[00:00:00] Speaker A: Welcome to the heart rate variability podcast. Each week we talk about heart rate variability and how it can be used to improve your overall health and wellness. Please consider the information in this podcast. For your informational use and not medical advice, please see your medical provider to apply any of the strategies outlined in this episode. Heart rate variability. Podcast is a production of optimal LLC and optimal HRV. Check us
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Welcome friends to the heart rate variability. Podcast. I am back with my good friend Nate Igwigman to continue our conversation. If you did listen to Nate's episode a few weeks back, highly encourage you to do that. We talked about the model he's developing, and then Nate, this is our second episode on the Biofeedback edition of the APB Journal. Just something that showed up in my mailbox, and I opened it up to the first article. And here's my friend Nate biofeedback integrated exposure therapy. And I was like, I got to get Nate. We already had you scheduled to be back on the show, and, wow, I cannot wait to dig in to this with you. So just Nate, if people didn't maybe hear your previous episode, maybe just a quick introduction, and I can't wait to start digging into your great article here.
[00:01:38] Speaker B: Well, thank you so much, Matt, and it's always a pleasure to be with you. Thanks for having me back on the show.
So I'm a clinical psychologist, a clinical health psychologist, and I work at the San Mateo Medical Center with a population of folks who have Medicaid insurance as well as people who have immigrated from all over the world. So I have a really diverse patient base, and I love working with them. I also am lucky enough to have a private practice in the Bay Area as well as the private practice in La. And I actually focus on biofeedback as well as other forms of therapy in both. And one of the things I am passionate about is integrating biofeedback with other types of evidence based therapies to try to augment the effect or try to improve the therapy or the access to the therapy in some way.
[00:02:30] Speaker A: Awesome. And I think as being exposed to this arena, I'm putting you on the leaderboard, if not number one, on that integration. That's where you got the folks who've just been doing biofeedback or neurofeedback, and that's sort of their base. But I love how you are bringing in these other best practices. Obviously, somebody who wrote a book called Connecting Paradigms I'm always fascinated on, okay, when we bring these best practices together, what do we get in addition to what we know about exposure therapy or motivational interviewing or biofeedback or whatever the modality is? Where's the magic when we bring these together and it challenges us professionally because we have to work in that gray area, I think, to get some of those benefits.
But I love the way I feel like I found my brother on this journey. So I am thrilled to dive in to this integration with oh.
[00:03:36] Speaker B: Thank you, Matt.
I think there's so much good work out there on that integration. But for me, the way that I think about it is in terms of mechanisms, right? So if we understand human suffering, various forms of human suffering, and then over time, we get to learn about what are the real mechanisms that maintain that suffering in various ways, and the more that we can understand that from a basic science perspective, then we can learn about different types of literature. And then people who are clinicians like me can blend, can experiment. Trials and studies can be done to see what's most effective. But the way I think about it is, let's try to cover as much ground in terms of those mechanisms as we can. Let's not fool ourselves that just one treatment is going to take care of all human suffering in one particular way. So if we can look at autonomic bottom up types of mechanisms, if we can look at central nervous system mechanisms or thought behavior feeling type mechanisms and combine those, I think that that direction is really exciting in mental health, that we could move almost I almost think about it as kind of a neurorehabilitative model of therapy. So being able to understand and I'm sure you read a little bit about that in this article being able to understand. What are some of the neural influences what are some of the autonomic influences that we can bring to bear and understand and rehabilitate someone through a therapy like exposure therapy or acceptance and commitment therapy, cognitive behavioral therapy. The more science that we know about it, the better we can blend.
[00:05:24] Speaker A: Well, let's start out as we explore the article, for those listeners who may not be aware of the idea of exposure therapy. I mean, in some ways, the name is really descriptive of what you're doing, but I know that there's a lot to that approach. So maybe just a really quick overview of when we're bringing in biofeedback to exposure therapy.
What do we want people to know about exposure therapy? Sort of at the 101 level?
[00:05:55] Speaker B: Yeah.
Okay. The 101 level.
Exposure therapy is a type of treatment for anxiety and related disorders. So most people are going to think about phobias, what some people call simple PTSD, as well as certain other types of conditions that are related to anxiety disorders, like obsessive compulsive disorder, things like that. And exposure therapy is well named. It does kind of say it all. It's actually kind of pervaded the culture. Right. I think I heard someone just the other day say, oh, yeah, that's like my exposure therapy. So it's kind of in the culture and so people understand it. It's a very old technique that actually came out of laboratory science in psychology a long time ago. So it has tremendous evidence behind it. The mechanisms are really, really well understood, behaviorally and now neurally and autonomically even.
And so essentially what exposure therapy would look like is that someone comes into therapy and they have some anxiety or related disorder. They work with a professional who understands exposure therapy, does it and in a really guided, structured, systematic way helps them step by step in confronting their fears, understanding why it is that they have fears at a central and autonomic level and behavioral level and thought based level and being able to expose them in a systematic way over time. And I've seen people it can be two sessions and depending on the condition, it can improve. Right. So it's effective in a shorter period of time.
