Atlas›Domain X · Body, movement, breath & physical›Guide 156
Guide X-156

Papworth method

1960England
A 17 · L 70 · M 1316 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the Papworth method as described in the one controlled trial of it, Holloway and West (Thorax, 2007, Box 1: five individual sessions with a respiratory physiotherapist in primary care). The guide also draws on the shorter Papworth-derived physiotherapy breathing retraining used in the BREATHE trial (Bruton et al., Lancet Respiratory Medicine, 2018: three face-to-face sessions, or a DVD and booklet). Current NHS physiotherapy leaflets on breathing pattern disorder are used only to show what the components look like in practice. No founder's manual exists in the public domain; the method is a physiotherapy tradition, not a trademarked programme. [source: Holloway & West 2007; Bruton et al. 2018; NIHR Evidence alert]

What it is. The Papworth method is an integrated breathing and relaxation technique that physiotherapists have used since the 1960s. It is named after Papworth Hospital in Cambridgeshire, England. It combines four elements: breathing training, education about stress and breathing, relaxation training, and step-by-step integration of the new pattern into daily activities and speech. Holloway and West trace its development to physiotherapy and medical writings by Innocenti (1969), Lum (1975, 1977), Cluff (1984) and Holloway (1994). The details given here come from those authors as the trial report cites them; the original texts are [uncertain: not verified]. No single named founder is documented. [source: Holloway & West 2007; Wikipedia, Papworth method]

How change is thought to happen. The method targets dysfunctional breathing, such as over-breathing (hyperventilation), upper-chest and accessory-muscle breathing, and frequent sighing and yawning. Holloway and West link these patterns to asthma symptoms and to anxiety. The client learns a quieter, nose-based, diaphragmatic pattern matched to what they are doing at the time. They also learn to notice their stress responses and how these interact with breathing, and to relax both specifically and generally. Practising the pattern first at rest and then in harder conditions is meant to make it automatic. Ideally it is learned while symptoms are quiet, so the client can use it at the first sign of symptoms. [source: Holloway & West 2007]

Who delivers it. In the trials it was delivered by respiratory physiotherapists. UK national asthma guidance describes it as a physiotherapy-led programme. For asthma and breathing pattern disorder, it is a physiotherapy intervention. The psychotherapist's role is to recognise when it may help, refer through the client's GP or respiratory team, prepare and support the client, and work with the psychological side: anxiety, panic, stress and avoidance. The relaxation and stress-education elements overlap with ordinary psychotherapy skills. Section 4 says what a psychotherapist may do directly and what belongs to the physiotherapist. [source: Holloway & West 2007; Bruton et al. 2018; CSP 2016 report of BTS/SIGN guideline] [synthesis on role division]

Not a treatment for asthma or any physical disease on its own. The method is offered alongside, not instead of, prescribed asthma treatment. BREATHE's authors stress telling patients that it is "in addition to, not instead of, current medication". A psychotherapist never advises a client to start, stop, reduce or change any asthma or other medicine. Any question about medicines goes to the prescriber (GP, asthma nurse or respiratory team). [source: Bruton et al. 2018; CSP 2016]

Evidence status (brief, as reviews state it).

  • Holloway and West 2007: 85 adults with mostly mild or well-controlled asthma in one GP practice. Respiratory symptom scores, anxiety, depression and Nijmegen scores improved compared with usual care, and the gains held at 12 months. Spirometry and end-tidal CO2 did not differ between groups. The same physiotherapist delivered treatment and did the assessments, and the active component could not be identified. [source: Holloway & West 2007]
  • BREATHE (Bruton et al. 2018), 655 adults with impaired asthma-related quality of life: Papworth-derived retraining, by physiotherapist or by DVD, gave a small improvement in asthma quality of life at 12 months compared with usual care. The DVD was non-inferior to face-to-face delivery. Neither changed lung function, airway inflammation or asthma attacks. [source: Bruton et al. 2018; NIHR Evidence alert]
  • Cochrane, breathing exercises for adults with asthma (Santino et al. 2020; 22 trials, one of them Papworth): breathing exercises "may have positive effects on quality of life, hyperventilation symptoms, and lung function" in mild to moderate asthma. They probably do not improve asthma symptoms. Adverse effects were not assessed. [source: Cochrane CD001277]
  • Cochrane, breathing exercises for dysfunctional breathing or hyperventilation syndrome (Jones et al., CD009041): only one small, poorly reported trial was found. The authors state there is "no credible evidence" either way. [source: Cochrane CD009041]
  • UK guideline position: the 2016 BTS/SIGN guideline, as reported by the Chartered Society of Physiotherapy, says physiotherapy-led breathing exercise programmes can be used alongside drug treatment. It cites the Papworth and Buteyko methods as beneficial examples and notes that programmes with more than five hours of contact appeared more likely to work. The 2024 BTS/NICE/SIGN asthma pathway states that BTS and SIGN have retained their non-pharmacological recommendations. The current wording of those recommendations is [uncertain: not verified]. [source: CSP 2016; BTS/NICE/SIGN pathway page]
  • Claims that the method treats depression or anxiety as conditions in their own right are not established by these trials. Anxiety and depression were secondary outcomes in a single asthma trial. [source: Holloway & West 2007; Wikipedia]

