New voices: One small, quiet act

Valerie (research participant) says 'It's like taking a Valium!'. Dorothy reports: 'I curled up on my side and just did it, really, really strongly and it took ten minutes, but when it went it was miraculous! It really felt like a "wow" moment!' 

Isobel has been lying on the floor in front of me for two minutes now. Her leg jolts slightly as a snore rouses her from a brief slumber. Half an hour ago Isobel entered my office rigid with fear and anxiety, her mind and heart racing. How did she move from panic to peace? What was Valerie's alternative to tranquillisers, and the secret of Dorothy's miraculous 'wow' moment? Breath.

There is far more to breathing than most of us normally think about. Whilst breath-work in one form or another is a long-established part of psychological practice, yogic breathing offers a richer and deeper set of tools. It's a kit that may provide psychologists working with more severe or enduring conditions with additional tools for emotional regulation, further enhancing existing third-wave therapeutic approaches.

My own 'natural' breathing has always been poor, with a typical asthmatic tendency to hyperventilation. It was only when I started to practise yoga that I first learned what it was like to breathe fully; to allow the movement of the breath to ripple out, away from my diaphragm through the whole of my body. The experience of peace and wellbeing that followed this practice was so profound that in addition to my doctorate in counselling psychology I trained as a yoga therapist and spent three years researching people's experiences of yoga for mental health.

As my trainings progressed I became increasingly curious about the mind–body connection. Listening to my research participants – several of whom had already experienced talking therapies – I was repeatedly struck by the fresh sense of confidence and empowerment yogic breathing practices had provided them with. I realised that psychologists could incorporate these simple yet effective strategies for emotional regulation into their clinical work.

As I say, breath-work isn't new in psychology: right from the start, pioneering French psychologist Pierre Janet spent two years in the Salpêtrière Hospital on detailed readings of the breathing patterns of neurotic patients. He identified a range of common yet irregular breath patterns that have informed the work of generations of therapists (Boadella, 1997). Over the years body-psychotherapists have continued to explore the relationship between childhood trauma, dysfunctional breathing and mental health. A wide range of body-based therapies now aim to restore the natural flow of breath, providing relief from psychological distress (see Totton, 2003).

Within contemporary psychology so-called 'third-wave' behavioural therapies, such as mindfulness-based cognitive therapy (Segal et al., 2012), the breath is used as an anchor to allow the mind to step back from ruminative thought patterns that maintain low mood and anxiety. In mindfulness meditation, clients are taught to follow the breath and to observe their internal experience in the present moment without judgement. Inspired by Buddhist and yogic philosophies, the third-wave departs from previous cognitive therapies by aiming to change the client's relationship to difficult thoughts as opposed to changing their content, and by offering tools for emotional regulation (see, for example, Hayes, 2004; Linehan, 1993).

In the classical yoga tradition, however, physical yoga practice, designed to release tension in the body, is followed by breath-work (or 'pranayama'), preparing the body and mind for the stillness of sitting meditation (Satchidananda, 1978). Humming like a bee, roaring like a lion, breathing through alternate nostrils and swirling the breath at the back of the throat, in the oceanic sounding ujjayi breath, are all examples of the wide range of tools yoga offers in working with the breath. For millennia, yogis have investigated the impact of shortening, lengthening, forcing, holding, releasing and deepening the breath on our physical and emotional states of being. Why not draw from this extensive tradition, complementing existing approaches?

Over the last 15 years there has been a growing interest in the West on the impact of yoga and yogic breathing practices on a range of mental health conditions. A significant challenge for researchers in the field has been the sheer breadth of yogic practices, making it difficult to generalise from any one particular study. Furthermore, whilst yielding some very promising results, until recently studies have often been limited by methodological inadequacies such as a lack of randomised control groups (Cabral et al., 2011; Kirkwood et al., 2005; Pilkington et al., 2005).

