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Health Talk 03: Biofeedback and How it Can Help: A Conversation with world class expert Dr. Gevirtz

bioAbout Health Talk

Living with a chronic condition can feel isolating. Health Talk by Flowly was born from wanting to bring often isolated voices into the fold, and connecting different ideas, experiences, and tools to your own health journey. 

We talk to health practitioners and chronic health patients to deconstruct the chronic condition journey— from how many have managed the challenging diagnosis experience, to new tools and tips that might help you. We cover conditions including chronic pain, anxiety, autoimmune diseases, and more.

Hosted by Celine, the founder of Flowly, this weekly podcast will dive into conversations with world class researchers, practitioners, and even more importantly, chronic condition warriors themselves.

Search “Flowly” on Apple Podcast or Spotify to find Flowly Health Talk!

This is an in-depth conversation about biofeedback with Dr. Richard Gevirtz, truly one of the most respected and pioneering experts in this space.

How does biofeedback work? What does it do? What does it have to do with Olympic level athletes? In this Health Talk, Celine tackles these questions with Dr. Gevirtz.

Dr. Gevirtz is a distinguished professor of psychology for the California School of Professional Psychology at Alliant International University. He’s been doing psychophysiology and biofeedback research and clinical work for the last 30 years. Dr. Gevirtz was also the former president of the Association for Applied Psychophysiology and Biofeedback. His primary research focus is in understanding the physiological and psychological mediators involved in conditions such as chronic muscle pain, fibromyalgia, and gastrointestinal pain. Dr. Gevirtz has studied applications of heart rate variability, biofeedback of pain, anxiety, cardiac rehabilitation, etc.

