Freediving static-apnoea training

1. Introduction

Version followed: static apnoea (STA) as AIDA International publishes it in its course system (AIDA 1 to AIDA 4, instructor levels) and as its competition rules (Version 16.0, November 2018, in a published abridged summary) describe it; CMAS is the other international federation that sanctions freediving competitions, but its own rule and course texts are [uncertain: not verified]. Safety framing from CDC/MMWR, the American Red Cross/USA Swimming/YMCA joint statement (2015), Divers Alert Network (DAN) and a 2024 sports-medicine review.

Static apnoea is a freediving discipline in which a person floats face-down in still water, usually a pool, and holds a single breath while a trained partner watches; in competition the score is the length of the hold [source: AIDA Education page; Freediving Gold Coast summary of AIDA rules v16]. It is taught by certified freediving instructors as one discipline among several (dynamic apnoea, constant weight, free immersion) [source: AIDA Education page]. The federations' implicit model of change is physiological and skills-based: relaxation of body and mind, efficient breathing before the hold and tolerance of the urge to breathe are trained progressively under direct supervision, with safety and rescue skills taught alongside [source: AIDA Education page] [synthesis: the phrase "model of change" is a framing, not federation wording].

This is not a method a psychotherapist delivers. Static-apnoea training belongs to certified freediving instructors with a trained buddy present. The psychotherapist's role is different and is the focus of section 4: recognising breath-holding in a client's life, screening and discussing risk, referring to properly certified instruction where a client wants to freedive, working with risk-taking and compulsive challenge-seeking, and supporting people bereaved by, or who survived, a breath-hold drowning [synthesis]. Breath-holding underwater can cause hypoxic blackout and drowning without warning, including in strong swimmers, in shallow water and with a lifeguard on duty [source: CDC MMWR 2015; NPR 2015]. A harm account follows section 5. Breath-retention practices in other traditions (pranayama kumbhaka, Wim Hof method, Buteyko) have their own Domain X guides; intense breathwork cross-refers to the Domain VII Holotropic Breathwork guide.

This guide gives no hold timings, no CO2 or O2 tables and no pre-hold breathing protocols. AIDA teaches "training tables" at its advanced level; their content is for instructors to teach in person [source: AIDA Education page].

2. Framework

2a. How the federations structure training (descriptive)

Entry requirements. AIDA courses are for adults (16-17 with a parent's or guardian's consent) who can swim a stated non-stop distance [source: AIDA Education page].
AIDA 1 (introductory). Basic freediving knowledge, relaxation of body and mind, finning, duck dives, equalisation [source: AIDA Education page].
AIDA 2 (Freediver). First level at which static apnoea, dynamic apnoea and constant weight are taught together; theory covers the breathing cycle, physiology, equalisation, technique, safety and equipment. AIDA 2 pool certification is the gateway to further pool courses [source: AIDA Education page].
AIDA 3 (Advanced Freediver). Adds training tables and further disciplines; theory includes shallow-water blackout, the mammalian dive response, surface intervals and a freediver's code of conduct [source: AIDA Education page].
AIDA 4 (Master Freediver). Requires a first aid and CPR course within the previous two years; prepares the diver to act as an assistant instructor [source: AIDA Education page].
Safety-specialist courses. Pool and depth competition safety courses (solo and team rescues, standby, stress management) and an emergency-care course for freediving accidents (FEMR), including hypoxia-related conditions [source: AIDA Education page].

2b. Instructor credentials (AIDA)

AIDA Instructor: trained on an Instructor Course run by an active AIDA Instructor Trainer; holds first aid certification; must pass performance and rescue demonstrations; a blackout or loss of motor control during the course is a fail; may teach AIDA 1, 2, 3 and Monofin [source: AIDA Education page].
AIDA Master Instructor: at least 12 months as an active instructor and a minimum number of certifications issued; may teach up to AIDA 4 [source: AIDA Education page].
AIDA Instructor Trainer: at least 12 months as Master Instructor, a higher certification count and co-teaching an Instructor Course; promotion is recommended by the Education Committee to the Board [source: AIDA Education page].
Other agencies. Courses are also run under other agency programmes (Freedivers UK lists PADI and RAID alongside AIDA; Go Freediving follows RAID) [source: Freedivers UK; Go Freediving]. CMAS freediving levels and instructor standards [uncertain: not verified].
Regulation. No government licensing of freediving instructors was found; credentialing is by the agencies [uncertain: not verified].

