Suggestions for mastering and generalizing breathing skills

Adapted from: Peper, E., Oded, Y., Harvey, R., Hughes, P., Ingram, H., & Martinez, E. (2024). Breathing for health: Mastering and generalizing breathing skills. Townsend Letter-Innovative Health Perspectives. November 15, 2024.   https://townsendletter.com/suggestions-for-mastering-and-generalizing-breathing-skills/

Breathing techniques are commonly employed with complimentary treatments, biofeedback, neurofeedback or adjunctive therapeutic strategies to reduce stress and symptoms associated with excessive sympathetic arousal such as anxiety, high blood pressure, insomnia, or gastrointestinal discomfort. Even though it seems so simple, some participants experience difficulty in mastering effortless breathing and/or transferring slow breathing skills into daily life. The purpose of this article is to describe: 1) factors that may interfere with learning slow diaphragmatic breathing (also called cadence or paced breathing, HRV or resonant frequency breathing along with other names), 2) challenges that may occur when learning diaphragmatic breathing, and 3) strategies to generalize the effortless breathing into daily life.

Background

A simple two-item to-do list could be: ‘Breathe in, breathe out.’ Simple things are not always easy to master. Mastering and implementing effortless ‘diaphragmatic’ or ‘abdominal belly’ breathing may be simple, yet not easy. Breathing is a dynamic process that involves the diaphragm, abdominal, pelvic floor and intercostal muscles that can  include synchronizing the functions of the heart and lungs and may result in cardio-respiratory synchrony or coupling, as well as ‘heart-rate variability breathing training (Codrons et al., 2014; Dick et al., 2014; Elstad et al., 2018; Maric et al., 2020; Matic et al., 2020).  Improving heart-rate variability is a useful approach to reduce symptoms of stress and promotes health and reduce anxiety, asthma, blood pressure, insomnia, gastrointestinal discomfort and many other symptoms associated with excessive sympathetic activity (Lehrer & Gevirtz, 2014; Xiao et al., 2017; Jerath et al., 2019; Chung et al., 2021; Magnon et al., 2021; Peper et al., 2022).  

Breathing can be effortful and In some cases people have dysfunctional breathing patterns such as breath holding, rapid breathing (hyperventilation), shallow breathing and lack of abdominal movement. This usually occurs without awareness and may contribute to illness onset and maintenance. When participants learn and implement effortless breathing, symptoms often are reduced. For example, when college students are asked to practice effortless diaphragmatic breathing twenty-minutes a day for one week, as well as transform during the day dysfunction breathing patterns into diaphragmatic breathing, they report a reduction in shallow breathing, breath holding,, and a decrease of symptoms as shown in Fig 1 (Peper et al, 2022).

Figure 1. Percent of people who reported that their initial symptoms improved after practicing slow diaphragmatic breathing for twenty minutes per day over the course of a week (reproduced from: Peper et al, 2022).

Most students became aware of their dysfunctional breathing and substituted slow, diaphragmatic breathing whenever they realized they were under stress; however, some students had difficulty mastering ‘effortless’ (e.g., automated, non-volitional) slow, diaphragmatic breathing that allowed abdominal expansion during inhalation.

Among those had more difficulty, they tended to have almost no abdominal movement (expansion during inhalation and abdominal constriction during exhalation). They tended to breathe shallowly as well as quickly in their chest using the accessory muscles of breathing (sternocleidomastoid, pectoralis major and minor, serratus anterior, latissimus dorsi, and serratus posterior superior).

The lack of abdominal movement during breathing reduced the movement of lymph as well as venous blood return in the abdomen; since; the movement of the diaphragm (the expansion and constriction of the abdomen) acts a pump. Breathing predominantly in the chest may increase the risk of anxiety, neck, back and shoulder pain as well as increase abdominal discomfort, acid reflux, irritable bowel, dysmenorrhea and pelvic floor pain (Banushi et al., 2023; Salah et al., 2023; Peper & Cohen, 2017; Peper et al., 2017; Peper et al., 2020, Peper et al., 2023). Learning slow, diaphragmatic or effortless breathing at about six breaths per minute (resonant frequency ) is also an ‘active ingredient’ in heartrate variability (HRV) training (Steffen et al., 2017; Shaffer & Meehan, 2020).

