Pranayama (nadi shodhana, kapalabhati, bhastrika, ujjayi, bhramari)

1. Introduction

Version followed: a descriptive account of the five practices as recognised yoga bodies and educational sources publish them: the Ministry of AYUSH Common Yoga Protocol (5th revised edition, 2022) for the place of pranayama in a standard yoga session and its textual lineage; the Art of Living / Sri Sri School of Yoga page for kapalabhati; the National Institute of Open Schooling (NIOS) yoga course and a university physical-education lecture (CEC, India) for bhastrika and ujjayi; the Chetry et al. (2024) review for bhramari; and teaching notes by Eden Goldman (YogaDoctors, 2015, hosted by USC) for nadi shodhana, ujjayi and the fast techniques. The gentler practices (bhramari, ujjayi, nadi shodhana without retention) are written as in-session procedures; kapalabhati and bhastrika are described, not taught. No rates, rounds, counts, ratios or retention (kumbhaka) timings are given anywhere in this guide. [source: Ministry of AYUSH 2022; Art of Living; NIOS; CEC; Chetry et al. 2024; Goldman 2015]

What it is. Pranayama is the yogic practice of regulating the breath. In the Yoga Sutras attributed to Patanjali it is the fourth of eight limbs (2.29); in the Hatha tradition the key text is the Hatha Yoga Pradipika, attributed to Svatmarama (15th century), which presents breath practices together with breath retention (kumbhaka) and body locks (bandha). B. K. S. Iyengar's Light on Pranayama is the best-known modern teaching text; he places pranayama within a broader practice (yama, niyama, asana) and says it should be undertaken only once a yoga practice is established and under an experienced teacher. Kapalabhati is classed in the Hatha texts as a cleansing practice (shatkarma) rather than a pranayama proper; the Common Yoga Protocol lists it as a variation of bhastrika kumbhaka. Ujjayi in its modern form is widely used within Ashtanga (vinyasa) yoga. [source: Wikipedia, Pranayama; Ministry of AYUSH 2022] Technique details from Light on Pranayama are not reproduced here [uncertain: not verified].

The tradition's account of how it works. Within the yoga tradition, prana is described as the life-force carried on the breath, and nadis as subtle channels through which it flows (for example ida, linked with the left nostril, and pingala, linked with the right). Nadi shodhana means, in the tradition's terms, purification of these channels, and the Art of Living page says kapalabhati "clears the nadis". These are the tradition's concepts and spiritual aims, not established anatomy or physiology, and they should be presented to clients that way. [source: Goldman 2015; CEC; Art of Living]

A clinical account of how change might happen. Research reviews describe pranayama as producing shifts in autonomic balance (for slow, humming and alternate-nostril practices, a move towards parasympathetic activity as indexed by heart-rate variability), along with changes in attention and self-reported stress; fast techniques (kapalabhati, bhastrika) are described as activating and produce different effects from slow ones. Evidence is promising but limited: most studies are small, short-term and use non-standardised protocols. In psychotherapy, the gentle practices are best understood as self-regulation and attention-training skills, not as treatments for any physical or mental disorder. [source: Saoji et al. 2019; Oinam et al. 2024; Chetry et al. 2024; Fincham et al. 2023]

Evidence status (brief). A meta-analysis of randomised trials of breathwork in general found a small-to-medium reduction in self-reported stress compared with controls, with most trials at moderate risk of bias (Fincham et al. 2023). A review of bhramari reported benefits on stress, anxiety, sleep and blood pressure, mainly from short-term and non-randomised studies, and noted no adverse events in the included studies (Chetry et al. 2024). Narrative reviews of yogic breathing and of bhastrika/kapalabhati report positive findings but call for larger, rigorous trials and emphasise teaching by a qualified teacher (Saoji et al. 2019; Oinam et al. 2024). Health claims made by schools (for example weight loss, "detoxification", diabetes benefits for kapalabhati) are the schools' own and are not established by these reviews. No pranayama is a treatment for physical disease, and clients should never change asthma, blood-pressure, cardiac or other medicines because of breath practice. [source: Fincham et al. 2023; Chetry et al. 2024; Saoji et al. 2019; Oinam et al. 2024; Art of Living] [synthesis: medicines statement]

Related entries. Slow-paced, resonance, diaphragmatic breathing, cyclic sighing, 4-7-8 and box breathing have their own entries in this family; HRV biofeedback is covered in Domain IX; Holotropic and similar intense breathwork are covered in Domain VII; the Wim Hof Method has its own entry (167); vase breathing and tummo are in Domain XIII.