2. Framework

Format in the sources.

  • Holloway and West: five individual sessions of about an hour, all with a respiratory physiotherapist, spread over the months between baseline and post-treatment assessment (about six months). An audiotape or CD with reminders was given at the third session, with practice encouraged at least daily. [source: Holloway & West 2007]
  • BREATHE face-to-face arm: three one-to-one sessions of about 40 minutes, roughly two weeks apart, plus a booklet. The session protocol was structured and checked for fidelity. [source: Bruton et al. 2018]
  • BREATHE self-guided arm: a DVD showing a physiotherapist teaching the exercises, explaining the rationale and answering common concerns, plus a booklet with a daily planner and progress charts. [source: Bruton et al. 2018]

Phases. The sources describe components and a sequence of practice positions, not formal phases. The phase structure below is synthesis built from them. [synthesis]

  1. Medical frame and referral. Goal: the breathing problem has been medically assessed, asthma or other disease is being treated, and the client has been referred to respiratory physiotherapy. Move on when there is a diagnosis, or medical reassurance that symptoms are not explained by untreated disease, plus a referral. [synthesis; ACPRC assessment guidance on symptoms unexplained by history and tests]
  2. Physiotherapy assessment. Goal: a baseline of breathing pattern and contributing factors. The physiotherapist takes a history and observes breathing at rest and in activity, may assess breathing and posture hands-on, and uses at least one outcome measure (for example the Nijmegen Questionnaire or the Breathing Pattern Assessment Tool). They also screen nose and sinus, upper airway, cough, exercise, biomechanics and psychological health. [source: ACPRC Breathing Pattern Disorder assessment guidance]
  3. Education and breathing training at rest. Goal: the client understands how stress and breathing interact and can produce a quiet, diaphragmatic, nasal pattern while lying semi-recumbent. [source: Holloway & West 2007]
  4. Relaxation training. Goal: specific and general relaxation that the client can call up on cue. [source: Holloway & West 2007]
  5. Integration. Goal: the pattern holds sitting, then standing, then during daily activities, and finally during speech. [source: Holloway & West 2007] The sources do not give criteria for moving from one position to the next [uncertain]. A workable rule is to move on when the client can keep the pattern comfortably, without strain or air hunger, in the current position. [synthesis]
  6. Home practice and self-management. Goal: regular practice with recorded prompts and planners, and using the technique at the first sign of symptoms. [source: Holloway & West 2007; Bruton et al. 2018]
  7. Ending and follow-up. Goal: the client keeps practising without the physiotherapist. Holloway and West reassessed at 12 months. Changing a habitual pattern can take weeks to months. [source: Holloway & West 2007; Royal Berkshire NHS leaflet]

Psychotherapy alongside. The psychotherapist's work runs in parallel with these phases. It covers screening, referral and preparation before phase 2; supporting practice and working on anxiety, avoidance and stress during phases 3 to 6; and keeping gains going and catching relapse after phase 7. [synthesis]

