What is biofeedback? 

Biofeedback is the process of measuring an individual’s physiological states and feeding information about these changes back to them so that they can learn how to regulate their physiological activity to improve their wellbeing (Gilbert & Moss, 2003). In biofeedback training, participants are given insight into changes in their physiology such as heart rate, breathing or even brain activity by showing them visualisations (e.g., moving graphs of changes in heart rate) of these changes (Schwartz & Andrasik, 2017). These visualisations contribute to participants’ awareness of internal body signals, also known as interoceptive awareness, which is an important part of effective emotion regulation (Gross, 2002; Kever et al., 2015). In addition operant learning principles such as conditioning and reinforcement are used to teach participants to effectively regulate their physiology. For example, a pleasant tone can indicate when someone has reached an optimal heart- or breathing rate (Hammond, 2005, 2007; Lehrer et al., 2000; Peper et al., 2009; Schwartz & Andrasik, 2017).

Biofeedback is effective in regulating stress and anxiety (Goessl et al., 2017; Hammond, 2005; Richardson & Rothstein, 2008; Schoenberg & David, 2014; Schwartz & Andrasik, 2017; Tolin et al., 2020; Yucha & Montgomery, 2008), however, various practical issues such as specific hardware requirements and high costs prevented a wide adaptation. Furthermore, biofeedback training involves many repetitive trials which makes it difficult for participants to stay motivated, particularly young participants (e.g. Parnandi & Gutierrez-Osuna, 2017). In addition, for treatments to be strengthened and tailored, it is crucial to know what factors contribute to successful change (and which ones do not) (Kazdin, 2014), however, there is a limited understanding of underlying mechanisms of change in biofeedback interventions (Weerdmeester, Van Rooij, Engels, & Granic, 2020; Wheat & Larkin, 2010). 

Our research 

The current project explores the potential of using biofeedback video games for anxiety regulation and aims to dentify possible mechanisms of change in biofeedback interventions for anxiety regulation. In the past four years, we have assessed the potential of DEEP, a biofeedback-based virtual reality (VR) game. In this game, players move through an enchanting underwater world by using their own breath. The game was created by Owen Harris and Niki Smit (Monobanda PLAY) to provide players with a sanctuary where they can de-stress. Within this project, the game is being further developed and validated as a possible intervention for youth with anxiety. DEEP stimulates players (through biofeedback) to use deep, diaphragmatic breathing. It is played by using a VR headset combined with a customized belt that measures the expansion of the diaphragm. The values of this sensor influence the game and are reflected in feedback in various ways. First of all, the player is informed about their breathing by way of their movement. Breathing in deeply through the diaphragm allows players to move up and forward, whereas shallow breathing halts their progress. The player is also given various forms of visual feedback. For example, a circle in the center of the screen shrinks and expands in accordance to the expansion of the player's diaphragm and elements in the environment (such as plants) change color or change in size/movement, mirroring the player's breathing. By giving this (bio)feedback to the player, they become more aware of their breathing and are stimulated to breath in a deep and calm manner. 

Where are we now?

We have conducted multiple studies including pilot studies, an implementation trial in a special eduction school, and most recently a Randomized Controlled Trial with highly anxious youth to assess whether a training with DEEP could help alleviate anxiety symptoms. In addition we wrote an extensive review regarding biofeedback interventions for anxiety regulation. In this review we identified several psychological mechanisms of change that may be tied to adaptive outcomes of biofeedback interventions and we included a set of guidelines to for a new phase of biofeedback therapy, inspired by game design and the potential of wearable biosensors. So far our results show that players feel significantly less anxious after playing DEEP and that the calming effects of a single play session can last for two hours on average.

Following our research, the developers now aim to bring DEEP to the masses by creating a stunning new experience for the Oculus Quest. In addition, in collaboration with health care partners we are finding new ways in which DEEP could contribute to people's well-being. For example, we are exploring whether DEEP could be used to help individuals that suffer from PTSD. Furthermore, we are exploring ways in which DEEP could be used in the current Covid-19 pandemic to relieve the stress of front-line medical workers or support people's recovery from the virus.