DBT Skill of the Day: Paced Breathing (ft. Marsha Linehan’s Example!)

In the Distress Tolerance module of DBT, there is an acronym called ‘TIPP‘. It is a prime skill to be used during times of immensely painful or intolerant emotions or urges, which feel impossible to manage at such a high intensity. TIPP stands for the following –

  • Temperature
  • Intense Physical Exercise
  • Paced Breathing
  • Progressive Muscle Relaxation

In a few weeks I will be learning about TIPP again in the DBT Skills Group I attend, when I will go into more detail. For the time being, I would like to focus this post on Paced Breathing, which is something I have been finding helpful in dealing with intense emotions – most significantly with anxiety.

Briefly, Paced Breathing is the name given to a specific type of slow, deep, mindful breathing. I will outline briefly how and why it can be so effective to use as a Distress Tolerance exercise, below:

When you breathe in, the sympathetic nervous system is activated. This leads to the heart rate speeding up amongst other physiological changes. During these times, the body enters a state of hyper-arousal and becomes ready to ‘fight, fly or flee’. This is why when someone is running it feels automatic and intuitive to breath in long, deep breaths and out short, sharp breaths – to keep the body revved up and provide it with the arousal and energy it needs.

Conversely, when you breathe out, it is the parasympathetic nervous system which is activated. This system slows the heart rate and other bodily functions right down again, and the body enters a state of ‘rest and digest’ – one of comparative calm.

During Paced Breathing exercises, it is therefore important to make the ‘out breath’ longer than the ‘in breath’. This results in the parasympathetic nervous system being more active than the sympathetic nervous system. As a result, arousal will decrease and a state of relative calm and control can be regained.

When you are in a state of hyper-arousal, for example extreme panic or anger, Paced Breathing enables you to bring your body back to baseline as quickly and effectively as possible; calming you right down on a fundamentally physiological level. This in turn enables you to regain the ability to manage yourself, regardless of the circumstances, even during a crisis.

Last week Marsha shared an example with us at the DBT workshop in London. She told us about a time when was running a Skills Group in Washington…

One of her clients had a husband who dropped her off for group and then waited for her in his car, as he did each week. During the break, the woman would go out into the parking lot and meet him until group recommenced. During one particular week, the woman walked out of the building and started walking towards her husband’s car to join him, when all of a sudden a bus went straight into the car – which the husband was sitting in. Immediately, the woman started panicking, screaming and shrieking with shock and fear, and becoming extremely (understandably) dysregulated.

Miraculously the husband was fine, but the woman initially was not. She was in such a state of intense hyper-arousal after witnessing the incident, and on the verge of a full-blown panic attack. She was hyper-ventilating and unable to bring her emotional reaction down, which was at an overwhelming and unmanageable degree. Marsha pulled the woman aside, made her take a seat, and directly guided her through a Paced Breathing exercise.

After under a minute, the woman had calmed down significantly, to such a degree that even Marsha was surprised. Within just a few minutes, she had reached a much more regulated state, and after not long at all was able to feel a regained sense of control enough to attend to the situation appropriately.

In recent weeks my own generalised anxiety has felt debilitating at times. The most helpful Paced Breathing exercise I know is one I have been heavily relying on, perhaps multiple times a day and for many minutes (up to 30) at a time. It has helped me stop amidst those moment of extreme distress, pause for a moment, attend to my body, regulate it at least partially, and regain that same sense of control that was necessary for Marsha’s client too.

It is called 9-0 (nine to zero) and this is how it works:

  1. Breathe in and out normally, slightly lengthening the out breath.
  2. Starting with 9 and decreasing to 0, label each of the out breaths with a number, i.e. In.. Out (9)…. In.. Out (8)…. In.. Out (7)….
  3. If you notice your mind wandering, gently bring your attention back to the counting of the breaths. Try to focus on the numbers and breathing, and nothing else. (You will realise that it is much harder to ruminate to the same degree whilst focusing so determinedly on a counting task without losing track; this is part of the point.)
  4. When you reach zero, start counting down again. This time don’t start with the number 9; start with the number 8.
  5. Work your way down to 0 again.
  6. When you reach 0, continue starting the counts again, each time decreasing the starting number by one, until you have reached zero again.
  7. When you have finished, if you need to, start again at 9, and repeat until you are feeling more regulated. This can take up to 20 minutes, although significant effects can be felt almost immediately.

See below, for a visual cue:

9 8 7 6 5 4 3 2 1 0…..
8 7 6 5 4 3 2 1 0….
7 6 5 4 3 2 1 0….
6 5 4 3 2 1 0….
5 4 3 2 1 0….
4 3 2 1 0….
3 2 1 0….
2 1 0….
1 0….
0….

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5 thoughts on “DBT Skill of the Day: Paced Breathing (ft. Marsha Linehan’s Example!)

  1. When I do paced breathing I frequently feel light headed. Today I actually passed out on the bus. What am I doing wrong? I was on the verge of having a major crying break down on the bus so my access to skills was limited.

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    • Hmm this is a good question. I have had this problem as well, I imagine either it’s due to the anxiety beforehand that often comes with stilted breathing, or it’s because maybe the balance between exhale and inhale of the paced breathing isn’t quite right? It’s important to breathe out for longer than in, because this activates the parasympathetic nervous system which is supposed to calm us down – slow heart rate, blood pressure etc. But if the exhale is too much, it probably “calms us down” on a physiological level “too much”, maybe blood pressure dips too low and drops substantially from what it was before, to the point that we start feeling dizzy and light/headed and even passing out? It’s probably going to take a while for your body to get used to the changes in oxygen levels that happen when you do breathing exercises if you’re relatively new to it. Maybe try breathing out for fewer seconds, don’t force yourself to breathe in or out in a way that is unnatural, e.g. try breathing in for 2 and out for 3 consistently or a length of time that works for you. Also keep a bottle of water with you, keep sipping and also use it for TIPP as that can be quite grounding. Let me know how it goes and if you find any answers or solutions! Take care.
      P.s. I am not a professional, just a regular 22 year old in recovery, this is just me theorising!

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  2. You’ll get this same effect with any traditional buddhist breathing exercise. Trad zen goes something like breath in counting the in breaths/counting both in/out for a count of 10-20 or a pyramid and then just watch the breath, bringing the mind back on wandering. Start with 1 min, go up to 20 if you like.
    Trad theravadan focuses on the breath as above but instead of using numbers just gets you to observe breath quality, eg long/short, fast/slow.
    Shooting training has a few interesting techniques, similar to yogic breathing – you can’t hold a crosshair steady if you freaking and self-hypnosis might simply say keep taking long deep breaths in. The out breath will take care of itself.
    After a short while your mind will focus on the breathing only and you will have chilled out.
    If you’re hyperventilating try focusing on any above technique for 30-60 seconds then just watch the breath. Too much technique can get in the way.

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