3. Guiding principles

  • Adjunct, never replacement. Prescribed treatment carries on unchanged. Practical meaning: every conversation about breathing work includes "keep taking your medicines as prescribed; ask your prescriber about any change". [source: Bruton et al. 2018; CSP 2016]
  • Medical assessment first. Breathlessness and chest symptoms need medical assessment before they are called dysfunctional breathing. Practical meaning: never label a client's breathlessness as "just anxiety". Refer for assessment, and urgently for new, severe or worsening symptoms. [synthesis; ACPRC assessment guidance]
  • Physiotherapist-delivered. The respiratory programme is taught by a respiratory physiotherapist. Practical meaning: the psychotherapist refers and collaborates rather than running the Papworth programme. [source: Holloway & West 2007; CSP 2016] [synthesis on scope]
  • Breathing suited to the activity. The aim is a pattern that fits what the person is doing, not slow breathing at all times. Practical meaning: never set breathing targets. Ask "does your breathing fit what you're doing right now?" [source: Holloway & West 2007; Wikipedia]
  • Gentle and quiet, not effortful. The method uses a diaphragmatic pattern, nose breathing and fewer sighs and yawns, and it does not use forced or connected breathing. Practical meaning: if a client is straining, gasping or getting dizzy, the technique is being done wrongly. Stop and refer back to the physiotherapist. [source: Holloway & West 2007] [synthesis on stop rule]
  • Breathing, relaxation and education together. No single element was isolated as the active one. Practical meaning: do not strip the method down to a single breathing trick. Stress awareness and relaxation belong with it. [source: Holloway & West 2007]
  • Graded integration. Practice moves from lying to sitting, standing, activity and speech. Practical meaning: expect the pattern to slip in harder conditions, and treat that slipping as information, not failure. [source: Holloway & West 2007]
  • Learn in calm, use early. Teach during remission and use the technique at the first sign of symptoms. Practical meaning: do not introduce new breathing skills in the middle of a panic attack or asthma flare. [source: Holloway & West 2007]
  • Little and often. Brief, regular practice spread through the day, with recordings and planners. Practical meaning: link practice to existing routines rather than setting long sessions. [source: Holloway & West 2007; Bruton et al. 2018; Royal Berkshire NHS leaflet]
  • Approach, not avoidance. Breathlessness from activity is not in itself harmful, and avoiding activity can increase fear and reduce fitness (as NHS physiotherapy leaflets put this). Practical meaning: help clients return to the activities they avoid, within medical advice. [source: Royal Berkshire NHS leaflet; Royal Papworth Breathlessness leaflet]
  • Psychological factors are part of assessment. Physiotherapy assessment includes stress, anxiety, depression, mental health history and social support. Practical meaning: offer to share relevant psychological findings with the physiotherapist, with the client's consent. [source: ACPRC assessment guidance]
  • Attributed claims. Effects on mood come from limited trial data. Practical meaning: tell clients the method may help asthma quality of life and breathing symptoms, and do not promise cures. [source: Cochrane CD001277; Holloway & West 2007]

4. Intervention inventory

The inventory has two parts. Part A (4.1 to 4.8) describes the components the respiratory physiotherapist delivers, so the psychotherapist knows what the client is being taught and can support it without changing it. Part B (4.9 to 4.16) is the psychotherapist's own work. Example language is illustrative wording for the psychotherapist, not physiotherapy scripts. This guide gives no breathing rates, counts or hold times. Where the physiotherapist sets any of these, they belong to the physiotherapist's programme for that client. [synthesis on structure]

Part A. Components delivered by the respiratory physiotherapist

4.1 Breathing-pattern assessment (physiotherapist)

  • Purpose / when: at the start, to set a baseline and find contributing factors. [source: ACPRC assessment guidance]
  • Steps (as described):
    • The physiotherapist takes a subjective history: symptoms, triggers, what makes them worse or better, and past medical, drug, lifestyle and social history.
    • They observe breathing at rest and during activity.
    • They may do a hands-on assessment of breathing and posture.
    • They complete at least one outcome measure, such as the Nijmegen Questionnaire, the Breathing Pattern Assessment Tool, an end-expiratory breath hold, the Self-Evaluation of Breathing Questionnaire or the Dyspnea-12.
    • They screen nose and sinus, upper airway, cough, exercise, biomechanics and psychological health, the last in line with their own skill set.
    • [source: ACPRC assessment guidance]
  • Example language (psychotherapist preparing the client, illustrative): "The physio will ask about your symptoms and watch how you breathe sitting and moving. They might ask to place a hand on your chest or ribs. You can say no, or ask them to show you first."
  • Watch for: clients with trauma histories who are anxious about being touched or watched while they breathe. Hands-on assessment is a physiotherapy procedure that needs the client's explicit consent, which they can withdraw at any moment. It is never sexual. A chaperone can be requested. The psychotherapist does not do hands-on assessment. [synthesis; USABP Code VIII on consent and the right to stop touch, as a comparable professional standard]

