Volume 42/Num ber I /January 2020/Pages 7 8 -9 4 /https://doi.org/IO . 17744/mehc.42.1.

06

NEUROSCIENCE-INFORMED COUNSELING

A Practitioner’s Guide to Breathwork

in Clinical Mental Health Counseling
B a b a tu n d e A id e y a n 1, G in a C . M a r t in 2, a n d E ric T. B e e s o n 3
Bouve College o f Health Sciences, Northeastern University
2Departm ent o f Rehabilitation and Counselor Education and Supervision,
University o f Iowa
d e p a rtm e n t o f Counseling@ Northwestern, The Family Institute at N orthw estern
University; C enter fo r Applied Psychological and Family Studies, N orthw estern
University

Breathwork techniques and therapies offer a set o f practical interventions for clinical mental
health counselors (CMHCs) and are viable methods for integrating physiological sensitivi­
ties in treatment by way o f the relaxation response. We discuss an organizing framework o f
breathwork practices and identify three broad categories o f breathwork within the field: deep
relaxation breathing, mindfulness breathwork. and yogic breathing. Each style is distinct in
how it is applied and in the specific respiratory patterns that users are instructed to use. We
also aim to elaborate the physiological effects, clinical research outcomes, and applicability
o f breathwork for treating mental illness. Overall, research findings indicate that breathwork
may be efficacious for treating anxiety, depression, and posttraumatic stress disorder. Despite
preliminary evidence for breathwork's efficacy for treating common psychological distress, more
research is needed to evaluate its utility for treating a wider range o f mental illness. CMHCs are
encouraged to incorporate breathwork techniques in their clinical treatment programs but must
appraise the value o f each technique individually.

Breathing, an essential function to sustain life, is an automatic behavior

that is regulated by the primitive centers of the brain and is critical to human
development and wellness. Dysfunctional breathing can lead to challenges in
emotion, thought, physiology, and behavior (Crockett, Cashwell, Tangen, Hall,
& Young, 2016). The intentional control of breathing patterns has emerged as a
therapeutic intervention employed by many clinical mental health counselors
(CMHCs). The therapeutic use of breathing techniques appeared in counsel­
ing literature decades ago, with a focus on educational settings (e.g., Rossman
& Kahnweiler, 1977; Wilkinson, Buboltz, & Seemann, 2001; Zaichkowsky,
Zaichkowsky, & Yeager, 1986). Since then, breathing interventions have been
applied to various elements of the human experience (Crockett et ah, 2016;

Babatunde Aideyan. © h ttp s :llo rc id .o rg /0 0 0 0 -0 0 0 2 -7 0 0 8 -5 4 7 1

Gina C. M a rtin , © h ttp s://o rcid .o rg /0 0 0 0 -0 0 0 2 -7 3 7 2 -5 3 0 7
Eric T. Beeson. © h ttp s ://o rc id .o rg /0 0 0 0 -0 0 0 1-6 8 5 9 -5 7 9 0
Correspondence concerning this a rticle should be addressed to Babatunde Aideyan, Bouve College o f
H e a lth Sciences, N ortheastern University, D e pa rtm e nt o f Applied Psychology. 4 0 4 In te rn a tio n a l Village,
Boston, M A, 02115. Em ail: aideyan.b@ husky.neu.edu