[00:07:38] Speaker A: And one of the things I love that you address right up front in the article is the dropout rate. Because guess what's? Not fun being exposed to the thing you hate the most or past trauma or phobias, not necessarily how most of us want to spend our afternoon. And obviously we set up an incredibly therapeutic environment in which for exposure therapy to have. We don't hand you a snake after introducing ourselves to you if that's your phobia. So I love to bring in why do you think we see a fairly high dropout rate besides maybe the obvious and how you're positioning biofeedback in order to address some of those challenges and fear with being exposed to our deepest anxieties and phobias.
[00:08:37] Speaker B: Exactly.
It's so hard to do. It's so hard to want to engage in, right? I mean, it's quite literally a therapy that asks you to move towards the thing that you've been moving away from maybe your whole life for many years. And so there's so many techniques as clinicians that we bring to bear to help support people through that very powerful and ultimately empowering journey for people who are able to really engage in it. Motivational interviewing is absolutely one education about fear and safety. Learning is really important because in some ways we're teaching people to master fear, right. And to have what I call an exposure mindset. I actually don't know if I made that up. I probably do, but an exposure mindset.
[00:09:25] Speaker A: The trademark for that. That's pretty good.
[00:09:28] Speaker B: Yeah, exactly. So when my patients have an exposure mindset, they tell me things like, oh, I had this opportunity to go if social anxiety is the fear, I had this opportunity to speak in front of my teammates and I took it because I really wanted to challenge myself. Now, that's the opposite of a phobia, right? And so if they have that, then they're moving absolutely in the right direction. So it is really scary. I never downplay that and I always want to make sure people are ready. So then that gets you to the question, what makes people ready?
I think to generally answer your question, then I'll move into biofeedback, which I.
[00:10:09] Speaker A: Just want to say in the article, this is protocol one. And that's where if you're interested from the clinical perspective, you get this article.
So I just wanted to throw that as we're in protocol One with the psychophysiological readiness piece of this. So this isn't some grand theory, this is a very structured process. And I just wanted to give you credit for the great work that you outlined in this article as well. So let's talk about the first protocol.
[00:10:42] Speaker B: Thank you so much, Matt. Just generally, and just as a quick aside before we go there, I know a population that we both care a lot about is people who have multimorbidities, have complex trauma, right? And so I actually think that one reason that people drop out is because you don't always have someone with just a snake phobia. Yes, they may have lots of other issues, right? And so we need to be really thoughtful about what we bring to bear. However, I believe that in some cases, that population and then just in general, here's what we know about people who aren't ready for exposure therapy or people who drop out or have actually worse outcomes after exposure therapy. Like they still have symptoms or I think this is really interesting, they just have a bad, not a bad relationship, but they don't have a good therapeutic or working relationship with their therapist. All of those things I just mentioned can be predicted by baseline physiological measures. So baseline lower heart rate variability is one of the strongest predictors of dropout. Poor working alliance with a therapist and poor outcomes in exposure therapy. Those are the people that tend to drop out. And you can slice the cake in different ways. So you could say baseline HRV, or you could say disordered breathing in some way. For example, the chemistry of your breathing is a little bit off in some way, or the mechanics are a little bit off. So however you slice it, the studies seem to be kind of pointing to the fact that those of us who drop out from this really difficult treatment have lower levels of physiological resilience, is one way I would put it. And so let's think about that bigger picture. So to me that would be I don't feel ready, I don't feel resourced, I don't feel equipped. Even if I can't articulate that myself or wouldn't be able to know it, that is going to be a prognostic, poor prognostic factor. And so this protocol that I'd outlined in that article is what I call, as you mentioned, psychophysiological readiness. Right? So this whole idea of readiness for exposure therapy so the whole idea of it, and I think it'll be obvious at this point, is to work with those physiological parameters. With biofeedback, we can work directly, as of course, you know very deeply. We can work with lower heart rate variability to improve that, to increase the heart rate variability, which would mean that the autonomic nervous system and the parts of the brain that are connected to the autonomic nervous system are regulating themselves in a more effective way. And therefore that physiological and I would also argue actually neurological readiness for exposure therapy can increase. So in that protocol, we talk about traditional biofeedback interventions that are really aimed at improving breathing and heart rate variability, but also psychoeducation about exposure and education, about fear learning and safety learning and how that happens in the brain. And I'm sure we'll get more into this, Matt, but I think when people come into therapy for exposure therapy, all they're thinking about is the trauma or the snake or the social speaking. Right. And they're thinking about their own fear. And it's very personalized, if that makes sense. Like I have a problem with this as opposed to there's something happening in my nervous system that has kind of been conditioned to this particular stimulus, the snake or the speaking or the traumatic memory. And when people can see or learn about the physiological aspects, they don't take it so personally because it isn't personal. Right, right.
