yeah, so I I've always been interested in the link between stress and heart disease. And you know, there's a lot of research on the negative effects of stress on heart disease, and not just heart disease, many other diseases like cancer and GI issues and dementia and Alzheimer's disease. So you know, chronic stress increases inflammation in the body. And with chronic stress come, you know, elevated levels of stress hormones, like cortisol and elevated blood pressure, and elevated blood sugars, which can contribute to damage to the artery walls and plaque buildup and eventually development of heart disease over time. So good stress management is really critical for for a healthy heart. And also, you know, emotions affect the heart. So we know that emotion are not just in the head, you know, they're experienced throughout the body, you know, often without conscious awareness and you know, different emotions affect the heart in different ways. So, like, for example, depression can trigger an increased heart rate in cardiac patients, people with depression may also have more sticky blood platelets, which can lead to things like blood clots, and also social isolation and feelings of loneliness, you know, people with heart disease, who are more you know, socially isolated, have a greater chance of dying than those with a stronger support system. So we know a lot about you know, the negative emotions and in the heart and you know, what about the positive emotions so, you know, positive emotions are cardioprotective you know, feelings of love and care have been found to lower blood pressure and heart rate. You Happy individuals have a lower chance of heart attack. And you know, all of this was really fascinating research to me, I'm always looking for ways to support my patients in reducing their stress and, you know, living heart healthy lives. And you know, especially right now, I think it's so important, you know, to learn ways to calm the nervous system, you know, there's so much like stress and anxiety in our world. And we're, like, really living in this time where everyone's nervous system is hijacked. And so we've got to do some self reflection, and you'll learn new and effective ways of handling the stress.

Dr. Regina Koepp  
Yeah, I've really, you know, if you're saying that, of course, negative emotions can impact the heart negatively and positive experiences, and emotions have a positive effect on overall health, including heart function. I remember a while ago reading a study, I did a presentation a few years ago at a keynote actually at the Atlanta VA for women veterans. And it was on creating a community of care and a care culture. And, and there's a, I thought I read some research on what it does to the heart when we actually give a gift. And then it actually, I think, one of the the studies that I cited in that talk was that it like lowered blood pressure or something. Do you know, is that consistent?

Dr. Maggie Johnson  
Round? Yes. Absolutely. So feelings of appreciation and, and gratitude, and gratitude, those positive emotions, have, you know, a cardio protective mechanism that actually lowers blood pressure? Yeah, so when we do those practices, like creating gratitude lists, that's something that you know, I really encourage my patients to do, you know, come up with, you know, 10 things that you're grateful for, just make a list 10 things that you're grateful for, and then they can be small things, they don't have to be, you know, major things it can be like, Okay, today, I was able to get my garage door open, whoa. So in a small things, little things like that, like creating a gratitude list is a really powerful activity to do.

Dr. Regina Koepp  
Yeah, I'm, we're at a stressful time in our family life. And I find myself like when I take walks with my husband, outside, and it's a beautiful day, just thinking like, Ah, we're so lucky to be going on a walk in the middle of the day, when my former life, I wouldn't be able to do this. Like just having a little bit of gratitude for the simple thing helps a lot with my own stress lately,

Dr. Maggie Johnson  
when I have my patients do a gratitude list. And then I have them check in, you know, how do you feel before writing the gratitude list? And then after you do your, your gratitude list, how do you feel and usually the patients you know, they feel they feel better from creating a list, they feel better. So it's like an immediate shift.

Dr. Regina Koepp  
So that's one element of coping with stress that can have benefits for our overall health, including our heart health. And then you're here today to talk specifically about biofeedback. And biofeedback as a stress management tool in and preventing cardiovascular disease or helping with cardiovascular disease when people have it. Can you can you start by sharing what biofeedback actually is?

