Breathwork as a Clinical Intervention: What Do We Know About Breathing

Written by Lloyd Lalande
There has been virtually no research to date aimed at advancing our understanding of breathwork as a clinical mental health practice. This lack of empirical study means there remains no universal agreement as to what Components make up a breathwork approach, no clear theoretical formulation of change processes, and no empirical foundation that can guide research, training and clinical practice. For
practitioners of Breathwork, this means it can often be a challenge to provide a rationale to clients and other health professionals for the use of the approach, and to find the language to express that rationale.

Research I have been undertaking over the past few years has been focused on developing an empirical base for breathwork as a treatment for depression and anxiety. The first step in this process was to search the existing literature to identify empirical support for the theoretical validity of breathwork, and to help define what exactly an empirically supported clinical breathwork approach looks like. As it turns out, there is a rich body of research that can provide empirical theoretical support for a three component clinical model of breathwork embodying the use of uninhibited breathing, mindfulness, and relaxation, which I refer to as Integrative Breathwork Therapy (IBT). The technique involves the therapist guiding the client through an approximately one hour process involving the ongoing regulation of breathing, relaxation and application of mindfulness, while the client lies comfortably on their back. A series of ten weekly sessions is the suggested norm. Specifically, this research provides a strong case for conducting efficacy research particularly relating to the treatment of depression and anxiety.

Of high importance to any approach aimed at improving mental health is a concise model of how psychopathology develops and is maintained. In a recent paper (Lalande, Bambling, King, & Lowe, 2011) which this article is based on, I have suggested that from a breathwork model perspective psychopathology involves,’the suppression of feelings, sensations and emotions experienced as aversive and inhibition of breathing as a central mechanism through which suppression is achieved. The need for ongoing control and defense against awareness of troubling somatic and psychological experience (necessary to maintain a sense of psychological balance) then results in a habitual, abnormal breathing pattern that becomes a more or less permanent feature of physiological functioning. Breathwork, therefore, assumes a link between the defensive adaptation of inhibited breathing, the presence of unintegrated psychosomatic experience, and the development and maintenance of psychopathology.’

Based on this model of psychopathology, a breathwork approach, in order to be effective seeks to optimally facilitate integration of rejected somatic experiences (e.g., sensations, feelings) by brining them into conscious awareness through the removal of breathing inhibitions (e.g., the adoption of a healthy breathing style) and then integrate those experiences by applying mindfulness and relaxation (Lalande, et al., 2011). Here I will focus on the breathing component of the approach.

One area of agreement among breathwork practitioners is the acceptance of “conscious connected breathing” as a defining feature of breathwork; but we need to be very specific as to how we are defining this important feature. In order for respiratory regulation used in breathwork to facilitate the removal of respiratory inhibitions (consistent with the model of psychopathology presented above) it needs to be comparable to the normal, healthy, relaxed, rhythmic breathing style described in the respiration literature. During a relaxed state, inspiration primarily involves the downward movement of the diaphragm and the outward movement of the abdominal wall and lower intercostal muscles, with some movement of muscles involved in expansion of the upper rib cage evident (Boadella, 1994; Bolton, Chen, Wijdicks, & Zifko, 2004).

A further feature of healthy inhalation, and therefore an aim in breathwork, is respiratory flexibility in which the thoracic cage has the freedom to expand in vertical, anteroposterior, and transverse directions (Bolton, et al., 2004). In regard to the exhalation, an agreed upon normal feature is that under most circumstances, it is effortless. The diaphragm, and other inspiration muscles are simply released from the expansion pressures exerted on them during inhalation, and exhalation then takes place entirely due to the elastic recoil of the lung, chest wall and diaphragm, with the assistance of gravity (Bolton, et al., 2004; Bradley, 2002). A further general feature of a normal healthy breathing pattern is its virtually unbroken rhythmicity. By basing conscious connected breathing on the natural, healthy, uninhibited breathing style as defined in the respiration literature we create a solid foundation from which we can guide clinical practice and training. It also allows us to explore the issue of breathing inhibition or pathology more easily.

Breathing Inhibition

Research has demonstrated that inhibited breathing is adopted as a means of defence against awareness of uncomfortable somatic experiences. Strained or inhibited breathing has been defined as featuring an extended, over-controlled exhalation, delayed onset of inspiration, and shortened duration of inspiration, as well as breath holding in more extreme cases (Fokkema, 1999). This definition, while perhaps overly simplified, is clinically useful for the breathwork practitioner in and of itself. A review of psychobiological research into aspects of respiration with animals and humans demonstrates strained (inhibited) breathing patterns develop in association with social factors, as well as the need for environmental vigilance, expectation and anxiety (Fokkema, 1999). For example, compared to being at home, being at work or with other people can elicit sustained inhibitory changes to breathing patterns (Anderson, 2001). Anderson and Chesney, (2002) found that over a one month period, inhibited breathing, characterised by subnormal breathing frequency, was linked to the perception of the environment as unpredictable, uncontrollable, or overwhelming. Coping with environments experienced as highly stressful imposes high attentional demands, which have been shown to inhibit breathing, with higher attentional demands correlated with increased inhibition (Denot-Ledunois, Vardon, Perruchet, & Gallego, 1998). Inhibited breathing, rather than being a transient response to an acute stressor, may be a “generalised breathing habit conditioned to the assessment that the world is a difficult or dangerous place” (Anderson & Chesney, 2002), an idea supported by the fact that breathing patterns can be shaped by classical conditioning (Shea, 1996).