[00:14:35] Speaker A: Yeah. So when you're starting to work with the heart rate and I love the idea of bringing in heart rate variability because you think EMDR all sort of the exposure therapies that have evolved over time, that readiness is such a key thing.
I always like to say we're not throwing anything out when we bring in heart rate variability in as a metric, we're just supplementing other ways clinically, your intuition, any assessments that you do. But as you see, especially working with folks that may be coming in with complex trauma histories, protocol one, and I'm sure this is flexible, but is sessions there's one through three and then four through six, you're really spending a lot of time building this readiness. I'd love to hear kind of some of the insights that you are finding people get through this process even before necessarily the exposure starts to happen and just some of those insights as they're getting to know their autonomic nervous system, what would you see with folks?
[00:15:49] Speaker B: Well, thank you for that question. I think it's really thoughtful. There's a lot of insights in that part of the clinical work. One is I think that biofeedback, the way that I explain biofeedback to people is that this is an opportunity to renegotiate your relationship with your body. I love that this is a way to get to know yourself in a totally new way. And so the pace diaphragmatic breathing practice, that's part of biofeedback for most of us or resonant frequency breathing is a way and a time where people can connect to their body. Right. So that's one insight. And if we were to put some jargon on that, that would be interceptive ability or what I call healthy interception. And that's being more accurate about what's going on in your body but also interpreting it in a more functional, adaptive, healthy way. So I think you're increasing interception and people actually, if we do a quick little aside in a different literature, the interception literature, which is totally fascinating, people who have poor interceptive ability do worse in exposure therapy. So you're kind of through this biofeedback, through this psychophysiological readiness protocol, you are improving, and there's evidence for this, you're improving interreceptive ability at some level. And that is probably also readying someone so they can understand when fear let's make this really concrete. Okay, well, I know this is happening in my body now because I'm more in touch. And so when that comes up, I know that I'm about to get overwhelmed or flooded or I know when this comes up, if I do this particular technique, I can ground and soothe myself. So that's one whole category of insight which is about interception or kind of body level insight.
[00:17:32] Speaker A: Well, just thinking therapeutically, obviously, exposure therapy, a type of intervention we do, but how important that is to any therapeutic outcome, whether we're talking about behavioral change, substance use, rumination, a range of disorders. And the session, the protocol one with these six sessions leading up to the exposure. Boy, what a great potential thing, I think, for all clinicians to think about, no matter what work they're doing. Because to be befriend and understand and work with and strengthen the autonomic nervous system is so foundational, I see, to most work we do. I'm trying to think about the exception to the rule and usually we throw in the Schizo, we go in the Schizoaffective range. But even there I just see that this so foundational to mental health when we just think about that as a general term.
[00:18:37] Speaker B: Yeah, I wish this were just embedded more culturally or we learned this earlier in life. But I agree. I think that this can help. Getting to know your body and improving autonomically derived physiological measures like heart rate variability are going to prepare you for almost any treatment.
I don't know. I wouldn't even call it an exception. But I think one thing that happens in really good therapy is that the therapist co regulates the patient. And I really believe that that physiological improvement just happens as part of people who have enough attachment base and enough secure attachment and aren't overwhelmed by trauma can meet a regulating human being in the form of a therapist and can improve those physiological measures. That's what I believe. But I think formally doing it with biofeedback, with equipment is really important and really helpful. Absolutely.
[00:19:37] Speaker A: Well, I guess we both agree every therapist needs to be trained on this, at least the protocol one, I think is the foundation. Like I said, I think about just motivational interviewing when we have these hard medical conversations. Not that a medical doctor is going to have the same sort of scope we're looking at, but just how that dysregulation, especially for folks that we work with homelessness, addiction, intimate partner violence, histories of trauma abuse. It's like that. Dysregulation is just a core of so many of the other struggles. That what happened to them that they carry on. And helping to find this regulation as part of helping them reach their goals, I just think is so exciting. The work that you're doing, and doing it across multiple populations is just why I'm so fascinated with your work, because it's not just like, hey, private practice, payout. You're working with all aspects of society which you don't often kind of see as these models evolve, especially when technology is involved and innovation is involved. So I love the scope of how you're implementing this.
[00:20:59] Speaker B: I find that really important to me from a values perspective, and I find that the populations who have come from all around the world respond incredibly well to these treatments. I would say just generally across populations, though, probably the most important insight that you can get during that first protocol, during that psychophysiological readiness, is safety and feeling safety. So if someone has never felt safety in their body and what that is like what you're talking about regulation, we could also use the word safety.
[00:21:32] Speaker A: Absolutely.