2c. Competition structure (descriptive)

In AIDA competitions each athlete has an Official Top (a set start moment), floats with the airway immersed, is checked for consciousness by touch with an agreed answering signal at set intervals, and on surfacing must complete a surface protocol in a fixed order (remove facial equipment, give an OK hand signal, say "I am OK") within a short window. A judge then shows a white, yellow or red card; a blackout, or failure to keep the airway out of the water, is a disqualification. A safety diver from the organiser must be in the zone throughout, and athletes must present a signed medical certificate of non-contraindication to freediving dated within the past year [source: Freediving Gold Coast summary of AIDA rules v16]. Both AIDA and CMAS sanction competitions, and a 2024 review calls strict adherence to their safety measures "paramount" [source: Muth & Tetzlaff 2024].

2d. The psychotherapist's framework (session format)

There is no federation-defined therapy phase structure; the following is [synthesis]:

Recognise breath-holding practice or challenge activity (intake, or when it emerges).
Assess context, safety arrangements, motives, risk-taking pattern and medical factors (one session, often revisited).
Inform and refer (psychoeducation on hypoxic blackout; referral to certified instruction and to medical review where indicated).
Work with the person on risk-taking, compulsive challenge-seeking, peer or online pressure, or grief and trauma after a drowning (ordinary course of therapy, length set by the presenting problem).
Review: move on when the client has a safe plan (or has stopped) and the underlying issue is being worked on; return to stage 2 if new risk appears.

3. Guiding principles

Never alone, never unwatched. Freediving safety sources state it as the core rule, including for breath-holds in very shallow water such as a bath [source: Freedivers UK; DAN 2023]. Practical meaning: any plan a client describes that involves holding the breath in water without a trained partner within reach is unsafe.
A trained buddy, not just a bystander. The buddy should be trained in freediving safety, not a casual observer or an untrained lifeguard [source: Freedivers UK]; DAN advises a trained buddy who can protect the airway [source: DAN 2023]. Practical meaning: "the lifeguard was there" is not a safety plan; in New York nearly all incidents occurred with a lifeguard on duty [source: CDC MMWR 2015].
One up, one down. One diver dives while the other acts as buddy [source: Go Freediving]. Practical meaning: buddies never hold their breath at the same time.
No hyperventilation. Hyperventilating before breath-holding lowers carbon dioxide and delays the urge to breathe, so oxygen can fall to the point of unconsciousness before the person feels the need to surface [source: CDC MMWR 2015]. The joint statement calls voluntary hyperventilation before underwater swimming and extended breath-holding dangerous and potentially deadly [source: Red Cross/USA Swimming/YMCA 2015]. Practical meaning: treat any mention of "big breaths first" or "purging" before a hold as a red flag.
Blackout comes without reliable warning. Blackouts give little warning and are hard to detect, even with a lifeguard present [source: NPR 2015]. Practical meaning: confidence, fitness and swimming skill do not protect; the four New York deaths were advanced or expert swimmers [source: CDC MMWR 2015].
After any blackout or loss of motor control, stop for the day. [source: DAN 2023]. A diver who has had a near-hypoxic episode is at higher risk of another [source: DAN 2023]. Practical meaning: a client who reports "a little samba" or "blacking out once" and carrying on needs a direct conversation.
Formal training and medical fitness. DAN recommends formal training for rescue and weighting; AIDA competition requires a medical certificate; pre-existing conditions raise risk [source: DAN 2023; Freediving Gold Coast summary; Muth & Tetzlaff 2024]. Practical meaning: refer to a certified instructor and, for medical questions, to a diving physician.
Medical cautions. Official medical contraindication lists for freediving [uncertain: not verified]. General breathwork cautions (cardiovascular disease and uncontrolled blood pressure, epilepsy or seizures, pregnancy, psychosis or bipolar disorder, panic disorder, glaucoma or retinal problems, recent surgery, asthma or other lung disease) are a reasonable basis for advising medical review before any breath-hold training [synthesis]. Never practise breath-holding or hyperventilation in or near water without trained supervision, or while driving [synthesis, consistent with CDC MMWR 2015].
Stay in role. The psychotherapist does not coach holds, set targets or supervise practice, even dry [synthesis]. Practical meaning: refer technique questions to an instructor.
Curiosity about meaning, not only risk. Breath-holding may serve calm, mastery, belonging, identity or self-punishment [synthesis]. Practical meaning: explore what it does for the client before advising.
Young people: safeguarding first. Preteens and teens take part in social-media breath-holding challenges without rescue staff or oxygen [source: CHOC 2022]. Practical meaning: follow local safeguarding procedures and involve parents or carers as the law and your code require [synthesis].

