Box breathing · Atlas

1. Introduction

Version followed: the four-phase equal-count pattern as Mark Divine published it in Time (2016), with the health-education variant (Healthline, RWJBarnabas Health) and the police "combat breathing" variant noted where they differ.

Box breathing (also called square or four-square breathing) is a low-intensity, paced breathing technique done at rest. It has four phases of equal length: breathe in, hold with full lungs, breathe out, hold with empty lungs. Mark Divine, a former US Navy SEAL officer and founder of SEALFIT, calls it his favourite practice and describes the equal ratio as "energetically neutral": he says it neither energises nor makes you sleepy, and leaves the body calm and the mind alert and focused [source: Divine, Time 2016]. The claim that box breathing is an official part of US Navy SEAL training is widely repeated but is not documented in the sources used here [uncertain: not verified].

Under the name "tactical" or "combat breathing" the same four-count, four-phase pattern is taught to police officers, military personnel and civilian firearms students. The aim is to control adrenaline surges and regain control under threat [source: Police Magazine]. The Canadian Armed Forces' Road to Mental Readiness (R2MR) programme makes tactical breathing one of its four core "Big Four +" skills. It states that tactical breathing "has been found to be an effective mental skill to improve performance" and that regular use may reduce anxiety and depression and improve coping with stress [source: National Defence, Big Four +]. The R2MR pages used here give no counts for its version [uncertain: R2MR pattern not verified].

How change happens, as sources describe it: a slow, regular rhythm with brief holds is said to reduce physiological arousal. Healthline explains that holding the breath lets carbon dioxide build up, which it says slows the heart rate [source: Healthline]. Deliberately pacing the breath also gives the person a sense of control over their body in stressful moments [source: Divine; Police Magazine]. For the psychotherapist, box breathing is a coping and self-regulation skill. It is not a stand-alone treatment for any mental or physical disorder [synthesis].

Evidence status.

Balban et al. (2023) ran a remote randomised controlled trial with daily 5-minute sessions over one month. They compared cyclic sighing, box breathing, cyclic hyperventilation with retention, and mindfulness meditation. Breathwork as a group, and cyclic sighing in particular, improved mood and reduced respiratory rate more than mindfulness. The summary used here reports no separate effect for box breathing [source: Balban et al. 2023; uncertain: box-breathing-specific results not verified].
Fincham et al. (2023) meta-analysed 12 RCTs (785 adults) of breathwork in general. They found a small-to-medium effect on self-reported stress (g = −0.35) and similar effects on anxiety and depressive symptoms. Most trials were at moderate risk of bias. The pooled estimate is for breathwork in general, not for box breathing [source: Fincham et al. 2023].
Healthline cites a 2024 study in COPD (Muhlisoh et al.) that reported effects on breathing frequency and none on oxygen saturation [source: Healthline; uncertain: primary study not verified].
Overall: the evidence for box breathing specifically is thin. Claims about blood pressure, insomnia, PTSD or performance come from the bodies that make them and have not been established by independent reviews. Box breathing does not treat any physical disease, and clients must never change asthma, COPD, heart or other medication because of it [synthesis].

Cross-references: cyclic hyperventilation with retention and Wim Hof-style breathing are covered in the separate Wim Hof guide (167). Holotropic and other intense, prolonged breathwork belongs to Domain VII. HRV biofeedback belongs to the Domain IX biofeedback guides.

2. Framework

Box breathing is a single technique, not a therapy with phases. Sources give no session count or phase criteria [uncertain: none published]. Below is a structure for building it into psychotherapy [synthesis], with published content marked.

