The breath can be a powerful tool to induce relaxation and reduce stress. As such, the breath may be a useful modality to support trauma survivors who are living with Post Traumatic Stress Disorder (PTSD). PTSD symptoms are rooted in disruptive stress responses, dysfunction of the autonomic nervous system, affect a multitude of psychophysiological systems, and are often related to how one remembers and perceives the traumatic experience (Mueser et al., 2007; Aideyan et al., 2020).
Cognitive therapies are available for treatment, but as many as two-thirds of patients still retain a diagnosis for PTSD after treatment, indicating the need for alternative and more effective modalities (Mathersul, et al., 2022). Since the nature of PTSD symptoms are stress-related and symptoms involve dysregulated autonomic responses, utilizing a treatment modality that relieves stress and regulates the nervous system may have potential significance for trauma recovery. Breathwork, defined as “conscious, controlled breathing done especially for relaxation, meditation, or therapeutic purposes” (Merriam-Webster, n.d.), is a modality that may be able to do both. This paper seeks to understand the relationship between breath and trauma survivors. It will explain the role that breathwork plays in trauma, highlight the advantages and limitations of using it with survivors, and describe best practices for the therapist to utilize when offering breathwork as a therapeutic modality.
The definition of trauma offered by Merriam-Webster is, “a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury” (Merriam-Webster, n.d., Definition 1b). The majority of research has been done with people who have been diagnosed with post-traumatic stress disorder (PTSD). PTSD is a widespread, highly disruptive condition that can result from exposure to traumatic stress (Mathersul et al., 2019). Symptoms of PTSD are typically of four clusters: (a) re-experiencing, including nightmares, intrusive memories, flashbacks, (b) avoidance of provocations of the traumatic experience, (c) persevering negative changes in perceptions and affect, such as disrupted memory, excessive shame and/or guilt, and depression, (d) dysfunctional arousal/responsiveness, including aggression, irritability, hypervigilance, difficulty sleeping, and trouble concentrating.
Breathwork includes a wide range of breathing techniques. This section will briefly focus on six different techniques that have been studied with people who have PTSD: (a) deep relaxed breathing, (b) mindful breathing, (c) yogic breathing, (d) breathing retraining, (e) breathing biofeedback, and (f) device-guided breathing. These breathing techniques are used in therapeutic settings because they can regulate the autonomic nervous system, which induces the relaxation response, thereby decreasing stress and helping one regulate their emotions (Aideyan et al., 2020).
Deep relaxed breathing, also known as diaphragmatic, abdominal, or relaxation breathing, is a widely used technique for the purposes of relaxation (Aideyan et al., 2020). It can be practiced by steadily breathing in while expanding the diaphragm, then exhaling slowly, allowing the diaphragm to contract. This type of breathing can be modified according to individual preferences or needs. For instance, how long one might breathe in, how long one might retain their breath after their inhale, if one might retain their breath after their inhale at all, and how long one might breathe out, can all be adjusted to what is most useful for the practitioner. Deep relaxed breathing incites the ANS by increasing parasympathetic activity while decreasing sympathetic activity, indicated by physiological activity such as the lowering of one’s breathing rate, heart rate, blood pressure, and oxygen use. This physiological activity is what comprises the relaxation response.
Mindful Breathing refers to a set of breathing exercises that involve sustained conscious awareness of one’s breath (Aideyan et al., 2020). If a person regulates their breathing patterns to be steady and flowing, they might be able to experience a meditative state of mind, which may allow them to pay closer attention to their bodily sensations and emotional experiences. These techniques are sometimes known as breathwork therapies, are more broad and structured, and may require the assistance of a trained therapist. Mindful breathing may allow a person to access thoughts, emotions, or memories that were previously unconscious, thus serving as a bridge between the conscious and unconscious (Young et al., 2010). This may have promising implications because one might not be aware of beliefs that they might have about the world because of their traumatic experience. These beliefs could be interfering with their ability to have appropriate responses to stress or healthy relationships.
Yogic breathing is often linked to movement and can involve elements of both diaphragmatic breathing and mindful breathing (Aideyan et al., 2020). For example, one might lift their arms overhead while they take an inhale, and bring their arms back down alongside their body as they take an exhale. It supports the connection between one’s mind and body, reduces sympathetic activity, and increases parasympathetic activity, thus stimulating the relaxation response (Mathersul et al., 2019). Yogic breathing has been studied in a diverse range of populations under a program known as Sudarshan Kriya Yoga (SKY). SKY centers around controlled, cyclical breath patterns, gentle physical postures, and periods of teachings. It has been shown to have a substantial positive effect on symptoms of depression, anxiety, and PTSD.
