Treating PTSD with connected breathing: A clinical case study and theoretical implications 

Research Paper  by P.A.J.M. de Wit, R. Moraes Cruz

ABSTRACT 

Extended connected breathing (Rebirthing-Breathwork) has been popular as a self-development tool for more than 4 decades, but has been subjected to minimal scientific research. Similarities between connected breathing and two therapeutic modalities used to treat posttraumatic stress disorder (PTSD)—Eye Movement Desensitization and Reprocessing and Somatic Experiencing—suggest connected breathing to be efficacious in treating PTSD. The underlying theoretical model in these three approaches suggests that trauma is a result of the blocking or repressing of spontaneous somatic and cognitive processing. This study investigated the efficacy of connected breathing to treat PTSD in a firefighter. Pre- and posttreatment measures consisted of instruments to measure PTSD symptom- severity, anxiety, depression and heart rate variability (HRV). After 8 connected breathing sessions the participant’s PTSD and comorbid symptoms were in complete remission. Subjective reports and HRV data-analysis support the blocking/repression theory and suggest a role of the parasympathetic nervous system in the blocking of spontaneous trauma processing. In this case the original trauma appears have been a traumatic birth. 

1. Extended connected breathing 

Extended connected breathing, also known as Rebirthing- Breathwork (RB), has been used as a technique for self- development for the past 45 years. Originally developed by Leonard D. Orr from experiences during extended submersions in warm water, RB in its present form was consolidated in the mid 1970s. It reached a global audience in the late 1970s and became one of several types of breathwork (Orr, 2002; Minett, 2004; Churchill, 2007; De Wit, 2016). Presumably because of its alleged ability to bring about rapid and profound change, RB was quickly incorporated in group-programs focusing on self-development (see Carr, 2014, for an in-depth ethnographic investigation of RB in this context). As such it has mostly been used in conjunction with various other self-development techniques. However, RB can also be practiced on its own, in the form of individual breathwork sessions. Such sessions basically consist of an hour or longer of conscious connected breathing—hence extended connected breathing (ECB). ECB is usually conducted in supine position, with eyes closed. Although not necessarily easy, as a technique ECB is remarkably simple. A connected breathing rhythm simply means that there are no pauses between inhale and exhale. In addition, the inhale is active—usually slightly intensified—and the exhale passive, i.e. completely relaxed (depending on the breather’s ability to relax the exhale, which is an acquired skill). Particularly during early sessions, ECB often leads to the somatic and/or cognitive activation of unsettling/ ‘‘traumatic’’ memories and to slightly altered states of conscious- ness, and is often accompanied by a state of increased mindfulness (Minett, 2004; De Wit, 2016; de Wit, Menezes, Oliveira, Costa, & Cruz, 2018). 

Despite its relative popularity, its alleged potential for transformation and healing, and its origin in the mid 1970s, to date RB has been subjected to minimal scientific research1. Literature searches in three scientific databases (Psy- chInfo, Scopus and Web of Science), conducted on March 26, 2019, using the descriptors ‘‘rebirthing’’ and ‘‘breathwork’’ (separately), resulted in only five outcome studies about RB—the youngest one published 15 years ago. These studies consist of three articles and two doctoral dissertations using either pre-experimental (no control group) or experimental designs. At least three of these studies investigated the effects of RB in a group-context and as part of a more comprehensive program that included other self- development techniques (Rubin, 1983; Rajski, 2002; Chou, 2004). We were unable to access the study by Sudres, Ato, Fouraste ́, and Rajaona (1994), but according to Lalande, Bambling, King and Lowe (2012) that study used no additional techniques besides RB. The study of Jones (1985) used positive thinking exercises in addition to RB. No further outcome studies were found. However, following Manne ́’s suggestion to create a specialization within RB for the treatment of trauma (Manne ́, 2003), Lalande et al. published an article in which they analyzed the potential value of RB for the treatment of anxiety and depression (Lalande et al., 2012). 

Expanding on Manne ́ ’s suggestion, the primary objective of the project of which this study is a first outcome is to evaluate the efficacy of RB/ECB2 to treat trauma—more specifically, to treat posttraumatic stress disorder (PTSD). Secondary objectives are to test three hypotheses related to a theoretical model of trauma that is being developed as part of the project. A rough outline of this model will be presented next, followed by the three hypotheses. 

2. A theoretical model of trauma: a preliminary outline 

Based on extensive personal and clinical evidence, De Wit et al. (2018) and de Wit, Oliveira, Costa, Cruz, and Menezes (2019) observe that ECB appears to share key features with two contemporary therapeutic modalities used in the treatment of trauma: eye-movement desensitization and reprocessing (EMDR) (Shapiro, 2018) and somatic experiencing (SE) (Levine and Frederick, 1997; Levine, 2010). De Wit et al. (2019) note that descriptions of the cognitive processing of traumatic memories during EMDR bear close resemblance with descriptions of the cognitive processing of memories during ECB, whereas the somatic activation during early ECB sessions and subsequent somatic processing have much in common with the therapeutic process during SE (De Wit, 2016; De Wit et al., 2018). Shapiro and Levine both refer to an innate self-regulatory capacity and propose that this capacity is the healing principle targeted by their respective treatments (Levine and Frederick, 1997; Levine, 2010; Shapiro, 2018). Based on Shapiro, Levine and de Wit et al., we hypothesize that this innate capacity encompasses a cognitive and a somatic component. Furthermore, we hypothesize that ECB spontaneously engages both these components, whereas the approaches used in EMDR and SE tend to primarily target one of them3. 

