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Articles & Research

HAT® Research: Completed and in-progress:

Integrating Heart Energy into Psychotherapy: Heart Assisted Therapy 

John H. Diepold, Jr., Ph.D.

APA Poster Session, San Francisco, CA / August 9, 2018

Heart Assisted Therapy (HAT) integrates and synthesizes traditional psychotherapy models with biophysical science. HAT is a deeply mindful, humanistic, integrative, and holistic mind-body approach to psychotherapy.  HAT incorporates the use of heart energy and respiration in concert with cognition, emotion, sensation, and a stabilizing breathing treatment while overlapping hands are placed over the heart (“heart-breaths”). The HAT model intrinsically engages the natural influence of the heart-brain-hands connection throughout the process of psychotherapy. 

The HAT model is a gentle, self-nurturing, and self-regulatory approach that is easy for both the patient and therapist to engage. There are only 4 Guiding Principles that serve to assist the therapist throughout the protocol: 1) Accept the negative, 2) Ponder the neutral, 3) Accentuate the positive, and 4) Prepare for the future. HAT incorporates the totality of the individual’s associated experiences to the identified trauma or issue, thus assuring a thorough treatment outcome. 

This approach arose from 35+ years of clinical experience (e.g., with traumatized individuals, test-takers, and athletes), and both complements and integrates traditional psychotherapy paradigms. HAT is designed to complement existing skills and orientations of the psychologist. The HAT model uses “awareness streaming” in concert with the body’s electro-physiology and respiration to facilitate healing and stabilizing shifts in emotion, sensation, cognition, and behavior.

Heart-breaths used in HAT involve normal respirations of the individual. There is no requirement or expectation that the person engages in any form of deep breathing, diaphragmatic breathing, or yoga-style breathing patterns. With HAT we work with what is characteristic of the individual, especially when addressing emotional topics and experiences.

Here are the directions when initiating the “9 Self-Regulating Heart-Breaths” (9 SRHB) that begin every HAT intervention. The therapist also performs the heart-breaths as they guide the individual through the process

  1. Overlap your hands and place them directly over the center of your chest over your heart. 
  2. Free your mind and blankly focus your attention on something in front of you (e.g., an empty space on the wall). 
  3. Take 3 normal respirations while keeping your hands over your heart (Heart-breaths). 
  4. Reverse your hands and again place them over your heart. 
  5. Again take 3 normal respirations while keeping your hands over your heart. 
  6. Reverse your hands once more and again place them over your heart. 
  7. Again take 3 normal respirations while keeping your hands over your heart. 

Proper hand positions when doing heart-breaths involve overlapping, flat hands placed over the heart in the center of the chest as shown in the figure below. The therapist can learn to use their natural hand positions as a guide throughout the HAT protocol. It is helpful to learn your natural hand positions over your heart as this information will always keep you on track. 

The HAT process also involves reversing the hand placements at various points of the protocol. Respiration is monitored and used as a guide throughout the therapy process utilizing the 4 Guiding Principles and Acceptance Statements where indicated. 

The heart-breath hands positions are normally occurring and often an unconscious activity that is evident world-wide. I posit it is an innate self-regulatory response, and that it is a potent electrophysiological intersection engaging biophysical, meridian, and chakra activities.

Heart energy is influential and interacts with the above referenced physical and bioenergy systems. Consider the following findings: 1) The heart produces the strongest rhythmic electromagnetic field of any organ in our body, 2) The electromagnetic field (EMF) produced by the heart is up to 5,000 times larger than the EMF produced by the brain, 3) Our heart rhythms affect the brain’s ability to process information, 4) Our emotions are manifest in the patterns of our heart’s field, and 5) The heart informs the brain’s ability regarding perception, emotional experience, and enhanced mental processing (e.g., Childre & Martin, 1999; McCraty, 2012).  Accordingly, incorporating heart energy into psychotherapy allows for a system-wide influence of resources for change.