2. Framework

Pranayama has no psychotherapy protocol of its own. In the yoga schools it is taught as a progressive discipline inside a wider yoga practice, by a teacher who decides when a student is ready for more demanding forms. The framework below sets out (a) how recognised bodies position pranayama, and (b) how a psychotherapist can stage the gentle practices within therapy. Part (b) is [synthesis].

(a) How yoga bodies position it. The Common Yoga Protocol places pranayama after loosening practices and postures and before meditation, within one structured session, and lists kapalabhati, nadi shodhana / anuloma viloma, sheetali and bhramari among its practices, each traced to the Hatha texts (Hatha Yoga Pradipika, Gheranda Samhita and others). The Protocol's source notes record that the classical nadi shodhana includes visualisation and internal retention with time units; those classical elements are not used here. Iyengar advises establishing a posture practice first and learning pranayama under an experienced teacher. Fast and forceful practices are repeatedly described as for supervised learning: the Art of Living page says kapalabhati should be learned "under the supervision of a trained Yoga teacher"; the CEC lecture says bhastrika should never be practised without a guru or teacher; a Japanese government summary of the Cramer et al. (2013) review of yoga adverse events advises beginners to avoid forceful breathing. [source: Ministry of AYUSH 2022; Wikipedia, Pranayama; Art of Living; CEC; eJIM summary of Cramer et al. 2013]

Who holds teaching authority. Teaching authority rests with lineage teachers and recognised schools (for example the Iyengar, Sivananda, Bihar/Satyananda, Krishnamacharya-derived and Sri Sri / Art of Living traditions) and, for therapeutic yoga, with yoga therapists credentialed by bodies such as the International Association of Yoga Therapists (IAYT). Psychotherapists should not present themselves as pranayama teachers unless they hold such training. [synthesis; school names as examples] Current IAYT credentialing requirements: [uncertain: not verified].

(b) Staging within psychotherapy [synthesis].

Phase 1: Screening and framing (first session in which breath work is raised). Goals: medical and psychiatric screening (Section 4.1), checking the client's cultural and religious relationship to yoga, agreeing a secular or tradition-respecting framing, and establishing the client's ordinary breathing pattern. Move on when contraindications are excluded or cleared by the client's doctor and the client gives informed consent.
Phase 2: Foundation (one to three sessions, a few minutes each). Goals: natural-breath awareness and an easy, comfortable posture; then one gentle practice (usually bhramari or nadi shodhana without retention). Move on when the client can do the practice without strain, breathlessness, dizziness or rising anxiety, and can say how it feels.
Phase 3: Integration (ongoing). Goals: use the practice as a coping and grounding skill (before exposure work, after a distressing disclosure, at the end of a session, at home before sleep); add ujjayi if useful. Practices stay short and unforced; the therapist does not lengthen breaths, add counts or introduce holds.
Phase 4: Referral (any time). If a client wants kapalabhati, bhastrika, retention practices or a deeper yoga practice, refer to a qualified teacher or yoga therapist after screening, and help the client bring what they experience back into therapy.
Format. Usually brief segments (a few minutes) within an ordinary individual session; the therapist demonstrates and practises alongside; seated in a chair is acceptable. No session count is published for psychotherapy use. [synthesis]

