It’s ironic that I’m writing this piece to other therapists about the importance and hazards of early breath work in clients with trauma.  Breath is about connecting with the inside.  Asking someone to notice anything related to the inside can be triggering for those of us whose survival depended upon not noticing it.  The inside is not neutral territory.  It’s Dresden after the war.  It’s where stuff once was.  Any coming home can feel incredibly complicated.  It involves more than simply flinging open a long-closed door and finding that everything missing has been kept safe inside.  Finding my way back into my own body has been torturous and is ongoing. I fled my body in middle-childhood into a new world of ideas and thought.  I fled into a bright, modern, and untouched country where I could belong… and where I couldn’t belong I could feign belonging.  People flee their bodies for reasons.  Those reasons need to be understood before safe travel into the body can occur for many people.

As I think about ways that simply noticing the inside can be triggering, several scenes flash through my mind:

Scene One: James and I are in second grade and this is the first time I’m having dinner at his house.  Their house is tiny and six of us are crowded around an even tinier table.  James’ father, also named James, had been to war.  He was the kind of man who worked in attics, on roofs, and on oil rigs.  He could be kind and would throw a baseball with you, but he could also snatch you up in an instant with a strong sun-leathered hand if you came at an angle he didn’t like.  Around the table I know what’s coming… they’re about to pray.  I had been around enough Southern Baptists to know that they pray before eating.  And I know this is coming too, I hear it in my chest way before he says it: “Thomas, you’re our guest, you want to say grace?”  My head is bowed and I search deeply inside, waiting for it to come.  It does not come.  Inside there is a deep and horrible silence until Senior says, “Junior, go on then.”   James Jr. mumbles effortlessly the “Heavenly Father… bless us… this food… from your bounty” stuff that I had heard so many times I could almost fake it.  The relaxed “Amen” tosses their collective breath toward a large pot of mashed potatoes in the center.  Inside I was completely cold, more evidence that I had to be an outsider.

Scene Two: By fourth grade, James had moved out of the city and into a trailer park in a suburb.  I only see him a few times after the move and I have to spend the whole weekend there.  After Sunday school, James asks me if I have ever been saved.  I told him that I had not.  The youth minister also comes to me and asks me if I want to accept Jesus into my heart.  This feels important. James says that it is important.  So, I do it. I stand with two or three other kids about my age with my back to a congregation of several hundred strangers.  My head is bowed.  I say the words out loud exactly the way I am supposed to.  I completely still my insides and I imagine my heart opening.  I feel absolutely nothing.  I know instantly that whatever was supposed to happen didn’t.  I’m not supposed to feel this alone.  It happened on the inside of the others, but it didn’t happen to me.

Scene Three:  I’m a counselor trainee and she’s one of my first clients.  I know that she is going to be a challenge even before we sit in my office.  I can feel her tension from the way her feet hit the carpet.  “I got problems.  I’m crazy.  My meds don’t work and I’m crazy.”  I haven’t even introduced myself and now she is pointing directly at me, “And don’t you… and don’t you… even start with that breathing stuff.  It don’t work.  Don’t even start with it.”  I tell her that my name is Tom and I promise that we will not talk about that breathing stuff.

Scene Four: I attend a workshop on Motivational Interviewing not long after starting my first “real” job as a therapist.  Before the workshop begins, one of the instructors announces that we will be opening with a relaxation technique.  My anxiety immediately skyrockets.  While the instructor says things like “now, notice your out breath,” I notice that it is becoming harder and harder for me to breathe.  I notice I am sweating. I am noticing thoughts like, “I didn’t pay $109.00 for breathing!  This is not a mindfulness workshop!  This sucks!  This is stupid!  When will this end?”  But, it doesn’t end soon.  It keeps going.  Then I think, “Wait, I teach this stuff.  What happens if I just do exactly what I’m asked to do and what I instruct clients to do?”  So, I do.  And, I am shocked at how quickly I calm down.

Breathing and noticing were highly triggering for me in the beginning in ways that had little to do with either breathing or noticing my breath.  They were wrapped up with performance anxiety.  They were wrapped up in other “inside” stuff.  Like my clients, they “didn’t work for me” for a long time and I didn’t want to hear it. Then, I dipped my toe in.  I dipped my toe in again.  I feel like I’m up to my waist now and the temperature feels just fine.

