PESI-The Mindfulness in Psychotherapy Summit-Mindf

(USPESI0803B - Ai-Live Premium)

CART provider is standing by.

Test. Test. CART provider is standing by. Closed captioning will begin momentarily.
Welcome back, everyone. Our next speaker is a mother and speaker of who is a pulmonologist. She's
a leader on mindfulness, integrated and pulmonary medicine, and has taught courses and led retreats
for a decade. She's been recognized as the San Diego top doctor, received the San Diego lung health
care provider of the year award and was recognized as "Mindfulness" magazine as one of the most
powerful women in the movement. She provides free well being sessions to reduce suffering among
health care professionals. She serves on the Americans for thoracic society. Please welcome Ni-
Cheng Liang.
>> Thank you for that introduction. I'm going to be sharing my screen for the the slides at this time.
Today we'll be talking about the use of mindful breath work for anxiety, panic, and pain. These are my
faculty disclosures. I invite all of you, if you haven't already to grab a piece of paper and a pen or
pencil. I would like for all of you to draw nine dots in the configuration. The invitation here is to use four
straight lines or less to connect all of the nine dots without lifting your pencil or pen. The invitation here
is to notice how you are broaching the brain teaser. Are you starting to judge me for asking you to do
this? Are you questioning why I'm asking you to do this? Is this something that you've seen before and
you forgot the solution? Are you tempted to look up the solution? How are you broaching this problem?
I'll give you about a minute or two to solve. You can feel free to try multiple times. What's coming up
for you as you try again? About 30 seconds left. Seeing if the notation of the time left for the exercise
has changed your approach at all. Stop. Pencils or pens down revealing some possible solutions. I've
asked you to do this, because this session maybe a little bit literally outside of the box. Broaching
some of life's inevitable difficulties and suffering may require an outside-of-the-box approach. Often
times as humans, we have a tendency to set up boundaries and rules that don't necessarily actually
exist. So for this particular solution, we can start off outside of the confines of the nine dots going
horizontally, vertically, and down. Recognizing that I started off with the solution erroneously. You can
come down this way and then across. Even as I'm doing this now, the sequence is difficult. The other
solution here is to actually make the dots bigger and slice the dots through with three different lines
creating the zigzag shape. Thinking a bit outside of the box and being open to new experiences.
Recognizing all of our humanity just as we are in our capacity for looking beyond the nine dots.
Jumping into our objectives for today. We'll be learning about when to discern the times when mindful
breathing practices and introducing them to your clients would be appropriate. We'll also learn
experientially some simple, mindful breathing practices that you can utilize in your sessions with your
client to help alleviate panic, anxiety, stress, pain, and shortness of breath. These will be hopefully
new self-management techniques for your clients. Or at very least, some reminders. Most importantly,
we'll personalize our approach by constructing mindful breathing prescriptions for you to use with your
clients in the real-life circumstances outside of your sessions with your clients. Outline for today, the
first section will be about assessing for readiness in using breath work with your clients. First doing no
harm, of course. Then we'll be practicing experientially on how to use mindful breathing to help
empower your clients and also to serve your clients. Then we'll go into the personalization of these

Page 1 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

mindful breathing practices and constructing them together with different possible clinical scenarios.
So I would like to start all of my sessions with the grounding practice. I would like to invite you to
uncross your legs, if you happen to be sitting. Closing your eye or lowering your gaze a few inches in
front of you. It is safe for you to do so. Settling into the moment. The support of whatever you are
sitting on. Recognizing that that support is always there for you. We only need to notice it. Giving
everything that came before and everything that is to come at door. Giving yourself full permission to
arrive. Fully present through this session together. Then as you are ready, inviting you to blink open
the eyes, letting the light back in. Thank you so much for practicing with me. These four stones will
represent the four different breathing practices I will be introducing today. I wanted to share a little bit
about my story and how I become an integrative pulmonologist. It wasn't the original plan. But life
circumstances led me in a way that has opened my own world and my own well being journey. Such
that it's been tremendously aligning to show up as my full authentic self as a healer, not just traditional,
conventional medicine, and integrative modalities to help mind, body, and spirit. When I was 31, this
will be coming up on 12 years, I was a new mom. This picture was taken ten days after my first born
came into this world. I was a pulmonary critical care fellow at time in my second year of clinical training
when I was diagnosed with a very aggressive form of breast cancer. So this is a picture of me on the
left during my head shaving party. At a time in my life when things were completely out of my control. I
had no idea how I would do with treatment. I only knew I had been diagnosed with breast cancer and
that I was fearing for my life. The only thing I could do to bring back any sense of control was to control
the amount of hair left on my head. I had friends that might have been looking to take out some of their
frustrations shave my head and my husband apples shaved also shaved his head in solidarity. After
five months of chemotherapy and three different surgeries, I lost every single piece of hair on my body.
There's a lot of gratitude and hair, particularly nose hair. Otherwise I had a runny nose all the time. I be
acutely aware of my breathing. The sensations were so sharp without nose hairs. I become short of
breath, because of how amemic I got. I think it was the first time I truly understood what
breathlessness meant and how anxiety, panic, and pain would affect my breathing and vice versa as
well. Recognizing it was al pathic approaches that saved my life. It was integrative approaches like
mindfulness practices and mindful breathing, acupuncture, reki, meditation, yoga that helped me
maximize my quality of life as a cancer survivor and really truly helped heal my own mind, body, and
spirit. It is with that background that I become the integrative pulmonologist. Seeking to incorporate
different aspects in convention with traditional approaches in the evidence-based integrative way. I
was co-author of the article of the American Journal of Respiratory and Critical Care Medicine. We'll be
broaching some of the topics and mindfulness and the combination with different exercises. It is but a
small part of the available practices within integrative therapies that are inclusive of the meditative
movement practice. Traditional practice like Chinese medicine and most of the breath work I'll be
teaching from the ancient traditions of med sen. Approaching food as medicine and then within
Chinese traditional medicine acupuncture and acupressure massage. It can be seamlessly integrated
within conventional med sen. There's a hash mark line, because there can be an ongoing
communication between the two modalities that can unify a healing plan to truly heal mind, body, and