[00:21:33] Speaker B: Framing it that way, framing it as safety, really provides a substrate from which someone can explore difficult things. So do you have safety with your therapist? Do you have safety in your own body? And I think that initial kind of intervention around therapeutic biofeedback as well as some of the other techniques that are in there, it aims to provide that. And if someone can achieve that, that's going to be helpful in all sorts of ways in addition to getting them ready for exposure therapy.
[00:22:05] Speaker A: Absolutely, that idea. And I think for some people, I know I had to really sit with it as I was working with people. I always remember a client saying, I feel like I have a time bomb inside of me and I don't know when it's going to go off. But what he was communicating is like, I don't feel safe with myself, I don't trust myself. And I think for some of us that are fortunate enough to have not had quite that experience, it's a very foreign thing to kind of conceptualize, but helping people gain that little bit of an island of safety, like understanding what that is, that space. And oftentimes, initially, like you said, it's that co regulation with a professional, with their therapist, where they may be feeling safe socially and within themselves, maybe for the first time in memory, if not realistically, within their life because their environment has always been, to some extent, unsafe with them. And that was such a powerful insight that I think when we may pass someone struggling on the street or something, it's that complexity behind some of the struggles that we don't always appreciate.
[00:23:23] Speaker B: I think that's so true, Matt, and I think that's so well said. And I think, if I'm quoting much smarter people than me, as I understand it, the autonomic nervous system kind of developed as a basic approach avoidance system.
If you really just boil it down, evolutionarily, why do we have it? Is basically to say, do I need to activate and mobilize my resources or can I rest and digest and can I have normal functioning happening? And so it has to be exquisitely tuned to the environment.
[00:23:57] Speaker A: Yes.
[00:23:57] Speaker B: So anything that someone says, the tone of someone's voice, someone's facial expressions that can alter the functioning of the autonomic nervous system right in the moment, right? That's what it's supposed to do. It's supposed to tell you approach or avoid. Now in the examples that you're giving, if someone has never had appropriate sense of this is the right time to avoid, this is the right time to approach, because they have that safety, that foundation, which I think about it kind of from an attachment perspective at this point, some secure kind of attachment with others that then they can transfer to themselves. If they don't have that, they're not going to have an accurate prediction system for approach and avoid. And that's just reasonable. It's just natural that they wouldn't have that. So just as you're saying, this type of work can help with that inner safety. But the other thing that I would tie in is low and high heart rate variability tend to be associated with low and high levels of compassion, not just self compassion, although that's how it's typically kind of spun in the literature because we're kind of in our culture, self compassion is so important and it's also compassion for others. It's also even generosity and moral behavior, actually, if you look at the behavioral experimental literature. And so you think about that, and so you think if someone is able to be regulated, they can have compassion for themselves and for others. They can understand how to reduce suffering, which is my basic definition for what compassion is in some kind of a natural way. So I think it provides all of that, or it can provide all of that.
[00:25:46] Speaker A: As you move through the first protocol, are you looking for certain?
I doubt, and I don't think I'm seeing it. That 10% to 20% improvement. Where do you say it like, okay, I'm getting some data, maybe quantitative with the HRV qualitative with just some feedback to move on to the second protocol, which we're starting. It sounds like more of the traditional exposure therapy. What are some of those metrics that you're looking for?
[00:26:24] Speaker B: Yeah, that's a great question. And it's so important to have that, right, just as a clinician to guide yourself, but also for the patient, so they can feel really confident in and of themselves. So I look at a few different measures that I think are important and wide ranging, and it does depend on the condition, but I always do what I think of as a burden assessment, an anxiety burden assessment, or a trauma burden assessment, which is what we do at our hospital, my colleagues and I that do biofeedback.
And those assessments invariably involve getting what I call a resting psychophysiological assessment, which I think a lot of biofeedback folks do, which essentially involves five minutes of just sitting and not any kind of breathing training or anything, just at its baseline. Five minutes of breathing, ideally with a capnometer, which I'm lucky enough to have, as well as a respiration belt and something that measures their heart. So at the end of that five.
[00:27:29] Speaker A: Minutes, can you detach, though, explain to our audience, who may not know what you're measuring with some of those? It just kind of breaks that assessment down for us because I'm sure a few people are like, what is that?
[00:27:44] Speaker B: Lost me on capnometer. Yes.
So what we're looking at is essentially how are you breathing mechanically? Are you breathing more from your chest and your shoulders, which would be correlated with more physiological anxiety or sympathetic outflow or you're breathing from your stomach? Right. So that's one thing we're looking at. We're also looking at how fast you're breathing. So I have people in my hospital who are traumatized, that 39 breaths a minute. And for reference, eleven to 14 is average. And if I breathe that way, I'm going to have a panic attack in 45 seconds.
