Heartbeats and healing

An idea is born

During 2020, I was commissioned to develop the outdoor education provision for children with a history of complex trauma. The intention was to adapt the way outdoor activities were delivered to benefit these children, while complementing the existing Cognitive Behavioural Therapy (CBT) approach. 

My initial thought process went over the basics of CBT: Thoughts are linked to feelings and feelings are linked to behaviour…. but what if the children don't really know how they feel? This could be due to a lack of appropriate emotional education or coregulation in their early childhood.  Also, their body may be so utterly dysregulated from stress and trauma that their feelings are not tolerable. These extreme feelings might be too overwhelming, thus inhibiting their behaviour becomes an impossible battle that they're destined to fight and lose… over and over again.   

I strongly believed that if the underlying bodily experience is in turmoil, the buzz words 'emotional regulation' is easier said than done!  I'd also observed that the majority of the children were not ready to engage in talking therapy. 

Outdoor activities

I hoped there were suitable alternatives to traditional talking therapy that would not make the children as defensive about their mental health. I spent weeks mulling over existing Adventure Therapy models.  I was met with a sense of frustration that the concepts were either a) already incorporated if resources allowed; or b) simply not feasible or appropriate due to the complex needs of the children.

The idea that outdoor activities could be beneficial for mental health always intuitively made sense to me, and I was keen to understand this on a more biological level (as opposed to the typically documented effects of increased self-esteem). Exercise can be a bit of a panacea for negative moods.  Feeling flat?  Go for a run or a bike ride.  Feeling stressed? Go for a hike in the mountains.  Feeling anxious? Engage in an hour of yoga. 

Initially motivated by physical goals, yoga became an unexpected gateway into the world of meditation – during a transformative 3-week immersion in an Indian ashram, I tried numerous techniques for regulating the nervous system.  I'd subsequently found myself wishing I could 'gift' the inner calm afforded to me through meditation and breathing practices. However, it would be naïve to assume that a child who has suffered trauma would experience the same positive effects through these techniques. 

Interoception

The previous year, I started an assistant psychologist post, working for Dr Dawn Wimpory (consultant clinical psychologist) and subsequently met Dr Lara Maister at Bangor University. They both introduced me to the theme of 'Interoception' and became academic supervisors for my PhD. 

While struggling to find a workable solution within the outdoor education commission, I incidentally started reading Professor Lisa Feldman Barrett's book How Emotions Are Made, conveying how neuroscientific research has radically updated psychological principles, and interoception is a key factor. Finally, inspiration struck me like a lightning bolt! 

Interoception is our internal sense of the body and includes the sense of the heart rate, respiration, energy, temperature, pain and digestion. It happens automatically as part of our body's aim to maintain homeostasis, but aspects of this internal communication between brain and body can reach conscious awareness.   

Interoception and mental health

Some interoceptive sensations manifest in a way that we experience as emotions when they are felt in the body, for example, anger, fear, sadness, anxiety, joy, excitement, calm. Continuous iterative signalling between body and brain can elicit emotional experiences (Craig, 2015). Feelings can therefore be construed as your brain interpreting your 'body budget' - a metaphor used by Feldman-Barrett. 

The ability to emotionally regulate is associated with internal interoceptive processes (Zamariola, Frost, Van Oost, Corneille & Luminet, 2019) and dysfunctional interoceptive systems are linked with mental health issues (Brewer, Murphy & Bird, 2021; Khalsa & Lapidus, 2016; Khalsa, Adolphs, Cameron, Critchley, Davenport, Feinstein et al., 2018), which can be caused by early trauma (Wilkinson, Dodgson & Meares, 2017). Research suggests that interoception can be enhanced through mindful body-based activities (Farb, Daubenmier, Price, Gard, Kerr, Dunn et al., 2015) and interoceptive awareness interventions can reduce symptoms of mental health disorders (Khoury, Lutz & Schuman-Olivier, 2018). 

Outdoor education seemed to be an ideal way to bring attention to 'interoception' because the body is working physically, so there is a lot of visceral experience as the heart rate and respiration changes. There is also real-time feedback from the external world i.e. wind, cold water, sensations from the terrain beneath the feet… orienting them in the present moment and reducing the risk of dissociating or retraumatising. 