I see many severely traumatized clients.  I have found strategies to get nearly all of them deep breathing daily.  We use breath extensively to manage distress as we work to reprocess their traumatic memories using EMDR.  EMDR requires noticing the inside.  Many of the same things that make breathing difficult for some clients may cause difficulty inside EMDR reprocessing, so working to navigate these difficulties early can make EMDR reprocessing smoother.  These approaches seem to work for many of my clients.

It’s Easier to Show it if You Live It

Breathing as a resource clicked in for me two years ago because it had to.  My past and present were colliding at places where there were once carefully constructed overpasses.  My anxiety skyrocketed and I had difficulty thinking or rationalizing my way out.  Once I incorporated deep breathing into my daily life, it was much easier to engage clients with it.  Finding my own way into breathing taught me a lot about the obstacles and some ways around them.  Listening very closely to clients taught me even more about the obstacles and ways around them.

When It’s Our Approach that is Triggering and Not Breath Itself

Part of the problem that many therapists have getting clients engaged in deep breathing comes from how they introduce it or how they help clients manage expectations related to it. These approaches can be very helpful when first introducing deep breathing with clients that you suspect may have problems:

  • Don’t oversell how easy or natural this “should be” for clients.  It will not feel easy or natural for many of them.  Expect that there will be issues.  Expect that you will need to help clients navigate around problems before they find their breath.
  • Explain how anxiety works before introducing deep breathing. Explain fight/flight/freeze.  Explain how anxiety exists to make energy.  That energy sits in our bodies.  Deep breathing can help release it.  Explain the benefits of deep breathing: potential to lower baseline anxiety, avoid many panic attacks, etc.  By explaining that anxiety processes are normal, biological, and adaptive, you help clients contextualize their internal processes within a broader framework.
  • Have a conversation with clients about what part of deep breathing didn’t work for them when they tried it previously. Tell the client that many people encounter problems, but that there are often ways around obstacles and that you are committed to helping them find a breath that is helpful.
  • Normalize that different aspects of deep breathing are difficult for many people. I explain (briefly and with minimal disclosure) how hard it was for me to engage with it initially and I explain how central it is for me now to manage daily stressors.
  • Don’t just describe deep breathing and send the client home to practice it. Demonstrate it in session.  You may need to do this again and again.
  • Model breathing.  It may be helpful for you to demonstrate a single deep breath while the client watches you. You can describe your own reaction to just that breath.
  • Anticipate performance anxiety. Before inviting the client to join you, explain that if the client is breathing at all, then he is doing it perfectly for this stage (many clients are initially consumed with the idea that they’re not going to do it right).  For clients that you suspect may be triggered by breathing, ask them to take only one breath with you.  Check in after that initial breath before taking more.
  • For new clients who have a clear excess of energy, take only a few breaths between check-ins. It’s rare for me now to take more than a few breaths with new clients when we first start breathing in session without checking in.
  • I usually walk the client through a body scan and scale the sensations at various locations in the body before and after breathing in session. Clients usually report a decrease.  Ask if that decreased knot, pressure, or tension feels less distressing than how it felt before.  As obvious as this question sounds, you may be asking the client to connect the mind and body in ways that haven’t connected in a very long time.
  • In initial sessions, it may be helpful to avoid connecting deep breathing too directly to trauma. Connect it with anxiety and body sensations of “stress” the client is experiencing in the present.  Explain it as a way to eventually manage panic, since that will be the initial motivation for many clients.  Focusing on trauma as a reason to do deep breathing can cause some trauma seeping in these early patient contacts, which can cause anxiety to peak unnecessarily.
  • Make sure that it is an appropriate time in session to engage in deep breathing with the client. Make sure that the client doesn’t need to be heard right now instead.  Be sure that your desire to show a client deep breathing isn’t interpreted as a denial of the client’s right to be stressed out right now and be heard by you right now.  Make sure that your use of deep breathing isn’t interpreted as a “punishment” for client distress in session.  As with any intervention, ask the client permission before you pivot to it.
  • At some appropriate point, explain that deep breathing is an important coping skills, but isn’t necessarily the cure for trauma seeping. Trauma treatment helps alleviate trauma seeping, but deep breathing can be incredibly helpful in that process and can help better manage trauma seeping until the time that deep healing can occur.