Page 2 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

spirit together. I like to remind everyone about the quote from the developer from the program. As long
as you are breathing, there's more right with you than wrong. This is a reminder about our tendency for
negative attention bias that our brains are hard wired to notice the negative. It was evolutionarily
advantageous for us to notice the potential dangers. In the 21st century, that doesn't serve us as
much. This quote is a reminder that our physiology as long as we are breathing is mostly in line
consistent with the ongoing living. But there's more right that's happening in our bodies in an
involuntary way than actually wrong. That using our breath to remind us of this can be quite powerful.
Especially for our clients. The image that I hope to conjure up with today's session is this one from
world COPD Day from November 2022. The lungs are able to help us grow to help us thrive, they can
be seen as a route network. A vessel from which to expand and to develop a sense of abundance
from. Particularly through the action of breathing, knowing that breath happens both involuntarily, and
voluntarily. It is one of the unique processes of the body that has involuntary control and they are
capable of controlling our breath as well. Here's a written practice of the breath that we will be covering
today. It is available for all of your clients, not just those with chronic lung disease, but applicability in
anyone that's interested in a simple breathing exercise. I was really encouraged to see the recent
article in JAMA psychiatry showing it is noninterior. There already 276 adults randomized in the
medicine arm that was a multi-center, randomized study. Levels of anxiety were assessed from the
clinical global impression of severity scale, preand post SSRI. They showed that mindfulness-based
stress reduction was equivalent to the escitalopram with regards to efficacy and anxiety. This we
knew. It is always great to see it being published in the high impact journal such as this reminding us
that integrative approaches can be non-inferior. Jumping right in. First doing no harm. We'll be
assessing the readiness of your client for the mindful breath work. When you are working with your
clients, your own intake about their readiness is going to be a key part in whether or not you decide to
introduce mindful breath work during that particular session. Also their own assessment of their current
distress level will be important as well in factoring their readiness. Approaching both approaching both
they are ready and whether or not they might actually be age to apply this in their real life with a sense
of curiosity and openness. Bringing in some mindful curiosity and asking your clients about what they
think regarding breath work and how they might be willing to try it or not. Then importantly, recognizing
that if there's prior trauma surrounding breath or cutting off of the breath, there may be some more
considerations and cautions that need to be taken when introducing the breath work. There's a risk of
traumatizing and worsening anxiety, particularly if prior traumas had to do with the breath. Being aware
of that and asking more specific questions about that in your session can help. Another thing that's
helpful when assessing for readiness is checking in with the circles of safety taken from the
mindfulness space reduction circumstance almost. When we go into the state of overwhelm with our
fight or flight responds sympathetic nervous system respondents activated, there's no learning or
growth in the area. Letting the overwhelm be a signal for us to do the self-compassionate thing. That's
to help us and our clients come back into a zone of safety. The zone of safety can easily be accessed
through present moment awareness. Doing something like the grounding practice that I introduce at
beginning of this session where we're noticing the support of the ground beneath our feet. Even

