When Calm Is the Wrong Goal — Hypoarousal and the Case for Up-Regulation in Therapy
Calming tools can deepen collapse. A yoga therapist's in-session protocol for hypoarousal — behavioural activation at the scale of a single posture.
A client sits across from me and tells me that she has been doing the box breathing that her therapist taught her (in for four, hold for four, out for four, hold for four), and nothing has shifted.
Her body language holds the key to why this breath practice is not helping. Her shoulders are rounded forward, her chest has folded in around itself, and her voice has very little rise and fall. When I ask how she is feeling, the answer is something close to not much, tired or depressed. She isn't anxious. She's flat.
Box breathing is an excellent tool and a strong protocol for many clients. It slows things down and evens them out. But this client is already slowed down. Offering a calming practice to someone in that state is like handing the brakes to a car that has stalled. What she needs first is up-regulation, something that brings her energy up, so that she has somewhere to come back into balance from.
One word, one answer
I see this often enough now that I've stopped thinking of it as one practitioner's oversight. It's a pattern in how our culture talks about regulation.
When we say a client is dysregulated, we usually mean too much — too activated, too anxious, too reactive. The tools follow. Breath that slows, grounding that settles, practices that soothe. For clients who struggle with depression and collapse, few body-based tools are offered, if any. When they are, it is often because trauma is present, and the referral goes to trauma-informed yoga, a world that is itself overwhelmingly oriented toward calming. The working assumption becomes that anyone with trauma needs to be down-regulated. For someone whose tendency is toward collapse, that just isn't the case.
Most clinicians can recognize hypoarousal, the lower edge of the window of tolerance, and descriptions of dorsal vagal shutdown are everywhere. What is far less available is practical guidance on what to do with a body that is shut down.
Where my map came from
My work is founded in yoga therapy, and the tradition I trained in named three states that look a lot like our current understanding of the autonomic nervous system's hypoarousal, hyperarousal and homeostasis. In yoga philosophy, the three recognized states are heavy, slow and lethargic (tamasic); fiery, heated and driven (rajasic); and balanced (sattvic). From the very beginning of my studies, practices were sorted by which state needed balancing, the heated one or the heavy one.
When nervous system regulation entered the mental health vocabulary, the practices people began naming as effective mirrored what I had already been doing. The difference was that the map I'd learned had a whole territory that the conversation mostly left blank. I'll use clinical language from here on, but that is where the distinction and my understanding of regulation come from.
A familiar mechanism at a smaller scale
If energizing a collapsed client before calming them sounds like a new idea, it isn't. Behavioural activation is one of the most thoroughly studied psychological treatments for depression (Uphoff et al., 2020). It is founded on the principle of act first, and let the mood follow, rather than waiting for motivation to arrive.
What I'm describing is behavioural activation at the scale of a single posture, inside a single session. The logic is the same; only the scale changes. No new evidence is needed to accept it, only the recognition that a well-established mechanism can operate at a much smaller level.
What it looks like in session
The signs are easy to recognize once they have been named. A collapsed posture, shoulders rounding forward, the body slumped. A monotone voice. A tendency toward depression rather than anxiety. Sadness that is maladaptive, the kind that loops rather than moves. Shame that collapses into sadness instead of mobilizing into anger.
And numbness, tuned out of the body rather than flooded by it. This can be easy to miss because numbness often reads as calm. A client who is quiet, still and unbothered can look regulated. When the conversation stalls, it becomes clear that they simply aren't there.
Now look around your practice room. Many therapy offices are furnished for settling, with deep couches, soft cushions and something to sink into. For a client who arrives activated, that is a kindness. For a client who arrives already rounded and slumped, the furniture is holding them in exactly the state the session is trying to shift.
Why body posture matters for emotion
When someone is closer to balance, they can reach adaptive emotion more easily. A lethargic body tends to mean lethargic thinking. Someone in a heavy, low emotional state usually feels it in their body too.
Stand that person up and something becomes available that wasn't before. A felt sense of their own strength. Self-empowerment. And sometimes adaptive anger, the anger that says I didn't deserve that, which is very hard to reach from a slumped chair. When the work depends on helping clients access adaptive emotion, the posture they are in is not a neutral detail.
The protocol
The core of this protocol is Peter Levine's idea of titration. Each step is scaffolding for the next and is anchored in what feels comfortable while gently exploring its edge. Nothing is imposed. It's a collaboration. You're never telling the client what to do — you're inviting them to try something and checking in to see how it's landing. At first you lead — sitting up first, standing first, moving first and offering the first suggestions for movement. Once the client has found what feels comfortable, the roles reverse and you mirror them.
Sit upright. Sit up first yourself and invite the client to join you. A firmer chair helps if one is available. Feet steady on the ground, spine long, shoulders beginning to open.
Stand first, and invite them to stand with you. This matters. You are leading by example, not instructing, and the client gets to borrow your posture before they have found their own. The goal is to have a tall, broad, confident posture. Feet slightly apart and palms facing forward can be helpful.
Check in at every step. What are you feeling? Does it feel any different? Are you comfortable taking it a little further, or shall we start the conversation from here?
If standing is moving them in the right direction, stay there. If more is needed, bring attention past the feet into the legs, feeling them strong and connected to the ground, with the shoulders broad. This is grounding that is strong and powerful, as distinct from grounding that calms.
If more is still needed, add movement. Start small. You move first and suggest the options — shake out the hands, then the feet, propeller or windmill arms, a big yawn up toward the ceiling. Invite your client to join in and explore what feels comfortable. Once they have settled into a movement that suits them, switch roles and mirror what they are doing. One or two minutes in all is enough.
Watch their movement. As they move, notice what looks easy and natural and what seems stiff or uncomfortable. Don't assume anything — use this as a cue to offer something different. If their propeller arms look as stiff as boards but shaking seemed natural, ask what feels best.