Dr. Maggie Johnson  
Yes, so So biofeedback is a technique that you can use to gain greater awareness of your body's own physiology. So it allows you to have a greater understanding of your own body and how things are interacting and to receive feedback about your own body. So your body is, is constantly sending you messages, you know, through your breath, through your heartbeat, through your skin temperature, muscle tension, and they're usually subtle and go undetected until they just intensify and like really grab your attention to things like a pain or a migraine headache or stomach ache or an anxiety attack like whoa, okay. I noticed you now. And so biofeedback is a way to understand and and recognize your body's messages, so that you can make changes then to better self regulate. So with biofeedback, you can measure basic physiological functions like this like heart rate and blood pressure and muscle tension, body temperature, respiration rate. And then using technology, you can receive an information or, or feedback about the body, which then helps you make subtle changes in your body to improve your well being and your performance. So you're you're noticing, you know what happens to your heart rate when you change your breathing. You know, what happens to your muscles, when you learn to relax or you know, release certain muscle groups are what happens to your skin temperature when you visualize positive mental images. So the goal is really to be able to better self regulate self regulation is key. And I also think to to understand biofeedback, I think it's also helpful to have an understanding of the nervous system. So, so our autonomic nervous system, it regulates our stress response, the sympathetic and the parasympathetic branches of the nervous system there like a gas pedals and the brakes. So our sympathetic is responsible for speeding everything up, increasing heart rate, and blood pressure, and breathing rate, it triggers the body's like fight or flight response, fight or flight response. And that provides us with that burst of energy to respond to perceived threats of danger. And then our parasympathetic nervous system is a complimentary system that slows everything down. It lowers lowers blood pressure, lowers heart rate, and breathing rate, and essentially, like brings us back to homeostasis. And so with biofeedback, we can learn to monitor our body's signals as they as they move through, you know, activation of the sympathetic and the parasympathetic nervous system. So just like, like we can go to the gym, right to strengthen our muscles, we can learn to strengthen our autonomic nervous system with biofeedback training, we can learn ways to you know, better self regulate and to really just to meet the challenges of everyday life.

Dr. Regina Koepp  
When a person is using biofeedback, like what equipment is used is our people look hooked up to like heart monitors and EEG s or like, how does it actually work? Like, what does it look like?

Dr. Maggie Johnson  
Yeah, so so there's lots of different lots of different tools, lots of different biofeedback machines and different methods of someone they might be connected up to equipment that's measuring their heart rate, or their heart rate variability, which I'll talk about a little bit later. They'll be post sensors that pick up sensors, you know, from their, from their ear or from their fingers, fingertips, and they might use EEG. Connect them use little sensors connected to their brains to look at different Brainwave. That's actually called neurofeedback. They might have a mechanism that connects to their breathing, like a little mechanism around their stomach that connects to measure their breathing and their respiration rate. There's lots of different ways to, to measure, measure different physiological responses.

Dr. Regina Koepp  
Before we get into the cardiovascular health, what other sorts of conditions is biofeedback, commonly used for shown effective with

Dr. Maggie Johnson  
Yes, so there are lots of there's a number of chronic conditions that biofeedback has been proven efficacious for things like stress and anxiety. Chronic Pain is a big one, fibromyalgia, high blood pressure, headaches, asthma, ADHD, PTSD, depression, just to name a few.

Dr. Regina Koepp  
Wow, okay. So a lot of groups are doing this from medical to mental health. That's great. Okay, so a person is using a biofeedback machine and is it always done with the machine? or can people do it just by like, looking at their own heart rate?

Dr. Maggie Johnson  
Yeah. So in some cases, I mean, so you can actually do biofeedback by like, for example, temperature, biofeedback, you can actually go on Amazon and get yourself a little thermometer, and you can use that to measure your temperature. You can actually do that at home. So it doesn't necessarily always have to. You don't have to always use equipment, there's actually a lot of apps now that are doing kind of like a biofeedback, like using the camera on your phone, it can pick up different sensors like heart rate and different measures to look at. You know, different biological markers. So that's really neat. And I think we're going to be seeing a lot more of that moving into the future with, you know, the advancement of technology these days. And and there are also devices that you and I'll talk a little bit more about this later with Heart Math, which was a type of which is the type of biofeedback that I use. And there is a personal handheld device, it's called an m wave, that the participants would take home to measure heart rate variability. So it's like a little personal handheld device that they would put their finger over and it would pick up heart heart rate variability, and it would be able to measure kind of your, your biological response to stress in real time at home.

Dr. Regina Koepp  
So biofeedback is used for lots of conditions like stress, chronic pain, high blood pressure, asthma, ADHD, PTSD, just to name a few people can use their own devices that they buy on Amazon or even just doing a temperature check. And then they can use more, I guess, technical assistance devices with a professional. So let's move into like biofeedback for cardiovascular health and cardiovascular disease. So how does biofeedback actually help with cardiovascular disease?

