Slow-paced, resonance or coherent breathing

1. Introduction

Version followed: the five-visit resonance-frequency protocol of Lehrer, Vaschillo, Zucker and colleagues (2013), with resonance-frequency assessment as summarised by Shaffer and Meehan (2020), used here as the paced-breathing core; the equipment-free "Coherent Breathing" variant as taught in Brown and Gerbarg's Breath-Body-Mind programme and as operationalised in Fincham, Strauss and Cavanagh's 2023 trial protocol. The full biofeedback (instrumented) version is covered in the Domain IX biofeedback guides (HRV biofeedback, entry 040); this guide cross-refers to it and concentrates on what a trained psychotherapist can teach with or without instruments.

What it is. Slow-paced breathing is a low-intensity, at-rest practice in which the client breathes smoothly, without breathing deeply and without holds, at a slow, steady rate. Three overlapping traditions use it:

Resonance-frequency (RF) breathing (Lehrer, Vaschillo and Vaschillo; Lehrer and Gevirtz). The client breathes at their individual resonance frequency, which the 2013 protocol describes as lying close to about six breaths per minute and found by testing several rates with heart-rate and respiration sensors. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
Paced breathing at about six breaths a minute without individual testing. Lehrer and Gevirtz describe cardiovascular resonance as occurring at "approximately 0.1 Hz (six breaths per minute)" and note that a breath-pacing device can stand in for feedback. [source: Lehrer & Gevirtz 2014]
"Coherent Breathing", the name used by its promoters (Stephen Elliott, whom Breath-Body-Mind credits and whose pacing recordings it uses, his role in naming it [uncertain: not verified]; and Richard Brown and Patricia Gerbarg, who teach it within Breath-Body-Mind). A recent trial protocol, citing Brown and Gerbarg (2012), describes it as breathing at about six breath cycles per minute with equal in- and out-breaths and no deliberate pauses. [source: Fincham et al. trial protocol 2023; BBM handout] Elliott's own specification of the rate in The New Science of Breath [uncertain: not verified].

How change is thought to happen. In the developers' account, breathing at about 0.1 Hz drives large heart-rate oscillations (respiratory sinus arrhythmia) because breathing and the baroreflex then reinforce each other: heart rate rises and falls in phase with the breath and in opposite phase with blood pressure. Repeated practice is proposed to strengthen baroreflex function and autonomic regulation, which the developers link to reduced stress reactivity and symptom improvement. [source: Lehrer & Gevirtz 2014] Brown and Gerbarg frame their practices within polyvagal theory as shifting "sympatho-vagal balance" towards states of safety and social engagement; this is their theoretical claim, not established fact. [source: Kripalu BBM workshop page] For psychotherapy, the practical mechanism is a portable, learnable self-regulation skill the client can use before, during and between sessions. [synthesis]

Status. This is a breathing skill, not a stand-alone psychotherapy. It is not a treatment for heart disease, hypertension, asthma or any other physical illness, and clients should never change prescribed medicines because of it. [synthesis]

2. Framework

Version A: Lehrer et al. (2013) five-visit protocol (instrumented; therapist with biofeedback training)

The 2013 paper presents a five-visit protocol refined in asthma research, with longer versions used for pain, anxiety, depression and other conditions. Its structure, in paraphrase: [source: Lehrer et al. 2013]

Visit	Goal	Core content	Move on when
1	Orientation and finding the resonance frequency	Explain sensors and display; brief practice at about six breaths per minute; test several rates close to that pace, as the protocol sets them out, briefly each with rest between; record the markers; assign home practice at the best rate	A best-fitting rate is identified, or a provisional rate is chosen and retested next time
2	Fine-tune rate; teach pursed-lips and abdominal breathing	Retest the chosen rate and rates half a breath faster and slower; teach pursed-lips exhalation and hands-on-chest-and-belly abdominal breathing; paced practice then feedback practice with rests	Rate confirmed; client can breathe easily at it with a longer out-breath and without overbreathing
3	Biofeedback without pacer	Client breathes in phase with the heart-rate trace (in as heart rate rises, out as it falls) without the pacer	Client can produce smooth, large heart-rate swings without the pacer
4–5	Consolidation and application	Review technique; paced and feedback practice; check whether the resonance peak has shifted; discuss using the skill with the client's symptoms and stressors	Client uses the skill independently and has a plan for daily life and flare-ups

