Patricia L. Gerbarg1,*, Richard P. Brown2 

Abstract 

New models for mental healthcare are needed to address the global epidemic of depression, anxiety, and post-traumatic stress caused by wars and other mass disasters. Excess stress and trauma are major drivers of mental health disorders. Mind-body interventions that balance and strengthen stress response systems can prevent and improve these conditions. Evidence-based, trauma-informed, breath- focused mind-body treatments can relieve psychological, emotional, cognitive, and somatic symptoms in survivors and caregivers during and after disasters. This overview describes Breath-Body-Mind programs that exemplify a new model of care using online platforms to deliver stress and trauma relief as well as for training community extenders to teach greater numbers of disaster survivors and frontline workers in Ukraine, Rwanda, Türkiye, Ireland, and other countries. Understanding neurophysiological processes that contribute to the beneficial effects is important for selecting and optimizing the safest, most effective, and efficient methods for stress and trauma relief. Teaching professionals and lay providers how to create an engaging, safe, supportive environment online and in person enables a small group to deliver accessible, culturally syntonic, non-stigmatizing, sustainable mental health interventions to large populations impacted by disasters. This overview offers guidelines for a scalable mind-body intervention, plausible mechanisms of action, summaries of studies, and fieldwork in mass disasters since the 2017 Rohingya genocide in Myanmar (Burma), and future directions. 

1. Introduction 

New models for mental healthcare are needed to deal with the global epidemic of depression, anxiety, and post-traumatic stress caused by mass disasters, including war, terrorism, population displacement, pandemics, economic inequity, and political unrest [1–3]. Global events that increase mental health risks include economic downturns, social polarization, public health emergencies, humanitarian emergencies, forced displacement, and climate change. Lack of access to care, low levels of mental health literacy, stigma, and poverty exacerbate the problem. 

Stress and trauma are potent drivers of mental health disorders [4]. Interventions targeting the systems that mediate stress response can mitigate acute and long-term adverse effects of war and other mass disasters. The magnitude of untreated mental illness worldwide dwarfs the professional and financial resources for treatment, especially in low-resourced countries [3]. Developing new methods and models of care, particularly accessible, affordable, sustainable community-based mental health treatments, is essential to reduce the chasm between people in need of mental health support and currently available services. 

Working on the frontline of public health emergencies takes a toll on the mental health of caregivers. Interventions are needed that also ameliorate stress, exhaustion, and burnout in providers for their well-being and to sustain the workforce necessary to deal with disasters. A recent systematic review of effective strategies to address the psychological impact of working on the front lines of public health emergencies concluded that mind-body interventions have the most substantial evidence for improving the quality of life of frontline workers [5]. 

First, guidelines that include key features of programs that could help reduce the deficits in global mental healthcare are proposed. Next, evidence-based plausible mechanisms of action that may contribute to the observed therapeutic effects of breathing practices on the autonomic nervous system (treatment target) are briefly reviewed. Breath-Body-Mind (BBM), a breath-focused mind-body stress and trauma relief program, is derived from ancient practices (qigong, yoga, tribal healing, and martial arts) that have been combined and shaped by neuroscience and psychology for modern therapy. This overview focuses on BBM programs for disaster relief, including clinical studies, fieldwork, and case vignettes. BBM is compared with the widely used Group Problem Management Plus program of the World Health Organization [6]. The extent to which these programs fulfill the proposed guidelines, potential clinical uses, limitations, and future directions is considered. 

1.1. New models for global mental health 

Ancient mind-body practices, such as yoga, qigong, and tai chi, have been used to reduce symptoms of stress and trauma as well as to increase stress resilience. Some systematic reviews find promising evidence; others question the quality of research, and most call for larger, better-quality studies [6–12]. Using modern neuroscience and clinical observation, we can amplify the impact of mind-body medicine, compress the learning curve, and accelerate response/remission [13]. Online open-access global plat- forms with translation can help to scale up training programs and globalize interventions [14]. Furthermore, through community extenders and online teaching, a small number of skilled providers may deliver treatment to thousands of people far more efficiently than in the model of one-to-one care. Professional training and supervision of community assistants to provide mental health services in low- and middle-income countries have been associated with significant improvements in mental health [15, 16]. 

1.2. Breath-Body-Mind Program Guidelines for global mental health 

For large-scale mental health interventions during and after mass disasters, the following guidelines are proposed: 

1. Intervention methods: a simple set of techniques that can be used in multiple settings, for example, hospitals, clinics, offices, outpatient programs, schools, community centers, bomb shelters, refugee camps, workplaces, at home, outdoors, onsite in disaster areas, in the field during combat. 

  1. Intervention effects: rapid positive responses include reduction of anxiety, depression, post-traumatic stress disorder (PTSD), insomnia, negative emotions, excessive aggressive behavior, feeling connected to oneself and others, pain, and stress-related physical symptoms. Also, it improves emotion regulation, energy, cognitive function, attention, executive function, and social engagement.
  2. Local people can be trained relatively quickly to teach basic methods as community extenders. In time, they can be trained to train more teachers, multiplying the task force.
  3. The methods must be safe regardless of age, gender, physical, or psychological conditions. Teacher training includes adaptations for children and for conditions such as respiratory disorders, physical injuries, mental illnesses, or acute trauma.
  4. Acceptable to people of diverse cultures, ethnicities, and religions with minor adaptations.
  5. Evidence of safety (few adverse effects) and efficacy based on prior effects in populations affected by mass disasters. 
  6. Costs are modest compared to conventional psychological interventions or medications.

1.3. Neuroscience and therapeutic effects of breathing practices 

1.3.1. Mechanisms of action 

Evidence supports numerous plausible mechanisms that involve in the neurophysiological responses to breath-based mind-body practices such as autonomic balance, pulmonary afferent activity, respiratory entrainment of brain electrical activity, oxytocin and vasopressin, and polyvagal theory 

1.4. Breath-Body-Mind Fundamentals Program overview 

The Breath-Body-Mind Fundamentals Program is usually given in 4-hour sessions on three consecutive days. On Day 1, participants are taught rounds of movements coordinated with breathing. Each day begins with introductory remarks and checking in to discuss how the participants are feeling, what they are hoping to gain, and how they are reacting to the practices. The first practice is activating with shaking, tapping, or brief (2 minutes) forceful breathing at 20 cycles per minute (cpm). The next practices include qigong movements paced at 4-2-4-2 (inhale for a count of 4, hold the breath for a count of 2, exhale for a count of 4, hold the breath for a count of 2) or 4-4-6-2, followed by simple arm movements with coherent breathing at 5 cpm (see below), 2 deep breaths with sighs, progressive muscle relaxation, coherent breathing in stillness with eyes closed, imaginatively moving the breath in circuits at 5 cpm, body scan, 2 deep breaths with sighs, rest, interoceptive self-awareness, and sharing. 