*This transcript is auto-generated

hey y'all my name is Celine and i'm the

founder of Flowly and your host today

for health talk by Flowly

as some of you might know Flowly is a

mobile platform for chronic pain and


and we use biofeedback to help you train

your relaxation system your nervous


and really help you manage all the

symptoms around it

in our health talk we talk to chronic

pain patients

advocates mental health warriors as well

as professionals in the industry and


to really learn from their expertise

today's guest is someone our whole team

has looked to for guidance

because he's such a foremost expert in

the biofeedback space

and we have Dr. Richard Gevirtz he's a

distinguished professor

of psychology for the california school

of professional psychology at alliant

international university

he's been doing psychophysiology and

biofeedback research

and clinical work for the last 30 years

dr Gevirtz was also the former

president for the association for


psychophysiology and biofeedback his

primary research focus

is in understanding the physiological

and psychological mediators

involved in conditions such as chronic


fibromyalgia gastrointestinal pain

and dr rivers has studied applications

of heart rate variability

biofeedback for pain and anxiety and

cardiac rehabilitation

just to name a few so welcome to health

talk richard

thank you good to be here so i wanted to

jump into

the interview first by asking you what

is biofeedback because i think some of

our community members know it but

many people have never had contact with

biofeedback so what is it

so biofeedback is a field that started

about 45 years ago when we started

getting a good enough technology to

measure physiology in a way that we


show it to the subject or client

and so biofeedback predicated on the on


um plasticity of the nervous system was


that if somebody could see what their

physiology was doing maybe they could

change it

and little by little we've understood

the field better and better as time was

going on

started off with very crude measurements

finger temperature

muscle tension uh just basic heart rate

but as technology has gotten better

we've been able to measure more and more

things about

physiology and feed them back including

eeg feedback heart rate feedback or

reliability feedback

as well as the traditional ones like

skin conductance

and temperature so it's a field that is


steadily um it has the disadvantage of

being in

space between traditional

science and alternative medicine

nih considers this alternative medicine

and when we apply for it they say no no

it's established science it shouldn't be

an alternative medicine

so it little by little it's kind of

finding its own

niche in that space but it has grown

steadily over those many years

what does biofeedback actually look like

like let's say today someone wants to

try traditional biofeedback um where do

they go

and what does a session actually what

does it look like

well there's a there's a certification

institute called

biofeedback certification international


bcia and they

certify the expertise of practitioners

and so it would vary depending on what

the problem was but

they would go to a practitioner who has

equipment that they would put

finger finger leads on ecg leads maybe

ec g leads on um

other kinds of things like that and then

after an assessment the person would

look at a screen

and they would see some aspect of the

physiology that there

that the clinician is trying to get them

to change

and then they would work on that using

relaxation breathing

uh or just straight um mental techniques

to try and change these things

and it would vary tremendously it might

be an athlete trying to

you know pro golfer trying to be able to

make 12-foot putts

just to learn a very specific skill to

do that it could be someone who's

depressed who has to learn to kind of

change their whole physiology

together with their mental uh techniques

or it could be physical disorders like

irritable bowel syndrome where they want

to change their physiology to be able to

alleviate the symptoms

so most practitioners use some

combination of some

psychological techniques as well as the

biofeedback but some only use


there's a whole series of techniques

called neural feedback that uses

eeg electron cephalogram feedback

which takes many many sessions but it's

a it's an up-and-coming area

not as much good solid data yet as there

are any other areas but

certainly of great interest with many

people yes

so you mentioned there's a lot of

different types of leads and

data you can get from biofeedback i know

that for us at flowley we focus on


heart rate variability about feedback

most accessible because it's also a

great entry point i think for people

that have

no access or experience with biofeedback

so i'd love to get your take on um

explaining what is heart rate

variability and what is

hrv biofeedback because it's an

education process for us to try

and share you know what are the benefits

and what does hrv biofeedback actually

do for you

okay so first hrv is separate from the


feedback is an intervention technique

hrv has been around for a while

and it refers to the differences in

beat to beat heart rate um so basically

when most of us are familiar with heart

rate from the gym where we just measure

our average heart rate heater from a


but if you measure beat by beat one our

wave to the next to the next

those distances between those airways


in healthy individuals and strangely the

more they differ the better

more healthy they are opposite of what

mostly would think we think variability

would be bad but here variability is


reason for that is that the variability

is being controlled by

a branch of the nervous system called

the autonomic nervous system

it has two branches the sympathetic

which is the fight flight fright

and the parasympathetic which is the

rest the gesture restore branch

they're like accelerators and brakes the

sympathetic's like an accelerator

a parasympathetics like a brake and they

work together

mostly reciprocally not always

reciprocally to kind of

manage both the environment of your


environment of your body making

adjustments for changes in blood