1. Factors that interfere with slow, diaphragmatic breathing

Difficulty allowing the skeletal and visceral muscles in the abdomen to expand or constrict in ‘three-dimensions’ (e.g., all around you in 360 degrees) during inhalation or exhalation. Whereas internal factors under volitional control and will mediate breathing practices, external factors can restrict and moderate the movement of the muscles. For example:

Clothing restrictions (designer jeans syndrome).  The clothing is too tight around the abdomen; thereby, the abdomen cannot expand (MacHose & Peper, 1991; Peper et al., 2016). An extreme example were the corsets worn in the late 19^th century that was correlated with numerous illnesses.

Suggested solutions and recommendations: Explain the physiology of breathing and how breathing occurs by the diaphragmatic movement. Discuss how babies and dogs breathe when they are relaxed; namely, the predominant movement is in the abdomen while the chest is relaxed. This would also be true when a person is sitting or standing tall.  Discuss what happens when the person is eating and feels full and how they feel better when they loosen their waist constriction. When their belt is loosened or the waist button of their pants is undone, they usually feel better.

Experiential practice. If the person is wearing a belt, have the person purposely tighten their belt so that the circumference of the stomach is made much smaller. If the person is not wearing a belt, have them circle their waist with their hands and compress it so that the abdomen can not expand. Have them compare breathing with the constricted waist versus when the belt is loosened and then describe what they experienced.

Most participants will feel it is easier to breathe and much more comfortable when the abdomen is not constricted.

Previous abdominal injury.  When a person has had abdominal surgery (e.g., Cesarean section, appendectomy, hernia repair, or episiotomy), they unknowingly may have learned to avoid pain by not moving (relaxing or tensing) the abdomen muscles (Peper et al., 2015; Peper et al., 2016). Each time the abdomen expands or constricts, it would have pulled on the injured area or stitches that would have cause pain. The body immediately learns to limit movement in the affected area to avoid pain. The reduction in abdominal movement becomes the new normal ‘feeling’ of abdominal muscle inactivity and is integrated in all daily activities. This is a process known as ‘learned disuse’ (Taub et al., 2006).  In some cases, learned disuse may be combined with fear that abdominal movement may cause harm or injury such as after having a kidney transplant. The reduction in abdominal movement induces shallow thoracic breathing which could increase the risk of anxiety and would reduce abdominal venous and lymph circulation that my interfere with the healing.

Suggested solutions and recommendations.  Discuss the concept of learned disuse and have participant practice abdominal movement and lower and slower breathing. 

Experiential practices: Practicing abdominal movements

Sit straight up and purposely exhale while pulling the abdomen in and upward and inhale while expanding the abdomen.  Even with these instructions, some people may continue to breathe in their chest. To limit chest movement, have the person interlock their hands and bring them up to the ceiling while going back as far as possible. This would lock the shoulders and allows the abdomen to elongate and thereby increase the diaphragmatic movement by allowing the abdomen to expand.  If people initially have held their abdomen chronically tight then the initial expansion of abdomen by relaxing those muscle occurs with staccato movement.  When the person becomes more skilled relaxing the abdominal muscles during inhalation the movement becomes smoother.

Make a “psssssst” sound while exhaling.  Sit tall and erect and slightly pull in and up the abdominal wall and feel the anus tightening (pulling the pelvic floor up) while making the sound. Then allow inhalation to occur by relaxing the stomach and feeling the anus go down.