When Practicing Deep Breathing in Session, Be Mindful of Performance Anxiety, Body Space, and Trauma

When I do deep breathing with clients in session initially, I am careful to turn my chair 90 degrees to the client and look at the wall ahead.  I am male and many of my clients are female.  I am aware that I am sitting in a very small room often with a severely traumatized person. After getting permission from the client to do some breathing in session, I tell the client something like the following:

I’m going to turn my chair so that you can see me from the side and get a good look at how I’m breathing.  Some people tell me that being stared at when they are trying to relax makes them anxious, so I turn my chair and focus on the wall.  I’m going to watch the wall in front of me and if you can try to match your breathing to mine.  Let’s take [two, four, etc.] deep breaths and I’ll keep count.  If you get light-headed, just breathe a little faster and ignore my pace.  You can’t do this wrong.  Just notice that your lungs are filling up and emptying.  You can keep your eyes open or close them, whatever helps you focus on what your lungs are doing.  I’m not going to move from my chair.

I’m careful to listen for the client’s breath and we can make adjustments from that.  After several sessions that includes breathing, clients are often comfortable with our chairs facing while doing breathing together.

When “It Doesn’t Work” Means that Deep Breathing Causes Anxiety to Increase in the First Few Moments of Being Still and Noticing

One of the best interventions that you can do when you suspect that a client may have problems with breathing is to anticipate and normalize a small to moderate peak in anxiety as soon as the client starts deep breathing.  Usually clients find their way through this phase after they have engaged with deep breathing several times.

When you first start with deep breathing, you may notice that your anxiety goes up for a moment.  Sometimes a part of us that is trying to keep us safe does not know that deep breathing is an okay thing to do.  It can help to just talk to that part nicely and say something like, “It’s okay, I’m just breathing.  I do this all the time.  These are my lungs.  I’m already breathing, I’m just breathing a little bit slower than usual.”  If your anxiety does peak, many people tell me that it lasts for just a moment and may pass quickly.  If it’s too much and you need to stop, just stop.  Try it again later and it may be better then.

When “It Doesn’t Work” Means that Relaxation is Triggering

When you work with clients with severe anxiety or extensive trauma histories, you should expect that relaxation will not feel “normal” to them initially.  Relaxation may not feel safe.  It may trigger rounds of negative self-talk.  Relaxation may feel numb.  A good way to manage this is to anticipate it and explain that the body learns to trust the sensation of more relaxed the more it is exposed to it.  I explain that when we do deep breathing in the beginning, we’re “dipping a toe” into relaxation and noticing.  We do this so that the body knows that it’s something that’s safe and sensible to move deeper into.

When “It Doesn’t Work” Means that Negative Self-Talk about Breathing Keeps it from Happening

Even clients who do well with deep breathing in session may struggle with persistent negative self-talk while breathing at home.  This is also best managed by anticipating it, asking about it, and providing psychoeducation related to how to manage it.

If you are starting to do deep breathing at home and your head becomes really busy telling you that deep breathing is a waste of your time, that you should be doing something more productive, that breathing is incredibly boring, that this is not going to work, or that this is stupid, just keep at it.  This internal conversation about breathing is very common.  Expecting that it may happen can help.  Just kindly say to that voice, “It’s okay, I’m just breathing.  I do this all the time.  These are my lungs.  I’m already breathing, I’m just breathing a little bit slower than usual.  That’s all I’m doing and this is what I need to be doing right now.”  Often this helps turn that voice down or let it step aside for a while.

When “It Doesn’t Work” Means Racing Thoughts Don’t Slow Down

Racing and anxious thoughts are one of the most common obstacles to deep breathing in very early sessions.  For clients new to breathing, a mind that is on the edge of panic can wind the body up faster than the body can release it. I have found that asking the client to imagine a visual hallucination on the out breath tends to briefly saturate the parts of the mind that are needed for it to race.  Many clients report that this slight modification to breathing is very helpful at significantly slowing the mind enough for breathing to bring some level of relaxation.  This intervention comes much easier to people that do well with visualizations or for people who have a history of smoking.  This intervention seems to work best very early in therapy and as breathing as a coping mechanism develops they may need to use the visual component less and less.

