Keeping Up with Technology – Biofeedback: A Technology for Social Justice

TheHealthPsychologist Member Contributions

Molly Brady, PsyD

Molly Brady, PsyD

Ava Drennen, PhD

Ava Drennen, PhD

Molly Brady, PsyD  & Ava Drennen, PhD

The obligation and opportunity that psychologists have to promote the wellbeing of those we serve through respect, fairness, and consideration of diversity issues is a guiding and foundational principle of our field (American Psychological Association, 2017). There are numerous examples of technological innovations offering psychologists new opportunities to promote social justice and reduce inequalities. This discussion, however, has focused to a large extent on how technology can promote social justice on a macro level; for example, developments in telehealth have focused on helping individuals from underserved populations improve access to care.

We have, however, also found technology to be a useful tool for promoting social justice on a micro level. Integrating biofeedback into treatment alongside traditional therapies such as cognitive-behavioral therapy (CBT) does much more than simply help patients learn to better manage their psychophysiological reactivity. It provides patients with information that is immensely helpful in challenging guilt, fear, and helplessness regarding their health, empowering patients to take meaningful action towards improving their wellbeing. This intervention is a clear illustration of an expanded definition of social justice described by Ivey, Ivey, and Zalaquett (2014), which also recognizes the value of micro level efforts. In addition to the importance of taking action on a community level to challenge institutionalized and systemic oppression (i.e. macro level social justice), there is also value in recognizing opportunities for the integration of social justice into each therapy session. In this case, a social justice perspective applied on a micro level may mean identifying and labeling issues of discrimination or marginalization that are informing the patient’s particular experience (Ivey, Ivey & Zalaquett, 2014). In the context of biofeedback, this could include reducing the self-blame patients may feel about their symptoms or distress, using surface EMG biofeedback data to highlight the presence of muscular tension as a survival mechanism: an unintentional bracing or “splinting” response to psychological or physical threat/trauma. Therapy can then focus on empowering the patient and building their confidence to take meaningful action on their own behalf, including learning to decrease unhelpful psychophysiological stress responses by practicing strategies for increasing voluntary nervous system control (e.g. implementing muscle relaxation protocols).

The inclusion of biofeedback along with more traditional talk therapy has great potential to help psychologists validate the experiences of their patients. It has been our experience that patients are often focused on a biomedical explanation for their concerns, and can be confused or frustrated when their medical providers refer them to health psychology. Many initial sessions in our health psychology practice have been spent challenging the patient’s perception that others believe them to be “crazy” or that their symptoms are “all in their head,” particularly with patients from cultures where mental health treatment carries greater stigma than medical treatments targeting pathophysiology. When biofeedback is integrated into treatment, psychologists can go beyond simply expressing an understanding that the patient’s experiences are indeed real, demonstrating instead to the patient that seemingly intangible mental experiences can have real, objective impacts on the body. When patients encounter objective evidence that they are not “crazy” or “weak,” the therapeutic relationship deepens and psychotherapy may be seen in less adversarial or threatening terms.

Biofeedback can also be used as a powerful tool for patient education regarding stress physiology. Knowledge is power: Biofeedback helps to demystify the complex mind-body connection by making this abstract concept more concrete, thus empowering patients through increased understanding of their physiology and psychology. Biofeedback also allows for an interactive, collaborative approach to educating patients about the connection between stress and health, a strategy that may be more effective for patients with low health literacy. The collaborative nature of this approach can also help decrease the power hierarchy inherent in the therapeutic relationship, as both patient and therapist can see and discuss the objective results together. Because somatic awareness and interpretation of interoceptive cues appears to differ across cultures (e.g., Ma-Kellams, 2015), biofeedback may be an especially helpful tool for psychologists working to bridge their understanding when working with patients from diverse backgrounds.

Biofeedback can be a particularly helpful tool in reinforcing agency, helping patients realize that they have the power to make an objective impact on their own health and wellbeing via behavioral health strategies. This could be especially true for individuals who have been disproportionately impacted by adverse childhood events (ACEs). For example, marginalized or underserved individuals experience disproportionally higher rates of ACEs (Andersen & Blosnich, 2013; Slopen et al., 2016), which manifest in physical changes that can be observed on a cellular level as captured by findings indicating epigenetic changes that occur in the context of ACEs (McGowan et al., 2009). In addition to these epigenetic changes that are associated with increases in cortisol levels and other factors that could result in heightened physiological reactivity (Brand, Engle, Canfield, &; Yehuda, 2006), exposure to ACEs confers greater risk for both physical and mental health concerns (Berger & Sarnyai, 2015; Brody et al., 2015; Monnat & Chandler, 2015).