Use your hands as feedback. Sit up straight, placing one hand on the chest and another on the abdomen. While breathing feel the expansion of the abdomen and the contraction of the abdomen during exhalation. Use a mirror to monitor the chest-muscle movement to ensure there is limited rising and falling in this area.  

Observe the effect of collapsed sitting.  When sitting with the lower back curled, there is limited movement in the lower abdomen (between the pubic region and the umbilicus/belly button) and the breathing movement is shallower without any lower pelvic involvement (Kang et al., 2016). This is a common position of people who are working at their computer or looking at their cellphone.

Experiential practice: looking at your cellphone 

Sit in a collapsed position and look down at your cellphone. Look at the screen and text as quickly as possible.

Compare this to sitting up and then lift the cell phone at eye level while looking straight ahead at the cellphone. Look at the screen and text as quickly as possible.

Observe how the position effected your breathing and peripheral awareness. Most likely, your experience is similar those reported by students.  Close to 85%% of students who complete this activity reported that their breathing was  shallower sitting slouched versus erect and about 85% of the students reported that their peripheral awareness and vision improved when sitting erect (Peper et al., 2024).

Suggested solutions and recommendations.  Be aware how posture affect breathing. While sitting, place a rolled-up towel against the lower back so that the person sits more erect which would allow the abdomen to expand when inhaling.

Self-image, self-esteem, and confidence. Participants may hold their abdomen in because they want to look slim (sometimes labeled as the “hourglass syndrome” associate expanding the abdomen as unattractive (PTI, 2023).  A flat abdomen is culturally reinforced by social media and fashion models and encouraged in some activities such as ballet. On the other hand, some people purposely puff up their chest to increase size and dominance (Cohen & Leung, 2009).

Suggested solutions and recommendations.  Discuss the benefits of diaphragmatic breathing including its ability to reduce anxiety in social settings that may enhance confidence. Similar to an earlier suggestion, have the person explore clothing with a looser waist that still supports feelings of attractiveness and power.

Feeling anxious, fearful or threatened. The normal physiological stress reaction is a slight gasp with the tightening of the abdomen muscles for protection when a stressor occurs (Gilbert, 1998; Ekerholt & Bergland., 2008). The stressor can be an actual physical event, social situation or thoughts and emotions.  Shallow breathing is a natural self-protective response.  This pattern is often maintained until one feels ‘safe’ enough to relax, which for many can have a duration of the entire day or until finding the relative safety of sleep.  

Suggested solutions and recommendations. Discuss how the physiological stress reaction is a normal response pattern that the person most likely learned in early childhood for self-protection.  This pattern is often observed in clients who are emotionally sensitive and/or react excessively to a variety of stimuli. Note that some people have learned not to show their reactivity on their face or in the overt behaviors, yet they continue to breathe shallowly as a telltale sign of ‘distress.’ People who breath shallowly may experience this response as burdensome. Discuss with them how to reframe their sensitivity as a gift; namely, they are more aware of other people’s reactions and emotions. They just need to learn how not to respond automatically. Encourage awareness of their breath-holding and shallow breathing. Follow this by teaching them to replace the dysfunctional breathing with slow, diaphragmatic breathing at 6-breaths-per-minute. A possible training sequence is the following:

• Teach slow, diaphragmatic breathing
• Practice evoking a stressor and the moment the client senses the stress response, shallow breaths or holds their breath have them shift to slow, diaphragmatic breathing.
• If the person slouches in response to stress, the moment they become aware of slouching, have then sit erect, look up and then breathe diaphragmatically.  (Peper et al., 2019)

Experiential practice: Transform stressful thoughts by looking up, breathing, and changing thoughts. 

Evoke a stressor and then attempt to reframe the experience (cognitive behavior therapy  or CBT approach).

Compare this to  evoking a stressor, then shift to an upright position while looking up, take a few slow, diaphragmatic breaths, and reframe the experience.

In almost all cases, when the client shifts position, looks up and then reframes, the stress reaction is significantly reduced and it is much easier to reframe the experiences positively compared to when only  attempting to reframe the experience (Peper et al., 2019).