4. Intervention inventory

The federations publish no psychotherapeutic interventions. Item 4.1 describes a supervised static session as the federations and safety bodies describe it, so the therapist can tell a supervised practice from an unsafe one; it is for orientation only and is not for the therapist to deliver. Items 4.2 to 4.12 are the psychotherapist's own work and are [synthesis] unless a source is tagged.

4.1 Understanding a supervised static session (orientation only, not for delivery)

Purpose: to know what legitimate practice looks like, so you can ask informed questions and spot gaps.
Steps (as sources describe them):
1. The diver trains within a certified course or club session, with aims stated at the start and safety cover confirmed for everyone [source: Freedivers UK].
2. A trained buddy stays within reach throughout, one diver at a time (one up, one down) [source: Go Freediving; DAN 2023]. In pool static the buddy's job involves timekeeping, communication, observing the diver, coaching and physical support at once [source: Go Freediving].
3. The buddy checks consciousness by an agreed touch and the diver answers with an agreed signal; no answer, or a wrong answer, means the diver is brought up [source: Freediving Gold Coast summary of AIDA rules v16].
4. On surfacing the diver completes a recovery and a surface protocol (in competition: facial equipment off, OK sign, "I am OK") so that the buddy can confirm full consciousness [source: Freediving Gold Coast summary].
5. If the diver blacks out, the buddy follows a rescue sequence DAN summarises as the Four Rs (Recognise, Retrieve while protecting the airway, Revive using tap-blow-talk, Recover); after any blackout or loss of motor control, no more diving that day [source: DAN 2023]. Calling emergency services and CPR where there is no breathing are standard first aid [source: CHOC 2022].
Example language (illustrative): "When you train, who is watching you, what training do they have, and what would they do if you stopped answering their signal?"
Watch for: any account missing a trained buddy, an agreed signal check, a recovery and surface check, or a stop-for-the-day rule; solo "dry" holds that drift into the bath or pool; app-led holds done alone [synthesis].

4.2 Asking about breath-holding (screening)

Purpose: breath-holding is rarely disclosed unless asked; ask when a client mentions freediving, spearfishing, competitive swimming, military or special-forces selection preparation, breathwork, "lung training", or online challenges, and with adolescents who swim [synthesis; activity contexts from CDC MMWR 2015, NPR 2015, CHOC 2022].
Steps:
1. Ask neutrally whether they hold their breath for training, sport, relaxation or fun, in or out of water.
2. Ask where (bath, pool, open water, while driving), with whom, and whether anyone trained watches.
3. Ask whether they breathe hard or fast first (hyperventilation) [source for the risk: CDC MMWR 2015].
4. Ask about episodes of dizziness, twitching, loss of control, "samba", or blacking out, and what happened next.
5. Ask how they learned it (instructor, club, app, video, friends).
Example language (illustrative): "Some people I see practise holding their breath, for sport or to calm down. Is that something you do? Where and with whom?"
Watch for: minimising ("it's only the shallow end"), secrecy, practice alone, prior blackout treated as a badge of honour, practice before or while driving [synthesis].

