What Is Heart Rate Variability Biofeedback?

Heart rate variability (HRV) biofeedback is a foundational therapeutic technique used to regulate Autonomic Nervous System physiology and improve physical and mental health.


Common to depression, anxiety, ADHD, PTSD, chronic pain and across most mental health conditions is dysregulation of the autonomic nervous system. Autonomic dysregulation is often overlooked but has far reaching negative impacts on client wellbeing, overall health and therapeutic progress. Impressive technological and neuroscientific developments have opened up the ability to image and modulate the dysregulated ANS physiology associated with mental health conditions, improving therapeutic outcomes, general health and empowering clients.

How Does HRV Biofeedback Work?

HRV biofeedback involves using a sensor that measures heart rate, which is then presented to the client in real time via a smart device, acting like a technological mirror that lets person interact and learn to regulate their heartbeat and nervous system. One of the main influences on the heart rate is breathing. By slowing down our breathing we are able to slow our heart rate. As there is a greater time between each heartbeat, there is a greater variability in the heart rate than if our heart was beating rapidly, where there is little variability in the time between each heartbeat. This is important because the portion of the autonomic nervous system that makes our heart beat faster is also involved in making us stressed, emotionally reactive and more likely to have social difficulties and be unhappy and unable to concentrate. Conversely, slowing the breath and heart rate activates the portion of the autonomic nervous system that allows us to relax, manage our emotions, concentrate and be prosocial and happier.

The wonder of combining slow breathing with heart rate variability biofeedback is we can see from breath to breath how well we are optimising our physiology, helping us learn quickly. With heart rate variability we are able to improve the balance in the autonomic nervous system to a greater extent than with slow breathing alone. Heart rate variability biofeedback is an evidence based treatment for a number of conditions such as anxiety, depression, trauma, insomnia, pain, cardiovascular disease and to improve peak performance, overall health and wellbeing..

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Case Vignette: Leyla

From a constant struggle with selfhood to a more grounded sense of self, more connectedness with others, and a safer sense of self in the world

Ever since we first met, Leyla described herself as a ‘bad girl’. She said: “Everybody thinks I’m bad, that I’m evil… that I’m dark. Am I bad? Am I evil?” she looked at me pleadingly. In that moment, Leyla, who was 34, seemed to me to be much younger than she actually was.

Despite all these issues Leyla was an insightful individual, and she had a sound level of awareness of her emotional and physiological states. She was well aware of her negative self-talk and negative core beliefs. She identified the following as the focus of her treatment: reduction in trauma-related intrusive thought and nightmares, better ability to regulate her emotions, such as anger outbursts, and feelings of despair, increased sense of self-worth and an ability to form and maintain healthy relationships, improvements in focus and concentration.

Leyla is a woman from a refugee background, and has a history of childhood physical and psychological abuse, domestic violence in the context of her marriage, and sexual abuse and persecution by the government in her country of origin.

When Leyla sought neurofeedback, her clinical presentation was complex, characterised by chronic and severe symptoms of post-traumatic stress disorder and depression. In therapy Leyla was often on guard and fearful, she described having intrusive memories and nightmares as well as chronic sleep problems. Leyla was depressed and had no motivation to engage in life. She also talked about difficulties with focus and attention. Since her arrival in Australia in 2013, she attempted suicide on several occasions and struggled with methamphetamine addiction. Leyla had a negative self-image, she had difficulties with relationships, and felt unsafe in the world. She also made decisions that placed her at risk of further traumatisation, and often let others decide on important matters in her life, after which she was left with feelings or anger, frustration and despair.

Leyla’s treatment lasted approximately two years and incorporated neurofeedback, heart-rate variability (HRV) biofeedback and existential psychotherapy. We also used art materials and the creative process to guide Leyla’s self-expression and processing of her experiences. The aim of neurofeedback and HRV biofeedback was to assist in stabilising and calming Leyla’s nervous system, and increasing the level of her emotional regulation. Through the use of existential psychotherapy and art in therapy, Leyla was able to explore her relationship to herself, others and the world around her. She was able to recognise the values, beliefs and principles she lived by, and find more flexibility in the choices that she made in her life, and in how she saw herself and her relationships with others. She gradually started seeing herself in a positive light, and sought a more balanced way of being in relationships: she reported being able to remain calm in emotionally charged situations, which would lead to the other person being calm, and a stressful situation would de-escalate; or she chose not to tell her whole life story to people she just met in an attempt to find a friend, and she chose not to remain in relationships with people who continued to hurt her. In her art piece, which she worked on over a number of weeks in our therapy sessions, she initially represented herself as an outline of a person with a broken heart. It gradually evolved into an image that represented a more vibrant and grounded self in the world that she started seeing as safer and more beautiful.

Leyla’s relationship with her physical body as well as the environment around herself shifted: she exercises regularly, started to eat healthier and spends more time in nature. She also started attending social, wellbeing and exercise groups. She enrolled into further studies, and started to seek out opportunities for socialisation. She also found a new way to connect with herself and allow transformation to occur in her personal and spiritual worlds: she recognised that she has seen herself as a victim, and discovered a side of her that is strong and resilient, honest and kind. Leyla opened up to a healing part of herself that allows creativity, growth and change.

**Client’s name has been changed, and some details of her story have been changed to protect her identity.