Recently, the development of maternal deprivation paradigms enable the simulation of human child maltreatment conditions in rodents (Ladd et al., 2000; Sanchez et al., 2001; Veenema, 2009). Neonatal maternal separation of 180 minutes a day during the 3rd to 10th neonatal days produces persisting changes in adult rats anxiety levels (Wigger & Neumann, 1999). Changes in the organisation of respiration and blood pressure are also shown to persist as a result of prolonged neonatal maternal separation stress (Genest, Gulemetova, Laforest, Drolet, & Kinkead, 2004).

Conditioned suppression of breathing is associated with elevations in blood pressure and high levels of CO2 in the blood, which in turn is associated with a tendency toward increased worry and negative mood (Dhokalia, Parsons, & Anderson, 1998). The interaction of psychological and biological mechanisms may therefore feed into each other and serve to perpetuate both inhibited breathing (Fokkema, 1999) and symptoms of depression or anxiety.

Inhibited breathing has further ramifications for neurological functioning. Given there is little or no reserve of oxygen in the brain it is very sensitive to any changes in the level of available oxygen present in the blood or changes to blood flow (Erecinska & Silver, 2001). If there is a slight deficiency of oxygen reaching brain tissue (mild hypoxia), which may take place if breathing is inhibited, energy production via glucose metabolism may remain unaffected while serotonin synthesis is reduced, which has been demonstrated to be the case in research with animals (Erecinska & Silver, 2001; Nishikawa, et al., 2005), and multiple studies of acute depression have found decreased frontal cortex metabolism and limbic activation, with the severity of depression linked to larger decreases in metabolism (Post, 2000). There is considerable support for the hypothesis that a deficit in serotonergic neurotransmission in brain pathways regulating mood make one vulnerable to major depression (Rosa-Neto, et al., 2004).

In summary, there is empirical support for the development of inhibited or strained breathing patterns in response to experiences perceived as difficult or threatening. And once established, inhibited breathing patterns may be maintained through a feedback loop involving cognitive, physiological and neurological Components.
In more general terms, there is a growing body of empirical research that suggests suppression of inner experience, whether achieved through inhibition of breathing or not, plays a role in the aetiology and persistence of both anxiety and depression (Gross, 2002; Purdon, 1999). For example, Campbell-Sills, Barlow, Brown and Hofmann (2006) found that in individuals with anxiety and mood disorders, suppression was ineffective (compared to acceptance) in regulating negative emotion, and associated with poorer recovery from negative effect, increased sympathetic arousal, and decreased parasympathetic responding (Campbell-Sills, et al., 2006). Suppression of thoughts, memories and emotions has also been shown to produces a paradoxical rebound of unwanted thoughts, memories and emotions during post-suppression periods (Campbell-Sills, et al., 2006; Dalgleish & Yiend, 2006; Wegner, 1994; Wenzlaff, Wegner, & Roper, 1988). Further, the tendency to try and avoid or control (vs. accept) inner experience has been implicated in generalised anxiety disorder (Roemer, Salters, Raffa, & Orsillo, 2005), and shown to be strongly correlated with anxiety-related psychological distress (e.g., body sensation fears, anxiety sensitivity) (Kashdan, Barrios, Forsyth, & Steger, 2006). Kashdan, et al. (2006) found individuals reporting greater experiential avoidance also reported diminished positive emotional experiences, life satisfaction, and meaning in life, along with less frequent positive events on a day-to-day basis. These studies are part of a growing body of empirical literature that offers support for the proposition that suppression of inner experiences is linked to psychopathology, and specifically depression and anxiety.

I have presented an empirically based rationale for a focus on guiding clients in the adoption of an uninhibited breathing style in a clinical model of breathwork referred to as Integrative Breathwork Therapy. The respiratory component is the first of three that form the foundation of the approach. Two additional Components, the application of mindfulness and relaxation are also essential for effective client outcomes and also have a considerable research literature that supports their use in a breathwork approach aimed at depression and anxiety. For a full discussion of these you can refer to the paper, Breathwork: An additional treatment option for depression and anxiety? published in the Journal of Contemporary Psychotherapy (Lalande, L., Bambling, M., King, R., & Lowe, R., 2011).


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Breathwork: An additional treatment option for depression and anxiety? Journal of Contemporary Psychotherapy, Online FirstTM, 1 March 2011. doi: 10.1007/s10879-011-9180-6

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Keywords; Integrative Breathwork Therapy, Clinical intervention, Inhibited Breathing, Healthy Inhalation 

© Lloyd Lalande 2013

About the author: Lloyd Lalande’s primary purpose is to foster the professional development of the field of breathwork. His work in developing Integrative Breathwork Therapy (IBT) as a standardized, evidence based approach to mental health is central to this mission.

Lloyd works in the School of Psychology at the Australian Catholic University (Brisbane) as a lecturer and course coordinator for the Bachelor of Counselling and Master of Clinical Counselling programs. He holds a Graduate Certificate in Mental Health (Psychotherapy) from the University of Queensland, School of Medicine (UQ). Currently he is completing a PhD at the Queensland University of Technology.Lloyd has been practicing breathwork since 1984. He has studied with the pioneers of Breathwork and became a certified breathwork practitioner in 1988.