3. Guiding principles

The tradition's concepts are the tradition's. Describe prana, nadis and spiritual aims as "in yoga, this is understood as..."; never as fact. [source: Goldman 2015; CEC] [synthesis: wording]
Gentle before forceful, and forceful only with a qualified teacher. In practice: the therapist teaches only bhramari, ujjayi and nadi shodhana without retention; kapalabhati and bhastrika are described and referred. [source: Art of Living; CEC; eJIM summary of Cramer et al. 2013]
Screen first. In practice: ask about cardiac, blood-pressure, neurological, eye, abdominal, respiratory, pregnancy and psychiatric history before any practice (Section 4.1). [source: Art of Living; NIOS; CEC] [synthesis: checklist form]
No retention, no counts, no forcing. In practice: breath stays smooth and comfortable; the therapist does not prescribe lengths, rounds or holds. Classical retention practices belong with lineage teachers. [synthesis; consistent with Iyengar's caution as cited in Wikipedia]
Stop at warning signs. In practice: stop at dizziness, faintness, heavy sweating, shaking, nausea, tingling, chest discomfort or panic; return to ordinary breathing. NIOS lists fainting, dizziness, excessive perspiration, excessive shaking and vomiting as stop signs for bhastrika. [source: NIOS] [synthesis: extension to all practices]
Never in or near water, or while driving. In practice: say so explicitly; any breath practice that alters consciousness carries a fainting risk, and breath-holding or over-breathing near water can cause blackout and drowning. [synthesis]
Practise on an empty stomach, sitting upright and comfortable. In practice: avoid practice straight after meals. [source: Art of Living]
Not a substitute for medicine. In practice: never advise changes to medication; involve the client's doctor where there is a physical condition. The Art of Living page itself says yoga "is not a substitute for medicine". [source: Art of Living]
Choice and control stay with the client. In practice: eyes open or closed, hands on ears or not, sound or no sound; the client can stop at any time without explanation. [synthesis]
No hands-on cueing. In practice: demonstrate on yourself; do not touch the client's face, nose, throat or abdomen. Any touch would need explicit consent and a professional basis, and is not needed for these practices. [synthesis]
Respect cultural and religious meaning. In practice: ask whether chanting, "Om" or Sanskrit names fit the client's beliefs; offer a neutral hum and plain names; do not proceduralise devotional or ceremonial forms. [synthesis]
Within competence. In practice: teach only what you have learned and practised yourself, ideally with a qualified teacher; seek supervision. [synthesis]

[source for section 3: as tagged; principle wording is synthesis]

4. Intervention inventory

The inventory covers assessment and framing, the three gentle practices as full in-session procedures, the two fast practices as description and referral only, and home practice, integration, referral and ending. Steps for the gentle practices are a [synthesis] built from the descriptions in the cited sources; example language is illustrative throughout.

4.1 Screening and medical clearance

Purpose / when: before any breath practice, and again before referral to a teacher of kapalabhati or bhastrika.
Steps:
1. Ask about heart disease (including pacemaker or stent), high or uncontrolled blood pressure, stroke, epilepsy or seizures, vertigo, hernia, back pain from a slipped disc, recent abdominal or other surgery, stomach ulcer or hyperacidity, hyperthyroidism, eye disease (glaucoma, retinal problems), lung disease (asthma, COPD, previous pneumothorax), pregnancy or recent childbirth, and menstruation (for kapalabhati, as the Art of Living page states). [source: Art of Living; NIOS; CEC] [eye, lung and pneumothorax items: synthesis, uncertain: not verified in the yoga sources]
2. Ask about panic attacks and panic disorder, psychosis, bipolar disorder or past mania, dissociation, recent trauma, and substance use. Fast or forceful breathing can reproduce panic-like body sensations; intense breath practices are widely cautioned against in psychosis and mania [synthesis; uncertain: not verified].
3. Screen for disordered breathing patterns (habitual over-breathing, sighing, chest breathing, breathlessness without medical cause). The Nijmegen Questionnaire is a self-report screen for hyperventilation-type symptoms; describe and use it as licensed, without reproducing items [uncertain: not verified]. Positive screens and unexplained breathlessness go to the GP or a respiratory physiotherapist first.
4. Where any physical condition is present, ask the client to check with their doctor before practice; for kapalabhati and bhastrika, any listed condition means referral elsewhere or not at all.
5. Record the screen, the client's consent, and what was agreed.
Example language (illustrative): "Before we try any breathing practice, I'd like to ask a few health questions. Some yoga breathing is gentle and some is quite vigorous, and the vigorous kinds aren't suitable for everyone."
Watch for: minimising ("my blood pressure is fine on tablets"); unreported pregnancy; a history of panic set off by body sensations; a client who wants the most intense practice. Working: clear yes/no answers recorded, medical input sought where needed.