Diaphragmatic breathing feels abnormal. How you breathe habitually is what feels normal unless there is overt illness such as asthma or emphysema. Any new pattern usually feels abnormal. When the person shifts their breathing pattern, such as in a transition from habitual shallow chest breathing to slower diaphragmatic abdominal breathing, it feels strange and wrong.

Suggested solutions and recommendations. Discuss the concept that habitual patterns are normal (e.g., a person who typically slouches when standing straight may experience that they are going to fall backwards). Emphasize the importance of making a shift in posture and leaning into the discomfort of the new experience. Often after practicing slow diaphragmatic breathing, the person may report feeling much more relaxed (e.g., sensing heaviness and warmth) with their fingers increasing in temperature.

2. Challenges that may occur when learning diaphragmatic breathing

Ideally, breathing is an effortless diaphragmatic process as described by the phrase, “it breathes me” (Luthe & Schultz, 1970; Luthe, 1979); however, some participants struggle to achieve this type of breathing.  The following are common challenges and possible solutions:

Distraction and internal dialogue. Many people struggle with thoughts jumping from one area to another. Some people refer to this mental state as “monkey mind.”

Suggested solutions and recommendations.  Validate that distraction and internal dialogue are normal and require continual managing and practice to overcome.  Experimental Practice: Have the person train focus during diaphragmatic breathing techniques by focusing on 1 item in the room. Remind them that when thoughts arise, note them briefly instead of engaging with them and then refocus on the item. Start with increments of time and increase with practice.   

Effect of gravity on breathing.  In the vertical position, exhalation occurs when the abdomen constricts (slight tightening of the transverse and oblique abdominal muscles and the pelvic floor) pushes the diaphragm up, allowing the air to go out. It needs to push against gravity.

In the vertical position, inhalation occurs when the abdominal muscles and pelvic floor muscles relax and the abdomen widens in all directions (360 degrees) which causes the diaphragm to descend as it is being pulled down by gravity. This process allows effortless inhalation. The experience is the opposite when lying supine on one’s back.  While lying down, gravity pulls on the abdomen that cause the diaphragm to go upward allowing the air to flow out during exhalation. Inhalation takes work because as the diaphragm descends it has to push the abdominal content upward against gravity.  

Experiential practice:  Erect versus supine

• Vertical position. Begin by exhaling completely by pulling the abdomen in and up while staying erect and not pressing/contracting the chest downward. At the end of exhalation, allow the abdomen to relax (pop out) and feel how the air is sucked in without trying to inhale
• Horizontal position. Begin by lying down, with the face pointing up. Inhale by expanding your abdomen and pushing your abdomen upward against gravity. Then let exhalation occur while totally relaxing as gravity pushes the abdomen downward, which pushes the diaphragm upward into the chest allowing the air to flow out.  Optionally, place a small bag of rice/beans (e.g., approximately one to five pound or. One-half to two kilograms) on your lower abdomen while lying down. When you inhale, push the weight upward and away from you by allowing the stomach, but not the chest, to expand. Allow exhalation to occur as the weight pushes your abdomen down and upward into your chest.  The weight is useful as it allows the mind to focus more easily on the task of feeling the movement of the abdomen.

Over breathing/hyperventilation. Even breathing at about six breaths per minute can cause hyperventilation can occur.  Hyperventilation occurs when a person is breathing in excess of the metabolic needs of the body and thereby eliminating more carbon dioxide. The result is respiratory alkalosis and an elevated blood pH as the dissolved carbon dioxide (pCO2) in the blood is reduced (Folgering, 1999).

The most common symptoms of over breathing are colder sweaty hands and light-headedness.  If this starts to occur, focus on decreasing the airflow during exhalation by exhaling through pursed lips making the sound, “Pssssssst.” While making this sound, make the sound softer with less airflow.  Alternatively, have them imagine a holding a dandelion flower a few inches from their lips and blow so softly the seeds do not blow away.  The blowing away of the seed is the feedback that you are blowing to hard as shown in Figure 2.

