SPECIAL ISSUE: The Impact of a Romantic Partner on Patient Experience of Heart Rate Variability Biofeedback
Biofeedback interventions are often conducted individually and rarely utilize the patient’s social network to improve self-regulation skills. This is a notable omission since social systems impact patients’ psychophysiology. Participants (N = 12) completed a heart rate variability biofeedback intervention with their romantic partner, either present or absent from the room. A qualitative interview explored how the presence or absence of a partner impacted the participants’ experience of the intervention. Biofeedback practitioners may find incorporating social support persons in biofeedback interventions beneficial.
To date, most biofeedback interventions have been individual, and research typically focuses primarily on the impact of biofeedback interventions on individual physiology (Frank et al., 2010; Schwartz et al., 2016). In a few theoretical papers the authors have suggested the use of heart rate variability biofeedback (HRVB) with romantic partners (Ehrenreich, 2018; Levit-Binnun et al., 2010), but there is a lack of empirical support for incorporating social support within HRVB interventions. This is of concern because individual interventions may not capture a critical part of the patient’s experience. Prior research has established that social interactions impact self-regulation, stress management, and autonomic physiology, which are key concepts within HRVB (Kleinbub, 2017; Palumbo et al., 2017). Positive perceived social support acts as a buffer to stress and leads to a reduced appraisal of the severity of the stressor (Cohen & Wills, 1985; Lakey & Orehek, 2011; Pietromonaco & Collins, 2017; Uchino et al., 2018). When training a patient to understand and manage their physiological responses, presence of a support person may increase a patient’s psychological resources to cope with stress and assist them in regulating their stress response. Consequently, utilizing social support as a resource within biofeedback may be an impactful addition to the typical clinical processes.
Method
A study was developed to explore how the presence or absence of a romantic partner may impact a patient’s experience with biofeedback. Data also were gathered on the participants’ change in HRV to provide additional context to the participant’s experience with the intervention.
Procedures
The sample consisted of 12 couples who were randomly assigned to either the “present” or “absent” condition. In the present condition, the partners were together throughout the intervention. In the absent condition, the partners were separated during the biofeedback intervention. One partner from each couple was randomly designated as the primary participant (PP) who participated in the biofeedback intervention. The other partner was designated as the support person (SP).
A photoplethysmography sensor was placed on the PP’s index finger in both conditions. The PP sat quietly for a 5-minute baseline period. Based on information from the biofeedback literature (Lehrer, 2013; Lehrer et al., 2020), the principal investigator (PI) then educated the PP on HRV and its connection to physical and mental health and coached the PP on proper breathing technique as needed. The PP then practiced breathing at resonance frequency by following a pacer and receiving visual feedback on their heart rate. The PP finished the biofeedback session with a 5-minute period during which they were encouraged to use the breathing technique to demonstrate their ability to regulate breathing and improve HRV.
For couples in the present condition, the SP was present in the room with the PP during the biofeedback session. However, the SP was not connected to the biofeedback software and served solely as a support for the PP. The SP was instructed to support the PP in any way they deemed appropriate as their partner was learning and practicing this new breathing technique. Some SPs offered physical touch (e.g., rubbing their back or holding hands), verbal encouragement, or advice. Some SPs chose not to interact with PPs and sat quietly beside them. One SP chose to practice the breathing technique with the PP. The PI did not direct the SP’s interaction with the PP to encourage comfortable and authentic interactions between the partners. For couples in the absent condition, the PP participated in the same biofeedback session but with the SP in a separate room.
The study concluded with a recorded, semistructured interview regarding the couple’s experience during the biofeedback session and their beliefs regarding whether the presence or absence of a partner impacts this experience.
Measures
To measure changes in HRV, participants were monitored with Body Health Analyzer software (Binacor, 2019) during 5-minute periods before and after a breathing intervention. The standard deviation of normal-to-normal rhythms (SDNN) was calculated from the pre- and postintervention periods. The difference between the SDNN in the pre- and postintervention periods was calculated to measure a change in performance. Higher positive numbers indicate more improvement in HRV. A negative number indicates poorer HRV outcomes following the breathing intervention.
