Chapter 4

The Extraordinary Healing Power of the Breath

There is a problem with our health today that relates to how we practice medicine, but even more importantly to how we take care of ourselves and each other. This is reflected in the most basic measure of our nation’s health, our life expectancy, which flatlined between 2010 and 2018, after decades of steady improvement. The 2010s, despite all of our advances in medicine and pharmaceuticals, will be a lost decade in terms of the overall health of the nation. The CDC blames two preventable conditions: an increase in drug-overdose deaths, from less than ten thousand in 1990 to over seventy thousand in 2017, and an increased suicide rate, from ten per hundred thousand in 1999 to fourteen per hundred thousand in 2017.46

The incidence of depression has also recently increased, from a rate of 6.6 percent in 2005 to 7.3 percent in 2015.47 The rise among twelve- to-seventeen-year-olds is even more striking, from 8.7 percent in 2005 to 12.7 percent in 2015. In 2017, 3.2 million adolescents had at least one major depressive episode, which represents 13.3 percent of this population.48 A myriad of related conditions, such as chronic anxiety, panic attacks, chronic pain, bipolar disorder, substance abuse, and ADHD are also plaguing adolescents. Our young ones and teenagers, who are exposed to so much at such a young age, are experiencing the greatest increases in these disorders.

We see this unfortunate trend in hospitals, where medical wards are filled with patients with preventable conditions. A 2020 study out of Johns Hopkins School of Medicine showed a total of 25 percent of medical ICU admissions were related directly to acute substance abuse issues and overdoses, accounting for 23 percent of total costs.49 This study doesn’t take into account admissions due to chronic medical conditions related to substance abuse, such as lung cancer from tobacco use or liver cirrhosis from alcohol consumption, which in certain populations make up 44 percent of ICU admissions.50 Herbert Benson, professor of medicine at Harvard Medical School, has reflected broadly on this issue: “More than 60 percent of visits to physicians in the United States are due to stress-related problems, most of which are poorly treated by drugs, surgery, or other medical procedures.”51

As noted by Dr. Benson, medicine has failed to respond adequately to the growing crisis. Increasingly, the practice of medicine has become more procedural, focused on genetics, the use of technology, and the coming explosion of artificial intelligence. In the most egregious examples, families have fought back, as when Ernest Quintana’s family complained when he was admitted to the hospital for respiratory failure from COPD and was told by a robot consultation that he had no lung left to work with, and that he should focus on palliative care.52

Combating the disconnect between the practice of medicine and our declining mental health is going to take several approaches, but one tool that can help in the battle against this epidemic of preventable conditions in our society is an organ: the lungs. We know this because the lungs have been doing this healing work for thousands of years, and some people have updated this knowledge and applied it to our world today.

The healing power of the breath was recognized as far back as 7000 BCE, in the Zoroastrian religion of Persia, now Iran, where breathing exercises were routinely practiced. This tradition was carried to the West, where both the ancient Greeks and Romans regularly engaged in breathing exercises and reflection. Meditation and chanting have remained an integral part of Judaism, Christianity, and Islam. But while Western religions talk and write about the breath—the Holy Spirit, and ruach—Eastern religions have made a strict focus on the breath being a part of spiritual enlightenment.

With three hundred million practitioners, Buddhism is one of the most widely observed religions in the world. For Buddhists, including those who follow the offshoots Zen and Tibetan Buddhism, breathing exercises are one of the foremost ways to practice their faith, the core from which all other habits, and ultimately enlightenment, spring. Buddhists believe you start with the breath, and the body and mind follow.53

Buddhism began with Siddhartha Gautama, a monk commonly known as the Buddha or Enlightened One, who lived on the Indian subcontinent sometime in the fifth century BCE. At age thirty-five, in a reaction to stress in his life, he set out to find enlightenment, learning from the local yogis of his time. After his training, he began teaching a unique path to spiritual insight. His ultimate goal was to achieve inner peace and understanding, a state he called nirvana.