So those are very concrete things that we're looking at. And then another thing we're looking at is internal respiration. That's the capnometry. So without going into too much detail, we basically need the right balance of carbon dioxide. And a capnometer is a piece of equipment that measures that and says, are you in the right range on that or not? And so we can get a sense of, is there internal chemistry off which can cause panic and other type of anxiety symptoms? We're looking at all those, and then we're looking at baseline heart rate variability. And we're looking at your baseline heart rate variability compared to other people your age. Right. What are particular reasons why it may kind of higher or lower? And so those are the physiological measures. And then I always give some kind of psychological measure. So symptoms for a post traumatic stress disorder or social phobia. Right. And then depending on the condition, sometimes I'm starting to give attachment based measures because I think that kind of captures a little bit more of that complex trauma aspect of things. And then there's a motivate. The last one is a motivational.
Every session I'm asking one to 1010 being the absolute most ready right now, if we were going to start exposure therapy, where would you be at on that scale? And I'm looking for people to be at around a seven or higher in readiness. Right. So we're going to be flexible based on that. So concretely, I'm looking at and I.
[00:29:56] Speaker A: Think you asked the good follow up, too, of why are you a seven and not a five? I think I saw that in the article, too, which I just had to throw that Mi gym in there that I love.
[00:30:08] Speaker B: Yeah. It's a classic motivational interviewing technique, and it works really well. It gets at what are the barriers. So as a therapist, you can biofeedback therapist, you can work with that, right?
[00:30:18] Speaker A: Absolutely.
[00:30:19] Speaker B: Yeah.
So I would love to see around a ten to 20% improvement in baseline heart rate variability. I'd love to see improvements in the mechanics, and if it's a problem, the chemistry of the breathing, the symptom measures, maybe that'll improve some, but that's not my primary target because we haven't really started the therapy for those symptoms yet.
[00:30:44] Speaker A: Yeah. Well, this is a theme that seems to be of our last several guests on the episode, that balance of healthy breathing.
I think that it's a pretty no brainer for the HIV nerds that listen to our show, is that you can just search healthy breathing and find great episodes by Dr. Azan, Dr. Hopper. In the past, we break it down, nasal breathing, all that stuff. But that dysregulated breathing and the biological state that that creates and that connection to psychological states is just something that I think is going to be a fascinating, continued theme of when do we teach people how to breathe in a healthy way as a culture?
Again, I was taught growing up in the Midwest, stick that chest out every time you inhale.
I was taught to breathe or socialize to breathe in unhealthy ways.
I'm just fascinated with how that connection. And I'm excited to see, as we continue to explore and HRV gets more and more prevalent, just that ability to help people breathe in a healthy way.
What are all the benefits folks get on top of everything else we're doing? We don't stop there. But, boy, if you're not breathing correctly, what kind of ceiling are we setting on how much we can help folks out at the same time? So I just love that this theme is developing through different profession approaches to understand the importance of healthy breathing.
[00:32:30] Speaker B: I do, too. And you couldn't have better people explaining that, so I highly encourage people to check those episodes out, too.
Also, if you look at the evidence on anxiety disorders, and Dr. Gerbertz, who I know that you've had on your show, talks about this adding breathing, really adding breathing training to any anxiety treatment is very evidence based move, say, shall we say it increases the effect size of any anxiety treatment. So it really should be routine. And it's always the first thing that I teach probably 90% of my patients that come in through primary care. Maybe they've never seen a psychologist. It's one of the first things that I do for them. Yeah. And I'm sure there's so much amazing information that Dr. Kazan and others have, dr. Hopper have. Shared. But one thing I think about is sometimes people don't understand, well, I breathe all the time. Why is it something that I've been breathing this way for 40 years? Why would I need to change anything? And one of the things I think it's important to realize is breathing is the connection between the environment and the body. So it has to be spot on. It has to be exquisitely, right, and matched to the needs in an appropriate way.
And our culture doesn't really promote that. Right. There's kind of this screen apnea idea where if I'm writing an email, check yourself, you may be holding your breath.
But breathing is just so important physiologically that we actually have multiple brain centers that are dedicated to kind of voluntary and involuntary breathing. And they're connected to so many systems in the brain, like emotion regulation systems. And as a person without any scientific background, you know what I'm talking about, because if you take a deep breath or if anyone's ever or a relaxing breath, I should say, you know what it feels like. So that's proof for you that breathing is connected to your emotion regulation system.
[00:34:36] Speaker A: I love it. So protocol one, and now let's move to protocol two where we got sensor enhanced exposure therapy. So once we have shown and we've got someone in a state of, if I'm using the correct term, readiness for the exposure, what's this look like now and again, I think for our audience, four to six sessions where we're getting that readiness, no matter, I think any trauma treatment now, we're really focused on that readiness piece. And I think that's a message we got to get out there a little bit better is you're not going to come in and hit it right away. Right. We're going to build the therapeutic rapport. We're going to build that safety up. But once we get that, what does the second protocol start to look like?
[00:35:28] Speaker B: Yeah, and I've got this where you.
[00:35:30] Speaker A: Throw snakes on people.