Stage	Goal	Typical format	Move on when
A. Screening and consent	Rule out reasons not to use breath holds, identify breathing-pattern problems and trauma links to the breath	Part of intake or one session segment	No unresolved medical caution, or clearance obtained; the client agrees
B. Rationale and teaching	Explain the published pattern and its stated purpose; demonstrate	Part of one session	The client can describe the four phases
C. Guided in-session practice	Practise a few cycles together, with the client free to stop at any time; review	Same and next session	No adverse effects; the client can do the pattern without coaching
D. Home and everyday practice	Regular practice at rest, then brief "spot" use in daily stress (Divine's "spot drills") [source: Divine, Time 2016]	Between sessions; brief review each session	The client uses it on their own and reports what they notice
E. Integration	Place it within the treatment plan (stress management, CBT, trauma work, operational readiness) without letting it become avoidance	Ongoing	The client uses it flexibly and does not rely on it to avoid feared situations
F. Ending	Maintenance plan, relapse cues, what to do if side effects appear	Final session(s)	Written plan agreed

Published patterns, stated as their sources give them (no lengthening, progression or extra holds are added here):

Divine (Time, 2016): breathe all the air out, hold empty for a four-count, breathe in through the nose for four counts, hold full for a four-count "without clamping down or creating back pressure", breathe out smoothly through the nose for four counts, and repeat. Divine suggests a longer daily session plus brief spot drills during the day. He says it can be used anywhere except during highly complex tasks [source: Divine, Time 2016]. Divine mentions practising in traffic. This guide advises against breath holds while driving (see section 3) [synthesis].
Health-education variant (Healthline; RWJBarnabas Health handout): sit upright with feet on the floor, breathe out to empty the lungs, breathe in through the nose for four, hold for four, breathe out through the mouth for four, hold for four. The handout gives four cycles per sitting, and Healthline suggests several sittings a day or as needed [source: Healthline; RWJBarnabas Health].
Police "combat breathing": breathe in through the nose for four, expanding the stomach; hold for four; breathe out slowly through the mouth for four, drawing the stomach in; hold empty for four. Repeat "until control returns" [source: Police Magazine].
Balban et al. (2023) trial arm: box breathing is defined as equal inhalation, retention and exhalation, practised in a daily 5-minute session over one month. This is a study protocol, not a clinical prescription [source: Balban et al. 2023].

3. Guiding principles

Safety screening first. Before teaching the holds, ask about heart, lung, neurological and pregnancy-related conditions. In practice: no breath holds until cautions are cleared [source: Healthline; synthesis].
The client controls the breath. In practice: the client may shorten, skip or stop any phase at any time, and stopping counts as a valid choice, not a failure [synthesis].
Gentle holds, never strained. Divine asks for holds "without clamping down or creating back pressure". In practice: watch for breath-holding with a closed throat, red face or straining, and coach a soft, open pause [source: Divine, Time 2016].
Comfortable volume, not big breaths. Big breaths raise the amount of air moved per minute and can feed overbreathing [source: Stonehewer 2009]. In practice: the inhale should feel smooth and moderate, not maximal [synthesis].
Use the published pattern only. In practice: do not lengthen the counts or holds, or set targets beyond what the source publishes. If the pattern is uncomfortable, drop the holds (section 4.6) instead of pushing [synthesis].
Stop rules are explicit and agreed in advance. In practice: dizziness or breathlessness means stop at once and return to ordinary breathing. If it does not settle, seek medical attention [source: Healthline]. Chest pain, palpitations, tingling or cramping, fainting, a surge of panic, dissociation or a flashback also means stop (section 4.1) [synthesis].
Never in or near water, never while driving or operating machinery. In practice: holds and overbreathing can impair consciousness; breath-hold practice in water risks shallow-water blackout [synthesis; uncertain: specific source for box breathing not verified].
A coping skill, not a cure. In practice: present it as one tool within the treatment plan and make no promises about curing anxiety, PTSD or insomnia [synthesis].
Watch for safety behaviour. Breathing techniques used to suppress feared sensations during exposure may stop clients learning that the sensations are harmless [source: Tolin]. In practice: in exposure-based CBT, agree when breathing is and is not used [synthesis].
Trauma-informed attention. In practice: breath focus and holds can bring up memories of suffocation, choking, smoke, drowning or restraint. Ask about these and offer eyes-open practice and grounding [synthesis].
Attribute the claims. In practice: say "Mark Divine reports…" or "the Canadian Forces programme states…" rather than presenting performance or health claims as fact [synthesis].
Medical issues go to medical staff. In practice: unexplained breathlessness, chest pain or a positive breathing-pattern screen gets a referral to a GP or respiratory physiotherapist. Never advise on medication [synthesis].