The teachings of Buddhism are summarized in four noble truths, all of which need to be accepted and followed in order for progress to be made. The first is an acknowledgment that pain and suffering are a regular part of life. It is normal to feel anger, disappointment, loneliness, and frustration. Second, we should understand that suffering comes from desire, from being disappointed in ourselves and others by creating expectations, from constant wanting and cravings. Destructive behavior originates from letting the emotions of life take over our thoughts in a damaging manner. The third truth is that if we are able to free ourselves from these detrimental thoughts, we will obtain wisdom and insight. This end goal is also called nirvana, which literally means blown out or extinguished—the extinguishing of our attachments.

The first three noble truths identify the problem (suffering), illuminate the cause (attachments), and describe what happens when the problem is solved (wisdom and nirvana). The fourth noble truth lays out the path from attachments to wisdom. This is the Eightfold path, or eight teachings to guide one’s journey. The first two teachings ask one to follow a path of wisdom by committing to the Buddhist path and pledging oneself to a moral life. The next three teachings show that ethics in behavior must be followed in speech by avoiding gossip and speaking truthfully; in action by refraining from killing, stealing, and overindulging in sensual pleasure; and in livelihood by not killing animals or trading in weapons or intoxicants. The last three teachings are dedicated to meditation. An effort must be made toward positive thinking, developing awareness of one’s body and feelings, and finally, improving concentration through enhanced mental focus. Commit, act, then practice and develop. This is the eightfold path.

The Buddha taught that the primary way to get to a calm and enlightened state was by utilizing one’s lungs. His teachings are captured in the text entitled Anapanasati Sutta. Anapanasati means “mindfulness (sati) of breathing (anapana)” and is the chief method by which insight is attained. According to the text, one should find a quiet place to sit alone, perhaps outside underneath a tree, and then begin to notice the breath, to concentrate on the inhales and exhales. If the breath is short, notice that it is short, and if long, notice that it is long. Later, more advanced breathing exercises can be practiced. Through this focus on the breath, one is able to push out other thoughts and begin to give attention to one’s mental capabilities, to release attachments and expectations in the quest for understanding.

Hinduism, another Indian religion founded in the fifth century BCE, also has at its core attending to the breath as a method to achieve enlightenment, mostly through the practice of yoga. One of the main yogic breathing practices is pranayama, a combination of the two Sanskrit words prana, meaning life force or vital energy, and yama, which means to extend or draw out. It’s a method aimed at achieving inner peace and control. The different methods of practicing pranayama all involve a focus on the breath, which is the source of our life force, our prana.

In the West in recent years, the teachings of Buddhism and Hinduism have been translated into the “mindfulness movement.” One of the first to bring the idea of mindfulness to the West was Thich Nhat Hahn, a Vietnamese Buddhist monk who lived in exile in France for many years. There, he counseled that “whenever your mind becomes scattered, use your breath as means to take hold of your mind again.”54

Despite this sound advice, the mindfulness movement has not been without controversy and criticism, with some calling it too divorced from its Buddhist roots, too much of a quick fix that has been tainted with a corporate edge. Some of this may be true, but the benefits outlined below show that a concentrated and dedicated focus on the breath has clear benefits.

If one tells a primary care physician today that one has depression, chances are a prescription for an antidepressant medication will be forthcoming—with little discussion about the cause of the hopeless feelings. TV producer Amy Weintraub knows the limits of this approach. For many years, she was stuck in a cycle of self-doubt, lack of pleasure, and decreasing energy. Exercise and coffee didn’t help, nor did a stable relationship or medication. Even with a successful career, Amy was entering into middle age without a sense of direction or purpose. She wasn’t experiencing what Virginia Wolf called “wave after wave of agony,” but rather what Emily Dickinson called “an element of blank,” experiencing a fog over her thoughts, a layer of cotton between her brain and her skull.55

Autumn always seemed to be Amy’s low point, as the New England sky turned dark, leaves disappeared, and the cold and rain forced everybody inside. She remembers the fall of 1985 as a particularly bad time, because a hurricane threatened her and her partner’s house in Newport, Rhode Island, and despite the impending storm, she couldn’t find any energy.