The participant’s experience was assessed with a semistructured qualitative interview. Participants were asked questions about their experience with biofeedback, their experience with being together or separated during the biofeedback session, and their opinions about the benefits or drawbacks of having an SP present. The interview questions were:
Please describe your experience participating in biofeedback.
What influence, if any, did your partner’s presence/absence during the biofeedback session have on your experience?
What do you believe are the benefits, if any, of having a partner present when practicing biofeedback?
What do you believe are the drawbacks, if any, of having a partner present when practicing biofeedback?
Participants
Despite attempts to assess diverse participants and relationships, all recruited couples were in heterosexual relationships and identified as monogamous. Most partners identified their sexual orientation as heterosexual (79.17%), with 12.5% identifying as bisexual and 8.33% as pansexual. The average length of the relationship was 4.26 (SD = 5.27) years, and two of the couples had children together. Most couples were dating but not cohabitating (45.83%), 37.5% were dating and cohabitating, and 16.67% were married. Of the PPs, 75% identified as White or Caucasian, and 25% identified as Black or African American. The average age of PPs was 23.5 (SD = 6.22) years. Half identified as male, 41.67% as female, and 8.33% as nonbinary.
Data Analysis
Qualitative data were gathered through semistructured interviews to answer the research question. Interviews were transcribed and deidentified before analysis. The researchers used thematic analysis (Doyle et al., 2020) based on the guidelines of Kiger and Varpio (2020). Although the sample size was limited, the data reached a saturation point, as indicated by repeating themes, and no new themes were introduced by the final participants. Descriptive statistical analyses were run on the quantitative data, and t tests were used to compare couples in the two conditions regarding change in HRV and relationship satisfaction.
Results
The average change in the SDNN of HRV for all primary participants was 28.77 ms. This result indicates that, on average, HRV increased following the breathing intervention. This finding is consistent with previous findings indicating that breathing at resonance frequency increases HRV (Shaffer & Ginsberg, 2017), which is the goal of HRVB and signifies healthier cardiac functioning (Lehrer, 2013). No significant differences in HRV changes were found between participants with a partner present compared with those whose partner was absent, but the small sample size limits the generalizability of quantitative data. However, differences were found in how the two groups perceived the experiences, as indicated by the qualitative analysis.
Partner Presence and Participant Experience
Couples in both conditions were more likely to use positive words (i.e., relaxing or enjoyable) to describe their experience than negative words (i.e., stressful). Couples in both conditions endorsed more codes related to the benefits of having a partner present than codes related to the disadvantages. Both the benefits and disadvantages of having a partner present, as identified by the participating couples, are detailed below.
Benefits
All couples were able to identify some benefits of having a partner present. However, the partners who were actually together during the intervention described advantages more frequently. The participants reflected on how their partner positively influenced their comfort, enjoyment, and ability to perform during the biofeedback intervention.
Security
All couples stated that having a partner present during the intervention provided a sense of security or safety. This was especially important considering the novelty of the intervention. Participants were in a new environment with a clinician they had just met and were completing a task with which they were unfamiliar. A sense of security may play a crucial role in helping individuals engage with the biofeedback intervention and be able to regulate stress. One couple discussed how the experience would have been uncomfortable if they had not been together. “But if you just realize that you’re safe and someone’s here with you, and you are not with a complete stranger, then it’s fine” (Couple 10). For partners that were separated during the intervention, they also acknowledged how it would have been more comforting to have their partner with them rather than in a separate room. “I mean, just knowing that someone is there for, especially in a new area, makes it more comfortable, especially for an anxious person like me” (Couple 3).
Assistance
Seven couples discussed how a partner may provide assistance to someone completing a biofeedback intervention. One partner described how they tried to help the other during the breathing intervention: “you started speeding up so I was trying to slow you back down” (Couple 4). Their partner found this to be helpful to pace their breathing. Another participant, whose partner was absent during the intervention, described how it may have been different if they had been together. “I think I would have been able to take deeper breaths. I think it would have just been, like, more grounding” (Couple 9).