4.2 Education: stress responses and breathing

  • Purpose / when: early, so the client understands why the pattern matters. The content covers recognising stress responses and how they interact with breathing. [source: Holloway & West 2007]
  • Steps (as described): explain over-breathing as a normal stress response that can persist after the trigger has passed. Name its typical signs: rapid upper-chest or mouth breathing, shoulder tension, frequent sighing or yawning, and breath-holding followed by over-breathing. Link this to symptoms such as breathlessness, air hunger, dizziness, tingling and throat tightness. [source: Royal Berkshire NHS leaflet; Holloway & West 2007]
  • Example language (psychotherapist reinforcing, illustrative): "When you're stressed your body breathes as if you're about to run. If that keeps going, it can cause the light-headedness and tingling you've been noticing. That's uncomfortable, and it's something you can learn to influence."
  • Watch for: a client hearing "it's only your breathing" as "it's all in your head". Validate that the symptoms are real. Watch also for the client using the explanation to stop seeking medical review of symptoms that are new or changing. [synthesis]

4.3 Diaphragmatic breathing training

  • Purpose / when: the core skill, which replaces accessory-muscle (upper-chest and shoulder) breathing with a diaphragmatic pattern and an appropriate breathing volume. [source: Holloway & West 2007]
  • Steps (as described in NHS physiotherapy practice):
    • Start lying supported semi-recumbent, with one hand resting on the abdomen.
    • Breathe quietly through the nose, letting the abdomen rise while the upper chest and shoulders stay relaxed.
    • Breathe out gently, with the out-breath longer than the in-breath, and let a natural brief pause come before the next breath.
    • [source: Holloway & West 2007; Royal Berkshire NHS leaflet; Royal Papworth Breathlessness leaflet on breathing control]
  • Psychotherapist's role: a psychotherapist trained in diaphragmatic breathing may reinforce this low, quiet pattern in session as a relaxation skill. For a client in a Papworth programme, they follow the physiotherapist's version rather than adding their own variations. [synthesis]
  • Example language (illustrative): "Let's check in with the breathing your physio showed you: one hand resting low on your tummy, shoulders soft, breathing in and out through your nose, nothing forced."
  • Watch for: pushing the abdomen out with effort, taking bigger breaths, breath-holding, or dizziness and tingling. These suggest over-breathing or strain. Stop, let the client breathe normally, and pass it on to the physiotherapist. Signs it is working: quieter breathing that is less visible in the upper chest, and the client reports more ease. [source: Royal Berkshire NHS leaflet on symptoms] [synthesis on stop rule]

4.4 Nose breathing, fewer sighs and yawns, and pauses

  • Purpose / when: to reduce habits that keep over-breathing going. [source: Holloway & West 2007]
  • Steps (as described):
    • The client is encouraged to breathe through the nose and to reduce yawning and sighing. [source: Holloway & West 2007]
    • NHS physiotherapy advice suggests that when a big breath feels needed, the client first tries swallowing or a slow controlled breath instead of a large sigh. [source: Royal Berkshire NHS leaflet]
    • Some Papworth-derived programmes add "controlled breath holds" or brief pauses in the breath cycle. These were part of BREATHE and of some NHS leaflets. They are taught and timed by the physiotherapist, and this guide gives no counts or durations. [source: Bruton et al. 2018; Royal Berkshire NHS leaflet]
  • Example language (illustrative): "You mentioned you sigh a lot when you're worried. What did your physio suggest instead? Let's notice when it happens in here."
  • Watch for: pauses or holds that make the client gasp or take a bigger breath afterwards, which NHS advice says should not happen. Any breath-holding practice is never done in or near water or while driving. It is not a contest of length. Clients who are pregnant, or who have heart disease, epilepsy or other medical conditions, need the physiotherapist or doctor to set any pauses. [source: Royal Berkshire NHS leaflet] [synthesis on water, driving and medical conditions]

4.5 Relaxation training, specific and general

  • Purpose / when: to lower general arousal and to release tension in particular areas (jaw, neck, shoulders, hands) that goes with dysfunctional breathing. [source: Holloway & West 2007; Royal Berkshire NHS leaflet]
  • Steps (as described): the method includes both specific and general relaxation. NHS advice asks the client to notice tension in the jaw, neck, shoulders and hands and consciously let it go. The precise relaxation protocol used at Papworth is [uncertain: not verified]. [source: Holloway & West 2007; Royal Berkshire NHS leaflet]
  • Psychotherapist's role: psychotherapists commonly teach relaxation, and they may support this element directly with methods they are trained in. They should tell the physiotherapist what they are using so the client is not given conflicting instructions. [synthesis; EABP Ethics Guidelines 6.b on parallel services]
  • Example language (illustrative): "As we talk about this, notice your jaw and shoulders. If there's tension there, see whether you can let some of it go, without changing your breathing on purpose."
  • Watch for: relaxation-induced anxiety (some clients feel more anxious as they relax). If this happens, keep the eyes open, keep it brief and give the client control. Signs it is working: the client can relax on cue during mild stress. [synthesis]