Dr. Maggie Johnson  
Yes, so we're, we're seeing biofeedback being offered, you know, more often as part of stress management training in cardiac rehab programs. And the research has shown that biofeedback training, you know, helps with treating high blood pressure, which is a major risk factor for cardiovascular disease. And according to the American Heart Association, close to half of all adults in the United States. Yes, I said, half suffer from high blood pressure. And, you know, with our aging population and increase in life expectancy, expectancy, this number is just, you know, expected to continue to go up. And, you know, risk factors for High Blood Pressure include modifiable factors like obesity and dietary factors, smoking, inactivity, stress, and negative mood states, like anger and hostility, and non modifiable factors, things like genetics and age and race, with African Americans being at higher risk, and gender, with men being more at risk. Actually, until a woman reached menopause, then their rate of high blood pressure goes up, which might be due to which may be due to the decline in estrogen. So basically, I say all this to highlight the importance of having a comprehensive approach for treating high blood pressure that targets both lifestyle changes, medication management, and good stress management. And oftentimes, treating high blood pressure is something that we're often doing in cardiac rehab. And it's a big part of cardiac rehab programs. And, you know, studies have shown that heart rate variability, biofeedback helps bring balance to the nervous system, and lowers blood pressure. And I'll give you a little bit of background on HRV HRV, or heart rate variability, background, biofeedback, which is also the type of biofeedback that we offered in our cardiac rehab program. So you might be thinking, Okay, what was heart rate variability or, or HRV. So HRV, or heart rate variability is the beat or the beat to beat variations between heartbeats between heartbeats. And this is different from your heart rate, which is the number of times your heart beats per minute. So HRV measures the time between each heartbeat. So the heart The heart is a muscle and it's constantly pumping blood throughout the body. And it's continuously shifting between an acceleration and the acceleration in a kind of like tug of war with the autonomic nervous system, which then creates our heart rhythm. As our heart rate is always changing depending on the activity or or your emotions, and variability is your heartbeats ability to shift and change. So healthy heart is a responsive heart.

And HRV provides information about the interactions between the sympathetic, and the parasympathetic nervous system. Remember those gas pedals and brakes, in our bodies, you know, ability to regulate those systems. So HRV is a good measure of performance of the cardiovascular system, and how well your body can handle stress. And it's not something that you can feel or observe without some kind of technological device. And so that's what we're measuring with biofeedback. And another interesting thing about HRV is that the HRV naturally decreases with age. And we also know that the lowered HRV is associated with an over activation of the nervous system. And it's a predictor of poor health outcomes, like increased increased risk of high blood pressure. And studies from the American Heart Association showed that low HRV is associated with higher risk of death in patients with heart disease. And patients have an increased risk of death following a heart attack if their HRV was low, compared to individuals with a higher HRV. So then, conversely, higher HRV is associated with greater resilience and Lower, lower stress. So when there's more balanced in the autonomic nervous system, HRV tends to be higher. So our goal and HRV biofeedback training, is to raise HRV. And I know I've gotten questions from before from patients asking me well, you know, don't you want to see a low heart rate variability, but no, you actually want to see higher. So higher HRV means more resilience, less stress, more adaptability, you know, greater ability to really to shift and change. And, you know, our body, our body was built for being activated. And, you know, for being able to recover, this is a good thing. You know, from an evolutionary perspective, we were wired to be able to spot danger in our environment, and our nervous system would would warn us of that danger. You know, like, if a saber toothed Tiger was lurking in the background and our ancient ancestors, if you know, Tiger was in the background, then they would kick in a fight or flight response to either run away or fight so that they didn't get eaten by that tiger for lunch. You know, and those that didn't have this built in alarm system while they got eaten and their genes and get passed on. And we're not related to those folks. We are very much wired for survival. But in you know, modern day life, there are, there's really only a few situations where we need that true fight or flight activation. And you know, where it becomes a problem is when we get stuck in that activation state, you know, like chronic stress and negative mood states, like, you know, like anxiety and depression and frustration and anger, which have all been correlated with a decrease in heart rate variability. And so HRV training, is helping the client get back to their baseline and improving emotional well being, and overall performance.

Dr. Regina Koepp  
So interesting. So when you're doing biofeedback, you're you're attending to HRV and trying to increase HRV to create a higher HRV level. Is that right? Yeah. And so you're monitoring HRV? Which is the, the length of time between beats

Dr. Maggie Johnson  
variation between each heartbeat? Yeah, exactly. The

Dr. Regina Koepp  
variation between each heartbeat, okay. So one, like, give an example. So, between beats a and b, could be a couple of seconds between beats B and C could be more or less. Between beats C and D. Could be less or more.

Dr. Maggie Johnson  
Yeah, exactly. It's not like a steady number, right? It's constantly changing depending on what we're doing or, you know, activity we're doing or the emotions that we're feeling constantly changing.