In efforts to understand the gentle yet impactful clinical outcomes with HAT, pilot study research has shown statistically significant increases in alpha power via EEG data compared to control, and increased brain registration of the electrical signal from the heart (ECG triggered ERP's), when overlapping hands are placed over the heart compared to controls.

This poster session shares some information about the basic science of the HAT protocol, the heart-brain-hands interactions, the role of respiration when using HAT, the heart-breath hand positions, and additional research findings. Clinical outcome data will also be shared. 

Behavioral and Perceptual Findings (Pilot Data):

Perceptions of Comfort for Spontaneous and Opposite HAT Hand Positions

Analysis of the subjective experience of spontaneous hands position, compared to reversed position of the hands over the heart and a control position, reveal statistically significant positive results on measures of perceived comfort ( e.g., warmth, relaxed, calm, and focused) with no differences in age, gender, or handedness. 

In an initial pilot study, 15 Subjects consisting of 6 females (mean age 54.7) and 9 males (mean age 48.3) were asked to overlap their hands and place them over their heart. Six subjects spontaneously placed their right hand over their left, and 9 subjects spontaneously placed their left hand over their right. Of the subject pool, 9 were right handed, 3 were left handed, and 3 were ambidextrous. Results reveal no pattern or differences in mean ages, gender, or handedness pertaining to spontaneous placement of left hand over right or right hand over left.

Below are three primary summary graphs from an expanded study of data (n=74) collected with colleagues studying ratings of comfort (scale 0 -10) for left over right (LoR) and right over left (RoL) hand positions as a function of sex, handedness, and experienced comfort.  Analyses were done in Statistica and then graphed in Excel.

The left graph below shows ratings of LoR and RoL when natural (spontaneous) position is left over right (left set of lines) versus right over left (right set of lines), separate for females (blue) and males (red).  Males and females are very similar.  Data clearly shows people rated LoR higher if their natural (spontaneous) hands position is left over right and lower in comfort when they reversed their hands. A similar pattern was found when the natural (spontaneous) hands position is right over left.  This effect is highly significant (p <.000001).


The right graph above compares LoR and RoL ratings for right handed, left handed, and ambidextrous persons. All three handedness groups show ratings of preference and comfort to their natural (spontaneous) position and are highly significant (p < .000001).

The graph below shows LoR and RoL comfort ratings as a function of people saying LoR is higher, or RoL is higher, or neither.  Results are clear, and significant (p <.000001). 

Conclusions:Regardless of age, gender or handedness, the natural (spontaneous) hands placement (left over right or right over left) is strongly associated with perceived comfort of the position compared to the reverse. 

Biophysical Findings:

Physiological Correlates When Engaging Spontaneous HAT Hands Position

1)    Equipment: ECG Triggered ERP LabView Analysis Program. This analysis program was written in LabView to perform off line analyses of EEG (brainwave files) triggered by the R spike in the QRS complex (contraction of the left ventricle) of the ECG (electrocardiogram) waveform. Using the telemetry device (B-Alert 10X), we record 9 channels of EEG brainwaves, and 1 channel of the ECG. The specially written program is designed to reveal evidence of the ECG in the EEG. The final result is one averaged ECG waveformplus nine averaged EEG waveforms, one per channel, all synched to the QRS of the ECG. 

2)    The initial “peek” into the heart-brain-hands connection: A single subject was studied and involved 4 conditions that ran for 3 minutes each while data was collected.  The 4 conditions were: 1) Eyes open with hands in the lap, 2) Eyes closed with hands in the lap, 3) Taking pulse with left hand, and 4) Spontaneous overlapping hands position over the heart as used in HAT (L/R for S) with eyes open.  When reviewing these pilot data, keep in mind that (1) there was no control for the order of the measured conditions, and (2) there was no matched control group (for example, replacing the HAT condition with a hands on abdomen control instead of on the heart).  This was an initial look regarding “proof of concept” comparing a HAT standard procedure (overlapping hands over the heart) with other procedures using the new ECG triggered ERP system.

