Development of Guided Respiration Mindfulness Therapy ... · Workshop presented at the Australian...

Development of Guided Respiration Mindfulness Therapy:

Manualization and Evaluation of Therapist Training and

Clinical Outcomes in the Treatment of Depression and

Anxiety

Lloyd Lalande B.Psych, Post Graduate Certificate Mental Health (Psychotherapy)

A thesis submitted as fulfilment for the

Degree of Doctor of Philosophy,

Queensland University of Technology

2017

Development & Evaluation of GRMT i

Declaration of Originality

I hereby certify that the work embodied in this thesis is the result of original research and has not

been submitted for the award of any diploma or higher degree in any other university, and that,

to the best of my knowledge and belief, the thesis contains no material previously published or

written by another person, except where due reference is made in the text of the thesis. Nor does

the thesis contain any material that infringes copyright.

Signed ated ………………………………

QUT Verified Signature

euroite

Development & Evaluation of GRMT ii

Development & Evaluation of GRMT

iii

Abstract

Breathwork is a psychotherapy intervention based on the use of modified breathing. While

Breathwork of various forms is used in some areas of mental health practice, there is, so far, no

standardised approach to treatment, no standardised training process and no evidence base for

effectiveness. Furthermore, the relationship between Breathwork and other forms of controlled

breathing and mindfulness has not been investigated. The research presented here was designed

to address these deficiencies. It adopted well established psychotherapy treatment development

protocols in a three stage program which: (1) identified a 3 component treatment model and

clarified its theoretical foundations, now referred to as guided respiration mindfulness therapy

(GRMT), (2) developed and evaluated a brief standardised training program aimed to equip

therapists with foundational knowledge and skill in the manualization approach, (3) evaluated

the clinical usefulness of the GRMT intervention in reducing symptoms of depression and

anxiety in an uncontrolled trial with 42 participants meeting DSM-IV criteria for depression or

anxiety disorder. Stage 1 resulted in qualified support for GRMT as a three component

treatment model comprised of sustained self-regulation of respiration, mindfulness, and

relaxation, and its possible utility in the treatment of depression and anxiety. Stage 2 established

that a brief, focused training program can equip therapists with basic knowledge and skills

required to deliver the standardised manual-based treatment. This study also showed that

therapists endorsed the intervention for clinical use and found it personally beneficial. Stage 3

showed GRMT produced clinically significant reductions in depression and anxiety symptoms

for the majority of participants. Experience of therapy was positive with participants reporting

increased control over symptoms, a more relaxed state, reduced experiential avoidance,

increased motivation to participate in healthy activities and increased mindfulness. These results

suggest that GRMT has promise as an effective brief treatment for depression, stress and

especially anxiety. Further research is needed to evaluate GRMT against active control

conditions.

Development & Evaluation of GRMT iv

Keywords

Anxiety, Breathwork, Depression, Mindfulness, Psychotherapy, Respiration, Therapist Training,

Treatment Development

!


v

Acknowledgements

Firstly, I would like to express my deepest gratitude to the following two people who have been

of invaluable help in the success of this project.

Professor Robert King. Robert guided the original mapping out of the methodological

approach taken in this study and acted as my principle supervisor during the second half of the

project. It was only after data collection was complete that I fully understood, and appreciated,

just how well the methodology mapped out by Robert matched the psychotherapy research

protocols for new treatment development research. Additionally, I have benefited from Robert’s

ability to bring calm and order to proceedings when my own anxiety levels were a little on the

high side.

Dr Matthew Bambling. Matthew was my principle supervisor for the first half of this project.

All the work of training therapists and conducting the clinical trial and associated data collection

was under the direct supervision of Matthew. Throughout this time I was often surprised by the

level of support and encouragement, patience and empathic understanding Matthew provided. It

was the kind of support that elicited in me a strong sense of loyalty and has resulted in impacts

that have powerfully shaped areas of my life beyond the research project.

In addition, I would also like to acknowledge and say thank you to Robert Schweitzer for

timely feedback and support as a second supervisor. As well as Roger Lowe for his contribution

in the early stage of the study. I would like to thank all the panel members at both my

confirmation of candidature and final seminar for their contribution. I would also like to thank all

the QUT staff, both academic and administrative who have provided support.

I am also grateful to the many therapists who were so generous with their time and made

such a valuable contribution to the study during the training and clinical trial phase. I would also

like to thank those individuals who came forward from the community to participate in this

study. I would like to express my gratitude to both the University of Queensland, where this

study was initiated, and the Queensland University of Technology for supporting me in this

study. I would also like to thank my mother who has provided ongoing encouragement during

this project, and all of my family who have believed in me and looked on with curiosity.

Development & Evaluation of GRMT vi

Publications

Paper 1: Lalande, L., Bambling M., King, R., & Lowe, R. (2012). Breathwork: An additional

treatment option for depression and anxiety? Journal of Contemporary Psychotherapy. 42(2),

113-119. DOI 10.1007/s10879-011-9180-6

Paper 2: Lalande, L., King, R., Bambling, M. & Schweitzer, R. (2016). Guided respiration

mindfulness therapy: Development and evaluation of a brief therapist training program.

Journal of Contemporary Psychotherapy. 46, 107-116. DOI: 10.1007/s10879-015-9320-5

Paper 3: Lalande, L. King, R., Bambling, M., & Schweitzer, R. (Accepted pending revision). An

uncontrolled clinical trial of guided respiration mindfulness therapy (GRMT) in the treatment

of depression and anxiety. Journal of Clinical Psychology.


vii

Presentations Relating to This Thesis

Lalande, L. (May, 2016). Introduction to GRMT. Presentation given to postgraduate counselling students at University of Canberra. Canberra.

Lalande, L. (November, 2015). Guided Respiration Mindfulness Therapy one-day workshop for mental health professionals. Presented to supervising psychologists at Australian Catholic University (Melbourne). Sponsored by School of Psychology, ACU.

Lalande, L. (2014). Developing a standardised clinical model of breathwork: Evaluation of therapist training and client outcomes in the treatment of depression and anxiety. Presentation to the School of Population Health, University of Adelaide, South Australia.

Lalande, L. (2014). Developing a standardised clinical model of breathwork: Research methodology, and evaluation of therapist training and client outcomes in the treatment of depression and anxiety. Presentation to the School of Psychology, University of Adelaide, South Australia.

Lalande, L. (2014). A Clinical Model of Breathwork: Client Outcomes & Introduction to Practice. Presentation to the Gestalt Australia & New Zealand (GANZ) Annual Conference, Brisbane, Australia.

Lalande, L. (2013). A Clinical Model of Breathwork: Therapist Training Outcomes. Keynote address to the Australian Breathwork Association Annual Conference, Sydney, Australia.

Lalande, L. (2013). Developing a standardised research-based breathwork intervention. Paper presented to the International Society for Psychotherapy Research (SPR) Annual Meeting, Brisbane, Australia.

Lalande, L. (2011). Developing a standardised clinical model of breathwork: Evaluation of therapist training and client outcomes in the treatment of depression and anxiety. School of Psychology (National) Symposium, Australian Catholic University (ACU), Brisbane, Queensland, Australia.

Lalande, L. (2010). Guided Respiration Mindfulness Therapy One-Day Workshop. Presented to the Australian Psychological Society, Special Interest Group: Mindfulness based interventions. Australian Catholic University, Brisbane, Queensland, Australia.

Lalande, L. (2010). Clinical Practice and a Standardised Breathwork Model. Keynote address presented to the Australian Breathwork Association Annual Conference. Adelaide, South Australia.

Lalande, L. (2010). Managing clinical issues in the practice of breathwork. Workshop presented at the Australian Breathwork Association Annual Conference. Adelaide, South Australia.

Lalande, L. (2010). Developing a standardised clinical model of breathwork: Evaluation of therapist training and client outcomes in the treatment of depression and anxiety. Queensland University of Technology (QUT) Symposium. Brisbane, Australia.

Development & Evaluation of GRMT viii

Lalande, L. (2009). What do we really know about breathwork - an empirical perspective. Keynote address to the Australian Breathwork Association Conference, Canberra, Australia.

Lalande, L. (2009). Common factors in the clinical practice of breathwork. Workshop presented at the Australian Breathwork Association Annual Conference, Canberra, Australia.


ix

Table!of!Contents!

!

Abstract(...................................................................................................................................................................(iii(

Keywords(...............................................................................................................................................................(iv(

Acknowledgements(............................................................................................................................................(v(

Publications(..........................................................................................................................................................(vi(

Presentations(Relating(to(This(Thesis(......................................................................................................(vii(

Table!of!Contents!.................................................................................................................................!ix(

List(of(Figures(.....................................................................................................................................................(xiv(

List(of(Tables(........................................................................................................................................................(xv(

CHAPTER!ONE!........................................................................................................................................!1(

Thesis!Overview!....................................................................................................................................!1(

Introduction(...........................................................................................................................................................(1(

Rationale(for(this(Study(...............................................................................................................................(2(Therapeutic+use+of+controlled+breathing+..............................................................................................................+3(Therapeutic+use+of+Mindfulness+................................................................................................................................+4(Therapeutic+use+of+Relaxation+...................................................................................................................................+5(Target+Disorders:+Depression+and+Anxiety+...........................................................................................................+6(

Treatment(Development(Research(.........................................................................................................(9(Treatment+Manual+..........................................................................................................................................................+9(Therapist+Training+......................................................................................................................................................+11(Evaluation+of+Training+and+Treatment+Outcomes+.........................................................................................+11(

Aims(...................................................................................................................................................................(12(

Methodology(..................................................................................................................................................(13(

Overview(of(Results(....................................................................................................................................(14(

Significance(of(Research(...........................................................................................................................(15(

Organisation(of(Thesis(....................................................................................................................................(18(

Paper(One:(Literature(Review(and(Clarification(of(Treatment(Model(..................................(18(

Paper(Two:(Development(and(Evaluation(of(a(Standardised(Training(Program(.............(18(

Paper(Three:(Clinical(Trial(Evaluation(of(Therapeutic(Effects(.................................................(18(

Development & Evaluation of GRMT x

CHAPTER!TWO!....................................................................................................................................!21(

Stage!One!(Paper!1)!..........................................................................................................................!21(

Breathwork:!An!Additional!Treatment!Option!for!Depression!and!Anxiety?!...............!25(

Abstract(.................................................................................................................................................................(26(

Introduction(.........................................................................................................................................................(26(

The(Guided(Respiration(Mindfulness(Therapy(Approach(..........................................................(27(

Suppression(of(Inner(Experience(and(Psychopathology(.............................................................(30(

Inhibition(of(Breathing(and(Psychopathology(.................................................................................(30(

Comparative(Psychotherapy(Approaches(.........................................................................................(32(

Support(for(Mindfulness(as(a(Component(of(Breathwork(..........................................................(33(

Neurological(Effects(of(Meditation(.......................................................................................................(35(

Deep(Relaxation(as(a(Component(of(Breathwork(...........................................................................(35(

Conclusion(............................................................................................................................................................(36(

Supplemental(Literature(Review(................................................................................................................(38(

Breathing(Based(Interventions(..............................................................................................................(38(

Mindfulness(Based(Interventions(..........................................................................................................(41(

CHAPTER!THREE!................................................................................................................................!45(

Description!of!Intervention!...........................................................................................................!45(

Overview(of(GRMT(Intervention(.................................................................................................................(45(

The(Core(GRMT(Intervention(Components(.......................................................................................(46(Respiratory+Regulation+..............................................................................................................................................+46(Mindfulness+.....................................................................................................................................................................+46(Relaxation+........................................................................................................................................................................+47(

CHAPTER!FOUR!..................................................................................................................................!51(

Transitioning!to!Stage!Two!(Paper!2)!.........................................................................................!51(

Guided!Respiration!Mindfulness!Therapy:!Development!and!Evaluation!of!a!Brief!

Therapist!Training!Program!..........................................................................................................!55(

Abstract(.................................................................................................................................................................(56(

Introduction(.........................................................................................................................................................(57(

Description(of(the(GRMT(Intervention(................................................................................................(59(

Development(of(Therapist(Training(.....................................................................................................(60(


xi

Method(..................................................................................................................................................................(62(

Design(...............................................................................................................................................................(62(

Ethical(Review(..............................................................................................................................................(62(

Therapists(.......................................................................................................................................................(63(

Training(Process(..........................................................................................................................................(63(

Training(Components(................................................................................................................................(64(

Measures(.........................................................................................................................................................(65(Guided+Respiration+Mindfulness+Therapy+Knowledge+Questionnaire+(GRMTLKQ)+..........................+65(GRMTLKQ+rating+manual+..........................................................................................................................................+66(Guided+Respiration+Mindfulness+Therapy+Competence+Scale+(GRMTLCS)+...........................................+66(Toronto+Mindfulness+Scale+(TMS)+.........................................................................................................................+67(Therapist+Perception+of+Treatment+......................................................................................................................+67(Guided+Respiration+Mindfulness+Therapy+Impact+Measure+(GRMTL+IM)+.............................................+68(

Results(...................................................................................................................................................................(68(

Training(Effectiveness(...............................................................................................................................(68(Therapists+Acquisition+of+Knowledge+..................................................................................................................+68(Therapist+Acquisition+of+Competence+..................................................................................................................+69(Impact+of+the+2LDay+Workshop+on+Therapist+Mindfulness+.........................................................................+70(

Therapist(Perception(of(the(GRMT(Intervention(...........................................................................(70(Therapist+perception+of+treatment+implementation+....................................................................................+70(Therapist+perception+of+training+...........................................................................................................................+71(Therapists+personal+experience+of+the+intervention+.....................................................................................+71(

Impact(of(the(GRMT(Intervention(on(Therapists(Wellbeing(.....................................................(72(

Discussion(............................................................................................................................................................(73(

Training(Effectiveness(...............................................................................................................................(73(

Training(Recommendations(....................................................................................................................(74(

Therapist(Intervention(Acceptance(.....................................................................................................(74(

Therapeutic(Impact(on(Therapists(receiving(GRMT(During(Training(..................................(75(Mindfulness+Effects+......................................................................................................................................................+75(

Limitations(.....................................................................................................................................................(76(

Conclusion(...........................................................................................................................................................(77(

CHAPTER!FIVE!....................................................................................................................................!79(

Transitioning!to!Stage!Three!(Paper!3)!.....................................................................................!79(

Abstract(.................................................................................................................................................................(82(

Development & Evaluation of GRMT xii

Introduction(.........................................................................................................................................................(83(

Method(...................................................................................................................................................................(86(

Design(................................................................................................................................................................(86(

Participants(.....................................................................................................................................................(86(

Treatment(........................................................................................................................................................(87(

Measures(..........................................................................................................................................................(88(

Analysis(.............................................................................................................................................................(89(

RESULTS(................................................................................................................................................................(89(

Primary(outcomes(........................................................................................................................................(91(

Secondary(Outcomes(..................................................................................................................................(95(

DISCUSSION(.........................................................................................................................................................(97(

CHAPTER!SIX!....................................................................................................................................!101(

Client!Experience!of!Guided!Respiration!Mindfulness!Therapy!.....................................!101(

Introduction(......................................................................................................................................................(101(

Method(................................................................................................................................................................(102(

Participants(..................................................................................................................................................(102(

Data(collection(............................................................................................................................................(102(

Analytical(strategy(....................................................................................................................................(103(

Results(.................................................................................................................................................................(103(

Symptom(reduction(..................................................................................................................................(103(

Relaxation(outcomes(................................................................................................................................(104(

Mindfulness(outcomes(............................................................................................................................(105(

Secondary(outcomes(–(unexpected(but(consistent(with(mindfulness(...............................(106(

Secondary(outcomes(–(unexpected(...................................................................................................(107(

Discussion(..........................................................................................................................................................(108(

CHAPTER!SEVEN!..............................................................................................................................!111(

Considerations!of!Mechanisms!of!Change!..............................................................................!111(

Processes(of(Change(.................................................................................................................................(112(Therapeutic+alliance+................................................................................................................................................+112(Mindfulness+and+Decentering+...............................................................................................................................+114(Problem+Actuation,+Exposure+and+integration+.............................................................................................+115(Intensity+of+Intervention+and+Reduction+of+Avoidance+Behaviour+.......................................................+118(


xiii

Mastery+Experiences,+SelfLEfficacy+and+Ontological+Safety+.....................................................................+120(

Conclusion(.........................................................................................................................................................(122(

CHAPTER!EIGHT!...............................................................................................................................!123(

Summary!of!Studies!........................................................................................................................!123(

Stage(One:(Specifying(Treatment(Approach(and(Rationale(for(Use(.....................................(123(

Stage(two:(Manualization(and(Evaluation(of(Therapist(Training(.........................................(124(

Stage(Three:(Evaluating(GRMT(in(the(Treatment(of(Depression(and(Anxiety(................(126(

Key(Strengths(and(Limitations(.............................................................................................................(127(

Future(Research(.........................................................................................................................................(128(

Treatment(Dissemination(......................................................................................................................(130(

Conclusion(....................................................................................................................................................(130(

REFERENCES!......................................................................................................................................!133(

APPENDICES!......................................................................................................................................!151(

Appendix(1:(Ethics(Approval(.....................................................................................................................(152(

Appendix(3:(Information(for(Participating(Therapists(..................................................................(154(

Appendix(4:(Informed(Consent(Form((Client)(...................................................................................(157(

Appendix(5:(Information(For(Participants(..........................................................................................(158(

Appendix(6:(GRMT(Treatment(Manual(.................................................................................................(161(

Appendix(7:(GRMT(–(KQ((Knowledge(Questionnaire)(....................................................................(177(

Appendix(8:(GRMT(–(KQ(Rating(Manual(...............................................................................................(179(

Appendix(9:(GRMT(Treatment(Adherence(Rating(Guide(and(Competence(Scale(...............(184(

Appendix(10:(GRMT(Impact(Measure(....................................................................................................(193(

Appendix(11:(Trial(Outcome(Battery(of(Measures(...........................................................................(194(Depression+Anxiety+Stress+Scale+...........................................................................................................................+195(Anxiety+Sensitivity+Index+.........................................................................................................................................+196(Working+Alliance+Inventory+L+Short+Form+.......................................................................................................+197(Outcome+Rating+Scale+..............................................................................................................................................+198(Toronto+Mindfulness+Scale+.....................................................................................................................................+199(GRMTLSelfLEfficacy+....................................................................................................................................................+200(

Appendix(13:(Treatment(End]Point(Interview(..................................................................................(201(

!

Development & Evaluation of GRMT xiv

List of Figures

Figure 1. Stage two flow chart of training components ................................................................ 16(

Figure 2. Stage three flow chart of clinical trial components ....................................................... 17(

Figure 3. Overview of study papers .............................................................................................. 19(

Figure 4. Slope of symptom response from pre-treatment for full sample of clients on DASS-21

full scale ................................................................................................................................ 92(

Figure 5. Slope of symptom response from pre-treatment for depression diagnostic group on

DASS-21 depression subscale .............................................................................................. 92(

Figure 6. Slope of symptom response from pre-retreatment for anxiety diagnostic group on

DASS-21 anxiety subscale .................................................................................................... 93(

(


xv

List of Tables

Table 1: Comparison of major features of MBSR with GRMT ................................................... 48(

Table 2: Comparison of major features of Progressive Relaxation with GRMT .......................... 49(

Table 3: Descriptive statistics for depression group on outcome variables .................................. 90(

Table 4: Descriptive statistics for anxiety group on outcome variables ....................................... 90(

Table 5: Depression and anxiety group t-statistics and Cohen’s d effect size from pre-treatment

to after session 3, 6 and 9 ...................................................................................................... 91(

Table 6: Frequency of depression group (n = 15) DASS-21 classification pre-treatment and at

terminating session ................................................................................................................ 94(

Table 7: Frequency of anxiety group (n = 27) DASS-21 classification pre-treatment and at

terminating session ................................................................................................................ 94(

Development & Evaluation of GRMT xvi

Development & Evaluation of GRMT 1

CHAPTER!ONE!

Thesis!Overview!

This opening chapter provides an introduction and orientation to the research project presented

in this thesis. It provides a brief background and motivation for the research as well as an

overview to the research and the results obtained. In addition, it describes the structure of the

thesis which is organised around three papers.

Introduction

Breathwork is a name given to various forms of alternative health practice based on the use

of modified breathing. While there are anecdotal reports of therapeutic benefits from the practice

of breathwork, there is little in the way of coherent literature and no agreement as to what

comprises a breathwork intervention. Consequently, so far, there has been no standardised

approach to treatment, no standardised training process, and no evidence base for effectiveness.

Drawing on the researcher’s experience adapting breathwork to clinical practice and the

empirical literature on comparable approaches and processes, this study identified and evaluated

a psychotherapy intervention based on the self-regulation of respiration, mindfulness and

relaxation, now referred to as guided respiration mindfulness therapy (GRMT). The core practice

of the GRMT intervention involves a 50 - 60 minute process in which the client is guided by the

therapist in maintaining their focus on the sustained self-regulation of respiration, application of

mindfulness to somatic phenomena as it emerges moment-to-moment, and relaxation.


Case examples of treatment response provided by the researcher from clients electing to try

the experimental GRMT approach during clinical practice strengthen the case for formal

empirical evaluation. For example, a female client reporting anxiety and a 10 year history of

Trichotillomania (primarily eyebrows and lashes) without remission, recorded an Anxiety

Sensitivity Index (ASI; Reiss, Peterson, Gursky, & McNally, 1986) score of 36 at intake which

reduced to 5 after 10 sessions of GRMT with remission from hair pulling maintained at 3

months. In a second case a professional male client presenting with panic attacks and reporting a

family history of panic, received five sessions over 12 weeks with treatment response assessed

using the ASI and the Depression Anxiety Stress Scale-21 (DASS; P. F. Lovibond & Lovibond,

1995). ASI score went from 51 at intake to 29 after the fifth session. DASS-21 full scale score

reduced from 37 to 12, and DASS-Anxiety subscale from 20 to 5, with a reported reduction in

panic attacks and fear of panic. A female client reporting depression and social avoidance

behaviour also received five sessions of GRMT and was assessed with the ASI and DASS on a

session-by-session basis. ASI scores reduced from 18 at intake to 4 after session five, while

DASS scores reduced from 42 to 7. The majority of post therapy scores in these cases where at

non-clinical levels based on population norms for both the ASI (Peterson & Plehn, 2010) and the

DASS (Henry & Crawford, 2005).

Rationale for this Study

In this doctoral study, a program of investigation was undertaken which involved

manualization of the intervention and development and evaluation of a brief, standardised

therapist training program designed to equip therapists with foundational intervention knowledge

and skill. This was followed by an open uncontrolled clinical trial of the intervention aimed at

evaluating its effectiveness as a clinical approach in the treatment of depression and anxiety

symptoms. The study aimed to explore the proposition that a relatively brief therapist guided

breathing intervention informed by the respiration literature (e.g., Bolton, Chen, Wijdicks, &


3

Zifko, 2004; Bradley, 2002) and traditional Buddhist respiration focused mindfulness meditation

practice (e.g., Ñāṇamoli, 1964) could induce a state of mindfulness, and produce therapeutic

effects that included reduction in depression and anxiety symptomology. The existing empirical

support for the effectiveness of interventions that utilise controlled breathing, mindfulness and

relaxation in the treatment of depression and anxiety, suggested that GRMT with its synthesis of

these components would be a comparably effective treatment.

Therapeutic use of controlled breathing

Historically, Western approaches to psychotherapy that have emphasised the importance of

deeper, freer breathing emerged relatively recently during the 1960s as fringe movements and

included Reichian therapy (Reich; see, Boadella, 1994) and Bioenergetics (Lowen, 1975), both

of which used bodywork with awareness of breathing. Holotropic Breathwork (Grof, 1988) was

developed by Stanislav Grof whose primarily interested was nonordinary states of consciousness

and their therapeutic and transformative effect (Reich, 2001). Initially these nonordinary states of

consciousness were induced through the use of LSD and later through the use of fast (but

otherwise unregulated) breathing, loud evocative music and energy-releasing body movement

(Reich, 2001). Breathwork practice described by Minett (2004) emerged during the 1970’s and

shares some features with the approach developed and evaluated in this thesis. All these

approaches have remained controversial and on the fringe of mental health practice.

Learning to regulate breathing has a centuries old history in Eastern approaches to wellbeing

(see, Liu & Chen, 2010). Qigong, for example, includes practices derived from Daoism and

Buddhism. When used for medical purposes as a therapy, Qigong teaches breathing which is

deep, features uninterrupted rhythmicity or “no obvious pause between inhaling and exhaling,”

avoids using forced exertion, and is without obstruction or sound (Liu & Chen, 2010, p.193).

This breathing pattern closely resembles the breathing pattern taught in the GRMT intervention

which is the focus of this thesis. Qigong is now well established as an area of academic study


and clinical research in China under the umbrella of Traditional Chinese Medicine. According to

Qigong theory, body, breath, and mind (described as the three adjustments) are in a reciprocal

relationship and health is achieved when all are integrated.

In the West, there has previously been little interest in research exploring emotion and

respiratory patterns (Boiten, Frijda, & Wientjes, 1994). However, the last few decades has seen

increased clinical and research interest in the role of breathing as a mediator between the mind

and body and its use in the regulation of the mind, mood and metabolism (Chaitow, Bradley, &

Gilbert, 2014). Additionally, controlled or regulated breathing is well-established as a

component of anxiety targeted interventions (Feldner, Zvolensky, & Schmidt, 2004). CBT aimed

at anxiety disorders generally employs a suite of interventions which often include the use of

breathing retraining or diaphragmatic breathing, as well as exposure to bodily sensations,

progressive muscle relaxation, and meditation (Hambrick, Comer, & Albano, 2010).

An example is panic control treatment, a CBT technique developed for panic disorder which

uses diaphragmatic slow breathing and graded exposure to anxiety related bodily sensations

(Kinrys & Pollock, 2004). In the first randomized controlled trial of panic control treatment for

panic disorder in adolescence, Pincus, May, Whitton, Mattis, and Barlow (2010) compared an

11-week manualized panic control treatment with a self-monitoring control group. Results

indicated participants in the panic control treatment group reported significant reductions in

anxiety, anxiety sensitivity, and depression in comparison to the control group. Importantly,

treatment gains were maintained at 6-month follow-up (Pincus et al., 2010).

Therapeutic use of Mindfulness

Interest in the effectiveness of mindfulness in clinical applications has seen considerable

growth over the last two decades with growth showing no sign of abating (Cullen, 2011). In the

UK a recent parliamentary report on mindfulness recommended the adoption of mindfulness

based therapies within the National Health System (Mindfulness All-Party Parliamentary Group,


5

2015), with specific recommendations made for health, education, workplace, and the criminal

justice system. Mindfulness based interventions are being used in increasingly diverse

populations and range of disorders (Didonna, 2009). For example, mindfulness based

interventions and yoga based therapies are increasingly considered in the treatment of

posttraumatic stress disorder within a defence force and veteran context (Steinberg & Eisner,

2015). Approaches that are comparable to the intervention in this current study are those with

formal mindfulness practice as their main component. Two interventions that meet this criteria

are mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990), and mindfulness-based

cognitive therapy (Segal, Williams, & Teasdale, 2002), both of which are informed by Buddhist

Vipassana meditation. These mindfulness based interventions have demonstrated effectiveness in

the treatment of depression and anxiety disorders (Hofmann, Sawyer, Witt, & Oh, 2010;

Vøllestad, Nielsen, & Nielsen, 2012) which are the target disorders in this program of research.

A recent meta-analysis of randomized controlled trials of treatments for anxiety disorders

(Bandelow et al., 2015) found mindfulness based therapies to have the largest mean pre-post

effect size (Cohen’s d = 1.56) of the psychotherapies evaluated, followed by individual cognitive

behavioural/exposure therapy (d = 1.30). The meta-analysis by Hofmann, et. al (2010) found

moderate pre-post effect sizes (using Hedges’ g, with magnitude interpreted using the same

criteria as Cohen’s d) of 0.59 for reducing depression symptoms and 0.63 for reducing anxiety

symptoms. Uncontrolled pre-post effect sizes for clients with anxiety disorders were found to be

0.97 and for depression 0.95, indicating a large effect. Another recent meta analysis of

mindfulness based therapy (Khoury et al., 2013) found a large pre-post intervention effect size

for anxiety (Hedge's g) of .89, and a moderate effect size for depression of .69.

Therapeutic use of Relaxation

The therapeutic use of relaxation has a long established history. Jacobson’s (1924)

influential work developing the progressive relaxation technique continues in revised form (e.g.,


Bernstein, Borkovec, & Hazlett-Stevens, 2000) to be a part of clinical practice for the treatment

of stress and anxiety disorders (Conrad & Roth, 2007). A meta-analysis evaluating the

effectiveness of relaxation training for reducing anxiety symptoms found a medium within-group

effect size (Cohen’s d) of 0.57 (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008). Applied

relaxation training has also been found to be as effective as cognitive therapy in treating

generalized anxiety disorder in two randomized controlled trials, with both studies showing

applied relaxation outperformed cognitive therapy at follow-up (Arntz, 2003; Ost & Breitholtz,

2000). Applied relaxation is a common component embedded in CBT interventions evaluated in

effectiveness and efficacy studies for anxiety disorders (Feldner et al., 2004; Stewart &

Chambless, 2009) and involves teaching clients to identify anxiety as it occurs and apply brief

relaxation exercises. In regard to relaxation techniques for depression, a Cochrane review found

relaxation training to be significantly better than minimal or no treatment, but less effective that

active psychological treatment (e.g. CBT) at reducing self-rated depression symptoms (Jorm,

Morgan, & Hetrick, 2008). Relaxation training is associated with the development of a range of

self-awareness and self-management skills (Smith, 1988; Smith, Amutio, Anderson, & Aria,

1996), and the ability to effectively manage stress has been shown to be a strong predictor of

psychological wellness (Edwards, 2003).

The literature cited above indicates that the use of controlled breathing, mindfulness and

relaxation have a history of use in mental health and empirical support for therapeutic benefits. It

also indicates that there is growing interest in research into the therapeutic benefits of related

approaches. Additionally, the research cited points to the promise of therapeutic effectiveness of

GRMT and provides support for the development and evaluation of this approach as a clinical

intervention aimed at the treatment of depression and anxiety.

Target Disorders: Depression and Anxiety


7

Anxiety and depression are high prevalence mental health conditions with a majority of

people not receiving help for these problems (Kessler, Chiu, Demler, Merikangas, & Walters,

2005; King et al., 2008; Slade, Johnston, Browne, Andrews, & Whiteford, 2009; Wang et al.,

2005). These conditions cause substantial adverse effects on individuals’ functioning in many

countries around the world (Ormel et al., 2008). Anxiety disorders are the most prevalent class

of mental health problem worldwide and are estimated to affect around 14% of the population

(Slade et al., 2009; Wittchen et al., 2011). In Australia, the prevalence of anxiety may be

increasing (Slade et al., 2009), with increased risk for employed men and women, women aged

45-64, and for women living in urban and non-regional rural areas (Reavley, Jorm, Cvetkovski,

& Mackinnon, 2011). A comprehensive systematic review of the global prevalence of major

depressive disorder found an annual rate of 4.7% (Ferrari et al., 2013). A mental health survey

conducted at the end of 1997 found that during the previous 12 months, 5.8% of the Australian

adult population (about 778,000 individuals) had one or more depressive disorders (Andrew,

Hall, Teesson, & Henderson, 1999). Of these, up to 78.6% also meet criteria for diagnosis of a

comorbid anxiety disorder (Andrew, et al., 1999). In the USA, between 1991 and 2002 the

prevalence of major depression went from 3.33% to 7.06% for all age groups (Compton,

Conway, Stinson, & Grant, 2006). Compared with clients with depression only, clients with co-

occurring anxiety and depression are reported to have increased levels of suffering, avoidance

behaviour, impairment in social and work functioning, and risk of suicide (Joormann, Kosfelder,

& Schulte, 2005).

Need for additional treatment options. In the case of anxiety it has been suggested that the

existing evidence indicates there is a need for the development and dissemination of additional

treatment options that offer more powerful treatment strategies and reach a broader range of

anxiety suffers (Schmidt & Zvolensky, 2007). A recent review examined 87 studies for CBT

treatment response rates for anxiety disorders found CBT treatment resulted in an overall


response rate across anxiety disorders of 49.5% at post-treatment with a slight increase at follow-

up to 53.6% (Loeric et al., 2015). Two clinical trials have included follow-up evaluations of

cognitive therapy for anxiety disorders, with one (Ost & Breitholtz, 2000) finding only 56% of

participants experienced clinically significant improvement at follow-up, while the other, (Arntz,

2003) found 53.3% recovered. This is consistent with an earlier report that suggested PTSD non-

response can commonly be up to 50% along with a high dropout rate (Schottenbauer, Glass,

Arnkoff, Tendick, & Gray, 2008). In the case of PTSD it has been suggested that the “limitations

of current mainstream approaches invite open-minded consideration of the range of promising

alternative and integrative approaches” (Lake, 2015, p14).

It is well recognised that only a minority of people with a common mental health problem

seek help, and this is particularly true of young people and men (Oliver, Pearson, Coe, &

Gunnell, 2005) who have difficulty talking about their problems (Harding & Fox, 2014; Taylor,

Adelman, & Kaser-Boyd, 1985). Anxiety disorder remission rates for children and adolescents

treated with CBT have been found to be between 20% to 46% (Ginsburg et al., 2011), which

suggests the majority of those being treated are not responding to this approach. In regard to

helping men, it has been questioned whether conventional therapeutic interventions make sense

(Shay, 1996). While there are established and effective treatments for anxiety and depression,

including brief psychodynamic and interpersonal psychotherapy and CBT, to date almost all

treatments are primarily talk-based requiring people to enter into dialogue to discuss their

problems. Potentially, this creates a barrier for people who have difficulty with talking about

problems. The unmet need of these populations suggests there is room for the development and

evaluation of therapies that place less emphasis on therapist-client dialogue, and which, if found

effective in the treatment of depression and anxiety, may provide an additional treatment option.