Page 3 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

noticing the sensations of our feet can be a little grounding practice. Also noticing the sensations of
hands and in the mindfulness -- the mindful self-compassion curriculum. There are worry stones that
participants are given to rub and that can actually help bring us back into the present moment of the
experience as well. Hopefully those ideas are helpful for you to introduce to your clients to help you
come back to the zone of safety. We invite you for the rest of the health care team. 21st century has
become quite siloed. We can intentionally change that. We can become partners and truly work
together. Towards the associated symptoms, decides what they are presenting to you. Asking if there's
an objective evaluation with loud work and looking at metabolic or hormonal abnormalities that could
contribute to the client's presentation in the particular session and beyond. Is there an integrated plan
between the mental health? We know the health can worsen in times of anxiety and stress. COPD
also has poorer outcomes with increased risk of exacerbations when someone also has clinical
depression. We know that anxiety and stress can worsen the symptoms, particularly shortness of
breath. The shortness of breath can further drive panic and anxiety and worsening pain. So it is all
related. The heart disease, pal palpitations that can be your clients in anxiety, panic, increase, and
stress. Endocrine-wise, thyroid dysfunction can affect someone's mood as well as other life cycle
endocrine-related abnormalities inclusive of whether someone is in the per imenopause or post
menopausal state. That may be affecting their mood. Irritable bowl bowel disease and others who are
patienteds who are further along in their cancer journey and have stage four disease. They could
manifest as well with different mood changes. They are anxiety provoking and create depression and a
lot of stress. Rheumatologic is linked as well. In fine miaul ya, their pain can be worse when they are
stressed. Dementia might be setting in. All of which can influence someone's presentation. More often
than not it can be a combination of any aspect of this. Any aspect of these within the different systems
of the body that can create the picture of the clinical presentation of your client showing up in your
clinical session with them. Thinking about what else to be contributing to your client's suffering is also
an important aspect of helping them heal. We'll shift now to talk about how we can change the breath
to empower our clients and to serve them and to power them to serve themselves in the moment of
suffering. A reminder from the late, great, to meditate with mindful breathing is to bring body and mind
back to the present moment, so you do not miss your appointment with life. Mindful breathing is a
conduit, a connector, a bridge between the mind and the body. And that bridge helps to bring the mind
and the body. I want to teach you some of the practices to help your clients do this. I wanted to lead
you out in the classical awareness of breath practice. If it is safe for you to do so, lower your eyes a
few inches in front of you. Focusing your attention on your breath. Perhaps first at the nostrils. Noticing
the in breath and out breath. Noticing the pause in between. I'm trying to change the breath in any
way, simply noticing breathing. As you are ready, noticing breath of the back of the throat. As you are
ready, noticing the chest rise and fall. With every breath. And if you are ready noticing that inflating
and deflating of the abdomen. Now invites you to feel where you feel the breath the moat. Focusing
your attention there. Recognizeing that other bodies sensations and emotions may be capturing your
attention. Choosing and intentionally bringing your attention back to where you feel your breath the
most, where you notice your breath the most. Hopefully observing your breath. As you are ready,

Page 4 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

blinking the open eyes and letting the light back in. Taking the next few moments to notice how you
feel now compared to just a few minutes ago. This is one version of awareness of breath practice that
we're not changing the breath in any way. There's an intentionality about leaving the breath just as it
is, as it comes and goes. In the next breath work practices that we'll be talking about and practicing,
we'll bring in the intention to change the breath. Seeing what you notice as you practice each of these
different types of breathing, perhaps to the awareness of breath practice. The first practice I'm going to
introduce is the breathing breath. For the purposes of today's session, I'm going to invite you to do two
breath cycles. No more than that, because there's some risk of hypocapnia or breathing down your
carbon dioxide to the point you can get dizzy or short of breath. To try to prevent that, we'll do two
breath cycles only for each mindful breathing practice. Inviting you to sit a little bit more upright,
ensuring that your head is on top of your neck, on top of your shoulders, on top of your hips. Being as
much in anatomic alignment to help set our lungs up for success when taking in deep breaths. It
maximizing our diagram and the ability to work most efficiently for us. We'll inhale and exhale through
pursed lips as if breathing and blowing out birthday candles. Dragging that exhale out two to four times
longer than the inhale. Exhaling and blowing out birthday candles. Taking a few moments to see how
you feel now and focusing on the breath cycles. All of the breath work practices that I will be teaching
today rely upon breathing in through the nose. Just a reminder that breathing in through the nose is
better than breathing from your mouth. Because the nose is a powerful part of the body that helps us
filter through the presence of tubinates and nose hairs and helps with the immunity by its capacity to
build up stores of mucus to help us get rid of microorganisms and irritants. Also it is as powerful
olfactory organ that enables us to recognize danger. Like the smell of gas or smoke, for instance. They
are powerful to the memory centers. Also taste is closely associated with smell. So reminding your
clients during these breathing practices to try as much as possible to inhale through the nose.
Because of all of these potential benefits that the nose provides for us with every breath. I want to
pause a moment here and invite some cultural competency and cultural humility about the origins of
the breathing practices. They came from thousands and thousands of years of practice of pranayama
which is from the yoga practices within Eric Arabic and Indian medicine. It is can be spilt into energy
control. The practices of pranayama we are there for controlling our own vital energy. We have the
capacity to control. Traditionally, you'll get breathing practices were done in preparation for a more still
type of meditation. We also know the practices have signature influences on the brain, namely in the
centers of fight or flight like the amygdala. They can also influence the balance between sympathetic
and parasympathetic. We can do this by controlling our respiratory rate. Oftentimes in pranayama,
breathing, when we want to reduce stress, anxiety, and pain. We're trying to slow down the respiratory
rate. We can control this through the ratio. The time spent during inhalation versus the time spent in
exhalation is in general when we prolong our exhale it can activate parasympathetic tone. Reminder
that breathing is a powerful example of the mind, body connection. It can unify the mind and body in a
powerful way. The mechanism of action of pranayama the mindful breath work that we're practicing
today is that it increases the frequency and duration of inhibitory and number impulses by activating
the stretch receptors. When we breathe deeply, we're breathing above title volume. When we don't