While the whole group of participants do the first round of coherent breathing, the assistant teachers pin (enlarge the image) each one in turn to closely observe their breath pattern. Participants divide into small groups of 8–12 in breakout rooms, each with a BBM teacher who leads simple group processes, such as introductions and brief sharing, and a second round repeating the practices with more individual teaching for coherent breathing as needed. The group returns to the main room for an hour of didactic instruction with discussion, and a third round of breathing and movement practices, sharing and a question-and- answer period. Each round extends the length of time for coherent breathing in stillness up to 20 minutes by Day 3. Participants are given access to free breath-pacing tracks and instructed to begin practicing on their own. The teachers meet before and after each session to share information on the students’ progress and any problems they observe. If any participant is not able to do coherent breathing by the end of Day 1, they may be given a short one-on-one session on Day 2 to evaluate and resolve residual difficulties. Days 2 and 3 are similarly structured with additional practices, such as attentional focus exercises and BBM practices for children. 

On Day 1, participants begin to experience noticeable symptom relief. They make comments such as “This is the first time I have stopped shaking since the war began 2 months ago” or “This is 

the most relaxed I can remember feeling”. On Day 2, many participants report that they were able to sleep for the first time in months or that their chronic pain (e.g., headache, back pain) stopped. On Day 3, participants often describe feeling reconnected to people and they thank the teachers for helping them feel “normal” again or for reminding them what it feels like to be happy. 

Following the 3-day program, participants are encouraged to practice coherent breathing for 20 minutes every day if possible and to attend an online group practice session (45–60 minutes) once weekly for 6 weeks. During those 6 weeks, most participants continue to improve with reduced symptoms of anxiety, depression, and trauma. For example, hearing air raid alarms no longer triggers panic attacks. Many choose to continue attending practice sessions and training to become BBM teachers because they want to share the practices with their families, friends, coworkers, and the people around them. 

Modifications are often used in working with different groups to accommodate the severity of their trauma symptoms (see BBM in Ukraine below), physical conditions, or cultural concerns, as the following examples illustrate. 

1.4.1. Post-COVID respiratory problems 

People with respiratory conditions, such as post-COVID, obstructive lung disease, or severe asthma, may need to begin at a faster breath rate and practice for a shorter period. Over time, many will be able to slow their breathing down more and practice for a longer period. This may take weeks or months. 

Coherent breathing helps improve respiratory function because the slow gentle inhalation leads to greater expansion of alveoli (air sacs within the lungs), better ventilation-perfusion matching, optimal oxygen exchange with each breath, and reduced expenditure of energy to breathe [33]. 

1.5. Coherent breathing 

Coherent (resonant) breathing, the foundational practice in BBM programs, is slow, gentle, natural breathing in and out through the nose with an equal duration of the inspiratory and expiratory phases, performed breathing at 4.0–6.0 cpm for the average adult [13, 21]. No effort is exerted to overfill the lungs or to expel all the air. A breath-pacing audio track is used to minimize mental activity (such as counting) while maintaining the breath rate. Coherent breathing was chosen because it induces an ideal state in which the individual is both relaxed and alerted with mental clarity and good cognitive function. Moreover, it is practical, versatile, and private. One can do coherent breathing with eyes open in a public setting while appearing to be merely breathing quietly. Because coherent breathing supports improved cognitive functions, it can be done while studying, working, or test- taking to reduce anxiety and enhance performance [13]. 

Coherent breathing calms people during and after disasters and other stressful events. The ability to calm down quickly and restore mental clarity is critical for dealing with emergencies and making life-saving decisions [37–39]. Furthermore, reducing the intensity of fear and improving the ability of survivors and first responders to stay calm, sleep, and restore energy reserves may reduce the risk of later developing PTSD [4, 45, 46]. 

1.5.1. Cultural issues 

Most cultures use breath practices in some form or another. Consequently, the therapeutic use of breathing is widely accepted across cultures. The only problem we have encountered has been in groups (usually fundamentalist Christian or Catholic) where there is a belief that breathing practices come from yoga and that yoga comes from the devil. BBM programs do not teach any religious practices. The techniques are derived from many different national and tribal traditions. When we explain this, give examples, and provide the basic scientific background, most people feel comfortable in learning BBM. 

Before teaching in a new country, we try to learn about the culture, traditions, and taboos (see the Ukraine section below). For example, in 2017, when we taught refugees from Middle Eastern countries who were living in shelters in Berlin, we had women teachers work with the women and male teachers work with the men. Our teachers wore modest clothing, similar to the garments of the refugees. The practices Dr. Gerbarg taught the women were gentler and accommodated the young children who were with them. She also taught the mothers how to teach their children coherent breathing to calm down and go to sleep. Dr. Brown taught the men more vigorous tapping practices that they enjoyed. 

In some countries, Western interventions are viewed with suspicion as forms of neocolonialism. BBM teachers have en- countered this concern, particularly in African nations that have suffered greatly in this regard. The expectation is that Westerners come to get money and exploit the people and their resources. Such attitudes are entirely understandable. Nevertheless, BBM methods have been welcomed and valued in Rwanda, South Sudan, Uganda, South Africa, and Nigeria. Mistrust is overcome as people realize that (1) the programs are free, (2) they provide rapid relief from distress, and (3) BBM teachers treat them with respect, listen and respond to their needs, incorporate their ideas, and train them to become independent teachers of their own people. 

1.6. Self-care and co-regulation 

Learning the skills to teach BBM practices is both an intellectual and experiential process. As BBM trainees themselves benefit emotionally and physically from the therapeutic effects, they acquire a greater comprehension of how to teach others. Simultaneously, their psychophysiological states are shifted toward calmer, steadier, more empathic, and aware functioning, 

preparing them to effectively co-regulate others and optimize the therapeutic benefits of the practices. To facilitate this process, we remind trainees to first focus on self-regulation by practicing the breathing techniques regularly. 

Co-regulation refers to the supportive, responsive interactions occurring between parents and children that soothe the child and the parent. Over time these interactions affect the neurological and emotional development of the child, become internalized, and form the basis for the self-regulation of emotions. Healthy co-regulation requires closeness, safety, and bonding [13, 19, 24, 25]. Overwhelming stress, neglect, or trauma can disrupt this process and lead to psychological and physical disorders. 