Particularly EMDR has been subjected to frequent clinical trials and has been proven efficacious in treating PTSD (Spates, Koch, Cusack, Pagote, & Waller, 2009; Chen et al., 2014). Systematic research into the efficacy of SE is only just beginning, but first results are positive (Payne, Levine, & Crane-Godreau, 2015b; Brom et al., 2017). The alleged capacity of ECB to activate the hypothesized combined innate self-regulatory capacity targeted by EMDR and SE (De Wit et al., 2018, 2019) would add substance to the expectation that ECB could constitute an efficacious treatment for PTSD. 

In the previous paragraphs some commonalities between ECB, and EMDR and SE were highlighted. There is however an important difference between ECB, and EMDR and SE. The process of accessing traumatic memories in both EMDR and SE is predomi- nantly therapist-directed; the therapist uses a protocol and/or their professional intuition to guide the client’s attention and help them access traumatic memories. Furthermore, in EMDR the therapist uses bilateral stimulation to engage (re)processing of these memories (Shapiro, 2018), while in SE the therapist uses techniques such as pendulation and titration to engage processing and prevent re-traumatization (Levine, 2010). In ECB, both the accessing and processing of traumatic memories occur spontane- ously, without direct intervention from the therapist. In ECB, the therapist normally only guides the connected breathing rhythm (De Wit, 2016; De Wit et al., 2018 for further details about this guidance). 

This observation has led us to the following inferences. We deduce that if ECB can be shown to lead to the spontaneous processing of traumatic memories—and, more specifically, to the spontaneous resolution of PTSD—this implies that in trauma/PTSD this processing is somehow prevented from happening; in other words, it is blocked. We hypothesize that ECB is able to remove or suspend this blocking, and re-engages spontaneous processing. We propose that this spontaneous processing involves the innate self- regulatory capacity proposed by Shapiro and Levine, while trauma/ PTSD impedes this innate capacity. 

Integrating the concept of blocking of the cognitive and somatic components of an innate self-regulatory capacity with the four symptom clusters of PTSD described in diagnostic criteria B-E in DSM-5 (American Psychiatric Association, 2013), we propose the following outline of a theoretical model for PTSD. 

It can be observed that salient aspects of unsettling impres- sions, or emotionally intense experiences tend to repeatedly intrude upon conscious experience for a number of days (Horowitz, 1975). During this time these intrusions gradually lose their acute/ raw edge and are consolidated into episodic memory. After this consolidation, they no longer intrude upon present conscious experience and can be retrieved from memory like any other consolidated memory. We propose that this process of repeated intrusions, until the experience has been processed and stored in episodic memory, is the observable part of the cognitive aspect of the innate self-regulatory capacity mentioned earlier. It should be noted that this processing of experiences, particularly stressful ones, is believed to extend to, or perhaps occur predominantly during sleep–in particular during REM sleep (Stickgold & Walker, 2013; Van Rijn et al., 2015). 

It is generally thought that traumatic experiences overwhelm the traumatized individual’s cognitive processing capacity, with the result that salient aspects of the traumatic experience are not automatically consolidated into episodic memory in the way ordinary experiences are (Horowitz, 1975; van der Kolk, 1996/ 2007). These aspects of the traumatic experience may be temporarily dissociated or forgotten; however, they often intrude upon the traumatized individual’s present experience in the form of cognitive intrusions (flashbacks, nightmares, etc.). In PTSD the transformation from acute experience, via repeated (but decreas- ing) cognitive intrusions to episodic memory doesn’t occur spontaneously. We submit that the spontaneous cognitive processing of unsettling experience is somehow blocked or repressed in PTSD. In PTSD the intrusions are not transformed or consolidated, they become problematic and unwanted, leading to continuation of the symptoms described in diagnostic criterion B for PTSD in DSM-5. EMDR is believed to re-engage the cognitive processing of traumatic memories and intrusions, leading to consolidation. This process is called Adaptive Information Processing (AIP) (Solomon & Shapiro, 2008; Shapiro, 2018). De Wit et al. (2019) propose that ECB equally engages AIP. However, de Wit et al. propose a different model for AIP than the one developed by Solomon and Shapiro. The model proposed by de Wit et al. does not involve neural networks, but expansion of consciousness. Furthermore, instead of the accommodation and assimilation of traumatic memories in existing neural networks proposed by Solomon and Shapiro, de Wit et al. propose a process of distillation and (re)evaluation of the meaning given to traumatic memories. 

SE is partly inspired by ethological observations of prey animals surviving a predator attack. These animals go through a phase of vigorous shaking and trembling before returning to normal behavior. Levine and Frederick (1997) and Levine (2010) proposes that this shaking and trembling helps complete truncated survival actions and ‘‘resets’’ the autonomic nervous system after high- energy survival-related behavior. As such this behavior constitutes salient observable aspects of the self-regulatory capacity referred to by Levine. We propose that this behavior demonstrates the somatic component of a more comprehensive innate self- regulatory capacity. Levine asserts that particularly in humans this shaking and trembling can be repressed or blocked by what he defines as fear-potentiated immobility (Levine, 2010). Based on extensive clinical experience, Levine observes that humans that go through the strong physical reactions of trembling and shaking often also experience overwhelming emotions—particularly rage (Levine, 2010). In PTSD, these symptoms—mostly related to the symptom group, which DSM-5 refers to as diagnostic criterion E (arousal/reactivity)—are blocked by fear-potentiated immobility. However, under certain circumstances these symptoms can emerge spontaneously. Levine points out that such eruptions (or bleed-throughs) tend to reinforce the immobility reaction, turning fear-potentiated immobility into a vicious cycle (Levine, 2010). SE uses a body-focused approach to stop this vicious cycle and to re- engage somatic processing. It gently stimulates and facilitates completion of survival movements and energetic discharge (Payne, Levine, & Crane-Godreau, 2015a). De Wit (2016) and De Wit et al. (2018) highlight the similarities in the therapeutic processes occurring during SE and ECB and link these to somatic processing of traumatic memories. 