Figure 2. Dandelion seeds as feedback when the person is blowing with too much effort. Alternatively, we recommend that the client imagine smelling the scent/fragrance of a flower that usually causes nose inhalation and then exhale gently through pursed lips ast if the air flows over a candle and, the flame does not move back and forth.

Mouth breathing.  Mouth breathing contributes to disturbed sleep, snoring, sleep apnea, dry mouth upon waking, fatigue, allergies, ear infections, attention deficit disorders, crowded miss-aligned teeth, and poorer quality of life (Kahn & Ehrlich, 2018). Even the risk of ear infections in children is 2.4 time higher for mouth breathers than nasal breathers (van Bon et al, 1989) and nine and ten year old children who mouth breath have significantly poorer quality of life and have higher use of medications (Leal et al, 2016).

Breathing through the nose is associated with deeper and slower breathing rate than mouth breathing. Nose breathing reduces airway irritation since the nose filters, humidifies, warms/cools the inhaled air as well as reduces the air turbulence in the upper airways.  The epithelial cells of the nasal cavities produce nitric oxide that are carried into the lungs when inhaling during nasal breathing (Lundberg & Weitzberg, 1999). The nitric oxide contributes to healthy respiratory function by promoting vasodilation, aiding in airway clearance, exerting antimicrobial effects, and regulating inflammation (McKeown, 2019; Allen, 2024). Note that alternate nostril breathing, such as breathing in one nostril for 5-seconds and out of the other for 5-seconds is another technique which some people find beneficial.

Slower breathing approaches also facilitates sympathetic parasympathetic balance and reduces airway irritation.  If the person breathes habitually through their mouth, refer them to health care provider to explore factors that may contribute to mouth breathing such as enlarged tonsils and adenoids or deviated septum. In addition, explore environmental factors that could contribute nasal inflammation such as allergies or foods such as dairy (Al-Raby, 2016).

Performance anxiety. Many participants are concerned about their performance.  The direct instructions such as “follow the graphic” causes the person to try hard to breathe with too much effort.  Explore some of the following indirect strategies to interrupt ongoing cognitive judgements and self-talk.

• Toning or humming (Peper et al., 2019a). While exhaling, have the person hum a sound with their mouth closed. Let the sound go for about 6 seconds, relax, inhale and hum again. Toning is very similar except you verbalize a tone such as “Oammm.” (For detailed instructions on toning, see: Anziani & Peper (2021)).
• Stroking down arms and legs during exhalation. Have a partner gently stroke down your arms from your shoulder past your fingertips as you are exhaling. The downward stroking is in rhythm with the exhalation.   As the arm is being stroked, attend to the sensations going down the arms.  Be sure that the toucher exhales at the same time and the stroking down the arm takes about six seconds. After being stroked for a few times, have the person imagine that each time they exhale they feel a flow down through their arms and out their fingers.

• Repeat the same process while stroking down the legs from the side of their hips to their toes.
• Finally, have the person imagine/feel the sensation streaming down their legs with each exhalation.
• Many participants will report that they sense a steaming going down their arms, that they hands warm up, and their thought have stopped.
• Integrated body movement with breathing especially flexion and contraction (Meehan & Shaffer, 2023). Integrate the normal response of flexion that induces exhalation and extension evokes inhalation. Be careful that the flexion movement does not encourage participants to compress their chest during exhalation, which tends to encourage chest breathing.  Have the person focus on their head staying tall and erect.  Have the person sit straight up with their feet slight apart and their hands palm down on their lap. Allow inhaling to initiate as the person simultaneously arches their lower back expanding the stomach, separating the knees and turning the hands palm up. Initiate exhalation while simultaneously bringing the knees together, turning the palms face down on the thighs and rolling the pelvic back slightly rounding the lower back. Do the movements smoothly while keeping the legs and shoulders relaxed.