Grand ECG triggered ERP Average of all 9 EEG channels comparing condition1 (Eyes Open) and condition 2 (Eyes Closed) over 157 seconds. 

The following graph show the visible cardiac R spike to be a) statistically greater in amplitude when the eyes were closed compared to eyes open, b) the visible cardiac R spike to be greater in amplitude when taking the pulse compared to eyes closed and eyes open, and c) the cardiac R spike was even greater in amplitude when overlapping hands were spontaneously placed over the heart (HAT) compared to any of the other conditions. These effects were all statistically significant (p’s <.001).

Cardiac R Spike and T Wave Comparisons

In the graphs below, the right graph pulls apart and graphically displays the cardiac T wave comparisons of Taking Pulse and the HAT Spontaneous Hands Position. The cardiac T wave reflects the re-polarization (recovery) of the ventricles.  As was evident with the R spike (left graph), the brain’s registration of the T wave is statistically greater in amplitude when overlapping hands were placed over the heart (HAT) compared to taking the pulse.                 


Measures of HAT Clinical Outcomes

Analysis of available clinical pre and post outcome data on patients treated with HAT for combat related PTSD, trauma, and loss/grieving events, clearly demonstrate statistically the healing benefits of HAT, which also transpires in a remarkably short time-span. A 3 - 6 month follow-up is currently being conducted. 

The graph below is a curve summarizing the findings for 22 treated incidents. Feedback on various pre and post measures were obtained after HAT treatment of the traumatic event as acquired by 2 therapists. The data strongly point to the clinical efficacy of HAT. 

The graph reflects the mean patient ratings of distress (0-10) before HAT (7), and then after HAT (0). The ratings of calmness after HAT (9.9) supports the reported absence of distress post-HAT. The average number of HAT sessions for a treated incident was 4 to 5. The patients’ reported comfort and satisfaction with the HAT psychotherapy approach was close to 10 across the variables.

The graph below visually displays the table information that follows depicting t test analysis comparing Pre and Post Distress values (p<0.0000001). 


Conclusions: Our pilot data indicates that patients recover from their highly distressing life experiences with HAT within an average of 4 to 5 sessions. Upon completion of the HAT protocol, there is a reported absence of distress to the treated life event. Patients report they like the HAT approach in psychotherapy and find it appropriate to their needs.

Research regarding HAT is ongoing at the University of Arizona under the direction of Gary E. Schwartz, Ph.D. Expansion of the pilot studies investigating the electrophysiological interactions of the heart-brain-hands connection (e.g., ECG triggered ERP, EEG, heart rate variability) is underway. The pilot data suggest that hands held over the heart have pronounced influence with the heart and brain that facilitate the calming results after completion of the HAT protocol. 

The interested clinician is referred to Heart Assisted Therapy (Diepold, 2018) to learn more about the development and applications of Heart Assisted Therapy.


Childre, D. & Martin, H. (1999). The HeartMath Solution. San Francisco: Harper Collins.

McCraty, R. ( 2012). The Energetic Heart: Bioelectromagnetic interactions within and between people. Boulder Creek, CA: Institute of HeartMath.


November 2017: For the past 2 years the research team at the University of Arizona has been laying the groundwork for highly sophisticated study of HAT and the HAT components. Several pilot studies have yielded exciting results pertaining to the influence of heart-breaths on heart and brain interactions! More information on the emerging data will be forthcoming.

December 2013: Study of the "Health Effects of Heart Assisted Therapy®-SR (HAT-SR)" is currently under way.  The research team of John H. Diepold, Jr., Ph.D. (Psychologist), Elisabeth A. Siegert, MD (Physician), and Maria E. Pfrommer, Ph.D., APN-C, RN, CNE (Nurse Practitioner, Nurse Educator) are evaluating the changes in physical and psychological health of residents in a Continuing Care Retirement Community after a six week pilot study using HAT-SR.  Heart Assisted Therapy®-SR is an abbreviated, three-step protocol for self-regulation (SR) for personal use by non-clinicians, which was derived from several components found in the HAT® model of psychotherapy. The participating residents are assigned randomly to either one of two treatment protocols and participate in pre and post treatment assessments.