Dr. Regina Koepp  
Okay, and when people come to see you for biofeedback, for cardiovascular health, their HRV may be low, and your goal is to increase HRV. Right. Okay. And that's it. Was it increasing the variability within the HRV or not? I'm just increasing the HRV. Overall, like, per minute. I am a little bit confused on that. Maybe it doesn't matter. Yeah. So so

Dr. Maggie Johnson  
yeah. And then it's Well, it's interesting. So in Heart Math, which is the type of biofeedback intervention that we offered in our, in our clinics, they're actually looking at a, something that's called coherence. And I can talk about that too, a little bit more when I talk about what the patient experiences when they come in for biofeedback treatment. But coherence is a measure that we're looking at that is measured by heart rate variability, and can actually be visualized on a graph. So we're actually looking at like graph outputs. Oh, cool.

Dr. Regina Koepp  
Okay, so what what does a person so say? A person is like, yes, sign me up, sign me up for biofeedback for cardiovascular health with Dr. Johnson. So what would they expect? Like? How does it all work?

Dr. Maggie Johnson  
Yeah, so Okay, so a client is coming in, for biofeedback for the first time. So. So during the first session, you know, we would we would talk about, you know, presenting issues, what's the reason this person is coming in to see me? You know, what are their goals for treatment, you know, what barriers are getting in the way of them, you know, achieving their goals. We assessed, you know, previous coping strategies, what's worked for them, what hasn't worked, you know, we do a clinical intake with psychosocial history, to rule out any serious mental health conditions that might interfere with their progress and treatment. And then after we've done, you know, an overall intake session. So, so just to back up a little bit. So like I said, so we use Heart Math, and our clinic, which is a HRV biofeedback training program. And one thing that we emphasize in this program is that it's not relaxation training. So the primary objective is to help the client learn tools to better self regulate, and to sustain better composure, and balance as they face, you know, everyday challenges. So, you know, I'll say to them, things like, you know, you've likely experienced a time when you felt like you didn't have much energy. And you may have even said, phrases like, I'm running low on fumes, or I'm drained. And I have them think about a time that they felt this way, and how it affected them, and those around them. So you know, when your energy is low, it can be difficult to think clearly and perform tasks and to bounce back, which are all the indications that your resilience is low. And in HeartMath, we use the analogy of an inner battery. So when when you have a high level of resilience, or fully charged battery, you have greater capacity to remain calm, to think more clearly. And to be more in control of your emotions, so that you don't overreact. And when your inner battery is low, like when your cell phone battery is low, there is an energy to draw from when you need it. And it's difficult not to be your best during stressful or challenging situations or, or really, even during everyday situations. So the key is learning how you spend and renew your energy. And we spend time you know, getting familiar with with their particular energy draining and energy gains situation.

And then I do a biofeedback assessment. And I get baseline measures. And I record heart rhythms and heart rate variability, where I can actually get your real time feedback about the person's physiology. And then I teach the bio feedback practices. And in Heart Math, we're, we're also looking at a measure called coherence. So coherence is it's a natural state, and can occur spontaneously when we're doing something that we enjoy or we're doing something where we feel positive, there's times when we feel like things are just like in sync and and flowing. You know, when we're in this state, you know, things can come up that would usually get under our skin but they seem to just kind of roll off our backs. So that's that's what coherence is all about. You know, when the mind when the heart when the emotions and the body when they're all working together in sync. It's not the same thing as being in a relaxed state, but rather what you know athletes call like being in the zone. Right and During that time is when we feel when we feel inspired or have a deep sense of connectedness not just to ourselves but to others and to even life itself. And that's what coherence is. And coherence is measured by heart rate variability, and can be visualized as a as a person's heart rhythm becoming more synchronized and ordered on a graph to imagine like smooth and harmonious waves on a graph. So a smoother heart rhythm pattern would indicate more balance within the nervous system, and a more balanced emotional state. So positive emotions like feelings of love and appreciation, they generate a smoother heart rhythm, and irregular or jagged heart rhythm pattern indicates less synchronized nervous system, and a more stressed emotional state. So like negative emotions, like anger, or anxiety, caused the heart rhythm to become more chaotic. And so HeartMath analyzes the smoothness or the or the jaggedness of the heart rhythm, and then assigns a score. And as clients improve their score, they increase their level of coherence. So using the Heart Math training program, we can objectively monitor heart rhythm patterns, and actually confirmed when one is in a coherent state. And with practice of tools, the client can learn, you know, how to shift into coherence, you know, with a goal that eventually they'll be able to use those tools in real life during challenging situations that would have previously caused them stress and drain their energy.

Dr. Regina Koepp  
Okay, a minute ago, you said, you know, as part of your clinical assessment and your biofeedback assessment, you assess for contraindications for biofeedback, like some some maybe severe mental health conditions, what are contraindications for biofeedback?