or blood flow but they also in in

adjustment to

external stimuli so when you're faced

with a very large threat

the break goes off the parasympathetic

goes off and the sympathetic goes on and


everyone's sort of familiar with the

fight flight response

that you get in a real major emergency


people can kind of think about it if

you're riding on the freeway

and suddenly the traffic stops and you

slam on the brakes and miss the car in

front of you by

two inches what's your physiological


a few seconds later after that you get

butterflies in your stomach

you get sweaty your hands get colder

your heart rate speeds up like


everybody kind of knows what that flight

response is

that only really applies during major


for the most part most of the day our

heart rate variability is controlled by

the breaking

of the parasympathetic which is making

adjustments for blood pressure

and in thinking processes and things

going on

so that's where the measurement of that

comes from and it

became important because it's really the

only way we can measure

the parasympathetic nervous system

sympathetic we can measure we've been

able to measure for a long time like

like palmer sweating

and putting electrodes on the palm and

right you get a sympathetic reaction you

your palm sweat and it shows up on this

on a scale

which is a pretty simple kind of

feedback but uh the but the

parasympathetic was much more elusive

until we had technology that allowed us

to look at

beat by the changes in heart rate and

what we know is that

the b by b changes are dominated by one

rhythm specifically

that comes from breathing and that is

when you breathe in

the brain goes off and when you breathe

out the brain goes on

so it makes sense if you think about it

when you're breathing in oxygen is

present in the alveoli

so you want your heart rate to be a

little faster take advantage of the


but then when you breathe out there's no

oxygen there so the brake

slows the heart down and gives you

a and over a lifetime it saves you like

450 million heartbeats

because of that rhythm and that rhythm

is the major

draw is a major drive of carbon

variability but not the only one but the

once we were able to measure that we

started studying

uh swamis and gurus and tibetan monks

and asked them to do what they do when

they get centered and calm

and what we found what they all do is

they breathe at a very slow specific


somewhere between four and a half and

seven breasts a minute

and their physiology is remarkable when

they do that

and we little by little came to

understand why that physiology works

that way is because they're using all

the different rhythms in their body are

lining up

becoming in a very specific coherent

fashion so that they line up so the

rises and falls and heart rate becomes

exaggerated during this

role what we call resonance frequency


and that's what the biofeedback is once

we kind of realized that the

swamis were using it we just sort of

modernized it for the

uh western market and it's basically

kind of high-tech

specific kind of meditation that comes

from this kind of visual breathing

with the technology though we can find

that resonance frequency very

easily now and uh

as your product is doing and once we

find that and people practice that on a

regular basis

we get some of the same benefits that

the swami's got that the guru's got

which is

very good blood pressure regulation very

good anxiety regulation very good

emotion regulation these are things that


with that kind of thing that's why we

always say it's a brand new idea it's

been that's 2500 years old

yeah yeah i love that and i remember

that really struck me when we first

talked and when i was first learning

about biofeedback or even the

hrv itself and resident frequency was

that it's been used for

thousands of years um but only now are

we figuring out how to make it more

accessible to everybody

um and one of the things i think also

fascinated me about your work is that

you work from

you work with everyone from like chronic

pain patients chronic illness

illness patients kids to high

performance athletes

and i think you know most of our

population comes from the chronic

health chronic illness space but they

might be curious about

how does biofeedback help athletes

um and you know what are some of your

experience around that

yeah well the the most the most uh


application is with athletes in

situations like

putting in golf hitting in baseball

uh gymnastics for a short gymnastics


uh diving where

your pre the pre anxiety going into the

activity really does determine how well

you're going to do

now as your anxiety levels go up your

muscles become less fluid in their


they don't move as smoothly you're not

as good of control of your autonomic

nervous system as you want it to be in

the optimal range

so anything that has that strong

emotional component to it has really


by learning how to be doing it

one of the the the most fun group i work

with are

rhythmic gymnastics these are adorable

little asian kids mostly

who uh and their coaches are russians

and bulgarians who are very very tough

and so these kids and i don't if you

know that sport it's the one with the

hoops and the

uh wall and it's right a lot of dancing

yeah tumbling and dancing to music with


and you can imagine how stressful it

would be you're throwing a ball away up

in the air catching on your neck

doing a flip so these little kids um

they're you know like eight to 12 year

olds mostly

get stressed before they go on and that

little bit of stress makes a big

difference to their performance at that

elite level

i'm talking about kids in the top 50 in


country right so when we taught them

when we taught them the technique we

just teach them how to do the

biofeedback just before they go on and

they get their autonomic direct system

into that optimal flow

and they definitely improve their

performance wow

that's really cool yeah and for those

who don't richard you're based in san

diego which is a big

golfing epicenter so i'm sure you get a

lot of golfers working with you

yeah we get some of those and it turns

out that on our campus there's a gym

that they run out to the

rhythmic gymnast kids so all of them in

san diego come