4.3 Safety-arrangement review

Purpose: to compare what the client does with what the federations and safety bodies require, without teaching technique.
Steps:
1. Go through the elements in 4.1 one at a time: certified instruction; trained buddy within reach; one at a time; agreed signal checks; recovery and surface check; stop after any blackout or loss of motor control; medical certificate for competition [sources as in 4.1].
2. Note each missing element in plain words with the client.
3. Agree what the client will change, or that they will stop until it is in place.
4. Record the discussion and your advice.
Example language (illustrative): "Let's check your setup against what freediving safety bodies say is the minimum. Which of these do you have in place?"
Watch for: the client hearing this as permission or endorsement; make clear you are not assessing their skill or setting targets [synthesis].

4.4 Psychoeducation on hypoxic blackout

Purpose: to give the client an accurate, memorable account of why breath-holding in water kills experienced people.
Steps:
1. Explain the mechanism in plain words: fast or deep breathing beforehand lowers carbon dioxide, which is what drives the urge to breathe; the urge arrives late, oxygen falls, and the person loses consciousness underwater before feeling they need air [source: CDC MMWR 2015; CHOC 2022].
2. Explain that the term "shallow water blackout" is misleading: depth is not the cause, so major water-safety bodies prefer "hypoxic blackout" [source: Red Cross/USA Swimming/YMCA 2015].
3. Give the facts: in New York State (1988-2011) 16 such cases were identified, 4 fatal; the 4 who died were advanced or expert swimmers aged 17-22 who had hyperventilated; almost all incidents happened with a lifeguard on duty [source: CDC MMWR 2015].
4. Explain that blackouts are quiet and hard to see [source: NPR 2015; CHOC 2022].
5. Check understanding by asking the client to explain it back.
Example language (illustrative): "The danger is that the alarm goes off too late. You can feel fine right up to the moment you lose consciousness, and from outside it looks like someone floating calmly."
Watch for: "that won't happen to me because I'm fit" (fitness was not protective in the New York data), fascination with the physiology, or fear responses in anxious clients; adjust detail to the person [synthesis].

4.5 Referral to certified instruction and medical review

Purpose: for a client who wants to freedive, to move practice into supervised, credentialed settings.
Steps:
1. Suggest a certified course with a recognised agency (AIDA, CMAS or another agency whose instructors are certified) [source: AIDA Education page; Freedivers UK].
2. Suggest the client checks the instructor's current status and level with the agency (AIDA lists Instructor, Master Instructor and Instructor Trainer) [source: AIDA Education page].
3. Advise medical review with a diving physician or GP before training where there is heart disease, blood-pressure problems, seizures, pregnancy, lung disease, eye conditions such as glaucoma, recent surgery, or a history of psychosis or panic [synthesis; specific freediving contraindications [uncertain: not verified]].
4. Suggest the client and family learn CPR [source: CHOC 2022].
Example language (illustrative): "If this matters to you, the safest way is to learn it from a certified instructor, with a trained buddy every time. Would you be willing to find out what courses are near you?"
Watch for: the client choosing an uncertified online "coach" or app instead; reluctance to see a doctor; clients who are not sure what certification means [synthesis].

4.6 Exploring the function of breath-holding and risk-taking

Purpose: to understand what breath-holding or risky water challenges do for the client (calm, mastery, belonging, a test of worth, thrill, numbing, self-punishment) before working on change [synthesis].
Steps:
1. Ask for a recent, specific episode: situation, thoughts and feelings before, during and after.
2. Map what it gives the client in the short term and what it risks or costs in the longer term.
3. Look for links to other risk-taking (substances, driving, self-harm, extreme sports) and to mood.
4. If self-harm or suicidal intent is part of the picture, carry out a standard risk assessment and safety plan under your service's procedures.
5. Reflect back the pattern and ask the client what they make of it.
Example language (illustrative): "What do you notice in yourself in the moments when you push your hold further than you planned?"
Watch for: passive death wishes framed as "testing limits"; dissociation or depersonalisation sought through holds; the client being unable to name any downside [synthesis].