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 Breathwork in Counseling

Young, Cashwell, & Giordano, 2010), including clinical mental health coun­
seling (Crockett, Gill, Cashwell, & Myers, 2017).
Breathwork is a self-regulated process that connects conscious with
unconscious, allowing the individual to work through physiological resistance
to emotional processing typically not accessible in traditional talk therapy
(Young et ah, 2010). Mental health professionals have called for bottom-up
approaches (e.g., Dahlitz, 2015; Field, Beeson, & Jones, 2015) that calm the
subcortical regions of the brain prior to using top-down approaches that focus
on the cortical regions of the brain responsible for executive functioning.
Breathwork is one such bottom-up approach that provides CMHCs with an
intervention applicable to clients across the full spectrum of human function­
ing, from peak performance to pathological experiences.
The increased focus on breathwork is timely given the growth of neuro­
counseling (Beeson & Field, 2017), as well as the need to understand and
apply concepts related to the biological bases of behavior (American Mental
Health Counselors Association [AMHCA], 2016; Council for Accreditation
of Counseling and Related Educational Programs, 2015; Insel et ah, 2010).
As our understanding of mental health and wellness increasingly incorporates
biological considerations, CMHCs need to develop skills that address the
underlying systems responsible for the full range of psychological functioning.
Breathwork has the potential to influence practice and research across all
systems of the National Institute of Mental Health’s (NIMH, n.d.) Research
Domain Criteria, at the genetic, molecular, cellular, circuit, physiological,
behavioral, and self-report levels.
Apart from Crockett at al. (2016), the evidence for breathwork in the
counseling field is limited to decades-old studies, anecdotal evidence, and
proxy research from other health disciplines. Perhaps one reason for this lack of
research is the unclear conceptualization of breathwork. Breathwork involves a
broad classification of innumerable techniques with much complexity in type,
application, and outcome. There is a need for more specificity about breath­
work interventions being used with whom and under what conditions, whether
it be circular, conscious connected, or fast and full breathing (Young et al.,
2010); Holotropic Breathwork (HB; Grof, 2014); Sudarshan Kriya yoga (SKY;
Zope & Zope, 2013); or another classification. Before more rigorous research
protocols are executed, the existing literature must be explored to operational­
ize breathwork techniques according to style, mechanism, and outcome. The
current article will address this gap by methodically summarizing breathwork
literature in the mental health counseling and allied fields and creating a
framework for breathwork in clinical mental health counseling that can be
evaluated with future research.

BREATHWORK AND THE RELAXATION RESPONSE

Clinical mental health counseling is experiencing a dynamic shift
toward integrating both physiological and neurobiological components in

journal o f Mental Health Counseling 79

 research and treatment (Crockett et ah, 2016; NIMH, n.d.; Young et al., 2010).
Counseling research is incorporating a variety of physiological variables such
as heart rate variability', fMRI scans, cortisol levels, and even genetic analysis
to further assess the correlates of mental illness (Alkadhi, 2013; Kemp &
Quintana, 2013; Kreibig, 2010; Lichtenstein, Carlstrom, Rastam, Gillberg, &
Anckarsater, 2010). The relationship between physiology and mental illness is
a crucial component that providers and researchers should be aware of, and
breathing techniques offer a way for CMHCs to integrate these aspects of phys­
iology and neurology clinically.
Patterns of autonomic nervous system (ANS) activity and emotion regu­
lation have been reviewed systematically in mental health literature (Alvares,
Quintana, Hickie, & Guastella, 2016; Crockett et al., 2016; Kreibig, 2010;
Young et al., 2010). Acute psychological stressors and traumatic events stimu­
late the hypothalamic-pituitary-adrenal (HPA) axis, which activates the ANS
and a series of physiological responses that support coping with external stress­
ors (Alvares et al., 2016; Kreibig, 2010). The challenge with mental distress is
that it is capable of perpetually activating these physiological reactions, which
can lead to dysregulated ANS activity and ultimately emotional dysregulation.
The American Psychological Association (APA, 2017b) provides a succinct
description of the effects of stress on the nervous system: “It’s not so much
what chronic stress does to the nervous system, but what continuous activation
of the nervous system does to other bodily systems that become problematic”
(para. 23).
The utility of breathwork in clinical mental health counseling is grounded
in the ANS and in activation of the relaxation response (Alvares et ah, 2016;
Kreibig, 2010). The relaxation response is a physiological mechanism that nor­
malizes ANS activity, encourages affect regulation, and essentially counteracts
the flight-or-fight response. In acutely stressful situations, such as an automo­
bile accident, activating the relaxation response may help one to regulate the
ANS and assess the situation from an emotionally stable position. This idea is
also relevant for stressors that are persistent and chronic; individuals can assess
their emotional states more accurately if they can consistently regulate their
ANS activity.
Our discussion on breathwork is founded on the notion that an array of
breathing techniques stimulate physiological mechanisms to induce a relax­
ation response. Such relaxation, along with sustained attention to the breath
and keen awareness of one’s physical and emotional sensations, renders breath­
work techniques practical interventions for helping clients strengthen their
mind-body connection and their emotional regularity.