A few weeks later she sat on her therapist’s couch in Providence and explained her extreme inability to feel pleasure. Her therapist observed that perhaps Amy would always experience “empty pockets.” Driving home afterward, Amy felt she had no choice but to stay on medication, try to get out of bed in the morning, and otherwise do the best she could.

This continued until one day, while collecting her absent neighbor’s mail, Amy noticed a catalog from the Kripalu Center, in Stockbridge, Massachusetts. The center offered yoga classes and retreats, and Amy signed up for one, despite having low expectations. Her expectations couldn’t have been more wrong: the three days in Stockbridge ended up being a revelation of sorts, an awakening of her body and mind that would lead her on a path to recovery.

The first thing the yoga instructor at the Kripalu Center asked Amy and her class to do was stand up straight and tall on their mats, shoulders back, head high. Then she asked them to put their hands in prayer position in front of their hearts with elbows out to the side. The instructor then told them, “Take a deep breath in and fill your heart with light. Hold the breath and feel the light as healing energy expands through your chest and through your whole body. Exhale and open your palms to receive. Stay empty. God loves your empty hands.”56

Over the ensuing hour, and with each pose and breathing exercise, Amy felt the slow awakening of her body and mind. Her shoulders relaxed, her heart expanded with positive feelings, and beams of light seemed to shoot through the tips of her fingers and toes. Insights rushed into her now calm mind, which before had been blank, suggesting the emptiness she had been experiencing was really an opportunity—in this case, to experience divine parts of life and to know that she was indeed worthy of affection and happiness.

After several days of participating in yoga classes, workshops, and evening music and chanting sessions, Amy returned to Newport in a rejuvenated state of mind, and continued doing the work of postures (asanas), as well as breathing exercises (pranayamas), with video tapes. Some mornings it was still difficult to get out of bed, but they were fewer, and on the bad mornings she did her breathing exercises in bed. Easy breath in, hold it, and easy breath out. A few months later, another big leap forward occurred while Amy was in the car, listening to a guided imagery tape. At the end of the tape, she was asked to “name” herself. The name that came to her was abundance. Her pockets were full now.

After recovering from her own depression, Amy gave up her successful career as a television producer and moved on to the higher calling of yoga teacher. For years she led 6:00 a.m. yoga sessions, encouraging people to just “get on the mat,” telling her students that yoga class is a nonjudgmental space, especially when it comes to internal voices of criticism. Accept life’s limitations and focus on what’s right with yourself, not what’s wrong. Acknowledge your feelings as valid, but don’t be controlled by them. Avoid too much introspection—focus on the breath and the body, and the mind will follow.

In her book Yoga for Depression, Amy tells stories of transformation that astonish those in traditional medicine. People come to her class the first time with shoulders hunched over, shallow breathing from their upper body, and eyes averted. In a few months, many are standing upright, breathing deeply from their belly, looking people in the eye, and smiling not with a mask on, but with the true smile of somebody at peace.

Foremost among those who have attempted to bring breathing and relaxation into the modern Western consciousness is Jon Kabat-Zinn. He sees mindfulness as the antidote to the information overload we all experience from cell phones, the Internet, and TV, as a way back to our families and loved ones.57

One day in 1972, while finishing his PhD in molecular biology at MIT, Kabat-Zinn saw a sign on campus for a talk given by a Buddhist monk. He attended the lecture, was transfixed by the monk’s ideas, and set off on a path to study meditation and mindfulness, bringing along his scientific background as he learned about this ancient discipline. Several years later he set up a center for transformational medicine at the University of Massachusetts Medical School and began to help some of the many people who had slipped through the cracks of traditional medical care. He told his patients to accept what he calls “the full catastrophe of life” as the place from which to move forward. Patients with all types of illnesses, from chronic pain to anxiety to cancer to heart disease, flocked to the center. In his practice, with its focus on the breath and quiet meditation, Kabat-Zinn has seen radical transformations in people’s lives that regular doctors can only wonder at.