BBM teachers learn how to create a safe holding environment with appropriate boundaries through online communication skills and consistent, supportive, non-judgmental, trauma- sensitive methods with a total focus on the needs of the students [47]. The most important communication skills include the teachers’ awareness of their own facial expressions, placement of their image in relation to the screen, and their voice tone, prosody (melodic qualities, rhythm, stress, intonation), and pacing. When the teachers create a good enough holding environment [46–48], participants feel safe enough to relax, lower their excess defensiveness, feel connected to others, open their hearts, and allow changes to occur. Responses from BBM program participants confirm that for all groups, and especially for traumatized populations during mass disasters, the emotionally safe environment wherein positive co-regulation can occur is as important as the techniques being taught. 

2. Results 

2.1. Effects of breath-centered mind-body practices in children and adults affected by war and other mass disasters 

Mind-body techniques have been shown to reduce the adverse effects of stress and trauma on child and adult survivors of war and other mass disasters [49–52]. During the past 20 years, Gerbarg and Brown developed sets of gentle relaxation, move- ment, breathing, and attention focus practices that have safely and effectively reduced symptoms of stress and trauma in healthcare providers, first responders, and survivors of mass disasters including the following: 9/11 World Trade Center Attacks in New York, Deepwater Horizon Gulf Oil Spill, South Sudanese people liberated from slavery, post-Genocide Rwan- dans, over 100 of the Chibok girls who were rescued from Boco Haram, Middle East refugees in Berlin shelters, US military personnel, veterans with PTSD and brain injuries, Rohingya refugee children in Bangladesh, healthcare staff and teachers during COVID in Northern Ireland, children in the Republic of Ireland, frontline workers with COVID-related stress through the Office of Mental Health of New York State, earthquakes in Türkiye, and the current war in Ukraine [13, 14, 53, 54]. 

In 2020, during the COVID pandemic, Dr. Gerbarg worked with BBM senior teachers to develop new methods for teaching effectively and efficiently online. By experimenting with various aspects of the online (Zoom) experience, they were able to figure out how to achieve this and how to teach it to others. Creating a safe environment, communicating nonverbally, and coregulating online were essential. One unintended benefit was that people from all over the world could participate in BBM online and feel more connected. This was especially important to the Ukrainians who worried that the world might forget about them. Concurrently, BBM could more easily provide disaster relief programs in any country with internet service. 

Programs, such as BBM, can be provided through online plat- forms and translated into whatever languages are needed for global open access. The COVID-19 pandemic highlighted the urgent need for safe, low-cost methods to quickly reduce the stress experienced by individuals, families, and healthcare personnel. During disasters, healthcare providers and first responders bear the dual burdens of caring for the injured while caring for their own families who are affected by the disaster. They use BBM practices to relieve their own stress and to remain alert and clear minded while caring for others during long, demanding work shifts. 

The following description of BBM programs in Bangladesh, Ukraine, Rwanda, Türkiye, Northern Ireland, and the Republic of Ireland exemplify applications of the eight guidelines for the proposed New Model of Care for Global Mental Health and Mass Disasters. They illustrate a high degree of acceptability, effectiveness in diverse settings, and steps taken toward sustainability. Although in-person BBM studies have used standardized measures of anxiety, depression, and PTSD [13], online studies did not use PTSD test measures [55, 56]. In trials, such as for RISE, as a government agency, the evaluators specifically avoided using tests that could be used to diagnose any psychological disorder in the employees. In studies of acutely traumatized survivors of mass disasters, tests for anxiety, depression, or PTSD that included any questions that might trigger trauma-related reactions in vulnerable individuals were excluded. We only used tests that had language we considered to be safe and not stressful or stigmatizing for participants. 

For information on available online BBM group interventions, teacher training programs, and research/evaluation collaborations, see http://www.breath-body-mind.com and http://www.breath-body-mind.com/ workshops. For information on the Breath-Body-Mind Foundation disaster relief programs in the United States and other countries, see http://www.breathbodymindfoundation.org. 

2.2. Breath-body-mind for Rohingya refugee children in Bangladesh 

The first use of online BBM teacher training occurred in March 2018. Dr. Gerbarg was contacted by members of No Limit Generation, a small non-profit organization whose mission was to provide “Safe Haven” schools wherein extremely traumatized Rohingya children in Bangladesh could leave the dismal, muddy 

refugee camps to experience a few hours of “normality” learning and playing. Brown and Gerbarg taught 16 schoolteachers BBM practices for children during six late-night 1-hour online Skype sessions. The children, aged 7–15, were among the 300,000 who were driven out of Myanmar during the August 2017 Rohingya genocide. Many had lost both parents and suffered brutal physical and sexual assaults as they fled from government militias. 

At first the children could not focus or concentrate. Some were withdrawn; others had angry outbursts. They enjoyed learning the breathing practices. The teachers observed that over the first 3 weeks, they became more engaged and their drawings became less chaotic. During the next 8 months, the children were able to draw coherent pictures and imagine themselves having a bright future [57]. 

2.3. Breath-body-mind in Ukraine 

The current war in Ukraine has profoundly affected the mental health and well-being of millions of people [54, 58]. On February 24, 2022, the day Russia launched the full-scale invasion of Ukraine, BBM teachers volunteered to assist and began contact- ing Ukrainians and translators. On March 16, BBM teachers held the first of many free online crisis relief sessions with Ukrainian translation [46]. Hundreds of Ukrainians registered. Anecdotally participants said that the BBM practices quickly helped them calm down, sleep, restore energy and mental clarity, reduce somatic pains, and increase stress resilience. 

Among the earliest attendees were “Liudmyla Moskalenko”, Ph.D., Associate Professor, Department of Psychology and Pedagogy, UHI, past President of the Ukrainian Association of Positive Psychotherapy (UAPP) and “Major Tetiana Vatulova”, Positive Psychotherapist, Extreme psychologist, Main Depart- ment of State Emergency Service of Ukraine in Poltava Oblast. We (Drs. Gerbarg and Brown) approached Drs. Moskalenko and Vatulova with a proposal for collaboration between BBM and UAPP. They agreed because the BBM practices were already relieving their own stress-related symptoms. Moreover, they were deeply concerned about the psychological survival of Ukraine’s psychologists who were in states of shock and exhaustion during the early months of intense bombing. The psychologists wanted to help others by immediately teaching the BBM practices they had just learned. However, we explained that before teaching others, they needed some weeks to practice, strengthen, balance, and replenish themselves. 