De Wit et al. (2018) emphasize that an attitude of allowing cognitive intrusions and somatic arousal is the key to successful early ECB sessions. They elaborate how during ECB repression of cognitive and somatic processing manifests as urgency and dissociation, and they present strategies to negotiate these so- called ‘‘psychophysiological defenses’’. They assert that, once re- engaged by allowing intrusions and arousal, cognitive and somatic processing occur spontaneously and don’t require specific therapeutic input. 

As far as we know, this article describes the first scientific outcome study that assesses the efficacy of ECB to resolve symptoms of PTSD. Furthermore, the project of which this study is a part is designed to test the hypotheses (elaborated above) that: 

•  psychological trauma (PTSD) can be conceptualized as a blocked self-regulatory capacity;
  
• this self-regulatory capacity has cognitive and somatic compo- nents;
  
• ECB spontaneously re-engages both the cognitive and somatic components of this self-regulatory capacity.
  In addition, it seeks to explore physiological and qualitative data that substantiate the cognitive and somatic processes proposed in the second hypothesis.

3. Method 

3.1. Design
A preliminary note on the design of this study: the study was originally planned as a pilot-project for a randomized controlled clinical trial to assess the efficacy of ECB to treat PTSD in emergency response professionals. The intention was to test the method with a small experimental and a small control group. In search for participants for this pilot study, a survey was conducted in a sample of 61 military firefighters from the state of Santa Catarina, Brazil—all participating in an 8-month residential training to become sergeant. Literature reviews indicated that the prevalence of (work-related) PTSD under first responders is high (Berger et al., 2012), leading to the expectation that the sample of firefighters would yield a sufficient number of participants for the pilot- project. Maximizing the homogeneity of the sample was a reason to limit participants to firefighters/first responders. The survey consisted of the Brazilian Portuguese adaptations of two connected self-report questionnaires: the Life Event Checklist for DSM-5 (LEC-5) (to assess trauma exposure), and the PTSD Checklist for DSM-5 with Criterion A (PCL-5) (to assess the severity of PTSD symptoms) (Weathers et al., 2013; Lima et al., 2016). Depending on what criterion was used to determine a provisional PTSD diagnosis on the basis of PCL-5 scores4, the scores of 3–5 firefighters warranted a provisional PTSD diagnosis. From the 61 firefighters that took part in the survey, seven (the five with a provisional diagnosis, plus two with subclinical symptom levels) were invited to take part in the first stage of the pilot-project, consisting of a diagnostic interview to confirm a PTSD diagnosis and assess comorbid symptoms of anxiety and depression. Five of the seven accepted the invitation, two declined. The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) (Weathers et al., 2015; Portuguese version, adapted for Brazilian context: Matsumoto & Neto, 2015) was administered to these five by a trained clinical psychologist. The PTSD diagnosis of only one of the firefighters was confirmed— the other four turned out to be virtually symptom-free. As it was no longer feasible to conduct a pilot-study consisting of an experimental and a control group, it was decided to conduct a clinical case study instead, using a pre-experimental, A-B-A single- participant design (where A stands for pre- and posttreatment baseline and B for treatment, Creswell, 2014, p. 174). The firefighter with the confirmed PTSD diagnosis was the study’s single participant. His PTSD appeared work-related (but see Discussion). As far as applicable to a single case study, the method adhered to the gold standards for outcome studies of PTSD treatments proposed by Foa and Meadows (1997). 

3.2. Participant 

The participant was a 28-year-old male firefighter of robust physical health and with a high, athletic level of fitness (see Results and Discussion for relevant mental health data). The participant was divorced, held a degree in theology, and, at the time of the survey, he had been a professional military firefighter for 9 years and 8 months and held the rank of corporal. The training for sergeant, in which he was taking part, took place at the training center of the military corps of firefighters of Santa Catarina in Floriano ́ polis and lasted from April 16 to November 30, 2018. Be- tween August 7 and November 21 the participant received 8 sessions of ECB. 