Besides helping patients deal with illness, he also encouraged a change in how medical students are trained. He recognized that patients wanted doctors who not only could make diagnoses, but also could empathize with people. Teaching mindfulness and awareness to medical students was a big part of this. At my own medical school, I once attended a session in which patients expressed what they liked about their doctors. One patient said the most important thing to him was for his doctor to take a seat in front of him, look him in the eye, ask him simply, “How are things going?,” and then pause and wait for an answer. The doctor wasn’t typing on a computer, looking at her phone, or answering a page. According to one study, the average time it takes a physician to interrupt a patient is eleven seconds.58 When a doctor can give patients just two minutes, it can make a big difference. This was the most important lecture I went to all year, and it deeply affected how I practice medicine.

Listening without judgement, being there in the moment, is at the core of the mindfulness movement, and it can be practiced in different ways. Some people enjoy breath exercises in the context of movement, as with yoga. Others may lie on their back and then go through a “body scan,” consciously cycling through the body as a whole and then each body part, paying attention to the feedback from that part—its temperature, its texture, how it interfaces with the air around it. Another powerful technique is to pick a single object, like a raisin or a leaf, and observe it as if one had never seen it before—how it looks, feels, smells, tastes. It is not about clearing the mind, but rather observing in the present, having these exercises spill over into life outside of meditation so that one’s awareness and appreciation open up.

The implications of cultivating mindfulness in medicine go beyond improved communication with patients. Much of medicine involves simple but careful observation, from doing a thorough physical exam to interpreting a chest X-ray or an MRI. Focused surveillance is a lost art, with the crush of data from technology and laboratory studies consuming much of doctors’ time, let alone all the time spent tending to the digital medical record. One 2015 study at Stanford University demonstrated that 63 percent of diagnostic errors occurred because no physical exam was ever done, 14 percent of errors resulted from correct exam findings that were misinterpreted, and 11 percent of errors occurred because the physical sign was missed or not sought.59 Mindfulness, with focused observation, could help guide us back to the bedside.

We now know that, physiologically, something important is happening during breathing exercises. The autonomic nervous system is deeply involved, which is the division of our nervous system that deals with everyday functions like breathing, heart rate, and workings of the gastrointestinal tract. The two main—and opposing—branches of this system are the sympathetic nervous system and parasympathetic pathways. The former gets turned on when one is scared, or under threat, and the hormone epinephrine (adrenaline) pours out from the adrenal gland, causing the heart rate to increase, the eyes to dilate, and sweat to rush out. This is the so-called fight-or-flight mechanism.

The parasympathetic system produces the opposite effect on the very same organs with the hormone acetylcholine—it calms heart rate and breathing rate, opens up blood vessels to the stomach, and provides a sense of well-being, appropriately termed rest and digest. Deep breathing is a potent inducer of the parasympathetic system. The release of acetylcholine not only calms our organs, it also stimulates the release of serotonin, dopamine, and prolactin, the feel-good hormones targeted by medicines like Prozac and Zoloft. But yoga and breathing exercises produce this effect naturally and without side effects.

The scientific literature showing how the release of hormones changes outcomes in many diseases, including those of the breath, is established and growing. Buteyko breathing, a method proposed in the 1950s by Ukrainian doctor Konstantin Buteyko, is aimed at getting control of hyperventilation by breathing through the nose, slowing down the breathing rate, and being aware of dysfunctional breathing. A randomized trial published in 2008 in Respiratory Medicine had asthma patients practice Buteyko breathing techniques, and at the end of six months there was an increase in those with well controlled asthma, from 40 percent of subjects to 79 percent.60 Somewhat surprisingly, the subjects practicing breathing techniques were also able to significantly reduce their use of inhaled steroids. Another study, published in 2009 in the journal Thorax, showed breathing exercises lowered anxiety and depression scores for people with asthma.61 While many asthmatics do need strong anti-inflammatory medicines to control their symptoms, it’s clear that breathing exercises can play an important role in treatment.