BREATHWORK TECHNIQUES IN CLINICAL

MENTAL HEALTH COUNSELING
Though there are a multitude of breathwork techniques that CMHCs may
consider, many of them share commonalities. Therefore, this section creates an

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 Breathwork in Counseling

organizational framework for breathwork in clinical mental health counseling

that includes deep relaxation breathing (DRB), mindfulness breathwork (MB),
and yogic breathing (YB). The following subsections include a description of
each technique, an overview of the physiological effects they produce, and a
short overview of clinical research outcomes. We do not endeavor to provide
a systematic review of empirical outcomes for each breathwork category, but
rather a narrative overview of key findings for each breathwork category, focus­
ing on the symptoms and constructs of psychological disorders that CMHCs
commonly encounter. A discussion of clinical applications of breathwork is
presented in a later section, “Applying Breathwork in Clinical Mental Health
Counseling.”
Deep Relaxation Breathing
DRB, often referred to as diaphragmatic breathing, relaxation breathing,
or abdominal breathing, is a prevalent breathwork technique shared across
several health disciplines, including nursing (Consolo, Fusner, & Staib, 2008;
S. D. Kim & Kim, 2005; Rickard, Dunn, & Brouch, 2015), dentistry (Biggs,
Kelly, & Toney, 2003), medicine (Chang, Liu, & Shen, 2013; Reyes del Paso,
Munoz Ladron de Guevara, & Montoro, 2015), and public health (Namuwali,
Mendrofa, & Dwidiyanti, 2016). Despite its versatility, the specific steps of the
technique do not vary much across different treatment settings. DRB involves
inhaling deeply and expanding the diaphragm, while steadily breathing in a fair
amount of air, followed by a slow exhale (Consolo et al., 2008). Paukert et al.
(2010) detail the following four-step process: “(a) take slow, even, deep breaths;
(b) inhale while counting slowly to three; (c) exhale while counting slowly to
three; (d) practice this with your eyes closed” (p. 644). Gaines and Barry (2008)
describe a similar three-step process with specific recommendations for the
frequency of use:
The relaxation breathing exercise [RBE] followed a pattern of inhaling for
the count of four, holding that breath for a count of seven, and exhaling for
a count of eight, repeating the cycle five times (Weil, 1998). Participants
did the RBE at three points during the day: upon arising, at midday, and
before going to sleep. Also, participants used it at any point during the
day when experiencing heightened feelings of anger or imminent loss
of control over an impulsive response or outburst of aggression, (p. 296)

What Are the Effects of Deep Relaxed Breathing?

The effects of slow, focused breathing have been carefully studied in med­
ical research as stimulating the ANS and triggering parasympathetic responses
(Liza, 2011; Pal & Velkumary, 2004). Parasympathetic activity increases while
sympathetic activity decreases during DRB, evidenced by decreased respira­
tory rate and oxygen consumption, decreased heart rate (Chang et al., 2013;
Kaushik, Kaushik, Mahajan, & Rajesh, 2006), and lowered blood pressure
(Howorka et al., 2013; Kaushik et al., 2006; Mourya, Mahajan, Singh, & Jain,

Journal of Mental Health Counseling 81

2009). The culmination of these physiological activations is the relaxation
response (Hoffman et al., 1982). Relaxation techniques like deep breathing
are described by the National Center for Complementary and Integrative
Health (2016) as processes that trigger the body’s “natural relaxation response,
characterized by slower breathing, lower blood pressure, and a feeling of
increased well-being” relaxation response. Though DRB can help clients
manage varying clinical symptoms, such as anxiety (Lickel, Carruthers, Dixon,
& Deacon, 2013; Su, 2010), aggressive behaviors (Gaines & Barry, 2008), and
PTSD symptoms (S. H. Kim et al., 2013), its therapeutic effects are rooted in
its capacity for regulating the ANS.