3.3. Instruments and equipment 

The pretreatment assessments consisted of The PTSD Checklist for DSM-5 with Life Event Checklist for DSM-5 and Criterion A (Portuguese version, adapted for Brazilian context—Lima et al., 2016), CAPS-5 (Portuguese version, adapted for Brazil—Matsumoto & Neto, 2015), Beck’s Anxiety Inventory (BAI), and Beck’s Depression Inventory (BDI) (Portuguese versions, adapted for Brazil—Cunha, 2001). Between the 5th and the 6th ECB session, a second PCL-5 (stand-alone version) was administered. The post-treatment assessments consisted of PCL-5 (stand-alone version), CAPS-5, BAI, and BDI (Fig. 2). PCL-5 contains 20 items: 5 items describing symptoms related to diagnostic criterion B, 2 items related to criterion C, 7 items related to criterion D, and 6 items related to criterion E. Each item is rated on a 5-point intensity scale ranging from 0 (not at all) to 4 (extremely). CAPS-5 contains the same 20 items, but whereas PCL-5 is a self-report questionnaire, CAPS-5 is scored by a clinician. In addition CAPS-5 contains items assessing DSM-5 criteria F and G, as well as 2 items related to dissociative symptoms. In both PCL-5 and CAPS-5 the symptom severity of the symptom groups can be determined by adding up the scores of the individual items belonging to each of the four diagnostic criteria. For a positive PTSD diagnosis DSM-5 requires 1 item in B, 1 item in C, 2 items in D, and 2 items in E with a score 􏰂 2. Although CAPS-5 also yields item scores, their weights differ from PCL-5 scores, due to the criteria by which the clinician is bound in deciding upon a score. CAPS-5 does not use a cut-off score for diagnostic purposes. 

In addition to sufficient symptoms in clusters B–E, a positive PTSD diagnosis requires a duration of the symptoms of more than one month (criterion F, assessed in CAPS-5), clinically significant distress or functional impairment caused by the disturbance (criterion G, assessed in CAPS-5), and direct or indirect exposure to a traumatizing event (criterion A, assessed in LEC-5, which contains 17 items). 

Furthermore, before every ECB session, the participant’s heart rate variability (HRV) was measured for 8 minutes (using a Polar H7 heartrate monitor in conjunction with the HRV logger application for iOS). 

3.4. Procedure 

The overall project was approved by the ethics committee of the Universidade Federal de Santa Catarina, Floriano ́ polis, Brazil (CAAE: 803767.000.0121; Parecer No.: 2.621.518). Before agreeing to participate in the study and signing a consent form, the participant was informed about ECB and about uncomfortable physical and psychological phenomena that can occur during a session (see De Wit, 2016, pp. 60–62 for a succinct description of these phenome- na). This instruction was repeated immediately before the first session, and strategies to deal with such phenomena were discussed. The sessions consisted of connected breathing, usually in supine position, on an 8-cm thick mat. They were all conducted by a single therapist with 8 years professional experience with ECB. The therapist was part of the research team. With one exception, the only interventions the therapist used were those that helped the participant maintain a connected breathing rhythm. Hardly any words were exchanged during the sessions. The therapist only used short (single- or two-word) encouragements to maintain, or adapt the breathing rhtyhm, and suggestions to stand up, lie down, or bend the knees. The exception occurred during the first part of session 3, when the therapist briefly guided the participant to connect with his anger during the first minutes of the session. No other therapeutic interventions were used. During sessions 2, 3, 6, & 7 the participant breathed in standing position for part of the session (when it was difficult to maintain the connected breathing rhythm due to falling asleep or lack of attention; and at the beginning of the third session, to enable the participant to get in touch with his anger—see De Wit et al., 2018, for a rationale for these strategies). During the initial instructions the participant was encouraged to find his own breathing rhythm during the sessions (with emphasis on the inhale, and without pauses between inhale and exhale), and to allow the rhythm to adapt to his emotional state. In principle the participant decided when the session was finished, but the therapist made sure (as far as possible) that there were no unfinished processes. After each session the participant verbally shared his experiences during the session. This verbal report was recorded and transcribed for later analysis. Pre-session conversa- tions between the participant and the therapist were written down by the therapist in a project-log. All sessions were conducted in the therapy room of a yoga center adjacent to the training center of the corps of firefighters. The duration of the sessions ranged from 32– 81 minutes (M = 54.6 min, SD = 16.3 min); they all commenced between 19 h and 20:45 h, after 11–12 h training days. 

3.5. Analyses 

Categorical results and scores from pre- and posttreatment assessments were compared, to verify efficacy of the treatment. Based on earlier research, the National Center for PTSD in the USA (NCPTSD) suggests a reduction in the PCL-5 score of ‘‘5 points as a minimum threshold for determining whether an individual has responded to treatment and 10 points as a minimum threshold for determining whether the improvement is clinically meaningful’’ (NCPTSD, n.d., p. 3). Spectral analysis of the pre-session HRV data was conducted using the method described in Ponnusamy, Marques, and Reuber (2011, 2012). The means of the HRV variables thus obtained were further analyzed for session-related patterns (using IBM SPSS). 

4. Results 

4.1. PTSD symptoms 

The results of the PTSD-related pre- and posttreatment assessments are summarized in Table 1. Criteria B–E refer to the four main PTSD symptom-clusters listed in DSM-5, i.e. intrusions (diagnostic criterion B), avoidance (criterion C), negative altera- tions in cognition and mood (criterion D), and marked alterations in arousal/reactivity (criterion E). The columns ‘‘number of items equal to or above 2’’ in the table indicate how many items in each symptom group had a score of 2 or more. 

All firefighters that participated in the preliminary survey— including the participant in this study—reported multiple expo- sures to traumatizing events in LEC-5, thereby satisfying diagnos- tic criterion A. CAPS-5 also confirmed criteria F and G for the participant. 

The scores for BAI and BDI were as follows: the pre-treatment anxiety score was 19 (light, bordering on moderate anxiety), the posttreatment score was 6 (no anxiety); the pretreatment depression score was 28 (moderate), the posttreatment score was 7 (no depression). 