it's right across the street from our

office yeah

that makes sense yeah i've pretty much

seen all of those kids and they're

it's real fun to work with because

they're all adorable

you were talking about the heart rate

variability um

and then you know how you integrate it

into like a biofeedback practice

uh maybe for some people would be

helpful to

understand what is the actual uh

correlation between practicing that type

of biofeedback

with helping pain or helping

anxiety relief so it depends on the


um so it turns out that when people

breathe at that resonance frequency

it has several effects on the body one

of them is that it changes a reflex in

the body of the reflex between blood


called the barrel reflex and we've got

good studies to show that when people

practice regularly they actually

changed this reflex which was never

thought to be

changeable it was thought to be an

immutable reflex

now we know that there's enough

neuroplasticity in the body that it can

be changed

with practice on a daily basis and again

that's why it's been around for

many many years so that's one

function but we also know we think that


breathing at this frequency has it seems

to bombard the brain

through a pathway called the vagal

afferent pathway

some people may have heard about vagal

nerve stimulators which stimulate this


externally so that pathway is a powerful

pathway into the brain it tells the

brain everything going on in the body

otherwise the brain wouldn't know what's

going on how to regulate it and it looks

like that pathway is greatly stimulated

by this technique as well

so for pain and anxiety and depression

for those patients we see with those we

have to try to fit it into what we think

is going on

for the depression it looks like this

technique actually directly stimulates

the vagal afferent pathway

in a way similar to electronic


and that seems to have anti-depressive

effects on the brain

almost a direct biofeedback technique on

the brain without

we usually combine it with talk

therapies but

which is what you should do but even

without it it seems to have some impact

um for other kinds of things for

for pain it depends on the nature of the

pain but the most common pain is a

chronic muscle pain

like low back pain attention headache

neck pain arm pain uh what we've worked

out is that there's a mechanism

that a little nodules in the muscles

called trigger points

are affected by the sympathetic nervous

system by that accelerator

and what we pretty sure happens is with


the parasympathetic break governs that


input into these trigger points so that

when that pain is released in the

trigger point it stays released

when you practice this biofeedback

and we've done a lot of work on that for

that kind of pain

for other kinds of chronic pain it's not

as dramatically effective

but the pathways that the brain

processes pain are affected by this

biofeedback as well

so people with like nerve pain or other

kinds of pain that

can modify that pain processing

by having the brain kind of process it

differently using this technique

right you know that's sort of the the

range of things going on with those

kinds of problems yeah and we've also

found like when we did case studies and

we're in the middle of clinical trials

now that

uh doing the sessions themselves often

are helpful for

relaxing uh feeling a little less pain

or less

anxious feeling more relaxed but we were

just talking about

you me and my co-founder julian before

this interview started that

consistency in practice is also very key

for biofeedback

and the way though our team talks about

is kind of like you know you gotta

go to the gym to work out your muscles

is that kind of how you think about it


you know why is it so important that

practice is part of your biofeedback

yeah so if you're trying to build up

muscle strength you can't just go to the

gym once

you've got to go on a regular basis and

keep on going if you want to maintain

that muscle strength so this is the same


and that's why probably meditation

techniques have been

daily for thousands of years right it's

not a one-time thing

yep so it looks like people need to

practice to keep those reflex changes

going that we're doing

they need to practice reasonably

regularly i mean i don't think

you have to be a fanatic about it but

when people practice pretty

regularly they seem to do it the other

thing is when you practice regularly you

over learn the technique so when you

need it you can use it

very quickly so even without about

feedback we find like our

our girls they're not allowed to use

biofeedback in their gym when when

they're performing

but they've learned this technique so

well in practice that they can implement

it immediately without

actually having feedback right then and

there so there's a couple of reasons

why it's important to practice on a

regular basis

yeah and what do you recommend like

daily few mi

ten minutes a day something like that

let's say minimum 10 minutes a day we

would prefer

20 minutes but we know most people's

lives don't allow for 20 minutes

right well nowadays with the pandemic

probably people have nothing else to do

but anyway

yeah it looks like 10 minutes is kind of

doable for most people

yeah if they really and if they're

really serious about it 20 minutes a day

seems to be

good and more is better the these the uh

gurus that we studied in india do it all

day long and they have remarkable

physiology i mean but yeah

most of us aren't going to do that but i

mean when you think about

squeezing in 10 minutes a day that's

pretty easy just think about 20 minutes

a little harder but

some people do that very nicely that's

what we that's what we think

we've actually found a lot of our users

will do it like 10 minutes in the

morning and then 10 minutes

at night so they break it up so that

it's easier for them

that's great yeah for some people it's a

very good

sleep inducer right so

not for everybody but for some people so

uh we

we've worked on studies with insomnia

and we combine it with uh

a cbt kind of interventions with

insomnia it seems to really help

uh help people go to sleep and stay

asleep i want to ask how did you begin

your work in this space like it's not