Noticing the body during outdoor activities can be done in a way that is child-friendly, fun and engaging. As a bonus, it is arguably less likely to make the children feel defensive about their mental health (compared with traditional therapy or directly asking about their feelings!)

Interoceptive awareness opportunities (IAOs)

Taking a lot of underlying theory into account, a curriculum of around 100 interoceptive awareness opportunities (IAOs) was devised to be delivered by outdoor instructors, when taking children on rock-climbing, biking, hiking and paddling activities. There's an abundance of bodily sensations to be noticed while engaging in these activities. Importantly, they are anchored to the present moment and therefore less likely to elicit painful historic memories (somatic/narrative), than more sedentary meditation practices.   

Outcome of the pilot

The pilot of interoceptive awareness opportunities in Afon Goch Children's Homes Ltd. was a success and is now integrated as part of standard provision.  There were some heartening anecdotes from instructors! For further information please read my peer-reviewed article published in The International Journal of Adventure Therapy (Forster, Maister & Wimpory, 2023). 

For a subsequent study, I planned to obtain empirical data, initiating an exciting collaboration between psychology and sports science departments at Bangor University.  Adult participants were recruited to test the efficacy of one exemplary cardiac interoceptive awareness opportunity, using well-operationalised variables in a laboratory setting.

Testing the concept using psychophysiological measures

I secured an internship funded by Higher Education Funding Council for Wales to collect the data I required, supervised by Dr Andy Cooke and Dr Germano Gallicchio during data acquisition and analysis.  Students at Bangor University were recruited and randomly assigned to an interoceptive (internal attentional focus) or exteroceptive (external attentional focus) experimental group. Electrocardiogram (ECG: electrical activity of the heart) and electroencephalogram (EEG: electrical activity from the brain) data was collected before and after physical activity on an exercise bike.

EEG was recorded during 2 minutes of internal focus to the heart, acquiring data for hearbeat evoked potentials (HEP); a measure of the cortical processing of the heartbeat, and is widely considered to be the best available biological measure of cardiac interoception. Neural activity after each heartbeat can be analysed for any effects on HEP between experimental groups.   

Additionally, cardiac interoceptive accuracy was assessed using the well-established Heartbeat Discrimination Task (HBDT: Whitehead, Drescher, Heiman & Blackwell, 1977), which takes approximately 20 minutes.  During this test, participants heard numerous sequences of beeping tones; half of the time the tones were exactly in synchrony with their heartbeat - precisely measured using ECG sensors - and half of the time the beeping sounds were slightly delayed. Participants were required to indicate whether they thought the beep was in synchrony with their heart or not. 

After these baseline measures were acquired, participants cycled on a laboratory exercise bike. They attended the laboratory on two separate occasions; during one session participants experienced a low exercise intensity and in the other session the bike was set to induce a higher level of physical exertion.  Immediately after exercise while their pulse remained raised, the interoceptive group were guided to attend to the sense of their pulse in their chest, hands, feet, head, stomach and legs for 20 seconds each. The exteroceptive group focused on a screen and located pulsing shapes immediately after exercise - this acted as control condition.  HEP and HBDT measures were gathered again when the heart rate had returned to baseline.

HEP analysis

Initial visualising of my EEG data suggests that there were some group differences at a cortical level. There appears to be a trend for interoceptive group participants to have greater activation over frontal regions, time locked between 200-300ms after each R wave of the cardiac cycle; this time-window is commonly reported in HEP research (Coll, Hobson, Bird & Murphy, 2021).  Please note, inferential analyses is in process - it's possible that the visible trends aren't deemed significantly different. 

HBDT results

HBDT data was analysed according to signal detection theory including positive predictive value (PPV); members of the interoception group had significantly higher PPV scores, in support of the main hypothesis. This outcome indicates that attending to the heartbeat following exercise can improve cardiac awareness, even when the heartbeat has returned to resting. 

(It's an indescribable joy when, after years of theorising, months of testing and hours of number crunching, a supportive p value is blurted out of your statistical software!) 

Stay tuned…

In the next issue I'll contextualise this research by describing a complex underlying theory of interoception, speculating about the implications for mental health interventions.

About the author

Kitty Goldthorpe is currently a psychology postgraduate researcher at Bangor University, focusing on interoception and mental health