Format: individual, in-person, with ECG or PPG heart-rate sensor and a respiration belt; Shaffer and Meehan add that live displays of heart rate and breathing are needed and that ECG is preferred during slow breathing. [source: Shaffer & Meehan 2020] Home practice in the 2013 protocol is twice daily, about 20 minutes each time, with a watch, computer pacer or home trainer; after the final visit the protocol describes continuing regular practice for a period, then occasional practice to keep the skill, and using it at times of symptom flare-up. [source: Lehrer et al. 2013] The instrumented details belong to the Domain IX HRV biofeedback guide (040).

Version B: Paced slow breathing without instruments (psychotherapy-friendly)

Where no sensors are available, the published fallback is to breathe with a pacer at about six breaths a minute rather than at an individually measured rate. [source: Lehrer & Gevirtz 2014] A typical integration into psychotherapy: [synthesis]

Screening session (part of assessment): medical and psychiatric screening, breathing-pattern screen, consent.
Teaching session(s) (one or two sessions, part of each session): rationale, posture, smooth not-deep breathing, longer or equal out-breath, pacer practice in session.
Practice and consolidation (following sessions): brief review of home practice at the start of each session; troubleshooting.
Application: using the skill around triggers, before exposure-based or emotionally demanding work (with the caveats in Section 5), and in daily life.
Ending: maintenance plan.

Move from teaching to application when the client can follow the pacer easily, without dizziness, tingling or air hunger, and reports the practice as tolerable. [synthesis]

Version C: Coherent Breathing as taught in Breath-Body-Mind

Brown and Gerbarg teach Coherent Breathing alongside "Breath Moving", a "Ha" breath, body scan, tapping, qigong movements and Open Focus attention, usually in multi-day workshops (for example a Friday-evening to Sunday-morning residential format) with home practice review. [source: Kripalu BBM workshop page] A BBM handout describes practice lying with legs supported on a chair or sitting, progressive relaxation of the body, and breathing in time with recorded bell tones (the Respire-1 recording, which the handout says is available from coherence.com). [source: BBM handout] In the Fincham et al. online trial, participants heard a roughly five-minute introductory audio and then practised with a guided audio of about ten minutes a day for 28 days, paced at about six breath cycles per minute. [source: Fincham et al. trial protocol 2023] Brown, Gerbarg and Muench state that these practices "may not be appropriate for all individuals" and that initial in-person training and evaluation improve results. [source: Brown, Gerbarg & Muench 2013, abstract]

3. Guiding principles

Gentle, not deep. The 2013 protocol repeatedly instructs clients to "Breathe easily and comfortably rather than deeply". Practical meaning: coach smoothness and slowness, never volume; deeper breathing is the commonest route to overbreathing. [source: Lehrer et al. 2013]
"Do not try too hard." Effort raises arousal and distorts the pattern. Practical meaning: lower the stakes, praise ease rather than precision. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
The rate is individual and comes from the published range. Practical meaning: use the published rate or range; do not push the client slower or longer than the published pattern, and do not add holds. [source: Lehrer et al. 2013; synthesis]
Watch for overbreathing at every step. Practical meaning: ask about lightheadedness, tingling, pounding heart, breathlessness, dizziness and anxiety; the remedy is shallower breathing, never deeper. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
The client can stop at any time. Shaffer and Meehan include telling the client this in the orientation. Practical meaning: say it explicitly before each first practice and honour it without debate. [source: Shaffer & Meehan 2020]
Screen first, and get medical input where needed. Practical meaning: no teaching until physical and psychiatric contraindications have been reviewed (Section 4, first entry). [source: Shaffer & Meehan 2020; Fincham et al. trial protocol 2023; synthesis]
Comfort and preference shape the method. Some clients find a pacer aversive but feedback easy; the protocol switches modes for them. Practical meaning: adapt pacing medium (visual, audio, counting, feedback) to what the client tolerates. [source: Lehrer et al. 2013]
Longer or equal out-breath, consistently. The Lehrer protocol favours a longer exhalation and asks that the ratio be held constant across trials; Coherent Breathing as operationalised uses equal in- and out-breaths. Practical meaning: pick one version, name it, and keep it stable. [source: Shaffer & Meehan 2020; Fincham et al. trial protocol 2023]
Regular practice is part of the method. Practical meaning: the skill is built at rest between sessions, then applied under stress. [source: Lehrer et al. 2013]
A coping skill, not a cure. Practical meaning: present it as one tool within the overall formulation; make no promises about symptom removal. [synthesis]
Physical safety setting. Practical meaning: practise only seated or lying in a safe place; never in or near water, in the bath, or while driving or operating machinery. [synthesis]
Attribute the theory. Practical meaning: describe baroreflex resonance as the developers' model and polyvagal or "balance" language as Brown and Gerbarg's framing; describe qigong "energy" language as belonging to that tradition. [source: Lehrer & Gevirtz 2014; Kripalu BBM workshop page; BBM handout]