4.2 Framing, psychoeducation and consent

Purpose / when: before the first practice; whenever a client asks what the practice "does".
Steps:
1. Explain what pranayama is (breath regulation from the yoga tradition) and that you will use only the gentle forms.
2. Give two accounts side by side: the tradition's (prana, nadis, balancing energy), attributed as the tradition's; and the clinical one (slow, smooth breathing and humming tend to calm the body and focus attention; evidence is promising but limited). [source: Goldman 2015; Chetry et al. 2024; Fincham et al. 2023]
3. Ask how the client relates to yoga, chanting and Sanskrit terms; agree plain names and a neutral hum if preferred.
4. State the stop rule, the no-water/no-driving rule, and that the client may stop without explaining.
5. Obtain verbal consent and note it.
Example language (illustrative): "In yoga this is described as balancing the flow of prana, the life-force. In plain clinical terms, slow, smooth breathing can help settle the nervous system. You can take either explanation, or neither. If anything feels uncomfortable, just stop and breathe normally."
Watch for: a client who feels the practice conflicts with their faith; expectation of a cure; a client who wants to please the therapist. Working: the client can restate the stop rule and chooses to try.

4.3 Preparation: posture and natural-breath awareness

Purpose / when: at the start of every practice; on its own for clients who find any breath change unsettling.
Steps:
1. Sit upright, feet on the floor, back supported if needed, hands resting on the thighs (the Art of Living page describes an erect spine with hands on the knees). [source: Art of Living]
2. Eyes open with a soft, lowered gaze, or closed if the client prefers.
3. Notice the breath without changing it: where it is felt, its temperature at the nostrils, the movement of belly and ribs.
4. Close by asking what the client noticed.
Example language (illustrative): "Let's not change anything yet. Just notice where you feel the breath most, maybe at the nose, maybe the chest or belly."
Watch for: breath-holding or effortful breathing when attention goes to the breath (common in anxious clients); rising anxiety; dissociation (glazed look, delayed responses). If present, open the eyes, orient to the room, and keep to brief breath awareness. Working: the client notices sensations with curiosity and stays present.

4.4 Bhramari (humming-bee breath)

Purpose / when: a calming practice for stress, anxious arousal, pre-sleep settling and session endings. Its review evidence covers stress, anxiety, sleep and blood pressure, mostly from short-term studies, with no adverse events reported in the included studies. [source: Chetry et al. 2024]
What the sources describe: a gentle in-breath and a slow out-breath during which a steady humming sound like a bee is made (described variously as a bee-like hum, "Mmmm" or "Om"); in the classical form the ears are closed with the thumbs or index fingers so the practitioner listens to the inner sound. The classical sources are the Hatha Yoga Pradipika and Gheranda Samhita; studies vary in protocol. [source: Chetry et al. 2024; Ministry of AYUSH 2022]
Steps [synthesis]:
1. Prepare as in 4.3. Lips lightly closed, teeth slightly apart, jaw soft.
2. Breathe in gently through the nose.
3. Breathe out slowly through the nose while making a soft, low, even hum. Keep it comfortable; no effort to make the out-breath longer than is easy.
4. Let the in-breath come naturally; repeat a few times at the client's own pace.
5. Optional: gently close the ears with the index fingers on the small flap at the front of the ear, or simply place the hands over the ears, to hear the hum inside. Offer this only as a choice.
6. Rest with ordinary breathing and notice the after-effects (vibration, quiet, warmth).
7. Debrief: what did you notice, where, and how is your mind now?
Example language (illustrative): "Breathe in through your nose... and as you breathe out, let a soft hum come, like a bee, as low and easy as you like. There's no right volume. If you want, cover your ears and listen to the sound inside."
Watch for: self-consciousness about making sound (therapist hums too; it can be done very quietly); light-headedness from forcing long out-breaths (shorten and soften); ear pain or ear infection (skip ear closure) [synthesis]; closed ears or closed eyes increasing dissociation or flashbacks in trauma survivors (keep ears and eyes open). Working: the client reports feeling calmer or quieter, the face and shoulders soften, speech slows.