4.6 Graded integration: positions, activity and speech

  • Purpose / when: to carry the pattern from rest into daily life. [source: Holloway & West 2007]
  • Steps (as described):
    • Practise semi-recumbent first, then sitting, standing, during daily activities, and finally during speech. [source: Holloway & West 2007]
    • NHS advice for speech: breathe in through the nose, speak on the out-breath, keep sentences short and avoid large in-breaths. For exercise: nose breathing for as long as is comfortable, keeping the upper chest relaxed. [source: Royal Berkshire NHS leaflet]
    • Breathlessness from activity is described as not harmful in itself, and pacing tasks is encouraged. [source: Royal Berkshire NHS leaflet; Royal Papworth Breathlessness leaflet]
  • Psychotherapist's role: therapy talk is ideal speech practice. With the client's agreement, the therapist can notice moments when breathing climbs into the chest as the client speaks about difficult material. [synthesis]
  • Example language (illustrative): "As you were describing that meeting, your breathing seemed to go higher and faster. Did you notice it too? Would you like to pause and let it settle the way you've been practising, and then go on?"
  • Watch for: turning speech into a performance the client fails at. Keep it invitational. Watch also for avoidance of exertion that has been medically cleared. Signs it is working: the client can talk about stressful topics with less breathlessness or air hunger. [synthesis]

4.7 Home practice with recorded prompts

  • Purpose / when: to turn a new pattern into a habit. [source: Holloway & West 2007; Bruton et al. 2018]
  • Steps (as described):
    • In Holloway and West, an audio recording with reminders was given at the third session, and practice was encouraged at least once a day. [source: Holloway & West 2007]
    • BREATHE provided a booklet with a daily planner and progress charts, with the aim to "embed the techniques into their daily lives". [source: Bruton et al. 2018]
    • NHS advice is to practise little and often, linked to everyday activities. [source: Royal Berkshire NHS leaflet]
    • BREATHE found no relationship between the amount of practice and benefit, so the minimum practice needed is unclear. [source: Bruton et al. 2018]
  • Example language (illustrative): "What's helped you remember to practise this week? Could we link it to something you already do every day, like waiting for the kettle?"
  • Watch for: perfectionism, practising until symptoms appear, or practice turning into constant checking of breathing. [synthesis]

4.8 Using the technique at the first sign of symptoms

  • Purpose / when: the method is ideally learned in remission so that it can be used early when symptoms start. [source: Holloway & West 2007]
  • Steps: the client starts the learned pattern and relaxation when they first notice symptoms. For people with asthma, this is always alongside their personal asthma action plan and reliever as prescribed, never instead of them. Royal Papworth's breathlessness advice uses a similar sequence: stop, take a helpful position, use breathing control, and use a handheld fan if that helps. [source: Holloway & West 2007; Royal Papworth Breathlessness leaflet] [synthesis on the asthma action plan]
  • Example language (illustrative): "When you first notice the tightness, what's your plan? Your asthma plan from your nurse comes first. The breathing is something you add alongside it, not a replacement."
  • Watch for: a client delaying their reliever or emergency help to "try the breathing first". This is unsafe. Gently correct it and contact the prescriber if it is a pattern. Severe or worsening asthma symptoms are a medical emergency. [synthesis]

Part B. The psychotherapist's own interventions

4.9 Recognising possible breathing pattern disorder

  • Purpose / when: when a client in therapy describes breathlessness, air hunger, frequent sighing or yawning, dizziness or tingling, throat tightness, or difficulty breathing while talking or eating, especially with stress or anxiety. [source: Royal Berkshire NHS leaflet]
  • Steps:
    1. Ask about breathing symptoms descriptively: when they happen, triggers, what helps.
    2. Ask whether a doctor has assessed the symptoms and whether the client has asthma or another respiratory or heart condition.
    3. Validated questionnaires such as the Nijmegen Questionnaire (a self-report symptom checklist for hyperventilation-type symptoms, used as an outcome in Papworth research and in physiotherapy assessment) are normally used within the physiotherapy or medical assessment. Do not use a score to diagnose. Do not reproduce items from memory. [source: Holloway & West 2007; ACPRC assessment guidance] [synthesis on scope]
    4. Note psychological contributors (stress, anxiety, depression, trauma) to share with consent.
  • Example language (illustrative): "You've mentioned feeling you can't get a full breath when you're anxious. Has a doctor looked at your breathing? There are physiotherapists who specialise in this, and it might be worth asking your GP about a referral."
  • Watch for: labelling physical disease as psychological. New, unexplained, severe or worsening breathlessness, chest pain, fainting, or breathlessness with other physical signs needs prompt medical assessment, urgently if acute. [synthesis; ACPRC guidance notes symptoms unexplained by history and tests as a point to consider]