Showing respect for the Ukrainians, their culture, their language, and their professional knowledge was key. Although we relied on Ukrainian translators, we also encouraged BBM teachers to learn words and phrases that would be used to teach BBM practices and for basic interactions, such as greeting, praising, thanking, and saying goodbye. All teaching materials were translated into Ukrainian. Ukrainian language practice videos were created for BBM teachers, who were encouraged to wear T-shirts featuring a beautiful sunflower symbolizing the spirit of Ukraine, designed by Yael Dresdner, a BBM teacher. The BBM theme song “Walk a Mile” by Jan Nigro was translated and recorded in Ukrainian [59]. The lyrics are “I want to walk a mile in your shoes. I want to know what you think and what you feel”. 

We asked for feedback every step of the way and did all that we could to respond to the feelings and needs of the Ukrainians. They appreciated our expressions of respect, the T-shirts, and the message of the song. Many said that they could sense our genuine concern for them, that we listened to them, and that we touched their hearts. 

When we asked the Ukrainians to tell us their most urgent needs, they asked for tools to help Ukrainian children whose mental health was endangered due to the brutal war. We engaged Jyoti Manuel, the founder of Special Yoga for children with special needs and a Level-4 BBM teacher, to offer additional child- focused sessions. Her guidance was invaluable. For example, BBM usually begins a session with energizing practices such as shaking or tapping parts of the body in rhythm with lively music. However, some of the Ukrainians complained that the shaking and tapping reminded them of the shaking sensations from bombs dropping. Jyoti Manuel substituted a more calming practice of self- hugging and gentle squeezing (instead of tapping) to help center and ground people in their bodies. BBM teachers reported that this “Hug and squeeze” technique was also very beneficial for quickly calming the children and for bringing those who were in dissociative states back to feeling connected to their bodies. 

2.3.1. Example: a child refusing to go down to an underground shelter during an air raid alert
A Ukrainian woman in crisis contacted a colleague during an air raid alert because her son would not go down to safety in the underground shelter. They were in imminent danger. Too big to carry, he lay on the ground screaming and thrashing his arms and legs. The colleague assisted her in contacting Jyoti Manuel by videophone for help. Sensing the mother’s level of distress, Jyoti showed the mother how to hug and squeeze herself to stop her anxiety bordering on panic. Using the tone and the cadence of her voice to co-regulate and calm the mother, Jyoti also modeled for the mother how to co-regulate and calm her child. Jyoti wrote (personal communication, January 23, 2024): 

“In that moment, talking about slowing the breath down would have been useless because she [the mother] wasn’t able to listen to an instruction, but she could hold and squeeze her body as she watched me do it—I guided with my body. I also hummed with her as a pathway to breathing—at least extending the exhale to help soothe her. It was a few minutes, which was all they had.” The mother calmed down enough to enable her to support her child to feel calm enough to go down to the shelter. 

2.3.2. Breath-body-mind progress in Ukraine 

During the next two years, the BBM program grew through the psychologists’ networks and word of mouth. The Breath-Body- Mind Foundation, a 501(c)3 not-for-profit, raised funds to pay the teachers and translators for BBM weekly practice sessions and teacher training courses. 

To date, 2,700 Ukrainians have attended online BBM crisis sessions (1–4 hours each); 6,212 attended weekly practice ses- sions; 326 (mainly psychologists and psychotherapists) completed BBM Fundamentals Courses (15 hours + 6 weekly 45– 60-minute practice sessions); 128 completed BBM Level-1 Teacher Trainings (40 hours); 37 completed Level-2 Teacher Training (40 hours); and 5 graduated Level-3 Teacher Training (46 hours). Ukrainian teachers now lead weekly practice sessions and assist in training more teachers. 

Although we have no means to count how many Ukrainians have been helped by Ukrainian BBM teachers, we can imagine, based on anecdotal feedback from the teachers who have added BBM to their toolkit of treatments, that the number is tens of thousands. 

The following reports are a small sample of the courageous work of dedicated Ukrainian therapists under the harsh conditions of war. 

2.3.3. Juliya Venger Ukrainian psychologist 

“BBM significantly improved my personal state, quickly solved my sleep problems, and stopped my son’s panic attacks. After BBM Teacher Training Level-2, I volunteered at a local school in Kyiv for 2 weeks. I gave the teachers two half hour sessions. Then I spent 7–10 minutes in each classroom teaching groups of 10–20 children, altogether almost 500 children (ages 7–17 years). Before I taught them, during frequent air raid alerts, when they had to go to the bomb shelter, they became quiet, did not smile, and could not do schoolwork very well. Energy and motivation were low. 

By the end of 2 weeks, the whole atmosphere changed. Their energy level got better. They got involved in creative activities and the school even produced a musical. During the air raid alerts they do breathing practices with smiles on their faces while walking to the shelter. The teachers use the practices in class- rooms in the shelter … The BBM practices improved the children’s study effectiveness. It calmed them down, relieved tension, and brought back smiles to their faces.” (personal communication, November 29, 2023). 

2.3.4. Liudmyla Moskalenko, PhD, Associate Professor, Department of Psychology and Pedagogy, UHI, past President of Ukrainian Association of Positive Psychotherapy
The Ukrainian psychotherapists were not only working long hours caring for their traumatized people, but also studying long hours on weekends trying to absorb information about trauma treatments being given to them by numerous outside organizations. They were aware that their own state of shock was impairing their ability to think clearly. It was more difficult for them to learn, even to understand simple instructions. We slowed our pace of instruction providing the extra time they needed to learn. When they responded to the BBM practices, they stopped shaking and felt relaxed for the first time since the war began. Some experienced a happy feeling for the first time in a year. BBM was the only trauma training in which they were taught to take care of themselves. 

Dr. Moskalenko said that the UAPP leadership wanted to save the psychologists of Ukraine and they appreciated the importance we place on self-care for caregivers [60]. Over time she saw that the psychologists who trained with BBM maintained better mental health overall, whereas those who did not deteriorated under the ongoing stress of the war [60]. 

2.3.5. Kateryna Boichenko, MA Psychology, BBM teacher Level-3
“I got familiar with this [BBM] about a year and a half ago. All My work was volunteering for people in Bucha, Bakhmut, Mariupol (Donetsk region), people who suffered from this terrible invasion. There was so much grief, trauma, pain, and fear. I was afraid to wake up in the middle of the night because I had horrors in my head. I stopped sleeping well. I couldn’t walk normally because of my back pain. All I could do those days was counsel people with deep understanding in my heart that I am doing it too slowly. There is so much trauma and so much pain that I have to do more. But I was exhausted.” 