4. Intervention inventory

The published pattern referred to throughout is the one the sources state: about six breaths per minute (Lehrer & Gevirtz 2014). The resonance-frequency protocol (Lehrer et al. 2013) finds an individual rate close to this by testing with sensors, and Coherent Breathing uses about the same pace with equal in- and out-breaths (Fincham et al. trial protocol 2023, citing Brown & Gerbarg 2012). Testing ranges for children are set by the protocol's authors (Shaffer & Meehan 2020) and are not given here. None of these includes breath-holds, and nothing here should be lengthened, slowed further or built up beyond them.

4.1 Screening, contraindications, consent and stop rules

Purpose / when: Before any teaching; repeat if health changes. [source: Shaffer & Meehan 2020; Fincham et al. trial protocol 2023; synthesis]
Steps:
1. Medical history. Ask about heart disease and rhythm problems, pacemaker, blood pressure, lung disease (asthma, COPD, current chest infection, breathlessness), kidney disease, recent surgery, pregnancy, epilepsy, eye disease (glaucoma, retinal problems), and current medicines.
2. Contraindications stated by the sources used here: a pacemaker (the device regulates heart rhythm externally) and acidosis where overbreathing is compensating for it, for example in some kidney disease, because slow breathing raises CO2 [source: Shaffer & Meehan 2020]. Exclusions in a coherent-breathing trial: problems affecting the ability to pace breathing, including active or chronic respiratory infection, breathlessness, cardiovascular problems, uncontrolled symptomatic asthma or COPD, abnormally slow or fast resting breathing, and other conditions or current events that impair breath control [source: Fincham et al. trial protocol 2023].
3. Further cautions commonly listed for breathwork: epilepsy, pregnancy, psychosis or bipolar disorder, panic disorder, glaucoma or retinal problems, recent surgery [uncertain: not verified in a professional source for slow-paced breathing specifically]. Treat them as reasons for medical clearance and a cautious, brief, eyes-open start rather than as automatic exclusions. [synthesis]
4. Overbreathing risk. Shaffer and Meehan advise that clients with asthma, generalized anxiety, low back pain or habitual overbreathing should first learn to breathe effortlessly before RF assessment, and that assessment be postponed until they can [source: Shaffer & Meehan 2020].
5. Breathing-pattern screen. The Nijmegen Questionnaire is a self-report screen for symptoms attributed to hyperventilation; Li Ogilvie, Kayes and Kersten (2019) found good content validity but poor structural validity for the original scoring, and recommend a revised 15-item version with a conversion table. Use it as a screening aid only, not a diagnosis; describe the tool to the client but do not improvise items [source: Li Ogilvie et al. 2019]. Positive screens, or breathlessness without a medical explanation, warrant referral to a GP or respiratory physiotherapist before breathing training. [synthesis]
6. Psychiatric and trauma screen. Ask how the client reacts to attending to the body and breath; prior panic attacks triggered by breathing exercises; dissociation; trauma involving suffocation, choking or restraint. [synthesis]
7. Medical clearance for any positive item in steps 1–3, from the treating physician. Never advise changes to asthma, cardiac, blood-pressure or other medicines. [synthesis]
8. Consent: explain what the practice involves, likely sensations, that it is a coping skill not a cure, and that the client may stop at any time. [source: Shaffer & Meehan 2020; synthesis]
9. Setting rules: seated or lying, never in or near water (bath, pool, open water), never while driving or operating machinery. [synthesis]
10. Stop rules (give them in writing): stop and return to ordinary breathing if lightheadedness, tingling, pounding heart, breathlessness, dizziness or rising anxiety appear and do not settle with shallower breathing [source: Lehrer et al. 2013]; stop and seek medical help for chest pain, fainting, irregular heartbeat or severe breathlessness; stop and ground for flashbacks, panic or dissociation (see 4.12). [synthesis]
Example language (illustrative): "Before we try any breathing, I'd like to check a few health questions, because slowing the breath changes heart rate and carbon dioxide. If anything feels wrong while we practise, just stop and breathe normally; you don't need my permission."
Watch for: reluctance to disclose health information; undiagnosed breathlessness; clients who want to use breathing instead of prescribed treatment. It is working when the client can state the stop rules back and has any clearance needed.