What Are the Outcomes o f Deep Relaxed Breathing?

Clinical research studies investigating DRB for treating mental health
conditions frequently track anxiety and stress outcomes. DRB has shown effi­
cacy in research settings for managing music performance anxiety (Su, 2010),
dental anxiety (Armfield & Heaton, 2013), anxiety associated with dressing
burn wounds (Park, Oh, & Kim, 2013), and anxiety associated with various
phobias (Lickel et al., 2013; Shiban et al., 2017). Research evidence also sug­
gests DRB is useful for managing chronic stress in college students (Perciavalle
et al., 2017), as well as promoting reductions in tension-anxiety in a group
of gynecological cancer patients (Hayarna & Inoue, 2012). Nursing studies
have shown that DRB is associated with significant reductions in depressive
symptoms in medical patients (Chung et al., 2010; Tsai et al, 2015), though
one study reported non-significant reductions in patients with coronary heart
disease (D’silva, Vinay, & Muninarayanappa, 2014). An intervention consisting
of mindfulness-based stretching combined with deep breathing had positive
effects on PTSD symptoms (S. H. Kim et al., 2013), though an earlier study
did not find significant improvements in the PTSD symptoms of Vietnam War
veterans after they were trained to use deep breathing in conjunction with
other mind-body techniques (Watson, Tuorila, Vickers, Gearhart, & Mendez,
1997). By and large, there is substantial evidence supporting the use of DRB
for treating acute anxiety and chronic stress, but more research must be done
investigating a wider range of mental health symptoms.
Mindfulness Breathwork
The health effects of mindfulness are widely regarded as effective and
beneficial for treating numerous clinical conditions, including depression,
anxiety, addiction, and PTSD (Creswell, 2017). This section describes MB,
which is the collection of breathing techniques and therapies that retain a
conscious—connected component. MB therapies promote a strong focus on
mindfulness and awareness of one’s breathing and sensations, which are said to
induce an altered state of conscious attention. The range of techniques that fall
under the MB umbrella are often referred to as breathwork therapies, because
they are comprehensive and structured treatments requiring the direction of a
therapist. While many other breathwork techniques are used in conjunction