4.7 Working with compulsive challenge-seeking

Purpose: for clients who feel driven to keep beating their record, take on dares or perform challenges for an audience, to loosen the compulsion and build choice [synthesis].
Steps:
1. Describe the cycle together: trigger (boredom, low mood, comparison online, a dare), urge, act, short-lived relief or pride, then return of the urge.
2. Use a motivational, non-confrontational stance: elicit the client's own reasons for change; avoid lecturing.
3. Identify high-risk situations (alone in a bath or pool, after watching challenge videos, among peers daring each other) and plan alternatives for each.
4. Practise riding out the urge without acting (noticing it, naming it, letting it peak and fall) using land-based, non-breath-holding tasks.
5. Work on underlying needs: self-worth, recognition, belonging, control.
6. Review progress by the client's account of urges acted on versus not.
Example language (illustrative): "It sounds like beating your last attempt matters a lot, and that the good feeling fades fast. What would you want instead of having to prove it again?"
Watch for: escalation (longer, deeper, more alone, more public), secrecy, posting attempts online, a "just one more" pattern; involve family or a coach with consent if risk rises [synthesis].

4.8 Social-media challenges and peer pressure (adolescents and young adults)

Purpose: preteens and teens take part in breath-holding challenges seen online, without the controlled setting, rescue staff or oxygen of supervised training [source: CHOC 2022]; the aim is to reduce exposure and build refusal skills.
Steps:
1. Ask in a non-judgemental way what challenges they or friends have seen or tried.
2. Give the facts (4.4) briefly and concretely, without graphic detail.
3. Rehearse what to say when friends push them to join [source for the advice: CHOC 2022].
4. Agree the simple rules CHOC gives: never play breath-holding games, never ignore the urge to breathe underwater, never swim without supervision [source: CHOC 2022].
5. With consent, or as safeguarding requires, involve parents or carers; suggest they learn CPR [source: CHOC 2022].
6. Apply your local safeguarding procedure if a young person is at ongoing risk [synthesis].
Example language (illustrative): "If someone at the pool says 'let's see who can stay under longest', what could you say that still feels OK with your friends?"
Watch for: the young person treating the facts as a dare; contagion within a peer group; avoid naming or showing specific challenge videos in session [synthesis].

4.9 Meeting the regulating need without breath-holding

Purpose: some clients use breath-holding to calm down or feel in control; offer land-based regulation that does not involve retention [synthesis].
Steps:
1. Name the need breath-holding meets.
2. Offer gentle, low-intensity paced breathing taught as published in the Domain X guides on diaphragmatic, slow-paced or resonance breathing (no holds, no targets); HRV biofeedback cross-refers to Domain IX.
3. Combine with grounding, movement or mindfulness the client already finds useful.
4. Review whether it meets the need; if the client returns to holds, revisit 4.6 and 4.7.
Example language (illustrative): "Let's find something that gives you that same settled feeling on dry land, without stopping your breath."
Watch for: the client turning slow breathing into a breath-hold contest; dizziness or tingling suggesting over-breathing, in which case slow down and return to normal breathing [synthesis].

4.10 Supporting survivors of a blackout or non-fatal drowning

Purpose: to address fear, trauma symptoms, shame and possible cognitive after-effects in someone who blacked out or nearly drowned [synthesis].
Steps:
1. Check medical follow-up was completed; if there are memory, concentration, mood or personality changes, refer for neurological or neuropsychological assessment (hypoxic brain injury is possible) [synthesis].
2. Screen for post-traumatic stress, panic and avoidance of water; use your usual trauma-focused assessment.
3. Address shame and self-blame, especially where the person was experienced or was competing.
4. If the client wants to return to freediving, explore the decision openly; DAN notes higher risk after a near-hypoxic episode [source: DAN 2023]; any return should be through certified instruction and medical review.
5. Treat trauma symptoms with an evidence-based trauma therapy within your competence.
Example language (illustrative): "You've been through something frightening that many people don't see coming. What's been hardest since then?"
Watch for: minimising ("it was just a samba"), rapid return to practice alone, unrecognised cognitive change, avoidance generalising to all water [synthesis].