Page 5 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

take time to take deep breathing, we're breathing at or below the title volume, which is a fraction of the
total lung capacity is capable of. There's a reflex that's activated. Our lungs intrinsically now how much
to inhale because of the receptors in the lung tissues themselves. Trusting our lungs know exactly how
much to inhale when we are inhaling to full capacity. Breathing deeply in the way withdraws
sympathetic tone in the skeletal muscle vas cue lature and it decreases for full vascular resistance and
decreasing blood pressure. It can help with reduction in blood pressure, especially for patients and
clients who might have hypertension, for instance. One way to remember that the breath work
practices are associated with the vagus nerve is knowing we are invoking the Vegas rule. I invoke the
Vegas rule by suffering a sense of confidentiality for the sharing that happens. When we practice
mindfulness and mindful breathing and pranayama we are invoking our own vagus rule and activating
the parasympathetic tone. Some of the published benefits are multifold. We know there's a decrease in
anxiety, pain, severity can also decrease. Many of my patients experience a reduction in shortness of
breath, particularly when using pursed lip breathing. There will be an improved cognition as well as
improved heart rate variability which is a measurement of parasympathetic tone. Some breath work
practices are going to be a decrease in the overall fatigue and daytime sleepiness. More about the
pursed lip breathing breath. This enables us to control our oxygenation and ventilation. Some of my
patients who get anxious when they are short of breath use this to help them increase their
oxygenation status.
If they are saturating low, doing pursed lips helps improve their oxygen levels and oxygenation. It also
helps to decrease carbon dioxide levels in the blood with the long, exhaled breath. When we purse our
lips and blowing out birthday candles, that creates a type of back pressure called positive pressure
which literally helps when the airways open. It helps to engage the other recruitment that make up the
lungs. Deeply breathing in the way also improves chest wall volumes. We're enabling the total lung
capacity to be met and also enabling the more complete ridding of carbon dioxides. The caution here
is to limit the number of a little bit more about pursed-lip breathing and reducing it in clinical settings.
Patients who have acute heart failure were presenting to the emergency room. They were randomized
with the usual care group with purse-lipped breathing. The visual analog scales for shortness of breath
and anxiety were utilized. So in looking at the result the, there were greater reductions in shortness of
breath and anxiety in the usual care group with the addition of pursed-lip breathing. Moving right along
we'll be practicing now the 4, 7, 8 breath. Inviting you to close your eyes or lowering your gaze if it is
safer you to do so. Sitting a bit upright. So that you can bring the tip of your tongue into the back of
your front, top teeth. Thinking of physical and metaphorical mind-body connection will inhale through
the nose for four counts. Two, three, four. Then two, three, four, five, six, seven. Then exhaling
through pursed lips for eight. Two, three, four, five, six, seven, eight. We'll do that one more time.
Inhale through the nose. Then two, three, four, five, six, seven. Then exhaling through pursed lips for
eight. Two, three, four, five, six, Seven, eight. As you are ready, breaking your open eyes and letting
the light back in. Taking a few moments to notice how you feel now compared to a few breath cycles
again.
One of my great mentors, Dr. Weil, derived the breath work from the pranayama approach. What's