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 Breathwork in Counseling

with other clinical treatments, MB techniques are typically administered as a

stand-alone intervention. For example, HB involves a variety of components
such as music, supportive touch, and deep and mindful breathing that takes
place over multiple hours (Rhinewine & Williams, 2007). Other common
MB therapies include circular breathing, conscious connected breathing,
integrative breathwork therapy, and guided respiration (Lalande, Bambling,
King, & Rowe, 2012; Lalande, King, Bambling, & Schweitzer, 2016; Young
et ah, 2010).
Despite the manualized structure of MB interventions, the key compo­
nents that perpetuate the various therapies concern paying mindful attention to
one’s breathing and eventually accessing an altered or heightened state of con­
scious awareness (Young et ah, 2010). By regulating the breath with consistent
flow and patterns, users can achieve a meditative mind, allowing them to pay
greater attention to their bodily sensations and inner experiences (Lalande et
ah, 2012). This may be able to translate clinically to a significant psychological
experience.
Holotropic Breathwork
HB can be used to further explain MB. An HB therapy session may last
one or more hours, and clients are guided throughout by a therapist. The thera­
pist is essentially a tool for the client to undergo a profound healing experience.
Two main components help to induce psychosomatic effects during HB: pro­
longed overbreathing, which is often described as hyperventilation, and music.
Not much is discussed about the specific selection of music in HB literature,
except that it must be “evocative” (Gibson, 2014; Grof & Grof, 2010), which
generally entails intense instrumental music with variations of dramatic sound
(Grof, 2014). Such evocative music is viewed as a guide for clients while oper­
ating in states of non-ordinary consciousness and as the driving force for experi­
encing a spectrum of emotions during the HB therapeutic process. Holotropic
breathers are instructed to “surrender completely to the flow of music, let it
resonate in one’s entire body, and respond to it in a spontaneous and elemental
fashion” (Grof, 2014, p. 11).
The respiratory effects of hyperventilation and the vibrations of the
evocative music allow holotropic breathers to access a non-ordinary state of
consciousness and experience the subconscious affective stimuli that perpetu­
ate their mental illness. HB may also involve bodywork, touch, group sharing,
or artistic expression, which are implemented to further shape and evoke a
therapeutic experience (Brewerton, Eyerman, Cappetta, & Mithoefer, 2012;
Rhinewine & Williams, 2007).
What Are the Effects of Holotropic Breathwork?
The biophysiological effects of prolonged overbreathing have been thor­
oughly documented across disciplines and are similar to those of abdominal
breathing (Eyerman, 2014; Huttunen et ah, 1999). The respiratory aspects
of MB catalyze a relaxation response. The increase in bodily awareness asso-

(J Journal of Mental Health Counseling 83

ciated with a relaxed state allows for deeper connections with one’s somatic
experience and is often likened to a psychedelic or out-of-body experience that
produces a cathartic or therapeutic event (Eyerman, 2014). The conscious con­
nected experience MB provokes may allow clients to access the subconscious
mental organizations that precipitate psychopathology (Lalande et ah, 2012).
When applied in treatment settings, MB techniques have the potential
to induce intense therapeutic effects due to psychosomatic reactions causing
powerful affective and bodily sensations (Eyerman, 2014; Watjen, 2014). It is
generally understood that MB allows for clients to “bridge the conscious and
unconscious mind, allowing for emergence and exploration of transparent
beliefs while facilitating the full experience and expression of all emotions”
(Young et ah, 2010, p. 115). This is due to the prolonged overbreathing stim­
ulating the vagus nerve, which activates multiple components of the nervous
system. The brain responds to these neural impulses and signals the release of
several different neurotransmitters such as oxytocin, dopamine, or serotonin
(Eyerman, 2014; Jerath, Edry, Barnes, & Jerath, 2006).
What Are the Outcomes ofHolotropic Breathwork?
Due to the complexities of administering MB therapies in mental health
research trials, many reports of its efficacy are anecdotal, based in theoreti­
cal assumptions, or conveyed colloquially by researchers. A 2013 report by
James Eyerman detailed the experiences of 11,000 patients who participated
in weekly HB sessions over a 12-year period. Eyerman (2013) reported many
patients having a “transpersonal” experience in at least one session, which
patients found to be substantially therapeutic.
Some of the more rigorous research designs involving MB have inves­
tigated its efficacy for treating addiction and substance use disorders, as well
as depression and anxiety. When administered as an adjunct intervention for
treating addiction and chemical dependency, HB was associated with positive
relapse prevention outcomes and reduced cravings (Metcalf, 1995; Taylor,
2007). Detailed case studies of the experiences of four patients with substance
use disorder practicing HB generated similar findings, suggesting that HB may
be a viable therapy for treating substance use disorders (Brewerton et al., 2012).
Studies have also tracked symptoms of anxiety and depression while treating
substance misuse and addiction with HB, and results indicate it is effective
for fostering improvements in these areas as well (Cervantes & Puente, 2014;
Cho, Ryu, Noh, & Lee, 2016; Cusens, Duggan, Thorne, & Burch, 2010).
Rigid empirical research studies investigating the efficacy of HB and other MB
therapies in mental health counseling settings remain sparse and implicate an
area for future research, but preliminary conclusions suggest MB is a poten­
tially powerful therapeutic method for treating alcohol use disorders, as well as
symptoms of anxiety and depression.