4.11 Bereavement after a breath-hold drowning

Purpose: to support families, partners, friends and team-mates after a death that is sudden, often of a young, fit person, and frequently described as preventable [source for "entirely preventable": NPR 2015; grief work is synthesis].
Steps:
1. Offer a space to tell the story in their own words and at their pace.
2. Give accurate information about the mechanism if wanted (4.4), which can lessen self-blame ("nobody could see it coming") [source: NPR 2015, family's account of a lack of warning].
3. Work with guilt and counterfactual thinking ("I should have stopped him"), anger at institutions, and the person's own risk-taking.
4. Screen for prolonged grief, post-traumatic stress, depression and suicidal thoughts in the bereaved; refer or treat within competence.
5. Respect meaning-making, including advocacy: one bereaved family founded an awareness organisation [source: NPR 2015].
6. Consider the needs of siblings and of anyone who found or tried to rescue the person.
Example language (illustrative): "Many families tell me they keep replaying it, looking for the moment they could have changed things. Is that happening for you?"
Watch for: blame splitting the family; inquests or investigations prolonging grief; anniversary reactions; a bereaved sibling or friend copying the activity [synthesis].

4.12 Supporting buddies, lifeguards, coaches and rescuers

Purpose: people who were supervising, rescued, or failed to notice can carry intense guilt and trauma [synthesis]; in New York each regulated-facility incident involved a lifeguard rescue attempt [source: CDC MMWR 2015].
Steps:
1. Normalise how hard hypoxic blackouts are to detect [source: NPR 2015; CHOC 2022].
2. Separate responsibility from blame; explore what was within their control.
3. Screen for post-traumatic stress and moral injury; treat or refer.
4. Support them through investigations or employer processes.
Example language (illustrative): "From the outside a blackout can look like someone floating calmly. What do you remember noticing?"
Watch for: hypervigilance at work, leaving the job abruptly, substance use, self-punishment [synthesis].

5. Handling problems

The federation and safety sources do not address psychotherapeutic difficulties; everything in this section is [synthesis] except where a source is tagged.

"I'm experienced, it won't happen to me." Do not argue skill. Point to the data: the four New York deaths were advanced or expert swimmers, and almost all incidents happened with a lifeguard present [source: CDC MMWR 2015]. Then ask what safety arrangement they would accept.
Client asks you to coach holds, set targets or watch a dry hold in session. Decline clearly and kindly; you are not trained or certified to supervise apnoea. Refer to a certified instructor (4.5) and offer 4.9 for the regulating need.
Non-adherence: continued solo practice. Restate the one non-negotiable (never in water without a trained buddy within reach, never while driving), record your advice, and keep working on function (4.6) and compulsion (4.7). If the person is a minor, or risk is acute and linked to suicidality, follow safeguarding and risk procedures.
Rupture: the client feels judged or controlled. Acknowledge it, separate respect for their passion or sport from concern about specific practices, and return to their own goals. Ask what would make the conversation feel collaborative.
Overwhelm after psychoeducation (anxious or health-anxious clients, recently bereaved). Slow down, reduce detail, ground, and check what they took away. Avoid mechanism detail that feeds rumination.
A young person refuses to involve parents. Explain the limits of confidentiality at the start; where there is ongoing serious risk, follow your safeguarding duty, telling the young person what you will share and why where that is safe.
Competitive freedivers presenting with performance anxiety. Work on anxiety, mood and identity; do not set or comment on performance targets; with consent, liaise with their certified coach or a sport psychologist; ask about loss of motor control or blackout history and stop-for-the-day practice [source for the rule: DAN 2023].
Breathwork clients who add holds in the bath, hot tub or pool. Name the specific danger: breath-holding or hyperventilation in or near water risks hypoxic blackout [source: CDC MMWR 2015; Red Cross/USA Swimming/YMCA 2015]. Advise that breathwork is done on land, seated or lying, and never while driving; for intense breathwork see the Domain VII Holotropic Breathwork guide.
Bereaved clients stuck in guilt or blame. Return to what could and could not be seen (4.4, 4.11); consider a trauma or prolonged-grief focused approach within competence; refer if not.
A colleague, coach or group running unsafe breath-holding. See the harm account (red flags) and raise the concern through the appropriate route: the person directly where safe, their agency or professional body, the facility operator, or safeguarding services if minors are involved.
The therapist's own reactions. Fear, fascination or helplessness are common with high-risk clients and drowning bereavement; use supervision.
Stuck clients. If talk about safety goes in circles, step back to values: what the water or the challenge stands for, and what else could carry that meaning.

