Breathing Through a (Really) Fragile Moment

Greg Sazima MD (author of Practical Mindfulness) provides you with his mindfulness toolkit on how to use a “breather.”

Source: Photomania/Pixabay


  • Meditation can help patients—and their caregivers—manage many difficult moments.
  • More hard-to-hold moments, such as panic, intense anger or sadness, thoughts of suicide/self-harm, or craving, may need a quicker fix.
  • The “Mindful Breather,” a self-guided exercise using aspects of CBT, relaxation breathing, and meditative tactics, can help.

Most mindfulness training is scheduled—a planned time to sit down under some optimal conditions to practice. But life generally happens “off the cushion.”  

In the first part of this double-feature, bloggety-blog lesson, I warbled about the preventive benefits of a meditation practice in moderating the difficult states we’ve all been faced with in this weird, stressful year. My metaphor for this application of mindfulness is a “vitamin.” Some intentional, regular practice in observation of the daily mindscape in body, heart, and head can cultivate a more adaptive response to incoming, unexpected moments of intensity. I distinguished the learning of particular triggers and their familiar responses as well as the basic benefit of a “been through this kind of thing before” wisdom, borne of honing awareness via meditation.

Sometimes, though, that pre-emptive training is not enough to manage a really difficult moment of intense, unexpected experience. You know the big ones: panic anxiety, intense anger, the sadness of a goodbye or a breakup, or thoughts of suicide or self-harm. Other tough moments can sneak up on us, too—like intense craving, especially for folks wrestling with addictions. Yet in these circumstances, no sitting cushion is in sight, no optimal space and time available to retire to and meditate.

When the moment is truly radioactive, it can help to have a more structured routine, some discrete first-aid for that abrupt suffering. Enter the “Mindful Breather,” a brief “hybrid” routine I’ve pieced together out of aspects of meditative, cognitive/behavioral, and stress management tactics.

I routinely teach this to patients, caregivers, and random strangers on the street as part of a protocol for hard-to-hold moments. It can be slotted in after some initial relaxation (diaphragmatic/”belly”) breathing, and before leaning on a PRN medication and/or reaching out to an emergency contact (me, another therapist, 9-1-1). MDs, caregivers, therapists, and educators can teach this sequence in around 15 minutes. I’ve been walking clinicians through it in Zoom trainings lately, first with an explanation, then a guided practice right then and there.

This routine surveys the moment in a step-wise sequence of relaxation breaths. With each big breath, we attend sequentially to realms of our momentary experience—physical, emotional, thought, and out to observing awareness. The breathing sequence works diagnostically by attending to aspects of the experience, and therapeutically via the belly breathing involved and using a moment of reflection to reduce the novelty value of the state. Some preparatory training and teaching comes first, then training the sequence of breaths and observations.article continues after advertisement

The training in abdominal or “belly” breathing is a stress management tool familiar to most clinicians. Here we use it to help visualize a slow “gathering” of attention on the in-breath and directing of attention sequentially on each exhalation. We first direct patients to fill with air “like filling a water balloon”: belly out first, then upper chest. After a brief pause, an even slower and more gradual exhaling to near-empty.

The teaching involves identifying the categories of our momentary experience:

  • Physical experience: interior sensations of breathing, heartbeat, and pain; and sense impressions of sight, hearing, smell, taste, and touch.
  • Emotional “tone” … often located in the chest; it’s useful to identify the general categories of calm, anxious, angry, sad, etc.
  • Thoughts—memories, speculation, judgments, and rumination; it’s helpful to distinguish “flurries” from “blizzards” in terms of intensity, and to identify familiar, personal judgments that occur in reaction to events.
  • The “field” in which all these phenomena are occurring: the “space” in the landscape, whether more spacious or contracted, and our own observing capacity, our mind’s eye witnessing the landscape.

The “breather” routine itself has three steps: set-up, checklist, and wrap-up. Below are my core instructions to patients.

Set-up: Find a place to take a “breather.” If in a public setting, excuse yourself to a quiet spot—step outside the office/building/room, or head to a restroom. If available, find a place where you can sit down or take an easy walk without being interrupted. Take a deep belly breath to settle yourself.

Checklist: Next, breathe through a four-step survey. With each slow, deep in-breath, imagine gathering energy and attention in the chest; with each out-breath, “breathe attention into” each of these four targets of experience:

  • Breath #1: Into your chest; then out, imagining your directing it into your whole body. Notice tension, restlessness, pain, calming—whatever is there.
  • Breath #2: Again into your chest; with the out-breath, imagine directing it into your heart, your emotional state. Notice what state is—anxious, angry, sad, content—whatever is there.
  • Breath #3: Once again into your chest; with this out-breath, imagine directing it up into your head, how your thoughts are. Lots of them? Kind of quiet? One of them crowding out any others? Try not to chase them; just observe whatever is there.
  • Breath #4: Once more into your chest; with this out-breath, imagine pulling your attention back and just be the watcher. Notice whatever is there in body, heart, head, and the space around all that. You’ve filled yourself with awareness, and are observing it all.

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One can repeat the whole checklist or some part of it, as needed; with thresholds defined for use of rescue medications and/or making an emergent contact. It’s helpful to reinforce the routine in subsequent visits.

One other thing: If a certain difficult moment is a common one, it’s useful to intervene early instead of after the proverbial horse is out of the barn. I routinely work with my patients to get a good sense of a reliable, early signal that indicates it’s time to take a breather.

With a little practice, this tactic can be really effective for managing a really fragile moment.


  • Episode #11 of my “A Practically Mindful Moment” podcast series walks through the “Mindful Breather” in detail.
  • The Carlat Psychiatry Report Podcast asked me to narrate a version for their series.
  • I’ve created a patient handout for clinicians to provide as a resource/ reminder.


Sazima MD, G.(2021) Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners. Miami, FL:Mango Publishing.

Practical Mindfulness

A Physician’s No-Nonsense Guide to Meditation for Beginners

Training exercises that work. Practical Mindfulness approaches mindfulness and meditation from a hands-on, how-to, irreverent perspective–appealing directly to smart readers curious about meditation. By applying Dr. Sazima’s training routines, learn to spend more time in real engagement with the world. Cultivate a deeper appreciation of experiences, from the everyday to the extraordinary, and live your life more fully, wisely, and joyfully.

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