Summarizing these results, the participant scored high in the initial PCL-5 and in the pretreatment CAPS-5, resulting in a positive PTSD diagnosis. After 5 ECB sessions the PCL-5 total score had been reduced by 18 points, ranging just above the cut-off point of 33 (see footnote 4). This reduction was well beyond the minimal threshold for clinical improvement suggested by the NCPTSD (10 points). The third PCL-5 was administered immediately before the final (8th) session, by which time the total score had been reduced by another 13 points (well below the cut-off score), and there were no longer sufficient items with a score to warrant a positive diagnosis. The posttreatment CAPS-5 (administered 1 week later) showed a further reduction5 and confirmed a complete remission of PTSD. Comorbid symptoms of anxiety and depression, which were (borderline) moderate before the sessions, were markedly reduced after the sessions. 

4.2. HRV data 

The pre-session means of the HRV variables obtained after spectral analysis were subsequently analyzed for session-related patterns. Only the variables considered related to the influence of the parasympathetic nervous system (PSNS) on the heartrate (HR) (Task Force, 1996; Toichi et al., 1997) showed a significant, session- related pattern. Said variables are the HF (recurrent changes in the high frequency domain ranging from 0.15–0.4 Hz. Task Force, 1996), the RMSSD (square root of the mean of the sum of squares of differences between adjacent normalized interbeat data points. Task Force, 1996), the SD1 (the standard deviation (SD) of the Poincare ́ plot—plotting each interbeat data point against the subsequent one—perpendicular to the line-of-identity. Toichi et al., 1997), and the cardiovagal index (CVI), also derived from the Poincare ́ plot (Toichi et al., 1997). Table 2 lists the pre-session means of these four variables. 

All four HRV variables associated with PSNS influence on the HR showed a statistically significant, strong, negative correlation with the number of the session. The statistical significance of the change (the decrease) in session- to-session values for each value was tested by calculating the Mantel-Haenszel linear-by-linear association. Summarizing, the pattern of decrease in PSNS-related HRV variables was statistically significant, indicating that—overall—the influence of the PSNS on the HR decreased as the sessions progressed. Note however, that all variables show an increase from the first to the second session, while HF and CVI also show an increase from the fourth to the fifth and from the sixth to the seventh session, and CVI also from the seventh to the eighth session. 

5. Discussion 

In this single case study ECB proved efficacious in treating PTSD. After 8 sessions the participant’s PTSD was in full remission and comorbid symptoms of anxiety and depression were greatly reduced. 

5.1. Marked emotional-cognitive shift 

The participant’s verbal pre- and post-session reports describe experiences that accompanied the processing of his traumatic memories. They are congruent with the trauma model described in the introduction, and indirectly support the hypotheses of somatic and cognitive processing. The reports show a marked emotional- cognitive shift in the time-period of the sessions.

Before the sessions the participant tried to avoid recalling traumatic experiences; he didn’t share them with anyone. He tried to control feelings of anger, but was not always successful. He felt caught in a negative cycle, which involved drinking, partying, negative emotions, financial problems, isolation, procrastination, bad sleep (due to nightmares), a chronic inability to be on time, regret and self-reproach. The main PTSD-related symptom groups associated with this period are avoidance (cluster C) and dissociative symptoms, and negative alterations in cognitions and mood (cluster D), with occasional eruptions of arousal/ reactivity (cluster E), and with occasional intrusions, particularly in the form of nightmares (cluster B). The eruptions of rage (interpreted by the participant to be due to lack of self-control) fed into cluster D symptoms (regret and self-reproach). The intrusions led to avoidance/dissociation-related behavior (drink- ing, partying, avoidance of sleep due to nightmares), leading to chronic problems with being on time, in turn feeding into cluster D symptoms. The hypothesized blocking mechanism (to be dis- cussed below, but related to avoidance/dissociation) was chal- lenged by the first ECB sessions. Intrusions became stronger from the time of the diagnostic interview (July 11), while arousal and reactivity (irritation/rage, as well as uncontrollable hunger) build up until the participant connected with, and embodied his rage during the first part of session 3. He reported having experienced an angry outburst a few days after the first session. The third session was the main session in which the somatic aspects of traumatic memories (related to symptom cluster E) were processed. The participant was able to access his rage directly in a safe situation and to embody it. After this session he acknowledged and processed his shame and self-reproach (symptom cluster D) connected with rage. Initially he was very ashamed of it, but he gradually came to accept it. After this session he no longer talked about feeling ‘‘irritated’’ when talking about certain past experiences, but about experiencing ‘‘rage’’. The remainder of the sessions was devoted to cognitive processing (symptom clusters B & D). During the fourth session the participant visibly experienced deep emotions, but shared none of the content of his experiences with the therapist. From the fifth session onward his experiences became very positive, notably he reported being able to forgive those people he had blamed before, including himself. During the period of the last three sessions he reported that he had left behind the negative cycle in which he had felt caught for several years, and was now able to take healthy control of his life. Despite increasing stress and anxiety (related to the approaching end of the training) he was able to remain positive and didn’t lose his equanimity. After the final session the participant briefly reflected on the positive changes he had made since starting the sessions. He highlighted that he no longer lost himself to anger during confrontations6 and that he could now talk with ease about his traumatic experiences—the memories no longer caused discomfort and he no longer felt he needed to hide them. 