Breathing retraining, breathing biofeedback, and breathing devices have also been used in the course of treatment. Breathing retraining is a coping technique for reducing levels of arousal and managing symptoms of distress and/or anxiety that is used in the course of treatment (Mueser et al., 2007). It has been taught as a key element as a part of cognitive behavioral therapy interventions to manage troublesome symptoms. Breathing biofeedback is a modality where a participant receives feedback about their biological responses, such as their heart rate variability or breathing frequency (Polak et al., 2015). It can assist one with breathing at a programmed rhythm during therapy. Breathing devices help alleviate the level of concentration required to pay attention to one’s breath by providing personalized musical instructions for one to use their breath to follow along with (de Jong & Boersma, 2010). This can be beneficial if the survivor has trouble paying attention to their breath, and can also alert the therapist if the breathing practice is being performed incorrectly.
The primary role of breathwork in therapy lies in its ability to regulate the autonomic nervous system (ANS) (Aideyan et al., 2020). The ANS is comprised mainly of the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS) (Becker & McQuade, 2020). The SNS plays an integral role in responses to stressors and the “fight or flight” activities, whereas the PNS is responsible for homeostasis and the “rest and digest” activities. Stressors and traumatic events activate the ANS (Aideyan et al., 2020). This ANS activation causes a series of physiological responses to be elicited. If this activation happens excessively, it can lead to dysfunction of the ANS, and consequently, dysfunctional emotional regulation. Emotional regulation can be a conscious or unconscious process that involves cognizance, comprehension (among cognitive, physiological, and behavioral expressions), and applicable responsiveness to emotional situations (Mathersul et al., 2022). It is intrinsic to many mental health disorders, including PTSD. Indeed, emotional dysregulation often manifests as symptoms of PTSD.
Mathersul et al. (2022) investigated self-reported and physiological emotional regulation in U.S. veterans with clinically significant levels of PTSD symptoms. The veterans participated in a breath-centered yoga (SKY) program or a cognitive processing therapy (CPT) control group. The researchers examined heart rate variability (HRV) as a biological marker to measure physiological emotional regulation, since participants may inaccurately respond to self-reported methods due to wanting to appear a certain way after the treatment, or because they may have an inadequate understanding of their internal emotional state. HRV is a reliable measure of healthy autonomic functioning, where higher levels of HRV indicate a greater ability to regulate one’s emotions. This study found evidence that self-reported emotional regulation improved with both the SKY group and the CPT group. However, physiological emotional regulation improved only in the SKY group. The study also indicated improvement in participants’ emotional clarity and their ability to manage their impulses in the SKY group.
One is able to induce the relaxation response with breathwork (Aideyan et al., 2020). The relaxation response reverses the fight-or-flight process and restores regulation of the ANS and emotional state. If one is able to reliably regulate their ANS despite the persistent stressors in their environment, they may be able to more skillfully assess their affective responses. Concentration on the breath, elicitation of the relaxation response, and effectively noticing one’s physical and emotional sensations can strengthen one’s integration of their mind with their body, further aiding the breathwork practitioner in their ability to self regulate.
Breathwork is a bottom-up approach in that it involves physiological and regulatory processes, as well as quiets the lower parts of the brain (Mathersul et al., 2019; Aideyan et al., 2020). Conversely, a top-down approach addresses the cognitive functions of the mind and one’s ability to self-regulate. Bottom-up approaches can be helpful if one is unable to be productive with therapeutic work that involves more executive functions of the brain, such as decision making, memory, or interpretation of sensation. If one becomes too distressed when trying to process a traumatic experience with a therapist, using a technique such as slow, relaxed breathing can reduce the activity of the sympathetic nervous system, calming the survivor, allowing them to be able to access these parts of their mind (de Jong & Boersma, 2010).
Polak et al. (2015) surveyed breathing biofeedback with eight patients who had chronic PTSD during trauma focused cognitive behavioral therapy (TF-CBT), a conventional therapeutic modality that invites the patient to discuss their traumatic experience at length. Using the breath during TF-CBT may decrease distressing symptoms and tax working memory so that the imagery associated with the experience isn’t as pronounced. The participants found the breathing instructions easy to understand, were not prevented from concentrating on their therapy, and their symptoms decreased faster than the control group who were not using breathing biofeedback during their treatment. Regular practice of breathwork can lead to habituation, thus reconditioning one to use a breathing technique whenever one remembers a traumatic memory or experiences a symptom of PTSD, thus giving the survivor a greater sense of relief from their symptoms.