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 B r e a th w o r k in C o u n s e lin g

Yogic Breathing
As one would imagine, YB is rooted in yoga practice. Practitioners are
required to be licensed yoga instructors and undertake specialized training
before using the method in clinical settings. There is sparse literature involving
the breathing components of yoga in mental health treatment, and CMHCs
are encouraged to do further research on the broader intersection of yoga and
mental health.
Yoga practice has experienced significant growth in recent decades across
numerous health disciplines and is generally considered a viable treatment for
a variety of mental health conditions (Bussing, Michalsen, Khalsa, Telles, &
Sherman, 2012; Kirkwood, Rampes, Tuffrey, Richardson, & Pilkington, 2005;
Louie, 2014; Shroff & Asgarpour, 2017). YB, which is also known as pran-
ayama in yoga practice, is the procedure of manipulating breath for achieving
specific results. It involves altering and controlling breath with specific patterns
and variations in rates of respiration (Brown, Gerbarg, & Muench, 2013). For
example, alternate nostril breathing consists of closing one nostril while inhal­
ing slowly through the other, and then repeating the exercise with the other
nostril closed (Brown et al., 2013). Other YB techniques include paced breath­
ing, resonance breathing, resistance breathing, and breathing with movement,
and each of these techniques contains explicit breathing and respiratory tasks
(Brown et al., 2013). YB practices typically include instructions for the specific
number of breaths over a period of time (e.g., 20 to 30 breaths per minute).

Sudarshan Kriya Yoga

SKY is the most commonly referenced YB technique in counseling lit­
erature and consists of a set of specific YB techniques, often combined with a
larger yogic intervention (Browm & Gerbarg, 2009; Zope & Zope, 2013). SKY
involves a set of highly structured breathing patterns. It consists of four com­
ponents: ujjayi, bhastrika, om chant, and Sudarshan Kriya (Brown & Gerbarg,
2005b; Zope & Zope, 2013). Ujjayi breath is a slow breathing process, requir­
ing users to complete just two to four inhalation/exhalation cycles per minute.
Bhastrika is short and quick, in a way the opposite of ujjayi. Users are instructed
to take 30 breaths per minute. After completing ujjayi and bhastrika, SKY users
are instructed to chant a prolonged “om” three times. Finally, Sudarshan Kriya
involves users breathing cyclically, which is breathing continuously with no
pauses, at three rates of respiration, slow, medium, and fast.

W hat Are the Effects o f Yogic Breathing?

YB has received attention in health-related literature due to the psy-
chophysiological effects that varied breathing patterns induce. Traditionally,
the aims in yoga are to connect breath to movement, which can be a highly
effective healing process that supports the body-brain connection (Brown &
Gerbarg, 2009). These effects are attributed to how YB patterns help balance
the ANS by way of reducing sympathetic nervous system activity and increasing
parasympathetic nervous system activity (Brown & Gerbarg, 2005a; Jerath et

(y Journal o f Mental Health Counseling 85

al., 2006). As in DRB and MB, one of the primary effects of YB is the stimula­
tion of a relaxation response. It is generally theorized that the positive effects
ofYB are also linked to vagal nerve stimulation (Jerath et al., 2006; Zope &
Zope, 2013).

W hat Are the Outcomes ofYogic Breathing?

