Part two: Trauma-informed approaches to treating eating disorders via telehealth

Presented by:

  • Emma Riebl, Primary Therapist at Within Health
  • Jacquie Rangel, Primary Therapist at Within Health
  • Caitlin Kelly, Primary Therapist at Within Health


Breathwork is a practice that has roots in various ancient cultures. The modern application of breathwork branches across fields to enhance mental, emotional, physical, and spiritual well-being.

What is breathwork?

Breathwork refers to different breathing exercises, techniques, and programs focusing on conscious awareness of your inhales and exhales. Breathwork exercises use deep, focused breathing that lasts a certain amount of time. There are several different types of breathwork practices, which include:1

  • Holotropic breathwork
  • Shamanic breathwork
  • Transformational breath
  • Clarity breathwork
  • Rebirthing breathwork
  • Vivation

Breathwork Physiology

As you inhale as a response, space is created in the thoracic cavity, and the heart enlarges, blood flow decreases, and the heart rate increases. Conversely, when you exhale, the space in the thoracic cavity is compacted, blood flow increases, and heart rate drops. 

The cycle of breath and emotional suppression

When we feel threatened, we unconsciously change how we breathe. If our nervous system kicks into fight or flight mode, we typically experience rapid upper chest breathing. In “freeze” mode, breathing typically becomes shallow or held. 

Much of this is automatic, i.e., below conscious awareness, and if these reactions to stress and trauma go on for long periods, it can cause real issues for our bodies and minds. It’s theorized that changes in breath are not just a nervous system response but also a way to suppress difficult emotions:2

  1. Traumatic/stressful event or environment
  2. Flight or flight or freeze response is triggered
  3. Breathing becomes altered
  4. Painful emotions and sensations are suppressed
  5. Habitual altered breathing

Diaphragmatic breathing

Diaphragmatic breathing - sometimes known as deep, relaxed, or abdominal breathing - optimizes the use of the diaphragm, resulting in slower, deeper breathing. In contrast to shallow breathing, diaphragmatic breathing is marked by lung expansion of the abdomen rather than the chest.3

Diaphragmatic breathing is known to improve heart rate variability (HRV), a measure of the variation in time between each heartbeat. It’s controlled by the autonomic nervous system, which contains two branches: the sympathetic nervous system and the parasympathetic nervous system, i.e., the fight or flight mechanism.4

Slow, deep breathing activates the parasympathetic nervous system's vagus nerve, which helps ease anxiety, re-focus the mind, and ground the body. Conversely, fast, shallow breathing activates the sympathetic nervous system and can create activation of the stress response.5

People with low HRV can easily experience acute stress, which can cause the fight-or-flight response to shift into overdrive. The higher our HRV, the more adaptable we are and the better how hearts can adapt to environmental changes. Therefore, the higher our HRV, the larger our window of tolerance when it comes to activating the stress response.5

Breathwork and emotional processing

Intense breathing patterns help to disrupt rigid neural networks in the brain and are thought to stimulate the release of these patterns, which can help with:

  • Unresolved emotional conflict
  • Trauma-related emotional disturbances

Furthermore, breathwork can trigger a state of transient hypofrontality, which occurs when there is decreased cerebral blood flow in the brain's prefrontal cortex. In the simplest terms, this means the thinking part of the brain gets a rest, allowing us to get out of our heads and into the moment, which allows deeper emotional processing to occur.6

Breathwork and PTSD

There is an increasing body of evidence that shows breathwork can prove beneficial in the treatment of PTSD:

  • A 2014 study by Seppala et al. saw war veterans recovering from PTSD practicing breathing techniques in a week-long workshop. The researchers reported that PTSD scores were significantly reduced at one month and one year.
  • A 2021 case study by De Wit et al. examined scores of PTSD, depression, anxiety, and HRV in firefighters. After 8 sessions of connected breathing, researchers found PTSD and comorbid symptoms were in complete remission.

Art Therapy

Creative expression can be a beneficial form of therapy, particularly for those needing help with their trauma. Talking openly about trauma can be difficult, but art therapy allows people to express their thoughts and feelings without words.7

Through art therapy, a therapist helps the client address emotional issues using a creative outlet—such as drawing or painting—and a talent for the creative arts is not necessary. The goals of art therapy are not to create aesthetically pleasing artworks. Instead, they include:

  • Establishing grounding, safety, and containment
  • Increase externalization of internal feelings
  • Explore boundaries
  • Channel impulses
  • Increase distress tolerance
  • Increase interpersonal skills
  • Increase body awareness and tolerance
  • Increase ability to self regulate
  • Move into the roles of survivor and thriver

There are several benefits of art therapy for the client, which include:7

  • Reduction and resolution of conflicts and distress
  • Emotional resilience
  • Better social skills
  • Improved self-esteem and self-awareness
  • Improved cognitive and sensory-motor functions

Benefits of art therapy for trauma survivors

As every trauma survivor copes differently, traditional talk therapies could be challenging for some who have difficulties opening up. For example, some people with multiple traumatic experiences have trouble with their verbal memory around their trauma and simply don’t want to recount the experience.7

A recent study published in the Journal of Trauma and Dissociation found that patients undergoing trauma-focused art therapy reported several beneficial effects, including improved relaxation, a decrease in PTSD symptoms, less intrusive thoughts of traumatic experiences, externalization of memories and emotions into artwork, and more confidence in the future.8

Furthermore, a 2021 review of studies into the effect of art therapy on trauma patients found evidence that art therapy or art psychotherapy can benefit children who have experienced trauma or have PTSD symptoms.9

Creating the virtual art space

The virtual art room is crucial in creating a safe space for clients. Art therapists must adapt to virtual art therapy to help clients feel safe in the home but feel like they are in an art room. For example, Within Health sends art boxes to clients to ensure they have the materials they need.

  • Creating rituals for containment
  • The sensory and kinesthetic experience of the art space
  • How the art material might feel, their fluidity and control, and their ability to arouse emotion
  • Screen tilting, i.e., the balance between monitoring the client and viewing the artwork.
  • Encrypting the artwork for sharing
  • Storing artwork
  • Creating community connection


  1. Cronkleton, E. (2023, February 10). Breathwork Basics, Uses, and Types. Healthline. Retrieved March 3, 2023.
  2. Russell, J. (2022, March 28). The science of holotropic breathwork in healing trauma - breathing exercises and healing practices. Jazmine Russell. Retrieved March 6, 2023.
  3. The Power of Breath: Diaphragmatic Breathing. (2018, July 27). U.S. Department of Veterans Affairs. Retrieved March 3, 2023.
  4. Heart rate variability: How it might indicate well-being. (2021, December 1). Harvard Health. Retrieved March 3, 2023.
  5. Neff, M. A. (2023, March 3). The window of tolerance: How to better handle stress. Insights of a Neurodivergent Clinician. Retrieved March 3, 2023.
  6. Hays, K. F. (2017). The transient hypofrontality edge. Psychology Today. Retrieved March 6, 2023.
  7. White, T. (2022, May 19). Art therapy for trauma: Here's how it can help. Psych Central. Retrieved March 4, 2023.
  8. Schouten, K. A., van Hooren, S., & Knipscheer, J., Kleber, R., & Hutschemaekers, G. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20, 1-17.
  9. Braito, I., Rudd, T., Buyuktaskin, D. et al. (2022) Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders. Irish Journal of Medical Science, 191, 1369–1383.