CBT Tool of the Week: BALLOON BREATHING (For Therapists)
Teaching for Child and Adolescent Therapists
Introducing “Balloon Breathing”
I use a simple name “Balloon Breathing” for the more technical term “Diaphragmatic Breathing” to describe to children how to take a deep, calming breath. It’s very important to use developmentally appropriate language when talking to children, and to make it fun and accessible. Many children have been told by adults to “Take a deep breath” and they have learned from experience that it does not help calm their anxiety. I ask kids about their experiences being told to “take a deep breath” and I acknowledge up front their prior responses and often negative expectations. Kids and teens frequently explain that they tried deep breathing and it didn’t work, and they no longer trust that it can help them. When introducing “Balloon Breathing,” I explain that it is different from just taking a deep breath and I validate their experience that a simple deep breath didn’t calm their anxiety. This validation builds trust and allows me to introduce something that will be different and may have the potential to help. I explain that actually it is not simple and takes a lot of practice before it can be helpful when they’re anxious or scared or worried. Additionally, we need to be truthful with kids. I tell them that it will not make their anxiety go away (which it will not), but it might just bring the intensity down a little bit, calm them down a bit, take the edge off a bit, help them tolerate or “ride out” their strong emotions a bit, and importantly, calm them enough to use all the tools they have learned to manage their anxiety.
What is “Balloon Breathing”
You may be quite familiar with Diaphragmatic Breathing. When teaching Balloon Breathing to children, it’s important to balance making it simple and easy to understand, while recognizing and acknowledging the complexity and difficulty of doing it correctly. Simply put, it is “taking a deep breath and imagining there is a balloon in your belly that you blow up with air when you breathe in (inhale) and let the air out when you breathe out (exhale).” This simple, understandable language and visual image helps children make sense of an actually challenging physical tool that has the potential to be very powerful. I explain “Balloon Breathing is a calming breathing technique that helps you slow down your breathing and breathe more deeply, and it’s especially helpful when you are feeling stressed, anxious, or scared.” I also explain that we are all born using our diaphragm to take deep breaths (or doing Balloon Breathing) naturally, but as we get older, we get in the habit of using our chest for breathing and shift to quicker, less deep breaths, where we suck in our belly to inhale and push it out to exhale.” Sometimes I’ll encourage children or teens to watch a baby breathe and see how they use diaphragmatic or Balloon Breathing.
Why Is It Important To Teach Kids Balloon Breathing?
I teach children that “When we feel anxious, our breathing changes and we often take short, quick, shallow breaths. If we continue to breathe this way, it can lead us to breathe very rapidly and even hyperventilate, which means to get light-headed, dizzy and our heart beats faster..”
I explain that “Quick, shallow breaths can make you feel more anxious, and lead to a racing heart, dizziness or headaches.”
I teach kids that “The cool thing about Balloon Breathing is that it’s a simple tool that you can use any time, any place and without anyone noticing. It is a quick, simple, and powerful tool that you always have with you and can use in most situations and circumstances.”
How To Teach Balloon Breathing
Teach the child/teen that Balloon Breathing involves taking slow, deep breaths and exhaling slowly. Explain that “You can do Balloon Breathing sitting up straight in a chair or lying down on your back.. It is best to place your hands on your belly or place one hand on your belly and one on your chest when you practice this breathing. There are different ways to do it, and you may find what works best for you.”
These are the steps that I explain and demonstrate. I always demonstrate first while the child/teen watches. Next, we take several breaths together. Kids/teens can feel uncomfortable being watched, so doing the breathing with them eases the discomfort. Although I am also taking balloon breaths, I observe them and later give feedback (see below).
Here is a sample explanation:
”Take a slow, deep breath in through your nose, breathing into your lower belly (counting to about 4 silently in your mind or with your fingers). Pretend you have an un-inflated balloon in your belly and you are blowing it all the way up. Feel it getting bigger and bigger in your belly. You will feel your belly pop out as you breathe in. When you inhale through your nose, you can pretend you’re smelling a big bouquet of fragrant flowers.”
When demonstrating the inhale, I count to 4 slowly with my fingers
“Pause and hold your breath with your belly sticking out (count to about 5 in your mind or with your fingers).”
I demonstrate holding my breath with my belly and chest expanded and count to 5 slowly on my fingers.
If a child/teen has difficulty holding the breath to 5, give them permission to count to 4 or whatever they can do. The pause is important, but you may need to tailor it to each individual.
“Exhale very slowly through your mouth (count to about 6 silently in your mind or count with your fingers). Pretend you’re pushing all of the air in your balloon out slowly, but strongly through your mouth. As you exhale, your belly will go down slowly. You can pretend you are blowing out 20 birthday candles, pushing all the air out until there is no more air to blow out.
Demonstrate exhaling with force. You may need to exaggerate the exhale to demonstrate. Make sure to show that all the air is released and demonstrate a relaxed body after the breath. You can talk about the difference between a tense body before a breath and a relaxed body after the breath.