Harm account

What was actually done

Breath-holding games and contests in pools. The CDC's New York State review (1988-2011) defined three "dangerous underwater breath-holding behaviors": intentional hyperventilation before or during submersion or swimming; static apnoea, meaning trying to hold the breath underwater as long as possible, including breath-holding games; and "hypoxic training", meaning prolonged underwater distance swimming or extended breath-hold intervals. Static apnoea was the most common behaviour. Fifteen of 16 incidents happened at regulated pools (indoor, outdoor and a wave pool) and one in a stream; one case involved a swimmer training for Navy SEAL selection [source: CDC MMWR 2015]. About a third of cases arose from games or spontaneous breath-holding competitions among recreational swimmers [source: NPR 2015].
Solo breath-hold training. NPR (29 May 2015) reported that Whitner Milner, a 25-year-old diver in Atlanta, drowned on 16 April 2011 while training to hold his breath, and that the medical examiner judged a breath-holding blackout the likely cause; it also reported that a former Australian Navy diver drowned in a New Jersey pool during breath-hold training, with the cause then under investigation [source: NPR 2015].
An informal contest during military training. On 24 April 2015 two US Navy SEALs were found on the bottom of the pool at the Naval Special Warfare Group 2 Combat Swimmer Training Facility, Joint Expeditionary Base Little Creek-Fort Story, Virginia, after arriving for an individual conditioning swim with a sandbag; both died. The Navy investigation found breath-holding the most likely cause (there were no witnesses or video), contrary to a written instruction and a verbal warning from the facility manager [source: Navy Times, 11 December 2015].
Social-media challenges. Preteens and teens (about 12-18) take part in underwater breath-holding challenges found online; hundreds of videos teach long underwater holds and people post their own attempts to encourage others, without the controlled setting, rescue staff or oxygen of supervised training [source: CHOC 2022].
Competition and supervised training. Hypoxic events also occur in sanctioned settings: in AIDA competition data (2002-2004) about 1.1% of static performances ended in loss of consciousness and about 9.6% in loss of motor control [source: Muth & Tetzlaff 2024]. These occurred with safety divers present and are a different risk from unsupervised play.

How it caused harm

Mechanism. Hyperventilation or breath-holding lowers carbon dioxide, delaying the brain's signal to surface; oxygen then falls and the person loses consciousness underwater, inhales water and drowns [source: CDC MMWR 2015; CHOC 2022]. Depth is not the cause, hence "hypoxic blackout" rather than "shallow water blackout" [source: Red Cross/USA Swimming/YMCA 2015].
Deaths and injuries. New York State: 16 people in 15 incidents, 4 deaths and 12 non-fatal outcomes; all 4 who died were advanced to expert swimmers aged 17-22 who had practised intentional hyperventilation [source: CDC MMWR 2015]. The extent of lasting injury among non-fatal cases [uncertain: not verified]. The 2015 Virginia SEAL deaths were ruled accidental drownings [source: Navy Times 2015].
Why supervision failed. All but one regulated-facility incident happened with a lifeguard on duty, and each involved a rescue attempt [source: CDC MMWR 2015]; blackouts give little warning and are hard to detect [source: NPR 2015]. Fainting can occur quickly once the urge is ignored [source: CHOC 2022].
Who was most at risk. Young people and young men (ages 7-47, mean 17; 13 of 16 male), strong and expert swimmers, people training for military selection, those training alone, and anyone who hyperventilated first [source: CDC MMWR 2015; NPR 2015]; preteens and teens copying online challenges [source: CHOC 2022]; divers who have already had a near-hypoxic episode [source: DAN 2023].
Psychological sequelae. A bereaved family described underestimating the danger and a false sense of security in a shallow pool with expert swimmers [source: NPR 2015]. Systematic data on grief, trauma or rescuer distress after these deaths [uncertain: not verified].

