The Use of Heart Rate Biofeedback Treatment to Assist the Regulation of Embodied Feelings: A Clinical Audit on the Process and Effects of Biofeedback in Clinical Practice

The care for Anorexia Nervosa (AN) at the Regional Eating Disorders Unit (REDU, NHS Lothian, Scotland) is aligned with the National Institute for Health and Care Excellence (NICE) guidelines, focussing on medical stabilisation, nutritional support, and addressing psychological and psychiatric needs. However, earlier service evaluations noted untreated issues of affect regulation and self-efficacy. To address this, the REDU team integrated third-wave Cognitive Behavioural Therapy (CBT) approaches to their standard practice, e.g., mindfulness. As part of the continuous quality improvement process of the unit, they collaborated with UCL psychophysiology experts and also added heart rate biofeedback (HRBF) during guided breathing to enhance their existing practice of mindfulness. Then, a clinical audit to assess the impact of these additions against standard practice was conducted. Patients engaged in guided breathing following two stress-inducing tasks (‘disorder-related’: meal planning and standard: a mathematical test) and received real-time HRBF. The audit aimed to determine whether this new practice met local standards of improving patients’ awareness and regulation of embodied feelings (here, elevated heart rate), and increasing their beliefs about such abilities (referred to as self-efficacy beliefs). Data on 6 patients’ self-efficacy beliefs, heart rate awareness and affect changes throughout the session, and qualitative feedback were collected. Observations indicated HRBF was feasible, well-received and acceptable in this setting. Patients’ self-regulatory abilities and related self-efficacy beliefs improved, with greater motivation to engage in HRBF compared to the ward’s previous standard practice of mindfulness. Despite the limitations of a small sample size and exclusion of acutely unwell patients, the audit demonstrated service improvements. Action points and recommendations are outlined, including a re-audit post-implementation to assess if the intervention meets local standards of care once formally implemented.