[00:35:31] Speaker B: Now just toss the snakes right away once they're physiologically ready.
Yeah.
Once the measures that I talked about earlier are looking good, and most importantly, the patient feels ready. I always try to have patients convince me that they're ready for exposure therapy. And when they do that, I know they're ready.
And then I'm just their coach. I'm just their guide. I'm their cheerleader. Right?
And so once we start that new protocol, or the second protocol, the sensor enhanced exposure therapy, it does look like traditional exposure therapy. The main difference is that we are putting specific sensors during every moment of every session of exposure therapy. From the moment that they sit down on that couch over there or in my hospital, they have certain sensors on that measure peripheral finger temperature, which is kind of a measure of vasoconstriction and vasodilation. So when people get really stressed or anxious by their phobic stimuli or whatever, or the trauma memory, some of the blood vessels will begin to constrict some and when it constricts, less blood flow. And that means colder hands. So it's kind of a sign of a little bit of a slower sign of body regulation or Dysregulation in the moment. And then if that's the tortoise, the hair is called skin conductance and that measures sympathetic outflow through the ecrine sweat glands in the fingers, moment to moment. When people see this, it blows their mind because they could think about that embarrassing thing that happened last Tuesday and the line goes up immediately. So it really tracks what you're thinking and feeling and heart rate variability depending on kind of the case.
And between those measures, we get such a good sense of where they're at physiologically. So the first thing that I do is I introduce them to those measures. And it does a lot, actually. It helps them understand fear from a physiological perspective, which helps them kind of with that diffusion a little bit depersonalization in a good healthy way from whatever it is that they're dealing with. And we do a little bit of training in those modalities. And then once we begin the exposures, we not only use the traditional measure of success, I guess you could say, in exposure therapy or habituation, which would be from zero to 100 if I started out at a 90 during this exposure. Now I'm down to a 70. Now I'm down to a 50. Now I'm down to a 45. Yahtzee, we're there. Not only are we looking at that, but we're also looking that the body is regulating itself.
And so the interesting thing that I found, I mean, you could say, oh, why not just do exposure therapy? And I don't have any studies to say yet, although I'd love to see this head to head trial of whether sensor enhanced exposure therapy is quicker than traditional exposure therapy. I think they both work, but my question is which one is quicker?
Yeah, so having access to that data is really useful for folks.
[00:38:51] Speaker A: Does the client, the patient, are they seeing the data as well during the exposure? So what's the session sort of look like at this point?
[00:39:03] Speaker B: Right, so they're sitting just kind of a normal therapy set up, but they've got a few sensors on their hands and we've got the computer kind of in between us. So we're like a team, me and the client, right? And we're seeing the computer, we're seeing the lines, and I've already trained them to know what the lines mean. So when this one goes up, that's fear, when this one goes down, that's fear. Or safety. On the other hand, so they're looking at that, they're making their own observations.
They're helping themselves use that data to inform whether they're ready for the next exposure or whether they're ready to take on a bigger exposure. So they're using all of that data in real time with me. Awesome.
[00:39:52] Speaker A: And then for those not familiar, what's exposure look like. So whether it's a phobia, whether it may be past traumatic stuff, or both, but what's that then? How do you expose them to that stimulus? That has been that fear, that phobia, that retraumatization in the past.
[00:40:20] Speaker B: It depends on the actual problem that they're coming in with. But I'll give you a concrete example, and I've presented on this case before because it was such a great case that worked so well.
It was a blood phobia, blood and injury phobia, and we did a lot of different exposures. Let me just give you some examples. So you guys have something to imagine, right? So we looked at pictures of blood or injury. We looked at a YouTube video of stitches being put in.
And you're going up and up, right? Yeah. And all the way to the point where the memory and the accident where this phobia actually came from is being verbally discussed. In this particular case, the patient was bilingual. So we started out in English, then we switched to the language that my client spoke, and that actually activates different levels of emotionality and physiological reactivity as well, and what's called coordinate bilinguals.
So those are just some examples of how you would expose but for some exposures, you actually like, I'm going to meet someone in a parking lot this next week. We're going to do an exposure there so I can bring some of my wearable devices with me in that case. But typically there's a lot you can do in office in terms of imagining an exposure or seeing or watching something or telling a story of a traumatic memory or just imagining that exposure. Therapists are usually very creative, and they work together with the person to come up with a shared understanding of this is what we're going to achieve together. So they write something called an exposure hierarchy list that the client approves they want to do. If we get through this, you're going to feel great about yourself kind of thing, and then you work your way through that.
[00:42:17] Speaker A: So I would imagine that you're there in the moment with someone that exposure, I'm assuming, even with being well resourced, being well supportive, can elicit, fight, flight, freeze responses. And for the individual, you're helping them through that. So humanitarian wise, I'm going to say, hey, they're in Nate's hands. They're in good hands. So from the nerd perspective, what are you seeing? Because I'm imagining traumatic responses on different levels of dorsal vagal, sympathetic amygdala based responses. What is going on on those sensors on that screen as people?