A study by de Jong and Boersma (2010) outlined one documented PTSD patient and several undocumented cases with PTSD or phobic disorder using a breathing device during therapy. The documented PTSD patient's symptoms were resolved in two sessions using this device. The device is easy to use, affordable, and particularly helpful if one has trouble concentrating on their breath. In addition, it can help the therapist objectively assess whether or not the patient is practicing the technique correctly.
Sustained conscious breathing can stimulate the vagus nerve, a major component of the autonomic nervous system, also known as cranial nerve X (Howland, 2014). The vagus nerve consists of 20% efferent fibers and 80% afferent or sensory fibers, meaning that 20% of its fibers carry information from the brain to the body, and 80% of its fibers carry information from the body to the brain. Stimulation of the vagus nerve activates a multitude of neurological pathways, stimulating the production of neurotransmitters, such as oxytocin, dopamine, and serotonin, which may be what leads to the increased feelings of wellbeing that are often reported from breathwork practitioners (Aideyan et al., 2020). This practice of regulating one’s breathing patterns restores homeostasis and reconditions the practitioner to healthier patterns of breathing. This can reverse dysregulated breathing practices that may have played a part in the dysfunction of the ANS, which may have led to dysfunctional emotional regulation.
Breathwork is not recommended for anyone with extreme asthma, unstable mental illness, recovering from surgery, or experiencing hallucinations (Young et al., 2010). Resistance may be evident in the form of shallow or altered breathing patterns, dissociation, or by opening one’s eyes during practice. While all of this may have a diminishing effect on the benefits of using breathwork, it is something to be worked with patiently. Resistance is a coping mechanism intended to keep the survivor safe. Addressing one’s level of resistance at the survivor’s pace is imperative so that the survivor does not become overpowered with emotion.
One of the major limitations of the research on breathwork is the lack of randomized, unbiased studies with significant sample sizes, appropriate control groups, and low dropout rates (Mathersul et al., 2019). Further, breathwork is a diverse modality, and more definite research is needed to determine which breathwork practices are most effective, with whom, and under what conditions (Aideyan, et al., 2022). The breathing pattern and volume of breath could also be useful to study (Polak et al., 2015).
Another limitation lies in the fact that paying attention to one’s breath can be difficult due to the level of concentration that is required. If breathwork is practiced incorrectly, it can lead to hyperventilation, oxygen deprivation, and shortness of breath (de Jong & Boersma, 2010). This can be problematic as the physiological results of breathing incorrectly could promote a sense of fear instead of providing a sense of safety. Finally, some participants may not be suited for breathwork, as one must be prepared for the psychological experiences that may arise during breathwork (Young et al., 2010). The practice may not be beneficial if the participant does not have any experience with this type of mental undertaking.
Some best practices for working with one’s breath is to allow time for the participant to process and reflect after their session (Young et al., 2010). Informed consent is necessary so that the participant can remain in choice about what the practice may involve. Additionally, whether or not the therapist will use touch should be discussed ahead of time. The role of the therapist is to observe their client as they are practicing breathwork, to ensure that they are engaging in the practice correctly, and are not exhibiting any indication of disordered breathing. In addition, the therapist is to be supportive so as to increase a sense of safety for the practitioner. The therapist is to remain present and connected, available to the practitioner should they need a blanket or a glass of water, but also to bear witness to the practitioner’s experience.
Breathwork shows a promising potential for providing relief from PTSD symptoms due to its ability to regulate the autonomic nervous system, induce the relaxation response, support emotional regulation, and reduce stress (Mathersul et al., 2022; Aideyan et al., 2020; de Jong & Boersma, 2010). More randomized, controlled, unbiased studies with large sample sizes are needed to strengthen the amount of evidence for the efficacy of breathwork to be used as a treatment modality, especially since the participant may find alternative or complementary modalities less stigmatizing than conventional methods (Mathersul et al., 2019). The breathwork modality should be appropriate for the practitioner and offered by a responsive, supportive therapist. The breath is a powerful tool that one always has access to. With breathwork, the survivor is empowered to find freedom from their symptoms from an internal locus of control.