The participant’s ability to talk with ease about his traumatic experiences by the end of the treatment is evidence that cognitive processing had occurred. After several sessions (1–4) he briefly commented that traumatic memories had emerged, but overall he was not able to report with sufficient detail about his mental experiences during those sessions. Thus a deeper, content-related analysis of the processes involved in the processing of traumatic memories was not possible. 

5.2. ECB activates traumatic memories and engages spontaneous processing 

From the first session the participant was encouraged to allow any mental and physical/physiological experiences that emerged spontaneously, including difficult ones, without trying to control them. He was instructed that it may be helpful to maintain a certain level of mindful attention when difficult experiences emerge, while at the same time allowing the experiences to unfold. These instructions were given directly before the first session and briefly reinforced before the third session. Apart from the therapist’s intervention at the beginning of the third session7, during the sessions the therapist only safeguarded the connected breathing rhythm of the participant and provided a safe environment in which traumatic memories could surface and be processed, no suggestions were given to access certain memories. No such suggestions were given during the conversations before the sessions either. These conversations had the character of a check-in about how the week/weeks since the last session had been and how the participant’s day had been (all sessions took place in the evening)8. The intervention at the start of the third session was the direct result of the participant’s remarks about his frustration and irritation in the week between the sessions (see footnote 7). This overall approach, the participant’s subjective reports, and the fact that the sessions resulted in the resolution of trauma, support the hypothesis that a connected breathing rhythm activates traumatic memories and (in combination with the attitude of allowing those memories to emerge) spontaneously engages their processing. Once activated and allowed to unfold, this process leads to spontaneous resolution of the trauma. The additional hypothesis that this spontaneous processing of trau- matic memories can be repressed or blocked implies that ECB suspends or removes this blocking. The activation of unprocessed memories through extended connected breathing may be related to activation of the autonomic nervous system (De Wit, 2016; De Wit et al., 2018), but the exact mechanism requires further research. 

5.3. Origin of the trauma 

Before starting the final session, the therapist and participant discussed what traumatic experience might have set off the participant’s PTSD. Before starting the third session the partici- pant had briefly mentioned his main traumatic experiences and they had all appeared work-related. He had been directly involved in a near motorway accident while returning from a work-related engagement in 2015, and he had been caught-up in a firefight at the outskirts of a favela in Rio de Janeiro while taking part in a military convoy in 2017. He had also mentioned these events during the initial survey, in the open questions related to criterion A that follow LEC-5. The worst event the participant reported on both occasions was being repeatedly exposed to news and information (from colleagues) concerning the Boate Kiss nightclub disaster in the South of Brazil, in January 2013. During a live concert in the nightclub a pyrotechnics device caused the insulation in the ceiling to catch fire. The fire and smoke spread rapidly. The nightclub lacked exit signs and had only one exit. In the panic that ensued most victims were trapped, and suffocated and burned. In addition a stampede at the entrance caused many injuries. The disaster killed 242 young people and injured at least 620 others. During the pre-session report before the third session, the participant confirmed that hearing and thinking about this event still caused him great anxiety, even though he had not been personally involved in the disaster—he emphasized that he didn’t understand why, he hadn’t even been there. 

Although secondary trauma has been accepted as a possible source of PTSD, the participant’s reaction to being exposed to information about the nightclub disaster slightly puzzled the therapist; the two traumatic events that the participant himself had been directly involved in had all occurred after the nightclub disaster. The missing link between the three events became clear when, during the conversation before the final session, the therapist realized that, due to language difficulties, he had misinterpreted a crucial word. It is part of the routine of RB therapists to question clients about their birth, since distressing perinatal experiences—birth trauma—often emerges during early breathwork sessions (Grof, 1985, 1988; Emerson, 1996; Orr, 2002; Churchill, 2007; De Wit, 2016). The therapist had inquired about the participant’s birth in the conversation before the third session. The misinterpreted word was atravessado, meaning transverse presentation, which the therapist had understood as atrasado, meaning late, or past the due date. In fact, the participant had been in a transverse presentation at the time of his birth, causing his mother severe agony. He probably wouldn’t have survived without an emergency caesarian. This information, which only became clear before the final session, made birth trauma likely. 

It is common knowledge among rebirthers that traumatic birth patterns tend to be mirrored in certain situations later in life—a phenomenon that has also been described by Grof (1985, 1988) and Emerson (1996). There is an easily recognizable common element shared by all traumatic events described by the participant: being in a life-threatening situation without exit. Crucially, this situation first presented itself during his transverse presentation at birth. During labor no part of his body had engaged, and his body had literally been wedged between the contracting walls of his mother’s uterus, with no available exit. In the nightclub disaster most of the casualties had died because they could not find or reach the exit. Similarly, the participant reported that the most traumatic part of the near car accident and the firefight had been that he had been wedged between two colleagues on the backseat of a car (in both events!). He had had no room to move or escape and described having felt utterly vulnerable, anticipating the deadly impact of (respectively) a crash or a bullet. Concluding, we hypothesize that the participant’s trauma originated with his traumatic birth; that the disturbing information about the nightclub disaster activated the participant’s presumably dormant birth trauma (leading to the onset of his PTSD symptoms); and that the other two events reinforced this activation (consolidating the symptoms). 