September 2015: Data analysis has been completed.  

Diepold, J. H., Jr., Pfrommer, M., Siegert, E., & Thompson, J. A. (2015). The health effects of Heart Assisted Therapy-SR. Unpublished manuscript.

In a 6-week pilot study of HAT-SR conducted at the Evergreens Continuing Care Retirement Community, randomized geriatric subjects (n=19) were assigned to an intervention or control group and administered pre and post surveys. The Cognitive and Affective Mindfulness Scale–Revised (CAMS-R) (Feldman et al, 2007) was used to measure four aspects of trait mindfulness, including attention, awareness, acceptance, and present-focus. Separate paired t-tests were conducted to compare CAMS-R scores pre- and post-intervention for the placebo and intervention groups. Results revealed a statistically significant increase from pre- (M = 36.75 ± 6.90) to post-intervention (M=38.76 ± 6.59) in CAMS scores for the intervention group, t (N=7) = -2.43, p < .05, but not for the control group, t (N=6) = .47, p = .65. 


After conducting the above referenced pilot study, the authors gained additional knowledge on the benefits of HAT-SR and were inspired to move forward with teaching caregivers of patients with dementia about stress reduction and the HAT-SR mindfulness enhancing technique.  The primary aim of this project was to teach HAT-SR to long-term care staff in a continuing care retirement community (CCRC) and evaluate the effectiveness of HAT-SR as an intervention to benefit staff and improve care for patients with dementia. The authors’ secondary aim was to assess baseline knowledge related to mindfulness and caregiver challenges and to evaluate the effectiveness of the HAT-SR teaching session at increasing the participant’s awareness of these two aspects of dementia care. 

Pfrommer, M., McConnell, E.S., Diepold, Jr. J. H., Siegert, E.A., & Thompson, J.A. (2015).  Heart Assisted Therapy-Self-Regulation (HAT-SR) for caregivers of persons with dementia. Manuscript in review for publication.

Results: Mean scores were slightly improved (M=39.00 pre to  M=39.73 post) after practicing HAT-SR for just one week, however, these results were not statistically significant. The End of Educational Activity survey revealed 100% of participants increased their knowledge base regarding mindfulness, 86% reported the educational activity was helpful in identifying the challenges faced by caregivers of patients with cognitive impairments, and over 85% of participants responded favorably to using HAT-SR as a tool to promote calm and relaxation and to improve their practice. 

(Now for the exciting subjective data!):

Thirty-four participants were taught HAT-SR and asked to practice HAT-SR for one week.  Of the 34 participants, 16 chose to practice HAT-SR and returned survey tools. All participants were eligible to receive 1 CEU after the educational session and then received an additional CEU for turning in their post surveys.  Of the 34 participants, 13 agreed to practice HAT-SR for one week and completed the post-CAMS–R and the End of Educational Activity Evaluation. Of the 34 participants there were 32 females and 2 males. Occupations represented included Registered Nursing (20%), Licensed Practical Nurses (9%), Certified Nursing Assistance (32%), Physicians (6%), Physical Therapist (6%), Administration (6%), Advanced Practice Nurse (3%), Coordinator, (3%) Activities Director (3%), and Housekeeper (3%)

Primary outcome

Qualitative analysis of the End of Educational Survey revealed a majority of positive response to all questions on the survey. Table 1 depicts the questions and common responses to the questions in the survey.