Dr. Maggie Johnson  
Yeah, so well, and what I meant by that, so in terms of the things that we were assessing for that would be contraindications are things like severe mental illness that hadn't been that had not been treated yet, like, we would want to refer them to see a mental health specialist or talk to a psychiatrist, you know, about, get them connected to mental health treatment, you know, before starting the biofeedback or if the patient had a suicide, suicidality, we would want to treat that before doing the biofeedback treatment. There really are very few contraindications to do biofeedback, it's a very safe intervention. very safe, very effective, evidence based intervention.

Dr. Regina Koepp  
The other thing I was wondering is, this is even before the assessment, but as you were talking, I was thinking, after I had my second child I had I was an older pregnancy. And so there's higher risk for complications and higher risk for postpartum preeclampsia, which is like high blood pressure after having a baby. And I had blood pressure spikes after I had a baby and went away. Like it was, I'm fine. But I remember like when my blood pressure was super high, I had to be readmitted into the hospital. So I was discharged home, I started to have high high blood pressure spikes. And that would just stay persistent. I remember I went to the pharmacy up the street from my house, because I didn't have a blood pressure cuff at home. But it was like super agitated. I was. Like, I remember it wasn't I didn't have shortness of breath, but I was just like, like, it just felt so chemically, like I wasn't right. And so I went up the street to the pharmacist, I got a blood pressure check. super high. The pharmacist was like, Well, let me check myself, you know, and I had just had a baby, I had a C section. So there was more to the medical picture. So the pharmacist checked herself. And it was normal because she thought well, maybe the cuff is broken. And then she got another cuff like off the shelf brand new one and tested it on her first and it was she had a normal reading like 120 over 80 And then we tested mine and it was super high, like super, super high. And so then I bought a blood pressure monitor and went home and called the doctor and we had to go back in, but I remember the experience of feeling like feeling like super agile tated and like that was I was on edge, I was agitated. I was. And I wondered if that was due to the, like elevated blood pressure itself that I was having all these negative feelings when my blood pressure was regulated, I didn't have as much of that, like, do you notice there's a physiological? Like how much I guess the question is how much does blood pressure actually influence, emotion and sort of emotional state?

Dr. Maggie Johnson  
That's a really good question. I would imagine, too, that, you know, postpartum you were just probably going through so much stress. You know, it's such a stressful time, and you're probably, you know, that you're probably under a lot of stress. And then on top of it, having high blood pressure, and then worrying about, you know, getting your blood pressure down was probably a very stressful time in general. But yeah, no, I that's, that's an interesting question. You know, we've been in that, like, constant like chronic, like fight or flight, stress, caught, being in that constant, you know, fight or flight, right, increasing your blood pressure, and then feeling the physiological effects of having high blood pressure, right, then increases more of that fight or flight. So it's like, you're kind of stuck in this like, like cycle of chronic stress. So that is a really interesting question. I don't know the answer to that. But like I said, I would imagine there's just you're kind of stuck in this chronic cycle of stress.

Dr. Regina Koepp  
Yeah, yeah. And then the blood pressure, you know, needed to get regulated. So and monitored, yeah, that it was so interesting. Because after my first child, I didn't have any of that. And I was, uh, you know, I was also I was an older pregnancy, that's there's higher risk for complications like that. But I just remember, that experience helped me to develop so much more empathy for people I know, who are living with high blood pressure. And just, it felt very physiological, it didn't feel like any type of stress I had had before. It felt like, like my, I could feel just energy rising. It was just so intense. And, and I just, I don't love that I had that experience, but I appreciate that I now have more compassion and empathy for people who are are living with high blood pressure and just this intensity, and then that that stress loop or that stress cycle, it kind of feeds on the you know, my my parasympathetic system was, was not functioning well, well enough to manage that, all of that. But yeah, just help me build so much more empathy.