Acceptance of mind-body therapies. People with self-defined anxiety and depression use

complementary and alternative therapies more than conventional therapies (Kessler et al., 2001),


9

with mind-body therapies (e.g., relaxation, meditation, hypnosis, biofeedback) being the most

frequently used by people seeking psychotherapy for anxiety or depression (Elkins, Marcus,

Rajab, & Durgam, 2005). This suggests there is a high level of acceptance of mind-body

approaches to wellbeing in the community.

Treatment Development Research

When setting out to evaluate a novel treatment approach that has not been empirically

assessed it is of vital importance to ensure that the research methodology employed closely

matches well-established psychotherapy treatment development research protocols appropriate

for early treatment development research. Recent decades have seen increased attention paid to

formalizing the processes involved in the development of new treatments and a number of useful

guidelines have been developed as part of a stage model (e.g., Carroll & Nuro, 2002;

Rounsaville, Carroll, & Onken, 2001). This thesis adopted recommendations made in the stage

model of psychotherapy treatment development to guide the focus, tasks and methodology of the

program of investigation. Additionally, guidelines and scales that enable the evaluation of the

quality of outcome research have also been developed over recent years (Kocsis et al., 2010; Ost,

2008). In this study these were used as a checklist to give an indication to how closely the

methodology mapped onto current best practice psychotherapy outcome research methodology.

Treatment Manual

A crucial first step in developing a therapist training program and subsequent empirical

evaluation of treatment outcomes from delivery of the treatment approach in a clinical setting is

the development of an intervention treatment manual (Rounsaville et al., 2001). The

development of an intervention treatment manual provides the foundation for all subsequent

work in this study. Therefore the importance of this initial step to the research described in this

thesis cannot be overstated. The foundational work that informed treatment manual development

is embodied in Stage 1 of this thesis and is described in the paper presented in chapter two.


Treatment manuals provide a number of important advantages for psychotherapy training,

practice, and research. In the facilitation of therapist training treatment manuals play the

important role of providing a precise and well organized way to approach training and

supervision of therapists (Lambert & Ogles, 2004). A treatment manual can help ensure trainee

therapists learn the key theoretical and practical elements of an intervention during the training

process. This enhanced training focus on key theoretical and practical elements can in turn

enhance treatment integrity in subsequent clinical practice. In other words, therapists are more

likely to deliver the intervention as proscribed.

A critical aspect of any therapist training experience is supervision and here treatment

manuals have been shown to play an important role. A treatment manual can help focus

supervision sessions on addressing any therapist deviation from proscribed strategies and

increase manual adherence in subsequent therapy sessions (Anderson, Crowley, Patterson, &

Heckman, 2012). There is also empirical evidence that structured clinical training and

supervision can enhance trainees ability to form a positive therapeutic relationship with clients

(Hilsenroth, Ackerman, Clemence, Strassle, & Handler, 2002) and thus lead to better client

outcomes.

Treatment manuals can also play an important role in the empirical assessment of the

effectiveness of therapist training. A treatment manual plays a role in evaluating the

effectiveness of training by guiding the development of scales for accessing treatment integrity

and therapist competence. Such evaluation can support claims of internal validity in treatment

trials. Importantly, manuals also enable replication of the treatment protocol in future research,

ensuring different trials of the same approach are indeed offering a comparable treatment to

clients (Perepletchikova & Kazdin, 2005). Manual development in this study followed

guidelines suggested by the stage model of treatment development (Carroll & Nuro, 2002;


11

Rounsaville et al., 2001). The treatment manual developed in this thesis is unique to the thesis

and was not derived from other manuals or models.

Therapist Training

Implementation of new therapies requires training, however the effectiveness of training

remains a relatively unexplored field (Herschell, Kolko, Baumann, & Davis, 2010). In this study

a multi-component training process was adopted which included an intensive experiential

introduction workshop, follow-up practice with supervision and feedback. The training

effectiveness literature suggests that this format is most likely to lead to therapist acquisition of

treatment knowledge and skill (Herschell et al., 2010). An important advantage of standardised,

treatment manual-based therapist training is that it can be specifically targeted toward ensuring

trainees gain knowledge and skill in those elements of the intervention that have been

theoretically identified as essential to effective implementation and client outcomes. The

subsequent use of manual-based tools for assessing therapist knowledge and skill can be used to

identify shortcomings in training and guide changes to the training protocol that increase training

specificity and effectiveness by emphasizing or de-emphasizing aspects of the training.

Evaluation of Training and Treatment Outcomes

The overall goal of the research described in this thesis was to specify the treatment in a

manualized form and then conduct an initial evaluation of its feasibility and efficacy. The

inclusion in clinical trials of a combination of quantitative and qualitative methods has been

recommended as a way of making more meaningful assessments of outcome (O'Cathain,

Murphy, & Nicholl, 2007). O'Cathain et al. (2007) found that researchers using mixed method

designs reported doing so as a way to explore the impact of interventions beyond what

quantitative methods alone would allow. Qualitative investigation of psychotherapy outcomes

has been recommended as it provides more opportunity for research participants to provide

personally meaningful reflections on their experience of an intervention and does not confine


them to the predetermined responses of quantitative measures (Hill, Chui, & Baumann, 2013).

Qualitative enquiry has also been specifically recommended in relation to providing greater

insight into the practice of mindfulness (Grossman, 2011, p.1039). This study included

qualitative methods at the therapist training stage to evaluate therapist perception of the

intervention, and the clinical trial stage to investigate client’s post-therapy perception of changes

attributed to receiving the intervention.

Aims

This project developed and evaluated the effectiveness of the manualization Guided

Respiration Mindfulness Therapy (GRMT) intervention and a standardised therapist training

program in the approach through a three stage process.

The main aims of these stages were:

1. To develop an initial theoretical model of the intervention and identify empirical research

that suggests support for its use in the treatment of depression and anxiety. This stage

was to provide a basis for the development of a therapy treatment manual.

2. To manualize the intervention and develop and evaluate a brief standardised therapist

training program composed of a two-day experiential workshop and subsequent program

of supervised practice. This stage of the research aimed to:

a. Assess if brief manualization training was sufficient for therapists to acquire

foundational knowledge of the intervention.

b. Assess if therapists could adhere to the treatment model and competently deliver

the intervention in a clinical context.

c. Explore therapist perception and acceptance of the intervention.

d. Gain preliminary data on the effect of the intervention on therapists’ sense of

wellbeing resulting from their experience of the intervention during training.


13

3. To gain preliminary effectiveness data for the standardised GRMT intervention as a

treatment for depression and anxiety in a community sample. The following

experimental hypotheses were tested:

a. Participants would experience significant reduction in depression, anxiety and

stress by treatment end (maximum 10 sessions) and that pre-post treatment effect

sizes would be at least equivalent to that demonstrated in published evidence

based treatments.

b. Therapeutic alliance scores would mediate improvements in depression scores but

that improvements in anxiety and stress scores would be relatively independent of

therapeutic alliance.

c. Mindfulness scores would predict depression and anxiety symptom reduction.

Methodology

This study involved three stages which are described below. Graphical overviews of the

training and clinical trial process are depicted in Figures 1 and 2.

1. Stage one of this study aimed to identify and clarify core components of a clinical

intervention that utilized respiratory regulation as a core feature, and thus provide the basis for

the development of a treatment manual that would provide the foundation necessary for further

empirical research. This stage involved a literature review aimed at identifying and appraising

empirical evidence which could provide theoretically sound support for the intervention as a

treatment for depression and anxiety symptoms. This process included clarifying the core

components of the treatment model and resulted in a clearly specified rationale for the use of the

intervention with depression and anxiety symptoms. This review supported further investigation

into the treatment model.

2. Stage two of this study firstly involved the development of the GRMT treatment manual

for individual therapy. Stage two then proceeded to developed and evaluated a brief standardised


therapist training program. The primary focus of evaluation had two key elements, (1) repeated

measures evaluation of the impact of a two-day experiential workshop on change in intervention

knowledge, along with post-workshop focused discussions to qualitatively explore therapist

experience of training, and (2) evaluation of the outcome of extended training comprising of six

supervised practice sessions on therapist competence in delivering the intervention in a clinical

trial. A secondary focus involved a repeated measures evaluation of the impact of (a) the two-

day workshop on therapist mindfulness, and (b) the impact on therapists receiving the

intervention during training in terms of wellbeing (relaxation, anxiety, worry, enthusiasm and

openness).

3. Stage three involved evaluation of treatment effectiveness in an open, uncontrolled trial

using both quantitative and qualitative methods. A single group (n = 42) repeated measures

treatment trial design was used with post hoc comparisons by diagnostic group (depression, n =

15; anxiety, n = 27). Response to treatment was assessed with session-by-session repeated

measures with data analysed using multilevel analyses. The study used standardised instruments

with established norms. Client perception of treatment outcome was assessed at treatment end-

point using a semi-structured interview.

Overview of Results

Stage one (Chapter 2) in this study identified a three component intervention, now referred to

as Guided Respiration Mindfulness Therapy (GRMT). This review established that there is

empirical support for the idea that sustained inhibited breathing can develop in response to

stressful environments. And further, that suppression of inner experience has been identified as

playing a role in the development of symptoms of depression and anxiety. The review also found

that interventions with comparable components to the GRMT intervention (e.g., modified

breathing, mindfulness, relaxation) have demonstrated effectiveness in the treatment of

depression and anxiety. For example, the review identified empirical support for yoga breathing-


15

based interventions and mindfulness-based approaches in treating these conditions. With

qualified support identified for the key theoretical assumptions of GRMT, the foundation was

laid for further development and evaluation of the approach. The intervention is described in

more detail in Chapter 3.

Stage two (Chapter 4) developed and evaluated a brief, standardised (e.g., manual-based)

therapist training program. Results indicated therapists new to the approach can acquire

foundational knowledge and skill in the approach. Furthermore, therapists endorsed the clinical

use of GRMT and found the intervention personally helpful.

Stage three (Chapter 5) established that GRMT does provide therapeutic gains when used as

a treatment for depression and anxiety. Results indicated rapid symptom response for depression,

anxiety, stress, and anxiety sensitivity, as well as an increase in sense of wellbeing, with the

majority of participants experiencing statistically and clinically significant symptom change.

Significance of Research

It is important to remember this is the first time this intervention has been evaluated and

more rigorous research with an active control comparison is recommended to determine if the

results can be replicated. However, this research does introduce a potentially useful new

treatment option into mental health practice that utilises different change processes to existing

treatments, and demonstrates specific efficacy for anxiety. The finding that therapists in this

study found the approach relatively quick and easy to pick up and endorsed its use in clinical

contexts is encouraging for dissemination of the approach. The intervention itself demonstrated

rapid reduction for both depression and anxiety symptoms, with large effect sizes suggesting this

intervention could be useful to a range of populations that experience anxiety and who could

benefit from a brief intervention that does not involve extensive engagement in dialogue.


Figure 1. Stage two flow chart of training components

recorded


17

Figure 2. Stage three flow chart of clinical trial components


Organisation of Thesis

This thesis is organised around three papers which are presented in chapters 3, 4, and 5 (see

figure 3 for an overview). Chapter 1 provides an overview while chapter 2 presents a deeper

examination of relevant literature. Chapter 6 suggests change processes that theoretically may

operate in the GRMT intervention, and chapter 7 provides a conclusion to the thesis. The papers

are organised sequentially in the order in which the study was undertaken as indicated by the

three main aims described above.

Paper One: Literature Review and Clarification of Treatment Model

The first published paper (chapter 2) was in the form of a literature review examining the

empirical literature relevant to the development and clarification of a respiration-based

intervention. The paper proposed a three component treatment model which is now referred to as

Guided Respiration Mindfulness Therapy (GRMT), and clarified the theoretical foundation for

its use as a clinical intervention for the treatment of depression and anxiety symptoms (Lalande,

Bambling, King, & Lowe, 2012).

Paper Two: Development and Evaluation of a Standardised Training Program

The second paper (chapter 4) addressed the operationalization of the standardised GRMT

approach involving manualization and development and evaluation of a standardised therapist

training program (Lalande, King, Bambling, & Schweitzer, 2016b). Also assessed was therapist

perception and acceptance of the intervention.

Paper Three: Clinical Trial Evaluation of Therapeutic Effects

The third paper (chapter 5) presents the findings of an uncontrolled trial evaluating its

therapeutic impact with depression and anxiety symptoms. Therapists trained to administer

GRMT during stage two of the study provided treatment. A total of 42 clients with a diagnosis of

depression and/or anxiety (DSM-IV-R) participated in the trial with symptom response evaluated

over the course of treatment using the Depression Anxiety Stress Scale (Lovibond & Lovibond,

1995) as the main diagnostic instrument. The contribution of alliance and mindfulness to

outcomes was also examined.


19

Figure 3. Overview of study papers


21

CHAPTER!TWO!

Stage!One!(Paper!1)!

The paper presented in this chapter aimed to define a clinical model of breathwork and

identify theoretical foundations for its use in the treatment of depression and anxiety. The aims

of this paper were achieved by identifying empirical research which suggested support for a

treatment model composed of 3 core components: respiratory regulation, mindfulness and

relaxation. This paper comprises the first stage of this thesis research project, and provided

sufficient clarification of the treatment model for the development of an early treatment

development manual and provided a theoretical foundation to move on to Stage 2 of the project,

the development and evaluation of a brief, standardised therapist training program.

Given the novelty of the intervention being proposed and investigated, the Journal of

Contemporary Psychotherapy seemed to offer a forum suitable for the dissemination of this

psychotherapy approach. The paper was well accepted by this journal with reviewers being

intrigued by the manuscript.

Given the time laps from when the paper presented in this chapter was published a

supplemental literature review is provided at the end of the chapter that aims to provide an

update of current empirical knowledge relating to breathing and mindfulness interventions. The

focus is primarily on identifying literature published after the publication of the paper presented

in this chapter.


This was a joint paper with all co-authors doctoral supervisors of the thesis. The candidate

was responsible for writing the content of the manuscript, with the co-authors providing support

in focus and presentation.


23

Statement of Contribution of Co-Authors for Thesis by Published Paper In the case of the following chapter: Chapter Two (Paper One) Publication title and date of publication: Lalande, L., Bambling M., King, R., & Lowe, R. (2012). Breathwork: An additional treatment option for depression and anxiety? Journal of Contemporary Psychotherapy. 42(2), 113-119. DOI 10.1007/s10879-011-9180-6 The authors listed below have certified that:

1. They meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise;

2. They take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication;

3. There are no other authors of the publication according to these criteria; 4. Potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or

publisher of journals, and (c) the head of the responsible academic unit, and 5. They agree to the use of the publication in the student’s thesis and its publication on the

Australasian Research Online database consistent with any limitations set by publisher requirements.

Contributor Statement of contribution Lloyd Lalande Conceptualized the development of the GRMT

intervention. Conducted the systematic review of the literature and writing of the paper.

Signature: Date: 3/07/2015

Dr Matthew Bambling Provision of conceptual guidance and critical reviews throughout the writing process.

Professor Robert King Provided conceptual guidance and critical reviews of the paper in final stages.

Dr Roger Lowe Provided feedback on the paper in final editing stages

Principal Supervisor Confirmation

I have sighted email or other correspondence from all co-authors confirming their certifying

authorship.

Professor Robert King

Name Signature Date



euroite


25

Breathwork:!An!Additional!Treatment!Option!for!Depression!

and!Anxiety?!

Lloyd Lalande


Dr Matthew Bambling

University of Queensland



Dr Roger Lowe



Abstract

Breathwork is an increasingly popular experiential approach to psychotherapy based on the use

of a specific breathing technique, however, claims of positive mental health outcomes rely on

anecdotal clinical evidence, and the approach itself has not been clearly defined. To ascertain the

likely efficacy of breathwork this review clarifies the approach and its theoretical assumptions

and examines relevant empirical research relating to breathing inhibition, suppression of inner

experience, and possible neurological and physiological effects. Additionally, research into

mindfulness-based psychotherapy and yoga breathing-based interventions with comparable

features to breathwork are examined. Findings suggest qualified support for the key theoretical

assumptions of the guided respiration mindfulness therapy (GRMT) approach described in this

paper, and its possible utility in the treatment of anxiety and depression. Further research aimed

at exploring specific efficacy of this approach for these disorders may yield a useful additional

treatment option utilising a different process of change to existing treatments.

Keywords: Anxiety, Breathwork, Depression, Mindfulness, Psychotherapy, Respiration,

Somatic

Introduction

Classed as a mind-body, complementary health practice (Sointu, 2006), breathwork has

achieved a degree of recognition as a form of psychotherapy in Europe (Sudres, Ato, Fouraste, &

Rajaona, 1994) and popular interest is likely to grow with rapidly increasing use of alternative

and complementary mental health practices, particularly mind-body approaches for depression

and anxiety (Elkins et al., 2005). Despite interest in the approach, breathwork has not been

subject to empirical investigation which could guide training and clinical practice, or suggest


27

how client change might occur. Currently, there is no universal agreement as to specific

components of the technique or the theory defining the approach. Rather than devaluing untested

complementary or alternative approaches to mental health, controlled effectiveness studies

should be undertaken to examine the evidence for these practices (Norcross, 2000). The one

study of breathwork attempted to date (Sudres et al., 1994) examined the effectiveness of a

standardised 10 session intervention with 12 depressed and anxious clients (DSM III-R).

Symptom change was assessed pre and post treatment and at 8-week follow-up with ten out of

twelve participants achieving clinically significant improvements (<p 0.5), which were

maintained at follow-up. Results of this study should be interpreted with caution due to the small

sample size, lack of a control condition and no examination of process variables thought

important in treatment outcome. However, the study provided preliminary evidence for a

respiration-mindfulness based intervention.

The Guided Respiration Mindfulness Therapy Approach

The technique described here involves therapists guiding clients through an approximately

one hour process involving the ongoing regulation of breathing, relaxation and application of

mindfulness, while the client lies comfortably on their back. A series of ten weekly or fortnightly

sessions is the suggested norm. Apart from providing a rationale for the approach and general

support, no additional cognitive or behavioural strategies are required for client change to take

place.

The technique that most defines breathwork and differentiates it from other relaxation,

meditation and yoga exercises is ‘conscious connected breathing.’ It must, however, be pointed

out that within the field of breathwork there has not been universal agreement on the details of

what conscious connected breathing entails or how it is applied within sessions. Clarification is

offered here based on clinical experience and empirical support. The guided respiration

mindfulness therapy approach involves therapists guiding clients in maintaining throughout the


session a continuous uninterrupted breathing rhythm with virtually no pauses between transitions

of exhale and inhale, with inhalation being active and involving expansion of the upper chest

(Dowling, 2000; Minett, 2004). The lead author’s experience with breathwork over the last 20 or

so years suggests exhalation should be a transition to complete letting go and relaxation of

respiratory muscles. Based on the respiration research literature (Bolton et al., 2004; Bradley,

2002), this breathing pattern is comparable to a normal, healthy breathing style which features

virtually unbroken rhythmicity and the complete release during exhalation of respiratory muscles

active during inhalation. This breathing style differs from that of a normal resting state in that

clients are encouraged to adopt an inhalation generally of greater depth, emphasising

mobilization of the entire chest. Therapist instructions (Lalande, 2007) include statements like

“Keep your breathing connected – no gaps or pauses – just a continuous rhythm” and “Just let go

on the out-breath”. In addition to guiding clients in maintaining the conscious connected

breathing technique described above, therapist support is also provided in maintaining

mindfulness involving developing detailed awareness to somatic experience as it unfolds

moment-to-moment, and the adoption of an accepting open attitude toward the inner experience

taking place. Therapist instructions include, “Focus on the dominate sensation in your body –

whatever stands out - study that” and “Whatever is happening right now, just allow it to be

there.” Throughout the session clients are also encouraged to relax (Dowling, 2000; Minett,

2004) by remaining alert to the presence of muscular holding-on (tension) in the inner landscape

they are observing and releasing the tension they identify. Clients may become aware of pre-

existing tension or tension may develop in the form of tightening-up as a defensive response to

emerging somatic experience. Relaxation in this approach does not include muscle contractions,

hypnotic suggestions, visualization, or counting with breathing used in other approaches to

relaxation (e.g., Lukas, Bredewold, Landgraf, Neumann, & Veenema, 2011). A therapist

instruction would be “Any tension you notice – just let it go.”


29

Client experience of guided respiration mindfulness therapy practiced as described in this

paper can include novel somatic experiences including increased awareness of tension, energy

flows and sensations, along with brief occurrences of heightened arousal including increased

emotionality, sadness, frustration and fear (observed clinically as tearfulness or restlessness, for

example). It is well accepted that breathing, relaxation and meditative practices can create

greater subjective physiological awareness (Schwartz & Schwartz, 1996; Smith, 1988).

Autonomic nervous system effects tend towards overall parasympathetic dominance (relaxation).

On completion of a session clients generally report a state of mental clarity, profound relaxation

and sense of wellbeing. Anecdotal client reports of change as sessions progress include

spontaneous cognitive and behavioural insights, improved interpersonal functioning, and sense

of, and desire for, increased authenticity.

The existing breathwork literature (e.g., Dowling, 2000; Minett, 2004) does not explicitly

provide a conceptual model of psychopathology. This paper suggests that psychopathology from

the guided respiration mindfulness therapy model perspective involves the suppression of

feelings, sensations and emotions experienced as aversive and inhibition of breathing as a central

mechanism through which suppression is achieved. The need for ongoing control and defense

against awareness of troubling somatic and psychological experience (necessary to maintain a

sense of psychological balance) then results in a habitual, abnormal breathing pattern that

becomes a more or less permanent feature of physiological functioning. The guided respiration

mindfulness therapy described here assumes a link between the defensive adaptation of inhibited

breathing, the presence of unintegrated psychosomatic experience, and the development and

maintenance of psychopathology. The approach aims to bring rejected somatic experience into

conscious awareness through the removal of breathing inhibitions, and then integrate those

experiences into the general flow of consciousness by applying mindfulness characterized as


detailed somatic awareness, acceptance and relaxation. The empirical basis for this formulation

will be presented in the following sections.

Suppression of Inner Experience and Psychopathology

The suppression of inner experience, which is assumed in breathwork to be detrimental to

mental health whether achieved through inhibited breathing or not, has been shown to play a role

in the aetiology and persistence of anxiety and depression (Gross, 2002; Purdon, 1999).

Campbell-Sills et al. (2006) also found suppression correlated with poorer recovery from

negative affect, increased sympathetic arousal, and decreased parasympathetic responding. The

tendency to avoid or control, rather than accept inner experience is suggested as a specific risk

factor in generalised anxiety disorder (Roemer, Salters, Raffa, & Orsillo, 2005), and has been

correlated with diminished positive emotional experiences and life satisfaction, and less frequent

positive events on a daily basis (Kashdan, Barrios, Forsyth, & Steger, 2006). It seems that

maintaining the suppression of unwanted thoughts, memories and emotions may also require

continuous vigilance to avoid their paradoxical re-emergence during post-suppression periods

(Campbell-Sills et al., 2006; Dalgleish & Yiend, 2006; Wegner, 1994; Wenzlaff, Wegner, &

Roper, 1988). A clinical breathwork model that aims to improve wellbeing by replacing

suppression of aversive inner experience (through inhibition of breathing) with acceptance and

integration of inner experience (by teaching a non-defensive, uninhibited breathing style along

with openness to experience) seems to be supported by the above research, especially in the area

of depression and anxiety.

Inhibition of Breathing and Psychopathology

Evidence shows that anxiety and expectation related to social and environmental factors

leads to the development of inhibited breathing patterns (Fokkema, 1999). Additionally, a

cognitive orientation toward the environment as unpredictable, uncontrollable, or overwhelming

is linked to inhibited breathing characterised by subnormal breathing frequency (Anderson &


31

Chesney, 2002). Stressful environments have been found to elicit sustained inhibitory changes to

breathing patterns (Anderson, 2001) with higher demands on attention producing more inhibition

(Denot-Ledunois, Vardon, Perruchet, & Gallego, 1998). Classical conditioning, which has been

shown to shape breathing patterns (for a review of influences on breathing, see Shea, 1996), may

play some role in inhibited breathing developing into a habitual style. As suggest by Anderson

and Chesney (2002), in response to the state of hopelessness experienced when facing an

uncontrollable environment “an inhibited breathing pattern would not be merely a transient

response to an acute stressor, but a generalized breathing habit conditioned to the assessment that

the world is a difficult or dangerous place” (p. 224).

Inhibited breathing also effects neurological functioning. Given there is little or no reserve of

oxygen in the brain it is very sensitive to any changes in level of oxygen present in the blood or

changes to blood flow (Erecinska & Silver, 2001). Animal models have demonstrated that a

slight deficiency of oxygen reaching brain tissue (mild hypoxia) can result if breathing is

inhibited, and while energy production via glucose metabolism may remain unaffected, serotonin

synthesis is reduced (Erecinska & Silver, 2001; Nishikawa et al., 2005). In humans, conditioned

suppression of breathing leads to reduced oxygen and high CO2 levels in the blood which in turn

is associated with a tendency toward increased worry and negative affect (Dhokalia, Parsons, &

Anderson, 1998). Multiple studies of acute depression have demonstrated decreased frontal

cortex metabolism and limbic activation, with the severity of depression linked to larger

decreases in metabolism (Post, 2000).

It has also been suggested that a biological pathway in which elevations in blood pressure and

CO2 levels resulting from strained breathing perpetuate inhibited breathing once it is established

(Fokkema, 1999). The physiological evidence suggests a pathway by which inhibited breathing

patterns might affect brain metabolism and serotonergic neurotransmission and create a feedback

loop involving cognitive, physiological and neurological components that increase risk for major


depression (Rosa-Neto et al., 2004). Overall, the evidence discussed above suggests the

interaction of psychological and biological mechanisms may perpetuate both inhibited breathing

and symptoms of depression or anxiety.

Comparative Psychotherapy Approaches

Rhythmic Breathing-Based Yoga Interventions

Two yoga interventions that utilise rhythmic breathing have shown promise in treating

depression (for reviews on yoga for depression and anxiety see, Madson, Campbell, Barrett,

Brondino, & Melchert, 2005; Pilkington, Kirkwood, Rampes, & Richardson, 2005).

Shavasana Yoga teaches slow breathing featuring a two second pause after each inhale and one

second pause at the end of each exhale, while relaxing flat on the floor with eyes closed

(Khumar, Kaur, & Kaur, 1993). Fifty female subjects suffering from severe depression were

assigned to either the yoga treatment comprising of 30 minutes daily practice over 30 days, or a

no-treatment control group. 64% of the treatment group experienced significant reduction in

depression scores (Zung Depression Self-Rating Scale; Stein, Pesale, Slavin, & Hilsenroth,

2010) while 44% recovered completely. There was no overall change in the control group at

treatment end. (Khumar et al., 1993).

A randomised controlled trial conducted over 4 weeks compared Sudarshan Kriya Yoga with

electroconvulsive therapy (ECT) and tricyclic antidepressant medication (imipramine) as an

intervention for depression (Janakiramaiah et al., 2000). The yoga intervention includes a

number of breathing techniques involving various degrees of control and forcefulness and was

practiced for 45 minutes once daily for six days a week over the four week trial period. All

groups achieved significant improvement on the Beck Depression Inventory (Carroll et al., 2002)

and the Hamilton Rating Scale for Depression (Hill & Lambert, 2004) with no significant

differences between treatments (Janakiramaiah et al., 2000). The two approaches above teach

different breathing styles yet both show promise as treatments for depression which suggests that


33

a breathwork intervention that utilises uninhibited rhythmic breathing as a treatment component

would be similarly effective.

Support for Mindfulness as a Component of Breathwork

Fundamental to the GRMT approach is the sustained self-regulation of attention on breathing

and the details of bodily sensations as they arise moment-to-moment along with maintenance of

an attitude of acceptance toward inner experience. These are considered key elements that

define mindfulness meditation in the psychotherapy literature (Bishop et al., 2004), and

components responsible for therapeutic change in mindfulness-based stress reduction (MBSR;

Kabat-Zinn, 1990). Therefore, research supporting the effectiveness of mindfulness in MBSR

may also suggest some support for the effectiveness of GRMT.

Both MBSR and GRMT utilise formal mindfulness practice as a key intervention to create

therapeutic change, however, in MBSR mindfulness of breathing is a passive observational

process while in GRMT the conscious connected breathing technique described earlier is

actively adopted with therapist support as a therapeutic tool. Clients complete the breathing

component of a GRMT session in about 1 hour, which is comparable to the formal meditation

practice in MBSR; however, a guided respiration mindfulness therapy session is not generally

administered more than once per week for clinical reasons.

Mindfulness interventions are steadily amassing considerable empirical evidence suggesting

effectiveness (for reviews, see Allen, Blashki, & Gullone, 2006; Baer, 2003; Bishop, 2002;

King, 2006; Langer, McLeod, & Weisz, 2011). A rigorous meta-analysis (Grossman, Niemann,

Schmidt, & Walach, 2004) assessing MBSR for a variety of mental and physical health problems

yielded a medium pre-post effect size for positive outcome on all mental health variables

(d=0.54) and physical health variables (d=0.53). More specifically, MBSR has been found

effective in the treatment of generalised anxiety disorder, panic disorder and depression (Kabat-

Zinn et al., 1992) with treatment effects maintained at 3-year follow-up (Miller, Fletcher, &


Kabat-Zinn, 1995). MBSR has also been found to reduce ruminative thinking with reductions in

rumination accounting for reductions in depression and anxiety related maladaptive cognitive

content and affective symptoms (Ramel, Goldin, Carmona, & McQuaid, 2004). Rumination

predicts the onset of depressive disorders, anxiety symptoms and mixed anxiety-depression

(Nolen-Hoeksema, 2000) and also predicts greater depression and anxiety and longer duration of

negative feelings (Leahy, 2002).

The mechanisms by which mindfulness meditation brings about change are suggested to

include: exposure type processes; relaxation; an increased capacity for emotional regulation and

processing; and a changed relationship to ones thoughts, feelings and sensations (Baer, 2003;

Bishop et al., 2004; Hayes & Feldman, 2004; Shapiro, Carlson, Astin, & Freedman, 2006).

Given the first two of these mechanisms are formally utilised in the standardised breathwork

approach this paper describes, and the second two are consistent with anecdotal reports of client

experience, and in light of our current understanding of mindfulness practice as an effective

component of therapeutic interventions for depression and anxiety, the application of

mindfulness in the GRMT approach should also contribute to therapeutic outcomes.

The guided respiration mindfulness therapy intervention being developed here, while

including mindfulness does have some distinct differences in that it uses respiratory regulation.

Mindfulness, as described in the psychotherapy literature sited above, does not involve therapist

guided, moment-to-moment support in maintaining a continuous cyclic breathing rhythm with

active inhalation and complete release of respiratory muscles on exhalation - described as a

healthy, natural breathing style in the respiration literature (Bolton et al., 2004; Bradley, 2002).

In other words, mindfulness does not actively focus on achieving and maintaining an uninhibited

breathing pattern on a moment-to-moment basis. The modification of habitual inhibited

breathing patterns is not addressed directly in mindfulness, even though this may be an outcome

of extensive mindfulness meditation practice. The respiratory regulation component of GRMT


35

not only substantially increases awareness of somatic phenomena; it actually elicits deeply

buried somatic experience to which mindfulness can then be applied. While it is correct to say

the breathwork approach described here is mindfulness-based practice, it is also true to say it is a

respiration-based practice that utilizes mindfulness as an essential component in the process of

integrating somatic material the respiratory component makes available to conscious awareness.

Neurological Effects of Meditation

Research into the neurological effects of meditation also suggests therapeutic utility as a

component of a breathwork intervention. A well-established characteristic of meditation is

increased alpha and theta activity, with increased alpha activity shown to relate to higher

serotonin activation (Anderer, Saletu, & Pscual-Marqui, 2000; Thorleifsdotttir, Bjornsson, Kjeld,

& Kristbjarnarson, 1989), while Kjaer, et. al (2002) found theta activity during meditation

related to a 65% increase in dopamine release. During meditation overall cerebral blood flow

also increases (Cahn & Polich, 2006) which may play a role in these changes. Meditation is

thought to modulate behavioural states related to arousal, attention, mood, and motivation at

least partly through serotonergic innervation (Mesulam, 2000). Additional support for this

proposition comes from EEG studies suggesting meditators are better able to regulate intensity

of emotional arousal (Aftanas & Golosheikin, 2005). The well-established link between

meditation and increased alpha and theta brain wave activity suggests another possible pathway

by which the clinical model of breathwork presented here might create therapeutic neurological

changes.

Deep Relaxation as a Component of Breathwork

Relaxation techniques are known to alleviate distress, anxiety and depression, increase

positive mood states (Jain et al., 2007; Luebbert, Dahme, & Hasenbring, 2001; Stetter & Kupper,

2002), and increase EEG theta brain wave activity, which is associated with reduced central

nervous system arousal (Jacobs & Friedman, 2004). Relaxation in breathwork is concerned with


not only relaxation in a general sense, but also with developing awareness of, and skill in

releasing, holding-on at the most subtle levels, especially while experiencing challenging inner

experiences. GRMT aims to develop the cognitive skills of focusing, passivity and receptivity

that Smith (1988) suggests relaxation techniques promote. Smith (1988) describes focussing as

“the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli

for an extended period,” passivity as “the ability to stop unnecessary goal-directed and analytic

activity” and receptivity as “the ability to tolerate and accept experiences that may be uncertain,

unfamiliar, or paradoxical” (p. 321). This suggests relaxation in GRMT may reduce arousal

levels through a repeated exposure-like process, while teaching a relaxation response to

provocative inner experience. In addition, it suggests developing a sense of safety with a

psychological process characterised by complete letting-go, defencelessness and surrender to

experience.

Conclusion

There is empirical support for the idea that sustained inhibited breathing patterns can develop

in response to stressful environments. Research also suggests inhibited breathing lowers brain

oxygen and reduces serotonin synthesis with consequent increase in depressive symptomology.

Further, a feedback loop involving cognitive, physiological and neurological components may

perpetuate inhibited breathing and symptoms of depression and anxiety. In addition to the

encouraging results from the breathwork study by Sudres et al. (1994) noted in the introduction,

there is empirical support for yoga breathing-based interventions in treating depression, and

meditation-based approaches demonstrate efficacy in the treatment of depression and anxiety.