I'm sure Europe, like I said, ethically, I know we're in good shape to ask kind of a crass question, but what the heck are you seeing during some really intense experiences for folks?
[00:43:17] Speaker B: Well, I feel like you've given me permission to be jargony, so feel free to cut in and ask me to simplify.
So for the people who want the nerdy level of detail, what I'm seeing in the beginning of exposure therapy, when we're first starting is vagal withdrawal, parasympathetic withdrawal, and sympathetic outflow. And what I see specifically with that would be increased, very steep increases that don't really go down, all that much of skin conductance levels. And I'm seeing temperature that just craters. So a lot of vasodilation. Right. And then I'm seeing an increased heart rate, reduced heart rate variability. That's what I'm seeing in the beginning of exposure therapy. And that's what I would call physiologically fear learning. So that's fear learning coming up. That's just what the autonomic nervous system does during fear learning. Right? So we're seeing that. And I'm exquisitely tuned into my client physiologically on the screen, as are they. And just with my eyeballs looking at them and feeling them and making sure that they're not getting to a point where the evidence suggests from Edna Foa back in the 80s that you have to get this type of reactivity for exposure therapy to work. You can't go around, you have to go through. And in this type of paradigm of exposure therapy, that's what we need. And so we frame this as good. This is what's happening. This is what's supposed to be happening.
And this is the key phrase. New learning can occur where the safety learning can occur. We're going to do that exposure until we start to see, and this is what I start to see later in exposure therapy. Skin conductance is going to go up, but it's going to go back down, or it's not going to go up as much. They're going to get bored by the things that they were phobic of. It's truly possible temperature is either going to stay the same or I've even had people's temperature go up when they're telling trauma stories, which means they're regulating their body so well that this doesn't have any charge. Their autonomic nervous system is no longer saying avoid retreat. It's saying, we're okay. This is just a memory. We're cool with that. Heart rate is not going to elevate. It's going to stay at the same place. And heart rate variability is probably going to remain stable, too.
[00:45:42] Speaker A: Excellent.
I'm sure this varies, but typically, how many sessions of exposure do people usually go through? We were talking about, I think, with the protocol one, the first one through three, maybe six sessions of that with the second. When you start the exposure, how many sessions are you typically looking at? Or is typical, not even it's so individualized. What would be, hey, Nate, I'm interested in this, but what's protocol two? How long does that usually take?
Is there an answer even to that very general question?
[00:46:26] Speaker B: I think there is.
First of all, I want to say that if you're going to do exposure therapy, the professional that you're working with needs to feel really clear about the diagnosis. You as a patient need to feel like, yeah, this is a great fit for me, and you're really working on one very specific thing that's extraordinarily clear if it's improving or not.
Once all of that's out of the way, I can answer your question. So if you've made all of those right decisions, in my experience, I would say on the lower end, it's actually two or three sessions. I've even had that with simple PTSD in some cases, believe it or not.
And then on the longer end, 1112 sessions, there are some if you're just talking about the pure exposure part, I think that's a pretty reasonable answer, at least in my experience. But it's often combined with cognitive behavioral therapy. And so for things like social phobia, it's important to have a little bit not just the exposure piece typically, so that can add. But I would say in my experience, probably three to eleven would be typical sessions.
[00:47:39] Speaker A: Great. So I know we're sort of hitting time here, so I got two probably episode long kind of questions, but I'll ask you to just kind of explore these. I think there's so much exciting work being done in the exposure therapy world. I think about things like EMDR, where we're bringing tapping in. You don't even have to disclose your trauma in some situations to your therapist. I know there's like virtual reality stuff being done that the VA has done some I mean, I see a future where you've got a VR headset on that has all your biometrics right there that may already exist in some lab somewhere. Where do you see with technology, I mean, you're bringing in really innovative approaches and technology into exposure therapy. Where do you see this at 510 years from now, as our technology gets less clunky, more wearable, more comfortable exposure could be in a virtual reality framework. Where do you see some of us going with this? Because I've just seen this a huge, exciting explosion of progress in trauma treatment over the last several decades.
Where do you think we're going with all this excitement that we're seeing?
[00:49:04] Speaker B: I'd answer that in two ways, Matt. I think, one, we need to keep learning about the mechanisms of trauma. The type of trauma doesn't seem to predict the symptoms super closely, as well as other factors. And so some people are always going to need that in depth therapy from a professional, whereas other people, I think, actually and this transitions into the second part, they're going to be okay with a computer based program. They're going to be okay with an app if they have enough resources and education themselves.