4.2 Rationale and psychoeducation

Purpose / when: First teaching session; revisit when motivation flags.
Steps:
1. Describe heart rate rising on the in-breath and falling on the out-breath (respiratory sinus arrhythmia).
2. Explain the developers' model: at about six breaths a minute the breath and the blood-pressure reflex (baroreflex) reinforce each other, producing large, smooth heart-rate waves; regular practice is proposed to train this reflex. [source: Lehrer & Gevirtz 2014; Lehrer et al. 2013]
3. Link to the client's formulation: a skill for lowering physiological arousal, practised at rest first, used under stress later. [synthesis]
4. State limits: it is a skill, not a cure; no promises about specific symptoms. [synthesis]
Example language (illustrative): "Your heart speeds up a little as you breathe in and slows as you breathe out. When the breath is slow and even, around six breaths a minute, those waves get bigger and smoother. The researchers who developed this think practising that pattern exercises the system that steadies your heart and blood pressure."
Watch for: health anxiety about heart-rate changes (normalise; if marked, address it first); over-literal hopes of a cure. Working when the client can explain the rationale in their own words.

4.3 Orientation to sensors and display (instrumented version)

Purpose / when: Visit 1 of the Lehrer protocol, when sensors are used. Full details in the Domain IX HRV biofeedback guide (040).
Steps (paraphrased): attach and test each sensor; show the client the live heart-rate and breathing traces and what they mean; keep answers to questions brief; explain that the task looks for the breathing speed at which heart-rate variation is largest; remind them they can stop at any time; invite questions. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
Example language (illustrative): "This line goes up when you breathe in and down when you breathe out. This one is your heart rate. We're going to look for the breathing pace where your heart-rate waves are biggest."
Watch for: performance anxiety about the screen; signal artefacts (a flat or low PPG signal suggests switching to ECG). [source: Shaffer & Meehan 2020]

4.4 Introductory paced-breathing practice

Purpose / when: Before formal rate testing (Lehrer Visit 1), or as the first practice in the equipment-free version.
Steps:
1. Seat the client comfortably, feet supported; eyes open at first. [synthesis]
2. Use a visual or audio pacer set to the published pattern: about six breaths per minute, as in the Lehrer protocol's warm-up. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
3. Instruct: breathe easily and comfortably, not deeply; let the out-breath be a little longer than the in-breath (Lehrer version) or equal to it (Coherent Breathing version). [source: Lehrer et al. 2013; Fincham et al. trial protocol 2023]
4. If the rate is hard to follow, Shaffer and Meehan describe allowing the client to approach it gradually in small steps; keep within the published range and never go slower than it. [source: Shaffer & Meehan 2020]
5. Practise for a few minutes, then pause and debrief sensations. [source: Lehrer et al. 2013]
Example language (illustrative): "Just let the breath follow the bar up and down. Small, easy breaths are fine; you don't need to fill up. Let the out-breath take its time." Verbatim cue from the protocol: "Do not try too hard." [source: Lehrer et al. 2013]
Watch for: breath-holding at the top or bottom of the cycle, gulping, raised shoulders, air hunger, overbreathing symptoms (4.10). Working when the client follows the pacer with little effort and reports neutral or pleasant sensations.