Page 6 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

unique about the pursed-lip versus the 4-7-8 breathing is there's a time. It may induce a shortness of
breath or panic, when that's arising, refer them back to pursed-lip breathing breath that doesn't have
that pause. Also namely for chronic lung decide patients, many of my patients wouldn't tolerate a
seven-count breath hold. Pursed-lip breathing still becomes a foundation for the breath work if
someone is not able to tolerate a breath hold. Next I'm going to invite you to practice diagrammatic
breathing with me. This can be done down or upright. -- diaphragmatic breathing. This can be done
down or upright. Making sure your hips and shoulders are in alignment. Reminding you to place your
hands on your belly over your naval. You navel. We'll inhale through your nose, pushing out your belly
towards your hand during the inhale. Inhaling for pushing out the belly and during exhalation through
pursed-lips. We'll do that one more time. Pushing the belly out towards the hands. Then pausing here
and exhaling through pursed lips. Bringing the navel closer to the spine. Adds you are ready, blinking
open eyes. Checking in with how you feel now after those two breath cycles of diaphragmatic
breathing. We know that it helps to decrease the respiratory rate. It helps to lower the blood pressure.
There's been reductions in anxiety and depression symptoms with practicing diaphragmic breathing.
When we combine some of the mindful breath work like personal breathing, there's actually the
capacity to improve lung function. In the study looking at over a thousand patients with chronic
obstructive pulmonary disease, this is a systemic review looking at the different improvements in
different lung volumes. Like forced volume and ratio that determines if they have obstructive lung
disease. It can help to improve the distance walked. And for any of your patients who might have
chronic lung disease, check in with them. See if they have enrolled in or will be enrolling in pulmonary
rehabilitation program. Recognizing that pulmonary rehabilitation is a multidisciplinary program with
group support, coaching, in breath work practices. Also with mental health support, often times from
psychology as well as educational approaches to conserving energy in addition to the important,
mindful breathing practices. Something to help your clients take advantage of if they happen to have
chronic lung disease. The next it will be practicing box breathing. For this first introduction to it close
your eyes and lower your gauge in front of you. Sitting more upright. It will create a metaphorical box
with our breath. We'll inhale through the nose for four counts. Two, three, four. Hold your breath for
four counts. Two, three, four. Exhale through your lips for four counts. Two, three, four. Hold your
breath for four counts. Two, three, four. We will inhale through your nose for four counts. Two, three,
four. Hold, two, three, four. Exhale. Two, three, four. Hold. Two, three, four. As you are ready, blinking
open eyes. Checking in with how you feel now compared to two breath cycles ago with box breathing.
Box breathing has been thought to enhance well being and improve cognitive particularly where they
need to have a calm focus. That helps to reduce the rate bringing about the sense of calm. It doesn't
bring as much some of the other reading techniques that we practice together. When you are teaching
your clients on how to do the box breathing, it is helpful to have a visual of this. You can literally draw a
box with them, your fingers, you can inhale for four counts, holding for four counts, drawing
horizontally, exhaling for four counts through your mouth. Then holding at that exhale for four counts.
Finishing the shape of the box. I know you know this. The quality of the life depending on the mind.
You see for improving the quality of one's mind and therefore life. So with these four different breath

Page 7 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

work practices, we'll move on now to helping you construct some personalized mindful breathing
prescriptions for your clients. The question that comes up is which breathing exercise is best? It
depends. Thinking about your clients desired outcome and what special considerations there are for
that particular circumstance. Really ultimately the mindful breathing exercise that's best is the one that
your client ultimately remembers to do in that particular moment. As we create these mindful
breathing, we invite you to be looking at how it might look like for you and your clients and also how
you might incorporate them into your own life. Thinking about the desired outcome. If the client is in a
high-stress situation, a high pressure situation that they need to perform well at, like a test or giving a
big talk, for instance, where they need to have a calm focus, then the present of presence through box
breathing is going to be your go-to for focus. If the client is having episodes of increased stress or
anxiety, then relying upon the breath work practices that have pursed lips like your blowing out
birthday candles, like you are blowing into a bubble wand, for instance, will be your go to. For those
that don't have any chronic lung disease, the forced breath will be helpful. Pursed-lip breathing for
anyone that can't tolerate a breath hold or anyone that has chronic lung disease. Next I'm going to
introduce.
Playful practice. This is the picture making. Enso is a moment of one breath. As they inhale, the brush
is introduced into an upstroke. As the artist exhales, the down stroke occurs. Recognizing the enso are
circles but they are imperfect, recognizing our humanity as being ultimately imperfect. Accepting each
moment as it is in all of its beautiful imperfection. So I'm actually going to stop screen sharing for a
moment here to show you on a white board on how to incorporate a breathing heart enso. Ultimately
we'll be applying the pursed-lip breathing breath to draw the shape of the half a heart with the pursed-
lip breath. Coming to my whiteboard here. We'll inhale through your nose drawing an upstroke. And
through the exhale coming down with the stroke. So you make half of the heart. To bring in more play,
you can switch to your non-dominant hand to do the other half of the heart. You'll create the upstroke.
And exhale breath with the down stroke making somewhat of an imperfect heart shape. So this maybe
one creative, playful way to incorporate something more tangible for your clients when they practice
pursed-lip breathing. You can even invite them to color in their breathing heart enso's as well. I'm
going to resume screen sharing here momentarily.
You and your client feel that breath work could have the capacity to help with the healing. Then the
first type of breath work would try to be the diaphragmatic breathing. The focus on the body sensations
rather than the breath itself. That may be one helpful rats spect of diagrammatic breathing that's not as
present in the other types of mindful breathing practices. Ultimately all of these breath work practices
can be used for helping to reduce the stress and anxiety. So the pursed-lip or the 4-7-8 breath can be
used in anyone that's experiencing shortness of breath. Namely pursed-lip breathing particularly for
those with lung disease and anyone that can't tolerate a seven-count breath hold. Diaphragmatic
breathing offers the non-breath alternative al tern anchor of attention for people who get more anxious.
We're focusing on the body sensations and the movement of the abdomen and the sensations of the
abdomen against the hand on top of the abdomen. There's more awareness of the physical body
sensations in diaphragmatic breathing. Boxed breathing has to do more with focus and enhancing