Dr. Maggie Johnson  
You do want to try and exercise we will, I'll teach you an exercise called Heart focus breathing that's used to help clients take the charge out of the stress rate reaction and to shift into a more coherent state. Yes, I would love that. Wonderful. Okay. Yeah. And I also encourage listeners to try this too. So So yeah, so let's start so adjust yourself if you need to, you know, find finding a comfortable in a seated position. If you need to readjust yourself can be helpful to have your feet flat on the floor with your sitting and share your hands resting in your lap. And so the first step is focusing your attention on the area of your heart. Just gently focusing on your heart area and beginning to breathe deeply in the center of your chest, right in the area of your heart

if you like you can put your hand over your heart, if that helps you connect

continuing to focus on your heart area, imagining that your breath is flowing in and out your heart area with ease.

breathing slowly and gently and through your heart. Maybe a count of five verse six. And breathing slowly and easily out through your heart to another count of five or six

continually continuing to breathe this way, and you tell your breathing feels, moves and balance, but not forced as you continue to breathe with ease for a few moments, finding a natural inner rhythm that feels good for you okay, what was that like for you? Was,

Dr. Regina Koepp  
I know, it's not supposed to be relaxing, but it was very relaxing. I know, biofeedback is not relaxation training, it's self regulation. It was it was self regulating. Yeah, I was more attuned to the noises in my environment. So just more aware, I would say. I feel calmer. Yeah, I know. Like, as I was talking about my own sort of high blood pressure after birth and surgery, I could feel my body rising as I was talking about or my, my blood pressure rising or my energy level rising. And then after doing this exercise, I feel calmer.

Dr. Maggie Johnson  
Yeah, yeah.

Dr. Regina Koepp  
What do other people tend to experience when whenyou do that?

Dr. Maggie Johnson  
Yes. So yeah, I've definitely interesting because I was I was just teaching this practice the other day to, to a patient. And one of the things he said was, he was surprised how, how quick it worked, you know, how quickly he was able to, to make that shift. And what I really what I think is, it's not something, these exercises are not things that you have to spend all day practicing. No, it can be done, you know, in a matter of a minute, you know, or longer. And, you know, it's a very simple tool that I think yields very powerful results to really help, you know, take the charge out of a stress reaction. And other clients have said that they, you know, feel more uplifted or more energetic or, or calm or relaxed, you know, this, we're not, you know, teaching, he's not relaxation training, but that doesn't mean that they don't necessarily feel relaxed. Or also a deeper kind of heart connection, that that comes up to, you know, the heart is like the center of emotion. And people who focus on their heart area will sometimes say that they feel a deeper heart connection, or a deeper emotional connection with themselves or, or or with other people.

Dr. Regina Koepp  
Yeah, that I actually was experiencing that. I'm glad that you said that. And as I was doing this exercise, I was reminded of one day I was driving I have to put a disclaimer at the beginning of this that we do this exercise. So people don't do it while they're driving. Because I was driving and listening to an NPR segment. Maybe it was like invisibIe LEA or some kind of cool NPR program. And, and they were playing sounds of heartbeats. And they gave a disclaimer at the beginning of of the show that and the disclaimer said like, don't drive or be careful if you drive listening to these heartbeats. And I was like, Oh, I'll be fine. I've such mind control that right. And I was listening to these heartbeats and and I don't know what today is about me and pregnancy, I was pregnant at the time with my first child. And I was listening to these heartbeats driving, my husband was in the passenger seat, and I was in the driver's seat. And I ran a red light. And I was like, so so like, moved by the heartbeat sounds that I was like in a. I don't know I was in another world. And, and so we have to remember to put a disclaimer on this one, but how powerful and when my kids now are four and six, and what we do sometimes in my family is we'll listen to through each other's heartbeats. And when I listen to my kids heartbeats, I almost like want to cry, because it's so it feels so deeply moving. And yeah, it just I'm to your point about this deeper heart connection.

Dr. Maggie Johnson  
Like the first time you hear the heartbeat in utero. So it's a powerful moment. And I'm also thinking to that, so I have a six month old, and we use a sound machine at night. And one of the one of the sounds is a heartbeat. And that's the one we always go to continue. He was sleeping in our and our room up until he was, you know, three or four months, and he would always put that heartbeat sound on. And yeah, it was it's so powerful. Absolutely.

Dr. Regina Koepp  
Yeah. Yeah, thank you for doing that exercise with us. I'm so curious if this will engender other you know, the listeners to think of what? Or maybe I would encourage the listener to think of like, what came up for them and, and their own deeper heart connection? Or if they're not driving, or please be cautious if you are driving? Just you know, what their experience was of this? I'd be so curious to hear about that. Okay, so So you've shared a bit about biofeedback. And you've done this exercise with us, which was really enlightening. So how does biofeedback actually how is it used in conjunction with psychotherapy?