I could imagine I think my dream would be that any person or therapist could have access to a device that measures skin conductance, temperature, heart rate, and heart rate variability that cost less than $50, or they could loan it out for a certain amount of time, and you don't need training to do it. That's one of the big problems. We've got a lot of training and biofeedback, and it takes a lot to really do it, but it needs to democratize in terms educationally and learning wise as well. So some device that people could learn about exposure therapy and maybe loan this device out to people and give very specific instructions about perhaps a self guided way to do it, I think would be a fabulous direction. And it doesn't feel like we're that far from that. I see a lot more work, actually, on the technological end than the educational end. So I want to put a plug in for that because I think we can make the best technology possible, but if only people like you or me can use it, it's not really a public health intervention. So I think we need to be thinking about that public health educational aspect of making technology that's usable for people who are not biofeedback nerds like you and me.
[00:50:57] Speaker A: I love it. Let's keep working on that, my friend. There's got to be a grant out there somewhere for us, because I think that that's absolutely. And I think for so many clinicians, how do because everything you're talking about is really so accessible in a way. But yet again, the technology is a little bulky still, and the training, like, we're almost there. And I'm excited to see the breakthroughs that more and more people are just learning about heart rate variability, skin conductance, temperature. I mean, all this stuff is polyvagal theory has broken down so many barriers to this that the future there is. Really?
Yeah. So so my final question for you here is I open up the journal, and I see, man, my friend Nate now has a biofeedback integrated exposure therapy model. I had you on a few weeks back with Dr. Snyder talking about the physiopsychological psychophysiological resilience training model you have. Dude, how many models do you have? Which I'm open for a lot because they're great episodes, but I would love just for those, and I highly if you haven't gone back and listened to that episode, I'm assuming listening to this episode with Nate, that that will be next on your listening, just sort of how do you bring these two things together? I see so many overlaps, where they fit, but just where do you see these coming together? How they complement each other with your overall holistic thinking?
[00:52:40] Speaker B: Well, the psychophysiological resilience training model is really transdiagnostic, not just for very specific things like exposure therapy. And the idea of that model is in that episode is just how do you recover from stress and how do you deal with thoughts and feelings in a way that reduces the likelihood of chronic stress from becoming maintained or activated? So I think the integration comes when, for particular clients, at least mixing and matching. So maybe some of them need also help with dealing with Rumination or not. Suppressing their feelings. In that case, I would borrow from the PRT model that we talked about in that other episode. But just to kind of broaden the question, I would say we really need to have continued models. The reason that I'm trying to work on these models is because we need really specific published models for clinicians to be able to follow. And they need to become simpler and simpler. They need to be like, recipes that people can use and follow. Not that they always have to do it exactly how I think I would do it, but just as a way to learn kind of basic techniques of incorporating psychophysiology into therapies that already work. So I think we just need more blended models that are out there for clinicians.
[00:54:05] Speaker A: Yeah. And what I just love and appreciate about your work is how do we make this accessible to folks, right.
The therapist who may not want to go take a 40, 80 hours course.
My passion is how do we get them the equipment they need for an affordable price that isn't a barrier, how do we get them the training they need for the barrier? And that's where with this model and for any clinicians out there, obviously, we still got the technological pieces involved in that.
But again, it's very accessible for folks of how to integrate technology in a way that improves clinical outcomes. And that's where I'm just really excited to be following your work and bringing this to our audience, because I really think this is the path forward, and you're tackling these questions that are going to be so important, hey, how do we maximize everything we're learning? How do we bring this into the sessions? And you're giving us answers to that. So I love being your fan and bringing your work to the wider audience.
[00:55:19] Speaker B: Thank you so much, Matt. You're so supportive and kind, and it really takes all of us you guys have done such a great job in your company along exactly what we're talking about. But there's these different waves of therapy that we've had historically, and I think the next wave, and Dr. Snyder, my close colleague and I agree on this, that this kind of neurorehabilitative model of therapy, almost as if you'd go to physical therapy, you need to do these exercises because this tendon needs strengthening. Well, the more that we learn about different brain and autonomic nervous system parts, the more we can have prescriptive rehabilitative techniques. And those techniques can be studied in large form in the types of models that Dr. Snyder and I are working on.
But the ultimate goal is how can they become more accessible to everyday people? How can they learn about these things?
How can we push some of these ideas out on apps that people have access to, that high level information? That's all we're really doing is just synthesizing information that's out there for consumption. Right, but that's what we need.
[00:56:27] Speaker A: Absolutely. Well, Nate, I really appreciate you. We'll put some contact information in the show notes, but, my friend, always great to see you. Keep up the amazing work. Again, it's the biofeedback special edition of the AAPB journal. Like I said, if you've been listening to this podcast and you're not an AAPB member, we don't have any official connection with them, but they've just been a great resource. Their journal is great, conference is great, and then I get learned that Nate's got another model with a special edition. So, my friend, thank you so much, and as always, you can find show
[email protected], and we'll see you next week. Thanks so much, Nate.
[00:57:13] Speaker B: Thank you.