4.5 Nadi shodhana / anuloma viloma without retention (alternate-nostril breathing)

Purpose / when: a balancing and calming practice for stress and anxious or scattered states, and to train attention. The tradition describes it as purifying the nadis and balancing ida and pingala; the clinical description is calming and focusing. [source: Goldman 2015; Ministry of AYUSH 2022]
What the sources describe: breathing in through one nostril and out through the other, alternating, with a natural, effortless breath; beginners leave out retention, and the classical form (Gheranda Samhita) adds retention, ratios and visualisation, which belong with qualified teachers and are not used here. [source: Goldman 2015; Ministry of AYUSH 2022]
Steps [synthesis]:
1. Prepare as in 4.3. Check that both nostrils are reasonably clear; with a blocked nose or a cold, use breath awareness instead.
2. Use the right hand: the thumb rests by the right nostril, a finger (commonly the ring finger) by the left. Demonstrate on yourself; do not touch the client. The precise hand position (mudra) varies by school. [uncertain: not verified]
3. Breathe out gently. Close the right nostril with the thumb; breathe in through the left.
4. Close the left nostril; release the right; breathe out through the right.
5. Breathe in through the right; close it; release the left; breathe out through the left. That completes one cycle.
6. Continue a few cycles at the client's natural pace, no holds, no counting, breath smooth and quiet.
7. Finish after an out-breath through the left, lower the hand, breathe normally through both nostrils, and debrief.
8. If the hand tires, it can rest; the practice can also be done by imagination alone (attention moving side to side) [synthesis].
Example language (illustrative): "Close your right nostril with your thumb and breathe in through the left... now switch, and breathe out through the right... in through the right... switch, out through the left. Keep it slow and easy; you set the pace."
Watch for: air hunger or breath-holding at the switch (remind: no pause needed); confusion about sides (reassure; the sequence matters less than ease); nasal blockage causing strain; arm fatigue; light-headedness. Working: breath becomes quieter and smoother, the client reports feeling steadier or more focused.

4.6 Ujjayi (victorious breath; ocean breath)

Purpose / when: to slow and smooth the breath, give the mind an audible anchor, and support calm, sustained attention; often used with postures in Ashtanga-style yoga. [source: Goldman 2015; Wikipedia, Pranayama]
What the sources describe: both nostrils are used for the in-breath; a soft sound is made at the back of the throat by a slight throat contraction ("a small, soft hissing sound", Goldman 2015; compared to the letter "hm" in the CEC lecture); the throat contraction should not be too strong (NIOS). The CEC lecture adds that it is not for people who are highly introverted, and that people with heart disease should not combine it with bandha and kumbhaka (locks and retention). Benefits claimed by teachers (calming, focusing, warming, better oxygenation) are the teachers' claims. [source: Goldman 2015; CEC; NIOS, with the NIOS attribution to ujjayi uncertain: not verified]
Steps [synthesis]:
1. Prepare as in 4.3.
2. Teach the sound first with the mouth open: breathe out as if gently fogging a mirror, noticing the slight narrowing in the throat.
3. Close the mouth and make the same soft sound on the out-breath through the nose.
4. Add the same soft throat sound on the in-breath.
5. Keep the sound quiet (audible only to the client or someone close by), the breath slow and unforced, no holds.
6. Practise a few breaths, then release the throat, return to ordinary breathing, and debrief.
Example language (illustrative): "Breathe out through your mouth as if you're fogging up a mirror... feel that soft narrowing in your throat? Now close your mouth and keep that soft sound as you breathe out through your nose. Just a whisper of sound, nothing forced."
Watch for: straining or gripping the throat (reduce to a whisper), coughing, a sore throat, chest puffing and shoulder lifting; light-headedness; inward absorption increasing withdrawal in very withdrawn clients (keep it brief and eyes open, in line with the CEC caution); never combine with breath-holding or locks. Working: breath slows and becomes even, the client reports a steadier mind or finds the sound a useful anchor.