Neurological and behavioural self-regulatory changes associated with meditation are also related

to positive mental health outcomes. This review has identified empirical evidence that suggests

support for a standardised breathwork approach based on three core components that together

promote somatic integration; the rhythmic relaxed breathing pattern, mindfulness, and


37

relaxation. There is qualified support for the key theoretical assumptions of the breathwork

approach described here and its possible utility in the treatment of anxiety and depression. Given

no standardised breathwork approach exists for research purposes (e.g. manualization, training)

or clinical practice, and to differentiate this breathwork approach with its emphasis on

mindfulness to enhance integration, this model has been referred to as guided respiration

mindfulness therapy (GRMT). There is sufficient evidence to conclude a case to undertake

efficacy research into the approach particularly relating to depression and anxiety.


Supplemental Literature Review

This section identifies empirical literature that has been published since the publication of the

paper presented above, with the aim of identifying any gains in knowledge relevant to the

development and evaluation of GRMT as presented in this thesis.

Breathing Based Interventions

While there is interest in exploring the efficacy and effectiveness of interventions that

utilize modified breathing for addressing mental health issues, as far as can be determined from a

literature search using Google Scholar and PubMed with the search term ‘breathwork’ no

empirical studies could be found that examine an intervention comparable to that described in

this thesis. The paper presented in the following chapter did however appear in the top search

results.

As already noted in chapter one, there is interest in yoga-based therapies and mindfulness

based interventions as treatment options for posttraumatic stress disorder within a defence force

and veteran context (Lake, 2015; Lang et al., 2012; Steinberg & Eisner, 2015). Steinberg and

Eisner (2015) suggest the literature on the use of yoga and mindfulness-based interventions for

PTSD in veterans strongly indicates these practices may be efficacious.

One intervention involving controlled breathing which has attracted some interest in the

research literature over recent years is Sudarshan Kriya Yoga (SKY) (for reviews, see Brown &

Gerbarg, 2005a; Zope & Zope, 2013). Training in this approach involves the use of three distinct

breathing techniques (Brown & Gerbarg, 2005b) which feature different degrees of control, force


39

and breathing rate. ‘Ujjayi’ breathing using very slow deep breathing at 2 to 4 breaths per

minute, practiced for 10 minutes. This is followed by ‘Bhastrika’ breathing which involves rapid

inhalation and forceful exhalation (with use of arms to increase force) at a rate of 30 breaths per

minute and practiced for 5 minutes. Finally, Sudarshan Kriya breathing involves rhythmic cycles

of slow, medium and fast breathing. Courses in this approach may also, but not always, include

yoga postures, and basic yoga knowledge.

GRMT shares with the yoga approach described above a focus on regulation of breathing.

However, GRMT is markedly distinct in the form of respiratory regulation and its use of

mindfulness and relaxation. GRMT aims to establish a natural, uninhibited breathing pattern and

specifically emphasises learning to identify and release any effort, control or straining involved

in exhalation, whereas SKY techniques involve what could be considered an extreme level of

control or inhibition of both inhalation and exhalation. Despite these differences, evidence

suggesting the effectiveness of yoga-based breathing interventions in the treatment of depression

and anxiety should, and least theoretically, suggest support for the therapeutic use of GRMT as a

potentially effective treatment of depression and anxiety.

The paper that precedes this chapter identified empirical research that suggested Sudarshan

Kriya Yoga was effective in the treatment of depression in a population of female university

students (Khumar et al., 1993). More recently, a 7-day group-based Sudarshan Kriya Yoga

intervention has been evaluated in a randomized controlled longitudinal study as a treatment for

PTSD in U.S. military veterans (Seppala et al., 2014). Twenty-one participants were assigned to

either the “breathing-based meditation” group or a wait-list control group (n = 10). Participants

receiving the intervention experienced reduced PTSD symptoms (e.g. re-experiencing,

hyperarousal), and reduced general distress, anxiety and respiration rate on completion of the

study and at one-year follow-up compared to a wait-list control group (Seppala et al., 2014).

Reduction in PTSD and anxiety symptoms were maintained independent of continued practice.


Confidence in the results of this study is strengthened by inclusion of a waitlist control group

with randomization, intention-to-treat analyses, self-report and psychophysiological outcome

variables, and follow-up assessments at 1 month and 1 year. These features, the authors point

out, are often missing in studies into novel interventions. This study strengthens the case for the

utility of breathing-based interventions for PTSD and for anxiety disorders more generally. It

also suggests GRMT may be similarly effective in the treatment of PTSD. Using means and

standard deviations reported by Seppala et al., pre-post intervention change in the active

intervention condition indicated a large within-group effect size of d = 0.93 for change on the

Mood and Anxiety Symptoms Questionnaire (MASQ).

Empirical evidence for the effectiveness of interventions utilizing controlled breathing are

not limited to approaches derived from yoga. For example, using a randomised controlled

research design, Hayama and Inoue (2012) evaluated the effect of a brief deep breathing

intervention on ‘tension-anxiety’ (as assessed on the Profile of Mood States-Short Form

(Japanese version)) that women with gynaecological cancer can experience during post-operative

chemotherapy. The intervention took 10 minutes to deliver and was comprised of three steps:

abdominal breathing, thoracic breathing and breathing with arms raised. Each step comprised of

10 deep breaths with slow exhales. The intervention was delivered pre-chemotherapy and post-

chemotherapy on the second, fourth and sixth day. The researchers found that clients who were

assigned to the deep breathing intervention group (n = 11) had significantly lower anxiety-

tension and fatigue scores on the tenth day following chemotherapy than patients in the control

group (n = 12) who had received treatment as usual chemotherapy and nursing care. This study

suggested that a brief, easy to adopt intervention utilizing controlled breathing may be effective

in reducing tension-anxiety in women receiving chemotherapy. An effect size calculation was

not possible as the authors did not report needed descriptive statistics.


41

Breathing interventions, when combined with relaxation, may also be useful in reducing

sensitivity to pain. In a recent study exploring the effect of deep and slow breathing (with or

without relaxation instructions) on pain perception, Busch et al. (2012) found deep slow

breathing decreased pain sensitivity but only when it was combined with relaxation. Decreased

pain sensitivity was also associated with a decrease in sympathetic activity but again, only when

deep slow breathing was combined with relaxation. This study suggests relaxation made an

important contribution to therapeutic outcomes and suggests support for the use of relaxation in

GRMT.

Mindfulness Based Interventions

Research into, and use of, mindfulness-based interventions is expanding rapidly and the

findings of this research can be used as an indication of the potential effectiveness of GRMT.

Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT)

are two mindfulness-based therapies (MBT) that both feature formal meditation practice as a

core element and informal mindfulness practices to enhance awareness of breathing, bodily

sensations and everyday activities. MBSR is an eight-week program involving weekly 150-

minute sessions consisting of didactic instruction, group discussion, formal meditation practice

(body scan, sitting meditation, walking meditation, loving kindness meditation), gentle hatha

yoga, and a 6-hour silent meditation retreat (Kabat-Zinn, 1990). GRMT is comparable to these

approaches in that it is based on a formal meditative process focused on breathing and bodily

sensations. Both MBSR and MBCT subscribe to an operational definition of mindfulness as

awareness involving intentional, non-judgemental attention to present moment experience

(Kabat-Zinn, 1982; Segal et al., 2002), which is comparable to to attentional focus of GRMT.

There now exists a solid body of empirical research that provides support for the

effectiveness MBSR and MBCT in treating a range of physical and psychological conditions

(Chiesa & Serrattic, 2011; Klainin-Yobas, Cho, & Creedy, 2012; Vøllestad et al., 2012).


Specifically, mindfulness-based therapies have proven effective in treating anxiety and

depression. A meta-analytic review examining the effectiveness of these MBT in 39 studies with

a total clinical sample of 1,140 participants (Hofmann et al., 2010) found robust within-group

effect sizes (Hedge’s g) for anxiety (0.97) and depression (0.95) symptoms. This review included

a range of physical and psychological conditions. As Hofmann et al. (2010) concluded:

“In sum, our findings are encouraging and support the use of MBT for anxiety and

depression in clinical populations. This pattern of results suggests that MBT may not

be diagnosis-specific but, instead, may address processes that occur in multiple

disorders by changing a range of emotional and evaluative dimensions that underlie

general aspects of well-being.” (p. 180)

In a RCT the eight-week MBSR program has been shown to lead to significant reductions in

anxiety for patients with anxiety disorders compared to a wait-list control condition (Vollestad,

Sivertsen, & Nielsen, 2011). For completers of the MBSR program (n = 31), reductions in

anxiety showed a within-group effect size (Cohen’s d) of 1.05, while the effect size for

reductions in depression symptoms was d = 0.96.

In a recent review of MBSR and mindfulness based interventions in cancer care, Carlson,

Rouleau, and Garland (2015) point out that high quality research and evidence for the

effectiveness of these interventions has proliferated over the last decade. Findings from their

review suggested that these interventions contribute to “reductions in psychological distress,

sleep disturbance, and fatigue, and promotes personal growth in areas such as quality of life and

spirituality” (Carlson et al., 2015).

The effectiveness of the standard MBSR program plus usual care has been evaluated against

a usual care only control group in a RCT examining reduction in depression and anxiety in

women with stage I–III breast cancer (Wurtzen et al., 2013). The authors reported statistically


43

significant and clinically meaningful reductions in anxiety and depression in the MBSR group

relative to the usual care group. At 12-month follow-up there was a medium within-group effect

size from baseline for depression (d = 0.55, n = 120) and anxiety (d = 0.36, n = 120) in the

MBSR group, compared to d = 0.18 , and d = 0.12 respectively for the usual care group.

A recent randomized controlled trial examined the effect of MBSR on depression, anxiety,

stress and mindfulness in a population of Korean nursing students (Song & Lindquist, 2015).

Compared with the waitlist control group, participants receiving MBSR reported significantly

greater decreases in depression, anxiety and stress, as measured using the Depression, Anxiety,

Stress Scale – 21 (DASS-21). Post-test DASS-21 scores indicated the MBSR intervention was

superior to the waitlist control with between group effect sizes for depression (d = 0.72), anxiety

(d = 0.51), and stress (d = 0.87) in the medium to large range.

The research cited above presents a handful of studies out of a large and continually growing

pool that demonstrate mindfulness based interventions provide therapeutic benefits with medium

to large effect sizes. Mindfulness is a core component of GRMT and it is reasonable to assume

that it will provide comparable therapeutic impact to the mindfulness-based interventions

discussed above. The research presented in this supplemental section strengthens the case for

examining the effectiveness of GRMT presented in the preceding paper.


45

CHAPTER!THREE!

Description!of!Intervention!

Detailing the intervention in a treatment manual operationalized the intervention proposed in

the previous chapter. This process ensured that a standardised approach was used for training

and clinical purposes. Further details of the intervention, its manualization and the development

of training are described in the chapters that follow. The treatment manual is provided as an

appendix. In this section a concise description of the intervention is provided. Also provided is a

comparison of GRMT with progressive relaxation and the Mindfulness-based Stress Reduction

(MBSR) program.

Overview of GRMT Intervention

The core practice of GRMT involves a 50 – 60 minute process during which the therapist

guides the client in the sustained application of the intervention’s three core components:

respiratory regulation, mindfulness, and relaxation. The treatment is administered with the client

taking a lying position with eyes closed and hands at their side. In general, no dialogue is entered

into during the entire 50 – 60 minute process, however, the therapist does take an active role in

coaching the client. Guided by the treatment manual developed for this study (see appendix),

therapists use a range of standardised verbal intervention statements aimed at encouraging client

engagement and adoption of the three core components, ensuring adherence to treatment

protocol, and maintaining client comfort and sense of safety.


In this study, total session length was 90-minutes. This length of time allowed for a 15-

minute opening segment in which outcome measures were completed, the intervention was

described or reviewed and any concerns about the intervention or its impact during the previous

week could be briefly discussed. A closing segment of 15-minutes provided a few moments for

further integration of the experience of the session, and an opportunity for the therapist to

normalize any client concerns and address any treatment related questions. The closing segment

also included negotiating a time for the next session.

The Core GRMT Intervention Components

The GRMT intervention is composed of three core components: 1) respiratory regulation, 2)

somatically focused mindfulness, and 3) relaxation. Clients are therapist guided in engaging in

all three components simultaneously in a focused manner for the entire session.

Respiratory Regulation

The respiratory component of the GRMT intervention focuses on three main areas which are

considered central to the aims and effectiveness of the intervention: 1) adopting and maintaining

a breathing pattern characterised by unbroken rhythmicity, 2) mobilization of the diaphragm and

upper chest, 3) complete release (relaxation) of all respiratory and peripheral muscles on

exhalation. The skilful adoption of this breathing pattern is considered an ideal which the

therapist consistently and sensitively guides the client toward. Standardised intervention

statements are designed to encourage establishment and maintenance of a breathing pattern

characterized by these features. Client’s ability to adopt the proscribed breathing pattern varies

considerably between individuals and develops progressively during and across sessions.

Mindfulness

The application of mindfulness in GRMT has two aspects: 1) the establishment of contact

with the physical sensation most dominant in the present moment and application of sustained

attention to that sensation, and 2) the adoption of an attitude of acceptance, which may be


47

characterized by a sense of surrender, openness, and vulnerability, to whatever sensations,

feelings or other phenomena are present. During a GRMT session, mindfulness is applied to an

amplified level of somatic experience (activation) that has been intentionally elicited through the

regulation of breathing. The targeted application of mindfulness to sensations further increases

awareness of somatic phenomena. As such, mindfulness in GRMT plays a dynamic role related

to an exposure type process. Engagement in GRMT is likely to challenge participants to develop

skills in affect regulation, tolerance and acceptance of novel psychosomatic experience beyond

what might be expected through practice of MBSR or MBCT (see Table 1 for a comparison of

MBSR and GRMT). Carlson (2012) suggested that learning ways “to hold the strong emotions

and sensations that arise can be transformative” and developing the insight that specific somatic

phenomena may be experienced as unpleasant, but are tolerable and constantly changing can

provide further liberation from suffering.

Relaxation

The application of relaxation in GRMT involves two parts: 1) developing skill in identifying

the presence of tension at increasingly subtle levels, and 2) learning to relax and release tension

when it is identified. The use of relaxation in GRMT is comparable to Jacobson’s (1924)

progressive relaxation in that it aims for the client to develop skills in identifying and relaxing

tension at increasingly subtle levels. A comparison of progressive relaxation and GRMT

technique specific elements is given in Table 2. While progressive relaxation is considered an

important component of anxiety treatments, it is considered insufficient on its own (Rodebaugh,

Holaway, & Heimberg, 2004). Its use as a component of the GRMT practice is to facilitate the

process of integration, for example by reducing defensiveness when encountering or being

exposed to previously suppressed, denied or warded off feeling states.


Table 1: Comparison of major features of MBSR with GRMT


49

Table 2: Comparison of major features of Progressive Relaxation with GRMT


51

CHAPTER!FOUR!

Transitioning!to!Stage!Two!(Paper!2)!

The critical review in the previous chapter identified empirical literature that suggested

support for an intervention based on the three components of respiratory regulation, mindfulness

and relaxation. What was evident in the review was the lack of literature, empirical or otherwise,

that directly defined or examined breathwork as a psychotherapy intervention, with the exception

of the one study of an unspecified intervention. This lack meant existent breathwork literature

offered little to inform the development and evaluation of a clinical intervention based on

respiratory regulation, mindfulness and relaxation. As a consequence, in order to inform the

conceptualization of what is now referred to as GRMT, increased weight was placed on

psychotherapy approaches featuring comparable components to the proposed intervention (e.g.,

mindfulness-based psychotherapies and yoga breathing interventions), other comparable

practices (e.g., relaxation and meditation), and the respiration literature itself.

As the reader will most likely notice, from this point on there is a de-emphasis of the use of

the term breathwork in this thesis. This shift is due not only to the insights gained through the

initial review of empirical literature mentioned above, but also the researcher’s attendance

during the course of this project at multiple annual conferences conducted by the Australian

Breathwork Association (listed in the Presentation section at the beginning of this thesis). Apart

from initial exposure to breathwork during the late 1980’s the researcher had distanced himself

from this community of practitioners due to concerns related to ethics and lack of informed

professional practice. Attendance at these events reinforced two main points, these concerns are


just as valid today as they had been in the past, and the practice of breathwork remains highly

variable, little understood, and infused with a diverse range of quasi-spiritual ideas and

approaches. These experiences highlighted for the researcher how much the approach in this

study, characterized by a meditative style and relaxation, deviated from current breathwork

practices. With the identification of the three-component model described in chapter 2, this

differentiation becomes even starker.

The following joint paper described the development and evaluation of a brief standardised

therapist training program. The introduction also provided further elaboration of the GRMT

intervention. The Journal of Contemporary Psychotherapy was the publisher of the review paper

presented in chapter 2, and seemed a suitable publication avenue for this part of the research

program. It is a peer-reviewed journal which provides an international forum in which to

examine complexities facing psychotherapists and positions itself on the leading edge of modern

developments in psychotherapy. The journal publishes empirical research on a range of

interventions that utilize mindfulness including Dialectic Behaviour Therapy and Acceptance

and Commitment Therapy among others. Its current H Index is 19.


53

Statement of Contribution of Co-Authors for Thesis by Published Paper

In the case of the following chapter: Chapter Three (Paper Two) Publication title and date of publication or status: Lalande, L., King, R., Bambling, M. & Schweitzer, R. (2016). Guided respiration mindfulness therapy: Development and evaluation of a brief therapist training program. Journal of Contemporary Psychotherapy. 46, 107-116. DOI: 10.1007/s10879-015-9320-5 The authors listed below have certified that:






Contributor Statement of contribution Lloyd Lalande

Developed and conducted training program, data collection and data analysis. Writing of manualscript.


Professor Robert King Provided guidance in the analysis of training data analysis. Provided critical reviews of the manualscript.

Dr Matthew Bambling Provision of guidance in training program development and critical reviews of the manualscript.

Robert D Schweitzer Provided feedback on the paper in final editing and revision stages


I have sighted email or other correspondence from all Co-authors confirming their certifying

authorship.


Name Signature Date



euroite


55

Guided!Respiration!Mindfulness!Therapy:!Development!and!

Evaluation!of!a!Brief!Therapist!Training!Program!

Lloyd Lalande


Robert King


Matthew Bambling


Robert D Schweitzer



Abstract

The present paper describes the development and evaluation of a standardised multi-component

therapist training program in guided respiration mindfulness therapy (GRMT). GMRT is a

manual-based, experimental clinical intervention involving concentrated focus on sustained self-

regulation of breathing, application of mindfulness to emergent somatic experience and

relaxation. Therapists (n = 61) new to the approach attended a 2-day experiential workshop and

were evaluated pre-post workshop for change in intervention knowledge, as well as change in

mindfulness. These trainees also participated in post-workshop focus group sessions to explore

perception of the intervention. A subset of 40 therapists participated in a second training

component, and 14 of these were rated for competent delivery of the intervention during

participation in a clinical trial. During training, therapists personally received the treatment

giving the opportunity to assess treatment session (n = 283) impact on sense of wellbeing.

Results indicated a brief focused training program can equip therapists with basic knowledge and

skills required to deliver the standardised manual-based treatment. Qualitative analysis of focus

group sessions showed that therapists endorsed the intervention for clinical use and found it

personally beneficial. This research provides a foundation for further evaluation of clinical

effectiveness of the intervention.

Keywords: Breathwork, Brief Psychotherapy, Mindfulness, Psychotherapy Training,

Respiration, Self-regulation, Treatment Development


57

Introduction

The implementation of new and novel therapies requires a range of processes before they can

be translated into clinical practice. The first process involves training therapists in the

implementation of the approach. The effectiveness of such training remains a relatively

unexplored field (Herschell et al., 2010). More specifically there is no current literature on the

training of practitioners in guided respiration mindfulness therapy (GRMT). GRMT is a manual-

based experimental approach to psychotherapy based on a process that syntheses three core

components which are sustained over the course of a session: 1) the self-regulation of respiration

utilizing an uninterrupted rhythmic breathing pattern aimed at removing breathing inhibition and

increasing contact with somatic experience, 2) application of mindfulness with a specific somatic

focus on physical sensations as they emerge moment-to-moment, and 3) the progressive

relaxation of tension at increasingly subtle levels. The approach draws on the lead authors

experience with breathwork (e.g., Minett, 2004), classical Buddhist respiration-mindfulness

concentration practice (e.g., Ñāṇamoli, 1964), and the respiration research literature (e.g., Bolton

et al., 2004; Bradley, 2002). A previous report (Lalande et al., 2012) proposing this three-

component model, presented a theoretical rationale and qualified support for the potential utility

of GRMT as a treatment for anxiety and depression. Empirical research was identified

supporting the proposition that habitual breathing inhibition can develop in response to stressful

environments. Also identified were interventions with comparable components to GRMT which

have demonstrated effective in the treatment of depression and anxiety. GRMT is comparable to

mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) and mindfulness-based cognitive

therapy (MBCT; Segal et al., 2002) in that it is based on a formal meditative process. A meta-

analytic review examining the effectiveness of these approaches in 39 studies with a total clinical

sample of 1,140 participants (Hofmann et al., 2010) found robust effect sizes (Hedge’s g) for


anxiety (0.97) and depression (0.95) symptoms. Both MBSR and MBCT involve passive

observation of breathing and physical sensations. GRMT is distinct from mindfulness training

taught in MBSR and MBCT in that practice involves sustained concentration on self-regulation

of breathing. Self-regulation of breathing has been suggested as a possible primary treatment for

anxiety (Jerath, Crawford, Barnes, & Harden, 2015) as it can promote an ANS shift from

sympathetic dominant state (e.g., anxiety) to a parasympathetic dominant state. GRMT is also

comparable to Jacobson’s (1924) original conceptualization of progressive relaxation training in

it’s aim for clients to learn to localize tensions and relax them at increasingly subtle levels,

however GRMT is distinct in that no muscle contractions are used and relaxation is learnt

through self-regulation of breathing and mindfulness. Unlike mantra based meditation which

uses controlled thinking in the form of silent repetition of a word or phrase (Ospina et al., 2007),

GRMT practice actively discourages engagement with thinking.

Case examples using the GRMT approach provided by the lead author gave an initial

indication of positive depression and anxiety symptom response measured on the Depression

Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995) and suggested investigation of

therapeutic effects is warranted. In an open, uncontrolled clinical trial evaluation of GRMT

associated with the evaluation of therapist training reported in this current paper, a community

sample of 42 participants with a DSM-IV diagnosis of anxiety and/or depression received up to

10 sessions of the manualized GRMT intervention. Results showed statistically significant

improvement (p < .001) in depression and anxiety symptoms (DASS) over the course of

treatment with 83% of participants also experiencing clinically significant improvement

(Lalande, King, Bambling, & Schweitzer, 2016a).

The current paper reports on the development and evaluation of a therapist training program

designed to achieve a standardised approach to treatment and benchmarks for therapist


59

competence. The broad aim being to lay a foundation for systematic research which could

evaluate the clinical utility of this intervention in a meaningful way.

Description of the GRMT Intervention

To practice GRMT, therapists learn to guide clients in applying the three core components:

respiratory regulation, mindfulness, and relaxation. The intervention can be completed in 50 - 60

minutes during which time the client is in a lying position with eyes closed and hands at their

side. Therapists learn to sensitively administer a range of standardised intervention statements

tailored to encourage client compliance to each component of the method. Respiratory regulation

involves adopting and maintaining a breathing pattern characterised by unbroken rhythmicity,

mobilization of the diaphragm and upper chest with depth of inhalation dependent on session

dynamics, and complete release of all respiratory and peripheral muscles on exhalation.

Relaxation of respiratory muscle control during exhalation serves as a centre point from which

progressive awareness of tension and its release encompasses the whole body. Mindfulness in

GRMT is somatically focused with particular attention given to establishing contact with the

most salient sensation at any given moment. Relaxation involves gaining skill in recognizing the

presence of tension at increasingly subtle levels and learning to release it throughout the therapy

session.

We suggest it is rare for people to intentionally develop a level of somatically focused

mindfulness concentration at which point insight spontaneously arises. The concept of making

and sustaining ‘contact’ with the body through attention and concentration is seen as the basis of

feeling in Buddhist psychology (Hanh, 1998) and is the starting point of therapy in GRMT.

Attention and concentration are deployed by having the client engage in the volitional regulation

of their respiration. Since the therapist is monitoring this engagement on a moment-to-moment,

breath-by-breath basis, there is little opportunity for the client to disengage cognitively or

behaviourally from attending to the respiratory regulation process and contact with their body.


Contact with somatic experience is deepened with the targeted application of mindfulness, and

engagement in the process of relaxation of tension. The therapist learns to address any

disengagement or deviation from protocol with an intervention aimed at helping the client

reengage. Psychotherapy in GRMT is characterised by insight and integration, which takes place

at the union of sustained concentration on regulation of breathing, establishment of mindfulness

of sensations, and the relaxation of physical tension employed as a defence against contact with

uncomfortable inner experience. Clients gain competence in approaching, tolerating and

accepting their inner experience, which will often be related to deep personal meaning. The

therapy experience can in part be characterised as exposure, and therapist training involves

learning to guide the process in a way that maintains client engagement. The therapy is

experienced as non-cathartic (e.g., meditative), safe and as comfortable as possible.

Development of Therapist Training

The first step in therapist training is manualization of the intervention. Guidelines suggested

by the stage model of treatment development (e.g., Carroll & Nuro, 2002; Rounsaville et al.,

2001) were adopted to produce a treatment manual that aimed to (1) provide a cohesive

framework to guide therapists delivery, (2) encourage intervention protocol adherence and

promote competence (Gearing et al., 2011), (3) inform therapist training and supervision and (4)

guide development of tools for evaluating the effectiveness of training.

The quantity of training ranges widely, however the general format suggested by Weissman,

Rounsaville, and Chevron (1982) is instructive and widely accepted (Miller & Binder, 2002;

Moncher & Prinz, 1991; Perepletchikova & Kazdin, 2005). This consists of a treatment manual,

an intensive didactic seminar, experiential role-play practice plus subsequent supervised practice

and feedback. Although research into the effectiveness of therapist training has been neglected

(Fairburn & Cooper, 2011) and evidence for effectiveness remains tentative (for a recent review,

see Beidas & Kendall, 2010), this model seems to have the most empirical support (Herschell et


61

al., 2010). Training effectiveness may be enhanced with increased emphasis given to a number

of key training components. Active learning, which involves behavioral rehearsal, modeling,

coaching and feedback is considered to be critical to effective training (Beidas & Kendall, 2010;

Perepletchikova & Kazdin, 2005), and has been found to differentiate the training outcomes of

different trainers even when the training is standardised, manual-based, and trainers are highly

experienced (Henry, Schacht, Strupp, Butler, & Binder, 1993).

Supervision seems to increase adherence (Anderson et al., 2012) but when explicitly focused

on increasing manual adherence may further enhance training effectiveness. Feedback in this

case should be based on actual practice behaviour observed in recorded sessions and evaluated

against treatment specific adherence and competence measures (Perepletchikova & Kazdin,

2005). This approach is more likely to improve adherence than reliance on therapists’ self-

descriptions of practice, especially in a new and novel treatment, because therapists may not

recognise and therefore cannot report those areas of clinical practice where competence needs to

be acquired, maintained and improved (Miller & Mount, 2001).

An important ethical issue in providing training in experiential practices is the amount of

personal exposure needed for competent practice. An instructive example that applies to GRMT

is offered by Segal et al. (2002, pp. 53-55) who found competence in mindfulness training, as

taught in Mindfulness-based Stress Reduction (MBST; Kabat-Zinn, 1990), requires therapists

have themselves been in the position of client and gained experiential knowledge of, and comfort

with, emergent experiences elicited by the intervention across multiple sessions. Segal et al.

(2002) point out that this deeper understanding of what takes place equips therapists to provide a

supportive and safe therapeutic environment for clients that fosters acceptance and engagement

with the intervention, especially when encountering challenging inner experiences. In this

current study some therapists, after satisfactorily completing the first two stages of training,

would continue their involvement under supervision in a clinical trial designed to evaluate


competence in delivering GRMT and the therapeutic effects of GRMT practice on depression

and anxiety symptoms. Therefore therapists need to be sufficiently familiar with the

psychosomatic dynamics of GRMT and the therapeutic process that unfolds across sessions. It is

therefore of great importance to give therapists sufficient personal experience of the treatment

they would deliver.

The current study involves development and testing of a standardised therapist training

program. The primary aim was to determine whether a brief training process is sufficient to

develop therapist knowledge and competence in GRMT practice. A secondary aim was to assess

therapist acceptance of a new therapeutic methodology. A novel component of the training

program comprises therapist participation in the GRMT therapy. This experiential component

allows preliminary evaluation of the impact GRMT practice on therapist well-being and

mindfulness.

Method

Design

The primary focus of the study had two key elements, (1) repeated measures evaluation of

the impact of a two-day experiential workshop on change in intervention knowledge, and post-

workshop focused discussions to explore therapist experience of training, and (2) evaluation of

the outcome of extended training on therapist competence in delivering the intervention in a

clinical context. A secondary focus involved repeated measures evaluation of the impact of (a)

the two-day workshop on therapist mindfulness, and (b) the impact of receiving the intervention

on therapists’ wellbeing.

Ethical Review

The study received ethical clearance from the Queensland University of Technology Office

of Research Ethics and Integrity, and was classified as ‘low risk’.


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Therapists

Participating therapists responded to study information sent out by email through university

and hospital mental health networks in Brisbane, Australia. All therapists went through a consent

process and were informed of: details of the content and aims of the study; the experimental

status of the intervention; and the experiential nature of the training process and the possibility of

physical or psychological discomfort as a result of receiving the intervention during training.

Participants were required to have a minimum of one year counselling experience or be currently

enrolled in a graduate clinical psychology or counselling program. Sixty-one therapists (male:

13%, female: 87%) completed the initial 2-day workshop. Participants identified themselves as

being a practicing psychologist (n = 17, 27.8%), probationary psychologist currently undertaking

graduate clinical training (n = 18, 29.5%), practicing counsellor (n = 14, 22.9%), currently

undertaking graduate counselling training (n = 5, 8.1%), social worker (n = 4, 6.5%), nurse (n =

2, 3.2%), and occupational therapist (n = 1, 1.6%). Four therapists had completed doctoral level

studies. The majority (n = 40) of these therapists volunteered to participate in the second

component of training, and 14 (male: 21.5%, female: 78.5%) of these who elected to participate

in the trial stage of the broader study were evaluated for competence in delivering the

intervention. All participants had a self-identified interest in holistic or somatically focused

approaches to treating depression and anxiety.

Training Process

The training process required therapists to be familiar with the client treatment manual

(Lalande, 2007). This manual comprised two sections to guide therapists in delivering the

intervention. Section one provided intervention characteristics, a rationale for use with the

targeted diagnostic syndromes of depression and anxiety, indications and contraindications, and

guidance on managing clinical challenges. Section two was practice focused. It provided detailed

narrative guidance therapists could use to orient clients to the use of respiratory regulation,


mindfulness and relaxation components of treatment. Guidance for actual GRMT facilitation

included a lift-out table, which spelt out intervention statements matched to observed client

respiratory cues. Instructions aimed to provide clear, succinct expressions of the behaviour the

therapist wished to encourage in clients to remain on protocol. Guidelines for sensitively

facilitating session completion and markers for characteristics of effective delivery were also

provided.

Training Components

The training program comprised three components. The first component was a standardised

2-day (14 hour) training workshop. This was first piloted with two therapists in order to establish

feasibility and timing of content and prompted a number of minor modifications. The workshop

was then offered on seven occasions between late 2008 and 2012 with 61 therapists attending.

Workshop content extended the treatment manual and provided a theoretical and technical

understanding of foundational skills and an experiential understanding of the therapeutic process.

The format included slide presentations, role-play demonstrations and discussion of specific

skills and procedures. Each day also gave therapists’ practice in delivering one live GRMT

treatment session under close supervision followed by debriefing and feedback.

The second component was 6 additional 3-hour training sessions. These involved therapists

meeting in pairs on a weekly basis and employing their training by administering GRMT to each

other in a live session. It’s important to note that these sessions were not role-plays. Sessions

were video record with recordings used to guide supervision aimed at encouraging manual

adherence. Therapists received a minimum of two supervision sessions either individually or in

pairs, as well as attending at least one group supervision meeting. Therapists were encouraged to

request additional supervision if needed either in person or by phone. On completion of these

two training components therapists had administered eight sessions of the intervention and had


65

personally received the treatment equivalent of what someone with a clinical condition would

receive.

The third component was participation in a clinical trial evaluation of the intervention.

Therapists were given the opportunity to treat one or more clients for up to 10 sessions.

Therapists could receive supervision as often as they requested or after every second session.

The first author conducted training and supervision.

Measures

Guided Respiration Mindfulness Therapy Knowledge Questionnaire (GRMT-KQ)

We developed a new 7-item measure, the GRMT-KQ, to assess therapist’s acquisition of

foundational knowledge. Items were constructed using a short answer format with clinical

vignettes requiring specific responses. Knowledge was ranked on 5-levels: high (5), medium (4),

minimum acceptable (3), somewhat less than satisfactory (2), or not at all satisfactory (1). These

levels were then collapsed into a dichotomous rating of either less than satisfactory knowledge

(levels 1 and 2), or satisfactory knowledge (levels 3, 4, and 5), representing what in the lead

author’s opinion was necessary for adequate delivery of the intervention. Areas assessed related

to: treatment rationale, respiratory regulation, mindfulness, managing client comfort, and

intervention specific meaning of integration. An example item being, “Before giving a client

their first GRMT session, it is necessary to give clear instructions in how to apply mindfulness.

What instructions would you give your client regarding this component of the approach?” This

short answer format was well suited to assessing basic knowledge as answers cannot be guessed,

they must be supplied. The GRMT-KQ was completed before and after completion of the 2-day

workshop. Two raters independently assessed pre- and post-workshop knowledge of GRMT.

The intra-class correlation coefficient (two-way random effect model for absolute agreement)

was .928 (CI = .970 - .989) pre-workshop and .822 (CI = .703 - .893) post workshop. This

indicated that the GRMT-KQ had acceptable inter-rater reliability. An estimate measure of


internal consistency was calculated by averaging ratings from the two judges (Cronbach's alpha

= .81) as suggested by A. F. Hayes and Krippendorff (2007).