4.10 Medical routing and the medication boundary

  • Purpose / when: whenever breathing work and asthma or other medical treatment overlap. [source: Bruton et al. 2018; CSP 2016]
  • Steps:
    1. State plainly that the method is in addition to prescribed treatment.
    2. Never comment on whether a medicine is needed, nor suggest reducing inhalers or other drugs, even if the client reports feeling better.
    3. Route every medication question to the GP, asthma nurse or respiratory team.
    4. As Asthma UK advised when the 2016 guideline was reported, patients should keep taking prescribed medicines and check with their GP or asthma nurse before starting breathing exercises for asthma.
    • [source: Bruton et al. 2018; CSP 2016]
  • Example language (illustrative): "I'm really glad the breathing is helping. Whether that changes your inhalers is a question for your asthma nurse. Please don't change anything until you've spoken to them."
  • Watch for: clients with health anxiety or ambivalence about medication who use breathing work as a reason to stop treatment. Explore this therapeutically and inform the prescriber with consent if there is risk. [synthesis]

4.11 Referral and collaboration with respiratory physiotherapy

  • Purpose / when: once there is medical assessment and the client is interested. [synthesis]
  • Steps:
    1. Explain what the programme involves: a few individual sessions with a respiratory physiotherapist covering education, breathing training, relaxation and integration, plus home practice. A self-guided version exists in research form (DVD or booklet). [source: Holloway & West 2007; Bruton et al. 2018]
    2. Refer through the GP or respiratory team, according to local pathways. Availability varies and is [uncertain: not verified] by area.
    3. With written consent, share relevant psychological information, such as anxiety, panic or trauma that affects breathing or touch.
    4. Agree who teaches what, so the physiotherapist owns breathing instructions and the psychotherapist owns the psychological work.
    5. Codes require practitioners to offer only what they are trained for and to refer when appropriate. EABP guidance asks therapists to discuss parallel services with the client to minimise confusion.
    • [source: UKCP Code items 23–24; EABP Ethics Guidelines 6.b] [synthesis]
  • Example language (illustrative): "Would it help if I wrote a short note for the physio about how anxiety affects your breathing? I'd only include what you're happy for me to share."
  • Watch for: the client feeling dismissed ("sent elsewhere"), or mixed messages between professionals. [synthesis]

4.12 Preparing the client and informed consent

  • Purpose / when: before the first physiotherapy session, especially with trauma histories, panic, or fear of breathlessness. [synthesis]
  • Steps:
    1. Explain that sessions involve observation of breathing and may include hands-on assessment.
    2. Explain that attention to breathing can at first make breathing feel odd or briefly heighten symptoms.
    3. Rehearse how the client can say "stop" or ask for changes, and that they may bring a companion or ask for a chaperone.
    4. Agree a plan for any surge of anxiety in the session.
    • [synthesis; ACPRC assessment guidance on hands-on assessment]
  • Example language (illustrative): "Paying attention to your breathing can feel strange at first. Sometimes it makes you more aware of it for a while. You're in charge: you can pause or stop at any point, and that includes being touched."
  • Watch for: dissociation, shame about the body, or freezing when observed. Agree adaptations with the client and, with consent, with the physiotherapist. [synthesis]

4.13 Supporting practice inside psychotherapy sessions

  • Purpose / when: during and after the physiotherapy course, to help the client keep practising and use the skills under emotional load. [synthesis]
  • Steps:
    1. Briefly review the client's home practice and what the physiotherapist has currently set.
    2. Invite a short practice of the client's own learned pattern at the start or end of a session if they want it.
    3. Use moments of emotional arousal in session as integration practice (see 4.6).
    4. Do not introduce counts, holds or new techniques yourself. Send technical questions back to the physiotherapist.
    • [synthesis]
  • Example language (illustrative): "Would you like a minute to settle into the breathing you've been practising before we begin? Just as your physio taught it. I won't add anything."
  • Watch for: the session becoming breathing coaching instead of psychotherapy, or the client relying on the therapist's presence to practise. Signs it is working: the client starts the pattern spontaneously when distressed. [synthesis]