Recognising it today

Features and phrases [synthesis, drawing on the behaviours defined by CDC MMWR 2015 and CHOC 2022]: "who can stay under longest"; underwater-length or breath-hold dares; filming holds for social media; "hypoxic sets" or "no-breathing laps" in swim, triathlon or military-selection preparation; "lung-capacity training" from apps or videos done alone; "big breaths first" or "purge" before going under; "it's only the shallow end"; "the lifeguard's there"; treating a blackout or loss of motor control as a normal part of training and carrying on.
Red flags in a colleague's, coach's or group's practice [synthesis]: breath-holding or hyperventilation-style breathwork offered in pools, baths, hot tubs or cold-water settings without trained apnoea safety; leaderboards or contests for holds; encouraging people to push past the urge to breathe; no agreed signal check, recovery check or stop-for-the-day rule; no certified instructor; under-18s without consent and supervision. The joint statement asks swim instructors to limit breath-holding and submersion exercises to a single inhalation and to set safety limits for underwater swimming [source: Red Cross/USA Swimming/YMCA 2015]; the US Navy now prohibits breath-holding outside command-organised sessions with a trainer observing [source: Navy Times 2015]; New York City requires pool operators to post warnings and to prohibit these behaviours unless enhanced supervision is provided [source: CDC MMWR 2015].
How legitimate versions differ: certified instruction (AIDA or another agency); a trained buddy within reach, one at a time; agreed touch-and-signal checks; recovery and surface checks; no more diving that day after any loss of motor control or blackout; rescue training; and in competition a medical certificate and safety divers throughout [source: AIDA Education page; Freediving Gold Coast summary; DAN 2023; Go Freediving; Freedivers UK].
Not the same as strangulation games. So-called "choking" or "blackout" games that use pressure on the neck are a different, also dangerous, practice; ask specifically which one a young person means [synthesis].

What to do instead and how to help those harmed

Safer alternatives. Breathe normally before and in the water, never hyperventilate, never play breath-holding games and never ignore the urge to breathe [source: Red Cross/USA Swimming/YMCA 2015; CHOC 2022]. Anyone who wants to freedive should learn through a certified course and always with a trained buddy [source: AIDA Education page; Freedivers UK; DAN 2023]. Families should learn CPR [source: CHOC 2022]. For calming or self-regulation, use land-based low-intensity paced breathing (4.9) rather than holds [synthesis].
If someone is found motionless in water. Get them out, call emergency services, start rescue breathing and chest compressions if needed [source: CHOC 2022]; lifeguards should respond quickly to anyone motionless in the water for any reason [source: Red Cross/USA Swimming/YMCA 2015].
Assessment and treatment of affected clients. Survivors: medical and, where indicated, neuropsychological review, trauma assessment and treatment (4.10). Bereaved families and friends: grief and trauma support (4.11). Buddies, lifeguards, coaches and rescuers: 4.12 [synthesis].
Ethical, reporting and legal duties [synthesis; local law and codes vary]. Follow safeguarding procedures for minors at ongoing risk; document risk discussions and advice; raise concerns about unsafe practice by a colleague, coach or facility through the person, their agency or professional body, the facility operator or safeguarding services as appropriate; stay within competence and do not supervise or coach breath-holding. Specific statutory reporting duties for drowning risk [uncertain: not verified].

Sources

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