Check in again. If movement doesn't feel right, go back to whatever felt safe and stay there.
The aim is movement to the point where it feels like it is moving them in the direction they want to go, and no further.
The check-ins aren't administration. They are part of the intervention. Clients often start by describing their state as stuck or thick. As things shift, the language changes to more energized, more alert, more alive. Giving someone words for what better feels like is something they can take home with them.
Processing while standing
This is the part I really to encourage you to try.
Once the client is standing and something has shifted, begin the conversation there, standing. When the talk is moving productively, invite them to sit back down. If they collapse again, and often they will, cue a straight spine or stand again.
It isn't one and done. It's a movement back and forth between two states, for as long as the session needs it. Posture stops being a setup before the real work and becomes central to the process.
What changes when working this way? The client starts to notice the link between how they are holding their body and what they can feel and say. Over time they begin to choose for themselves which posture helps them reach the emotion that is being blocked. That choice is theirs and reinforces a sense of agency.
Your comfort level matters
When I have worked with clinicians and demonstrated movement, it is very common for them to ask, "What if movement feels awkward, embarrassing or unnatural?" I can often see that discomfort in how they move.
It may seem obvious, but it is worth stating — if you are offering movement to a client, it is essential that you have practised being comfortable with movement yourself.
Take a pause here. Stand up, shake out your arms and feet, and try propeller arms. How does it feel? You may need to keep practising until it feels natural. Not all is lost if you aren't comfortable or if your client isn't. A lot can be gained by sitting up tall and standing.
When this may not work
I am not going to offer a list of contraindications. I genuinely beleive that nobody is destabilized by sitting up straight, and safeguards that make this broadly accessible are built into the method — titration, collaboration, mirroring and slowness.
When this goes wrong, it's usually because a safeguard was skipped — telling instead of collaborating, jumping straight to shaking before sitting up and checking in, or moving from one step to the next without pausing to notice.
The pause is the method. Sit up, check in and notice. Stand, check in and notice. Then movement, check in and notice. The check-in and noticing are as much the intervention as the movement is.
One distinction worth noting is that collapse as a state is different from physiological exhaustion. A body that is genuinely depleted needs rest, not activation. And for clients with a trauma history, activation can occasionally overshoot. If it does, the route back is the settling work most clinicians already know well.
Between sessions
The homework begins with self-observation — noticing how the body is connected to emotional state, and then experimenting with shifting that state through posture.
The tools are simple. Sit up straight. Find a sturdier chair; the chair can mirror your posture, and your posture can mirror the chair. Shake out the hands and feet, if that landed in session. Broaden the shoulders. Stand, and explore what strength feels like in the legs. And any movement the client finds genuinely pleasurable, including dancing, swaying or bouncing. Remember that exploration is central to this protocol. Movement should not be prescriptive — offer suggestions as a starting point, and then explore.
Power poses
One practice I've used in my work on integrating body-based practices into psychotherapy (Paivio & Robinson, 2023), both as homework for clients and in training for therapists, is the power pose. The in-session protocol above needs a practitioner in the room. Power poses are the piece a client can most easily practise on their own.
The client stands in front of a mirror and finds a pose that makes them feel empowered. Three are a good place to start.
Warrior one. One foot steps back, the front foot steady and firm with the knee slightly bent, arms reaching overhead.
Superhero. Hands on hips, feet slightly apart, gaze straight ahead.
Wonder Woman. Wrists crossed in front of the heart.
I have found that the third option works especially well with clients who have experienced interpersonal trauma, or who have a history in which anger was threatening. For them, the Superhero pose can feel too confrontational. Wonder Woman balances protection and strength.
A word on the research. In 2010, Carney, Cuddy and Yap reported that two minutes in an expansive posture made people feel more powerful and also changed their hormones. The hormonal findings did not hold up on replication, and the first author later said publicly that she no longer believed them. The effect on how people report feeling, though, has held up across a much larger body of studies. That is the part I use clinically. I'm not asking anyone's cortisol to change. I'm asking them to notice whether they feel stronger and a little more congruent with the body they want to inhabit.
An invitation
If you have a client who has been faithfully practising their box breathing and getting nowhere, try standing up with them next session. Sit, notice. Stand, notice. See what opens up in the conversation that wasn't there from the couch.
I'd genuinely like to hear what you find. And if you have a client whose collapse isn't shifting and you're wondering whether yoga therapy might sit alongside the work you're already doing, I'm always glad to talk. You can reach me HERE.
References
Carney, D. R., Cuddy, A. J. C., & Yap, A. J. (2010). Power posing: Brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363–1368.
Cuddy, A. J. C., Schultz, S. J., & Fosse, N. E. (2018). P-curving a more comprehensive body of research on postural feedback reveals clear evidential value for power-posing effects: Reply to Simmons and Simonsohn (2017). Psychological Science, 29(4), 656–666.
Paivio, S. C., & Robinson, K. J. P. (2023). Yoga therapy as complement to EFTT: Integrating body-based intervention. In S. C. Paivio & A. Pascual-Leone, Emotion-focused therapy for complex trauma: An integrative approach (2nd ed., pp. 305–333). American Psychological Association.
Ranehill, E., Dreber, A., Johannesson, M., Leiberg, S., Sul, S., & Weber, R. A. (2015). Assessing the robustness of power posing: No effect on hormones and risk tolerance in a large sample of men and women. Psychological Science, 26(5), 653–656.
Uphoff, E., Ekers, D., Robertson, L., Dawson, S., Sanger, E., South, E., Samaan, Z., Richards, D., Meader, N., & Churchill, R. (2020). Behavioural activation therapy for depression in adults. Cochrane Database of Systematic Reviews, 7, CD013305.