The integration of biofeedback along with cognitive interventions into a single treatment plan seems to have a synergistic effect. When patients are able to see the objective results of relaxation training via biofeedback, this process also seems to spark a cognitive change, as patients often begin to change their beliefs about how much power they have to effect changes in their own mental and physical health. Additionally, biofeedback can help patients gain a deeper appreciation of the key role that cognitions play in one’s emotional and physical health, an important concept of cognitive therapies. Patients are often surprised to see a clear association between different types of thoughts and the corresponding physiological changes presented via biofeedback, making tangible the benefits of cognitive therapy.

It has been long-hypothesized that there are several processes at work during biofeedback treatment, from the basics of operant conditioning and feedback learning to examining values and modifying one’s sense of agency in determining one’s own experience (McKee, 1978). Although these explanations of change processes at work in biofeedback treatment are not novel concepts, there is great potential for these principles to be applied in a particularly meaningful way to strive toward social justice when working with underserved patients.

While biofeedback has tremendous potential as a tool that psychologists can use to promote the ideal of social justice within more conventional psychotherapy, many factors must be considered to ensure that it is employed in a culturally sensitive manner. Clear communication and explanation about biofeedback is critical, especially when language barriers are present. Some patients may be suspicious of this technology, worried about what information the technology might capture, and how this information will be used. It is imperative that psychologists work toward meeting patients where they are at, considering unique cultural conceptualizations of the mind-body connection. Furthermore, cultural and gender differences in proxemics and physical touch must be considered.

Ultimately, our challenge is this: How do we harness the immense potential for biofeedback to deepen our ability to listen to patients, bridge cultural gaps, and promote social justice, one person at a time?



American Psychological Association. (2017). Ethical principles for psychologists and code of conduct. Washington, DC: American Psychological Association.

Andersen, J. & Blosnich, J. (2013). Disparities in adverse childhood experiences among sexual minority and heterosexual adults: Results from a multi-state probability-based sample. PloS ONE, 8(1): e54691. 10.1371/journal.pone.0054691.

Berger, M. & Sarnyai Z. (2015). More than skin deep: Stress neurobiology and mental health consequences of racial discrimination. Stress, 18(1), 1-10. doi: 10.3109/10253890.2014.989204.

Brand, S.R., Engel, S.M., Canfield, R.L., &Yehuda, R. (2006). The effect of maternal PTSD following in utero trauma exposure on behavior and temperament in the 9-month-old infant. Annals of the New York Academy of Sciences, 1071, 454-458. doi: 10.1196/annals.1364.041

Brody, G.H., Tianyi, Y., Miller, G.E., & Chen, E. (2015). Discrimination, racial identity, and cytokine levels among African-American adolescents. Journal of Adolescent Health, 56(5), 496-501. doi:

Ivey, A., Ivey, M., & Zalaquett, C. (2014). Intentional Interviewing and Counseling: Facilitating Patient Development in a Multicultural Society, (8th ed). Brooks & Cole: Belmont, CA.

Ma-Kellams, C. (2014). Cross cultural differences in somatic awareness and interoceptive accuracy: A review of the literature and directions for future research. Frontiers in Psychology, 5, 1-9. doi: 10.3389/fpsyg.2014.01379

Monnat, S. M. & Chandler, R. F. (2015). Long term physical health consequences of adverse childhood experiences. The Sociological Quarterly, 56(4), 723-752. doi: 10.1111/tsq.12107

McGowan, P. O., Sasaki, A., D’Alessio, A. C., Dymov, S., Labonté, B., Szyf, M., Turecki, G., & Meaney, M. J. (2009). Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. Nature neuroscience, 12(3), 342-8. doi: 10.1038/nn.2270

McKee, M. G. (1978). Using biofeedback and self-control techniques to prevent heart attacks. Psychiatric Annals, 8(10), 92-99. doi: 10.3928/0048-5713-19781001-13

Slopen, N., Shonkoff, J.P., Albert, M.A., Yoshikawa, H., Jacobs, A., Stoltz, R., & Williams, D.R. (2016). Racial disparities in child adversity in the US: Interactions with family immigration history and income. American Journal of Preventative Medicine, 50(1), 47-56.