[source for section: Divine, Time 2016; Police Magazine; Healthline; RWJBarnabas Health; National Defence; Balban et al. 2023; Fincham et al. 2023; Stonehewer 2009; Tolin]

4. Intervention inventory

A trained psychotherapist may teach box breathing. It is a low-intensity paced-breathing skill practised at rest. The published patterns are given in section 2. The steps below use Divine's version unless stated otherwise. Session structure and wording are [synthesis] unless a source is cited.

4.1 Screening, consent and agreed stop rules

Purpose / when: before the first practice, and again if health changes (for example a new pregnancy, a cardiac event or surgery).
Steps:
1. Ask about heart conditions, any severe health condition and pregnancy. Healthline advises checking with a doctor first in these cases [source: Healthline]. Also ask about these, which are commonly treated as cautions for breath-holding breathwork: uncontrolled blood pressure, epilepsy, asthma or COPD (current control, recent flare), glaucoma or retinal problems, recent surgery, psychosis or bipolar disorder, and panic disorder [synthesis; uncertain: not verified as box-breathing-specific contraindications]. If any apply, get medical clearance or use the holds-free adaptation (4.6).
2. Screen for breathing-pattern problems. Ask about breathlessness, frequent sighing or yawning, tingling, dizziness, chest tightness, and "asthma-like" symptoms that do not respond to inhalers. Stonehewer lists these as features of dysfunctional breathing [source: Stonehewer 2009]. The Nijmegen Questionnaire is a 16-item self-report screen for hyperventilation-type symptoms, scored 0–64, usually with a cut-off above 23. The empirical basis of that cut-off is unclear and the questionnaire is a screen, not a diagnosis [source: Ogilvie & Kersten]. If symptoms or a screen suggest a breathing-pattern disorder, refer to a GP or respiratory physiotherapist rather than treating it yourself [synthesis].
3. Ask about trauma linked to the breath: choking, strangulation, near-drowning, smoke inhalation, gas or restraint [synthesis].
4. Agree the stop rules aloud. Dizziness or breathlessness means stop and return to ordinary breathing; persistent symptoms mean medical attention [source: Healthline]. Chest pain, palpitations, tingling, muscle cramping, faintness, panic, dissociation or flashback also mean stop. Chest pain or fainting means following the service's medical-emergency procedure [synthesis].
5. Agree where not to practise: never in or near water, never while driving or operating machinery, and never during tasks that need full attention [synthesis; Divine also excludes "highly complex" tasks: source: Divine, Time 2016].
6. Get verbal consent and record it.
Example language (illustrative): "This exercise has short pauses where you hold your breath gently. Before we try it, I'd like to check a few health things. Have you ever been told you have a heart or lung condition, or are you pregnant?" / "If you feel dizzy, short of breath or uneasy at any point, just stop and breathe normally. That's always fine."
Watch for: vague answers about chest or breathing symptoms (clarify, or refer), the client minimising symptoms to please you, and fear of the breath itself. Signs this step is working: the client can repeat the stop rules back and knows who to ask for clearance.

4.2 Rationale and psychoeducation

Purpose / when: before teaching, so the client knows what the technique is and what is claimed for it.
Steps:
1. Describe the four equal phases and the names (box, square, tactical breathing).
2. Explain the stated purpose: Divine describes the effect as calm body and alert, focused mind [source: Divine, Time 2016]. Police and military trainers teach it for managing adrenaline surges [source: Police Magazine; National Defence].
3. Give an honest evidence statement: some trials support breathwork in general for stress, but research on box breathing alone is limited (section 1).
4. Explain that it is a skill you practise when calm, so that it is available under stress [synthesis].
5. If panic is part of the picture, explain that overbreathing lowers carbon dioxide and can itself produce dizziness and tingling, and that deep breaths can make this worse [source: Meuret, SMU 2010]. So the inhale should be smooth, not big [synthesis].
Example language (illustrative): "It's called box breathing because it has four equal sides: in, hold, out, hold. People in high-pressure jobs use it to steady themselves. The research on this exact pattern is still thin, so let's treat it as an experiment and see what it does for you."
Watch for: the client expecting a cure (reframe it as a tool), or seeing it as "just breathing" (link it to their own goals). Signs this step is working: the client can say in their own words why they would practise it.

