The Science Behind Some Unconventional Therapy Advice
Ice baths, slow breathing, and getting out of bed in the middle of the night
Just a quick note that I was published in Scientific American again (!) discussing the benefits of raising conscientious kids (link here). As someone high on the conscientiousness scale, this might have been a bit self-serving (lol). But in reality it was an excuse to talk about recent fascinating research on how the way we tend to think about self-control is all wrong. I hope you enjoy it!
Despite being in what is arguably the most touchy-feely profession imaginable, I’m pretty allergic to most things that could be described as “crunchy,” “hippy dippy,” or “woo woo.” I’ve never been to an acupuncturist. I don’t care about astrology. When I get a massage, I ignore any mention of aromatherapy benefits or how my body needs to “release toxins.” I love a good processed food. As I’ve discussed before, I think maternal instinct is a myth.
It’s the scientist in me that just doesn’t enjoy or get a lot out of practices that are pseudoscientific at best and simply nonsense at worst.
At the same time, I’m well aware that there are strategies I suggest to clients that sound like they have a bit of “woo woo” to them. Maybe to you there’s not a big difference between, say, loving kindness meditation (a hippy dippy name if I’ve ever heard one!) and astrology.1 Unfortunately, it can be hard to know whether a therapist is providing a skill that has some evidence to support its effectiveness or is (intentionally or not) trying to sell you some snake oil.
Here, I’ve broken down three strategies from my clinical practice that on the surface seem strange but have scientific evidence to suggest their usefulness.
Slowing Down Your Breath Will Help Keep You Calm
You’ve probably been told more than once to “take a few deep breaths” to calm down. But what if it wasn’t the inhale that mattered as much as the exhale?
Paced breathing is a technique that involves slowing down and controlling the pace of your breath. It is a core component of mindfulness meditation as well as distress tolerance skills in dialectical behavior therapy (DBT).
Importantly, paced breathing involves having a longer/deeper exhale than inhale - for example, counting to four during an inhale, and then counting to six during the exhale. Many clients are surprised that this part of breathing matters, and when they try it for the first time realize that focusing on the exhale makes the practice a bit more challenging/counterintuitive than what they are used to.
Physiologically, the answer to why paced breathing might help you feel calm is a bit complicated, but it appears to come down to the relationship between breathing and our hearts. Slowing down our breath to approximately 6 breaths/minute (also known as resonance frequency) appears to maximize heart rate variability, or the variance of time in between heart beats. High heart rate variability is an indicator of good heart health and has been shown to be related to better emotion regulation and more positive mood.
But what about the inhaling vs. exhaling part? Well, when we inhale, our heart rate increases, and when we exhale, our heart rate decreases. Varying our inhales and exhales thus helps increase heart rate variability and when we exhale, we likely feel the calming effects of our heart rate slowing down.
I’m probably providing an oversimplified version of things (I’m not a physiologist!), and the relationship among our nervous system and our subjective experience is still being studied, but overall these are the prevailing theories as to why paced breathing helps us get and stay calm.
As a bonus, here’s a kid-friendly version of paced breathing: Hold out a finger (or have your child do the same) and ask them to pretend that it’s a birthday candle that they need to blow out. Then, together, you can practice “blowing out the birthday candle,” waiting until they extend their exhale for a certain amount of time before lowering your finger, and repeating as necessary.
Not Falling Asleep? Get Out of Bed!
Out of all the skills I discuss with clients, the ones that people are most skeptical about and resistant towards involve trying to improve their sleep. Some strategies people automatically understand will probably help them sleep better, even if they find them inconvenient (e.g., not looking at their phones in bed, not drinking alcohol before bed). However, whenever I tell people that if they don’t fall asleep within fifteen minutes, the best thing they can do is get out of bed and do something else, even if it’s in the middle of the night, they look at me like I suddenly grew two heads.
“But I want to sleep more, not less. How is getting out of bed every time I can’t fall asleep going to help me?!”
The answer lies in a core tenet of Cognitive Behavioral Therapy for Insomnia (CBT-I). CBI-I is an evidence-based multicomponent therapy made to treat a variety of sleep issues, including difficulties falling asleep, staying asleep, and/or waking up too early. It’s considered the gold standard and first line of treatment to address insomnia from a variety of medical organzations, including the American Academy of Sleep Medicine, U.S. Department of Veteran Affairs, and the American College of Physicians.