A handful of research studies have investigated YB as a standalone or
an adjunct intervention. Most of these studies utilized SKY. SKY has shown
considerable effect for treating common psychological presentations such as
depression (Descilo et a l, 2010), anxiety (Katzman et a l, 2012), and PTSD
(van der Kolk et al., 2014). However, the most intriguing contributions found in
studies of YB in clinical mental health counseling involve the varying popula­
tions studied. A diverse range of samples have shown significant improvements
after receiving SKY interventions, including patients with psychiatric diagnoses
(Doria, De Vuono, Sanlorenzo, Irtelli, & Mencacci, 2015; Janakiramaiah et
al., 2000), prisoners (Sureka et al., 2014), tsunami survivors (Descilo et al.,
2010), war veterans (Carter, Gerbarg, Brown, Ware, & D ’Ambrosio, 2013;
Seppala et al., 2014), and individuals living with AIDS (Brazier, Mulkins, &
Verhoef, 2006). Consistent positive outcomes across several different studies
and participant samples confirm a substantial evidence-basis for YB in clinical
mental health counseling.

APPLYING BREATHWORK IN CLINICAL

MENTAL HEALTH COUNSELING
The models of psychological disorders and corresponding clinical treat­
ments have increasingly recognized the connection between the brain and the
body in recent decades (NIMH, n.d.; van der Kolk, 2015). In fact, the effects of
trauma are known to impact the brain, the body, and the mind, and therefore
cannot be treated without addressing all three (van der Kolk, 2015). Behavioral
health schools of thought have acknowledged that trauma and stress leave a
lasting physiological and psychological impression on an individual (Alkadhi,
2013; van der Kolk, 2015), yet psychophysiological theories have only recently
become part of the clinical mental health literature (Moss, 2013; Sharma,
2014; Slonirn, 2014).
Traditionally, counseling has primarily focused on interventions of the
mind, but mental health texts are progressively advocating for clinicians to rec­
ognize the importance of physiology and neurology in treatment. For example,
a special edition of the Clinical Social Work journal focused entirely on topics
integrating mind and body (Northcut & Strauss, 2014), and a newly added sec­
tion to the journal o f Mental Health Counseling centers on neurocounseling
(Beeson & Field, 2017). Mental health treatment paradigms now acknowledge
the neurobiological considerations of psychological symptoms; thus, CMHCs
must seriously consider treatments addressing patients’ physiology as well
(Duros & Crowley, 2014).

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 Breathwork in Counseling

Engaging physiological systems through breathwork can augment and

solidify treatment. A client may be aware of the need for essential skills such
as mindfulness and assertive communication when dealing with a stressful
experience, but applying these skills is impossible when overwhelmed with
physiological arousal. Breathwork offers a practical tool for normalizing the
dysregulation one endures in mind and body when chronically stressed. The
relaxation response, along with sustained attention to breath and keen aware­
ness of one’s physical and emotional sensations, renders breathwork techniques
practical interventions for helping clients strengthen their mind-body con­
nection. Breathwork is an evidence-based treatment that strengthens emotion
regulation via management of physiological states.
Clinicians should navigate this territory with caution. Both the American
Counseling Association (2014) and the APA (2002) codes of ethics detail a
professional responsibility for psychotherapists to use evidence-based prac­
tices when treating patients. Virtually all health disciplines require that pro­
viders apply interventions, such as breathwork therapies, with beneficence
and non-maleficence. We have provided an introductory review of common
breathwork interventions used in counseling, but it is the responsibility of each
clinician to carefully evaluate each breathwork technique and/or therapy and
determine what is appropriate for their clients. Clinicians should be aware of
the risks clients may endure when practicing any breathwork technique. As
described by Duros and Crowley (2014), “clinicians must be clear about the
goal, the rationale, and the safety plan, while being able to explain these ele­
ments to a client in a way he/she understands” (p. 243). Ultimately, CMHCs
are expected to implement an informed consent protocol when utilizing
breathwork interventions in their practice (AMHCA, 2016).
The major barriers that CMHCs encounter when considering applying
a breathwork technique are training requirements. Some techniques, DRB for
instance, are rather simple and require a moderate level of clinical aptitude.
Because minimal training is required for applying a therapy such as DRB, clini­
cians should strive to maintain treatment fidelity through patient feedback and
clinical supervision. Objective ratings, such as physiological measurements
and ratings by third-party clinical observers, should also be implemented in
order to monitor the intervention.
Other breathwork techniques are more complex and require extensive
training and/or a full certification. For example, Grof Transpersonal Training
(GTT), an institution founded by psychiatrist and HB researcher Stanislav
Grof (2019), offers an HB certification training program. Clinicians seeking
the credentials of “Certified Holotropic Breathwork facilitator” are required
to attend seven five-and-a-half-day modules and a two-week intensive training
(Grof, 2019). Though clinicians would receive highly specialized training,
pursuing HB facilitator certification requires considerable commitment; it
may not be feasible for some. However, obstacles associated with certification
and training offer CMHCs an opportunity to collaborate with providers across