“Wait a few seconds (count to about 5 Mississippi) before taking another breath.”
Demonstrate counting to 5 Mississippi silently
Teaching When To Do Balloon Breathing
One of the most helpful aspects of this tool is that kids and teens can use Balloon Breathing any time, any place and without anyone noticing. It is a quick, simple, and powerful tool that they always have with them and can use in most situations or circumstances. I explain this to them directly.
Like any new tool or strategy, it is always important to learn and practice it in the easiest circumstances. I use many analogies for kids/teens, trying to find ones that are personally relevant. Often, sports analogies are helpful. I explain that someone playing soccer doesn’t learn to dribble the ball at the first game. They learn at practice, and then practice repeatedly until they try it in a real game. Similarly, we don’t want kids/teens to try their Balloon Breathing for the first time when they are stressed, scared, or anxious. We want them to learn and practice when they are calm and relaxed. When they have mostly mastered the skill, then they are ready to begin using it in the more challenging situations such as being scared or anxious.
Thus, encourage the child/teen to start practicing Balloon Breathing when they are calm and relaxed. Explain that learning how to do this tool when they are calm will make it easier to use when they’re not calm, and use appropriate analogies of learning a new skill or tool. Explain that once they feel like they’re comfortable doing Balloon Breathing, then they can try using it when they’re stressed, scared or anxious.
It’s helpful to be concrete and specific about where and when they can use Balloon Breathing. Some will naturally experiment with it, but others will need explicit guidance on when and how to use it. Explain that they can take Balloon Breaths at school, work, home, just before an anxiety producing event or situation such as a test, sport, performance, raising their hand to speak at school, or talking to a new friend. Make the examples personal and relevant. For example, explain, “You can take Balloon Breaths before you get really anxious. If you are anxious about a test the next day, practice Balloon Breathing the day before, then the night before, the morning of the test, right before you start the test, and even during the test.
Provide explicit instructions for practicing. I recommend they practice 3 to 5 Balloon Breaths twice a day. I usually suggest practicing first thing in the morning and before bed, but work with the child/teen to find times that work for them.
Give the kids/teens a written plan! I give kids/teens a binder and handouts with the specific practice exercises for the week. A Balloon Breathing practice handout will have brief instructions for practicing (as described in previous paragraph). I also provide them a handout with information about the tool such as Balloon Breathing. If I’m working online, I share these documents through a HIPAA-secure portal and ask them to keep them all together in an online folder.
Tips for Balloon Breathing
Even with all the instruction, children and teens will need tips and ongoing instruction and practice to learn correct Balloon Breathing. I provide the following tips:
“As you inhale slowly through your nose, your belly will slowly rise first and then your lungs will fill with air and your chest will expand. Watch and feel the hand on your belly rise. The hand over your heart will barely move or may not move at all. Try to keep your shoulders relaxed and still, not moving up and down when you breathe in or out.”
“As you exhale slowly, watch and feel your belly gradually go down. Your chest and shoulders will barely move or may not move at all.”
“Practice Balloon Breathing first while you’re feeling relatively calm. You need to be comfortable breathing this way when feeling calm, before you can feel comfortable breathing when you are stressed or anxious.”
“Be Patient! It takes time to learn to do Balloon Breathing well and to feel the positive effects of it.”
“Practice Balloon Breathing when you first start to feel anxious. Don’t wait until your anxiety is super high to start Balloon Breathing.”
Remember, Balloon Breathing will just take the edge off your anxiety or fear and bring it down a bit. It can also allow you to think more clearly and figure out what tools to use to also help you calm down. Don’t expect it to make all your nerves and anxiety go away.”
“Make sure that you aren’t hyperventilating or taking very fast and shallow breaths; it is important to pause for a few seconds after each breath.”
“The purpose of Balloon Breathing is not to avoid anxiety or make your feelings go away. The goal is to help you calm down a bit, tolerate or “ride out” the feelings, or use all your tools to manage your thoughts and feelings.”
The Diaphragm and How Balloon Breathing Calms Us Down
Balloon Breathing is technically called “Diaphragmatic Breathing.” It is helpful to understand that this type of breathing affects the diaphragm and leads to a calming effect throughout the body. The diaphragm, a dome-shaped muscle at the base of the lungs, plays an important role in Balloon Breathing. When we inhale, our diaphragm contracts and moves downward. This creates more space in our chest cavity, allowing the lungs to expand. In a description from the Johns Hopkins Children’s Hospital, they explain that diaphragmatic breathing (or Balloon Breathing) allows the body to trade more incoming oxygen for outgoing carbon dioxide. This causes the heart rate to slow and can lower or stabilize blood pressure. Using our diaphragm also activates our vagus nerve, which is the nerve in our body that triggers our body’s relaxation response (or parasympathetic nervous system) and lowers the body’s stress response (or sympathetic nervous system).