4.5 Resonance-frequency assessment (instrumented)

Purpose / when: To find the individual rate (Lehrer Visit 1). Requires heart-rate and respiration sensors and biofeedback training; cross-refer to Domain IX (040).
Steps (paraphrased from the published protocol):
1. Hold the in:out ratio constant across trials. [source: Shaffer & Meehan 2020]
2. Test several rates close to six breaths per minute, as the protocol sets them out, briefly each with rest between; the rate list is not reproduced here. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
3. Before each trial, ask the client to breathe at this pace, following the pacer. [source: Lehrer et al. 2013]
4. After each trial, check the actual breathing rate; repeat trials where the client drifted off pace or where artefacts contaminated the record. [source: Shaffer & Meehan 2020]
5. Record, for each rate: heart rate-breathing phase; peak-to-trough heart-rate amplitude; low-frequency (LF) power; height of the LF peak; smoothness of the heart-rate curve; whether there is a single LF peak. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
6. Choose the rate where most markers converge; weigh client comfort to break ties. If the best rate lies at the end of the tested range, the published protocol tests just beyond it until the markers decline. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
7. If results are unclear, assign the rate that looked best and retest at the next visit. [source: Lehrer et al. 2013]
Example language (illustrative): "We'll try a few speeds for a couple of minutes each, with rests. There's no right answer; your body tells us which pace suits it."
Watch for: fatigue across trials; overbreathing at the slower rates ("shallower and smoother breaths" is the published remedy). [source: Shaffer & Meehan 2020]

4.6 Fine-tuning the rate (instrumented)

Purpose / when: Lehrer Visit 2 and later visits; relaxation changes heart-rate amplitude, so the rate may shift.
Steps: retest the chosen rate and its neighbouring rates, briefly each; confirm with the Visit 1 markers; in later visits, check whether the LF peak has shifted and adjust if needed. [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
Example language (illustrative): "Let's double-check today's best pace; it can move a little as you get more relaxed at this."
Watch for: client attaching anxious significance to a changed number (normalise: it is an individual and slightly moveable characteristic). [source: Lehrer et al. 2013; synthesis]

4.7 Pursed-lips exhalation

Purpose / when: Lehrer Visit 2, to lengthen the out-breath gently. [source: Lehrer et al. 2013]
Steps: breathe in through the nose; breathe out slowly through lightly pursed lips, as if blowing gently through a straw; keep the breath soft, not forced; combine with the paced rate once comfortable. [source: Lehrer et al. 2013]
Example language (illustrative): "Breathe in through your nose, then let the air out slowly through your lips as if you were cooling soup without making the spoon ripple."
Watch for: forcing the exhalation (tension in face and abdomen), which raises effort and can trigger air hunger; nasal blockage (use relaxed mouth breathing instead). Working when the out-breath lengthens without strain. [synthesis]

4.8 Abdominal (diaphragmatic) breathing

Purpose / when: Lehrer Visit 2 (or Visit 3 if not yet learned), so that slow breathing moves the belly rather than the upper chest. [source: Lehrer et al. 2013]
Steps:
1. Client places one hand on the chest and one on the abdomen. [source: Lehrer et al. 2013]
2. Therapist models: the lower hand rises on the in-breath, the upper hand stays fairly still. [source: Lehrer et al. 2013]
3. Client practises briefly; the protocol limits teaching time and advises stopping and returning later if it becomes frustrating. [source: Lehrer et al. 2013]
4. Combine with pursed-lips exhalation at the paced rate; home practice includes a short hands-on check. [source: Lehrer et al. 2013]
Example language (illustrative): "Let your lower hand do the moving. The top hand can just rest there and notice."
Watch for: pushing the belly out muscularly; breath-holding; frustration (switch back to simple paced breathing). Clients with trauma linked to the abdomen or body image may prefer hands on the lower ribs or no hands at all. [synthesis] The therapist does not touch the client to cue this. [synthesis]

