It is no secret to anyone that knows me that I have a complex relationship to the practice of deep breathing. While it’s something I do for myself every day, I have seen clients turn off from practicing grounding strategies altogether after trying breathing exercises with little or no success. First, we’ll talk a little bit about what it is, and then get into some important caveats for why it may not work for everyone.

A variation on this, called “box breathing” has become increasingly popular in breath-based body work for promoting relaxation. Also called “square breathing”, box breathing is a way of visualizing a type of breathing exercise that’s been promoted to people in high stress environments. Breathe in for 4 seconds, hold for 4 seconds, breathe out for 4 seconds, rest for 4 seconds.

But there’s a catch. One of the reasons people often find deep-breathing ineffective— aside from the fact that it actually takes a lot of practice to do it well— is that it’s just not what the person needs in the moment.

If you’re having trouble, you may also wish to use an app to help you in your practice. There’s no shortage of breathing apps to take advantage of, so here are a couple that I’ve had luck with:

While diaphragmatic breathing is helpful for people who practice the skill regularly and are comfortable with being in their bodies, for many people drawing attention to the body is more disconcerting than comforting. In cases of complex trauma, sometimes our bodies can feel like hostile territory. Drawing more attention to the body may not be the thing that brings you peace of mind. This might be a time to focus on externally-based strategies such as sensory input. While we’re using our body and our sensory organs to ground ourselves, the focus is on what is happening outside of our body. For some people, this sort of exercise may be necessary before any body-based approaches like diaphragmatic breathing are possible. But another thing that really surprises people about deep breathing is that for certain conditions, it can actually make things feel worse. Below you’ll find information about conditions where diaphragmatic breathing may not be indicated.

But the sensitivity of this alarm system varies from person to person, and what is uncomfortable for some might be terrifying for others. It may be that in addition to regular old claustrophobia— the fear of enclosed spaces— our bodies are reacting to CO2-rich air and sounding the alarm.

Panic Disorder is pervasive and often hard to diagnose. As a matter of fact, it’s actually one of the most common reasons people self-refer to the emergency room, as it can feel very much like you’re having a heart attack. So what can you do to turn off that alarm system? The vagus nerve is partially responsible for calming us down, so naturally many doctors and therapists have long prescribed deep breathing for patients with the intention of activating that nerve and shutting off the alarm.

And this is where it gets muddy. Some scientists propose that people experiencing CO2-related Panic Disorder might actually be exacerbating the condition by taking in larger quantities of CO2, or conversely, expelling too much. To handle these somewhat contradictory approaches, doctors have proposed using devices called capnometers, allowing patients to see their blood CO2 levels in real time, and adjust their breathing accordingly. This is a type of biofeedback called “Capnometer Assisted Therapy (CART)”, and it involves taking slow but shallower breaths

While not everyone attempting to use diaphragmatic breathing is suffering from panic disorder, or could benefit from something like CART, the existence of such a treatment points out the fundamental flaw in a one-size-fits-all approach to managing anxiety. One really important thing to know about breath work is that it’s actually a really precise science. Scientists have discovered that there is, in fact, an optimal breathing rate for resetting the body.

Remember how in another article I wrote about the need to assess whether you’re having a fight, flight or freeze response? Only half of our autonomic nervous system (ANS) is actually designed to produce anxiety to motivate us to move in the face of danger. The other half is designed to sedate us and calm our bodies.

Traumatic dissociation, where due to previous life experiences someone starts to become fatigued, disoriented and sometimes amnestic is a down-regulating process. “Down-regulating” processes are designed to still the body and signal to the brain that it should release neurotransmitters and hormones that promote calm, like GABA. While dissociation is not dangerous, per se, over time it can be easier and easier for your brain to slip into this sort of response and it can be quite disruptive. Extreme cases of dissociation involve a complete separation from reality, or in one particularly strange case documented by Bruce Perry, the body released so many sedatives into the blood that a patient slipped into a coma.

This means that it may very well be that the very last thing you want to do is calm the body even more. I have seen children fall completely asleep because well-meaning therapists failed to assess whether the trauma reaction in front of them was parasympathetic or sympathetic nervous system-dominant. In situations like this, consider up-regulating activities like movement.