“Then there was a time I tried to become familiar with BBM practices and I started breathing between my consultations. In about a month, it really helped. I started walking almost without pain. In about 2 months, I began to realize that my sleep was better than before. I started to offer this to clients, first to those who weren’t sleeping well. Their feedback was really great and inspiring. Then I started to offer these practices to people with high levels of anxiety and different fears. They responded really well, too. Because before I was used to coping with stress with running and exercises. Clearly at that time it wasn’t an option, and it wasn’t an option for people who were hiding in bomb shelters. These practices became really helpful.” 

“I am extremely grateful to … every person in BBM Foundation. You have put so much effort, love, compassion to whole countries, to a lot of different people … who desperately need it today 

… in these times of disaster, really challenging times. I sincerely hope that we can contribute more to spread these effective practices to all corners of the world where they are vitally needed today” [16, 60]. 

Mind-body programs, such as BBM, can fulfill many immediate, short-term, and long-term needs of disaster survivors as outlined in the Breath-Body-Mind Program Guidelines for global mental health, which are consistent with the recommendations of others who have experience in serving people affected by war and other mass disasters. For example, BBM addresses most of the recommendations for mental health assistants for civilian survivors of the Russia-Ukraine War as proposed by Anjum et al. [61]

2.4. Breath-body-mind in Rwanda 

BBM supports and provides immediate and short-term benefits 

Relief from physical pain through vagal activation (antinociceptive effects) and by anxiety reduction. 

The group becomes a social support. 

BBM practices engender a sense of safety. BBM teaching methods enhance the sense of safety. 

BBM methods activate the social engagement system, which includes feeling connected. 

Participants report feeling more hopeful. BBM provides resources through weekly group practice sessions and the training of local providers. 

BBM enables participants to keep up with home and work responsibilities. 

BBM supports long-term benefits 

BBM integrates well with all forms of mental health treatment and improves outcomes. 

By improving energy, mental focus, mental clarity, and calmness, BBM improves problem solving. BBM improves stress resilience, autonomic balance, and autonomic stress response.
Participants feel empowered to take care of themselves and the people in their environment.
BBM teaches self-care for helpers while helping others. [61]. Assistants (CHAs) to therapeutic groups of 18–20 people for 16 

A review of the evidence on multisystemic healing initiatives (already applied in Rwanda) proposed a scalable multisystemic framework for societal healing in Rwanda [62]. Nearly 25 years after the 1994 Rwanda genocide, the 2018 Rwanda Mental Health Survey conducted by the Rwanda Biomedical Centre revealed the following persistent mental health challenges in the survivors and the general population: major depressive disorder (35% of genocide survivors; 12% of the general population) and PTSD (in 27% of genocide survivors; 3.6% of the general population) [62]. A recent meta-analysis of 19 original studies con- ducted in the country found that the proportion of genocide survivors who had PTSD was 37% [63]. 

In 2018 Dr. Brown traveled to Rwanda where he trained ten BBM teachers. BBM teacher, Cecelia Beach, has also taught there. In Kigali, Dr. Jean Bosco Niyonzima created and implemented a community-based social healing model at the Ubuntu Center for Peace, which is responsible for 3,500 genocide survivors. His model integrates BBM practices with collective group narrative and local rituals. BBM continued online teacher training for Dr. Niyonzima, Rwandan psychologists, and others. The Ubuntu Center program is supervised by Rwandan psychologists and delivered in person by 200 trained Community Healing 

weeks. Graduates transition to long-term support groups. 

Dr. Niyonzima presented the effects of this program on 1,889 participants [16]. The percentages of subjects with depression (PHQ-9), anxiety (GAD-7), and PTSD (PCL-5) at baseline were 61.5%, 62.6%, and 14.4%, respectively. At the endpoint (16 weeks), the percentages of depression, anxiety, and PTSD dropped to 25.5%, 27.5%, and 5.2%, respectively. Concurrently, significant increases were found in work productivity (30%) and children’s school attendance (30%). An impressive decrease occurred in domestic violence (59%). Rwandans continue BBM teacher training, and they initiate programs in Kigali and other locations. By combining online teacher training with in-person delivery by CHAs, Dr. Niyonzima and his team have created a highly effective program, even for severely traumatized people with documented anxiety, depression, and PTSD. 

Dr. Niyonzima adapted his program for high school students from disadvantaged, impoverished, traumatic, and violent back- grounds. The first year shows a high level of student engagement with strong, positive benefits. In this innovative program, psychologists provide once-weekly supervision to students who are trained as community assistants. Students teach BBM to their classmates (personal communication, January 12, 2024). 

3. Discussion 

The scientific evidence for the effects of voluntarily regulated breath practices on the central integration of sensory information about the external environment and the internal physiological state is strong and growing. The use of mind-body practices derived from worldwide ancient healing, spiritual, and martial traditions to change internal attentional, perceptual, emotional, cognitive, and executive functions re-emerges in modern treatments for PTSD and other stress-related mental health conditions. Although mind-body studies show positive effects on symptoms of stress and trauma, reviews indicate that most of the studies are small and of mixed quality. 

BBM, a program developed by Brown and Gerbarg over the past 25 years, includes breath-centered mind-body practices used as adjunctive and stand-alone treatments for individuals and for groups as large as 450 people. Dr. Gerbarg has integrated these methods into psychotherapy and psychoanalysis for patients with a wide range of psychological disorders, including severe complex trauma, childhood sexual abuse, PTSD, attention-deficit disorder, and severe anxiety disorders [13, 21, 73]. 

BBM programs have been shown to significantly reduce symptoms of anxiety, depression, and PTSD. The techniques are easily adapted to diverse cultures with benefits for children and adults affected by war and other mass disasters (e.g., terrorism, traffick- ing, torture, abuse, floods, earthquakes). Because the programs have minimal adverse effects and are easily adaptable for people with mild-to-severe physical and mental health conditions, there are few limitations to the clinical uses of BBM. However, the evidence base is limited because many of the studies are small or have no control group. Nevertheless, even small studies of BBM yield statistically significant positive results due to robust ESs. 

Limitations of this overview of BBM online group programs for mass disasters include the following: limited number of clinical 

studies; small number of RCTs; small sample sizes; possible sources of bias in the studies selected for review; lack of baseline measures of PTSD, anxiety, or depression in many studies; and lack of physiological measures (e.g., pulse, blood pressure, HRV) in online studies. Modulators of response would be of interest in future studies, for example, baseline autonomic state indicators and PTSD measures. Such studies would be more feasible in post- disaster populations who are living in safe, stable locations where in-person testing, funding, equipment, research staff, and time for such measures are available. Assessments of cost-effective- ness compared with other interventions would be useful. Additional studies by groups other than BBMF, for example, Barnardo’s and the Ubuntu Center, would be helpful. 