On your out breath, imagine that the air you are exhaling is like blue colored smoke… or some other color that comes easily to you.  Imagine slowly blowing out a thin stream of colored smoke that goes out at the pace of your breath and then spreads out evenly several feet in front of you.  Some people find that this is easier to imagine this with their eyes open, others find it easier with their eyes closed.  Now, let’s take a breath and see if you are able to see the smoke…  Good.  Now, let’s take a breath and see if it is possible for you to worry while you are breathing out the colored smoke… Good.  Now, you have a strategy that can help slow your mind when it is racing and you need to do breathing to stay out of panic.

When “It Doesn’t Work” Means that It Doesn’t Calm Me for Long

For many highly traumatized clients, the body doesn’t know what to do with deep breathing.  I explain to clients that deep breathing is a practice that becomes more powerful the more you use it and get in touch with it.  This helps you better manage client expectations by normalizing the progressive nature of most adaptive coping skills.

I want to explain clearly what is likely to happen as you practice deep breathing at home.  You may do it several times and not notice much.  If you keep at it, you may notice that it calms you down some and then your anxiety goes right back up not long after you do it.  That is normal.  People often come and tell me that doing deep breathing for five minutes calms them for a very brief period (30 seconds or so) and then their anxiety goes right back up.  That’s normal. This feels like a complete waste of time to spend five minutes breathing and to feel calmer for 30 seconds.  It gets better once your body gets used to it.  It doesn’t know that feeling a little more relaxed is okay.  You teach it that it is okay by continuing to dip your toe into it a few minutes at a time several times per day.  Once you have done it for several weeks, you will notice that it calms you more and longer.  Anxiety is like the gas petal.  Breathing is like the brake.  Do you remember when you first drove and you put your foot on the brake?  It took a while for you to figure out how to work it.  Now you are able to work it almost without thinking about it.  Breathing is a practice that gets stronger the more you do it.

When “It Doesn’t Work” Means that I Forget to Do It

Well, it’s hard work for many of us to monitor our anxiety and to take steps to lower it.  I normalize this.

When we’re anxious, anxiety thinks that the solution is to be more anxious.  It wants to wind us up all the way.  Deep breathing taps the brake.  It takes some of the energy out, but when you’re really anxious it will be one of the last things on your mind if you don’t have a plan to anticipate it.  I love deep breathing.  I show every client I have how to do it.  There are few things that I’m more excited about.  Still, I might notice that I’ll have something tumbling around in my head that will make stress in my body.  I’ll often ignore it.  Three hours later, I notice that I still have something tumbling around in my head that is still making stress in my body.  Still, I ignore it.  Then, maybe six hours later, it finally reaches the point where it punches me in the stomach and I now have to do something about it.  I do a few minutes of deep breathing and it quickly quiets my body and my mind and lets me carry on, sometimes for the rest of the day.  It’s hard work to become aware and to act on that awareness.  Awareness of it comes easier the more you are aware.  And, breathing gets more effective the more that you do it.

When “It Doesn’t Work” Means that My Baseline Anxiety is Not Decreasing

Many therapists tell clients to use deep breathing to manage distress when anxiety is increasing.  This is a helpful strategy, but it is just as important that clients engage in deep breathing during the parts of the day when they feel the most relaxed (which is likely to also be a time of high anxiety, it’s just inside their normal range).

When we first start deep breathing, our bodies do not know what we are doing.  It does not know for sure that we’re calming down.  It needs to be trained.  Breathing works much better after our bodies know what we’re doing and it can see, “Oh, we’re calming down now.”  As we notice that we’re getting anxious, deep breathing can help keep us out of the panic zone.  However, if you also do it when your anxiety isn’t going up sharply, it can help lower your baseline anxiety.  During these times, you dip you toe into calm deep breath and your “normal” range of anxiety will become lower.  As the amount of anxiety that is normal for you goes down, you have more room before you hit the panic range.  You can more easily absorb stressful things that come at you when your “normal” range of anxiety is lower.  This can help you develop more of a cushion.  So, it is important that you practice deep breathing when your anxiety is increasing.  It is just as important that you practice in at your “normal” range.

I’d love to hear your strategies for helping clients navigate to breathing as a resource.