4.7 Kapalabhati (skull-shining breath): description and referral only

What it is: classed in the Hatha texts as a cleansing practice; the Art of Living page describes sitting upright, then repeated active, forceful exhalations made by drawing the navel towards the spine, with a passive in-breath as the belly relaxes, practised in rounds on an empty stomach and followed by rest with eyes closed; its own claimed benefits include energising the nervous system, metabolism and digestion. Goldman describes forceful exhalations with passive inhalations from a quick contraction and release of the lower belly. Numbers of strokes, rounds and pace are matters for a qualified teacher and are not given here. [source: Art of Living; Goldman 2015; Wikipedia, Pranayama]
Contraindications as sources state them: artificial pacemaker or stent; epilepsy; hernia; backache from a slipped disc; recent abdominal surgery; menstruation; pregnancy and the period shortly after childbirth; hypertension or heart problems only under a yoga expert's guidance. [source: Art of Living] Additional cautions [synthesis; uncertain: not verified in the sources cited]: glaucoma and retinal disease (pressure changes); uncontrolled blood pressure; psychosis, bipolar disorder or past mania; panic disorder (it reproduces arousal sensations); lung disease or a history of pneumothorax.
Psychotherapist's role: do not teach it. If a client asks about it or already practises it: screen (4.1), share the school's own contraindication list, and refer to a qualified teacher of a recognised school or a credentialed yoga therapist, with medical clearance where any condition is present. Ask the client to report after-effects in therapy. [synthesis]
Example language (illustrative): "Kapalabhati is a vigorous practice that yoga schools themselves say needs a trained teacher, and it isn't suitable with some health conditions. If you'd like to learn it, let's check those first, and I can help you find a qualified teacher."
Watch for: dizziness, tingling in the hands or around the mouth, cramping of the hands, chest tightness, faintness, nausea, abdominal or back pain, headache, eye pain or visual change, rising panic, agitation, sleeplessness or elevated mood after practice. Any of these: stop the practice and, if physical, seek medical advice. [synthesis; stop signs partly from NIOS]

4.8 Bhastrika (bellows breath): description and referral only

What it is: named after the blacksmith's bellows; NIOS calls it "basically fast breathing" that can also be done slowly, with deep, forceful filling and emptying of the lungs through the nose, and calls it a "heating" pranayama; the CEC lecture describes rounds that begin with kapalabhati strokes and says the method varies, with one version in the Hatha Yoga Pradipika; Goldman describes forceful nasal breathing with equal force on in- and out-breath. Rates, rounds and any retention are for a qualified teacher and are not given here. [source: NIOS; CEC; Goldman 2015; Wikipedia, Pranayama]
Contraindications as sources state them: high blood pressure; any heart problem; hernia; vertigo; hyperacidity; ulcer; recent abdominal surgery; "too much heat in the body"; stroke; hyperthyroidism (NIOS). High blood pressure, heart disease, hernia, gastric ulcer and epilepsy; never without a guru or teacher (CEC). [source: NIOS; CEC] Additional cautions [synthesis; uncertain: not verified in the sources cited]: pregnancy; glaucoma and retinal disease; psychosis, bipolar disorder or past mania; panic disorder; asthma, COPD or previous pneumothorax.
Stop rules as published: stop at once with fainting, dizziness, excessive sweating, excessive body shaking or vomiting. [source: NIOS]
Psychotherapist's role: as for kapalabhati (4.7). Do not teach; screen, inform, refer, and integrate the client's experience into therapy. [synthesis]
Example language (illustrative): "Bhastrika is a fast, forceful breath. Yoga sources list quite a few conditions where it should be avoided, and say it should be learned with a teacher. That's outside what I'd teach here, but we can talk through whether it's right for you."
Watch for: the same signs as 4.7, plus over-breathing effects (light-headedness, pins and needles, muscle cramp in the hands and feet, feelings of unreality, panic). [synthesis]