5.4. The PSNS and repression/immobility/dissociation 

The overall decrease of PSNS influence on the participant’s HR as the sessions progressed supports a clinical explanation of PTSD resolution that is congruent with the trauma model proposed in the introduction. Levine (2010) describes a behavioral sequence that humans and higher mammals instinctively resort to when confronted with (life)-threatening situations (Schauer & Elbert, 2010; De Wit, 2016; De Wit et al., 2018). The first part of this sequence is characterized by increased embodiment and by activation of the SNS (it includes the well-known flight and fight responses). The second part of the sequence is characterized by increasing levels of immobility and dissociation, and by deacti- vation of the SNS and increasing disinhibition (hence activation) of the PSNS. The participant’s high PSNS at the beginning of the ECB sessions (and its subsequent reduction as the sessions progressed) can be interpreted as a phenomenon underlying Levine’s concept of fear-potentiated immobility (Whitehouse & Poole Heller, 2008; Payne et al., 2015b). The initial high activity of the PSNS can be interpreted as a physiological correlate of an activity (Levine suggests immobility) that results in the repres- sion or blocking of the somatic component of the self-regulatory capacity. Unrepressed, this capacity would lead to spontaneous resolution. The initial high activity of the PSNS can also be interpreted as a physiological correlate of symptoms related to dissociation. If, and how this high level of PSNS activity can be linked to birth-related trauma requires further research, but Levine’s concept of immobility appears to fit. The overall reduction of PSNS influence on the HR as the sessions progressed can be interpreted as the physiological correlate of the lifting of repression/blocking/immobility, resulting in the re-engagement of the self-regulatory capacity and the resolution of the trauma. The decrease of PSNS activity also coincides with a decrease in dissociative symptoms. 

We compared HRV-related variables with the information from the pre- and post-session reports summarized. Considering CSI and CVI as the most reliable correlates of SNS and PSNS influence on the HR (Toichi et al., 1997), we see an initial rise in both SNS and PSNS activity, and a simultaneous rise in arousal (irritation and hunger—SNS-related) and sleepiness (PSNS-related). PSNS activity starts to decrease after the second session and SNS activity after the third session. The decrease in PSNS activity appears to level out after session 6 (there is a slight increase in the CVI, but a continuing decrease in RMSSD). Our interpretation of the SNS activity after session 5 is that it responds to present circumstances. After session 6 the uncertainty in the life of the participant increased significantly and led to an increase in anxiety about the future. At the same time however, the participant’s coping abilities and resilience appea- red to have improved. There was a marked increase in anxiety (as per the participant’s subjective reports) at the time of session 7, but although none of the uncertainties that presented themselves between sessions 6 and 7 had been resolved at the time of session 8, by then the participant was at peace with the situation and confident that he would be able to cope with whatever life would put in his way. The participant received none of the common therapeutic input (cognitive behavioral therapy [CBT]) to improve his coping abilities. From a therapeutic perspective this develop- ment occurred spontaneously in conjunction with the ECB sessions. In short, the patterns of CSI and SDNN from session 5 onward can be interpreted as reflecting the response of the ANS to present life circumstances, no longer to past trauma. Further- more, the activation of the SNS was no longer met with an increase in PSNS activity (reflecting an immobility/dissociation response), it was an appropriate response to present life circumstances and the participant no longer resorted to the negative coping patterns he had resorted to before the sessions. 

Summarizing this case, using HRV data as correlates of trauma- related psychophysiological activity, we conclude that ECB first challenged the blocking/repression of the hypothesized innate self-regulatory capacity, correlating with a decrease in PSNS activity. Once the blocking/repression had been suspended/ removed, the somatic component of the self-regulatory capacity became engaged, culminating in the embodiment of rage in session 3. Session 3 was followed by a decrease in SNS activity, presumably because arousal/reactivity was resolved due to somatic processing. Cognitive processing of traumatic memories followed somatic processing and (spontaneously!) led to im- proved cognitive functioning (e.g. a spontaneous shift to positive coping strategies). 

5.5. Limitations 

The results of this study are highly encouraging, but the study had its limitations. Although congruent with extensive clinical experience, this study had only one participant and its results do not allow generalization. The results call for a proper clinical trial and as such this pilot study was valuable. The basic design of this study is workable and can be used for an experimental trial. Objectivity might be better guaranteed by (a) therapist/therapists that is/are not part of the research team, and by the use of a formalized treatment manual (as per the guidelines set out by Foa & Meadows, 1997). In this study the clinician administering CAPS- 5 was not blind (as originally intended), since she diagnosed only one firefighter with PTSD and this firefighter was the only one returning for a post-treatment assessment. As stated in the subsection Marked emotional-cognitive shift, the participant was not able to provide sufficient detail of subjective experiences during the sessions to carry out a more profound qualitative analysis of his cognitive processing. Furthermore, it would be preferable to perform HRV measurements in the morning, upon awakening, to prevent confounding influences from experiences before the session (e.g. in this case some of the training days featured exams, others involved high levels of physical exercise, while others mainly consisted of theoretical classes). Finally, it should be noted that the theoretical model presented here is a mere outline—a working model—based on clinical experience with ECB and on existing literature related to EMDR and SE. We are working on a more comprehensive theoretical trauma model. 