Considering the large number of people seriously affected by mass disasters, the literature is meager. It is extremely difficult to do high-quality clinical studies under the conditions of mass disasters, particularly randomized controlled trials. Larger, higher-quality studies may be precluded by the paucity of quickly available research funding during wars and other mass disasters, reluctance of researchers to work in unsafe disaster areas, de- struction of infrastructure, and the movements of populations. Nevertheless, it is imperative that we simultaneously provide crisis psychological relief and learn more about how to deploy treatments with the greatest efficacy, safety, and efficiency. 

Resources are inevitably insufficient and time to provide treat- ments is extremely limited. Despite the challenges and limita- tions, models of care based on group interventions, in person or online communication, and community assistants under the supervision of healthcare professionals can deliver much-needed mental health support as well as opportunities to gather useful information, clinical observations, anecdotal reports, and both qualitative and quantitative data. 

4. Conclusion 

New models of care are urgently needed globally to bridge the gap between survivors of mass disasters and available psychological support services. Evidence from fieldwork and research supports the use of breath-centered, trauma-informed mind-body pro- grams, as exemplified by BBM, to mitigate the adverse effects of war and other mass disasters on diverse populations of survivors and their caregivers. It is possible to design rapidly effective mind-body programs that may be readily accepted, non- stigmatizing, relatively low-cost, low-risk, and sustainable for large populations regardless of nationality, culture, religion, ethnicity, gender, age, or severity of physical and psychological injuries. Support is warranted for crisis programs and further studies to validate and extend the evidence base, particularly considering the growing populations of traumatized and dis- placed people living with untreated psychological injuries. 

References 

  1. World Health Organization. World mental health report: transforming mental health for all. Geneva: World Health Organization. 2022 June 16 [cited 2024 Jan 20] Available from: https://www.who.int/publications/i/item/97892400 49338
  2. Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017; 47(13):2260–74. doi: 10.1017/S0033291717000708
  3. Rahman A, Naslund JA, Betancourt TS, Black CJ, Bhan A, Byansi W, et al. The NIMH global mental health research community and COVID-19. Lancet Psychiatry. 2020;7(10): 834—36. doi: 10.1016/S2215-0366(20)30347-3
  4. Halbreich U. Stress-related physical and mental disorders: a new paradigm. BJ Psych Adv. 2021;27(3):1–8. doi: 10.1192/ bja.2021
  5. Neil-Sztramko SE, Belita E, Hopkins S, Sherifali D, Anderson L, Apatu E, et al. What are effective strategies to respond to the psychological impacts of working on the frontlines of a public health emergency? Front Public Health. 2023;11:1282296. doi: 10.3389/fpubh.2023.1282296
  6. World Health Organization. Group Problem Management Plus (Group PM+): group psychological help for adults impaired by distress in communities exposed to adversity (generic field-trial version 1.0). Geneva: World Health Organization; 2020. License: CC BY-NC-SA 3.0 IGO.
  7. Niles BL, Reid KF, Whitworth JW, Alligood E, Williston SK, Grossman DH, et al. Tai Chi and Qigong for trauma exposed populations: a systematic review. Ment Health Phys Act. 2022;22:100449. doi: 10.1016/j.mhpa.2022.100449
  8. Cramer H, Anheyer D, Saha FJ, Dobos G. Yoga for posttrau- matic stress disorder – a systematic review and meta- analysis. BMC Psychiatry. 2018;18(1):72. doi: 10.1186/ s12888-018-1650-x
  9. Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017;58:115–24. doi: 10.1016/j.cpr.2017.10.004
  10. Laplaud N, Perrochon A, Gallou-Guyot M, Moens M, Goudman, David R, et al. Management of post-traumatic stress disorder symptoms by yoga: an overview. BMC Complement Med Ther. 2023;23(1):258. doi: 10.1186/ s12906-023-04074-w
  11. van der Kolk B, Stone L, West J, Rhodes A, Emerson D, Suvak M, et al. Yoga as an adjunctive treatment for posttrau- matic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559–65. doi: 10.4088/JCP.13m0 8561
  12. Zhu L, Li L, Li XZ, Wang L. Mind-body exercises for PTSD symptoms, depression, and anxiety in patients with PTSD: a systematic review and meta-analysis. Front Psychol. 2022; 12:738211. doi: 10.3389/fpsyg.2021.738211
  13. Gerbarg PL, Brown RP, Streeter CC, Katzman M, Vermani M. Breath practices for survivor and caregiver stress, depres- sion, and post-traumatic stress disorder: connection, co- regulation, compassion. Integr Complement Med OBM. 2019;4(3):1–24. doi: 10.21926/obm.icm.1903045
  14. Gerbarg PL, Brown, RP, Mansur S, Steidle K. Chapter: Survi- vors of mass disasters: breath-based mind-body interven- tions and global platforms. In: Okpaku S, editor. Innovations in global mental health. Cham: Springer; 2021. p. 1557–79.
  15. Connolly SM, Vanchu-Orosco M, Warner J, Seidi PA, Edwards J, Boath E, et al. Mental health interventions by lay counsellors: a systematic review and meta-analysis. Bull World Health Organ. 2021;99(8):572–82. doi: 10.2471/BLT. 20.269050
  16. Niyonzima JB. Tackling trauma and common mental disor- ders through a community-based social healing approach in Rwanda. In: Gerbarg P, Brown RP, editors. Mind-body treatments for global mental health and provider self-care: mass disasters, refugees and PTSD: experiential training and lecture. American Psychiatric Association Virtual Summer Course. June 12, July 29, 2023. Available at: https:// http://www.breathbodymindfoundation.org/.
  17. Benarroch EE. The central autonomic network: functional organization, dysfunction, and perspective. Mayo Clin Proc. 1993;68:988–1001. doi: 10.1016/s0025-6196(12)62272-1
  18. Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76(Suppl 2):S86–90. doi: 10.3949/ccjm.76.s2.17
  19. Porges SW, Carter CS. Polyvagal theory, and the social engagement system. Neurophysiological bridge between connectedness and health. In: Gerbarg PL, Brown RP, Muskin PR, editors. Complementary and integrative treat- ments in psychiatric practice. Washington (DC): American Psychiatric Association Publishing; 2017. p. 221–40. ISBN: 9781615370313.
  20. Brown RP, Gerbarg PL. The healing power of the breath. simple techniques to reduce stress and anxiety, enhance concentration, and balance your emotions. Boston (MA): Shambhala; 2012. ISBN: 9781590309025.
  21. Brown RP, Gerbarg PL, Muskin PR. How to use herbs, nutrients, and yoga in mental health care. New York: W.W. Norton & Company;. 2009. ISBN-10: 0393705250. Noble DJ and Hochman S. Hypothesis: pulmonary afferent activity patterns during slow, deep breathing contribute to the neural induction of physiological relaxation. Front Physiol. 2019;10:1176. doi: 10.3389/fphys.2019.01176
  22. Sakakibara M, Hayano J. Effect of slowed respiration on cardiac parasympathetic response to threat. Psychosom Med. 1996;58(1):32–7.
  23. Craig AD. Interoception and emotion: a neuroanatomical perspective. In: Lewis M, Haviland-Jones JM, Barrett LF, editors. Handbook of emotions. 3rd ed. New York: The Guilford Press; 2008. p. 272–92. ISBN-13:978-1593856502.
  24. Porges SW. Cardiac vagal tone: a neurophysiological mecha- nism that evolved in mammals to dampen threat reactions and promote sociality. World Psychiatry. 2021;20(2):296–8. doi: 10.1002/wps.20871
  25. Porges SW, Furman SA. The early development of the autonomic nervous system provides a neural platform for social behavior: a polyvagal perspective. Infant Child Dev. 2011;20(1):106–18. doi: 10.1002/icd.688
  26. Strigo IA, Craig AD. Interoception, homeostatic emotions and sympathovagal balance. Philos Trans R Soc Lond B Biol Sci. 2016;371(1708):20160010. doi: 10.1098/rstb.2016.0010
  27. Mather M, Thayer JF. How heart rate variability affects emotion regulation brain networks. Curr Opin Behav Sci. 2018;19:98–104. doi: 10.1016/j.cobeha.2017.12.017
  28. Philippot P, Chapelle G, Blairy S. Respiratory feedback in the generation of emotion. Cognit Emot. 2002;16:605–27. doi: 10.1080/02699930143000392
  29. De Couck M, Caers R, Musch L, Fliegauf J, Giangreco A, Gidron Y. How breathing can help you make better deci- sions: two studies on the effects of breathing patterns on heart rate variability and decision-making in business cases. Int J Psychophysiol. 2019;139:1–9. doi: 10.1016/j.ijpsycho. 2019.02.011
  30. Laborde S, Lentes T, Hosang TJ, Borges U, Mosley E, Dosseville F. Influence of slow-paced breathing on inhibi- tion after physical exertion. Front Psychol. 2019;10:1923. doi: 10.3389/fpsyg.2019.01923
  31. Herrero JL, Khuvis S, Yeagle E, Cerf M, Mehta AD. Breath- ing above the brain stem: volitional control and attentional modulation in humans. J Neurophysiol. 2018;119(1):145–59. doi: 10.1152/jn.00551.2017
  32. Bernardi L, Porta C, Spicuzza L, Sleight P. Cardiorespiratory interactions to external stimuli. Arch Ital Biol. 2005;143 (3-4):215–21. PMID: 16097498.
  33. Nolan RP, Kamath MV, Floras JS, Stanley J, Pang C, Picton P, et al. Heart rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control. Am Heart J. 2005;149(6):1137.
  34. Sevoz-Couche C, Laborde S. Heart rate variability and slow- paced breathing: when coherence meets resonance. Neuro- sci Biobehav Rev. 2002;135:104576. doi: 10.1016/j.neubiorev. 2022.104576
  35. Thayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart rate variability, prefrontal neural function, and cognitive
  36. Thayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart rate variability, prefrontal neural function, and cognitive performance: the neurovisceral integration perspective on self-regulation, adaptation, and health. Ann Behav Med. 2009;37(2):141–53. doi: 10.1007/s12160-009-9101-z 