4.9 Heart-rate biofeedback breathing without a pacer (instrumented)

Purpose / when: Lehrer Visit 3 onwards; also for clients who find a pacer aversive. Full procedure in Domain IX (040). [source: Lehrer et al. 2013]
Steps (paraphrased): client watches the heart-rate trace and breathes in as heart rate rises and out as it falls, aiming to make the swings as large and smooth as possible; short blocks of practice with rests; pacer support only where needed. [source: Lehrer et al. 2013]
Example language (illustrative): "Start breathing in as the heart line starts climbing, and let the breath out as it turns down. Keep the breaths small." Protocol reminder in paraphrase: do not breathe deeply, especially if dizzy or lightheaded. [source: Lehrer et al. 2013]
Watch for: chasing the trace with ever-deeper breaths (overbreathing), frustration with the screen. Working when heart-rate waves become large, regular and in phase with breathing. [source: Lehrer et al. 2013]

4.10 Recognising and managing overbreathing (hyperventilation and hypocapnia)

Purpose / when: Throughout every session and at home.
Steps:
1. Teach the signs in advance: lightheadedness, tingling, pounding heart, breathlessness, dizziness, anxiety [source: Lehrer et al. 2013]; Shaffer and Meehan add faintness and a heart that feels like it is beating too hard [source: Shaffer & Meehan 2020]. Explain that these come from blowing off too much CO2. [source: Shaffer & Meehan 2020]
2. If they appear: breathe more shallowly, never more deeply; "shallower and smoother breaths". [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
3. If they do not settle within a short time: stop the paced breathing, return to ordinary breathing, sit upright, rest, and debrief. [synthesis]
4. Persistent symptoms, muscle cramping of hands or feet, chest pain or fainting: stop practice and seek medical assessment. [synthesis]
5. For clients with a history of overbreathing (asthma, anxiety, habitual fast breathing), first practise effortless, gentle breathing before slowing to the published rate. [source: Shaffer & Meehan 2020]
Example language (illustrative): "Tingling or feeling a bit floaty usually means the breaths are too big. Make them smaller and quieter; you want less air, not more."
Watch for: clients interpreting symptoms as a heart attack or loss of control (link to panic formulation, Section 5). Working when the client can catch and reverse early signs alone.

4.11 Coherent Breathing with recorded tones (Breath-Body-Mind version)

Purpose / when: Equipment-free version for groups or individuals; matches the Brown and Gerbarg teaching. Therapists wanting the full programme (with movement, qigong and other practices) should train with Breath-Body-Mind. [source: Kripalu BBM workshop page; BBM handout]
Steps (paraphrased from the BBM handout and trial description):
1. Position: lying with legs supported over a chair, or sitting relaxed. [source: BBM handout]
2. Progressively relax face, throat, tongue, hands, belly, hips, legs and feet, letting the body be supported. [source: BBM handout]
3. Play a pacing recording (the handout names Elliott's bell-tone recordings) and let the breath gradually synchronise with the tones; the trial version uses equal in- and out-breaths at about six cycles a minute without deliberate pauses. [source: BBM handout; Fincham et al. trial protocol 2023]
4. When the mind wanders, return part of the attention to the tones and the breath. [source: BBM handout]
5. Close by letting the breath return to its own rhythm and debriefing. [synthesis]
Example language (illustrative): "Let the tone guide the in-breath and the next tone guide the out-breath. You don't need to get it exactly; let the breath settle into the rhythm."
Watch for: sleepiness (fine at bedtime, less so in session); lying down feeling exposed for trauma survivors (offer seated, eyes open); pregnancy or reflux making the legs-up position uncomfortable (seated instead). [synthesis] Working when breathing follows the tones easily and the client reports calm or neutral states.

4.12 Managing distress, panic or dissociation during practice

Purpose / when: Whenever attention to the breath triggers fear, intrusive memories or numbing. Not covered in detail by the sources used here. [synthesis]
Steps: stop pacing; invite eyes open and orientation to the room; feel feet on the floor; name the time and place; resume ordinary breathing; validate; later, explore what the breath focus evoked; if it recurs, shift attention to external cues (a visual pacer, counting tones) or replace breath work with other grounding. [synthesis]
Example language (illustrative): "Let's pause the pacing. Open your eyes, look around and tell me three things you can see. Your breathing can do whatever it wants now."
Watch for: freezing, flat affect, long silences, sudden tears or startle. Working when the client returns to present-moment contact and can decide whether to try again.