GRMT-KQ rating manual

To foster rating reliability, therapists GRMT-KQ responses were rated with a manual

specifically developed for this study. The first author, who acted as the first rater, developed a

draft manual. This was then reviewed for clarity and adequacy of guidance by a second rater

previously trained in the GRMT intervention. Both raters then independently rated 2

questionnaires. Discrepancies in judgements were discussed leading to further refinement of

rating guidance. Raters then independently rated test responses from 20 therapists. This last

process was repeated twice before satisfactory agreement between raters was achieved. The

resulting 5-page rating manual contained context and aims of knowledge assessment, and

scoring system including a standardised rubric and narrative guidance for interpreting alternative

or ambiguous responses. The two raters independently rated all questionnaires.

Guided Respiration Mindfulness Therapy Competence Scale (GRMT-CS)

The GRMT-CS was developed based on the client treatment manual in order to evaluate

therapist competence in facilitating the core GRMT intervention. The general structure of the

widely used Cognitive Therapy Scale (Young & Beck, 1980) was used as a model. The GRMT-

CS consisted of 13 items rated on a 7-point scale from 0 (very poor) to 6 (excellent). A score of

≥ 3 was considered satisfactory competence, while a score of ≤ 2 was considered unsatisfactory.

The scale had two parts. Part A (10 items) assessed the use of key intervention statements in

guiding the client in the application of respiratory regulation, mindfulness and relaxation, as well

as general support. For example, guidance provide for inhalation was graded from a score of 0

corresponding to “Therapist failed to coach client in the regulation of inhalation” to a score of 6

which corresponded to “Therapist consistently worked with client throughout the session to

ensure appropriate depth and speed of inhalation to ensure engagement with therapy process


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and manage client comfort.” Part B contained 3 additional items rating, (1) the degree

interventions were provided when needed, (2) correctness of interventions chosen for target

behaviour, and (3) therapist flexibility in delivering interventions. Item 1 of part B was rated

slightly differently to other scale items in that it used a continuum ranging from, too little (-0 -1,

-2), adequate but less than ideal (-3, -4), high correspondence (-5, 6, +5), adequate but more than

ideal (+4, +3), and too much (+2, +1, +0). Fourteen therapists provided at least one GRMT

treatment and submitted recordings of at least one full session (session 3 or later). All sessions

were rated by the lead author who also provided 5 additional sessions (exemplars of competent

practice), which were rated and used as a reference point. Cronbach's alpha coefficients

demonstrated the GRMT–CS (with item 1 of part B removed due to modified scoring) to have

excellent internal consistency (α = .96).

Toronto Mindfulness Scale (TMS)

The Toronto Mindfulness Scale (Lau et al., 2006) was used to determine if therapists’ state-

mindfulness changed from pre- to post workshop. The TMS is a 13-item measure using a 5-point

Likert scale with a range of 0 (not at all) to 4 (very much). The scale comprises two subscales:

‘curiosity’ reflecting an attitude of interest in connecting with ones experience, and

‘decenteredness’ reflecting the capacity for observing thoughts without over identification with

them. The TMS has demonstrated good internal consistency (a = .84 – .88) across a number of

studies (Lau et al., 2006). Cronbach’s α coefficients in the present study showed good internal

consistency pre-workshop (α = 0.79) and post-workshop (α = 0.88).

Therapist Perception of Treatment

In order to explore therapists’ perception of the intervention semi-structured focus groups

were conducted at the end of each 2-day workshop. Discussion centred around three areas, (1)

implementation of the GRMT intervention in therapists own clinical contexts, (2) experience of

training from a professional perspective, and (3) therapists’ personal experience of receiving the


intervention. Audio recordings of group discussions were transcribed verbatim resulting in a

16,000-word transcript. This was then analysed following Braun and Clarke's (2006) guidelines

to identify the major themes and subthemes in therapists’ experience.

Guided Respiration Mindfulness Therapy Impact Measure (GRMT- IM)

The GRMT-IM is a 5-item self-report measure developed for this study to obtain preliminary

data on the impact of GRMT sessions on therapist wellbeing. Items were rated from very little

(1) to very much (10), and assessed change in level of relaxation (How relaxed would you say

you are at the moment?), anxiety (How would you describe the level of anxiety you are

experiencing right now?), worry (What level of worry are you experiencing about your life at the

moment?), enthusiasm (How enthusiastic would you say you feel about your life at this

moment?), and openness to experiencing (At this moment, how receptive would you say you are

to observing unpleasant thoughts and feelings without trying to control or change them?).

Therapists completed the scale immediately before and shortly after receiving the GRMT

intervention during training. Cronbach’s α coefficients in the present study showed good internal

consistency (α = 79).

Results

Training Effectiveness

Therapists Acquisition of Knowledge

GRMT knowledge increased significantly (t (60) = 24.52, p < .001) from pre to post-

workshop. The mean post-workshop knowledge score was 3.7 (SD = .67) out of a possible score

of 5, compared to 1.5 (SD = .55) pre-workshop with a very large effect size (Cohen’s d) of 3.58.

Using the cut-off scores for acceptable knowledge, outlined in the method section above, by

post-workshop 43 (70%) therapists demonstrated acceptable knowledge on 6 or more assessment


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items, with twenty three (37.7%) rated as demonstrating acceptable knowledge on all seven

items.

Therapist Acquisition of Competence

Competent delivery of the intervention was evaluated. Session recordings were provided by a

subset of therapists during their participation in a clinical trial associated with a broader program

of research. Recordings were also provided by the first author for rating as a ‘gold standard’

comparison. All recordings were evaluated for competence using part A and B of the GRMT-CS.

On part A of the GRMT-CS therapists achieved an overall mean competence score of 3.77

(SD = 1.47). Ten therapists (71.5%) demonstrated a satisfactory level of competence (mean score

of ≥ 3) with ratings ranging through excellent (n = 2), very good (n = 5), and good (n = 3). Three

therapists were judged as delivering borderline adequate delivery, while one was judged less

than adequate. By way of comparison, the 5 recordings from the lead author had an overall mean

of 5.26 (SD = 0.65). After recordings from the four therapists who failed to demonstrate

adequate delivery were removed from the data the remaining therapists mean competence score

(M = 4.43, SD = 0.78) was not significantly different from the mean competence score of the

researcher (t = 1.94, df = 22, p = .065), although the effect size (d = 1.05) was large.

Part B of the GRMT-CS evaluated the timing, correctness and flexibility of delivery of

interventions. Therapists achieved an overall mean score of 3.96 (SD = 1.58). Ten therapists

(71.5%) were ranked as providing intervention statements when needed (timing) with a rating of

high (n = 6), or adequate (n = 4) timing. The same therapists (n = 4) ranked as less than

competent on part A of the GRMT-CS were also rated as demonstrating less than adequate level

of timing with the majority (n = 3) falling into the too little range, while one demonstrated over-

use of interventions. Eleven therapists (78.5%) where ranked as competently providing correct

interventions for observed client behaviour, and flexibility in providing interventions, with

ratings of high (n = 6), or adequate (n = 5). Three therapists ranked as less than adequate on both


these items. No treatment model non-compliant therapeutic techniques were evident in any of the

recorded sessions.

The relationship between therapist competence (as measured by the GRMT-CS) and

knowledge acquisition (as measured by GRMT-KQ score post-workshop) was investigated

through Pearson correlation. This indicated a moderate association, which was not significant

because of the small sample size (r = .411, n = 14, p = .144).

Impact of the 2-Day Workshop on Therapist Mindfulness

Therapists (n = 61) mindfulness increased significantly from pre-workshop to post-workshop

as measured with the TMS (paired sample t test, t (df - 60) = 5.292, p < 0.01). The pre-workshop

mean of 31.93 (SD = 6.46) increased to 36.48 (SD = 8.31), with a medium effect size (d = 0.61).

However, the TMS curiosity subscale scores did not change significantly from pre-workshop (m

= 18.02, SD = 3.87) to post-workshop (m = 18.59, SD = 4.32, t (df - 60) = 1.237, p = 0.221) with

an effect size of d = 0.13. The TMS decenteredness subscale scores did change significantly (t

(df – 60) = 6.714, p < .001), with a pre-workshop mean of 13.92 (SD = 4.14) which increased to

17.86 (SD = 5.11) post-workshop with an effect size of d = 0.84.

Therapist Perception of the GRMT Intervention

Therapist (n = 61) perceptions of the GRMT intervention were evaluated through thematic

analysis of the transcript of post-workshop focus group sessions. A range of clear sub-themes

were identified under three themes: treatment implementation, training, and personal experience

of the intervention.

Therapist perception of treatment implementation

There was consensus across sessions that the intervention was useful, easy for clients to pick

up, and worked quickly. It was seen as a good fit with current trends in psychotherapy with one

therapist stating, "I see similarities with some of the facets of things like ACT and mindfulness

which are very popular and people are accepting very widely now." There was overall


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endorsement and enthusiasm for its implementation with broad (but not universal) applicability.

Therapists across sessions also felt it would be useful in the treatment of trauma, and generally

beneficial for clients who have difficulty regulating emotions, avoid inner experience, or have

difficulty verbally articulating issues. One therapist stated, "Some people really struggle to put

their thoughts and their feelings into words, and this … you just go through the process and it

completes itself and very little verbal interaction is required."

Therapist perception of training

Therapists found the client treatment manual useful and engaged with it, for example, one

therapist stated, "I thought I would experiment with some of those things in the back of the

manual today, and I wasn't sure if I was saying too much, but afterwards [the “client”] said no,

she thought they were really appropriate." Therapists across multiple focus group sessions

indicated they felt they had acquired some basic confidence after two days of training. For

example, one therapist referring to the second day of training stated, "I found I had a bit more

confidence today in speaking up and keeping [the client] on track. I felt like I was more able to

attend to what was happening with [the client]." There was general agreement across sessions

that more training was needed to become competent in the good timing of interventions and in

managing unusual client reactions. A number of therapists reported experiencing powerful,

unambiguously intervention linked therapeutic effects during the two sessions experience during

the workshop. These included regressed states which, while experienced as positive, where

identified as indicating the need for adequate therapist training to ensure clients can work

through this material in a mindful and integrative way.

Therapists personal experience of the intervention

Therapists discussed themes of somatic effects, psychological effects, and therapeutic

experiences. Somatic effects where captured in one therapist’s statement that, “I became a little

bit anxious then that seemed to pass. Then my right arm felt very painful and jerking about …


Then after that I seemed to experience very pleasant, extremely pleasant, very regular, smooth

breathing and that continued for the rest of the session." Other somatic effects discussed were

increased feelings of energy and arousal which was not reported as distressing, just notable

transient experiences. The psychological experience of wellbeing and sense of spiritual

connection was also discussed in multiple focus group sessions. For example, one therapist

described, "This great sense of love and loving and being loved came over me, and then … a big

feeling of spiritual connection and that was just wonderful." Therapists expressed surprise and

excitement about gaining insight into previously unconscious psychological material and

experiencing what felt like its integration. For example, a number of therapists mentioned

integration of grief experiences, "…for me it was like going through a grief process … my father

died in November … I was right back there … I reconnected to it with the breathing, and it

changed at the end.” Another therapist stated, "I liked it because you process grief, you

recognise it and you process it, and it's safe to do it." A number of therapists described

regression type experiences, for example, one therapist stated, "I saw myself when I was very

little, and an experience … I found intolerable as a child … and I was almost back in that

experience and I got an emotional release around that … and that was when I understood what

this process was about." Therapists across sessions also reported that with repeated practice they

were able to engage more fully with the therapeutic process and that the intervention was

personally useful and highly engaging.

Impact of the GRMT Intervention on Therapists Wellbeing

Sixty-one therapists personally received up to 8 sessions of the GRMT intervention during

the training process. Change in therapists’ sense of wellbeing after receiving a session, as

measured with the GRMT-IM, was evaluated for a total of 283 sessions. The GRMT-IM mean

score increased significantly from pre-intervention (m = 6.27, SD = 1.29) to post-intervention (m

= 7.99, SD = 1.296) (t (df – 282) = 22.428, p < 0.01) with an effect size of d = 1.32. All 5 items


73

on the GRMT-IM showed significant change from pre- to post session in the expected direction

with large effect sizes for relaxation (d = 1.42), anxiety (d = 1.04), and worry (d = 0.94), and

medium effect sizes for enthusiasm (d = 0.65), and openness to experience (d = 0.61).

Discussion

This study evaluates the implementation of a therapist training program which aims to

disseminate guided respiration mindfulness therapy. GRMT is a novel, experimental clinical

intervention based on sustained self-regulation of respiration, somatically focused mindfulness

and relaxation.

Training Effectiveness

The results show an experiential 2-day training workshop that utilised known elements of

effective training can equip therapists with foundational knowledge in this unfamiliar

intervention. The majority of therapists (71.5%) assessed for competence were able to deliver the

core GRMT intervention at a satisfactory or better level, intervene appropriately and in a timely

manner in response to client cues and use interventions relatively flexibly. By way of

comparison, Sholomskas et al. (2005) found a 3-day CBT training plus supervision resulted in

54% of therapists achieving adequate levels of adherence and skill in videotaped role plays as

assessed using the Yale Adherence Competence Scale (YACS; Carroll et al., 2000). The YACS

is comparable to the scale developed in this study in that it uses a 7-point, Likert-type scale and

rates the degree to which therapists adhere to treatment protocols and competently deliver the

intervention. Although no direct comparison was possible due to the use of different measures,

this suggests that therapists can acquire a working knowledge of, and basic competence in,

GRMT that is comparable to that achieved in CBT.


Training Recommendations

We are mindful that knowledge acquisition after completing the 2-day workshop can be

improved, and that nearly 30% of therapists assessed for competence failed to acquire a

satisfactory level in performing the GRMT intervention. This group were resistant to using a

standardised manual, which suggests further training alone is unlikely to establish competence.

It is important to bear in mind that GRMT is a novel approach to therapy and training introduces

a fundamentally new set of technical intervention skills, practice awareness and theoretical

assumptions. This was reinforced by therapists’ perception of the need for further training

expressed in the post-workshop focus group sessions. While the experiential nature of GRMT

may not suit some therapists, for the majority of therapists competence is likely to improve with

continued practice. Specifically with increased skill in accurately interpreting client respiratory

behaviour, successfully administering the manualized interventions, and increased comfort with

the experiential nature of the intervention. Consequently, it is recommend that foundation level

training be strengthened by providing a second 2-days of training that focuses more intensely on

these practice components; increasing the number of supervised training practice sessions from 6

to 10; and strengthening the coaching aspects of supervision. Additionally recommended is

introducing clear competence assessment that is ongoing to identify training non-responders

early and some form of examination and certification system as a necessity.

Therapist Intervention Acceptance

An important finding in this study was that most therapists appeared to accept the

treatment manual and engaged with it when administering the intervention. Therapists also

expressed strong endorsement for the clinical implementation of GRMT and specifically

identified potential benefit for clients who have difficulty regulating emotions, avoid inner

experience, or have difficulty verbally articulating their problems. Therapists were comfortable

with the experiential nature of the intervention, generally did not find it overly challenging or


75

difficult to facilitate, and perceived it as personally beneficial. Therapists also experienced the

intervention as fast acting and relatively easy to pick up. This is important as innovations that are

perceived by therapists and other stakeholders as relatively simple to learn and use will be more

readily adopted (Greenhalgh, Robert, Bate, Macfarlane, & Kyriakidou, 2005).

Therapeutic Impact on Therapists receiving GRMT During Training

Results suggest that GRMT can produce therapeutic effects. There has been little attention

given to the evaluation of training effects on therapists’ personal experience in the research

literature. One study which has (Montagno, Svatovic, & Levenson, 2011) examined the impact

of a 3-day experiential training in emotion-focused therapy on therapists’ intervention

competence and personal lives through both quantitative and qualitative methods. Their results

showed experiential training increased therapists’ ability to process emotions and levels of self-

compassion consistent with the treatment model. In the current paper evaluation of the impact of

GRMT sessions on therapist well being (subjective experience of relaxation, anxiety, worry,

enthusiasm and openness to experience) using the GRMT-IM and qualitative analysis showed a

large effect size for the GRMT-IM pre-post sessions, suggesting the intervention has an effect,

particularly in increasing relaxation and reducing anxiety. This conclusion is strengthened by

support from the qualitative data, which showed therapists experienced a range of meaningful

and unexpected therapeutic effects. This also suggests the approach may offer therapists

themselves a useful option for engaging in their own therapy and self-care that does not require

extensive dialogue, external interpretation and other elements commonly associated with

psychotherapy.

Mindfulness Effects

The results suggest training in GRMT may increase some aspects of mindfulness in

therapists. The significant change on the TMS decentred subscale score pre/post workshop may

indicate GRMT increases the capacity for a decentred perspective on one’s inner experience.


This increase was consistent with the significant change observed on item 5 (openness to

experience) of the GRMT-IM, which is conceptually similar to decenteredness in the TMS. The

non-significant change on the TMS curiosity subscale in this study may reflect the high pre-

workshop mean for this therapist group compared to what might be expected in non-therapist

populations (Altmaier & Maloney, 2007). It could be expected that therapists are relatively

curious about their own functioning, reflecting a personality characteristic related to the

profession.

Limitations

A lack of trained trainers meant all training, including supervision was delivered by a single

trainer. While results are based on a standardised training program with content and delivery

remaining constant over multiple trainings, it remains to be seen if a comparable outcome would

result if a different trainer delivered the same training program. Secondly, given time restraints,

the same issue meant a lack of suitably experience raters to rate session competence.

Consequently, all clinical session recordings were rated with the GRMT-CS by one rater

introducing the possibility of rater bias with no assurance that the competency scale was used

consistently across all therapists. Future work is needed to establish interrater reliability of this

scale.

The development of tools that make it possible to assess therapist acquisition of knowledge

and competence in the approach was an important feature of this study. In addition to further

work needed to establish the interrater reliability of the GRMT-CS, there is scope for further

development of the GRMT-KQ. However, good internal consistency suggests each item

measures the same core construct and that it is reasonable to make inferences about knowledge

of GRMT from scores on this questionnaire.

This study used a new self-report measure (GRMT-IM) to assess wellbeing effects of the

intervention. This measure was designed to be quick to administer, not create a burden for


77

therapists, and be sensitive to the main areas GRMT was expected GRMT impact. As it turned

out the 5-items yielded a scale that had acceptable reliability, but it is a new instrument and its

reliability and validity outside of this study is unknown.

While the use of focus groups to assess therapist perception of treatment proved valuable, it

did not provide precise numbers of how many therapists felt the same way. Future research could

include forced choice questions on a Likert-type scale to get a more precise understanding in this

area. Furthermore, while results indicated therapist endorsement for GRMT, therapists self-

selected to be involved in the study and had a pre-existing bias toward holistic treatments. It is

unknown if GRMT would receive the same level of endorsement among therapists more broadly.

Conclusion

Findings indicate a brief, focused training program is effective in establishing a foundational

level of knowledge and skill in the use of manual-based GRMT for therapists with no prior

experience of the intervention. Therapists found the intervention personally useful and also

endorsed its clinical use. This study provides a foundation for systematic research aimed at

evaluating the clinical utility of this intervention.


79

CHAPTER!FIVE!

Transitioning!to!Stage!Three!(Paper!3)!

With a group of therapists equipped with a foundational level of skill it was possible to

evaluate in a clinical trial the therapeutic effects of GRMT in the treatment of depression and

anxiety. As indicated in the previous paper, therapists continued under close supervision during

this stage of the program. Therapist competence was evaluated during this process and informed

the results reported in the previous chapter. The two previous papers in this study had been

published in the Journal of Contemporary Psychotherapy, and the novel status of the intervention

under investigation suggested that this journal remained an appropriate publisher. It also means

that all three papers are easily accessible as a connected sequence of studies. This journal was

also considered appropriate for a clinical trial with quantitative assessment of symptom response

in the treatment of two major psychological conditions. The following paper is a joint author

work, with all authors being doctoral supervisors for this thesis.


Statement of Contribution of Co-Authors for Thesis by Published Paper

In the case of the following chapter: Chapter Four (Paper Three) Publication title and date of publication: Lalande L. King, R., Bambling, M., & Schweitzer, R. (Submitted). An Uncontrolled Clinical Trial of Guided Respiration Mindfulness Therapy (GRMT) in the Treatment of Depression and Anxiety. Journal of Contemporary Psychotherapy. The authors listed below have certified that:






Contributor Statement of contribution Lloyd Lalande

Conducted the clinical trial, data analysis and writing of the manualscript.


Professor Robert King Provision of critical reviews throughout the writing process. And provided support in study design and data analysis.

Dr Matthew Bambling Provided guidance in conduct of clinical trail and critical reviews of the paper in final stages.

Ass. Prof. Robert D Schweitzer Provided feedback on the paper in final editing stages


I have sighted email or other correspondence from all co-authors confirming their certifying

authorship.


Name Signature Date


euroite


81

An!Uncontrolled!Clinical!Trial!of!Guided!Respiration!

Mindfulness!Therapy!(GRMT)!in!the!Treatment!of!Depression!

and!Anxiety

Lloyd Lalande


Robert King


Matthew Bambling


Robert D Schweitzer



Abstract

Guided Respiration Mindfulness Therapy (GRMT) is a newly manualized intervention that

synthesises a sustained focus on self-regulation of respiration, mindfulness, and relaxation. In

our previous publication (Lalande et al., 2016b) we reported an evaluation of a manual-based

GRMT therapist training program for the treatment of anxiety and depression. Here we report

the outcomes of the manualization treatment program for depression and anxiety with clients.

Forty-two participants with a primary diagnosis of depression or anxiety disorder participated in

an uncontrolled clinical trial which evaluated treatment response using standardised assessment

and outcome measures with data collected on a session-by-session basis for between 3 and 9

sessions. For the majority of participants, treatment led to significant reduction in symptoms of

depression, anxiety and stress, as well increases in overall wellbeing. Results suggested GRMT

may be an effective additional treatment option for reducing depression, anxiety and stress

symptoms, which does not rely on cognitive or behavioural techniques.

Keywords: Anxiety, Depression, Mindfulness, Psychotherapy, Respiration


83

Introduction

Mindfulness-based interventions that focus on the formal application of mindfulness have

demonstrated efficacy in reducing anxiety symptoms (Chen et al., 2012), and moderate effect

sizes in the treatment of depression and anxiety (Hofmann et al., 2010). Guided respiration

mindfulness therapy (GRMT), is an experimental clinical intervention based on the use of

therapist guided, sustained self-regulation of breathing with strong links with meditation

practice. It is unique in that it does not rely on CBT or other dialogue based approach treatment

techniques. Research comparing meditation practice with passive breathing to meditation

practice using active, self-regulation of breathing (Wang et al., 2011) found participants

perceived the later as more intense and rated it higher in terms of sense of connectedness and

depth of meditation. The additional intensity and duration of an intervention using active

regulation of breathing may counter the tendency for mind wandering that can take place during

less engaging mindfulness practice. Smallwood and Schooler (2013) suggest that mind

wandering will account for a substantial amount of an individual’s time during almost any

cognitive task. Additionally, Arch and Craske (2006) found empirical support for the proposition

that the practice of focused breathing can positively affect the capacity for emotional regulation

when subsequently engaging with environmental stimulus without any intent to engage in a

mindful or accepting way.

A main focus of therapist guidance in GRMT is supporting the client in removing breathing

inhibition and establishing an uninhibited breathing pattern associated with a relaxed state

(Bolton et al., 2004; Bradley, 2002). Inhibited breathing patterns can develop from the

experience of anxiety and expectation involved in engaging with stressful environments

(Fokkema, 1999), with inhibition becoming sustained over time (Anderson, 2001). Anderson and

Chesney (2002) found that experiencing the environment as uncontrollable or overwhelming


also had an inhibiting effect on breathing. It also seems the higher the demands on attention the

more inhibition that results (Denot-Ledunois et al., 1998). Respiratory disturbances are

suggested to play an important role in anxiety and instability in respiratory patterns has been

shown to be associated with panic disorder (Wilhelm, Trabert, & Roth, 2001). The above

research suggests that deviations from a relaxed healthy breathing pattern may take place, at

least in part, as a defensive response to uncomfortable or intolerable bodily sensations. And once

established, an abnormal breathing pattern may become a permanent feature of physiological

functioning potentially leaving an individual more prone to anxiety.

The idea of avoidance of contact with somatic experience is captured in the construct of

experiential avoidance (S. C. Hayes, Wilson, Gifford, Follette, & Strosahl, 1996) and more

recently, has been suggested by Kashdan et al. (2006) to be a general mechanism underlying the

development and maintenance of psychological distress. The tendency to avoid unpleasant

bodily sensations has also been suggested as a mediator between anxiety sensitivity and

psychopathology (Panayiotou, Karekla, & Panayiotou, 2014). Anxiety sensitivity, a trait

characterised by the tendency to respond with fear to bodily sensations associated with anxiety

(Reiss et al., 1986), is suggested to play a central role in the phenomenology of anxiety disorders

(S. Taylor, 1999), as a risk factor (Feldner et al., 2004) and their aetiology and maintenance

(Naragon-Gainey, 2010), especially in regard to panic and post-traumatic stress disorder

(Olatunji & Wolitzky-Taylor, 2009).

From a psychodynamic perspective, the removal from awareness of unpleasant sensations related

to, for example, depression and anxiety, is seen as a key factor in the formation of psychological

defences (Blackman, 2004).

A core aim of GRMT is to bring rejected somatic experience to conscious awareness through

the removal of breathing inhibitions, and then integrate those experiences into the general flow

of consciousness by applying mindfulness characterized by somatic awareness and acceptance,


85

and at the same time increase tolerance for somatic discomfort. Theoretically, this aim suggests a

link between the defensive adaptation of inhibited breathing, the presence of unintegrated

psychosomatic experience, and the development and maintenance of psychopathology (e.g.

depression and anxiety).

The GRMT intervention synthesises three core components: respiratory regulation,

mindfulness, and relaxation. Respiratory regulation involves teaching a breathing pattern

characterized by continuous rhythmicity, expansion of the chest, and relaxed exhalation

(relaxation of all respiratory and peripheral musculature). Therapist suggestions in regard to

depth and speed of inhalation, and guidance in relaxing exhalation, are made in response to the

energetic and emotional dynamics of the client’s engagement with the process. In addition to the

concentration demanded in the ongoing regulation of breathing, mindfulness is applied to

somatic experience. Here, mindfulness is defined as sustained concentration on, and acceptance

of, the physical sensation most dominant in any given moment. The client is encouraged not to

engage with thoughts and impressions which come and go in the mind. When clients do become

distracted with mental content this will commonly be accompanied by disengagement from self-

regulation of respiration. By ongoing monitoring of the clients respiration, the therapist can

recognize disengagement or deviations from the proscribed breathing pattern and intervene with

targeted instructions aimed at reengagement. Relaxation involves the cessation of all

unnecessary movement, as described in classical Buddhist meditation literature (Ñāṇamoli,

1964, p.79), and plays a role in reducing arousal levels while establishing a relaxation response

to provocative inner experience. The intervention is implemented in an eyes closed, lying

position with hands at side and takes between 50 to 60 minutes to facilitate. Therapist guidance

focuses on guiding clients in the skilful application of the three core components in a way that

manages the dynamic interplay of physiological and psychological processes and optimises

engagement while minimising physical and psychological discomfort or cathartic expression.


The respiration and mindfulness elements of the GRMT intervention suggest it may be

effective in reducing avoidance and increasing tolerance, acceptance and integration of somatic

phenomena, which in turn could lead to a reduction in depression and anxiety symptoms. We

recently completed an empirical evaluation of a manual-based GRMT therapist training program

(Lalande et al., 2016b) which demonstrated therapists can acquire foundational treatment

knowledge and competence in this approach. This study provides a preliminary evaluation of the

effectiveness of manualized GRMT for the treatment of anxiety and stress symptoms, and

examines the relationship between depression, anxiety and stress outcomes and mindfulness,

therapeutic alliance, and intervention specific processes hypothesised to contribute to client

outcomes.

Method

Design

A within-subject repeated measure design was used, with clients assigned to either a

depression group or anxiety disorder group dependent on primary diagnosis at intake. Self-report

measures were collected at baseline and on a session-by-session basis at the start of each weekly

session. The study received ethics approval from the Queensland University of Technology,

Office of Research Ethics and Integrity.

Participants

Clients. Study participants were recruited through an online community noticeboard and

newspaper advertisements. Forty-two eligible participants, with a mean age of 38 years (SD =

13.2) and 55% being female, successfully completed preliminary telephone screening and a

structured clinical interview using the Mini International Neuropsychiatric Interview (M.I.N.I.;

Sheehan & Lecruier, 1998) conducted by the first author. Inclusion criteria include: 1) 18 years

of age or over, 2) fulfil diagnostic criteria (DSM-IV) for either depression or anxiety disorder.

Exclusion criteria included: 1) presence of acute suicidality, 2) psychosis, 3) current substance


87

abuse, 4) concurrently receiving other psychotherapy, 5) and change or commencement of

antidepressant/antianxiety medication within the last 6 weeks. Based on primary diagnosis 15

(35.7%) participants were assigned to the Depression group, and 27 (66.3%) were assigned to

the Anxiety group. Specific diagnoses included: major depression (n = 13), dysthymia (n = 2),

post-traumatic stress disorder (n = 7), generalized anxiety disorder (n = 7), panic disorder

(w/without agoraphobia) (n = 3), social phobia (w/without agoraphobia) (n = 9), and specific

phobia (n = 1). Thirty-four (80.9%) participants met criteria for at least one comorbid anxiety

and/or depressive disorder. Six participants were receiving medication for depression (n = 5) or

anxiety (n = 1) with length of time on medication ranging from 6 months to 9 years (m = 4.5

years). Twenty-one participants (50%) screened positive for personality disorder using the

standardised assessment of personality – abbreviated scale (SAPAS; Moran et al., 2003) using a

cut-off of 4 or above. Forty-three percent of participants identified themselves as in a

relationship and 24.4% as unemployed.

Therapists. Treatment sessions were administered by the first author and n=19 therapists

who had completed an empirically evaluated standardised training program in the manualized

GRMT intervention (for details of training and treatment integrity protocols, see Lalande et al.,

2016b). All therapists received individual case supervision from the first author.

Treatment

The GRMT intervention was based on a protocol developed by Lalande (2007) and provided

weekly for a duration of 90 minutes. Session structure involved initial 15 minutes to complete

outcome measures, review treatment method and answer any questions, 60 minutes to administer

the GRMT intervention, and 15 minutes for further integration if needed and to address any

questions. Sessions were conducted across two university counselling training clinics.


Measures

The Depression Anxiety Stress Scale – 21 (DASS-21; Lovibond & Lovibond, 1995) was used

as the primary outcome measure and is composed of three 7-item self-report scales that assess

depression, anxiety and stress symptoms. It has proven reliability in adults with mood and

anxiety disorders with Cronbach’s α of .94, .87, and .91 respectfully for depression, anxiety, and

stress subscales (Antony, Bieling, Cox, Enns, & Swinson, 1998). Total scale Cronbach’s alpha in

the present study was .80.

The Anxiety Sensitivity Index (ASI; Reiss et al., 1986) is a frequently used self-report scale of

sensitivity to anxiety. The ASI has demonstrated excellent reliability across numerous studies

has satisfactory test-retest reliability and demonstrated criterion and construct validity (Rector,

Szacun-Shimizu, & Leybman, 2006; Reiss, Peterson, Gursky, & McNally, 1986). Cronbach’s

alpha in the present study was .88.

The Outcome Rating Scale (ORS; Miller, Duncan, Brown, Sparks, & Claud, 2003) is a

commonly adopted 10-point scale designed to assess general wellbeing, personal wellbeing,

interpersonal wellbeing, and social functioning on a session-by-session basis. Cronbach’s alpha

in the present study was .93.

The Toronto Mindfulness Scale (TMS; Lau et al., 2006) was used to assess change in state

mindfulness and is a 13-item measure with two subscales of Curiosity and Decentering. The

TMS has demonstrated good internal consistency with Cronbach’s alpha of .77 to .89 (Lau et al.,

2006). Cronbach’s alpha in the present study was .82.

The GRMT Self-Efficacy Scale (GRMT-SE) is a 10-item measure developed for this study to

assess changes in hypothesised intervention specific processes including: perceived level of

breathing inhibition; ability to focus on, explore and accept body sensations; confidence in

ability to regulate thoughts and emotions. Items are rated on a 5-point scale ranging from rarely

to almost always with specific items of: 1) I find myself noticing my breathing, 2) My breathing


89

feels free and uninhibited, 3) I tend to notice areas of my body that are tense and am able to relax

them, 4) It is easy for me to just let my exhale go in a totally relaxed way, 5) I find it easy to

focus on and explore the sensations in my body, 6) I find I can accept all the sensations and

feelings in my body, 7) I feel confident I can regulate my thoughts and emotions, 8) I find the

breathing technique easy, 9) I find myself using the breathing pattern when I am at home or

work, 10) I am confident I am doing the breathing technique correctly. Cronbach’s alpha in the

present study was .73.

The Working Alliance Inventory – Short Form (WAI-SF; Tracey & Kokotovic, 1989) was

used to measure the strength of the therapist-client relationship which is a known predictor of

treatment outcomes. The scale has strong psychometric properties (Tracey & Kokotovic, 1989).

Cronbach’s alpha in the present study was .95.

Analysis

Analysis include, paired sample t-tests conducted along with effect size (Cohen, 1988)

calculations evaluating change on study measures from baseline. Multilevel model analyses

using SPSS (with base model using, AR(1): Heterogeneous covariance structure and random

intercept) were used to estimate treatment session effect over time. Data was analysed for the full

sample of clients and individual depression and anxiety groups.

RESULTS

Means and standard deviations for all measures across three time points for depression and

anxiety groups are displayed in Tables 3 and 4.