37. Zaccaro A, Piarulli A, Laurino M, Garbella E, Menicucci D, Neri B, et al. How breath-control can change your life: a systematic review on psycho-physiological correlates of slow breathing. Front Hum Neurosci. 2018;7;12:353. doi: 10.3389/ fnhum.2018.00353 

38. Yu J. Regulation of breathing by cardiopulmonary afferents. Handb Clin Neurol. 2022;188:233–78. doi: 10.1016/B978- 0-323-91534-2.00014-X 

39. Lamotte G, Shouman K, Benarroch EE. Stress and central autonomic network. Auton Neurosci. 2021;235:102870. doi: 10.1016/j.autneu.2021.102870 

40. Hsu SM, Tseng CH, Hsieh CH, Hsieh CW. Slow-paced inspiration regularizes alpha phase dynamics in the human brain. J Neurophysiol. 2020;123(1):289–99. doi: 10.1152/jn. 00624.2019 

41. Jayaram N, Varambally S, Behere RV, Venkatasubramanian G, Arasappa R, Christopher R, et al. Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia. Indian J Psychiatry. 2013;55(Suppl 3):S409–13. doi: 10.4103/0019-5545.116318 

42. Doody JS, Burghardt G, Dinets V. The evolution of sociality and the polyvagal theory. Biol Psychol. 2023;180:108569. doi: 10.1016/j.biopsycho.2023.108569 

43. Grossman P. Fundamental challenges and likely refutations of the five basic premises of the polyvagal theory. Biol Psychol. 2023;180:108589. doi: 10.1016/j.biopsycho.2023. 108589 

44. Manzotti A, Panisi C, Pivotto M, Vinciguerra F, Benedet M, Brazzoli F, et al. An in-depth analysis of the polyvagal theory in light of current findings in neuroscience and clinical research. Dev Psychobiol. 2024;66(2):e22450. doi: 10.1002/ dev.22450 

45. Obradović J, Sulik JM, Armstrong-Carter E. Taking a few deep breaths significantly reduces children’s physiological arousal in everyday settings: results of a preregistered video intervention. Dev Psychobiol. 2021;63(8):e22214. doi: 10.1002/dev.22214 

46. Jowf GI, Ahmed ZT, Reijnders RA, de Nijs L, Eijssen LMT. To predict, prevent, and manage post-traumatic stress disorder (PTSD): a review of pathophysiology, treatment, and biomarkers. Int J Mol Sci. 2023;24(6):5238. doi: 10.3390/ijms24065238 

47. Fletcher KL, Comer SD, Dunlap A. Getting connected: the virtual holding environment. Psychoanal Soc Work. 2014; 21:90–106. doi: 10.1080/15228878.2013.865246 

48. Bahn GH. Understanding of holding environment through the trajectory of Donald Woods Winnicott. Soa Chong- sonyon Chongsin Uihak. 2022;33(4):84–90. doi: 10.5765/ jkacap.220022 