6. Conclusion 

As far as we know, this is the first evidence-based outcome study demonstrating the efficacy of ECB to treat PTSD. Considering the time ECB has been around, we believe this study was highly overdue. Awareness of the global costs of PTSD is growing rapidly, with estimates of lifetime prevalence ranging from 2.1–5.0% in the general population, to 80% among certain groups of refugees (Kessler et al., 2009; Norris & Slone, 2013; Koenen et al., 2017). The potential of ECB to provide a relatively simple and effective treatment for PTSD deserves urgent further investigation. To assess the general efficacy of ECB to treat PTSD, clinical trials are necessary. Three-arm clinically controlled trails in which the efficacy of ECB is compared to no treatment as well as to another treatment (e.g. EMDR or CBT) are the present standard. We recommend to initially restrict testing to participants with single- incident or work-related PTSD, particularly when using research designs with minimal therapeutic input that rely on the engage- ment of spontaneous processing. Participants with more complex forms of PTSD may require a different therapeutic setup, and clinically focused pilot studies are recommended in such cases. 

The procedures and the results of this study offer preliminary support for the outline of a theoretical model and the hypotheses presented in the introduction. To advance the development of the theoretical model, further qualitative and quantitative analyses, particularly of the actual processing during ECB, are necessary. If confirmed by further research, the finding that healing trauma and (e.g.) acquiring new coping skills are spontaneous internal processes (which may be facilitated, but are not delivered by external agents), seriously challenges fundamental contemporary therapeutic principles. Finally, the role of birth trauma as a potential antecedent of secondary (vicarious) trauma deserves further research. 

Footnotes: 

1 Moreover, ‘‘rebirthing therapies’’ appears high on Norcross, Koocher, and Garofalo’s list of (probably) discredited psychological treatments (Norcross, Koocher, & Garofalo, 2006). However, it is very likely that the term ‘‘rebirthing therapies’’ used in the report by Norcross et al. does not refer to extended connected breathing as discussed here, but to a controversial therapy predominantly applied to children and adolescents with attachment disorders. In 2000 the use of this treatment led to the death of 10-year-old Candace Newmaker (see e.g. De Wit, 2016). Gerard Koocher, one of the co-authors of the report, also co-wrote a chapter in a book about evidence-based treatments for children and adolescents (Koocher, McMann, & Stout, 2014). In that chapter a confusing mix of rebirthing-breathwork and rebirthing therapy (the controversial attachment therapy) is presented. The mention of the Newmaker case, as well as the references used in that chapter make it clear that the attachment treatment and not rebirthing-breathwork is meant. It is quite likely that the same confusion pervades the report by Norcross et al. The fact that the attachment treatment has also been called ‘‘rebirthing’’ has led to abundant confusion and is one of the reasons why extended connected breathing is nowadays referred to as rebirthing-breathwork instead of merely rebirthing (De Wit, 2016). 

2 In the remainder of this article we will use the term extended connected breathing (ECB) instead of Rebirthing-Breathwork (RB) in order to: (1) indicate that the treatment solely consists of extended sessions of conscious connected breathing; and (2) to prevent confusion with the attachment therapy that is also called ‘‘rebirthing’’ (see footnote 1). 

3 Although in their theoretical models and therapeutic approaches EMDR and SE focus predominantly on cognitive and somatic processing respectively, like ECB, both EMDR and SE appear to engage both modes of processing. Nevertheless, while stressing the inclusion of somatic processing in EMDR, Shapiro explains the phenomena associated with such processing ‘‘simply as a manifestation of the information being processed’’ (Shapiro, 2018, p. 81), thereby stressing the cognitive character of such processing. Levine on the other hand, recently brought SE conceptually closer to cognitive processing by proposing that SE facilitates the transmutation of trauma-related procedural (behavior-related) memories to episodic memories (Levine, 2015). 

4 The individual item scores in PCL-5 can be summed to obtain a total symptom severity score (ranging from 0–80). Different cut-off points can be used to yield a provisional PTSD diagnosis. The National Center for PTSD in the US suggests a cut- off point of 33, based on preliminary validation work (National Center for PTSD, n.d.). Alternatively, each item rated 2 (‘‘moderately’’) or higher can be considered to endorse a symptom. Thus, in accordance with DSM-5: at least 1 item with a score 2 for cluster B; at least 1 item with a score 2 for cluster C; at least two 2 items with a score 2 for cluster D; and at least 2 items with a score 2 for cluster E items yields a provisional PTSD diagnosis.

5 During the posttreatment diagnostic interview, for all items of the CAPS-5 both the past week and the past month were scored. The scores in Table 1 indicate the answers for the past month (because the PTSD diagnosis is based on that score). The measures for the past week were as follows: cluster B: 3, 0 (symptom severity score: 3, number of items with a score 2: 0); cluster C: 0, 0; cluster D: 1, 0; and cluster E: 4, 1. Thus, the total severity score for the week after the last session was 8, with only one item 2. 

6 This change was independently confirmed to one of the researchers by four of the participant’s colleagues in the training. 

7 Before the start of the third session the therapist suggested that the participant (deliberately) connect with his rage, and instructed him to breathe in standing position. As the participant focused on feelings of anger and irritation, the therapist actively encouraged him to allow these feelings to unfold. The rationale for this intervention was discussed with the participant before the session, after he had expressed strong frustration with the increase in irritation and the uncontrollable hunger and sleepiness between session two and three. Following this discussion the decision to apply the strategy was taken jointly. 

8 During the check-in before the third session the therapist briefly inquired about traumatic events in the participant’s life, and also about the participant’s birth. During the check-in before the final session, these events were explored more in depth to resolve some confusion about the origin of the participant’s trauma (see next sub-section: Origin of the Trauma). 

Keywords: PTSD, Breathwork, EMDR, Somatic Processing

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