Table 3: Descriptive statistics for depression group on outcome variables

Measure Pre-treatment Post-session 3 Post-session 6 Post-session 9

M SD n M SD n M SD n M SD n

DASS-21 (GPD) 29.20 9.71 15 17.93 11.25 14 12.30 5.61 10 10.38 6.56 8

# Depression 10.60 4.35 15 7.21 4.96 14 5.20 2.82 10 4.13 4.32 8

# Anxiety 6.80 4.75 15 3.50 3.41 14 1.50 1.50 10 1.25 1.58 8

# Stress 11.80 3.98 15 7.21 4.19 14 5.60 3.20 10 4.63 2.66 8

ASI 23.27 11.64 15 14.07 9.42 14 10.00 8.39 10 6.63 3.92 8

ORS 3.56 1.26 15 5.58 2.64 14 5.37 1.37 10 5.81 2.29 8

TMS 26.36 6.61 14 30.14 10.65 14 27.70 9.56 10 33.25 10.49 8

# Curiosity 15.07 4.51 15 15.79 5.71 14 14.80 6.12 10 17.13 5.89 8

# Decentering 11.93 3.38 14 14.36 5.95 15 12.90 4.35 10 16.13 5.33 8

WAI - - - 5.35 1.12 13 5.40 1.20 10 5.34 1.46 8

GRMT-SE 15.21* 5.86* 14* 19.43 7.25 14 2 20.90 8.93 10 23.67 10.98 6

*GRMT-SE scores after session 1

Table 4: Descriptive statistics for anxiety group on outcome variables

Measure Pre-treatment Post-session 3 Post-session 6 Post-session 9

M SD N M SD n M SD n M SD n

DASS-21 (GPD) 29.00 9.28 27 16.12 9.23 25 11.68 5.08 19 9.89 5.33 14

# Depression 8.00 4.57 27 4.64 3.78 25 3.11 3.23 19 2.57 2.62 14

# Anxiety 9.44 4.35 27 5.00 4.09 25 3.11 2.25 19 2.50 2.34 14

# Stress 11.56 4.74 27 6.48 3.57 25 5.47 2.98 19 4.21 2.57 14

ASI 24.85 10.92 27 14.32 11.08 25 12.89 10.98 19 10.21 9.29 14

ORS 4.38 2.05 27 5.55 2.16 25 6.20 2.40 19 6.04 2.12 14

TMS 25.30 9.64 27 25.08 9.20 25 26.05 8.07 19 23.43 8.89 14

# Curiosity 13.59 5.69 27 12.88 5.53 25 13.89 4.63 19 13.07 5.03 14

# Decentering 11.70 5.28 27 12.20 5.26 25 12.16 4.87 19 10.36 5.74 14

WAI - - - 5.73 0.92 23 5.79 0.58 17 5.80 0.86 12

GRMT-SE 15.33* 4.42* 27* 18.24 6.22 25 2 20.37 7.99 19 20.21 6.83 14

*GRMT-SE scores after session 1


91

Primary outcomes

Statistical significance and magnitude of change (Cohen’s d, adjusted for differing sample size)

was assessed independently for the depression and anxiety diagnostic groups on all measures for

three time points: from pre-treatment to after session 3, 6, and 9 (Table 5).

For the full sample of clients, there was a significant session by general psychological

distress interaction (full scale DASS-21) (Figure 4). Linear, F(1, 61.36) = 50.79, p < .001, and

quadratic trends, F(1, 40.10) = 17.35, p < .001, significantly described the pattern of change in

data over time. Adding a cubic time term to the model showed this trend approached statistical

significance F(1, 162.56) = 3.68, p = .057. These results reflect an initial decrease in general

psychological distress which plateaued as sessions progressed and then tended to decrease

Table 5: Depression and anxiety group t-statistics and Cohen’s d effect size from pre-treatment to after session 3, 6 and 9 Depression Diagnosis Group Anxiety Diagnosis Group

Measure Pre to post-

session 3

Pre to post-session 6 Pre to post-session

9

Pre to post-session 3 Pre to post-session 6 Pre to post-session 9

t p d t p d t p d t p d t p d t p d

DASS (GPD) 2.70 .018 1.07 3.47 .007 2.02 3.40 .011 2.14 3.85 .001 1.39 5.13 .000 2.21 4.93 .000 2.33

# Depression 2.76 .016 0.72 3.12 .012 1.41 3.09 .017 1.49 3.85 .001 0.80 5.13 .000 1.20 4.93 .000 1.30

# Anxiety 2.70 .018 0.79 3.47 .007 1.38 3.40 .011 1.39 5.37 .000 1.05 7.68 .000 1.72 8.71 .000 1.82

# Stress 2.67 .019 1.12 3.07 .013 1.67 3.18 .015 1.99 6.72 .000 1.20 7.02 .000 1.48 6.65 .000 1.77

ASI 2.64 .020 0.86 3.26 .010 1.26 3.28 .013 1.70 6.13 .000 0.95 6.25 .000 1.09 6.05 .000 1.40

ORS -3.34 .005 0.98 -3.78 .004 1.38 -2.57 .037 1.34 -4.63 .000 0.55 -3.97 .001 0.82 -3.54 .004 0.80

TMS -.927 .372 0.42 .365 .724 0.16 -1.23 .264 0.84 -.224 .825 -0.02 -.559 .583 0.08 .147 .886 -0.19

# Curiosity -.541 .597 0.14 .871 .406 -0.05 -.197 .850 0.41 .447 .659 -0.12 -.244 .810 0.05 .250 .806 0.09

# Decentred -1.03 .323 0.50 -.356 .731 0.25 -1.88 .108 1.00 -.992 .366 0.09 -.779 .446 0.09 .000 1.00 -0.24

DASS (GPD) = Depression anxiety stress scale – full scale. ASI – Anxiety sensitivity index. ORS = Outcome rating scale. TMS = Toronto mindfulness scale


further. Adding group x session

interaction to the model showed no

significant difference between the

depression and anxiety

group in the slope of change

for general psychological distress,

F(1, 55.35) = .22, p = .638.

Additionally, there was no significant

difference in the level of general

psychological distress between the

depression and anxiety group, β =

.412, t(27.35) = .23, p = .81, although the depression group had a slightly higher level. To

determine if change on the DASS-21

was significant across its subscales we

ran multilevel models with the full

sample which again showed that linear

and quadratic trends respectively

significantly described the pattern of

change over time for depression, F(1,

86.97) = 18.42, p < .001; F(1, 70.18) =

4.78, p = .03, and anxiety, F(1, 85.27) =

38.98, p < .001; F(1, 79.19) = 15.78, p

< .001. For the stress subscale, linear,

F(1, 131.60) = 15.69, p < .001, quadratic, F(1, 168.08) = 7.64, p = .006, and cubic F(1, 172.44)

= 5.91, p = .016, trends significantly predicted slope of change suggesting reduction in stress

Figure 4. Slope of symptom response from pre-treatment for full sample of clients on DASS-21 full scale

Figure 5. Slope of symptom response from pre-treatment for depression diagnostic group on DASS-21 depression subscale


93

resumed after plateauing. There was no significant difference between depression and anxiety

group in level of stress, β = .40, t(37.04) = .546, p = .58, or slope of change for depression,

anxiety or stress over time. These

models suggest the depression group

had a significantly higher level of

depression, β = 1.92, t(37.06) = 2.09, p

= .043, and lower level of anxiety

which was almost significant, β = -1.53,

t(31.74) = -1.85, p = .073, compared to

the anxiety group, which was consistent

with diagnostic groupings. To examine

diagnostic symptom response for

depression and anxiety group more

closely we ran independent multilevel models which showed that depression response for the

depression group followed the quadratic trend and plateaued, while for the anxiety group a

significant cubic trend indicated reduction in symptoms resumed after plateauing (Figure 5 and

6).

Clinical significance analysis for depression, anxiety and stress outcomes. To determine if

individual change on the primary outcome measure was clinically significant DASS-21 full scale

(GPD) and subscales raw scores were converted into percentile ranks (based on a large

normative sample (n = 2982)) using the computer program developed by Crawford et al. (2009).

Percentile ranks were then translated into the corresponding DASS-21 classification of distress

using cut-offs suggested by Lovibond and Lovibond (2005). Number of individuals falling into

each symptom severity classification pre-treatment and at last assessed session for depression

Figure 6. Slope of symptom response from pre-retreatment for anxiety diagnostic group on DASS-21 anxiety subscale


and anxiety groups is displayed in Tables IV and V. For the depression group, 73.7% of clients

with elevated pre-treatment depression scores returned to the normal range, with the same

number of participants with elevated general psychological distress returning to the normal

range. For the anxiety group, 70.3% of clients with elevated anxiety pre-treatment returned to the

normal range, while 77.7% with elevated general psychological distress pre-treatment returned

to the normal range.

Table 6: Frequency of depression group (n = 15) DASS-21 classification pre-treatment and

at terminating session

Classification pre-treatment (%) Classification at terminating session1 (%)

DASS-D DASS-A DASS-S GPD DASS-D DASS-A DASS-S GPD

Normal 1 (6.7) 4 (26.7) 2 (13.3) 1 (6.7) 12 (80) 13 (86.7) 14 (93.3) 12 (80)

Mild 1 (6.7) 1 (6.7) 3 (20) 2 (13.3) 1 (6.7) 1 (6.7) 1 (6.7) 2 (13.3)

Moderate 10 (66.7) 8 (53.3) 7 (46.7) 9 (60) 2 (13.3) 1 (6.7) - 1 (6.7)

Severe 1 (6.7) 1 (6.7) 1 (6.7) 2 (13.3) - - - -

Extremely Severe 2 (13.3) 1 (6.7) 2 (13.3) 1 (6.7) - - - -

1Range of sessions completed = 2 – 9; Percentile cut-offs corresponding to each DASS-21 category: normal = 0-78, mild = 78-87, moderate = 87-95,

severe = 95-98, extremely severe = 98-100

Table 7: Frequency of anxiety group (n = 27) DASS-21 classification pre-treatment and at terminating session

Classification pre-treatment (%) Classification at terminating session1 (%)

DASS-D DASS-A DASS-S GPD DASS-D DASS-A DASS-S GPD

Normal 7 (25.9) 3 (11.1) 3 (11.1) 2 (7.4) 24 (88.9) 22 (81.5) 22 (81.5) 23 (85.2)

Mild 7 (25.9) 3 (11.1) 9 (33.3) 4 (14.8) 3 (11.1) 2 (7.4) 4 (14.8) 3 (11.1)

Moderate 10 (37) 10 (37) 9 (33.3) 17 (63) - 2 (7.4) - -

Severe 1 (3.7) 7 (25.9) 5 (18.5) 2 (7.4) - - 1 (3.7) 1 (3.7)

Extremely Severe 2 (7.4) 4 (14.8) 1 (3.7) 2 (7.4) - 1 (3.7) - -

1Range of sessions completed = 2 – 9; Percentile cut-offs corresponding to each DASS-21 category: normal = 0-78, mild = 78-87, moderate = 87-95,

severe = 95-98, extremely severe = 98-100


95

Secondary Outcomes

Anxiety sensitivity. At baseline ASI scores were strongly correlated with DASS-21 Anxiety

scores, r(42) = .52, p < .001, and moderately correlated with DASS-21 Stress scores, r(42) = .34,

p = .02. No statistically significant correlation was observed between ASI and DASS-21

Depression scores. Multilevel model analysis showed for the full sample, sessions led to

significant reduction in anxiety sensitivity, F(1, 70.62) = 47.21, p < .001. There was no

significant difference between depression and anxiety group in slope of decline, β = -.31,

t(26.29) = -.861, p = .39, or level, β = -2.65, t(35.20) = -1.08, p = .28, although the depression

group level was lower.

Overall wellbeing. Multilevel model analysis of change in overall wellbeing (ORS) for the

full sample of clients, as measured on the Outcome Rating Scale, showed a significant increase

over sessions, F(1, 107.52) = 25.47, p <.001, with no significant group difference in level of

overall wellbeing, β = -.79, t(45.03) = -1.18, p = .24, or slope of change over sessions, β = .09,

t(41.70) = -1.08, p = .28. Reductions in DASS-21 Depression, β = -.15, t(262.88) = -8.03, p <

.001, and Stress, β = -.07, t(246.66) = -3.09, p = .002, significantly predicted higher ORS scores,

while DASS-21 Anxiety and ASI scores did not.

Mindfulness. No significant Pearson correlation was observed at baseline (n = 41) between

TMS full scale or TMS Curiosity and Decentering scores and the full-scale DASS-21 or its

subscales of Depression, Anxiety, and Stress. Additionally, no significant correlation was

evident for any other combination of time points. Multilevel model analyses did however, show

a significant change in TMS Decentering subscale scores over sessions, F = (1, 182.25) = 4.62, p

= .03, but no significant change in Curiosity. TMS Decentering also significantly predicted

reductions on DASS-21 Depression, β = -.25, t(239.61) = -4.55, p < .001, and to a lesser degree,


Stress, β = -.12, t(223.23) = -2.45, p = .015, but not Anxiety, with no significant difference

between depression and anxiety groups.

Working Alliance. Mean total WAI-S scores for both depression and anxiety groups were at

the positive end of the 0-7 rating scale (see table 3 and 4). For the full sample, WAI-S scores

were not significantly correlated (Pearson’s r) with DASS-21 full-scale scores for any

combination of measurement interval. Multilevel model analyses did however suggest a

significant increase in WAI-S subscale scores over sessions for task, F(1, 82.37) = 8.82, p =

.004, and goal, F(1, 87.73) = 5.00, p = .02, while bond was relatively stable across sessions. The

depression group had a significantly lower level of agreement on bond, β = -04, t(54.47) = -2.26,

p = 02, and task, β = -.05, t(58.88) = -2.59, p = .01, compared to the anxiety group, but no

significant group difference in level of agreement on goals. Multilevel models showed that for

the depression group agreement on goals significantly predict reduction in stress, β = -.89,

t(38.06) = -2.07, p = .04, while for the anxiety group, agreement on goals significantly predicted

reduction in anxiety, β = -1.29, t(134.79) = -2.56, p = .01.

GRMT Self-Efficacy. Client self-efficacy in applying GRMT increased significantly over

treatment, F(1, 90.11) = 20.42, p < .001, with no significant difference between depression and

anxiety group on either level or slope of change. Overall self-efficacy significantly predicted

reduction in general psychological distress (DASS-21), β = -.59, t(-177.31) = -7.50, p < .001, and

reductions in DASS-21 subscales of Depression, β = -.23, t(195.24) = -5.93, p < .001, Anxiety, β

= -.22, t(241.03) = -7.38, p < .001, and Stress, b = -.20, t(214.20) = -5.94, p < .001. Individual

GRMT-SE scale items all significantly increased over the course of sessions (p � .006), with the

exception of item 1 (p = .09). To examine the contribution of individual GRMT-SE scale items

to outcomes multilevel models were run with all scale items included as fixed effects. Results

showed item 2 (My breathing feels free and uninhibited) significantly predicted reductions in

DASS-21 Anxiety scores, β = -.49, t(168.16) = -2.41, p = .017, and almost significantly


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predicted reductions in Anxiety Sensitivity, β = -.97, t(221.22) = -1.84, p = .06. GRMT-SE item

4 (It is easy for me to just let my exhale go in a totally relaxed way) almost significantly

predicted reductions in DASS-21 Depression, β = -.51, t(176.66) = -1.92, p = .056, and

significantly predicted reductions in Anxiety, β = -.89, t(172.54) = -4.63, p < .001, Stress, β = -

1.33, t(197.35) = -5.53, p < .001, and Anxiety Sensitivity, β = -1.75, t(215.24) = -3.54, p < .001.

GRMT-SE item 7 (I feel confident I can regulate my thoughts and emotions) significantly

predicted reductions in Depression, β = -1.22, t(215.07) = -4.95, p < .001, Anxiety, β = -.70,

t(199.14) = -4.01, p < .001, and Stress, β = -.84, t(174.31) = -4.71, p < .001, along with

reductions in Anxiety Sensitivity, β = -1.35, t(233.49) = -3.00, p = .003, and increases in overall

wellbeing (ORS), β = .59, t(215.53) = -5.89, p < .001.

DISCUSSION

This trial provides preliminary evidence that guided respiration mindfulness therapy may

be efficacious in the treatment of depression and anxiety. Results indicated that significant

treatment effects were evident from session 3 for depression, anxiety and stress symptoms, as

well as in anxiety sensitivity. These changes were associated with large effect sizes which

continued to increase as sessions progressed. By way of comparison, Kabat-Zinn et al. (1992)

conducted a study evaluating the impact of the mindfulness-based stress reduction program on

generalised anxiety disorder, panic disorder and depression in a sample of patients with anxiety

disorder. Using pre-post intervention means and standard deviations provided by Kabat-Zinn et

al. (1992) effect sizes (Cohen’s d) could be calculated. Using data collected on the Beck Anxiety

and Depression Inventories, the effect size for anxiety reduction was large, d = 1.01, while the

effect size for depression was moderate at d = .62 respectively. A recent meta analysis of

mindfulness based therapy conducted by Khoury et al. (2013) also found a large pre-post

intervention effect size for anxiety (Hedge's g) of .89, and a moderate effect size of .69 for

depression. These studies suggest the treatment effect sizes found in the current study of GRMT


are comparable to and even exceed those demonstrated in mindfulness-based approaches. The

finding that symptom response for depression, anxiety and stress was clinically significant for

the majority of clients at termination provides further strong support for the effectiveness of

GRMT. Results also show that depression, anxiety and stress symptom response shared a

comparable trajectory over the course of sessions, although analysis at diagnostic group level

indicated a more sustained decline in anxiety for the anxiety group compared to the plateauing

decline in depression for the depression group. The strong result for the outcome rating scale

suggests this intervention goes beyond symptom reduction to a more generalized impact on

perceived wellbeing across the domains of individual, interpersonal, social, and overall

wellbeing. The ORS has previously shown a strong positive correlation with the OQ45

indicating that it can provide valid information about functional change (Campbell & Hemsley,

2010).

We chose the Toronto Mindfulness Scale to capture changes in state mindfulness resulting

from GRMT sessions. Mindfulness outcomes were limited to change on the TMS Decentering

subscale which predicted reductions in depression. Decentering reflects the capacity for

detached observation of somatic, emotional and cognitive experience and has been proposed as a

mechanism functioning within mindfulness based interventions (Baer, 2003; Brown, Ryan, &

Creswell, 2007; Shapiro et al., 2006). One explanation for the lack of change in Curiosity may be

that the TMS was designed to assess state mindfulness immediately after engagement in

meditative practice. In this study participants had little or no experience of meditative practice

and measures were administered one week after the previous session. Administering the TMS

directly after GRMT sessions may have produced a different result.

The findings from analysis of GRMT-SE items 2 (My breathing feels free and uninhibited),

and 4 (It is easy for me to just let my exhale go in a totally relaxed way), offer initial support to

the proposition GRMT reduces breathing inhibition with a subsequent reduction in psychological


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distress, particularly in terms of anxiety, stress and anxiety sensitivity. Also of note is that an

increase in participants perceived confidence in regulating thoughts and emotions (GRMT-SE

item 7) strongly predicted reductions in depression, anxiety, stress, anxiety sensitivity, as well as

increases in overall wellbeing. The active self-regulation of respiration and attention employed

in GRMT, along with accepting engagement with somatic experience may promote the belief in

efficacy related to self-regulation. Self-efficacy beliefs are part of the concept of mastery, and

gaining mastery has been suggested as central to psychotherapy and shown to contribute to better

psychotherapy outcomes (Grenyer & Luborsky, 1996).

This study found that task and goal agreement aspects of the working alliance increased over

sessions and that goal agreement predicted reductions in stress for the depression group and

reductions in anxiety for the anxiety group. Research suggests the importance of task and goal

agreement in predicting outcomes in more active interventions (Hoffart, Oktedalen, Langkaas, &

Wampold, 2013; Weerasekera, Linder, Greenberg, & Watson, 2001). In the current study client

agreement on task and goal suggests acceptance of the technical aspects of the approach (e.g.,

self-regulation of breathing, and application of somatically focused mindfulness), and the

treatment goal (e.g., reduced breathing inhibition and increased contact with and tolerance of

somatic experience), and that these were experienced as meaningfully related to distress

reduction.

The results of this study should be interpreted with caution due to the lack of an active

control condition. The GRMT-SE measure was developed for this study to make it possible to

assess intervention specific processes and was therefore an important feature of the study.

Further work needed to establish the reliability of the instrument, however, adequate internal

consistency suggests it is reasonable to make inferences about changes in GRMT self-efficacy

base on measure scores.


Further research aimed at seeing if the results of this study can be replicated in more rigorous

research, specifically in the form of a randomised controlled trial with an active treatment

comparison, is suggested as a high priority. It is also important to establish if symptom

improvements are retained after treatment ends. Results of this study provide strong preliminary

support for the use of GRMT as a brief clinical intervention for the treatment of symptoms of

depression, anxiety and stress.


101

CHAPTER!SIX!

Client!Experience!of!Guided!Respiration!Mindfulness!Therapy!

Introduction

The quantitative results presented in the previous chapter (Chapter 5) indicate that Guided

Respiration Mindfulness Therapy (GMRT) shows promise as a treatment for reducing symptoms

of depression and anxiety and increasing sense of wellbeing. This chapter will present results

from a qualitative treatment end-point interview that assessed client perception of their

experience of the GRMT intervention. While the quantitative results presented in the previous

chapter suggest a strong case for the efficacy of GRMT in the treatment of depression, anxiety

and stress symptoms, they say little about the subjective experience of clients receiving GRMT

and how treatment impacts their lived experience. Qualitative analysis which directly asks

participants about their experience is particularly important when exploring an experiential

intervention that focuses on teaching self-regulation of respiration and development of

mindfulness skills. In order to assess participants experience of GRMT a semi-structured

interview was conducted at termination of sessions. For the majority of cases, this meant clients

could reflect on changes that had occurred over a period of 8 or more weeks. This provided the

opportunity for participants to identify changes that may be more personally meaningful or

enduring.


Method

Participants

A subset of twenty-two participants (mean age of 39, SD = 14, Range = 20-66, Female =

50%) who participated in the clinical trial described in the previous chapter were available to

participate in a treatment end-point interview. Eight (36.4%) participants had a primary

diagnoses of depression and 14 (63.6%) anxiety disorder, while 50% had screened positive for

personality disorder. Participants demographic characteristics are comparable to the full sample

of clients. Twenty-one (95.5%) participants completed 8 or more sessions while one completed 5

sessions.

Data collection

A semi-structured interview was developed to ascertain clients perception of treatment and

any changed experience perceived to be the result of receiving the intervention. Interviews were

conducted at treatment end-point by the therapist assigned to the client. The semi-structured

interview was guided by a questionnaire containing nine questions designed to capture clients

perception of treatment related changes in their lives. Questions included: 1) If anything has

changed for you as a result of receiving GRMT sessions, what is it that you might have noticed

has changed? What is different?; 2) What do you think is the most significant thing to come out

of your experience of GRMT sessions?; 3) In the GRMT session, what do you think it is that

contributes most to any changes you noticed?; 4) We have not focused on your thoughts in the

GRMT sessions, what sort of effect have sessions had on your thinking, if any?; 5) Have you

incorporated any part of the GRMT approach into your life? For example, the breathing,

focusing on sensations, acceptance?; 6) Given your experience of GRMT, do you think there is

anything we should add, or is missing from the approach that might make it more effective?; 7)


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Is the GRMT therapy something you would consider again?; 8) Is this something you would

recommend to others?; 9) Do you have anything further you would like to mention, anything at

all?

Analytical strategy

All interviews were listened to in full and transcribed verbatim. Thematic Analysis

procedures described by Braun and Clarke (2006) were used to analyse the transcripts. Braun

and Clarke’s Thematic Analysis has been utilized in the analysis of participants experience of

mindfulness-based cognitive therapy by Allen, Bromley, Kuyken, and Sonnenberg (2009) who

suggested it an appropriate approach where the qualitative enquiry is is embedded within a

quantitative trial. Analysis involved repeated reading of transcripts aimed at initial identification

of a range of specific ideas or themes. These were then coded or identified as a theme relevant to

the focus of the research. A process of comparison and differentiation with ongoing referencing

back to the transcript data resulted in the development of a structure of overall themes with

associated sub-themes that closely mapped onto client meanings and experience represented in

the verbatim data.

Results

The thematic analysis revealed clients experience of changes attributed to the intervention

could be classified into five overarching themes, (1) symptom reduction, (2) relaxation

outcomes, (3) mindfulness outcomes, (4) secondary outcomes – unpredicted but consistent with

mindfulness, and (5) secondary outcomes – unexpected. Themes and their subthemes are

discussed below.

Symptom reduction

This overarching theme relates to participants’ perception of movement toward experiencing

less distress characterized by symptom reduction. In this theme clients reported: reduced anxiety,


social anxiety, and panic, as well as less fearfulness; reduced rumination and more even moods;

a cessation of suicide thoughts and fantasies present prior to treatment; less anger; and reductions

in physical pain, alcohol use and medication use. Regarding alcohol use, one client stated, “I've

been drinking much less, that's nearly 3 months. And yes, overall my moods are more even than

they use to be. Maybe I have dealt with certain situations that in the past would have sent me

straight down. Maybe I've been reacting to things better. In situations I haven't had before I’m

definitely more tolerant and more accepting of things.” In regards to anxiety, one client simply

stated, "My anxiety that I use to have, you know it's almost gone. I'm much more relaxed now

than before I started. And I feel much better, that's for sure.” Another stated, “I think I'm in a

better state now. Um, I'm a bit more conscious of my breathing. The reason I came here was

because I was having depression and anxiety episodes. They haven't gone 100%, in the past 2

weeks maybe I've had two, but I'm able to control them much better. I’ve found that when it

happens I start breathing and it helps a lot. And they're less and less over time, so I think I'm on

the right path.”

Relaxation outcomes

This theme had two subthemes, (1) relaxation skills, and (2) relaxation effects. Relaxation

skills participants commented on were: ability to recognise physical signs of tension, stress,

worry, anxiety, and panic; confidence in ability to use breathing regulation and somatic

awareness to mediate tension, stress and panic symptoms and achieve relaxation; and ability to

relax and attend to breathing without following thoughts. For example, when asked what seemed

to contribute most to any changes, one client stated, “I think just learning to relax and breathe,

without thinking about things. I know through some of the sessions you were saying, it's ok to

have thoughts but you don't need to entertain them. So that was really good, just learning to let

go of thoughts and not following them through. Yeah, and just breathing and relaxing, I always

feel calmer at the end”. The development of increased capacity to recognize and regulate stress is


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captured in this statement from one client, “Before, I felt I couldn’t talk to anyone about my

problems because I didn’t know what the problem was. I didn't know it was stress and anxiety. I

wasn't aware of my stress before, I never knew it was stress. I can make the comparison now. I

can notice what is going on with my body. I'm very aware now. Even if I don’t feel like I'm

stressed, I can feel if I'm out of breath and maybe having an anxiety attack, I can tell now from

my body change and then use the breathing to release the stress, and have more control the

stress”.

The second subtheme included client reports of: better sleep; sense of wellness; reduction in

tension headaches; and experiencing the body as “ not as locked up.” One client described how

they had improved sleep when they said, “I’ve used the breathing as a relaxation technique,

especially when I wake up in the middle of the night I use it to help me go back to sleep. It

definitely helps at night to put me back to sleep. That’s probably what’s changed the most.”

Another commented, “I'm sleeping better, that's another big point. Before I was having a lot of

trouble sleeping, sometimes I’d sleep only 2 hours, and sometimes taking medication. Now I

don't take anything and I'm sleeping really well.” For approximately thirteen percent of

interviewed clients their reported experience of the intervention only included relaxation related

outcomes.

Mindfulness outcomes

The mindfulness theme contained three subthemes, (1) increased acceptance of self, others

and life in general, (2) increased tolerance and acceptance of somatic experience, and (3)

reduced over-identification with thoughts. In the first subtheme clients reported: increased

honesty about feelings and emotions; development of a sense of trust in oneself; the perception

that self, others, and the world is neither good or bad; awareness that life can be tough, painful,

and full of challenges, but can be accepted and it’s possible to cope and go on; ability to put

problems into perspective; and feeling that one has grown as a person. In the second mindfulness


subtheme clients reported: not running away from uncomfortable physical sensations and

emotions; stepping out of over-identification with the body, and recognition of the value of

paying attention to the body. An example of greater acceptance of sensations was evident in one

client’s statement that, “I’m probably better at accepting sensations that are annoying. Before I

had feelings that would really bother me, certain physical sensations. But now I find I’m aware

of those sensations but they don’t bother me so much. I think that would definitely be from

practicing this technique. I think on the whole I can accept things better.” In the third

mindfulness subtheme clients reported: recognition that thoughts come and go and are always

changing; not accepting the first thought that comes to mind as ‘true’; and ability to get out of

rumination and let go of unproductive thoughts. One client describe their experience of change

in the comment that, “Before I used to be very negative, but now I've come to be more

contemplative of things. I'm happy to just be an introvert and think about things more, but

alternative ways of thinking, not always just accepting the first thought that I have.” Another

client reported, “If something comes up, instead of thinking about and agonising over it, I’m able

to say to myself, ‘Ah, I’m having that thought which regularly happens but I don’t have to feel

overcome by it. And it’s stopping the thought from further aggravating the anxiety or concern

that I might have. Previously the thought would snowball, in fact snowball is too slow a term, it

would ramp up very, very rapidly and I’d be panicking. And I’ve come to learn that I would also

engage in rapid shallow breathing the minute I would think about something that was difficult or

concerning. I don’t seem to be doing that anymore, I’ve notice that changing.” Twenty-seven

percent of participants reported relaxation plus mindfulness related outcomes.

Secondary outcomes – unexpected but consistent with mindfulness

All items in this theme could be categorised as experiences of insight and included:

recognition and insight into destructive attitudes and behaviour that the client felt needed to be

addressed; insight into how cognitive factors (e.g., negative attitudes) influence symptoms;


107

insight into how ones negative thoughts and self-criticisms can be projected onto others and

generalized to all situations; and recognition of ones responsibility toward others (e.g., family

members) and when that responsibility has been neglected. One client described their experience

of insight with this observation, “Sometimes I'm looking forward to a session and other times I

feel like its going to be wasting your [therapists] time which in itself is something. For me to

step back and go, ‘I'm thinking that I'm wasting your time’, and then I start to see that I have a

similar thought when I do anything else where I don’t feel I'm doing well. When I'm doing work

for someone I feel like I'm wasting their time even though they are quite happy with the work.

So there’s more than one way it’s [the intervention] making me aware of things that have

contributed to me feeling sad and useless.”

Secondary outcomes – unexpected

This theme contained two subthemes, (1) self-confidence and, (2) motivation. Self-

confidence was characterised by: sense of self-efficacy and confidence in decision making,

including when dealing with problems; a positive outlook with optimism and confidence about

the future; feeling of being able to face the world and cope with whatever life brings; increased

confidence and comfort speaking up and engaging in interpersonal and social situations. A

number of clients reported improved interpersonal functioning. For example, one client reported,

“After one session, I had a discussion with my wife, and it could have been a bit touchy, but I

said to myself before going into the discussion that I’m likely to have a heightened emotional

response to some of the things she might say, but I’m just going to notice them, not be concerned

about them.” The subtheme of motivation included: increased sense of self-determination;

intention to adopt and actual adoption of new behaviour; and experiencing creative ideas

beneficial for wellbeing during sessions and feeling motivated to introduce them into ones life.

One client captured both of these subthemes when they said, “At the end of some of the sessions

I had this feeling of optimism, and sometimes strength. Strength in the sense of ability to make a


decision and do it, and feel like it was a good decision to make. I've taken up yoga for example,

because I’d finish one of these sessions, and after being still for so long merely breathing I felt

very good.” Another client captured the sense of motivation when they reported, “My general

impression when I'm doing the breathing, the feeling I have at the end of the session, I feel like

standing up and doing things, to unleash my creativity. I've taken the initiative to start practicing

writing, painting, and practicing music. Really trying to return creativity to my life as I had

abandoned it. Yeah, at the end of the session I felt like getting up and I had a million ideas about

things I want to create. It was something that was there but life pushed me to bury it.” Over half

of participants (59%) reported relaxation, mindfulness and secondary outcomes.

Discussion

Qualitative analysis of client’s experience of GRMT extends the quantitative results

presented in the previous chapter by providing an indication of the subjective experience of

engaging with this intervention. The results indicate that while some clients experience

primarily relaxation outcomes as a result of receiving GRMT, the majority of participants

experienced a range of mindfulness related outcomes. This suggests that the change process

experienced varies for different people along a continuum from relaxation and symptom

reduction to deeper insights which may be of a transformational nature.

The GRMT intervention did not have a specific focus on engaging with or changing

cognitions, and this was clearly stipulated in the treatment protocol. The qualitative data

demonstrates that GRMT, with it’s focus on learning to self-regulate breathing and apply

mindfulness to somatic phenomena, can be effective in fostering cognitive change characterized

by self-efficacy beliefs related to self-regulation of thoughts, emotions, and somatic experience

while engaging with the challenges of life. Participants reported being less perturbed, more

relaxed and able to handle more effectively situations in which previously they coped less well.

These results are consistent with the proposition that mindfulness is associated with self-


109

regulation (Brown & Ryan, 2003), and comparable to the finding that participation in

mindfulness-based cognitive therapy increased participants sense of emotional regulation and

acceptance of thoughts and feelings (Allen et al., 2009). Results are also consistent with the

finding that increased confidence in regulating thoughts and emotions predicted reductions in

psychological distress, reported in the previous chapter. Whether individuals think in self-

enhancing or self-debilitating ways, whether they persevere when faced with difficulties, and the

quality of their emotional well-being and vulnerability to stress and depression, are all influenced

by self-efficacy beliefs(Bandura & Locke, 2003). GRMT seems to provide a tool that allowed

clients to connect with their somatic experience, and maintain that connectedness while

experiencing sensations, emotions and cognitions which would normally be avoided due to their

aversive nature. It seems clear that for at least some of these clients, GRMT provided a

fundamentally different experience that had ramifications for how they experienced themselves

and their sense of agency functioning in the world.


111

CHAPTER!SEVEN!

Considerations!of!Mechanisms!of!Change!