4.3 Core box breathing, guided in session (Divine's published pattern)

Purpose / when: first teaching and early sessions, for general stress reduction and arousal regulation in a client who has been screened.
Steps:
1. Seat the client upright and stable, feet on the floor, hands resting loosely. Healthline gives this posture [source: Healthline]. Eyes open or closed, as the client chooses [synthesis].
2. Demonstrate one cycle yourself while counting aloud.
3. Guide the client through the pattern as published: breathe the air out; hold empty for a four-count; breathe in through the nose for four; hold full for a four-count, softly and without clamping or back pressure; breathe out smoothly through the nose for four; repeat [source: Divine, Time 2016].
4. Count aloud at a steady pace that suits the client. You set the rhythm of the count, not its length [synthesis].
5. Guide a few cycles, then stop and return to ordinary breathing. Do not lengthen the counts or the practice in this first session [synthesis].
6. Debrief: what they noticed, any discomfort, and their rating of tension before and after on a simple scale such as 0–10 [synthesis].
Example language (illustrative): "Let the air go… and rest empty, two, three, four. Now in through your nose, two, three, four. Pause gently with the throat soft, two, three, four. And out through your nose, two, three, four." / "What did you notice in your body just now?"
Watch for: straining or a locked throat during holds, gasping after a hold (the pace or volume is too much: switch to 4.6), dizziness or tingling (stop: overbreathing), and rising anxiety during the empty hold (air hunger). Signs it is working: smoother breathing, lowered shoulders, a slower spontaneous breath afterwards, and the client reporting feeling calmer or more focused.

4.4 Seated health-education variant (nose in, mouth out)

Purpose / when: for clients who find exhaling through the nose uncomfortable or who were taught the version in health-education materials.
Steps: sit upright with feet on the floor. Breathe out slowly to empty the lungs. Breathe in through the nose for four, hold for four, breathe out through the mouth for four, hold for four. The RWJBarnabas handout gives four cycles per sitting [source: Healthline; RWJBarnabas Health].
Example language (illustrative): "In through your nose for four… hold… and let it out slowly through your mouth for four, like a long, quiet sigh… hold."
Watch for: forceful mouth exhalation or big gulps of air, which push towards overbreathing [source: Stonehewer 2009]. Coach a slow, quiet exhale. Signs it is working: as in 4.3.

4.5 Brief everyday use ("spot drills") and tactical use under stress

Purpose / when: once the client can do the pattern at rest. Used before or after predictable stressors such as a meeting, a call-out or an exam, and to regain control during an adrenaline surge in safe settings. Divine describes brief spot drills during the day [source: Divine, Time 2016]. Police training uses repetition "until control returns" [source: Police Magazine]. R2MR teaches tactical breathing alongside goal setting, visualisation and self-talk [source: National Defence, Big Four +].
Steps:
1. With the client, identify two or three predictable stress points in their week.
2. Rehearse a short run of the pattern in session, linked to an imagined cue (for example standing outside the meeting room) [synthesis].
3. For operational clients, practise in positions that match the role (standing, seated in a vehicle that is not moving) and with eyes open [synthesis].
4. Agree where it must not be used: not while driving, not in water, and not in place of acting on a real threat or a needed task [synthesis].
5. Review its use in the next session.
Example language (illustrative): "Before you walk in, give yourself a few boxes, then go in and get on with the task." / "This is something you practise when it's quiet so it's there when things get loud."
Watch for: using it to delay or avoid necessary action (see 4.8), and using it in unsafe settings. Signs it is working: the client reports using it on their own and recovering faster after stress peaks.