it's you know it's really

been picking up steam over the past i

don't know a few decades but

how did you even start well i was lucky

enough to be a student of one of the

one of the giants of the field of


the measurement of psychological factors


physical physiologic physiology named dr

peter lang

still going strong in his 90s down in


uh and so he uh it was a student of the

university of wisconsin in madison

and he offered an advanced class that he

led me into called

blood sweat and tears the subtitle it's

like something or other blood sweat and

tears and

he was a ve he's a brilliant brilliant

guy and it was a

very inspiring course so it just

inspired me to really try to understand

this mind body i was always interested

in mind body

connection i thought that was an

interesting phenomena

and so at the time we had some

technology and i did some research with

him on that

but as the technology grew it got more

and more possible to study this and

then we realized there were some

applications of this in the beginning of

the field of biofeedback

so i was dabbling in biofeedback while

being an

uh faculty member and then realized that

this was really a powerful technique so

i started doing

part-time clinical work together with my

academic work

and then began to develop a whole

pattern of research

at the same time i had a colleague in

the field i mean dr paul lehrer

out in rutgers who was also doing

similar kinds of things mostly focusing


asthma and we were good friends and

great colleagues and so we kind of began

to figure this out together

in this heart rate variability about 15

18 years ago

we didn't really know we were doing but

we figured it out little by little

with the help of a brilliant russian

scientist named evgeny veshilo

who was the cosmonauts

physiologist in russia before he came


and so the great story he tells is they

were watching the heart rates of their

cosmonauts in space

and one of the guys every day for about

15 20 minutes would show these heart

rate patterns that were really

dramatic rises and falls

and they thought it was space sickness

they thought it was a problem so he

calls up and said yuri what's going on

he said leave me alone i'm meditating

oh that one of those cosmonauts was a

breath meditator

and was producing these patterns and so

uh evgeny

brilliant he was an engineer

physiologist figured it out what the

physiology was and really helped us

understand it

and he's now in the states and doing

remarkable stuff

also at rutgers now wow that's a really

cool story

um it also kind of leads into my next

question because

your work is inevitably tied to

technology and

as it develops it i i feel it must

change your work in some ways so how has

you know the developing tech changed how

you've thought about the space or your

research in recent years

so when i started in 1965

we needed a good-sized room and an

electrical engineer to measure heart


yeah and now we're doing it with our

watches yeah

um so as the technology improved in

terms of

measurement of all the all the phenomena


emg the less electromyographic muscles

that's a fairly technical tech you need

fairly good equipment with noise

cancellation to be able to do that


so much better brainwave technology is

so much better

heart rate technology that finally

allows us to look at beat by beat

changes in heart rate

and that's what allowed this whole field

of hrv to occur without that

yeah so all the technology plus the

software to analyze it

um is really been fantastic and now

we're on the verge of wearable

technology that

is going to give us all this stuff and

very hopefully and fairly

cheap wearable techniques uh right now

we're waiting for the price to come down

and the wearables enough for the

scale it up to the population but that's

going to really change things like when

we have

big open scale we're talking to big

insurance companies who are looking to

scale it up

big numbers of their patients they've

done that in some places in finland they

did that with

almost every um finnish university

student has some kind of a

technique to do this that's very cool

yeah so we're totally tech we're totally

dependent on technology

yeah made all the difference i wonder if

that's a

factor in this next question because we

asked our flowley community if they had

any questions for you and this question

that came up a few times is

some of our users have done bio feedback

like in the 70s

80s um or even in recent years but as

you know

biofeedback is not totally accessible to

many people

for people living in more rural areas or

not big cities it might be hard to even

find a clinic or specialist that can do


um and so one of the questions was

you know if about feedback has been

studied and

clinically validated for you know many


why do you think it hasn't taken off in

the mainstream

or you know why haven't more people

heard about it do you think it's

something to do with like the tech or

the accessibility

things like that um generally it's been


who have been the practitioners but

psychologists are not known for their

high tech ability

and so you know they it's been

comfortable for them to do talk


and adding biofeedback would be it's a


some of them more and more of them are

doing it like it's taken a bit of

convincing to get people to learn a

whole new skill set same for physical


or other tech other technology or other

professions so that's one reason the

other reason you mentioned is the cost

and uh accessibility because you know in

a small rural area you're not going to

probably find a

practitioner just doing biofeedback yeah

but as the technology gets better we are

hoping to train like nurses and doctors


or social workers or other people to do


and now this pandemic is forcing us to

try to use

uh ad distance technology as well

and that may actually be good for the

field we might be able to get something

in the hands of people so we can have

our sessions with them

online uh for people especially in

inaccessible areas right now it's

everybody but

eventually we'll get people back to the

clinic which we prefer

but uh but we're using the technology to

check on practice now which we weren't

doing before and that's kind of yeah