4.13 Breath Moving (Breath-Body-Mind)

Purpose / when: Brown and Gerbarg combine Coherent Breathing with "Breath Moving"; the BBM handout describes, after a few minutes of coherent breathing, imagining the breath moving between different places in the body. [source: BBM handout; Kripalu BBM workshop page] The detailed sequence is taught in BBM training [uncertain: not verified].
Steps: after settling into the paced rhythm, invite the client to imagine the breath travelling between parts of the body in time with the tones, without changing the rate or depth. [source: BBM handout; synthesis for the wording]
Example language (illustrative): "As you keep the same easy rhythm, imagine the in-breath travelling up from your feet and the out-breath flowing back down."
Watch for: body areas that carry trauma or pain (let the client choose where the breath "goes"); imagery effort increasing breathing depth. [synthesis]

4.14 Home-practice set-up

Purpose / when: From the first teaching session.
Steps:
1. Choose a pacer: the 2013 protocol names a watch, a computer pacer or a home trainer, and lists several apps of the time; a pacing audio is used in the Coherent Breathing trial. [source: Lehrer et al. 2013; Fincham et al. trial protocol 2023]
2. Agree when and where (seated or lying, safe place; never in or near water or while driving). [synthesis]
3. State the practice as the version followed publishes it, attributed: Lehrer et al. assign twice-daily practice of about 20 minutes at the resonance rate with pursed-lips abdominal breathing; the Fincham et al. trial used about ten minutes a day for four weeks. Do not set targets beyond the published pattern; a shorter amount the client will actually do is a reasonable start. [source: Lehrer et al. 2013; Fincham et al. trial protocol 2023; synthesis]
4. Agree a simple log (done or not, any symptoms). [synthesis]
Example language (illustrative): "The researchers who designed this ask for regular practice twice a day. Let's find times that fit your life, and you note whether you did it and how it felt."
Watch for: practising while lying in the bath, in bed while very drowsy only, or during driving; app settings drifting slower than the published rate. [synthesis]

4.15 Applying the skill in daily life and in psychotherapy

Purpose / when: Lehrer Visits 4–5 discuss using the technique with the client's symptoms, personality and stressors, and at times of flare-up, but the paper says that discussion is beyond its scope. The integration steps below are therefore synthesis. [source: Lehrer et al. 2013; synthesis]
Steps: identify trigger situations; rehearse a brief version of paced breathing in session while imagining the trigger; use at the start of sessions to settle; use after emotionally demanding work to down-regulate; in CBT for anxiety, agree when it is a coping skill and when it should be dropped so that it does not become a safety behaviour (Section 5). [synthesis]
Example language (illustrative): "When you notice the tightness before a meeting, try a minute of the slow pace you've practised, then go in anyway."
Watch for: using the breathing to escape all discomfort; overbreathing under stress (smaller breaths). Working when the client uses it flexibly and reports regained steadiness rather than avoidance.

4.16 Ending and maintenance

Purpose / when: Final sessions.
Steps: review what the client learned and which version and rate they use; agree the maintenance pattern the protocol describes (continued regular practice for a period, then occasional practice to keep the skill alive, and using it at flare-ups); give the written stop rules again; plan a booster contact if useful. [source: Lehrer et al. 2013; synthesis]
Example language (illustrative): "Like any skill, this stays sharp if you keep using it now and then. What will remind you?"
Watch for: dropping practice entirely once well; returning symptoms (offer a refresher).

5. Handling problems

The developers' sources cover rate difficulties, overbreathing and pacer aversion; most other guidance below is synthesis and is marked.