Flooded by emotions.  Although very rare, at times when the person allows the abdomen to relax, they may experience by the emotions from a past trauma as the habitual bracing patterns are relaxed.

Suggested solutions and recommendations. Validate these emotions for the person. Explain that this is a normal process that may occur if past trauma has occurred. Clients who have had past trauma often experience hypervigilance, which may interfere with the relaxation response that occurs during more optimal states of breathing. Transitioning to a more optimal rest state may be uncomfortable for a person who has experienced trauma because it reduces hypervigilance. This can feel uncomfortable as hypervigilance in these cases serves a protective role, even if it is an illusory feeling of protection from future harm. Since persistent hypervigilance can interfere with the relaxation response, the benefits of allowing a relaxation response to occur through slower breathing should be highlighted.  Grounding techniques as described by Peper et al (2024a) can be useful to become centered.

3. Strategies to generalize the effortless breathing into daily life.

Generalizing the skill occurs after having mastered diaphragmatic breathing in different positions (sitting, standing, lying down, and while performing tasks). It is important to remember that our breathing patterns are conditioned with our behavior. Become aware how breathing affects cognitions and emotions and how emotions and cognitions affects breathing. The following are some strategies that may facilitate learning and generalizing the slower breathing skills.

Observing how our behavior affects our breathing:  Anything that may evoke the alarm or defense reaction tends to cause the person gasp and/or hold their breath. For example, when a person is sitting peacefully, make an unexpected noise behind their back or movement in their periphery of vision. In most cases they will gasp or hold their breath.  Usually, they are unaware of this process unless they are asked what happened to their breathing. The major reason for the breath holding is that the stimuli triggers an alarm/defense reaction and when we hold our breath our hearing is more acute (we can hear approaching danger earlier).  The problem is that we give this response when there is no actual, immediate or present threat.

Experiential practice. Sit comfortably.  Now as quickly as possible without rotating the head, look with your eyes to the extreme right and then left and back and forth as if trying to identify danger at the periphery.  Do this for a few eye movements. Almost everyone holds their breath when doing this exercise.  For generalizing the skill, ask the person to observe during the day situations in which they hold their breath, ask them if it was necessary and encourage them to start diaphragmatic breathing.

Observing how breathing affects our thoughts and emotions. Breathing patterns are intrinsically linked to our emotions and thoughts as illustrated in the many language phrases such as sigh of relief, full of hot air, waiting with bated breath.  At the same time, our breathing patterns also affect our thoughts. For instance, when we breathe shallowly and more rapidly, we can induce feelings of fear or anxiety. If we gasp, we can experience thought stopping.

Experiential practices: Incomplete exhalation: Observe what happens when you exhale less than you inhale. Begin by exhaling only 70% of the air you inhaled, then inhale and exhale again only 70% of the air you just inhaled continue this for 30 seconds.  Many people will experience the onset of anxiety symptoms, lightheadedness, dizziness, neck and shoulder tension, etc. (Peper & MacHose, 1993). If you experience symptoms during this exercise and you have experienced these symptoms in the past, it is likely that unknowingly breathing in a dysfunctional pattern could have evoked them. Therefore, practicing effortless breathing may interrupt and reduce the symptoms.  Do this practice while observing the person carefully and immediately interrupt and distract the person if they start feeling dizzy, too anxious, or trigger the beginning of a panic attack or PTSD symptoms.