Dr. Maggie Johnson  
Yeah, yeah, great question. So. So in my, in my experience, biofeedback has been a really powerful tool that I've been able to offer my patients, you know, we're, we're really living in this time where we crave immediate results and objective data. And, you know, biofeedback is a really powerful tool that can provide that, and, you know, some clients can be,

can be hard to engage them in traditional therapy. And, you know, biosci, saying that interesting and engaging, and might be able to increase a client's willingness to participate in therapy, and biofeedback, you know, maybe a more acceptable form of treatment for some clients. And I think can be a really great place to start for treatment. And when I, when I worked in cardiac rehab, you know, I would often get referrals for biofeedback training for patients with symptoms of anxiety, and chronic high blood pressure, you know, my patients would often say they wanted to get rid of their anxiety, or have better control of their anxiety client, or the client that experienced a heart attack, they might experience anxiety about having another heart attack, or over exerting themselves into having another heart attack. And they might be too afraid to exercise and avoid activity altogether, and then lose their confidence in their ability to function in their careers or with their families, leading to more inactivity and, and more anxiety, and there would just be, like, so much anxiety present. And so, you know, how do we stay within our bodies? And in our experience, when there is unpleasantness there, you know, everything is saying, like, I don't want to be here in my own body. So, I might ask a patient, you know, when anxiety is showing up, what does that feel like in your body? Our bodies, hold on to our stress and our trauma, and just out of interest, like start checking in, what does it feel like in your body? Where where are you resisting? And they may notice tension in their neck or their jaw, or tightness in their chest, or, or rapid breathing, or over breathing? No biofeedback can help clients can help clients recognize when they're engaging in things that activate their stress response, when they're not in that coherent state. And then we can use tools to shift back into coherence and kick in that parasympathetic response. You know, when when there's discomfort, when there's a discomfort, there's like this tensing against the discomfort and you know, thoughts about trying to get rid of the discomfort. This doesn't feel good. So I, I must be in danger. And so, you know, with practice, the patients will start syncing, like the different layers of resistance, like they'll see the resistance, you know, in real time through the biofeedback Can you see how, how it you know, flavors are experienced, but it's not actually what's happening. So, you know, you know, okay, I'm not having another heart attack, this is my body feeling anxious, you know, this is my body trying to energize me. And there's this very useful equation that we use in therapy, that's suffering equals pain times resistance, or suffering equals pain times, worry. So suffering is caused by, like resisting the pain. So what we resist persists. And with biofeedback, patients learn how to recognize and, and bring awareness to their physiological reactions, like the body's natural tendency to resist or resist things that feel uncomfortable. And, and they might also recognize what's getting in the way. So things like judgment, and critical thoughts, and ruminating thoughts, like attempts to control their situation. So, you know, patients learn to disengage from from unhelpful thinking patterns, like I'm never gonna get better to then create space for more skillful thinking and action. So instead of engaging in attempts to control the situation, or going down that rabbit hole of self defeating thoughts, like I can't do anything, I feel so useless. They can use more skillful actions, like engaging in biofeedback, breathing skills, like engaging in heart focus breathing, to restore that balance to the nervous system, and then help them connect to their goals, and what really matters to them, like their intention to take better care of themselves. So, you know, I might not be able to do things exactly like I used to. But I can take small steps to engage in activities, and follow the advice from my cardiac rehab team. So I really see it as a, like a really nice complement to cognitive behavioral approaches, or mindfulness based therapy, you know, what really happens to your physiology when you change your thinking, or when you let go of negative thoughts. And so patients can get that real time feedback, and it makes it easier to make those changes when you're getting that feedback.

Dr. Regina Koepp  
Wow, you have just laid down there are so many things that I want to follow up on here. One is that you talked about this can be a helpful starting place for psychotherapy, especially I'm thinking about the high levels of stigma and gate for older adults to engage in mental health. High levels of stigma for men to engage in mental health, right? So if and if this is a sort of bridge, and a tool that can help to reduce some of that stigma and create some measurable, action oriented, improve health and well being right, and heart health, a lot of older adults actually if they are receiving any mental health care are receiving it in the context of medical care or primary care. And so I think this is a great bridge, especially for groups that are historically left out of mental health care, and especially if African American folks are at a higher risk. And and with histories of mistrust, right? This also might be a helpful bridge because of the objectivity I, I also was thinking back to this equation, so you said there's an equation that you use suffering equals pain times resistance or pain times worry, can you break that down a little bit more for us, like give us an example?

Dr. Maggie Johnson  
Yeah, so Okay, so in the equation, so, pain, so pain is the actual, like actual normal pain, like, you know, chronic back pain or depressions, that the normal pain of life and resistance is the mental anguish caused by trying to resist that pain. So the equation helps us learn to distinguish between the normal pain of life like the physical discomfort or difficult emotions, and then an actual suffering the mental anguish caused by trying to fight against basically the cause by fighting against the fact that life is sometimes painful. So, so yeah, so So the chronic, so it's still it's a pain, the actual pain is chronic chronic back pain, right? So your chronic back pain that you're, that you're experiencing, and then the resistance is the worry thought about that pain. So the worry thought like, you know, I'm never gonna be able to be the same again, or I can't, you know, spend time with my grandchildren more. And all of those worry thoughts that are around the pain that's causing the pain to be more significant than it actually is.