4.6 Holds-free equal-count adaptation [synthesis]

Purpose / when: when holds are cautioned (pregnancy without clearance, cardiac or respiratory conditions, panic linked to air hunger, trauma linked to suffocation), or when holds cause distress. This is the clinician's adaptation, not a published box-breathing version.
Steps: keep the even rhythm but leave out both holds: breathe in smoothly, then out smoothly, at a comfortable even count. Do not add counts beyond the published pattern. If even counting is stressful, let the client simply breathe slowly and naturally while noticing the rhythm. Get medical clearance before reintroducing holds where a medical caution applies.
Example language (illustrative): "Let's leave the pauses out. Just breathe in, and out, at an even pace that feels easy."
Watch for: the client feeling they have "failed" (normalise the adaptation), and continued dizziness, which suggests overbreathing and calls for slower, smaller breaths or a referral. Signs it is working: comfort, and steadier, quieter breathing.

4.7 Home practice and self-monitoring

Purpose / when: after a comfortable in-session practice, to build the skill so it is available under stress.
Steps:
1. Agree a regular, short practice at rest using the published pattern the client learned. Divine describes a daily session plus spot drills, and Healthline describes several sittings a day or as needed [source: Divine, Time 2016; Healthline]. Let the client choose the time and place. Do not set targets beyond the published pattern [synthesis].
2. Link practice to an existing routine, for example after brushing teeth [synthesis].
3. Offer a simple log: when, setting, tension before and after (0–10), and any side effects [synthesis]. The R2MR app lets users compare heart rate before, during and after its tactical-breathing exercise [source: National Defence, R2MR app page]. Optional heart-rate tracking should stay descriptive, not a target [synthesis].
4. Repeat the safe-setting rules: seated or lying down, not in the bath, pool or open water, not while driving.
5. Review the log at the start of the next session.
Example language (illustrative): "When in your day could you fit in a few boxes when things are fairly calm?" / "Note anything odd, like dizziness, and we'll look at it together."
Watch for: no practice (see section 5), checking the heart-rate number compulsively, and practising only during crises. Signs it is working: regular use and the client noticing an effect sooner.

4.8 Use within CBT for anxiety and panic

Purpose / when: as one coping skill within a CBT plan for stress, generalised anxiety or panic, while protecting exposure work.
Steps:
1. Teach box breathing as a general arousal-regulation skill for calm moments and the end of the day, separate from exposure tasks [synthesis].
2. Tolin's slides list breathing retraining used as a safety behaviour as a concern, and call the integration of breathing retraining with exposure "problematic" [source: Tolin]. Agree with the client that during planned exposure and interoceptive exercises they will not use box breathing to suppress sensations, unless the plan says otherwise [synthesis].
3. Use interoceptive exposure to bodily sensations as the CBT protocol describes, rather than breathing that dampens them [source: Tolin].
4. Stress gentle, unforced breathing. Meuret argues that "taking deep breaths actually worsens hyperventilation and symptoms" in panic [source: Meuret, SMU 2010].
5. If hyperventilation is prominent, consider referral for capnometry-assisted respiratory training (CART), which uses CO2 feedback to slow and especially make breathing shallower [source: Meuret, SMU 2010].
6. Fade reliance: over time ask, "What happens if you don't use it this time?" [synthesis].
Example language (illustrative): "Box breathing is useful for winding down, but in our exposure practice we want your body to learn that these feelings pass on their own, so let's leave it out of those exercises."
Watch for: the client using the technique as a ritual to prevent panic, the belief "I'd collapse if I didn't breathe this way", and empty holds triggering air hunger and panic (switch to 4.6). Signs it is working: less fear of sensations, and use of the skill becoming optional.