The scientific evidence that these same breathing exercises improve mental health conditions and chronic pain is also increasing every year. A 2016 study involving ninety college students with depression and/or anxiety showed significant improvements in those who took either a yoga or mindfulness course, but not in the control group.62 A 2014 study split sixty-four women with post-traumatic stress disorder into groups and sent them to either yoga or education about their condition, with yoga significantly improving symptoms compared to supportive health education.63 A 2012 analysis involving 1007 subjects demonstrated that yoga improved pain symptoms significantly in patients with chronic disability.64

Breathing and stress-reduction exercises seem to help people suffering from mood and breathing disorders. But studies have also investigated how stress-reduction exercises affect the different inflammatory genes and proteins expressed in our bodies. A milestone study published in 2013 followed twenty-six subjects who had no prior experience with relaxation exercises as they underwent eight weeks of training. Blood samples were collected before and after their exercises and analyzed for the expression of different genes by measuring levels of ribonucleic acid, or RNA, the first structure made from DNA on the way to protein synthesis.65 Compared to blood drawn prior to relaxation techniques, in blood drawn afterward there was a significant decline in RNA production associated with the inflammatory response, stress-related pathways, and even cell-death pathways (indicating these cells could potentially live longer). Genes that showed increased activity were those associated with improved energy metabolism, insulin secretion, and proteins that regulate genetic health and longevity.

A subsequent review paper pulled together thirty-four similar studies, recording inflammatory markers not only in healthy controls but also in subjects with leukemia, breast cancer, and dementia. Positive results in patients who practiced various breathing and meditative exercises were demonstrated across the board.66

The power of the breath has been used not just to heal, but to attain extraordinary feats that appear to defy laws of physiology. One of the most striking examples is the practice of g-tummo meditation by Tibetan monks. Tummo is the Tibetan word for inner fire, and the tummo meditation technique helps explain how the monks who practice it are able to sit outside overnight in the freezing cold of the Himalayas wrapped only in a thin sheet.

The techniques of “vase breathing” make this superhuman feat possible. Vase breathing requires one to sit quietly and focus on expanding the stomach as a breath comes in, imagining one is pouring water into a vase. Then, instead of exhaling all the way, one stops at about 90 percent of total exhalation, maintaining a round shape to the abdomen. When this practice is repeated in cycles, the increased ventilation that breathing with the stomach provides, along with the increased rate of breathing, has been shown to dramatically raise body temperature.

Wim Hof has recently taken the idea of g-tummo breathing to new heights, often quite literally. Born in 1959 in the Netherlands, he is nicknamed “The Iceman” for his Guinness World Record–breaking accomplishments in cold weather. He set the world record in 2011 for immersion in ice by staying submerged up to his neck for one hour, fifty-two minutes, and forty-two seconds. He has climbed Mount Everest to twenty-two thousand feet in only shorts and shoes, and he ran a full marathon in Finland, above the Arctic Circle, at -20 degrees Celsius, clad in a similar manner. With mastery of his breath and his meditative practices, Hof is redefining what is considered physiologically possible for a human.67

Take a moment to fall awake. Befriend yourself and your emotions. These and other mindfulness ideas can transform lives and be one approach to solving the daunting problems we face with increasing incidence of mental health disorders, deadly drug abuse, and depression. Changes in society are going to come at an increasingly rapid rate, and we need new tools and approaches to combat the stresses of the new reality. As Thich Nhat Hanh has said, “Feelings come and go like clouds in a windy sky. Conscious breathing is my anchor.”68 And more importantly, Buddhist Annabel Laity has counseled us: “Breathe! You are Alive!”69

46. Susan Scutti, “Drug Overdoses, Suicides Cause Drop in 2017 US Life Expectancy; CDC Director Calls It a ‘Wakeup Call’,” CNN Health (website), December 17, 2019, https://www.cnn.com/2018/11/29/health/life-expectancy-2017-cdc/index.html.

47. A. H. Weinberger, M. Gbedemah, A. M. Martinez, et al., “Trends in Depression Prevalence in the USA from 2005 to 2015: Widening Disparities in Vulnerable Groups,” Psychological Medicine 48, no. 8 (June 2018): 1308–1315.

48. National Institutes of Health, “Major Depression,” National Institute of Mental Health website, https://www.nimh.nih.gov/health/statistics/major-depression.shtml.

49. Donald Westerhausen, Anthony J. Perkins, Joshua Conley, et al., “Burden of Substance Abuse-Related Admissions to the Medical ICU,” Chest Journal 157, no. 1 (January 2020), https://journal.chestnet.org/article/S0012-3692(19)33736-5/fulltext.