In a ground-breaking mixed-methods randomised control study by Patricia Kinser and her colleagues, participants with major depressive disorder reported a significant decrease in ruminative thought patterns, implicated in maintaining the condition, following an eight-week yoga intervention. The programme incorporated a range of yogic breathing practices, and participants reported obtaining some effective self-care techniques for managing symptoms of stress and depression (Kinser, Bourguignon, Taylor et al., 2013; Kinser, Bourguignon, Whaley et al., 2013).

From a neurological perspective, there has also been an explosion of interest in the impact of yoga and breathing on the nervous system, the body and the mind. Generally it is agreed that by breathing more slowly and deeply the levels of carbon dioxide and oxygen in the body are balanced, enabling better oxygen absorption and correcting the imbalance created by anxious hyperventilation (Bernardi et al., 2001; Farhi, 1996; Telles & Desiraju, 1991).  

Furthermore, some yogic breathing practices – particularly forms of slow, resistance breathing such as 'ujjayi', involving a slight contraction in the glottis – may trigger the autonomic nervous system to move out of sympathetic 'fight or flight' mode and into parasympathetic 'rest and digest' mode (Field, 2011; Jerath et al., 2006; Streeter et al., 2012). There is also evidence to suggest that yogic breathing may play a role in promoting autonomic flexibility; that is, the capacity to move more efficiently between sympathetic and parasympathetic mode (Telles et al., 2011).

These studies have significant implications for psychologists working with clients experiencing chronic, deeply entrenched patterns of emotional dysregulation. Working on placement in an NHS community recovery team, I could really see the impact of childhood trauma hard-wired into the body and the breath. My clients certainly benefited from third-wave therapies, which helped them to begin to step back from their thoughts and reactions, but at times of more acute distress simply watching the breath was not enough to shift out of fight or flight. Furthermore, it could be an enormous challenge to breathe more slowly and deeply in the face of overwhelming fear or anxiety. In these cases I felt clients could have really benefited from prior training in yogic breathing techniques.

As a trainee, my focus was primarily on developing my skills as a talking therapist. Now, however, within my independent practice as a psychologist and yoga therapist, I work more directly with my yogic toolkit. When clients approach me for yoga therapy, in addition to taking a full case history – including any physical or medical complaints – I assess the quality of the client's natural breathing through observation and client feedback. We discuss treatment options, and I tailor breathing practices to the specific needs of each client.

For clients with depression who want to lift themselves I might teach kapalabhati, a method of rapid chest breathing designed to lift the nervous system; for clients with anxiety I teach ujjayi to focus the mind, slow the breath, and direct it more deeply into the lower lungs. For clients whose anxiety has led them to hold chronic tension in the body, restricting the breath – such as Isobel – I teach them to expand the breath more fully through the body. Sometimes if clients are interested in the broader yogic philosophy we might explore this and at other times (perhaps if a client already has their own religious or spiritual practice) this may not be appropriate and we focus on the mechanics of breathing.

So let's go back to Isobel – she's been lying on the floor since the start of this article, after all. Isobel and I begin by simply observing her breathing and her present moment experience of body and mind. Next we practise a few stretches to release any tension that might constrict her breathing, before practising a simple yogic three-part breathing practice, called dirga breath, designed to encourage a deeper, fuller breath. Next I invite Isobel to let go of any effort and simply watch the slow, rhythmic swell in the breath in the body, observing the gentle pause at the end of each exhale. After two minutes, I quietly direct Isobel's attention to the sounds around her, orienting her back into the room, and I invite her to observe the effects of the practice in the breath, body and mind. Next, we work together on embedding this sequence into her daily routine. We explore breathing practices she can use to cope when she feels triggered, and write flashcards as a reminder.

Although further research is required to explore the impact of specific practices on different clinical presentations, a growing number of studies and my own qualitative research and clinical work suggest that clients find yogic breathing both useful and practical in emotion regulation. These techniques – which could easily be delivered to psychologists in training workshops – may even provide relief for clients with more severe mental health difficulties, enhancing existing third-wave approaches.

As one research participant commented, 'The breathing is with you all the time, wherever you are… You don't have to do anything, don't have to remember, just breathe!' One small quiet act: the act of breathing.

Holly Kahya is a Chartered Psychologist
[email protected]

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