One of the main components of CBT-I is known as stimulus control. The idea behind stimulus control goes all the back to your PSYCH 101 class that taught you about operant conditioning: There are reinforcing factors that increase the likelihood of a behavior and punishing factors that decrease the likelihood of a behavior.
For example, being in a dark room, comfortable bed, and feeling sleepy are all factors that increase (or reinforce) the likelihood that you will fall asleep. However, when we have trouble falling or staying asleep and we stay in bed, then we start associating being in bed with punishing stimuli (i.e., things that keep us awake): Worrying about all the things we have to do the next day, tossing and turning, doomscrolling on our phones, and everything else we think and do when we can’t sleep.
Thus, stimulus control in CBT-I involves trying to make your bed your happy, sleepy place again, filled with all the reinforcing factors that will help you fall and stay asleep. A common refrain in CBT-I is that your bed is only for two things: Sleep and sex.2
If you find yourself stuck in bed and awake after fifteen minutes or so, the best thing to do is get out of bed and go do something else until you feel sleepy again. Usually I tell clients to find some not-very-exciting books or magazines to keep on hand and read them under dim lights. Then, when you notice your eyelids start dropping, go back to bed, and repeat as necessary.
Unfortunately this means that there will be some nights where you may not get a lot of sleep. Importantly, this also means that you are giving yourself nights where you are spending less time awake in bed. As you retrain your brain and body to associate your bed with sleep, gradually you will start falling asleep faster and (hopefully) sleeping better.
Is it a pain? Yes. Will it only work if you do it consistently, likely for more than a few nights? Unfortunately also yes. A recent systematic review suggests that stimulus control by itself may be just as effective for improving one’s ability to fall asleep than other components of CBT-I for some people. If you find yourself spending a lot of time in bed doing things other than sleeping, it could be worth a shot to try to get a better night’s sleep.
Stressed? Dip Your Face In An Ice Bath!
Another distress tolerance skill from DBT involves changing the temperature of your body to feel less stressed. Specifically, the advice provided is to dip your face in an ice bath and hold your breath to help “calm your nervous system.” Sounds unpleasant, right? Does dunking your face in cold water actually help you feel less overwhelmed?
Yes!
The answer comes back to our hearts, actually. All air-breathing vertebrates, including humans, have what is referred to as the mammalian diving reflex that allows us to optimize respiration (i.e., survive longer) when we are submerged in water. Specifically, when our face is submerged underwater and we hold our breath, a nervous system response is triggered to slow down our heart rate, restrict blood flow to our limbs, and preserve oxygen to our vital organs. Further, the reflex is stronger in colder water, likely because colder water signals more danger to our bodies.
Obviously this is helpful if we’re, say, drowning, but we can also utilize this reflex to our advantage if we’re feeling panicky or stressed. By submerging our face in cold water or (to a lesser extent) putting ice packs on our face and holding our breath, we can activate this reflex and help slow our heart rate, thus helping us feel more calm. Importantly, the reflex doesn’t happen if we simply submerge our limbs - we have to trick our body into thinking that our face (and ideally, our nostrils) are underwater.
This is likely one reason why people find cold plunges to have mental health benefits - icy water can feel weirdly calming!3
This reflex works so effectively that I tell clients that they need to talk to their doctor if they are pregnant or if they have a history of heart issues before trying this technique. I usually don’t recommend it unless someone is so overwhelmed that they aren’t able to try other skills or if for whatever reasons other skills aren’t effective.
Pop Culture Sidebar: My husband and I are watching ER for the first time (it rules!) and the dive reflex makes a guest appearance on the excellent season 4 episode “Exodus.”
Loving kindness meditation is actually one of my favorite meditation practices (I find it very peaceful!) and it’s associated with improving positive mood, including for those in helping professions. As for research on astrology, here is where I link you to one of my favorite studies on the topic that shows that narcissism is related to being into horoscopes: “Even the stars think that I am superior: Personality, intelligence and belief in astrology.”
And only the latter because even psychologists know that advising against sex in bed is likely a bridge too far for most people!
The science behind all the purported benefits of cold plunges vary from sketchy to wow, actually, yes, jumping in cold water can help you. Here’s an NPR article on it if you want to learn more.