The overall aim of this study was: to define and operationalize a clinical model of breathwork

now identified as guided respiration mindfulness therapy; to ascertain if therapists could learn

the approach in a relatively brief training program and find it acceptable as a clinical practice;

and to conduct a clinical trial to explore the impact of the intervention on symptoms of

depression and anxiety. These basic questions are consistent with the initial stages of developing

a new treatment model as outlined in a stage model of treatment development (Carroll & Nuro,

2002; Rounsaville et al., 2001). In order to ascertain the presence of intervention specific

treatment effects and to be able to make any claims about these effects it was necessary to take

into consideration the possible contribution of the therapeutic alliance. The alliance is well

established as a common factor that contributes to psychotherapy outcomes across all therapy

modalities (Horvath, Del Re, Fluckiger, & Symonds, 2011). Additionally, given the focus on

mindfulness in the GRMT intervention, it made theoretical sense to include an evaluation of

changes in participants mindfulness. Results related to these two constructs did suggest they

played a role in predicting outcomes. The purpose of this chapter is to engage in a brief

theoretical exploration of aspects of GRMT, starting with alliance and mindfulness and then

moving onto other processes or mechanisms of change that may be active in the GRMT

intervention.


Processes of Change

Therapeutic alliance

An initial consideration of the results of the clinical trial (chapter 5) in this study must

consider the contribution to outcomes that can be attributed to the therapeutic alliance. The

therapeutic or working alliance is well recognised in the psychotherapy research literature as a

mechanism of change independent of a range of factors including theoretical orientation,

research methodology, and use of treatment manuals targeting specific disorders (Fluckiger, Del

Re, Wampold, Symonds, & Horvath, 2012; Horvath et al., 2011). In Bordin’s pan-theoretical

model of the working alliance (Bordin, 1979) collaboration involves the establishment of an

emotional bond, agreement on therapeutic goals, and cooperative effort to bring about change

through agreement on tasks. This study examined the contribution of bond, task and goal

agreement to symptom change with the 12-item short form of the well-established working

alliance inventory (Tracey & Kokotovic, 1989) and found a statistically significant increase in

agreement on task and goal over time, with bond remaining relatively stable over time.

GRMT is a highly experiential intervention composed of a clearly defined and unchanging

methodology which clients engage with repeatedly from session to session. Because of this

consistency client mastery of the technical aspects of the intervention and familiarity with the

experiential dynamics of the therapeutic process can be expected to increase relatively quickly

over time. When clients perceive themselves as developing increased competence in their use of

the intervention, and their engagement with the intervention as meaningfully linked to their goal

of symptom reduction as positive treatment outcomes are experienced, both task and goal

agreement are likely to be strengthened. This suggests therapists’ ability to provide the client

with an early experience of perceived skill acquisition may be an important part of fostering

client engagement in terms of task agreement. If early skill acquisition is linked to client

experience of therapeutic impact this would be expected to strengthen goal agreement. If this is


113

the case it suggests therapists’ use and adherence to the treatment manual with its standardised

and targeted interventions plays an important role in alliance building, at least in terms of task

and goal agreement.

Scores on the Bond subscale of the WAI-S were relatively stable over sessions and remained

at the positive end of the 0-7 rating scale. The shared understanding of client problems that

develops over time in dialogue based interventions was only minimally present in the GRMT

intervention as it was operationalized in this study. In fact, discussion of client problems was

minimized in an effort to maintain treatment integrity and strengthen any claim of treatment

efficacy. With the lack of dialogue, the therapist-client bond may not have evolved or deepened

in a way that matched client constructs of relationship and this may have been reflected in the

stable responses on the WAI-S. The way in which the therapist-client bond is experienced in

GRMT may be distinct to established conceptions in that it emphasises sense of safety as a key

element necessary for clients to feel comfortable engaging in the treatment. The WAI-S, with its

focus on therapist liking for the client is not ideally suited to capturing aspects of alliance as they

manifest in GRMT with it’s largely non-verbal therapist-client relationship and highly

experiential therapy process. Further research is needed to clarify the role of therapeutic bond in

GRMT.

While alliance as reported above appears to play an important role in client engagement with

GRMT, a number of factors suggest it is unlikely that alliance factors alone account for the

outcomes observed in this thesis and there is reason for confidence that there were intervention

specific effects.. These include the strength of the statistically and clinically significant results

along with client reported changes captured in the end-of-treatment qualitative interview; the

minimal verbal therapist-client interaction that characterizes the approach and the fact that

therapists did not attempt to directly influence cognitive or behavioural change and non-protocol

interventions were not evident in the reviewed clinical sessions.


Mindfulness and Decentering

A recent meta-analysis exploring mediators in mindfulness-based stress reduction (MBSR) and

mindfulness-based cognitive therapy (MBCT) found support for mindfulness as a mediator of

therapeutic outcomes (Gu, Strauss, Bond, & Cavanagh, 2015). A specific component of

mindfulness which has been proposed as a mechanism of change in mindfulness based

interventions is the construct of ‘decentering’ which is also described as reperceiving (Shapiro et

al., 2006). Decentering describes the capacity to take an observer or witnessing perspective when

experiencing sensations, feelings, and thoughts, and relating to these phenomena as transitory

internal physical and mental events that lack permanence. According to Shapiro et al, (2006)

decentering facilitates exposure or the ability to contact and endure previously avoided states

along with an increased capacity for self-regulation. A decentered position makes it possible to

observe uncomfortable emotional and physical states like anxiety while maintaining a stable and

adaptable state rather than being embedded in these states and controlled by them. In effect,

extending the time between stimulus and response and making automatic and defensive

behaviour patterns less likely to emerge.

The results of the clinical trial in this study showed that TMS (Lau et al., 2006) decentering

subscale scores assessed on a session-by-session basis one week after the previous treatment

session significantly increased over sessions, and that decentering predicted reductions in

depression and stress, but not anxiety. The increase in decentering is consistent with research

conducted by Feldman, Greeson, and Senville (2010) who demonstrated that mindful breathing

leads to increased decentering. Guided by a script adapted from Mindfulness-Based Cognitive

Therapy (Segal et al., 2002) participants in the Feldman et al. study were asked to pay particular

attention to the physical sensations associated with breathing. And return attention to breathing

and sensations when their mind wandered away from this focus. Results indicated that directly


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after practicing mindful breathing novice meditators experienced an increase in decentering as

measured on the Toronto Mindfulness Scale (Lau et al., 2006).

The relationship between decentering and depressive symptoms has been investigated

through a questionnaire based study of a population of 495 university students with results

suggesting increased decenteredness may be associated with less depression (Gecht et al., 2014).

Even though the data analysis of the clinical trial in this thesis showed decentering did not

predict reductions in anxiety, the capacity for a decentered perspective is suggested to play a role

in reduction of anxiety. In a randomized controlled trial, Hoge et al. (2014) assess the role of

decentering and mindfulness as mediators of outcome in MBSR for adults with generalized

anxiety disorder. Analyses revealed that change in decentering and change in mindfulness

significantly mediated the effect of MBSR on anxiety. When both decentering and mindfulness

were included in the mediation model, increases in decentering had a significant indirect effect

on outcome, while mindfulness did not. Results suggested improvements in GAD symptoms are

partly explained by increased levels of decentering. These results are supported by a study that

assessed an acceptance-based behavioural therapy and applied relaxation in the treatment of

generalized anxiety disorder (Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015). Results

showed decentering increased significantly over the course of treatment and was correlated with

decreased anxiety and worry symptoms. The finding in this thesis that decentering predicted

depression and stress reduction, and the evidence cited above for decentering as a mechanism of

change in mindfulness interventions suggest decentering is most likely to be a mechanism of

change in GRMT. Further research however is needed to clarify the role of decentering in

GRMT.

Problem Actuation, Exposure and integration

Grawe (1997) suggests that four fundamental mechanisms of change, (1) mastery

experiences, (2) clarification of meaning, (3) problem actuation, and (4) resource activation, are


responsible for the established effectiveness of a broad range of highly diverse forms of

psychotherapy. Grawe further suggests, “the effectiveness of a given form of therapy is a

function of the extent to which these mechanisms of change are activated by concrete therapeutic

procedures, not the specific form that these therapeutic procedures take” (p.4).

Grawe (1997) has identified problem actuation as a mechanism of change based on the

premise that clients’ direct experiencing of their problems is fundamental to successful change.

Grawe notes that experience-activating procedures can take many forms including Gestalt

techniques, psychodrama, focusing, exposure to real feared situations, and interpersonal

interactions involved in couple therapy. Activation of emotional experience is a starting point for

therapeutic change in emotion focused therapy (Greenberg & Pascual-Leone, 2006), and CBT

interventions for social anxiety (Rodebaugh et al., 2004). In CBT for anxiety, exposure is used

on the basis that fully experiencing feared situations is necessary for improved self-regulation

(e.g., Foa & Kozak, 1986). There is increasing empirical support for the role of in-session depth

of emotional activation and reflection on that arousal, in experiential psychotherapy outcomes

(Elliott, Greenberg, & Lietaer, 2004). In mindfulness based interventions, reductions in worry

and anxiety is also suggested to take place via a reduction of avoidance of painful inner

experiences which in turn facilitates processing these experiences (Kabat-Zinn et al., 1992; J. M.

Miller et al., 1995; Roemer, Salters-Pedneault, & Orsillo, 2006).

Theoretically, a comparable problem actuation process would be operating in GRMT.

Learning to adopt a relaxed, uninhibited breathing pattern is the foundation of the therapeutic

process in GRMT. This study identified empirical research showing that inhibited breathing can

develop as a response to the stress of engaging with the environment, and can become a habitual

breathing pattern. This thesis has suggested that individuals may adopt inhibited breathing

unconsciously to block awareness of uncomfortable somatic experience, and that this may lead

to symptoms of depression and anxiety. Empirical research has shown that changes in


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respiration do influence emotional states (Boiten et al., 1994). The idea that people

unconsciously modify respiration in ways that provide protection from somatic discomfort is not

new to Western psychotherapy. For example, Lowen (1975) suggested inhibition of breathing is

adopted as a defensive strategy that limits energy flows, aliveness and cognitive flexibility. In

this somatic context Lowen further suggests that by regulating respiration in a way that lifts the

energy level in the body beyond the noise of muscular tensions defensive holding patterns can

come to conscious awareness, a process that can be described as problem actuation. And once

available to conscious awareness can be released, allowing for the integration of the underlying

experience.

In GRMT, problem activation may play an important part in bringing about change through a

comparable process. The application of GRMT with its process of self-regulation of respiration,

mindfulness and relaxation seems to establish conscious contact with defensive holding patterns

and previously suppressed psychosomatic experience. Once somatic experience is contacted and

sustained attention directed to it, a process involving acceptance, habituation, and tolerance

seems to then lead to integration of troubling phenomena. Observations made by Seppala et al.

(2014) in their randomised controlled study of the effectiveness of a breathing based meditation

intervention with military veterans with PTSD support the proposition that breathing based

interventions can bring about integration of troubling experiences. In their study participants

reported re-experiencing traumatic memories while in the physiological state induced by the

breathing regulation but were less impacted by traumatic memories after the intervention which

suggests some level of integration was achieved. Seppala et al. (2014), suggest these practices

may be particularly beneficial for PTSD as breathing-based meditation practice tends to mediate

hyperarousal, autonomic dysfunction, negative affect, and the emotion regulation difficulties that

characterize PTSD. Drawing on empirical research into neurophysiological changes related to

the practice of a range of meditation and breathing techniques, Jerath et al. (2015) came to the


similar conclusion, that self-regulation of breathing could be a primary treatment for anxiety

through the process of promoting an ANS shift from sympathetic dominant states like anxiety to

parasympathetic dominance.

The above discussion suggests that the fundamental mechanisms of problem actuation and

exposure may be important mechanisms of change operating in GRMT, and that when these are

matched with awareness and relaxation bring about symptom change through a process of

acceptance and integration.

Intensity of Intervention and Reduction of Avoidance Behaviour

The mechanisms of problem actuation and exposure discussed in the previous section are

related to the intensity of the GRMT intervention. GRMT can be considered an intense

intervention due to its sustained, therapist guided focus on application of the three components

of the approach (respiratory regulation, mindfulness and relaxation) which remains virtually

unchanged during an individual session and from session to session. Increased intensity of a

single approach may be more potent in bringing about change than engaging in a variety of

different therapeutic methods experienced momentarily, even when they make sense as a

sequential therapeutic process. The intensity and duration of the GRMT intervention with its

therapist guided respiratory regulation and sustained concentration on breathing and sensations,

may counter the tendency for mind wandering that can take place during less engaging activities

and reduce the impact of problem actuation and exposure. Smallwood and Schooler (2013)

suggest that mind wandering will account for a substantial amount of an individual’s time during

almost any cognitive task. As previously noted, experiential avoidance, which mind wandering

may be considered one form of, has been suggested as a general mechanism underlying the

development and maintenance of psychological distress (S. C. Hayes et al., 1996; Kashdan et al.,

2006). An early study of intervention intensity conducted by Foa, Jameson, Turner, and Payne


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(1980) assessed outcome from daily sessions compared to weekly sessions of exposure for

agoraphobic clients. They found the more intensive intervention to be more effective than spaced

sessions and concluded that the positive outcomes for the more intense intervention format may

be due to the lack of opportunity for clients to engage in avoidance behaviour. Another example

using a different form can be found in a recent study of intensive behavioural therapy for panic

disorder with agoraphobia (Knuts, Esquivel, Overbeek, & Schruers, 2015) which involved 5 full

consecutive days of CBT treatment with coaching from a behavioural therapist. Results indicated

a rapid reduction in anxiety symptoms. Two different examples of intensity come from Eastern

traditions. Therapists practicing Qigong are reminded to keep in mind that integration of the

Three Adjustments is the underlying goal of all Qigong practice (Liu & Chen, 2010). The Three

Adjustments refers to body, respiration, and mind. A method used in Qigong to cause integration

is the ‘extending method’ which involves, “extending one adjustment to the extreme to induce

the state of Three Adjustments integrated into one,” (Liu & Chen, 2010, p.203) with respiration

being the recommended adjustment, although any of the three can be chosen. A further example

is insight meditation (Vipassana) which aims to establish full contact with the experience of the

body including physical sensations, the contents of the mind, and perceptions of phenomena

(collectively known as the four foundations of mindfulness), with the goal of developing insight

into the nature of experience. Insight meditation uses sustained practice of sitting meditation,

which forces increased contact or awareness of the body by eliciting physical and psychological

discomfort which must be accepted and surrendered to.

A common element in these approaches shared by GRMT is that they take as their starting

point for psychological change the establishment of contact with the body which is sustained

through attention. This sustained contact and attention brings into awareness uncomfortable

somatic experience, which one must then have the courage to be with in a new more open and

relaxed way.


Mastery Experiences, Self-Efficacy and Ontological Safety

In GRMT the experience of openness referred to above can be described as an act of

surrender or defencelessness, of passively encountering with acceptance whatever experience is

presented in the present moment. Non-surrender implies a lack of acceptance and a defensive or

adversarial stand against experience. Mindful surrender involves letting go of defence and

instead facing ones inner experience in a spirit of openness and vulnerability. Paradoxically, this

may lead to a sense of self-control and mastery. The paradoxical theory of change (Beisser,

1970) asserts that fully identifying with one's current experience, including those aspects of the

experience that are undesirable, will paradoxically create conditions that support growth.

Acceptance allow the continuous integration of emergent experience, thereby establishing

conditions that allow for the continuing possibility of change. A comparable theoretical position

is at the heart of the conceptualization of growth and change proposed by Rogers (1961) which

suggests as one makes greater contact with their own inner world, especially feelings, one

gradually learns to trust in ones own ‘organismic’ functioning and use ones feelings as the

reference point for living an authentic life.

It seems reasonable to suggest that any approach to change that increases the sense of safety

with inner experience is strengthening an experience of ontological safety (e.g., a sense of safety

in ones own existence). GRMT may foster an experience of ontological safety and thus provide

an experience of embodiment that is definite, certain, stable, and reliable as apposed to

precarious and easily threatened by interaction with others or the world (Laing, 1973, p.90).

Laing suggests that when a person is secure in their own being, anxieties “do not arise with

anything like the same force or persistence, since there is no occasion for them to arise and

persist in this way” (p. 65). Increased sense of ontological safety may develop hand-in-hand with

an increased sense of mastery and self-efficacy. As noted in chapter 5, analysis of the outcomes

of the clinical trial component of this thesis found that participants confidence in regulating


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thoughts and emotions increased over the course of sessions and that these increases predicted

reductions in depression, anxiety, stress, anxiety sensitivity, and increases in overall wellbeing.

Additionally themes participants reported in the end-point interview reported in chapter 6

included confidence and self-efficacy in managing difficult situations and engaging in

interpersonal situations, as well as optimism for the future. These outcomes suggests that GRMT

provided participants with a mastery experience which Grawe (1997) defines as concrete, real

life experience related to learning to manage situations that previously were experienced as

anxiety provoking or difficult, and consequently developing a self-efficacy expectation toward

managing such situations in the future.

Self-efficacy can be considered a universal construct in mental health (Scholz, Dona, Sud, &

Schwarzer, 2002) and a considerable amount of evidence (see, Bandura & Locke, 2003) has

provided support for Bandura’s (1977) classic theory on self-efficacy which proposes that all

therapy approaches are effective to the extent that they alter self-efficacy beliefs. Expectations of

personal efficacy play a powerful role in determining the initiation of coping behaviour, level of

effort expended and persistence over time in the face of challenges and subjectively aversive

experiences. Bandura (1977) proposed four principle sources of information from which

expectations of self-efficacy are derived: performance accomplishments, vicarious experience,

verbal persuasion, and physiological states. He also suggested that greater changes in perceived

self-efficacy would result from the source of information which provides the greatest level of

dependability. In the context of the current research and the discussion above, it can be

suggested that information in the way of physiological states and an experience of the body that

develops a sense of ontological safety and security, offers the greatest level of dependability and

trustworthiness on which to base a sense of self-efficacy. It could be hypothesised that the rapid

symptom reduction the findings of this study have demonstrated may be linked to the

interventions ability to provide participants with an intensified experience of their body and an


opportunity to develop self-regulatory skills characterized by tolerance, non-defensiveness, and

acceptance, that lead to experiences of integration. If an individual has available to them: 1) a

technique that they know through direct personal experience, and 2) that they are sufficiently

competent in using, and 3) helps them maintain and further strengthen a sense of ontological

safety and security, continued use of those skills is likely to be positively reinforced, and

therapeutic outcomes are likely to be enduring. Further research into GRMT could examine these

propositions.

Conclusion

It is possible that a number of mechanisms could be active in this novel experimental approach,

including the therapeutic alliance, mindfulness, exposure and reduction of experiential

avoidance. These mechanisms may fall under more global mechanisms as the above discussion

suggests. For example, experiencing closer contact with one’s own physical functioning and

somatic experience through the sustained volitional control of breathing and somatically applied

mindfulness may provide an individual with an increased sense of safety in their own being, and

a sense of self-efficacy in their ability to manage the dynamics of their internal world as they

engage in day-to-day functioning. Although this is a speculative proposal, the above cited

literature suggests it is not without theoretical and empirical support. Further research into

GRMT is required to establish if indeed these propositions have any empirical basis for this

intervention.


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CHAPTER!EIGHT!

Summary!of!Studies!

The aim of this project was to apply the discipline of systematic scholarship to the evaluation

of an intervention which has never previously been formally investigated. The project was based

on the premise that an intervention utilising sustained self-regulation of breathing, the

application of mindfulness to emergent somatic experience, and relaxation, could be a useful

additional treatment for depression and anxiety. GRMT was seen as having some specific

advantages over other interventions for depression and anxiety because of its simplicity and

minimal requirement for verbal therapist-client interaction. The process of treatment

development and evaluation involved three stages. The first stage involved consideration of the

relationship between the proposed clinical model of breathwork and related interventions aimed

at clarification of the treatment model. Once a clinical model was clarified this could then guide

treatment manual development. The second stage involved development of a formal

intervention manual and the development, implementation and evaluation of a therapist training

program. The third and final state was an uncontrolled trial that used both quantitative and

qualitative measures to evaluate treatment impact with a sample of people experiencing

clinically significant depression and/or anxiety.

Stage One: Specifying Treatment Approach and Rationale for Use

The first stage of this study (reported in chapter 2) focused on developing an initial

formulation of the treatment model by exploring empirical literature in a range of relevant areas.


An important consideration in conducting this review was to maintain a high scholarly standard

by ensuring that only empirical research was considered. Empirical research was identified

showing the link between the development of unhealthy breathing patterns (e.g., strained or

inhibited) and anxiety, vigilance, and environmental demands. Using the model of healthy

respiration defined in the respiration literature made it possible to clearly specify the nature of a

healthy, uninhibited breathing pattern which could then form a core component of a clinical

model of breathwork. Stage one also identified mindfulness as a key component of a clinical

treatment model. This then allowed for an examination of the empirical literature on mindfulness

based therapy interventions with proven efficacy in the treatment of depression and anxiety.

Empirical research into the use of yoga breathing practices in the treatment of depression and

anxiety was also explored and further strengthened the case for the use of self-regulated

respiration in treating depression and anxiety. Finally, relaxation was identified as an important

component of the treatment model. Based on this exploration of the empirical research, the stage

one investigation resulted in a paper identifying a three component clinical model of breathwork

made up of respiratory regulation, mindfulness and relaxation, and provided a conceptualization

of psychopathology based on this model. The research presented in this paper provided sufficient

cause to further develop and explore the utility of a clinical respiration based intervention that is

now referred to as guided respiration mindfulness therapy.

Stage two: Manualization and Evaluation of Therapist Training

Stage two of this project focused on the development of the GRMT treatment manual and

subsequent development and evaluation of a standardised therapist training program which was

based on the treatment manual (reported in chapter 4). The primary aim of this stage was to

determine whether a brief training process was sufficient to develop therapist knowledge and

competence in delivering the GRMT intervention. Results provided strong support for the

effectiveness of this training program. The majority of therapists who attended the initial two-


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day training workshop acquired foundational knowledge after training. Training outcomes also

showed that the majority of therapists who received further supervised training and who were

evaluated for competence could competently deliver the intervention in a clinical trial. Results

also indicated a high level of treatment integrity with therapists adhering to the treatment

manual. The well-defined and uncomplicated nature of the GRMT intervention, and the good

level of therapist acceptance and perception of treatment effectiveness may have been influential

in therapists following intervention protocols, as suggested by Perepletchikova and Kazdin

(2005). While there is room for further improvement in training effectiveness, results indicated a

multi-level training which utilised training components known to be effective can equip

therapists’ with foundational knowledge and skill in GRMT.

Therapists’ acceptance of GRMT was assessed using qualitative methodology in which

therapists’ participated in a semi-structured focus group conducted on completion of each two-

day workshop. Analysis of focus group discussions identified three overall themes: therapists’

perception of treatment implementation, therapists’ perception of training, and therapists’

personal experience of the intervention. Therapists’ were highly enthusiastic about the

intervention and endorsed its use for clinical practice with a range of mental health problems and

populations. Therapists’ identified a number of strengths of GRMT including the minimal

reliance on verbal interaction, the speed at which the intervention seemed to work, the relative

speed that it can be picked up, and the potential for deep therapeutic effects. The two-day

workshop was well received and the treatment manual was experienced as helpful. However, the

need for further training to develop increased competence was emphasised.

In edition to demonstrating training effectiveness, the stage two study provided the

opportunity for an initial quantitative self-report assessment of therapeutic effects of the

intervention on therapists who received it during the training process. Findings showed that

therapists’ experienced powerful post-GRMT session wellbeing effects. This quantitative data


supported the qualitative data collected in the post-workshop focus groups which indicated that

therapists’ experienced a range of therapeutic effects from their practice of GRMT during

training. Therapists reported some of these therapeutic effects were experienced as surprising in

their depth and personal meaningfulness. Overall therapists’ found the intervention personally

beneficial. The encouraging results of the qualitative analysis regarding therapeutic effects of

GRMT and the preliminary evaluation of the impact of GRMT on therapists’ wellbeing provided

encouragement for further empirical evaluation of GRMT and strengthened the rationale for

conducting the clinical trial stage of this study.

Stage Three: Evaluating GRMT in the Treatment of Depression and Anxiety

Stage three in this study involved a clinical trial of GRMT as a treatment for symptoms of

depression, anxiety and stress (reported in chapters 5 and 6), in which 42 clients with a DSM-IV

diagnosis of either depression (n = 15) or anxiety (n = 27) were evaluated after receiving

between 3 and 9 sessions of the intervention. The trial used standard measures to assess

symptom response on a session-by-session basis. Findings showed the intervention was effective

in reducing depression, anxiety, stress, and anxiety sensitivity, and in increasing sense of

wellbeing. The majority of change in DASS scores took place by session six and then plateaued,

with very large effects sizes by treatment end. In this study the task and goal agreement aspects

of the working alliance increased over sessions, and goal agreement predicted reductions in

stress for the depression group, and anxiety for the anxiety group. The Decentering aspect of

mindfulness was also found to predict reductions in reported depression symptoms and stress

symptoms for both depression and anxiety groups. Additionally, the qualitative findings

indicated a range of mindfulness related outcomes were experience by participants, which

suggests assessing mindfulness needs to go beyond the use of self-report measures like the TMS.

A strong predictor of all outcome measures (reductions in depression, anxiety, stress, anxiety

sensitivity, and increase in wellbeing) was clients increased confidence in their ability to regulate


127

thoughts and emotions. Overall, both quantitative and qualitative methods used to evaluate

changes resulting from receiving the GRMT intervention indicated it may be an effective

additional treatment option for depression and anxiety.

Key Strengths and Limitations

Using items from the Psychotherapy Outcome Study Methodology Rating Scale (Ost, 2008),

and the RCT of Psychotherapy Quality Rating Scale (Kocsis et al., 2010) as a checklist, this

study used to a considerable extent current psychotherapy research methodology appropriate for

a treatment in the early stage of development.

A key strength of this study was the use of a treatment manual and treatment adherence

focused supervision. This gave some assurance that the intervention taught during training was

consistent with the manualized protocols. Observation of treatment sessions during the clinical

trial gave further confirmation that the intervention was delivered in accordance with the

standardised protocol. The fact that the treatment being delivered was the treatment under

investigation gives confidence in the internal validity of the study.

The study employed a structured diagnostic interview, and depression and anxiety specific

outcome measures with good psychometric properties well suited to the purposes of the study

were used on a session-by-session basis. A clear description of the sample was provided,

including DSM-IV diagnosis, inclusion/exclusion criteria, demographics, prevalence of

comorbidity, and possible presence of personality disorder. Recruiting a community sample and

lenient exclusion criteria suggest the client sample can be considered comparable to clients

seeking treatment for depression and anxiety and further suggests generalizability of study

findings. Just over 80% of participants met criteria for at least one comorbid anxiety and/or

depressive disorder. This is important as comorbidity is a dominant feature of people with

depression and anxiety. The design ensured that clients did not receive other treatment during the

study (psychological or medical) that would confound results. Symptom severity (DASS scores)


was reported from baseline. Clinically significant response was reported for the main outcome

measure (DASS) using established population norms. Treatment was delivered by multiple

therapists and as mentioned above, was guided by a standardised, manualized intervention with

checks for therapist competence and adherence. Measuring client response on a session-by-

session basis and using a multilevel analysis meant loss of client outcome data due to early

withdrawal from the study was minimized and it was possible to obtain initial indication of dose-

response for the GRMT intervention.

A limitation of the training stage of this study was that all training including supervision was

conducted by a single trainer, so it is unknown if similar results would be obtained with a

different trainer. Therapist competence ratings were also made by a single rater so rating bias

may have been present and the reliability of the rating instrument is yet to be established.

Additionally, there is the possibility of bias in therapists responses during focus group

discussions, who may have experienced high levels of gratitude to the facilitator and wished to

respond in the affirmative. The interpretation of results of the clinical trial must consider that

there was no control or active comparison condition. There was also no follow-up so it is

unknown if treatment effects are maintained over time. And further work is needed to establish

the reliability of the GRMT-SE measure developed specifically for this study.

Future Research

The promising results of this study encourage further theoretical and empirical exploration

and development of the GRMT treatment model. Further research is needed to establish if the

GRMT training effectiveness findings can be replicated with a different trainer, since all training

was conducted by only one trainer and a different trainer may produce different training

outcomes. This study was guided by the stage model of treatment development and aimed for an

outcome that established the empirical foundation needed for more rigorous research. With this

foundation established, further research aimed at seeing if the results of this study can be


129

replicated in more rigorous research, specifically in the form of a randomised controlled trial

with an active treatment comparison with demonstrated effectiveness in targeted disorders, is

warranted and should be of a high priority. This is particularly so given the need for effective

interventions discussed in the opening chapter. An additional important issue requiring further

research is ascertaining whether treatment effects are maintained over time.

The results of this program of investigation suggest that cognitive and behavioural changes

and neurological effects all play some role in bringing about the change in symptoms that

quantitative and qualitative analyses in this study identified. Understanding the role of each of

these domains would add to our understanding of the intervention and support its further

development. It is important to keep in mind that this intervention uses a minimal of verbal

interaction between therapist and client, and no attempt is made to directly modify cognitions or

behaviour. Yet clients reported positive changes in thinking, including related to perception of

ability to cope. Clients also reported experiencing greater confidence and behaviour change in

interpersonal and social situations. Future research could include assessment of changes in self-

efficacy beliefs and how these might be related to processes in GRMT, for example, exposure to

somatic experience and increased capacity for self-regulation of breathing and attention.

Additionally, research into the neurological impact of GRMT would serve to help understand the

mechanisms of action by which this approach works.

The treatment manual developed for this study was intended to be brief, therapist friendly,

and fit the needs of the initial stage of treatment development. As such, there is further work to

be done in manual development. For example, results from the therapist training evaluation in

stage two of this study suggest including a focus on timing, correctness and flexibility in delivery

could make improvements. Additionally, the inclusion of a psychoeducation component that

integrates with the theoretical foundation of the intervention may add to clients’ ability to adopt

the intervention and generalise its core practices to everyday functioning. Potentially this


intervention could be adopted with a range of populations and disorders, in which case the

manual will need to be extended to provide an orientation for therapist and client that matches

the specific needs of those populations or problems. The manual in this study was developed for

individual therapy. Future development aimed at adapting the manual for group intervention

contexts may provide cost and time savings, however, care will be needed to ensure that group

delivery is well controlled, acceptable to both therapist and client, and meets ethical care

standards.

Treatment Dissemination

The high level of endorsement the manualized intervention and standardised training

workshop received from therapists is highly encouraging for future dissemination of the

approach. The relative simplicity and ease of learning associated with this intervention means it

may be more accessible than more complicated interventions. Additionally, the positive therapist

response the GRMT intervention received in this study, including the ‘self-care’ effect

therapists’ experienced, along with the general interest in interventions that utilise mindfulness

also suggests broader interest and potential for the dissemination of the intervention. Training in

this intervention may be well received as a component of psychotherapy training curriculum and

offer an experience of experiential therapy not usually available.

Conclusion

This study developed and evaluated a manualized clinical model of breathwork described as

guided respiration mindfulness therapy. This process included defining the GRMT intervention

and developing a standardised therapist training program based on the GRMT treatment manual.

The findings demonstrated that therapists with no prior exposure to the approach can develop

foundational knowledge and skill in delivering the manualized intervention after completing a

brief, focused training program. The development of a standardised training program with

demonstrated effectiveness provides a foundation for further research into this intervention.


131

Clinical trial results of this study demonstrated that guided respiration mindfulness therapy

can be effective in rapidly reducing symptoms of depression, anxiety and stress, and increasing

sense of wellbeing. The minimal verbal therapist-client interaction of GRMT suggests the

intervention might be helpful for populations who have difficulty identifying and talking about

emotions. The focused nature of the intervention and effectiveness of the brief therapist training

program suggests GMRT could be disseminated relatively easily where a brief intervention that

produces rapid symptom response is required.


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APPENDICES!!


Appendix 1: Ethics Approval


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Appendix 2: Informed Consent Form (Therapist)

INFORMED CONSENT FORM (THERAPIST)

Thank you for deciding to participate in this research project Name of the project: Developing a Manualization Breathwork Intervention: Assessment of Therapeutic Outcome and Mechanisms of Change Investigator: Lloyd Lalande Your Contact Details: Name: ________________________________________________________ Phone: ________________________ / _____________________________ Address: _____________________________________________________________________ ___________________________________________________________ Post code: _________ Email: ___________________________________________________ In signing this document, I acknowledge that I have the right to withdraw from the study at any time without penalty. I also understand that there is no benefit for participation beyond those attributed to participation itself and that all aspects of my participation will remain confidential. I also agree to keep confidential any information or experiences shared by other participants during the workshop training and throughout my involvement in the study. I hereby agree to be involved in the above research project. I have read and understand the research information sheet pertaining to this research project and I am aware of the experiential nature of the intervention I am learning and I understand the nature of the research and my role in it. Signature of participant: Date:


Faculty of Health

School of Psychology & Counselling


Appendix 3: Information for Participating Therapists

INFORMATION FOR PARTICIPATING THERAPISTS

Title of the project:

Developing a Manualization Breathwork Intervention: Assessment of Therapeutic Outcome and Mechanisms of Change

Part one of this project seeks to assess the effectiveness of a respiration based psychotherapy intervention training consisting of a two-day workshop followed by 6 supervised practice sessions. After completing this you will be invited to participate in the clinical trail part of the study. Please talk to Lloyd for more information about this.

Principle investigator

Lloyd Lalande Contact details: Phone 3278 1683. Mobile: 0402 715 934

Project Supervisors

Dr Matthew Bambling (ACU)

Ass. Professor Robert King (QU)

Dr Roger Lowe (QUT)

What is the purpose of this study?

This study seeks to assess the effectiveness of a manualization training, composed of an intensive 2-day workshop and 6 independent paired practice sessions with supervision. The study will collect data to assess if therapists’ experience any change in levels of mindfulness and perceived wellbeing as a result of participation in training. After completing the entire training participants will be awarded a certificate of completion.

What is the intervention under investigation?