Question                            Number (N)                             Percentage (%)   Comments (or n/a)                                                                                      

1. This continuing education activity increased my knowledge base about HAT-SR and mindfulness enhancing techniques.       15         100% strongly agree/agree           n/a

2. This continuing education activity was helpful in identifying the challenges faced by caregivers of patients with cognitive impairments   15    86.67% strongly agreed/agreed   13.33% undecided          n/a

3. I am confident I will be able to perform the HAT-SR technique        15         85.7% strongly agreed/agreed      14.29% undecided         n/a

4. HAT-SR would be useful for caregivers to family members with cognitive impairments?          15         93.0 % strongly agreed/agreed     7% undecided        n/a

5.  What did you like best about this continuing education activity?    15         Open-ended:       “Breathing; it relaxed me; it is easy; learning a new technique to help myself and residents; the calm feeling you experience right after the exhale; ease of performance with immediate effect; self help; taking myself into a peaceful state; the relaxing quality; I like the acceptance statement in the activity; It made me feel better afterwards and made me real proud of who I really am; my head feels clear afterwards; quick and easy to learn; learning a skill that can be used in practice; and It helps people”.

6. What did you like least about this continuing education activity?       8        Open-ended:       “The phrase; remembering to do it (n=2); rushed education; nothing (n=2); the last set of heart breaths; Relaxing; and felt I should do it more”.

7. Would you recommend this continuing education activity to other healthcare professionals?”    14         86% strongly agreed/agreed  7.1% undecided  7.1% no     n/a

8. Do you have any prior knowledge of mindfulness practices? If so, can you please elaborate?      14         36% yes    64% no     Yoga (n=3), meditation, learned during labor training, 4-7 breathes technique, I have an interest in positive psychology, read an article

9. Do you think the HAT-SR exercise is something that enhanced your practice? If so, can you please elaborate?     11         73% yes   27% no           “Yes, I can do HAT in a shorter time frame; yes, because I think everyone needs an exercise such as mindfulness practice in our everyday lives as acceptance and mindful to others and especially to the residents; yes, thinking clearly increases caregiver acceptance of where the patient is right now in their disease process and; yes, taught my mom and to a patient.

10. Do you think the HAT-SR exercise is something that enhanced your compassion for your patients? If so, can you please elaborate?”   13   69% yes  31% no            “It let's me have more patience; I am more relaxed so I can see past my stress and empathize; no, I am always compassionate; help calm them down; I am always compassionate; keeping me calm and remembering to breath really helps; absolutely more compassionate and especially with combative/ resistive and verbal abusive residents and; the exercise helps diffuse my frustrations towards different patients”.

11. Do you think the HAT-SR exercise is something that has enhanced your ability to have more patience? If so, can you please elaborate?      13         77% yes   23% no           “Not really, already overly patient (n=2) HAT-SR relies me and makes me more aware of my feelings; make me think before I react; HAT-SR reminded me that it is okay as an employee to take a few moments to myself if needed; not really; in accepting them (residents) for who they are and more than happy to help them and leave a smile on their face every single day; more aware, we all have burdens; calmness and; yes, more aware, we all have burdens”

12. Do you think the HAT-SR exercise is something that has enhanced your ability to be more attentive to your patients? If so, can you please elaborate?          13         67% yes  25% no    8% maybe  “Yes, because I'm relaxed I am more aware; yes, in understanding them and be at their present moment and help to relate to how they feel; yes, gives me patience; it increased awareness of the stressors on caregivers and; no, I have always been hyper aware of others feelings”.

13.  What was the one most important thing you learned about yourself from practicing the HAT-SR technique?     13         Open-ended:       “Slow breathing to calm self; that I can control my emotions with this technique, less stress; calming my mind; I can control my thoughts, emotions, and feelings; facilitates relaxation when tense or tired; helps with stress; that I actually have patience somewhere inside of me; accepting my staff (more so even than myself and the residents); breathing is important; thinking clearly; I need to be able to calm myself; I need to make more time to take care of myself and;  I need to do it to be calm”

14. Do you plan to continue using this self-care exercise?        14         71% yes   7% no   7% undecided    7 % “ I will try”               n/a