49. Gerbarg PL, Dickson F, Conte VA, Brown RP. Breath- centered virtual mind-body medicine reduces COVID- related stress in women healthcare workers of the Regional Integrated Support for Education in Northern Ireland

  1. Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. Treating survivors of torture and refugee trauma: a pre- liminary case series using qigong and t’ai chi. J Altern Complement Med. 2008;14(7):801–6.
  2. Telles S, Naveen KV, Dash M. Yoga reduces symptoms of distress in tsunami survivors in Andaman Islands. Evid Based Complement Alternat Med. 2007;4:503–9.
  3. Telles S, Singh N, Joshi M, Balkrishna A. Posttraumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study. BMC Psychiatry. 2010;10:18.
  4. Hickey G, Stynes H. Evaluation of Barnardo’s National Wellbeing Project. Dublin: Barnardo’s; 2023.
  5. Gerbarg PL, Brown RP. Online mind-body trauma relief for Ukrainians. Glob Ment Health Psychiatry Rev. 2022;(3):19–20.
  6. Gillam W, Godbole N, Sangam S, DeTommaso A, Foreman M, Lucke-Wold B. Neurologic injury-related predisposing factors of post-traumatic stress disorder: a critical examina- tion. Biomedicines. 2023;11(10):2732. doi: 10.3390/bio medicines11102732
  7. Rainone GJ, Zelmanovich R, Laurent D, Lucke-Wold B. How war has shaped neurosurgery. World Neurosurg. 2023;178: 136–44. doi: 10.1016/j.wneu.2023.07.100
  8. Gerbarg PL, Brown RP, Mansur S, Steidle K. Survivors of mass disasters: breath-based mind-body interventions and global platforms. In: Okpaku SO, editor. Innovations in Global Mental Health.Cham: Springer Cham; 2021. p. 1557–79. ISBN: 978-3-319-70134-9. doi: 10.1007/978-3-319-70134-9
  9. Seleznova V, Pinchuk I, Feldman I, Virchenko V, Wang B, Skokauskas N. The battle for mental well-being in Ukraine: mental health crisis and economic aspects of mental health services in wartime. Int J Ment Health Syst. 2023;17(1):28. doi: 10.1186/s13033-023-00598-3
  10. Walk a Mile Ukrainian/ English Extended Version, per- formed by Adriana Lomysh Campbell, written by Jan Nigro ©1987, 2023 Janimation Music BMI. Ukrainian translation by Helen Spiyan. Arrangement by Jeff Waxman, Sound Engineer: Doug Robinson. Produced by Janice Nigro.
  11. Moskalenko L. Presentation about Ukraine Project. 2022 Nov 13. [cited 2024 April 5] Available from: https:// http://www.breathbodymindfoundation.org/.
  12. Anjum G, Aziz M, Hamid HK. Life and mental health in limbo of the Ukraine war: how can helpers assist civilians, asylum seekers and refugees affected by the war? Front Psychol. 2023;14:1129299. doi: 10.3389/fpsyg.2023.1129299
  13. Kayiteshonga Y, Sezibera V, Mugabo L, Iyamuremye JD. Prevalence of mental disorders, associated co-morbidities, health care knowledge and service utilization in Rwanda – towards a blueprint for promoting mental health care

services in low- and middle-income countries? BMC Public Health. 2022;22(1):1858. doi: 10.1186/s12889-022-14165-x 

63. Lordos A, Ioannou M, Rutembesa E, Christoforou S, Anastasiou E, Björgvinsson T. Societal healing in Rwanda: toward a multisystemic framework for mental health, social cohesion, and sustainable livelihoods among survivors and perpetrators of the genocide against the Tutsi. Health Hum Rights. 2021;23(1):105-18. 

64. Kurt G, Uygun E, Aker AT, Acarturk C. Addressing the mental health needs of those affected by the earthquakes in Türkiye. Lancet Psychiatry. 2023;10(4):247–48. doi: 10.1016/ S2215-0366(23)00059-7 

65. Olagunju AT, Bioku AA, Olagunju TO, Sarimiye FO, Onwuameze OE, Halbreich U. Psychological distress and sleep problems in healthcare workers in a developing con- text during COVID-19 pandemic: Implications for workplace wellbeing. Prog Neuropsychopharmacol Biol Psychiatry. 2021;110:110292. doi: 10.1016/j.pnpbp.2021.110292 

66. World Health Organization. Scalable psychological inter- ventions for people in communities affected by adversity. Geneva: World Health Organization; 2017. 

67. World Health Organization. Problem management plus (PM+): individual psychological help for adults impaired by distress in communities exposed to adversity (generic field- trial version 1.1). Geneva: World Health Organization; 2018. License: CC BY-NC-SA 3.0 IGO. 

68. Song HS, Lehrer PM. The effects of specific respiratory rates on heart rate and heart rate variability. Appl Psychophysiol Biofeedback. 2003;28(1):13–23. doi: 10.1023/a:1022312 815649 

69. Schäfer SK, Thomas LM, Lindner S, Lieb K. World Health Organization’s low-intensity psychosocial interventions: a systematic review and meta-analysis of the effects of prob- lem management plus and step-by-step. World Psychiatry. 2023;22(3):449-62. doi: 10.1002/wps.21129 

70. Bryant RA, Dawson KS, Keyan D, Azevedo S, Yadav S, Tran J, et al. Effectiveness of a videoconferencing-delivered psy- chological intervention for mental health problems during COVID-19: a proof-of-concept randomized clinical trial. Psychother Psychosom. 2022;91:63–72. doi: 10.1159/0005 20283 

71. Thayer JF, Lane RD. A model of neurovisceral integration in emotion regulation and dysregulation. J Affect Disord. 2000;61(3):201–16. doi: 10.1016/s0165-0327(00)00338-4 

72. Park G, Thayer JF. From the heart to the mind: cardiac vagal tone modulates top-down and bottom-up visual perception and attention to emotional stimuli. Front Psychol. 2014;5: 278. doi: 10.3389/fpsyg.2014.00278 

73. Gerbarg, PL, Brown RP. Mind-body practices for recovery from sexual trauma. In: Bryant-Davis T, editor. A guide to recovery and empowerment. Lanhem (MD): Rowman & Littlefield; 2011. p. 199–216. 

1Department of Behavioral Medicine, New York Medical College, Valhalla, NY, 12401, USA.

2Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 12401, USA. 

*email: patgerbarg@gmail.com 

Keywords: mass disasters, paced breathing, refugee, stress, post-traumatic stress disorder, healthcare workers