The approach being developed and evaluated in this study is based on the use of modified breathing, mindfulness and relaxation. It is a stand-alone treatment that can be used in clinical practice. The approach teaches clients to breath in a natural, relaxed and uninhibited way, while at the same time studying their somatic experiences with an attitude of acceptance, and relaxing completely. So it does require the client’s active participation in directing and controlling their attention. The core activity takes approximately 60 minutes with the entire session taking 90

Queensland University of Technology Faculty of Health School of Psychology & Counselling Brisbane Australia


155

minutes. During a session the client lies comfortably and the therapist guides their breathing and attention, encourages relaxation, and offers support as required.

What is the expected duration of my participation in the study?

The duration of your participation in this stage of the study starts with attending the 2-day introductory workshop. You will have the option to then continue in an extended training component involving 6 further training sessions with supervision. The duration of your participation will vary, however, these 6 sessions are expected to be conducted weekly. So total duration is expected to be not less than about 10 weeks. If you want to develop your clinical skills in practicing this approach you can continue your participation into the clinical trial stage where you have the opportunity to treat one or more clients.

What are the procedures for my involvement in this study?

Participation in the study requires that you first attend the two-day introductory workshop. During the workshop you will have practice giving and receiving the intervention. After the workshop you will need to negotiate with another participant to conduct six swapped session, which are video taped. A therapy room will be provided for your use at the university, which is set up for this purpose. Supervision will be integral to the 6 practice sessions.

Are there any risks associated with involvement in the study?

There are minimal risks associated with your involvement in this study. However, the treatment approach is experiential and you may experience some temporary psychological or physical discomfort during practice. If you have any concerns you can talk to the Lloyd.

What are the potential benefits from participating in the study?

There are a number of potential benefits. You may find that the workshop and follow-up sessions has a beneficial effect. Participation in the study will provide you with high quality training and supervised practice in delivering the breathwork intervention. Therapists completing the workshop and the six paired supervised sessions, will be awarded a certificate acknowledging their participation.

Are my details kept private and secure?

Yes, personal details of participating therapists are kept confidential and stored in a locked room.

What happens if I change my mind about participating?

Your participation in this training effectiveness study is voluntary; therefore you are free to withdraw from this study at any time without prejudice.

What happens to data already collected should I withdraw?

Withdraw prior to completion of the study does not effect the use of data already collected.

Can I get feedback about the study?


If you would like to know any results related to this study you can call Lloyd.

How do I give consent to participate?

We would like to ask you to sign a written consent form to confirm your agreement to participate.

What if I have further concerns about my participation?

QUT is committed to researcher integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Officer on 3138 2340 or [email protected]. The Research Ethics Officer is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.


157

Appendix 4: Informed Consent Form (Client)

INFORMED CONSENT FORM Thank you for deciding to participate in this research project Name of the project: Developing a Manualization Breathwork Intervention: Assessment of Therapeutic Outcome and Mechanisms of Change Your Contact Details: Name: ________________________________________________________ Phone: ________________________ / _______________________________ Address: _____________________________________________________________________ _________________________________________ Post code: __________ Email: _______________________________________________________ In signing this document, I acknowledge that I have the right to withdraw from the study at any time without penalty. I also understand that there is no benefit for participation and that all aspects of my participation will remain confidential. I hereby agree to be involved in the above research project as a respondent. I have read and understand the research information sheet pertaining to this research project and understand the nature of the research and my role in it. Signature of research participant: Signature of witness: Date:


Faculty of Health

School of Psychology & Counselling


Appendix 5: Information For Participants

INFORMATION FOR PARTICIPANTS What is this project called? The simple name for this project is: An evaluation of a breathing based therapy - a different approach to treating depression and anxiety Who is involved in this project? Lloyd Lalande is the principle investigator. To contact him call, 3623 7341 email: [email protected] This project is being supervised by: Dr Matthew Bambling (Australian Catholic University, School of Psychology) Dr Roger Lowe (QUT, School of Psychology and Counselling) Associate Professor, Robert King (University of Queensland, School of Medicine) What is the purpose of this study? This PhD study aims to evaluate the effectiveness of the intervention is in reducing stress and treating depression and anxiety. What is the therapy being studied? The approach being evaluated in this study combines breathing, meditation and relaxation, so it does require your active participation. The treatment sessions take approximately 90 minutes to complete. During a session you lie comfortably and the therapist guides your breathing. What is the expected duration of my participation in the study? It will depend on how many sessions you receive. Treatment ends when your anxiety and/or depression symptoms drop to within the normal range or after receiving a maximum of 10 sessions. It is expected that treatment sessions will be conducted weekly or fortnightly. You will also be contacted by phone 3 months after completion of treatment to assess how you are doing. What are the procedures for my involvement in this study? Participation in the study requires you to attend an initial interview to assess your depression and/or anxiety symptoms. Once accepted into the study you will be assigned a therapist. Each session will include therapy and will also require you to complete the questionnaires used to assess how you are progressing. You will be able to negotiate session times with your therapist. You will need to allow approximately 90 minutes for each session. The study will take place at the Psychology Clinic at Kelvin Grove campus of QUT, or if more convenient for you, the Counselling Clinic at Australian Catholic University at Banyo.

The official name of the project is: Developing a

Manualization Breathwork Intervention:

Assessment of Therapeutic Outcome and

Mechanisms of Change


159

Are there any risks associated with involvement in the study? There are minimal risks associated with your involvement in this study. However, any treatment for depression or anxiety may involve some physical or psychological discomfort. Discomfort in this study may come about as a result of discussing problems you are having in your life. Also, practicing therapy involves a breathing exercise, meditation and relaxation, may cause temporary discomfort due to physical feelings and sensation, which are unfamiliar to you. What are the potential benefits from participating in the study? Most people find therapy to be a very positive experience. If therapy is successful you may experience a reduction in stress levels as well as reductions in depression and/or anxiety symptoms. Your participation may also give you skills for managing your mental and emotional states in the longer term. Are there other treatments available? Yes, there are alternative treatments for depression and anxiety. Medication is available for both depression and anxiety and can be prescribed by your doctor. A variety of psychotherapy treatments are also available. Are my details kept private and secure? Yes, we take special care to ensure your information remains private and secure. Once data has been collected from your therapy sessions it will be stored separately from your personal details and will not be linked to them. All documents will be stored in a locked room. As is normal practice, what is discussed in therapy sessions will remain confidential. What happens if my symptoms get worse? If for any reason you are feeling worse, or are unhappy with your treatment you are free to discuss you concerns with your therapist. You may also speak to the principle researcher. Other treatment options may then be provided through referral or other intervention as required. What happens if I change my mind about participating? Your participation in this study is voluntary; therefore you have the right to withdraw from this study at any time without prejudice. What happens to data already collected should I withdraw? If you decide to withdraw from the study after commencing, all data already collected will still be used in the study. Can I getting feedback about the study? You are free to discuss the results of your individual involvement in the study with your therapist. If you would like to know the results of the study you can call or email the principle researcher, Lloyd Lalande. How do I give consent to participate? You can simply sign the written consent form to confirm your agreement to participate. What if I have further concerns about my participation? QUT is committed to researcher integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Officer on 3138

Important: if you decide to commence

medication for depression or anxiety, or another

form of therapy, while participating in the study

you will need to inform your therapist as this will

mean you are no longer eligible for participation.


2340 or [email protected]. The Research Ethics Officer is not connected with the research project and can facilitate a resolution to your concern in an impartial manner.


161

Appendix 6: GRMT Treatment Manual

Guided Respiration Mindfulness Therapy Treatment Manual for Individual Therapy

(Brief research manual intended as a supplement to participation in face-to-face training)

Lloyd Lalande

© Copyright 2008 Lloyd Lalande Not to be reproduced in any form without the prior

written permission of the Author. Do not quote without author’s permission.


Section 1

About This Manual

This manual is designed to supplement training in which participants learn the Guided Respiration Mindfulness Therapy (GRMT) procedure through supervised practice. This manual is only to be used by therapists who are currently attending, or have already attended, a Guided Respiration Mindfulness Therapy training program. The aim of this manual is to provide you with basic guidance in facilitating Guided Respiration Mindfulness Therapy with your clients. It provides you with:

• A brief description of the history of Breathwork • A description of three core components of the GRMT approach • A description of clinical issues • A step-by-step guide to conducting GRMT sessions

About Breathwork

Breathwork is a psychotherapy intervention based on the use of modified breathing. While breathwork of various forms is used in some areas of mental health practice, there is, so far, not standardised approach to treatment, no standardised training process and not evidence base for effectiveness. Despite these deficiencies, breathwork has acquired some popularity as an alternative health practice and component of personal-growth workshops. The lack of a standard agreed upon approach has played a role in the field of breathwork remaining marginalized and fragmented with virtually no empirically based published literature that could guide clinical practice, training, or professional standards. To date, one empirical pilot study has been conducted (Sudres, Ato, Fouraste, & Rajaona, 1994) using an unspecified breathwork intervention, which suggested effectiveness in treating depression and anxiety.

Guided Respiration Mindfulness Therapy (GRMT)

Guided Respiration Mindfulness Therapy (GRMT) represents a refinement, clarification and further development of existing Breathwork approaches and is, for the first time, informed by empirical research, and identifies mindfulness as a core component. Guided Respiration Mindfulness Therapy is a standardised 3-component approach. Respiratory regulation is the foundation of GRMT and is characterized as a natural, uninhibited breathing rhythm and is based on the empirical literature on respiratory regulation. GRMT also formalizes mindfulness meditation as an essential component of the intervention, along with deep relaxation. Sufficient research has been conducted into the components of GRMT to suggest likely effectiveness in improving mental health, especially with anxiety and depression. For example, GRMT uses rhythmic breathing and the use of yoga rhythmic breathing techniques as a treatment for depression have been shown to significantly reduce depression symptoms, and be comparable to antidepressant medication (Janakiramaiah et al., 2000; Khumar, Kaur, & Kaur, 1993).


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Mindfulness meditation is also a component of GRMT and mindfulness-based interventions have demonstrated effectiveness in treating a variety of physical and psychological conditions including depression and anxiety (Baer, 2003). Meditation practice in general has been linked to increased alpha and theta brain wave activity which has been associated with increased serotonin and dopamine release (Anderer, Saletu, & Pscual-Marqui, 2000; Kjaer et al., 2002; Thorleifsdotttir, Bjornsson, Kjeld, & Kristbjarnarson, 1989), which play a role in regulation of mental states related to arousal, attention, mood and motivation. Relaxation, also a component of GRMT, has empirical support in alleviating distress, anxiety and depression and increasing positive mood states (Jain et al., 2007; Luebbert, Dahme, & Hasenbring, 2001; Stetter & Kupper, 2002). However, the user of this manual needs to be aware that the empirical foundation for GRMT is still under development and GRMT is not at present an empirically validated treatment.

Psychopathology from a GRMT perspective

Psychopathology, from the GRMT perspective involves: • Development of habitual inhibition of breathing as a way of controlling or suppressing

awareness of somatic effects (feelings, sensations, and emotions), which are deemed unacceptable or too uncomfortable to tolerate. Theoretically, these somatic effects may be associated with past or current stressful, troubling or traumatic life experiences.

• Suppression or avoidance of somatic effects is posited to have a detrimental impact on mental health and wellbeing, and specifically, creates reduced cognitive, emotional and behavioural flexibility, which can in turn lead to psychopathology (e.g., depression and anxiety).

Healing from an GRMT perspective

A major aspect of healing in GRMT involves both the activation and integration of suppressed or avoided inner experience, which is theoretically comparable to an exposure type process. The suggested result of this process is greater emotional, mental and behavioural flexibility. Other paths of healing are active in GRMT and were discussed in the workshop. • Activation refers to the process of bringing previously suppressed or avoided somatic

experience to conscious awareness which allows it to be observed, related to in a more adaptive way (processed) and accepted (integration). Activation is primarily facilitated by learning to breath in an uninhibited way (e.g. the Respiratory regulation pattern).

• Integration is achieved through relaxation and applying mindfulness to somatic experience.

Indications and Contraindications

GRMT may be an effective treatment for depression and anxiety because its somatic focus exposes the client to a variety of somatic experiences including previously suppressed or avoided feelings. Client’s with extreme anxiety and rigid defences need to be carefully assessed to determine that they understand the nature of GRMT and feel safe enough to use the approach. The combination of breathing, relaxation and meditative processes in GRMT also has the potential to induce an altered state of consciousness, making it important to ensure the client has an adequately stable sense of self.


Indications: • Anxiety • Depression • Stress

Contraindications include: • Psychosis • Active suicidality

The Three Core Components of GRMT GRMT is made up of three core components. Understanding and learning to apply these components is the foundational task of practicing GRMT. The three core components are:

1. Respiratory Regulation 2. Mindfulness 3. Relaxation

1. Respiratory regulation

This breathing pattern involves an active inhalation which is includes mobilization of the entire chest, and aims for a completely passive exhalation (that is, relaxation of all respiratory and peripheral muscle control). The breathing is maintained in a continuous uninterrupted rhythm. Inhalation and exhalation have the following characteristics:

Inhalation in GRMT:

• Breathing is includes mobilization of the entire chest • Generally deeper than normal for a resting state • Speed and depth can vary to manage energy and comfort level • Aims to establish capacity for full, flexible breathing

Exhalation in GRMT:

• The out-breath is always as relaxed as possible - release of all muscular control • Neither inhibited (slowed down) nor forced (pushed out) • Naturally varies throughout session • Becomes progressively more relaxed during sessions and from session to session

Nose or Mouth

In GRMT the breathing is done using either the mouth or nose but not a mix of both at the same time (e.g., if you breathe in through the mouth you also breath out through the mouth). This is to encourage a deeper level of relaxation and reduction in control. Breathing through the nose plays a role through olfactory neurons in synchronizing brainwave activity and so is an important


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driver of integration. However, nose breathing may be restrictive at times, especially during heightened emotional experiences.

2. Mindfulness.

There is general consensus in the psychotherapy literature that mindfulness is composed of two central components: (1) the self-regulation of attention on immediate, present moment experience (often the breath or body sensations), and (2) the adoption of an orientation to present moment experience that is characterised by acceptance, curiosity and openness (Bishop et al., 2004).

In GRMT mindfulness plays a vital role that involves:

a. Attention to the details of whatever bodily sensations and feelings are dominant at any given moment.

b. Adoption of an attitude of openness, curiosity and, most importantly, acceptance of inner experience. That is, inner experiences of sensations, feelings, emotions, etc., are simply accepted, without judgement, just the way they are.

c. Disengagement from thoughts (e.g., following stories, analysis of ones experience, naming experience, or mental attempts at problem solving). Attention instead is held on, and repeatedly returned to, maintaining the breathing and observation of sensations/feelings.

Engagement in conversation with the client during a session about “issues” arising is inconsistent with treatment protocol, and discouraged as this detracts from the aim of integration of the experience.

3. Relaxation.

In GRMT, the client relaxes in a reclined position (generally on ones back with hands at side) and resists the temptation to move around or fidget. As much as possible, physical tensions are released as they are identified. Progressively deeper levels of relaxation are achieved as subtler levels of tension are identified and released. Often physical tension is the first thing a client becomes aware of as they start practicing the GRMT technique.

Clinical Issues

Intense feelings During the opening stage of a GRMT session clients will start to relax into the process and be aware that something is happening. As a session progresses, sensations, feelings or emotions can come to awareness. Sometimes one or more of these experiences can become intense and the client may feel like they want to get rid of the feeling, start moving, scratching, rubbing their face, etc.. Sometime these may be amplifications of feelings that are very familiar to the client (e.g. restlessness, loneliness, frustration, anxiety, irritability). In GRMT, resisting, fighting against, or running away from an experience can have the effect of making it more intense. On occasion a client may experience tetany (tightness of muscles associated with forced breathing that usually appears in the hands). While this can be uncomfortable, it is harmless and passes.


Applying the three core components of GRMT ensures the experience is as comfortable as possible.

Catharsis

Catharsis is not encouraged in GRMT. While the spontaneous experience of emotion (e.g., sadness accompanied by tears) may be part of the process, clients are encouraged to return to focusing on their breathing, relaxing and applying mindfulness. GRMT is not about acting out feelings, it is about integrating them. In GRMT catharsis may be a strategy for running away from experience rather than accepting the initial discomfort of establishing oneself in the here and now.

Suspension of breathing

Suspension of breathing can take place at any time during a session. It is more likely to occur when sensations or emotions are becoming more prominent and the client’s desire (either conscious or unconscious) to move away from full contact with their experience. Pauses in breathing can also result from a natural response to changes in CO2 levels from respiratory drive control. Frequency of suspension of breathing varies considerably between individuals. As a general rule it is best not to let a client stop breathing for more than two or three breaths. Suspension of breathing is usually observable as the client’s breathing becoming shallower and then stopping for one or two breaths before resuming briefly before repeating only with an extended gap in breathing. The sense is that the client is drifting away from full consciousness. This is a seductive state for the client and intervention is needed to bring the client back to full awareness of their breathing for the GRMT process to be optimally effective and provide benefits that go beyond relaxation outcomes. In some cases prompting the client to return to their breathing is all that is needed – although this may need to be done repeatedly. However, sometimes even constant verbal prompting to breathe is not effective and the client continues to drift off. At this stage it might help to ask the client what is happening in their body, what are they aware of in the body. This might help them resume breathing. If extra support in maintaining the respiratory regulation pattern is needed it can involve encouraging active engagement with breathing and trying the following:

1. have the client hold their arm in the air. 2. have the client open their eyes. 3. have the client sit up 4. and as a last resort, have the client walk around the room.


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Section 2

GRMT: Step-by-Step

The setting

A room suitable for therapy (quiet, private) is usually adequate for conducting GRMT. The only special requirement is the provision of something comfortable for the client to lie on. Ideally this is some form of mattress or foam pad. A yoga mat covered with a blanket, or equivalent, may be satisfactory. A pillow is also required. The client will need to be kept comfortably warm so a blanket should be available if needed. Some clients will want a blanket to add to a sense of safety. Uncomfortably bright direct over-head lighting should be avoided or dimmed if possible.

Session length

Sessions can generally be conducted within 90 minutes with efficient use of time before and after the core GRMT practice of approximately 60 minutes. An initial session without GRMT can be used to assess the client, introduce GRMT and its rationale and schedule a future appointment for a GRMT session. In order to complete a session within 1½ hours you will need to commence the breathing component after approximately 10 minutes to allow sufficient time. Although the breathing component of most GRMT sessions takes about 1 hour to complete, you will need to allow a few minutes of relaxation to complete the session.

Physical touch during GRMT

Generally touch is not necessary during a GRMT session. Touch for providing ‘comfort’ for example stroking the clients forehead is not part of the treatment protocol and has a negative effect on client experience and is more likely a reflection of therapist need and counter transference. However, touch on the arm or shoulder may be appropriate on occasions when: • The client has repeatedly drifted away from the breathing • The client needs brief reassurance of safety

Inform the client how and when you may use touch and gain their approval for this.


Session One The aims of the first session are:

1. To develop the therapeutic alliance 2. To explain GRMT and its rationale (reduced suppression and integration) 3. To give instructions in applying core components of GRMT 4. Discuss the possibility of discomfort during the session and ways to manage it 5. To guide the client through their first experience of the GRMT technique 6. To debrief the session

Stage 1: Forming alliance and establishing rationale for treatment

In the first session an important task is ensuring the client feels both motivated to engage in the GRMT technique and safe doing so. Motivation and sense of safety are enhanced when: • The client feels their primary emotional experience is understood by the therapist. • The client can see how the GRMT approach can lead to symptom relief (e.g., through

stress/anxiety reduction, less rumination, integration). • The client feels confident in the therapist’s ability to support them. The therapist’s own

confidence in explaining and delivering GRMT and their sense of safety with the approach, will help establish the client’s sense of safety and trust.

Three steps to establishing client sense of safety: 1. Forming initial connection with the client. This can be done by obtaining a brief account of what the client feels are their primary emotional symptoms and any hypothesis they have as to their cause – especially vulnerabilities related to their history. 2. The client’s willingness to entertain a link between unintegrated past experiences and current difficulties regulating emotional states. Just acknowledging the possibility of some kind of relationship – i.e., lack of integration (a result of habitual inhibition of breathing) can lead to emotional difficulties in the present, is sufficient. 3. Gaining an initial understanding of the rationale for GRMT (e.g., promotes integration of unintegrated experiences/feelings/emotions). Stage 2: Giving directions for practicing GRMT

Primary Instructions

Before the client starts practicing the GRMT technique the therapist needs to explain what’s involved and to answer any questions they may have about the process. It is also necessary to discuss the possibility of discomfort and how you will manage or minimise it. This should be done while you are still seated. “Before we start the actual breathing, I need to explain what’s involved. If you have any questions, feel free to ask them. The first thing is the breathing pattern …(and so on).”


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1. Respiratory regulation pattern Example of statements explaining respiratory regulation: “The first thing you need to focus on is the respiratory regulation pattern. In GRMT you breathe in a full way that expands the upper chest. The breathing is done in a continuous rhythm of inhale and exhale, with no gaps or pauses between the breaths. The moment you finish breathing in, you let go and breathe out. The moment you have finished breathing out, then straight away you take your next in-breath. No pauses, no gaps, just a continuous in-out rhythm with a completely relaxed out breath. It sounds something like this….” Give a brief demonstration of breathing rhythm.

“You can breathe using your nose or your mouth, whichever is more comfortable. I recommend you breathe through your mouth. But choose one or the other, so if you breathe out through your mouth, also breathe in through your mouth.”

“Sometime you may drift away from the breathing rhythm. When that happens, I will remind you to keep breathing.”

2. Applying mindfulness

1. Focus on the details of the most dominant sensation or feeling

“The third thing you need to do is apply mindfulness – this has two parts. The first part is to focus in on whatever sensation stands out the most, or is most dominant. After 5 minutes or so of breathing you might start to notice other sensations in your body. For example, you might notice a tingling sensation in your leg. Explore that sensation; see if you can find the centre of it, the place where it is strongest. If you feel the urge to move, or scratch and itch, rather than doing so, see if you can locate the centre of that feeling and study it. The idea is to direct your attention there and study the smallest detail. And all the while, you are breathing and relaxing.”

2. Adopt an attitude of acceptance (and openness and curiosity) “The second part of mindfulness involves accepting whatever is going on in the session. Whatever sensations or feelings you are having, even if they feel unpleasant, the idea is to accept them completely, just the way they are.” You can also say, “If you have any sensations standing out in your body, just observe them and let them run their course. Not getting carried away with them or trying to fight or change them.”

3. Explain what to do with thinking: “As far as thinking goes, the idea is to just let thoughts go, to acknowledge them, but not engage with them. As much as possible focus your attention on maintaining the breathing pattern, focussing on the dominant sensation with acceptance, and relaxing.”

3. Relaxation Example of what you might say to the client: “The next thing is relaxation. During a GRMT session the aim is to totally relax. When you lie down, it is best to lie on your back with your arms at your side. The idea is to relax more and more into that one position without fidgeting or moving around. Any tension or holding-on you notice anywhere in your body, as much as possible, relax and let it go. Some movement is spontaneous and unavoidable, just a natural part of the GRMT process, so that’s ok too.”


Secondary instructions

1. Put aside expectations of performance It is a good idea to encourage the client to put aside expectations about their practice of GRMT and expectations about the process of GRMT. “An GRMT session does not require you to do it perfectly. In fact, that is not possible. What’s important is that you stay with the process. In other words, your intention to maintain the breathing pattern, relax tension, and apply mindfulness. GRMT works best when the intention is to stay with the process. I will be helping you do that by providing guidance when needed.” 2. Acceptance of novel experiences as part of the process Encountering a variety of internal experiences is what the GRMT process is all about. These inner experiences can take different forms. Sometimes they involve strong sensations or emotions. Sometimes they may involve images and thoughts. Some sessions will seem calm and comparatively uneventful. Whatever takes place in a session is just part of the process. Let the client know that while the basic instructions and process are the same for every session, their experience of each session will be different. 3. Discuss possible discomfort and its management There are two main forms of discomfort a client can experience, 1) when sensations, feelings or emotions are experienced as intense, and 2) when extra effort is needed to maintaining full consciousness and the rhythmic breathing pattern. Example of what to say: “Sometimes the sensations or feelings can seem a bit uncomfortable. If that happens the idea is to check that you are relaxing your out-breath, relax your whole body as much as you can, tune into the details of whatever is most intense, and accept whatever is going on. If you need to, you can tell me what is happening for you and I will give you some guidance.”

Some clients may experience tetany (tightness of muscles associated with forced breathing). If this happens it can be uncomfortable so the client should be forewarned of the possibility: “Sometimes a person will experience muscle tightness, mainly in the hands. It is not uncommon for some people to experience a bit of it at some time in the beginning stages of learning the technique. (Demonstrate what it looks like). I will be guiding you in a way that minimises the chance of it happening, but if it does, relax your exhale and explore the details of it. And remember, you can let me know if you are concerned.”

Explain how you will provide support if the client drifts away from the breathing (see previous section).


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4. Completion of the GRMT session A GRMT session usually takes about 60 minutes to complete if facilitated efficiently, and comes to an end naturally. It is important to ensure, however, that you have 75 minutes available in case it is needed. Ideally, completion of a session is determined by the client, however in clinical practice because of time constraints this is not always possible. Further, clients may not recognise when they are complete when first learning the approach. Additionally, a client may feel profoundly relaxed, or are enjoying a meditative state, that they are reluctant to give up this feeling. The client may be able to recognise completion of a session when: 1. the body feels calm with no strong sensations, and there is a sense of completion 2. there is a profound feeling of relaxation 3. breathing feels easier and more spontaneous The therapist can get a sense of the client’s level of completion by observing these three items. Toward the end of the session, if the client appears relaxed, letting the client know that they have been breathing for nearly an hour (by saying, “How are you going,”) may help in keeping the session within a reasonable time frame. Deep and/or fast breathing builds or maintains higher energy levels. After 50 minutes you can assess whether you need to suggest to your client that their inhale be a little shallower or gentler, or that they can “take it easy” or “it’s ok to relax.” This will help the session come to completion. Example of what to say about completion: “When it looks like you are starting to get close to completion I will say, “How are you going” to let you know. You don’t have to jump up straight away, what’s important is that the feelings in your body have pretty much settled down and you feel relaxed.”

It is important that the level of sensations the client is experiencing is at a low level before they get up from the session.

Stage 3: Conducting the GRMT session

1. Commencing the first GRMT session

1. Ensure client has turned off mobile phone. 2. Have the client lie down and get comfortable. 3. Check to see if they want a blanket or cover. 4. Encouraging client to start breathing and initial observation: “Ok, if you start breathing in

a continuous rhythm I will just watch for a few moments and then give you some guidance.” This gives the client a chance to relax into the process a bit.

5. Based on your observation start the process of guiding client toward establishing the respiratory regulation pattern. Initially, it is important to have the client breathe with sufficient depth to initiate activation.

6. After approximately 10 minutes you can ask the client what they are noticing in their body to get an idea of what they are experiencing. If they report “nothing” you may need to recommend fuller breathing with a focus on the top part of the chest.


7. Once you feel the session is progressing, you can give further guidance regarding any of the core components, as required based on your observations (see table below). You do not need to talk continuously.

2. Observation and guidance during GRMT

The main suggestions you will need to give during a GRMT session are reminders of the core components:

1. Maintaining the respiratory regulation pattern 2. Maintaining Mindfulness (focus on sensations and acceptance) 3. Relaxing totally

Guidance is given as suggestions (rather than commands). Starting suggestions with “Maybe …” or “Perhaps …” can be useful in this regard. If the client is experiencing discomfort, it is more important that they follow your suggestions. In these cases you can state what you are observing and suggest what to do. For example, “John, I can see that you are …… (struggling a bit there/experiencing a bit of discomfort/etc.) and I would like to suggest that you try …… (taking shallower breaths/relaxing even though it feels a bit intense/accepting everything that is going on/etc.).” Checklist for adherence to GRMT treatment model protocol The following list can be used to check you are administering therapy as it is intended. BEFORE COMMENCING GRMT 1. Provide an explanation of the treatment rationale to the client (e.g. integration) 2. Convey your own confidence and sense of safety with the GRMT approach to the client. 3. Give a clear explanation of how to apply respiratory regulation 4. Give a clear explanation of how to apply mindfulness 5. Give a clear explanation of how to apply relaxation 6. Discuss the possibility of intense feelings 7. Discuss how support will be provided in the event of intense feelings. 8. Discuss the possibility of difficulty maintaining the breathing pattern 9. Discuss how support is provided in event of difficulty maintaining the breathing pattern 10. Describe the completion process IN SESSION GUIDANCE 11. Provide in-session support for Respiratory regulation 12. Provide in-session support for Mindfulness 13. Provide in-session support for Relaxation 14. Provide in-session support for managing any intense feelings 15. Provide general encouragement throughout session


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Guide for in-session instructions (Also provided as a lift out guide)

Observation Action required

Example of suggestion to client

INHALE

Very shallow breathing

encourage deeper breathing into the upper chest

“I’d like you to breath about twice as deep as you are” “Perhaps taking a few deep breaths where you fill right up.” “Direct your breathing right up into the top of your chest.”

Lack of movement in the chest

Encourage breathing into upper chest

“Breathe a little more into the top part of your chest.” “Take your breath right up into the top of your chest.”

Drifting away from breathing

Encourage breathing and a few deep breaths

“Come back to your breathing.” “Breathing.” “Take a few deep breaths.” “See if you can stay with your breathing.” “You are drifting away from your breathing a bit, see if you can really focus on keeping your breathing going.”

Drifting away from breathing and unable to maintain fully awake state

Encourage extra effort to maintain deep/full breathing. May need to have client sit up.

“You seem to be drifting away, lets see if it is easier if you open your eyes for a bit and at the same time go for some deep breaths.” “I want you to really focus on keeping your breathing going, and if you can’t I’ll get you to sit up, and that might make it easier.”

Pausing after the exhale

Encourage connected breathing

“The moment you finish breathing out – straight away, take your in breath. “Keeping your breathing connected-no gaps or pauses-just a continuous rhythm”

Very slow or tentative inhale

Encourage more enthusiastic inhale

“Perhaps experiment with taking your in-breath faster.” “I’d like you to take your in-breath a little quicker.” “Try taking your inhale twice as fast, see what that’s like.”

Too deep or rapid accompanied by excessive activation

Encourage shallower or slower inhale

“Maybe breathing a bit shallower.” “Even shallower.” “It’s ok to relax.”

EXHALE

Holding the breath after inhale is complete


“The moment you finish breathing in – instantly, let go.” “Keeping your breathing connected-no gaps or pauses - just a continuous rhythm”

Restricting the exhale – respiratory muscles

Encourage letting go of control of exhale

“Just letting go on the out breath” “Just letting the out breath gush out” “Letting go of all control on the out breath” “It’s safe to let go”

Restricting the exhale – throat

Encourage free flow of air through the

“See if you can reduce the noise on your out-breath.” “Perhaps opening your mouth a little more so there is no restriction.”


throat/mouth

Forcing or blowing the exhale out

Encourage relaxing the exhale

“There’s nothing you need to do on the out breath, just let gravity do the work.” “See if you can relax your mouth/jaw/etc. on your out breath.”

MINDFULNESS

General reminder to explore sensations

Encourage detailed awareness of sensations

“Tuning into the dominant sensation in your body, and studying that.” “Really focusing on whatever sensation stands out the most” “Whatever sensation stands out – put your attention on that”

General reminder to accept whatever is happening

Encourage acceptance

“Accepting whatever is going on.” “It’s safe to surrender to whatever is happening.” “Accepting everything.”

RELAXATION

Lack of relaxation Encourage total relaxation of whole body or specific part of body

“Any tensions you notice, just letting them go.” “Relaxing your whole body.” “It’s safe to relax.” “Letting go.”

OTHER

Breathing through a mix of nose and mouth

Encourage breathing either through the mouth or the nose – or whichever seems most appropriate

“Remember, breath either in and out of your mouth, or in and out through your nose – whichever feels easier, but not a mix of both.” “I’d like to suggest you breathe in and out of your mouth/nose.”

Client wants to talk rather than breathe

Have client focus on the GRMT

“I understand you want to talk about the process, but it works best when you stay with the breathing.”

MANAGING DISCOMFORT

All All discomfort is managed in basically the same way – encouraging all components of GRMT to be applied and assuring the client that they are safe. That it is safe to relax, let go, surrender.

Tetany (usually hands) due to forceful breathing

Check that client is applying core components of GRMT, with a particular focus on relaxation of the exhale. Encourage shallower breathing. Reassure client that they are safe and the feelings will pass.

Client feels too cold

On occasion a client might report experiencing intense cold. While it is good to have a warm cover available, this may make no difference, and the experience usually passes relatively quickly. Feeling hot, accompanied by sweating, may also occur on occasion.

© Copyright Lloyd Lalande, 2007.


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3. Completion of the GRMT session Judging when a client has finished requires sensitivity on the therapist’s part. The main criterion for completion is that the level of energy the client feels in their body has receded and they feel relaxed. You can ask the client “what are you feeling in your body now” to check this. When the client is ready to get up, remind them that they have been in a meditative state and need to move slowly until they feel grounded. The client can be invited to changing physical position, perhaps moving onto their side. As the therapist, be mindful not to engage in any analysis, problem talk, or additional ‘therapy’. Normalize the experience of the session and address any questions or concerns related to the intervention. Homework Some clients will want to practice breathing at home. In this case you can suggest they practice the breathing pattern for 5 minutes or simply notice their breathing anytime. Trying to do a full GRMT session at home is not advisable (or necessary) until the client has developed reasonable skill in using the technique. Second and Subsequent Sessions The second and subsequent sessions start with acknowledging the client’s feelings and observations about the impact of the GRMT over the past week. Any concerns about GRMT can also be discussed. This is followed by the core GRMT activity. The therapist’s role is to provide similar support as in session one. However, only a brief reminder of the core components of GRMT is needed and can take place as the client is starting to breath.

4. Termination

In the treatment of depression and anxiety termination after 10 sessions can be anticipated by both client and therapist from the beginning depending on symptom status. It is important for the therapist to keep in mind that some people will find termination difficult due to the level of vulnerability and trust they can experience with the therapist. Some clients may want to continue GRMT even after symptom reduction as a personal growth approach. Other clients may feel that after only a few sessions they have addressed their initial distress and received sufficient benefit to terminate.