50. W. Andrew Baldwin, Brian A. Rosenfeld, Michael J. Breslow, et al., “Substance Abuse-Related Admissions to Adult Intensive Care,” Chest Journal 103, no. 1 (January 1993), https://journal.chestnet.org/article/S0012-3692(16)38290-3/fulltext.

51. William J. Cromie, “Meditation Changes Temperatures,” Harvard Gazette, April 18, 2002, https://news.harvard.edu/gazette/story/2002/04/meditation-changes-temperatures/.

52. “Fremont Kaiser Patient Told He’s Dying Via Tele-Robot Doctor Visit,” CBSN Bay Area, March 8, 2019, https://sanfrancisco.cbslocal.com/2019/03/08/kaiser-patient-told-dying-robot-doctor-video-call/.

53. BBC, “Religion,” BBC website, https://www.bbc.co.uk/religion/religions/buddhism/.

54. Thich Nhat Hanh. The Miracle of Mindfulness: An Introduction to the Practice of Meditation (Boston: Beacon Press, 1999), 15.

55. Amy Weintraub, Yoga for Depression: A Compassionate Guide to Relieve Suffering through Yoga (New York: Broadway Books, 2004), 2.

56. Ibid., 3.

57. Jon Kabat-Zinn, Meditation Is Not What You Think: Mindfulness and Why It’s So Important (New York: Hachette Books, 2018), 133.

58. Naykky Singh Ospina, Kari A. Phillips, Rene Rodriguez-Gutierrez, et al., “Eliciting the Patient’s Agenda—Secondary Analysis of Recorded Clinical Encounters,” Journal of General Internal Medicine 34 (2019): 36–40.

59. Abraham Verghese, Blake Charlton, Jerome P. Kassirer, et al., “Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes,” American Journal of Medicine 128, no. 12 (December 2015): 1322–1324.

60. Robert L. Cowie, Diane P. Conley, Margot F. Underwood, and Patricia G. Reader, “A Randomised Controlled Trial of the Buteyko Technique as an Adjunct to Conventional Management of Asthma,” Respiratory Medicine 102, no. 5 (May 2008): 726–732.

61. M. Thomas, R. K. McKinley, S. Mellor, et al., “Breathing Exercises for Asthma: A Randomised Controlled Trial,” Thorax 64, no. 1 (2009): 55–61.

62. Nasrin Falsafi, “A Randomized Controlled Trial of Mindfulness Versus Yoga: Effects on Depression and/or Anxiety in College Students,” Journal of the American Psychiatric Nurses Association, 22 (August 26, 2016): 483–497.

63. B. A. Van der Kolk, L. Stone, J. West, et al., “Yoga as an Adjunctive Treatment for Posttraumatic Stress Disorder: A Randomized Controlled Trial.” Journal of Clinical Psychiatry 75 (2014): e559–565.

64. Arndt Büssing, Thomas Ostermann, Rainer Lüdtke, et al., “Effects of Yoga Interventions on Pain and Pain-Associated Disability: A Meta-Analysis. Journal of Pain 13, no. 1 (January 2012): 1–9.

65. Majoj K. Bhasin, Jeffrey A. Dusek, Bei-Hung Chang, et al., “Relaxation Response Induces Temporal Transcriptome Changes in Energy Metabolism, Insulin Secretion and Inflammatory Pathways,” PLOS One 8, no. 5 (May 2013): e62817.

66. Nani Morgan, Michael R. Irwin, Mei Chung, et al., “The Effects of Mind-Body Therapies on the Immune System: Meta-Analysis,” PLOS One 9, no. 7 (2014): e100903.

67. Wouter Van Marken Lichtenbelt, “Who Is the Iceman?” Temperature 4 (2017): 202–205.

68. Thich Nhat Hahn, Stepping into Freedom: An Introduction to Buddhist Monastic Training (Berkeley, CA: Parallax Press, 1997), 8.

69. Hahn, Breathe, You Are Alive: The Sutra on the Full Awareness of Breathing (Berkeley, CA: Parallax Press, 2008), i.