Page 8 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

focus, noting there's more breath holds. In each breath cycles, there's two as opposed to the other
breathing practices. Keeping that in mind. It should be reserved for people who don't have any chronic
lung disease and who are able to tolerate more breath holds. And to help your clients remember to
practice these mindful breathing exercises, I developed the COVID bat acronym in the last three years
in the last three years of taking care of COVID patients and in my own mindfulness journey that was
very much tested in the last three years. So the mindful exercise that I'm introducing here is an
acronym. So there's lots of different mindfulness acronyms out there. But hopefully with this one, it is
easy to access, easy to remember. In moments of pain, anxiety, stress, difficulty, remember to use the
COVID bat acronym. B is to breathe. Breathe mindfully. This mindful breathing can be a simple
awareness of breath or any one of the needing to tame and heal and focus on the thoughts about that
particular situation. Most importantly attending to the needs. This is an opportunity for self care. An
opportunity for self-compassion. Asking what is it we need? T is for transition. It is intelligencal and self
compassionate to help alleviate the discovering. Hopefully you remember to do some of the breathing
practices. Ultimately the prescriptions that you come up with your clients are not set in stone. They do
depend on the desired outcome and giving your client agency as you introduce to choose what will
work best for them in the particular moment. Someone who has insomnia might benefit from 478
breathing or diaphragmatic breathing. If your client is anxious, it is time to bring back the experience.
Anyone that has shortness of breath can use the pursed-lips breath or the diaphragmatic breathing
Beth. I wanted to answer some frequently asked questions. We'll have a formal Q & A session shortly.
How many breaths per practice? We don't want our clients to experience dizziness or shortness of
breath, if we can help it. How long before there's a sustained change? How long before people note? It
can be as short as that practice all the way up to practicing for nine months. In my own clinical
experience, there's been a more sustained change and habit formation after four to eight weeks or so.
Giving the choice to your clients. A morning practice before they engage in any of the morning routine
when they are in bed. They can sit upright and start doing the breathing practices. They can remain
laying down and doing diaphragmatic breathing before they get up through the day. Particularly for
clients who might have difficulty falling asleep, that time is a good time to be doing some of the breath
work practices as well. Of course, what else can they practice? For anxiety and panic. The space is
our power to choose our response. The space that they choose to help them grow and liberate
themselves. How do you see it affecting your own life and work. Once you think the barriers or
challenges might be? Asking you now what's one way you are going to incorporate mindful breathing?
Could it be you'll practice yourself or try some of these mindful breathing practices with your clients?
Particularly those suffering with anxiety, pan I guess, shortness of breath, or pain. Being playful and
open to experience how you'll incorporate the practices. I wanted to review with links and resources.
When I was the director for UC a couple of years ago, I recorded some mindfulness for us as healers
in the moments of mindfulness. There's an awareness of breath practice. They are not changing our
breath in any particular way. Also the shortened versions of some of the other practices of
mindfulness. All of you are welcome to utilize those for your own healing as well. The American lung
associate has a great video on pursed-lip breathing. And breathing exercises. The diaphragmatic