References

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kriya yoga (SKY) in melancholia: A randomized comparison with electroconvulsive therapy

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Appendix 7: GRMT – KQ (Knowledge Questionnaire)

GRMT – KQ

Name: ____________________________________ Date: _________________ Workshop: Start / End The goal of these questions is to help us assess the effectiveness of this workshop in conveying an understanding of some aspects of the approach. Please provide a brief response to each situation, as best you can. Please feel free to answer in point form where appropriate. Thank you.

1. (a) How would you describe the breathing pattern used in GRMT to a new client? (b) What specific instructions might you give them regarding the inhale and the exhale?

2. If a client wanted help for either depression or anxiety and you suggest GRMT as a possible treatment option, what rationale might you give your client for considering this approach?

3. Before giving a client their first GRMT session, it is necessary to give clear instructions in how to apply mindfulness. What instructions would you give your client regarding this component of the approach?


Breathwork Workshop for Therapists: Assessment of Training (cont.)

4. With reference to the 3 components of Guided Respiration Mindfulness Therapy, what suggestions might you give a client who is struggling with very intense feelings during a session?

5. If your client were to deviate from maintaining the breathing pattern used in GRMT, what are some of the things you might observe about their breathing?

6. How might you guide a client who is drifting away from full conscious awareness (including difficulty maintaining the breathing pattern) during a GRMT session?

7. A major function of Guided Respiration Mindfulness Therapy is thought to be the promotion of integration. In the context of GRMT, what do you think integration refers to?


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Appendix 8: GRMT – KQ Rating Manual

GRMT – KQ RATING MANUAL

To be used for

Assessing introductory GRMT workshop participant knowledge using the GRMT-KQ

Overview

This 2-day workshop introduces therapists to the GRMT technique. Participating therapists were asked to complete a 7 item questionnaire at the start of the first day of the workshop and then again at the end of the second day of the workshop. Participants were generally assumed to have little or no knowledge of specific techniques prior to the workshop. Aim of Assessment

The Guided Respiration Mindfulness Therapy Knowledge Questionnaire (GRMT-KQ) aims to evaluate the effectiveness of the workshop in teaching participants the basic knowledge needed for effective facilitation of the GRMT approach. Assessing participants’ level of technical and theoretical knowledge of key facilitation elements of the GRMT approach that were taught during the workshop gives some indication of workshop effectiveness in creating the understanding needed for further development of competency. It is important to note that it is principally the workshop that is being assessed, not the participant. The workshop’s educational aim it to impart to participants a basic understanding of the GRMT intervention. As this is the first time most participants have been exposed to the approach, and it is a relatively brief training (2-days) it is expected that therapist knowledge will still be tentative. It is important that any assessment of ‘competence’ reflect this early stage of training with its minimal exposure to the intervention. Participating therapists are not expected, nor deemed to have developed the competence, to deliver the intervention to clients until at least the completion of a further 6 practice sessions conducted under close supervision. Guidance for rating assessment items

The knowledge questionnaire focuses on these key areas: Basic understanding of the respiratory regulation and mindfulness components, a rationale for use of the approach with depression/anxiety, managing client discomfort, and the meaning of integration. GRMT-KQ Rating instrument

Rating categorises participant responses as either competent or not competent. The competent category is divided into 3 levels while the not competent category is divided into two levels.


GRMT – KQ RATING INSTRUMENT

!

Category) Levels)) Criteria)

Satisfactory!Knowledge!

5.!High!level!knowledge!!

Answer!contains!most!items!for!effective!facilitation.!May!also!demonstrate!additional!awareness.!

4.!Medium!level!knowledge!!

Some!items!may!be!missing.!But!demonstrates!good!understanding.!

3.!Minimum!acceptable!knowledge!!!

Demonstrates!somewhat!accurate!understanding,!however,!some!items!may!be!missing.!Answer!lacks!clarity!or!specificity!!

Less!than!satisfactory!knowledge!

2.!Somewhat!less!than!satisfactory!knowledge!

Answer!indicates!lack!of!understanding.!Most!items!missing.!

1.!Not!at!all!satisfactory!knowledge!!

Answer!indicates!lack!of!understanding.!Answer!does!not!contain!any!needed!items.!

Rating Guidelines

The following explanations are intended to help guide raters’ in the assessment of participant responses and are to be used in conjunction with the ideal response table below.

Items 1 and 5

These items ask participants to demonstrate understanding of the main features of the respiratory regulation component of the intervention. Item 1 asks for a description of the breathing pattern used, and item 5 asks what might be observed it this pattern is deviated from. Correct answers for both items will at a minimum indicate the following knowledge:

• The correct breathing pattern features a continuous rhythm with no pauses or gaps between inhale and exhale, and

• features a complete relaxation of respiratory muscles on the exhale

Item 2

This item is intended to capture participants’ knowledge of the rationale for the use of the intervention as a treatment for anxiety and depression.


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A range of responses are acceptable and are listed in the table below. Relaxation on its own is not an adequate example of a rationale.

Item 3

Item 3 is intended to demonstrate understanding of the intervention specific application of mindfulness. General description of mindfulness without reference to the body is not adequate on its own. For the response to be rated as medium competence (4) it should specifically identify the following two items. The term ‘feelings’ may be used in the absence of sensations.

• A focus on the ‘sensations’ – ideally, with reference to the ‘dominant’ sensation. • The term ‘acceptance’

Item 4

Item 4 aims to assess participants’ skill in managing client discomfort with reference to the 3 components of the intervention, respiratory regulation, mindfulness and relaxation. Participant responses should suggest guiding the client in applying the 3 components with reference to:

• ‘acceptance’ • ‘relaxing’ • maintaining the connected breathing pattern’ and importantly, and ‘breathing shallower’

Responses indicating assurance of support can be interpreted as the participant having an awareness of the importance of providing client assurance of safety.

Incorrect responses include:

• encouragement to breathe deeper • stop breathing or terminate the session, • sit up, or discuss the meaning of the feeling.

Item 6

This item seeks to assess participants’ knowledge of what specific guidance or instructions to provide if a client drifts away from full conscious awareness and maintenance of their breathing. Correct answers contain active interventions and can include instructions aimed at

• remind clients to maintain focus on breathing, • breathing deeper or returning to rhythmic breathing • sit up and breathe, and touch on arm as reminder.

Incorrect responses include:

• Discussion with clients • Any responses not aimed at encouraging maintenance of breathing

Item 7

This item seeks to assess participants’ understanding of the term ‘integration’ in GRMT. Answers should indicate

• resolution of past suppressed or avoided somatic experience, or the symptoms generated by previously suppressed experience (includes ‘trauma’ or ‘traumatic experiences’)


Inadequate responses include:

• Body and mind functioning together • Acceptance of feeling (on its own with no other explanation)

RATING GUIDE

QUESTION Linked to manual instruction

RATIONALE Complete answer Items

1. (A) How would you describe the breathing pattern used in GRMT to a new client? (B) What specific instructions might you give them regarding inhale and exhale?

Basic understanding of respiratory regulation component of intervention

(Part A) 1. A continuous rhythm - No pauses or gaps between inhale/exhale. 2. Relaxed exhale – release of muscular control. 3. Expansion of upper chest. 4. Nose or Mouth, not mixture (Part B) 1. The moment you finish breathing in/out, let go/take your next breath. 2. Let go of all control (relax) on exhale. 3. Take your in breath up into your chest.

2. If a client wanted help for either depression or anxiety and you suggest GRMT as a possible treatment option, what rationale might you give your client for considering this approach?

Ability to communicate understanding of theoretical processes of change

1. Approach causes integration of un-integrated somatic experiences underlying client problem 2. Restoration of normal level of serotonin synthesis by correcting shallow/strained breathing 3. Stress/anxiety reduction as a result of integration 4. Likely reduction in rumination/worry. 5. Better ability to manage/accept troubling situations/feelings

3. Before giving a client their first GRMT session, it is necessary to give clear instructions in how to apply mindfulness. What instructions would you give your client regarding this component of the approach?

Basic understanding of mindfulness component as specifically used in intervention

1. Focus on the dominant sensation in your body – explore the details of that – find the centre of that sensation 2. Accept whatever sensations or feelings are taking place – don’t try to get rid of them or minimise them 3. Take a position of ‘witnessing’ your somatic experience 4. Let thoughts/mental stories go. Don’t follow any thoughts.

4. With reference to the 3 components what suggestions might you give a client who is struggling with very intense feelings during a session?

Clinical issues: Managing discomfort

1. Breathe a little shallower 2. Encourage acceptance of experience 3. Maintain Breathing Pattern: - Relax your exhale (just let is drift out) - Maintain connected breathing

5. If your client were to deviate from maintaining the conscious connected breathing pattern what are some of the things you might observe about their breathing?

Basic understanding of respiratory regulation component of intervention.

1. Pauses/Gaps between exhale/exhale 2. Forcing or straining exhale (with accompanying sounds). 3. Very shallow or no breathing 4. Excessively deep/forced inhale 5. No movement of chest (abdomen only)

6. How might you guide a client who is drifting away from full conscious awareness (including difficulty maintaining the breathing pattern) during a session?

Clinical intervention skill. Managing clinical issues

1. Encourage deeper inhale and/or give instruction to take a few deep breaths 2. Touch clients arm as reminder 3. Have client sit up and continue breathing until maintained


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7. A major function of GRMT is thought to be the promotion of integration. In the context of GRMT, what do you think integration refers to?

Understanding of principle of change central to the intervention

1. The activation (through respiratory regulation) and integration (through mindfulness and relaxation) of previously suppressed or avoided inner experience. These suppressed inner experiences contribute to psychopathology.


Appendix 9: GRMT Treatment Adherence Rating Guide and Competence Scale

Rating Guide and Competence Scale for Assessment of Treatment Integrity in GRMT

Developed by Lloyd Lalande

Queensland University of Technology Australia

Overview

This manual is a supplement to Rater Training and provides guidance in rating therapist's level of treatment integrity in their facilitation of Guided Respiration Mindfulness Therapy (GRMT) during participation in the clinical trial of GRMT conducted as part of Doctoral studies at the Queensland University of Technology (QUT). Treatment integrity is made up of 3 components: (a) treatment adherence, (b) therapist competence, and (c) treatment differentiation. The GRMT intervention is behavioural in nature and teaches clients to regulate their breathing, relax and apply mindfulness to somatic experience. The regulation of breathing is aimed at removing respiratory inhibition and establishing an uninhibited, spontaneous breathing pattern, that is, a normal, healthy breathing pattern characterized by unbroken rhythmicity and release of respiratory muscles on exhalation (Bolton, Chen, Wijdicks, & Zifko, 2004; Bradley, 2002). The theoretical rationale for the use of the intervention is that inhibition of breathing develops as a defensive strategy to block awareness of the somatically held component of unintegrated past troubling experiences. The technique increases awareness and acceptance of feeling states thereby facilitating integration of unintegrated material. A session lasts 90 minutes with approximately 60 minutes dedicated to the core GRMT exercise during which the client lies comfortably on the floor. The technique can induce a meditative altered state, increased awareness of somatic material and induce brief periods of heightened emotional arousal.

Research Context

Therapists in this research study have participated in a 2-day workshop introducing the GRMT technique which included two practice sessions in administering the intervention, and a follow-on series of 6 supervised practice sessions administering the intervention along with supervision based on viewing of video recordings of practice. Therapists had little or no knowledge of the intervention or specific techniques prior to receiving this training. Therapists went on to administer the intervention, under further supervision, with a client with a DSM-IV-R primary diagnosis of either a depression or anxiety disorder.

The Role of the GRMT Therapist

The role of the GRMT therapist can, to some extent, be thought of as a coach. Similar to a sports coach, the therapist aims to guide the client in firstly adopting more-or-less the correct technique. As the client becomes more familiar with the technique in a general sense, the therapist refines their instructions and focuses on fine-tuning the client’s technique. While the client will have their own style of breathing, the general principles of healthy breathing remain universal. Also


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each client will face slightly different challenges when learning the technique, and will have their unique responses to that experience. Therapists are actively engaged with the client in managing the smooth, non-cathartic progression of sessions. They are not simply parroting reminders to breathe or relax. In guiding the client in the establishment and maintenance of the breathing pattern, at times the therapist may be working very closely and intensely with the client. At other times, and particularly as the client becomes more competent themselves with the technique, very little intervention may be needed for the client to maintain their engagement with respiration, mindfulness and relaxation, or work through intense feelings. However, support will always be necessary.

THERAPIST COMPETENCE IN GRMT

Therapists operationalize the 3 core components of the intervention by actively coaching clients using instructions contained in the manualized protocol, with the aim of sustaining client’s engagement with the intervention process. Competence goes beyond a technical focus on the presence or absence of intervention elements, to a focus on therapy process. Competence involves the ability to sensitively guide and support the client in learning to skilfully applying the three components of the intervention in order to create an efficient and effective therapeutic experience. Competence relates to these broad areas:

• Observational and interpretation skills (differentiating respiratory behaviour and other somatic cues)

• Selection of appropriate interventions for targeted client behaviour • Immediacy of delivery of interventions • Overall management of client experience

Competence includes: • High level of attention maintained on observing and tracking client behaviour. • Ability to respond to observed client behaviour with consistent support in guiding the

client in engaging and maintain the therapy process. • Timely responses to observed client respiratory cues (e.g., strained breathing, insufficient

breathing, excessive breathing). • Timely encouragement to relax (e.g., by responding to observed restlessness, agitation,

fidgeting, distress). • Timely encouragement to remain mindful with a focus on dominant sensations, attitude

of acceptance, and disengagement from thoughts or following mental stories. • Therapist flexibility in modifying delivery of intervention instructions in instances where

the client does not respond to initial suggestions. • Ability to determine clients level of present moment energetic experience and when

necessary encourage changes in respiratory pattern either to increase level of activation or to reduce it.

• Overall provision of a high level of safety and support.

Competent therapists’ traits


Competence can further be characterised by specific therapist traits: • Attentiveness / Interest • Courage to engage with the client • Flexibility (in responding) • Capacity for empathy • Tolerance of affect both in oneself and others • Comfort with being present (with the client)

Low competence in GRMT: Some of the most common mistakes observed in therapists new to the approach are:

• Hesitancy or failures to timely intervene in guiding respiratory behaviour. • Failure to (correctly) identify the most important respiratory behaviour to target in any

given moment. • Failure to guide client's breathing in a way that achieves and maintains for the client an

optimum level of activation and engagement with the process.

Low competence can be characterised by the following features: • Low level of attention paid to the client while they engage in the breathing intervention.

o Therapist has difficulty maintaining focus on the client • Poor skill in tracking the client’s moment-to-moment respiratory and somatic state. • Intervention statements are used but have little or no relationship to client’s current

respiratory functioning or somatic state. Examples are: o Suggestions to relax, when the client is ‘asleep’ o Stating to the client ‘you are doing great’ when they are clearly not adhering to

the technique, and require specifically targeted instructions to engage in the intervention.

o Encouraging the client to ‘take a deeper breath’ when they are already breathing at a greater depth or speed than is required, or are clearly experiencing discomfort due to excessive breathing.

o Having the client sit up and breathe when this intervention is not needed, or conversely not taking this action when it would be advantageous.

• Intervention is infrequent and insufficient to maintain client’s engagement in the process as an optimal level.

o Fear of intervening or encouraging engagement in the breathing process. • Interrupting the breathing session to discuss the clients experience • Ending the session abruptly (violently), while the client is still, to a significant degree,

engaged in the therapeutic process.

TREATMENT ADHERENCE IN GRMT

Two general classes of therapist behaviour are of importance in treatment adherence, those unique or essential elements of the approach, and those that do not have a place in the therapy and undermine the treatment’s integrity (McCrimmon & Alheid, 2004). Or as Moncher and


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Prinz (1991) put it, “the core consideration in verifying adherence to protocol is whether the implementer performed the major operations prescribed by the intervention and did not engage in non-prescribed procedures” The assessment of adherence also provides a clear delineation of the treatment compared to other treatments. The presence of adherence can be demonstrated by:

1. The frequency with which an element of therapy is administered within a session 2. The frequency of non-proscribed treatment elements 3. The percentage of sessions in which adherence occurred acceptably 4. The mean extent of adherence

RATING GRMT SESSIONS

Video Recordings

Video recordings of therapy sessions can be used to rate both therapist adherence and competence.

• Ability to see client and therapist important to assessment • Rating video provides the opportunity to hear and see client and therapist behaviours:

o What the therapist is actually doing – behaviour, level of attentiveness/distraction o See client's breathing behaviour and other physical phenomena, and gauge fit with

therapist intervention (or lack of intervention) o Observe use of touch and other interventions involving movement of client

Audio Recordings

Audio recordings can be used to rate the presence and frequency of intervention statements, and differentiate GRMT from other therapy approaches. However, rating of audio recordings requires a relatively high level of familiarity with breathing behaviour and the ability to differentiate between the sound of different breathing phenomena, for example, strained, forced, inhibited breathing, or breathing patterns within the proscribed perimeters. Rating of video recordings is superior. Disadvantages for rating: In talking therapy, audio recordings contain dialogue from both therapist and client. In GRMT client talk is minimal. Instead, the only client ‘audio’ during the actual GRMT session is the sound of breathing. If the breathing is not audible the rater has no way of knowing if the therapist is responding to client respiratory cues. Relaxation is also core component of the intervention, with only audio, the rater cannot tell if the client is restless and cannot know if the therapist is responding to this.

Rating Transcripts of Sessions

Rating of transcripts focuses on therapists’ statements made during the session and can indicate: • Presence or absence of proscribed interventions • Frequency of intervention statement


INTERVENTION PROTOCOL

The following table is contained in the research treatment manual and is used by therapists to guide their use of interventions. In rating it can be used to assess (a) which component an intervention statement being used is associated with; (b) the appropriate use of an intervention related to the observed behaviour, and; (c) the level of match between the form of intervention used and the form suggested here. Coding Schema RR-I: Respiration – Inhale RR-E: Respiration – Exhale RR-R: Respiration – Rhythmicity RR-GF: Respiration – General focus Re: Relaxation M-SA: Mindfulness – Somatic Awareness M-A: Mindfulness – Acceptance M-T: Mindfulness – Not engaging with thoughts GS: General Support MD: Managing Discomfort NCI: Non-Compliant

COMPONENT 1 - RESPIRATORY REGULATION

INHALE (RR-I)

Observation Action required Example of suggestion to client

Very shallow breathing

Encourage deeper breathing with some expansion of the upper chest

“I’d like you to breath about twice as deep as you are” “Perhaps taking a few deep breaths where you fill right up.” “Direct your breathing right up into the top of your chest.”

Lack of movement in the chest

Encourage breathing which mobilizes upper chest

“Breathe a little more into the top part of your chest.” “Take your breath right up into the top of your chest.”

Drifting away from breathing (but can maintain awake state)

Encourage breathing and a few deep breaths

“Come back to your breathing.” “Breathing.” “Take a few deep breaths.” “See if you can stay with your breathing.” “You are drifting away from your breathing a bit, see if you can really focus on keeping your breathing going.”

Drifting away from breathing (and difficulty maintain fully awake state)

Encourage extra effort to maintain deep/full breathing. In encouragement is not effective and client appears to 'fall asleep'

“You seem to be drifting away, lets see if it is easier if you open your eyes for a bit and at the same time go for some deep breaths.” “I want you to really focus on keeping your breathing going, and if you can’t I’ll get you to sit up, and that might make it easier.”


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have client sit up and breath enthusiastically.

"Ok, how about we get you to sit up for a bit. Now take some deep breaths"

Very slow or tentative inhale

Encourage more enthusiastic inhale

“Perhaps experiment with taking your in-breath faster.” “I’d like you to take your in-breath a little quicker.” “Try taking your inhale twice as fast, see what that’s like.”

Too deep or rapid accompanied by excessive activation

Encourage shallower or slower inhale

“Maybe breathing a bit shallower.” “Even shallower.” “It’s ok to relax.”

EXHALE (RR-E)


Holding the breath after inhale is complete


“The moment you finish breathing in – instantly, let go.” “Keeping your breathing connected-no gaps or pauses-just a continuous rhythm””

Restricting the exhale – respiratory muscles

Encourage letting go of control of exhale

“Just letting go on the out breath” “Just letting the out breath gush out” “Letting go of all control on the out breath” “It’s safe to let go on your out breath”

Restricting the exhale – throat

Encourage free flow of air through the throat/mouth

“See if you can reduce the noise on your out-breath.” “Perhaps opening your mouth a little more so there is no restriction.”

Forcing or blowing the exhale out

Encourage relaxing the exhale

“There’s nothing you need to do on the out breath, just let gravity do the work.” “See if you can relax your mouth/jaw/etc. on your out breath.”

RHYTHMICITY (RR-R)


Pausing after exhale


“The moment you finish breathing out – straight away, take your in breath. “Keeping your breathing connected-no gaps or pauses-just a continuous rhythm”

Pausing after inhale


“The moment you finish breathing in – instantly, let go.” “Keeping your breathing connected-no gaps or pauses-just a continuous rhythm””

GENERAL FOCUS (RR-GF)


Client generally breathing satisfactorily.

General encouragement to remain focused on breathing

"Focusing on your breathing" "Paying attention to your breathing" NOTE: General suggestion to focus on breathing should be minimised and not be used as a replacement for specifically targeted statement.


COMPONENT 2- RELAXATION (Re)


Lack of relaxation Encourage total relaxation of whole body or specific part of body

“Any tensions you notice, just letting them go.” “Relaxing your whole body.” “It’s safe to relax.” “Letting go.”

Breathing through a mix of nose and mouth

Encourage breathing either through the mouth or the nose – or whichever seems most appropriate

“Remember, breath either in and out of your mouth, or in and out through your nose – whichever feels easier, but not a mix of both.” “I’d like to suggest you breathe in and out of your mouth/nose.”

COMPONENT 3 - MINDFULNESS

Somatic Awareness (M-SA)

Observations Action required Example of suggestion to client

When client is generally breathing satisfactorily. Client is experiencing heightened activation.

Encourage detailed awareness of sensations to deepen process. Moderate intensity of experience (along with acceptance of sensations)

“Tuning into the dominant sensation in your body, and studying that.” “Really focusing on whatever sensation stands out the most” “Whatever sensation stands out – put your attention on that” NOTE: Care needed to ensure not used when client is drifting away from breathing and respiration focused intervention is more appropriate.

Acceptance (M-A)


General reminder to accept whatever is happening. Client is experiencing intensity or discomfort.

Encourage acceptance of sensations, feelings, or whatever is going on.

“Accepting whatever is going on.” “It’s safe to surrender to whatever is happening.” “Accepting everything.”

Not engaging with thoughts (M-T)


May seem distracted. May be drifting away from maintenance of breathing pattern.

Reminder to resist engagement with thoughts and stories

“Just letting any thoughts go” “Not following any stories.” “Just notice thoughts and let them go, bringing your attention back to your body and focusing on your breathing and sensations.”


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GENERAL SUPPORT AND ENCOURAGEMENT


a. Client is generally engaging well, or b. Client is working hard at maintaining the process during a challenging moment

Provision of encouragement. Checking in. Assurance of safety. Encouragement to stay engaged with process

"You are doing really well" "That's great" "That's sounding really good" "How are you going?" "Can you tell me what's happening in your body right now – ok, great" "Stay with it, you are doing fine" "I know it's a lot of work (can be challenging, etc.), but you are doing great" Note: may be followed by targeted suggestion tagged on end

MANAGING DISCOMFORT (MD)


All All discomfort is managed in basically the same way – encouraging all elements of GRMT to be applied and assuring the client that they are safe. That it is safe to relax, let go, surrender.

Tetany (usually hands) due to forceful breathing

Check that client is applying key elements of GRMT, with a particular focus on relaxation of the exhale. Encourage shallower breathing. Reassure client that they are safe and the feelings will pass.

Client feels too cold

On occasion a client might report experiencing intense cold. While it is good to have a warm cover available, this may make no difference, and the experience usually passes relatively quickly. Feeling hot, accompanied by sweating, may also occur on occasion.

OTHER


Client wants to talk rather than breathe

Have client refocus on the GRMT

“I understand you want to talk about the process, but it works best when you stay with the breathing.” “There will be plenty of time to talk about what the experience later.”


Reference

Bolton, C. F., Chen, R., Wijdicks, E. F. M., & Zifko, U. A. (2004). Neurology of breathing.

Philadelphia: Butterworth Heinemann.

Bradley, D. (2002). Patterns of breathing dysfunction in hyperventilation syndrome and

breathing pattern disorders. In L. Chaitow, D. Bradley & C. Gilbert (Eds.), Multidisciplinary

approaches to breathing pattern disorders. London: Churchill Livingstone.

McCrimmon, D. R., & Alheid, G. F. . (2004). Neonatal stress alters adult breathing. Journal of

Physiology, 554(3), 591.

Moncher, F. J., & Prinz, R. J. (1991). Treatment fidelity in outcome studies. Clinical Psychology

Review, 11(3), 247-266.


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Appendix 10: GRMT Impact Measure

[To be completed by therapist] Please fill in one of these before and after your session. After filling in the pre-session copy, put it aside so you don’t refer to it when you fill in the post-session copy. Thank you. Name ____________________________________________ Session number ___ Date ___________ (Please circle) BEFORE SESSION / AFTER SESSION Please read each of the questions below. Please take a few seconds to notice how you are feeling about each item at this moment, and indicate your response by circling the appropriate number. Thank you. 1. How relaxed would you say you are at the moment?

1 2 3 4 5 6 7 8 9 10 Very little Very much

2. How would you describe the level of anxiety you are experiencing right now?


3. What level of worry are you experiencing about your life at the moment?


4. How enthusiastic would you say you feel about your life at this moment?


5. At this moment, how receptive would you say you are to observing unpleasant thoughts and feelings without trying to control or change them?



Appendix 11: Trial Outcome Battery of Measures

PRE-SESSION TREATMENT MEASURES (To be completed at the beginning of each session)

Date: _____/_____/_______ Therapist Name: _______________________________ Participant Name: ______________________________ Session Number: ____________ Next Session (Day/Date/Time): ____________________________

Thank you for your participation in this study!


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Depression Anxiety Stress Scale

Instructions: For each of the statements below, please mark the box which best indicates how much the statement applied to you over the past 7 days. There are no right or wrong answers. Do not spend too much time on any one statement. Thank you.

Did not

apply to me at all

Applied to me to some degree, or

some of the time

Applied to me a considerable

degree, or a good part of the time

Applied to me very much,

or most of the time

1 I found it hard to wind down ! ! ! ! 2 I was aware of dryness of my mouth ! ! ! ! 3 I couldn’t seem to experience any positive

feelings at all ! ! ! !

4 I experienced breathing difficulty (e.g. excessively rapid breathing in the absence of physical exertion)

! ! ! !

5 I found it difficult to work up the initiative to do things ! ! ! !

6 I tended to over-react to situations ! ! ! ! 7 I experienced trembling (e.g. in the hands) ! ! ! ! 8 I felt that I was using a lot of nervous energy ! ! ! ! 9 I was worried about situations in which I might

panic and make a fool of myself ! ! ! !

10 I felt that I had nothing to look forward to ! ! ! ! 11 I found myself getting agitated ! ! ! ! 12 I found it difficult to relax ! ! ! ! 13 I felt downhearted and blue ! ! ! ! 14 I was intolerant of anything that kept me from

getting on with what I was doing ! ! ! !

15 I felt I was close to panic ! ! ! ! 16 I was unable to become enthusiastic about

anything ! ! ! !

17 I felt I wasn’t worth much as a person ! ! ! ! 18 I felt that I was rather touchy ! ! ! ! 19 I was aware of the action of my heart in the

absence of physical exertion (e.g. sense of heart rate increasing, heart missing a beat)

! ! ! !

20 I felt scared without any good reason ! ! ! ! 21 I felt that life was meaningless ! ! ! !


Anxiety Sensitivity Index

Please use the past 7 days when considering each item. Provide an answer for every statement as best you can. Please answer as honestly and spontaneously as possible. There are neither ‘right’ nor ‘wrong’ answers, nor ‘good’ or ‘bad’ responses. What is important to us is your own personal experience.

Very little A little Some Much Very much

1. It is important to me not to appear nervous ! ! ! ! !

2. When I cannot keep my mind on a task, I worry that I might be going crazy ! ! ! ! !

3. It scares me when I feel ‘shaky’ (trembling) ! ! ! ! !

4. It scares me when I feel faint ! ! ! ! !

5. It is important to me to stay in control of my emotions

! ! ! ! !

6. It scares me when my heart beats rapidly ! ! ! ! ! 7. It embarrasses me when my stomach growls ! ! ! ! ! 8. It scares me when I am nauseous

! ! ! ! !

9. When I notice that my heart is beating rapidly, I worry that I might have a heart attack

! ! ! ! !

10. It scares me when I become short of breath ! ! ! ! ! 11. When my stomach is upset, I worry that I

might be seriously ill ! ! ! ! !

12. It scares me when I am unable to keep my mind on a task

! ! ! ! !

13. Other people notice when I feel shaky ! ! ! ! !

14. Unusual body sensations scare me ! ! ! ! ! 15. When I am nervous, I worry that I might be

mentally ill ! ! ! ! !

16. It scares me when I am nervous ! ! ! ! !


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Working Alliance Inventory - Short Form

Instructions: Please indicate how you feel about your Therapist by putting a circle around the appropriate number. 1. My Therapist and I appear to agree about the things we will do in therapy to improve my situation

1 2 3 4 5 6 7 Never Rarely Occasionally Sometimes Often Very often Always

2. What my Therapist and I are doing in therapy gives me new ways of looking at my situation


3. I believe my Therapist likes me


4. My Therapist does not appear to fully understanding what I want to accomplish in therapy


5. I feel confident in my Therapist’s ability to help me


6. My Therapist and I are working toward mutually agreed upon goals


7. It is clear to me that my Therapist appreciates me


8. My Therapist and I agree on what is important for me to work on in therapy


9. My Therapist and I trust one another


10. My Therapist and I have different ideas on what my problems are


11. My Therapist and I have established a good understanding of the kind of changes that would be good

for me 1 2 3 4 5 6 7 Never Rarely Occasionally Sometimes Often Very often Always

12. I believe the way that my Therapist is working on problems with me is correct



Outcome Rating Scale

Over the last 7 days, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels.

Individually (Personal well-being)

I----------------------------------------------------------------------I

Interpersonally

(Family, close relationships)

I----------------------------------------------------------------------I

Socially (Work, school, friendships)

I----------------------------------------------------------------------I

Overall

(General sense of well-being)

I----------------------------------------------------------------------I

Low

Levels

High

Levels


199

Toronto Mindfulness Scale

Instructions: Please consider your actual experience at the present moment. Below is a list of things that people experience to varying degrees at various times. Please briefly reflect on each item and indicate the extent to which you think each statement is an honest reflection of your current experience.

Not

at a

ll

A li

ttle

Mod

erat

ely

Qui

te a

bit

Ver

y m

uch

1. I experience myself as separate from my changing thoughts and feelings

0 1 2 3 4

2. I am more concerned with being open to my experiences than controlling or changing them.

0 1 2 3 4

3. I am curious about what I might learn about myself by taking notice of how I react to certain thoughts, feelings or sensations.

0 1 2 3 4

4. I experience my thoughts more as events in my mind than as a necessarily accurate reflection of the way things ‘really’ are.

0 1 2 3 4

5. I am curious to see what my mind is up to from moment to moment. 0 1 2 3 4

6. I am curious about each of the thoughts and feelings that I am having. 0 1 2 3 4

7. I am receptive to observing unpleasant thoughts and feelings without interfering with them.

0 1 2 3 4

8. I am more invested in just watching my experiences as they arise, than figuring out what they could mean.

0 1 2 3 4

9. I approach each experience by trying to accept it, no matter whether it is pleasant or unpleasant.

0 1 2 3 4

10. I am curious about the nature of each experience as it arises. 0 1 2 3 4

11. I am aware of my thoughts and feelings without over-identifying with them

0 1 2 3 4

12. I am curious about my reactions to things 0 1 2 3 4

13. I am curious about what I might learn about myself by just taking notice of what my attention gets drawn to.

0 1 2 3 4


GRMT-Self-Efficacy

Please indicate how often each statement is true in regard to your experience since your last session. Provide an answer for every statement as best you can. There are no “right” or “wrong” responses, so please answer as honestly and spontaneously as possible. What is important here is your own personal experience.

Rarely A little Some Much Almost always

1 I find myself noticing my breathing.

! ! ! ! !

2 My breathing feels free and uninhibited.

! ! ! ! !

3 I tend to notice areas of my body that are tense and am able to relax them.

! ! ! ! !

4 It is easy for me to just let my exhale go in a totally relaxed way.

! ! ! ! !

5 I find it easy to focus on and explore the sensations in my body.

! ! ! ! !

6 I find I can accept all the sensations and feelings in my body.

! ! ! ! !

7 I feel confident I can regulate my thoughts and emotions

! ! ! ! !

8 I find the breathing technique easy.

! ! ! ! !

9 I find myself using the breathing pattern when I am at home or work.

! ! ! ! !

10 I am confident I am doing the breathing technique correctly. ! ! ! ! !

Thank you again for taking the time to complete these questions!


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Appendix 13: Treatment End-Point Interview

QUESTIONS FOR TREATMENT END-POINT INTERVIEW!

____________________________________________________________________________ I would like to ask you some questions about your experience of GRMT. By considering these questions you are helping us to understand what seems to work in GRMT.

1. If anything has changed for you as a result of receiving GRMT sessions, what is it that you might have noticed has changed? What is different?

2. What do you think is the most significant thing to come out of your experience of

GRMT sessions?

3. In the GRMT session, what do you think it is that contributes most to any changes you noticed?

4. We have not focused on your thoughts in the GRMT sessions, what sorts of effect have

sessions had on your thinking, if any?

5. Have you incorporated any part of the GRMT approach into your life? For example, the breathing, focusing on sensations, acceptance?

6. Given your experience of GRMT, do you think there is anything we should add, or is

missing from the approach that might make it more effective?

7. Is the GRMT therapy something you would consider again?

8. Is this something you would recommend to others?

9. Do you have anything further you would like to mention, anything at all?

Thank you for your participation!

Development of Guided Respiration Mindfulness Therapy ... · Workshop presented at the Australian...

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