C Journal of Mental Health Counseling 87

a wide range of disciplines to advance integrated mind-body interventions.
Rather than pursuing full HB facilitator certification, the GTT website offers a
facilitator search tool that CMHCs may consider using instead.
Finally, clinicians must evaluate the utility of any intervention, breath-
work included, in the context of the multicultural experience of their client.
Several articles and texts relevant to the field of counseling offer guidelines for
multicultural considerations of the treatment of psychological disorders (APA,
2017a; Arredondo & Toporek, 2004; Ratts, Singh, Nassar McMillan, Butler,
& McCullough, 2016). Because of the physiological nature of breathwork,
counselors may be inclined to minimize the role of breathing in a client’s
multicultural experience; however, breathing and the manipulation of breath
are a common practice in many religious and spiritual customs. Specifically,
yoga, which is tied to a multitude of Eastern traditions and practices, maintains
a profound spiritual connection with the act of breathing (van der Veer, 2007).
Qigong, a well-researched wellness practice involving breath, movement, med­
itation, and body posture, is deeply rooted in Chinese culture (Jahnke, Larkey,
Rogers, Etnier, & Lin, 2010).

CONCLUSION
We provided an organizing framework of breathing techniques for
CMHCs. Three broad categories were identified: DRB, MB, and YB.
Furthermore, we aimed to highlight the physiological effects breathwork inter­
ventions stimulate, in line with recent dialogues in mental health treatment
(AMHCA, 2016; Beeson & Field, 2017). Many breathing techniques induce a
series of physiological responses promoting relaxation. This mechanism regu­
lates the nervous system, which in turn helps regulate emotions.
Though the three breathwork categories presented are similar in that they
typically induce a relaxation response and share numerous respiratory patterns,
they also possess discernible distinctions. DRB is primarily distinguished by
how users manipulate the diaphragm when it is implemented, which involves
expanding it deeply during periods of inhalation. While DRB requires users
to breathe in a slow and deliberate manner, YB and MB interventions often
involve a variety of respiratory rates. MB techniques are complete interventions
that require the guidance of a therapist. Two key components set MB apart
from the other breathwork categories: (1) profound awareness and mindfulness
of one’s breathing and the (2) occurrence of non-ordinary states of conscious­
ness. Both MB and YB are highly manualized, calling for users to follow spe­
cific instructions. YB techniques are often one component of a broader yoga
intervention and are unique in their focus on users’ breathing patterns and rates
of respiration.
A considerable amount of empirical evidence exists to support the utility
of breathwork in the treatment of psychological distress. Most clinical studies
utilizing breathwork interventions track common ailments, and therefore more
research must be done to establish efficacy across a wider range of psycholog-

88 ( j1 Journal of Mental Health Counseling

 B re a th w o rk in C o u n s e lin g

ical traits. Our findings suggest breathwork may offer significant benefits for
clients in numerous mental health settings. The evidence also appears to cor­
roborate our conceptualization of a breath-based relaxation response. There is
a need for further empirically based studies conducted within clinical mental
health research. The field is moving in this direction, and we hope this article
will serve as a foundation for future clinical studies on the effects of these tech­
niques within the clinical mental health context.

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