4.9 Home practice

Purpose / when: once a gentle practice is learned without strain in session. [synthesis]
Steps:
1. Choose one practice (bhramari, nadi shodhana without retention, or ujjayi) and a natural moment (on waking, before sleep, before a stressful event). Practise on an empty stomach, seated (the Art of Living page advises an empty stomach for kapalabhati; extended here as general good practice). [source: Art of Living] [synthesis]
2. Agree "a few easy breaths" rather than any target of length, number or duration; the client stops whenever they wish.
3. Repeat the safety rules: never in the bath, pool or open water, never while driving or operating machinery, stop at warning signs.
4. Optional brief log: when practised, what was noticed before and after. No scoring targets.
5. Review at the next session.
Example language (illustrative): "Between now and next week, if you'd like, try a few humming breaths before bed. There's nothing to achieve; just notice what happens. And never do any of these breathing practices in the bath or while driving."
Watch for: the client turning practice into a test or a compulsion; escalating to longer, faster or held breaths after online videos; using it only to escape every flicker of anxiety (see 4.10). Working: the client uses it flexibly and can describe its effect.

4.10 Integrating breath practice into psychotherapy (including anxiety and panic)

Purpose / when: to make the practice serve the therapy rather than replace it. [synthesis]
Steps:
1. Place the practice deliberately: as an opening settle, a pause after difficult material, a closing ritual, or a coping skill rehearsed in session.
2. Debrief body experience: what was felt, where, and what it brought up (memories, images, feelings); link to the client's goals.
3. In CBT for anxiety and panic, use calming breath as a coping or grounding tool, but avoid it becoming a safety behaviour that prevents the client from learning that the feared sensations are harmless; during interoceptive or situational exposure, do not use the practice to abort the exposure unless planned. There is a debate on this in the CBT literature [uncertain: not verified]. Fast practices should not be used as an informal interoceptive exposure.
4. With trauma survivors, keep eyes open, ears uncovered and practices short; titrate attention to the body; return to orientation if dissociation appears.
5. Respect the client's spiritual meaning if they hold one; explore it as you would any other value, without endorsing or disputing the tradition's claims.
Example language (illustrative): "That was a lot to talk about. Would it help to take a few humming breaths before we go on? ... What do you notice now?" / "This week, during the exposure, let's see what happens if you let the racing heart be there without doing the breathing."
Watch for: avoidance disguised as calming; the client relying on breath control to feel safe at all; spiritual bypassing (using practice to avoid painful feelings); emergence of strong emotion or memories, to be met with ordinary therapeutic pacing. Working: the client uses breath flexibly and still engages with feared or painful material.

4.11 Referral and collaboration with yoga teachers and yoga therapists

Purpose / when: a client wants to learn kapalabhati, bhastrika, retention practices or a fuller pranayama practice, or wants yoga alongside therapy. [synthesis]
Steps:
1. Screen (4.1) and, where any condition is present, ask the client to obtain medical clearance.
2. Suggest a teacher of a recognised school or a credentialed yoga therapist; encourage the client to tell the teacher about their health and mental-health history (with their consent, you may share relevant cautions).
3. Discuss the school's own contraindications and that forceful practices are learned under supervision (as the schools state). [source: Art of Living; CEC]
4. Ask the client to bring experiences, including adverse ones, back to therapy; pass on adverse physical effects to the client's doctor.
Example language (illustrative): "If you'd like to go further with pranayama, a qualified teacher is the right person. Tell them about your heart condition and your panic history, and let's hear how it goes."
Watch for: teachers who promise cures, push intense practices on beginners, discourage medication, or claim spiritual authority over the client's life; rapid personality change, sleeplessness or elevated mood after intensive retreats (seek psychiatric assessment). Working: the client practises safely and their experience is integrated into therapy.

4.12 Ending the practice and ending therapy

Purpose / when: at the end of each practice and at therapy termination. [synthesis]
Steps: after each practice, return to ordinary breathing, open the eyes, orient to the room, and check the client is steady before standing; at termination, review which practice helped, when to use it, the safety rules, and where to learn more if wanted.
Example language (illustrative): "Let your breath go back to normal... look around the room... how are you feeling? Take your time before you stand up."
Watch for: light-headedness on standing; the client leaving in a dissociated or very relaxed state before driving (wait until fully alert). Working: the client leaves alert and with a clear, safe plan.