Experiential practice: Gasp or sniff-hold sniff. Observe what happens when you are performing a cognitive task and you rapidly gasp or do sniff-hold-sniff again before exhaling.  Begin by sequentially subtracting mentally, the number 7 from 146 (e.g., 146, 139, 132….). Do this as rapidly as possible and do not make a mistake. While doing the subtracting, take a rapid gasp (such as one is triggered by surprise or fear), alternatively, take a quick sniff through your nose, hold your breath and take another sniff on top of the first one, then exhale.  Whereas subtrating numbers is a skill most adults can perform, the ‘time pressure’ along with the direction to avoid mistakes may be the ‘immediate’ source of strain. Whether it was the time pressure, the direction to avoid mistakes or the direction to gasp, observe what happened to your thinking process. In almost all cases, your higher-order thoughts (doing the sequential subtraction under time pressure while gasping) have disappeared, replaced by the immediate thoughts of ‘performance anxiety.’

If you blank out on exams or experience anxiety, gasping and breath holding may be one of the factors that increases symptoms and affects your performance.  If you are aware that you are holding your breath or gasped, use that as the cue to shift to slow diaphragmatic breathing and you may find that your performance improves. Therefore, observe when and where you were blanking out, gasping and/or holding your breathing then substitute slow, effortless diaphragmatic breathing.

How to develop awareness and interrupting of dysfunctional breathing response. Most participants are unaware of their somatic responses until symptoms occur. Being aware of the initiation of a somatic response may assist you in identifying triggers and interrupting the developing process. A significant component of the training is symptom prescription rehearsal.

Symptom prescription is a practice in which the participant simulates/acts out the psychophysiological pattern associated with their symptoms.  They amplify the body pattern until they feel the onset of the actual symptoms.  The moment the person feels the beginning of the symptom, they stop the practice  and initiate slow breathing and relaxation. After practicing the symptom rehearsal, they are instructed to become aware of the onset of the symptom and then use that signal to  trigger the effortless breathing while looking up and shifting the body into an upright sitting position (Peper et al., 2019). Gasping and breath holding are normal responses to unexpected stimuli; however, they may trigger sympathetic activation even when there is no actual danger.

Experiential practice: Developing awareness on neck and shoulder tension:

Sit comfortably and practice effortless breathing for a minute. Take a fearful gasp and observe what happens in your body (e.g., slight neck and upper chest tension, light headedness, slight radiating pain into the eye, etc.). Shift back to effortless breathing until all symptoms /sensations have disappeared.

• Now gasp with less effort and observe the first sensations, use the awareness of first sensations to trigger the effortless breathing and continue to breathe until symptoms have disappeared
• Continue this practice. Reduce the gasping effort each time.
• After having developed the initial somatic sensation then during the day observe what triggers this response and immediately shift to slower diaphragmatic breathing. After you have shifted to effortless breathing, reflect on the trigger. Was it necessary to react? If yes, explore strategies to resolve the issue.

The same process can be done to assist with desensitization to painful memories or stressful events. Each time the person becomes aware of their somatic reaction to an evoked memory or stressful event, they shift to effortless diaphragmatic breathing. If they find that it is difficult to interrupt the emotional memories and it triggers more and more negative thoughts and associations, use the sniff-hold-sniff technique and follow that with box-breathing or any of the other quick somatic rescue techniques (Peper et al., 2024a). Box-breathing in this context could include a brief breath-holding. A typical box-breathing technique is to breath in for a count of four, hold for a count of four, breath out for a count of four, then breath in again for a count of four, continuing the figurative 4-4-4-4 count of breathing.

Practice slower diaphragmatic breathing during the day. Implement effortless diaphragmatic breathing through regeneration and interrupting the stress response.