4.14 Working with anxiety, panic and fear of breathlessness

  • Purpose / when: when anxiety, panic attacks, health anxiety or avoidance of exertion keep the breathing problem going. Holloway and West found reductions in anxiety and depression scores in the Papworth group. Royal Papworth describes an anxiety–breathlessness cycle in which fear leads to inactivity, which leads to more fear. [source: Holloway & West 2007; Royal Papworth Breathlessness leaflet]
  • Steps:
    1. Draw out the client's own cycle: trigger, then breathing change, then sensations, then interpretation, then behaviour such as avoidance or checking.
    2. Work on catastrophic beliefs about breathlessness within evidence-based therapy for the anxiety presentation, for example CBT for panic or health anxiety.
    3. Support graded return to medically cleared activities.
    4. Discuss openly the role of breathing skills: as a coping tool used flexibly, or as a safety behaviour if the client believes they would come to harm without it. The current CBT literature on this debate is [uncertain: not verified] here.
    5. Do not promise that breathing work will cure panic.
    • [synthesis]
  • Example language (illustrative): "The breathing is a useful tool. I'm also curious what you think would happen if you got breathless and didn't do it. Shall we look at that belief together?"
  • Watch for: symptom vigilance growing (constant monitoring of breathing), breathing skills used rigidly to avoid all sensations, or panic set off by attending to breathing. Adjust the plan with the physiotherapist. [synthesis]

4.15 Integrating body experience into psychotherapy

  • Purpose / when: when changes in breathing bring up emotion, memories or meanings, such as earlier illness, fear of suffocation, or medical trauma. [synthesis]
  • Steps:
    1. Invite the client to notice and describe what happens in the body during practice, without interpreting.
    2. Link it to the material of therapy when the client is ready.
    3. Respect a client who simply wants a practical skill.
    • [synthesis]
  • Example language (illustrative): "When you practised slowing down this week, you said you felt suddenly sad. What was that like? Does it connect with anything we've been talking about?"
  • Watch for: pressing for meaning or memories. Not every sensation has a psychological story. [synthesis]

4.16 Recognising adverse effects, passing them on, and ending

  • Purpose / when: throughout, and at the end of the physiotherapy course. [synthesis]
  • Steps:
    1. Know what the trials report. Holloway and West received no adverse events from patients or GPs. BREATHE reported adverse events by group, with fewer in the intervention arms, and its authors found "no adverse effects" of either intervention. Cochrane did not assess adverse effects. [source: Holloway & West 2007; Bruton et al. 2018; Cochrane CD001277]
    2. Recognise signs of over-breathing during any breathing practice: dizziness, light-headedness, tingling in the hands, feet or mouth, air hunger and throat tightness. Cramping or spasm of the hands and feet, heightened panic, and worsening asthma symptoms are further signs. If they appear, stop the practice and let the client breathe normally. Pass this on to the physiotherapist or GP. Seek urgent medical help for chest pain, fainting, severe breathlessness or an asthma attack that does not respond to the client's action plan. [source: Royal Berkshire NHS leaflet on symptoms] [synthesis on stop and escalation rules]
    3. General breathwork cautions on cardiovascular disease, uncontrolled blood pressure, epilepsy, pregnancy, psychosis or bipolar disorder, panic disorder, glaucoma or retinal problems and recent surgery mainly concern intense, forced or connected breathing and long breath-holds. The Papworth method is gentle and taught after medical referral, so those questions belong to the referring doctor and the physiotherapist. Intense breathwork such as Holotropic Breathwork is covered in the Domain VII guide. [synthesis]
    4. Before ending, review what helped, the relapse signs (old habits of sighing, upper-chest breathing or avoidance returning) and a plan to go back to the physiotherapist or GP if symptoms return.
  • Example language (illustrative): "What would tell you the old pattern is creeping back? And who would you contact: your physio, your GP, or me for the anxiety side?"
  • Watch for: drop-out when symptoms ease, and relapse at times of stress. Signs it is working: fewer breathing-related symptoms, less avoidance, and a client who can describe their own plan. [synthesis]

5. Handling problems

The sources say little about clinical difficulties. Guidance below is synthesis unless a source is tagged.