5. Handling problems

None of the cited sources addresses psychotherapy-specific problems; all guidance below is [synthesis] unless a source is tagged.

Dizziness, light-headedness, tingling, cramping hands, feeling unreal. Likely over-breathing or forcing. Stop, breathe normally and quietly, feet on the floor, eyes open; do not stand until it passes; next time shorten, soften and slow. NIOS lists fainting, dizziness, excessive perspiration, excessive body shaking and vomiting as reasons to stop bhastrika immediately. [source: NIOS] [synthesis: application]
Panic or rising anxiety during practice. Common in clients who fear body sensations. Return to ordinary breathing with eyes open and orient; normalise; if appropriate, link to the panic formulation (breath sensations are feared cues). Return to brief natural-breath awareness (4.3) or stop breath work and use other grounding.
Dissociation, flashbacks or emotional flooding. Stop, open eyes, uncover ears, orient to the room and to the present, use ordinary grounding; later, revisit with shorter practices, eyes open and more choice.
Physical symptoms. Chest pain, palpitations, severe headache, eye pain or visual change, abdominal or back pain: stop and advise medical assessment; urgent symptoms need emergency care. Do not resume until medically cleared.
"It doesn't do anything." / stuck clients. Reduce effort and expectation; switch practice (humming suits some, alternate-nostril others); use breath awareness only; or drop breath work, which is optional.
Self-consciousness or embarrassment (especially with humming). Therapist practises alongside; do it very quietly; offer silent alternatives (nadi shodhana).
Religious or cultural objection. Use plain names and no chanting, or omit; never pressure. For clients from yoga traditions, invite them to bring their own teacher's guidance and respect it within safety limits.
Escalation and "more is better". Clients who try to make breaths longer, add holds, or move to fast practices from online videos: restate why the practice is kept gentle, share the schools' own contraindications, and refer to a qualified teacher (4.11). Classical retention practices are not taught in therapy.
Non-adherence. Explore barriers; shrink the practice to a few breaths attached to an existing habit; accept that home practice is optional.
Over-reliance or safety behaviour. If the practice is used to avoid all distress or to escape exposure, discuss its function and plan sessions or exposures without it.
Ruptures. A client may feel managed ("you're just trying to calm me down") or that the practice dismisses their distress. Acknowledge, stop the practice, return to the content, and ask how they want to use (or not use) breath work.
Mood elevation, sleeplessness, unusual experiences after intensive practice or retreats. Ask about practice intensity; advise stopping intensive practice; arrange psychiatric assessment if signs of mania or psychosis appear. Intensive breathwork such as Holotropic breathwork is covered in Domain VII.
Nasal blockage, colds, ear problems. Skip nadi shodhana with a blocked nose; skip ear closure in bhramari with ear pain or infection; use breath awareness instead.
Pregnancy. Keep to gentle, unforced practices with the client's maternity care team informed; kapalabhati is contraindicated in pregnancy as the Art of Living page states. [source: Art of Living] [synthesis: remainder]
Clients with asthma, COPD or other lung disease. Keep to gentle practices, stop with any breathlessness, never change medicines, involve their respiratory clinician. [synthesis]
Water, driving and machinery. Repeat the rule whenever home practice is discussed; never practise in the bath, pool, open water or while driving.

Sources

Books cited:

Iyengar, B. K. S. Light on Prāṇāyāma: The Yogic Art of Breathing. New York: Crossroad, 2011 edition as cited in the Wikipedia article; original publication year [uncertain: not verified].
Svatmarama (attributed). Hatha Yoga Pradipika, 15th century; cited via the Common Yoga Protocol and Wikipedia [uncertain: no specific translation verified].
Gheranda Samhita; cited via the Common Yoga Protocol, Chetry et al. 2024 and Wikipedia [uncertain: no specific translation verified].

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