• Support regeneration. Each day set aside 10 to 20 minutes to practice slow effortless diaphragmatic breathing at about 6-breaths-per-minute. In the beginning 10 to 20 minutes may be too long, thus in some cases have the person practice a few times a day for two minutes and slowly build up to 10 or more minutes. The practice is not just a mechanical process of breathing it includes mindfulness training.  Namely, as you are breathing each time you exhale imagine a flow doing down your arms and legs and as you inhale an energy coming into you.  Whenever your attention drifts bring it back to the breathing.
• Integrate breathing with daily activities. Practice slower breather before eating, after putting the seat belt on in the car, or whenever a notification pops up on the cell phone.
• Set reminders and alarms on your phone to check how you are feeling and breathing. Leave notes on nearby furniture such as a nightstand, on the shower door, and/or on the kitchen table as reminders to be mindful of your breath. If stressed or breathing shallowly, take a moment to breathe slowly.
•  Interrupt the stress response.  During the day when you are aware that you shallow breathe, are holding your breath,  feel anxious, experience neck and shoulder tightness, or worry and use that as a cue to shift position by sitting or standing more erect, looking upward and take a few slow diaphragmatic breaths.
• Use cue condition to facilitate this process.  Each time you begin the practice smell a specific aroma or do some behavioral movement and then do the breathing.  After a while the aroma or behavioral movement will become the classically conditioned cue to trigger the effortless breathing.
• Use role rehearsal and conditioning to generalize the skill. Generalizing the skills often takes more time than what may be expected. In a culture where instant relief is expected— implied message associated with medication— self-mastery techniques are different and challenging as they take time to master the skill and implement them during daily life. The process of mastery is similar to learning to play a musical instrument or sports. Learning to play the violin requires practice as well as practice with failures along the way until one is ready for more challenging musical pieces, recitals, or performances.

A useful strategy to implement the learning is role rehearsal in the office, at home at work, and in real life.  It is usually much easier to practice these skills in a safe space such as your own room or, with a therapist compared to with other people or, at work. To generalize the skill most efficiently, it can be helpful to practice in a safe environment while imagining being in the actual stressful location This process is illustrated by the strategy to reduce social anxiety and menstrual cramps.

Social anxiety when seeing my supervisor. Master effortless breathing in a safe environment. Role rehearsal in imagery. If you observed that you held your breath when your supervisor is around, begin with imagery when your supervisor is not present. Sit, comfortably. Let go of muscle tension and breathe effortlessly, evoking a scenario where your supervisor is walking by and continue to breathe slowly as you imagine the scene. Role rehearsal in action.  Ask another person to role-play your supervisor. Sit, comfortably. Let go of muscle tension and breathe effortlessly. Have this person walk into the room in a similar way that your supervisor would. Imagine that person is your supervisor while practicing your effortless breathing. Repeat until the effortless breathing is more automatic. Practice many times in real life.  Whenever the rehearsed situation occurs, implement slower paced breathing.

Menstrual cramps that causes most women to curl up and breathe shallowly when experiencing menstrual cramps (Peper et al., 2023). Master effortless breathing in a safe environment. Practice breathing lying down. While lying down, breathe diaphragmatically by having a three-to-five-pound weight such as a bag of rice or hot water pad on your abdomen.  If you have a partner, have the person stroke your legs from the abdomen to your toes while you exhale. Role rehearse experiencing pain and then practice lower diaphragmatic breathing. Namely, tighten your abdomen as if you have discomfort, then focus on relaxing the buttocks and sensing the air flowing down your legs and out your feet as you exhale. Practice in real life.  A few days before you expected menstruation, practice slow diaphragmatic breathing several times for at least 5-10 minutes during the day. When your menstruation starts practice the slower and lower breathing while imagining the air flowing down the abdomen, through the legs and out the feet.

Summary/Conclusion

Breathing is the mind-body bridge.  It usually occurs without awareness and breathing changes affect our thought, emotions and body.  Mastering and implementing slower breathing during the day takes time and practice. By observing when breathing patterns change, participants may identify internal and external factors that affect breathing which provides an opportunity to implement effortless diaphragmatic breathing to optimize health as well as resolve some of the triggers.  As one 20-year-old, female student reported,   

The biggest benefit from learning diaphragmatic breathing was that it gave me the feeling of safety in many moments. My anxiety tended to make me feel unsafe in many situations but homing in  and mastering diaphragmatic breathing helped tremendously. I shifted from constant chest breathing to acknowledging it and in turn, reminding myself to breathe with my diaphragm.

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