Enjoyment
Four couples described how being together makes the experience more fun or enjoyable. The couples described the sense of enjoyment was increased by simply having someone with whom to share the experience. When elaborating on why the partner’s presence makes it more enjoyable, Couple 3 simply but impactfully replied, “we both just like each other’s company.”
Providing context
A final benefit of having a partner present was reported by three couples. These couples believed that the partner was able to provide more information to the clinician about the participant’s health and lifestyle. Multiple perspectives may be beneficial for a clinician to understand better the individual’s real-world experience and how to use biofeedback interventions most effectively to create long-term change. One couple described how having a partner present was also more reflective of real life outside of clinical settings. “And also, I’m with her all the time, so it’s more realistic, because in the real world, I’m not just with a stranger, I’m with her all the time, so it’s more of what you see in everyday life” (Couple 6).
Disadvantages
Although the participants primarily discussed benefits of having a partner present during a biofeedback intervention, all couples also identified at least one disadvantage. The participants recognized how a partner being present may make it more difficult to engage in the intervention or to do so authentically. Couples in each condition identified disadvantages at equal rates.
Distraction
Eight couples expressed concern that the partner could distract the person trying to complete the intervention. This could occur in a variety of ways, such as through discussions, laughing together, or making the individual think about their partner rather than focus on the intervention. When asked about potential drawbacks of having a partner present, the PP of Couple 4 immediately stated to their partner, “You were making me laugh!”
Self-presentation
Another disadvantage identified was self-presentation, meaning that the participants felt that a partner observing the intervention may put additional pressure on the PP. The PP may try to impress their partner and thus might be less honest with themselves and the clinician about their ability to perform the exercise. Six couples endorsed this theme. One couple in the present condition stated that it had not been a concern for them, but they expected other couples may find it a challenge: “but I can see how it can be more pressure, like people watching you while you’re doing it” (Couple 8).
Distressing presence
Finally, one couple recognized that partners may not always be supportive, possibly due to the partner’s unwillingness or inability to provide support in a way that was helpful to the individual completing the intervention. This lack of support could create additional distress for the individual because the lack would be more keenly felt. This possibility was endorsed by a couple in the present condition in which the PP felt the SP was too quiet during the intervention and did not provide appropriate encouragement.
Discussion
The results of this study indicate that although there may not have been a quantifiable change in HRV based on partner presence, there was clearly an impact on how participants experienced the intervention. The participants overwhelmingly viewed having a partner present during the HRVB intervention as more beneficial than disadvantageous. The participants used words such as “enjoyable,” “fun,” and “interesting” to describe having a partner present during an intervention. Although partner presence does not appear to improve physiological outcomes, it also did not have a negative impact. Therefore, including a romantic partner may improve the patient experience without harming their performance. Taking into account prior studies on the impact of patient satisfaction on retention rates and clinician satisfaction (Bhanu, 2010; Leebov & Scott, 1993), researchers should explore how improving patient experience by including social support persons may impact service outcomes for biofeedback practitioners.
Another benefit that participants identified focused on an important concept for biofeedback clinicians. The participants described how incorporating a partner provides more context for the biofeedback training. Not only does having an additional person provide information give the clinician a better picture of the patient’s real-world context, it also allows the patient to practice in an environment more reflective of their natural environment. Although patients may learn skills in clinical settings, they are encouraged to practice at home to create lasting change. To bridge the gap between clinic and home, a partner may bring a more familiar and natural feel to the clinic. Having their partner be aware of and involved in the process may also increase the likelihood of completing the assigned exercises at home. However, the potential disadvantages to having a partner present during a biofeedback intervention are important. An SP may also be a distressing presence, depending on how the PP received the support. As described by the participants, the partner can serve as a distraction or cause additional stress to the individual, which is counterproductive. The researchers also recognize the possible logistical challenges of including an additional person (e.g., scheduling and informed consent). These challenges are common for professionals working with multiple parties in healthcare or therapeutic settings. However, the biofeedback clinician can attenuate several of these disadvantages with appropriate guidance. Suggestions for effectively incorporating social support into biofeedback interventions should be detailed further in future research.
Contributor Notes