4.9 Trauma-informed use with first responders and veterans

Purpose / when: many police, military, fire and paramedic clients already know tactical breathing from training [source: Police Magazine; National Defence]. The therapist can build on this familiar skill to support regulation in psychotherapy, including PTSD treatment, while respecting operational culture.
Steps:
1. Ask what version they were taught, where, and how it works for them. Use their terminology [synthesis].
2. Screen for breath-related trauma: smoke, gas, drowning, choking, restraint, body armour or mask-related claustrophobia [synthesis].
3. Practise eyes-open, seated, with the client facing the door if they prefer, and offer them control of the count [synthesis].
4. Use it to regulate before and after trauma-focused work, not to avoid processing within an evidence-based trauma therapy [synthesis].
5. Say plainly that a breathing skill does not replace treatment for PTSD, depression, substance use or suicidality. Follow standard risk assessment [synthesis].
6. Watch for peer or leadership pressure to "just breathe through it" instead of seeking care [synthesis].
Example language (illustrative): "You'll probably know this from training as tactical breathing. How do you use it on the job?" / "If the pauses ever bring back anything from a call or deployment, just tell me and we'll change it."
Watch for: flashbacks or dissociation during holds (stop, ground, switch to 4.6), using the skill to suppress emotion completely, and shame if it "doesn't work". Signs it is working: the client uses it to stay within tolerance during therapy and in daily life.

4.10 Ending and maintenance

Purpose / when: final sessions, or when breathing work is complete within a broader therapy.
Steps: review what the client learned and when it helps. Write down their own version (the published pattern, or the holds-free adaptation), the safe settings and the stop rules. Identify early warning signs of stress and plan when to use the skill. Agree what to do if new health problems arise (stop the holds and check with a doctor) [synthesis].
Example language (illustrative): "Let's write down your version, when it helps you most, and when you'd check with your doctor before using it."
Watch for: stopping all practice suddenly, or over-relying on it as the only coping strategy. Signs it is working: the client names several coping options, with box breathing as one of them.

[source for section 4: Divine, Time 2016; Healthline; RWJBarnabas Health; Police Magazine; National Defence; Stonehewer 2009; Ogilvie & Kersten; Tolin; Meuret, SMU 2010; synthesis as marked]

5. Handling problems

All responses are [synthesis] unless a source is cited.

Dizziness, light-headedness, tingling or cramping: these suggest overbreathing or too large a breath. Stop and return to ordinary breathing [source: Healthline]. Next time, use smaller, smooth breaths [source: Stonehewer 2009] or the holds-free adaptation. If symptoms persist after stopping, seek medical attention [source: Healthline]. Repeated symptoms call for a breathing-pattern assessment by a respiratory physiotherapist.
Air hunger or panic during the empty hold: stop the holds at once, reassure and ground. In panic disorder, use the holds-free adaptation, or deal with the fear through planned interoceptive exposure rather than breathing control [source: Tolin; synthesis].
Chest pain, palpitations, faintness: stop and follow the medical-emergency procedure. Get medical review before any further breathing practice.
Pregnancy, cardiac or respiratory conditions: no holds without medical clearance [source: Healthline]. Never suggest changing inhalers or other medicines, and pass any change in symptoms on to the treating clinician.
Flashback or dissociation: stop, open the eyes, orient to the room (name objects, feel the feet), and change the method (4.6, or a different grounding skill). Explore the link to the breath later.
"It doesn't work" / stuck client: check how they are actually doing it (often forced or rushed), check expectations (calm, not blank), and offer the variant (4.4). Accept that some clients prefer other regulation skills.
Non-adherence: reduce the practice to a minimal routine, link it to a habit, explore beliefs ("it's too simple", "it's for soldiers"), and review obstacles without blame.
Resistance or scepticism: be honest that the evidence for this pattern is limited. Offer it as an experiment and invite the client to judge it by their own log.
Over-reliance or ritualised use: discuss it as a possible safety behaviour [source: Tolin]. Plan graded experiments without it.
Rupture (feeling patronised, or tested on their own professional skill): acknowledge their expertise (especially with first responders), invite feedback, and let them lead the practice.
Unsafe settings: if the client has been practising holds while driving, swimming, bathing or diving, give clear safety advice to stop practising there.
Escalating to longer holds or more intense breathwork on their own: advise against lengthening the pattern. For hyperventilation-and-retention methods, see the Wim Hof guide (167); for holotropic and other intense breathwork, see Domain VII.
Signs of a medical breathing disorder (breathlessness, asthma-like symptoms not helped by inhalers, a positive Nijmegen screen): refer to a GP or respiratory physiotherapist [source: Stonehewer 2009; Ogilvie & Kersten].

Sources

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