Page 9 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

breathing there's a wonderful video. There's one available online as well. In summary recognizing the
mindful breathing introduced today originated from voga. They are part of the con consolation of
integrated therapies with traditional western systems of practice to fully integrate and create a healing
plan for your patient to heal mind, body, and spirit. We know that slowing down the respiratory rate and
prolonging the exhale activates the vagal nerve to help foster increase in the rest and digest the
nervous system which is a parasympathetic nervous system. And that when we are choose our
different mindful breathing practice, it depends on the circumstances of your client and also the
desired outcome in the particular moment. It may be for some of your clients a good idea to teach
them a variety of these practices if they are ready for them. And to give them agency to help them pick
which one might be best for them in the particular moment. In this way, we can empower our patients
and our clients with these important, powerful, self-management techniques. Reminding you that
mindful breathing is a very powerful mind, body connector that can be utilizeed to empower and serve
your clients and help them serve in self-compassionate ways. With that I thank you for your attention.
Feel free to e-mail me as well if questions arise. I also want to give mention to the audio resources that
are available in this summit. There's a mindful breathing practice that I recorded for all of you to utilize
as well. Whether it be in session or for yourselves, or as inspiration in teaching your clients how to use
mindful breathing. Included in the handout section are an article that I wrote for the Americans are sis
society and published on mindfulness. It can be utilized for anyone that wants to try the pursed-lip
breathing, recognizing your clients will learn from a multitude of different ways from experiential to
reading it to hearing it to watching it. There's a text prescription of the force of the breath. I hope you'll
take advantage of the resources for yourself and to help your clients. Thank you very much for your
attention.
>> Thanks so much. We were kind of noticing maybe there were some updates on this particular slide
deck. If you send those our way, we'll make sure to get these to the audience. Because everyone is
really excited about all of this. I have a ton of questions for you as well. Just to tell everybody we're
going to send you an updated slide deck. Thank you for the resources. I think having the concrete
tools helps us in terms of just kind of getting into applying. Lots of questions. I'm going to get to what I
can. This first one is about helping people in the middle of a panic attack in session. Sometimes in
therapy, we kind of wait for the panic to pass. Then engage in some grounding. That's one to handle it.
Any insight into that, any other strategies that we might be able to take away when somebody is in the
midst of panic in the moment?
>> Yes. That's where relying on -- invitation for mindful awareness in the moment of panic can be
helpful. Sometimes naming what is arising for them. They can allow and accept they are having a
panic attack. That's one key component. And it takes tremendous awareness to do that. In my own
patient population, some of whom experience panic, some have been able to help themselves out of
panic attack and facilitating the panic to pass faster by doing an awareness of breath. It was just
coming back into the resort of safety. A key recognition they are in the zone of overwhelm during
panic. That using that as a signal to do the self-compassion and bring back into the safety. Sometimes
it can be as simple as noticing the support. With with regards to any of the breath work techniques that

Page 10 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

might be helpful, definitely 4, 7, 8 breath, pursed-lip breath, and diaphragmatic breathing would be the
ones that I would go to. Also using that acronym might be helpful as well. They go through the letters
and acronyms and figuring out their own transition for what might be most helpful for the panic and
what their healthy response might look like. Hopefully that helps.
>> Yeah. Just to refresh, you go through what the BAT means again?
>> Yes. Breathe in one of those mindful breathing exercises or in just taking one mindful breath
without trying to change it in any way. A is to attend. Attend to the present moment, naming the
emotions and body sensations and thoughts. Asking ourselves a question what is it that I need in this
moment. How can I show myself kindth? T is to transition into that healthier response. It can be the
breath work. Also hand to heart can help reduce the cortisol levels as well and other respectful touch
XXIII for options.
>> Hand to heart reduces the court some levels.
>> Yeah. It also helps to 11 cute ox oxytocin as well.
>> When you talk about bringing the body to dominance. I think it was towards the beginning. We have
a question about the use of the word tone when we're referring to the parasympathetic person. Can
you talk about what tone means and how it applies to us?
>> Tone in the way that I used it with the magnitude of parasympathetic versus sympathetic. In a lot of
these mindful breathing practices, we're helping to augment or parasympathetic activation or
magnitude. Hopefully that will clarify what tone means.
>> Yes. One we have a about kids. Children and adolescents, the use of the exercises. What do you
think?
>> Yeah. Super helpful if they are open to it. Might be difficult to try to tell a kid what to do. But when
they are open to it and when it is taught to them in a playful way, that can be helpful. Using that
balloon blowing for bubble blowing type picture to get them to purse their lips to exhale. There's also
the balloon breath. It is fun to blow up the balloon for kids. One thing my daughter has done to help is
utilizing one of our pets. We have rabbits. Luckily they are not that big. She will take a rabbit, put a
rabbit on her belly. Luckily the particular chosen rabbit is not super squirmy and utilizes the presence
of the animal, which we also know helps to alleviate anxiety and stress. But to put the animal on the
abdomen and do diaphragmatic reading. If you don't have a pet, the weighted stuff animal is a good
idea.
>> That's a good idea. The other day my kids were using the small bean bags on their belly. That's
cool. Whenever I tried to teach deep breathing to my toddler, I got screamed at. No deep breathing.
The element of creativity is something I've had to learn, especially with kids obviously. Breathing into
the belly is different for folks. It is certainly a learning experience.
>> The older kids might be helpful and playful. They can play around with their non-dominant hand
and color in their hearts. Being creative in how they are introduced. This is an interesting one. Clients
who engage but struggle, because moving into the state of calm feels scary. It makes -- it sounds like
why would that be? It makes sense to us as clinicians. That calm would be unfamiliar, scary for clients.
Do you ever encounter that in your clinical practice?