Can't keep to the pace / feels breathless at the slow rate. Usually the breaths are too deep or the client is holding at the turn. Make breaths smaller; for habitual fast breathers, practise effortless breathing first and approach the published rate gradually within its range. [source: Shaffer & Meehan 2020; Lehrer et al. 2013] Never push slower than the published pattern. [synthesis]
Lightheadedness, tingling, pounding heart. Overbreathing: breathe more shallowly, not more deeply; stop if it persists (4.10). [source: Lehrer et al. 2013; Shaffer & Meehan 2020]
Finds the pacer aversive. Switch to heart-rate feedback (instrumented) or to a different pacing medium (audio tones, a slow visual, a watch). [source: Lehrer et al. 2013; synthesis for the non-instrumented options]
Abdominal breathing will not come. Do not spend long on it; return to simple paced breathing and try again later. [source: Lehrer et al. 2013]
Unclear resonance frequency. Practise at the best-looking rate and retest; the rate can shift as the client relaxes. [source: Lehrer et al. 2013]
Breath focus triggers panic. In panic disorder, breathing sensations are often the feared cues. Start eyes open, short, with an external pacer; frame symptoms as harmless CO2 effects; if panic follows, stop and ground (4.12) and review the formulation. [synthesis] In CBT for panic and anxiety there is a debate about whether breathing techniques can act as safety behaviours that maintain fear when used to avert feared catastrophes [uncertain: not verified in the sources used here]; a practical response is to teach the skill for general arousal regulation, and not to use it during interoceptive or situational exposure unless the treatment plan specifies otherwise. [synthesis]
Trauma: breath focus evokes suffocation, choking or assault memories. Offer choice of posture, eyes open, the therapist out of the client's direct line, short trials; never hands-on cueing; consider grounding-first work before breath practice. [synthesis]
Dissociation or drowsiness. Shorten practice, keep eyes open, sit upright, use external tones; drowsiness is acceptable at bedtime but not when the goal is alert self-regulation. [synthesis]
Non-adherence. Explore barriers; link practice to existing routines; accept a smaller amount than the published pattern as a start rather than abandoning it; review logs without judgement. [synthesis]
"It doesn't work for me." Check technique (depth, holds, rate drift), expectations (a skill that builds with practice, not instant relief), and whether it is being used only at peak distress. [synthesis]
Rupture (client feels dismissed: "you're telling me to just breathe"). Acknowledge, explain how the skill fits the wider work, and let the client decide whether and when to use it. [synthesis]
Health anxiety about heart-rate changes on screen. Normalise heart-rate waves as healthy variability; consider equipment-free practice if the display feeds checking. [synthesis]
Medical issues emerge (chest pain, palpitations, fainting, unexplained breathlessness, pregnancy, new diagnosis). Stop and refer for medical review; resume only with clearance. Do not adjust medicines or advise others to. [synthesis]
Client wants to slow down further, add holds, or practise in the bath, pool, open water or while driving. Decline: these go beyond the published pattern or into settings where loss of awareness is dangerous. Breath-holding and hyperventilation in water carry a risk of blackout and drowning. [synthesis] Intense or cathartic breathwork (holotropic and similar) is a different practice; see Domain VII.

Evidence status (brief)

A 2023 meta-analysis of 12 randomised trials (785 adults) found breathwork associated with lower self-reported stress than control conditions, small to medium in size (g = −0.35), with similar small effects for anxiety and depressive symptoms; most studies were at moderate risk of bias. [source: Fincham et al. 2023]
Lehrer and Gevirtz note that HRV biofeedback has been studied across many conditions (including asthma, hypertension, IBS, chronic pain, depression, anxiety and PTSD), but few areas have extensive controlled-study support. [source: Lehrer & Gevirtz 2014]
Publisher descriptions of Brown and Gerbarg's book call the approach "side effect–free"; this is a marketing claim, and the clinical sources above document overbreathing effects and contraindications. [source: Shambhala book page; Shaffer & Meehan 2020; Lehrer et al. 2013]
No source supports slow breathing as a treatment for physical disease; present it as a self-regulation skill alongside usual care. [synthesis]

Sources

Books cited:

Brown RP, Gerbarg PL (2012). The Healing Power of the Breath: Simple Techniques to Reduce Stress and Anxiety, Enhance Concentration, and Balance Your Emotions. Shambhala.
Elliott S. The New Science of Breath [uncertain: edition, year and content not verified].
Lehrer PM, Vaschillo E, Vaschillo B (2000), resonant-frequency biofeedback training paper, Applied Psychophysiology and Biofeedback [uncertain: exact title, volume and pages not verified].

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