  • "It's not in my head" (resistance to a psychological framing). Present breathing pattern disorder as a physical habit that stress can drive and keep going, and that a respiratory physiotherapist treats. Lead with the physiotherapy referral and offer the psychological work as optional. Illustrative wording: "Your symptoms are real and physical. Stress is one of the things that can keep the pattern going, and that's the part I can help with." [synthesis; Royal Berkshire NHS leaflet on causes]
  • No improvement (stuck). First check whether the client attended physiotherapy and is practising as taught. Then ask the GP or physiotherapist to review the diagnosis and treatment, since persisting symptoms may need medical reassessment. Look at psychological maintaining factors: avoidance, symptom monitoring, ongoing stressors, depression. Remember the size of the evidence: BREATHE found a small average benefit, and the dysfunctional-breathing review found no credible evidence either way, so non-response is not the client's failure. [source: Bruton et al. 2018; Cochrane CD009041] [synthesis]
  • Non-adherence to home practice. Shrink practice into brief moments linked to routines, and use the client's recording, planner or booklet if they have one. BREATHE found no link between amount of practice and benefit, so avoid blaming. Explore what practice means to the client, for example a reminder of being ill. [source: Bruton et al. 2018; Royal Berkshire NHS leaflet] [synthesis]
  • Overwhelm or panic set off by attending to breathing. Stop. Shift attention outwards: eyes open, feet on the floor, describing the room. Let breathing return to normal without instruction. Afterwards, normalise the experience and plan a gentler approach with the physiotherapist, such as shorter, eyes-open practice or starting with relaxation of the jaw and shoulders rather than attention to breath. In a panic-disorder formulation, treat this as useful information about feared sensations. [synthesis]
  • Hyperventilation symptoms during practice (dizziness, tingling, cramping of the hands, air hunger). The client is probably trying too hard or breathing more deeply. Stop, return to natural breathing and tell the physiotherapist. Do not restart the exercise with your own instructions. [source: Royal Berkshire NHS leaflet on symptoms] [synthesis]
  • Asthma symptoms in session. The client follows their own asthma action plan and uses their reliever as prescribed. Call emergency services if symptoms are severe or do not respond. Breathing techniques never delay this. [synthesis; Holloway & West 2007 frames the method as adjunct to usual care]
  • Client wants to cut or stop medicines because breathing "works". Do not agree or disagree about the medicine. Route the question to the prescriber, explore the wish therapeutically (fear of side effects, wanting to feel "not ill"), and with consent let the prescriber know if the client seems about to stop treatment. [source: Bruton et al. 2018; CSP 2016] [synthesis]
  • Client is following online breath-hold or "breath-training" programmes alongside. Ask what they are doing. Breath-holding and hyperventilation exercises are never done in or near water or while driving. Encourage the client to check any additional method with the physiotherapist or GP. Refer to the separate Buteyko and intense-breathwork guides (Domain VII for Holotropic Breathwork) rather than combining methods. [synthesis]
  • Refusal of, or distress about, hands-on assessment. The client may decline any touch at any time. Help them say so and, with consent, tell the physiotherapist so that assessment can be adapted (for example observation only, or a chaperone). Touch is never sexual. [synthesis; USABP Code VIII as a comparable standard on the right to refuse touch]
  • Rupture: the client feels "passed on" or confused by conflicting advice. Name it, make clear you are continuing the work, and agree roles across professionals: the physiotherapist owns breathing instructions, the psychotherapist owns psychological work. Discuss parallel services openly with the client. [source: EABP Ethics Guidelines 6.b] [synthesis]
  • Breathing becoming a new focus of worry (hypervigilance). Reduce monitoring and checking, and move practice towards brief, automatic use in daily life. Work on health-anxiety beliefs. [synthesis]
  • Trauma linked to breath (choking, suffocation, intubation, assault involving the throat or chest). Go slowly, with eyes open and the client in control. Consider trauma-focused therapy before or alongside breathing work, and tell the physiotherapist with consent. [synthesis]
  • No local service or a long wait. BREATHE showed a self-guided DVD-and-booklet version could be non-inferior to face-to-face sessions. Whether a current digital version is available locally is [uncertain: not verified]. Ask the GP or respiratory team about what is available rather than improvising a physiotherapy programme. [source: Bruton et al. 2018; NIHR Evidence alert]
  • Children and adolescents. The Papworth trials enrolled adults aged 16 to 70. Paediatric use is [uncertain: not verified]. For children, refer through the paediatric respiratory team, involve parents or carers, and seek the child's assent. [source: Holloway & West 2007; Bruton et al. 2018] [synthesis]
  • Severe asthma or other significant disease. Holloway and West note that most participants had mild or well-controlled asthma, so the effect in severe asthma is unknown. Leave decisions about suitability to the respiratory team. [source: Holloway & West 2007]

Sources

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