Page 11 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

>> Yeah. When I'm teaching the breath work, that comes up quite frequently. Because patients are
used to feeling stress and anxiety as more a port of their lives than calm. Knowing that our brains love
comfort and familiarity, it can be very scary to invoke something that's going to create a foreign season
sayingses for them. Going slow there's no deadline and pressure. Going blow and working with
grounding practices. Noticing the sensations in the feet first as a way to align the mind and body might
be a baby stepping stone. We know the challenge is where growth and learning can happen.
Breakthroughs can happen as well. Leaning into the discomfort and being mindful of the balance
between going too far to overwhelm versus too far into the comfort zone. That's where I think
mindfulness practice is so important to do that. There are many different ways decides breathing to be
mindful and develop mindfulness. Not necessarily to introduce these practices for these patients and
clients who are so used to anxiety and stress and depression as being such a large part of their reality
that the focus is on therefore their own recognition of the present experience as opposed to trying to
go jump into alleviation of any of the anxiety or stress. I think it starts with awareness entirely.
>> We've had a lot of questions about COVID. And long COVID.
>> Yes.
>> The range. What to do as mental health clinicians, how do we help deal with some of the symptoms
and the associated anxiety coming from the shortness of breath or going alongside if that makes
sense?
>> Yeah. Absolutely. Seeing patients now for the last three years with COVID and more and more
patients coming in with long COVID, I have no doubt the integrated approach is going to be a way that
we help these patients. With long COVID, many patients have objective findings that are normal. But
pulmonary function testing ends up being normal. Their stress tests end up being normal. But it doesn't
mean they are not suffering. We know that long COVID affects multiple organs, also namely the brain
as well. Lung manifestations, cardiovascular, endocrine hits almost every system. So the beginning
part of our session together on thinking about what else can be going on with all of the other organ
systems that could have been affected by long COVID can be potentially be helpful and also clear
lines of communication with their other health care professionals. When the clients coming in and most
likely have long COVID, and there's more depression or anxiety just so common with long COVID
patients, I think any one of these practices would be helpful. But if shortness of breath happens to be a
key foundational aspect of it. Then I would stay away from the practices initially and work more on
diaphragmatic breathing and on personal breath first.
>> Thank you for that. For patients with obstructed nasal conditions, I thought it was an interesting
one, fractures and allergies, what do you do? They asked about adjusting to mouth breathing. How do
you handle that?
>> So some deep breathing, whether it is through the nose or mouth is better than no deep breathing.
If the nose happens to be super congested, yes. I would make an intentional effort to work with their
own health care professionals in getting the nasal congestion alleviated. Because the nose is so
important. So advantageous for us to breathe. Especially in through the nose. The nose doesn't have
any indeterminants or hairs or basically the filtration in the mouth is very lacking. >>fter your story, and

Page 12 of 13 Downloaded on: 09 Mar 2023 11:03 AM

 PESI-The Mindfulness in Psychotherapy Summit-Mindf
(USPESI0803B - Ai-Live Premium)

you presenting, I do feel more grateful for my nose. I knew nose breathing was healthy. Today it was
really solidified. Thank you for that. We have one more minute. I want to try to get one more question
in. You talked about trauma and sort of being aware, contraindications to relationship with trauma.
>> Sometimes their breath is something that's already abnormal at baseline. Knowing a little bit more
about their medical history. Two is was there any sort of trauma related to the breath? A witn't suicide
attempted related to breath? Is there an association of drowning or strangulation? Or even a heavy
weight on top of the chest. Some of these things are subtle. The questions to ask would be open
ended for sure. Then also specifically asking about the breath. What's their relationship? What's the
current relationship with your breath? Do they even notice it? Do they do any breath work already? Is
there any difficulty with inhalation versus exhalation as well. Hopefully that's helpful. Really just coming
into this with mindful curiosity and care when we're asking about trauma.
>> Sure. What we know about trauma work is eventually the breath could be a really healing place to
work. In the beginning probably better to explore other approaches and ways to be mindful, if you will,
that are familiar to the body and less traumatizing.
>> Yeah. Alternative anchors are super helpful.
>> Well, we're out of time. Thank you so much for being here. That was really informative. We
appreciate you. You are welcome back any time.
>> Thank you so much for having me. Thank you, everyone, for being here.
>> Thank you, Dr. Liang. We'll take a short break. We'll be back soon. Take care.

Page 13 of 13 Downloaded on: 09 Mar 2023 11:03 AM