i think it's going to uh i think it's

you're seeing uh


online uh online buzz about especially

heart rate variability

biofeedback is all over the place now

uh and the biggest segment are athletes

who are using it to check their fitness

so if you check your fitness level if

you do baseline levels every day if you

buy the equipment and do that

if your heart rate variability dips is

usually a sign of over training

um some of the best football soccer

teams in the world are doing daily

harvard variability checks and their

technique on that technique leo messi is

the probably best soccer

football player in the world for barsa

he his strength of goodness coach checks

with harvard variability every day

um i'm just saying try to gear the

training forward so that

and that of course is very sexy so

people are really interested

you gotta get the celebrities into it

and then people pick it up

um well then what are another question

that came up is do you have any tips for


that are just starting with biofeedback

or um

you know what are some best metrics to

measure your progress with biofeedback

that's the

question we get a lot when people use

clothing there's a couple of metrics

that we were talking about earlier

um you can if you can get some equipment

like fully full equipment will allow you

to do this

that the person has you can get baseline

levels when that is your

your heart rate variability should be

measured when you're breathing normally

at normal situations

just sitting there reading or something

that's the only valid measurement of

your resting levels

so you can definitely see progress in

that over weeks

if you have equipment that'll do your

resting levels quick note we do do it so

people that are

our pro subscribers we actually measure

your resting heart rate variability at

the beginning of every session

so that we can give you that data point

so that's a great point yeah so

you can we have some published data

showing dramatic changes in that resting


so this is really not something you're

doing during the time you're just

sitting quietly

but your autonomic nervous system is

showing like a 25

more efficiency it's really like getting

a much better thermostat

imagine that you've got a crappy

thermostat so it gets way too warm

before the

ac goes on and way too cold before the

heat goes on

and you get a technician and to tune up

that thermostat so it's very quickly

switches back and forth

and comfortable temperatures all the


that's what happens and that shows up

with one of these metrics that you guys


to at the resting level um we can also

use a

another metric for practice because when

you practice what happens is the

the other metrics don't work anymore but

there is a couple of things you can look


some fancy ways of looking at the

practice that show

us if you're practicing effectively or

not and that practice progress usually

comes pretty quickly within a week you

should see much

better progress and again you guys are

trying to put that in as your feedback

yeah people people should be able to see

that they're getting

up to snuff pretty quickly once you hit

that peak of that though then that's it

the rest of your life it'll always be

the same but that particular one but

you'll see

gains in heart rate variability resting

levels over the course of

weeks and months yeah i know we talked

about how like you

you can only max out your hrv to a

certain level like we're not super human


once you get to that max though it still

takes some work to maintain it from my


right it still requires practice correct

last question is

how can people take what they learn like

in sessions like in

our platform or in other platforms like

heart math

work with you what are the best ways

they can practice

or implement it when they're not doing

the bio feedback session

first thing is what we've already said

they have to overlearn it in practice so

they really got it

just like any other motor skill right so

you can't

you can't perform well on the golf

course if you haven't practiced enough

to get your swing down right

so once you get the technique down then

you can use what we call

rescue breathing techniques in in the

situations you're in

um and so most people don't do the

dysfunctional thing they

hyperventilate when they get anxious

they'll take very big deep breaths

which works only for a few breaths but

after that makes you worse

we teach our folks to do everything from

athletes to

depressed people is when they're feeling

their physiology acting up

use their resonance frequency breathing

even four or five

slow diaphragmatic breaths and they

report to us that as time goes on they

get really good at that

yeah so they can take those a few


and and use it in for performance

for uh like they're a business meeting

that is very stressful

uh nobody has to see you're doing it you

just slowly shift your

me every day me every day

so you do that in those kinds of

situations uh

and and the if you practice it's

quite an effective technique for doing

it i mean we

you and i so yeah some years ago i had


get an mri and i didn't think i had any

stress about that at all

but they put you in this machine with

this thing right in your nose banging

went crazy and i realized this is

actually kind of stressful so i just

went into my residence frequency

breathing and i almost fell asleep

i was able to stay still i was able to

really calm down my anxiety they got a

really nice clear picture

so i mean i really you know i did

practice what i preached at least in

that situation

yeah i always have to remind myself that


preach this and i talk about this all

the time but i need to have the

discipline to do it as well

thank you so much for being here richard

because i think biofeedback

is amazing in that you're using external

tools but really strengthening

your internal resources and it's kind of

putting the power back in your own hands


control how you feel and so i think it's

incredible work

you've paved the path for so many people

and teams like ours

so thank you so much for joining us

today well good good work for you guys


so happy to see you going yeah thanks





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