Dr. Regina Koepp  
Yeah, that's so helpful. I, and then, and then you're, it sounds like you're saying that the intervention point with that equation, the suffering equals pain times resistance is in reshaping our relationship to that resistance. And to that anguish, like, I think you said, what, what we resist persists. And so is that right? Am I understanding that right?

Dr. Maggie Johnson  
Yeah, yeah. So recognizing, you know, where the resistance is showing up, you know, and how it's like slavery in our experience, but it's actually different than it's not the same as our actual experience, the ways that certain things are creating more suffering in your life, than the average life is already tough enough. Right? And so all the ways that the resistance is creating more suffering in your life. Yeah,

Dr. Regina Koepp  
powerful. So now say that there are therapists or other other health professionals who want to refer clients or loved ones, to a program that's using biofeedback for cardiovascular health? How would they go about finding a program like yours? Or what would their approach be? Like? I guess it's a two part question. How would they discuss this with their patient? And then how would they help their patient find a biofeedback for cardio help vascular health provider?

Dr. Maggie Johnson  
Yeah, yeah. Great question. So, so when talking about biofeedback, with with, with a, with a patient with cardiovascular disease, I would, I would first really want to validate, you know, how difficult it can be living with heart disease, you know, it can be really difficult living with heart disease, you know, when you're living with a chronic heart condition, you you may feel stressed, or feelings of anger or sadness, you know, your sleep may be off, or you may have noticed more issues in your relationship. And when I start to talk about, you know, all the ways that heart disease could potentially negatively affect a person, they're usually pretty on board and unable to relate with their own experiences. And so, then I'll you know, kind of segue into you know, when the body is stressed, you know, that puts more tension on your body and, you know, can increase your heart rate and your blood pressure, which is not healthy for the heart. And so, learning, you know, good stress management interventions can help your heart and, you know, also help you learn ways to cope with the problems that might may be associated with living with a chronic heart condition. And so with bios, and with biofeedback, we can learn how your body reacts to different kinds of stressors, and figure out different ways to decrease your stress and learn tools to create more balance in your within your nervous system and increase more positive emotion so that you can live more heart healthy. And usually, folks, you were saying earlier, usually folks are pretty interested like in this type of modality, like this is something new and it's interesting, and usually, folks are usually pretty interested in trying biofeedback. And so if you know someone is interested or wanting to refer their patients for biofeedback, a really great place to start is BC ia.org, which is the biofeedback certification international alliance, which is it has a lot of great information about biofeedback. And you can also search for a certified Biofeedback Practitioner in your area. So that's a really great place to start. Also, if you work in the VA, and your facility has a whole health programs, they will ask if they offer Heart Math, or any other types of biofeedback programs. A lot of VAs now are offering Heart Math and other forms of IOC back in their facilities now. So that's a really exciting and great thing.

Dr. Regina Koepp  
Oh, those are great resources. So B, C i a.org. Like, Bravo, Charlie Indigo alpha.org. Yes. Okay. And I'll link to that in the show notes. And then also some health medical centers like the VA Health Care System, each VA Health Care System, or VA hospital or medical center has their own sort of range of programs. So you can check in to see if your local VA offers whole health or biofeedback or alternative health programs. Is this considered alternative health?

Dr. Maggie Johnson  
Yeah, so the so yes. Can complementary and alternative medicine? Yeah.

Dr. Regina Koepp  
Oh, great. Thanks, complementary and alternative medicine. And so you can check with your medical center to see if they offer any, any programs like this. That's great. Well, Dr. Johnson, thank you so much for taking the time to share with us. All of your knowledge about biofeedback and heart health and overall mental health. I, I hope this helps a lot of people in the community to get started, you know, improving their heart health and living a great quality of life for optimal quality of life. Thank you.

Dr. Maggie Johnson  
That's thank you so much for having me and for giving me this opportunity to talk about biofeedback. I love talking about this topic and ways to live heart healthy. And you know, biofeedback is such a powerful tool to use and it's easy to use, it's safe, it's effective. It's evidence based, you know, it's used to improve quality of life for people of all walks of life, to help them find more balance and peace, and that's something that we all need right now. So thank you so much for having

Unknown Speaker  
me.